Clinical Analysis of Radiologic Measurements in Patients with Basilar Invagination

Park

et al. 2021

Neurosurgical Focus

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OBJECTIVEThe authors sought to evaluate the usefulness of indocyanine green (ICG) angiography and Doppler sonography for monitoring the vertebral artery (VA) during craniovertebral junction (CVJ) surgery and compare the incidence of VA injury (VAI) between the groups with and without the monitoring of VA using ICG angiography and Doppler sonography.METHODSIn total, 344 consecutive patients enrolled who underwent CVJ surgery. Surgery was performed without intraoperative VA monitoring tools in 262 cases (control group) and with VA monitoring tools in 82 cases (monitoring group). The authors compared the incidence of VAI between groups. The procedure times of ICG angiography, change of VA flow velocity measured by Doppler sonography, and complication were investigated.RESULTSThere were 4 VAI cases in the control group, and the incidence of VAI was 1.5%. Meanwhile, there were no VAI cases in the monitoring group. The procedure time of ICG angiography was less than 5 minutes (mean [± SD] 4.6 ± 2.1 minutes) and VA flow velocity was 11.2 ± 4.5 cm/sec. There were several cases in which the surgical method had to be changed depending on the VA monitoring. The combined use of ICG angiography and Doppler sonography was useful not only to monitor VA patency but also to assess the quality of blood flow during CVJ surgery, especially in the high-risk group of patients.CONCLUSIONSThe combined use of ICG angiography and Doppler sonography enables real-time intraoperative monitoring of the VA by detecting blood flow and flow velocity. As the arteries get closer, they provide auditory and visual feedback to the surgeon. This real-time image guidance could be a useful tool, especially for high-risk patients and inexperienced surgeons, to avoid iatrogenic VAI during any CVJ surgery.

Section: Discussionmentioning

confidence: 99%

Intraoperative surveillance of the vertebral artery using indocyanine green angiography and Doppler sonography in craniovertebral junction surgeries

Park

et al. 2021

Neurosurgical Focus

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“…Although we do not fully know the amount of distraction required for neurological recovery and prevention of neurological complications, our published data showed that the change rate of Modified Ranawat index after surgery was correlated with postoperative Hirabayashi recovery rate. 52 It is impossible to simplify clinical outcomes into a linear curve. However, the amount of radiological change has a substantial correlation with the clinical outcomes.…”

Section: ) Congenital Kyphosis and Bimentioning

confidence: 99%

“…Therefore, the C1-2 distraction and craniocervical realignment should be performed very carefully under intraoperative neuromonitoring (IONM) to avoid excessive distraction and subsequent stretching injury of the spinal cord or VA. Although we do not fully know the amount of distraction required for neurological recovery and prevention of neurological complications, our published data showed that the change rate of Modified Ranawat index after surgery was correlated with postoperative Hirabayashi recovery rate [ 52 ]. It is impossible to simplify clinical outcomes into a linear curve.…”

Section: Treatment Of Craniovertebral Junction Deformitymentioning

confidence: 99%

Evaluation and Surgical Planning for Craniovertebral Junction Deformity

et al. 2020

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Craniovertebral junction (CVJ) deformity is a challenging pathology that can result in progressive deformity, myelopathy, severe neck pain, and functional disability, such as difficulty swallowing. Surgical management of CVJ deformity is complex for anatomical reasons; given the discreet relationships involved in the surrounding neurovascular structures and intricate biochemical issues, access to this region is relatively difficult. Evaluation of the reducibility, CVJ alignment, and direction of the mechanical compression may determine surgical strategy. If CVJ deformity is reducible, posterior in situ fixation may be a viable solution. If the deformity is rigid and the C1-2 facet is fixed, osteotomy may be necessary to make the C1-2 facet joint reducible. C1-2 facet release with vertical reduction technique could be useful, especially when the C1-2 facet joint is the primary pathology of CVJ kyphotic deformity or basilar invagination. The indications for transoral surgery are becoming as narrow as a treatment for CVJ deformity. In this article, we will discuss CVJ alignment and various strategies for the management of CVJ deformity and possible ways to prevent complications and improve surgical outcomes.

“…Ambiguous landmarks lead to low reliability or consistency for confirming basilar invagination (BI). [14][15][16] Accordingly, we must establish a more reliable and consistent method for diagnosing CVJ pathologies.Many methods for diagnosing BI and CVJ pathology may imply that choosing just one method in clinical circumstances is complicated. These measurements can show variable results due to multiple reasons.…”

mentioning

confidence: 99%

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confidence: 99%

Evaluation of Cervicomedullary Compression Around the Craniovertebral Junction: Commentary on “Measurement of Deformity at the Craniovertebral Junction: Correlation of Triangular Area and Myelopathy”

Hong

2022

Neurospine

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The craniovertebral junction (CVJ) is the region around the skull base and the upper cervical spine (atlas and axis), along with its neurovascular components, including the brain stem, spinal cord, vertebral artery, and venous plexus. [1][2][3][4][5][6] The stability of CVJ is dependent on a robust ligamentous complex and the shape of the bony structures, which are also responsible for much of the axial rotation (C1-2 joint) and flexion-extension movements (C0-1 and C1-2 joint). 7,8 CVJ pathologies are usually rare and can result in progressive deformity, myelopathy, severe neck pain, and functional disability, such as difficulty swallowing. 3,[9][10][11][12] The most common causes are rheumatoid arthritis, trauma, neoplasm, infection, and congenital bony malformation. These CVJ pathologies may alter the quality of life because of the neck pain, disabling headache, dysphagia, and myelopathy. 12,13 In most cases, standard radiographs, computed tomography, and magnetic resonance imaging typically conduct the proper diagnosis of CVJ pathology. However, no one-single method has been recom mended to properly diagnose CVJ pathology due to the overlying structures on lateral plain radiographs. Ambiguous landmarks lead to low reliability or consistency for confirming basilar invagination (BI). [14][15][16] Accordingly, we must establish a more reliable and consistent method for diagnosing CVJ pathologies.Many methods for diagnosing BI and CVJ pathology may imply that choosing just one method in clinical circumstances is complicated. These measurements can show variable results due to multiple reasons. First, anatomical landmarks may be ambiguous, thus leading the interpreter to measure different results. Second, measurement errors can be made by the interpreter himself or on the radiographs. The lack of confidence in anatomic landmarks can cause unreliable results, and it is hard to obtain absolute true-lateral radiographs in every patient.Variations in measurement may lead to a different type of treatment. Therefore, we need to determine how reliable and reproducible these measurements are. 16