Vertebral artery injury during anterior decompression of the cervical spine. A retrospective review of ten patients

Smith, Stacy; Se, Emery; Dudley, Anne; Murray, Kathleen; Leventhal, Marvin R.

doi:10.1302/0301-620x.75b3.8496209

Cited by 214 publications

(123 citation statements)

References 18 publications

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“…Moreover, due to erosion of the anatomical structures, bony landmarks are not always reliable. Especially when the vertebral artery runs an abnormal course, screw placement has a potential risk of neurovascular injury, and vertebral artery injury on the dominant side can cause cerebellar infarction and possibly fetal sequelae [2,22,23]. Moreover, due to severe spinal deformity and small anatomical size of the vertebra (the lateral mass and pedicle) in the most RA cervical lesions, screw placement procedures are highly technically demanding and pose the potential risk of neurovascular injuries even though intraoperative fluoroscopy is used.…”

Section: Discussionmentioning

confidence: 99%

Computer-assisted screw insertion for cervical disorders in rheumatoid arthritis

et al. 2006

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To reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions, the authors have been using C1/2 transarticular and cervical pedicle screw fixations. Pedicle screw fixation and C1/2 transarticular screw fixation are biomechanically superior to other fixation techniques for RA patients. However, due to severe spinal deformity and small anatomical size of the vertebra, including the lateral mass and pedicle, in the most RA cervical lesions, these screw fixation procedures are technically demanding and pose the potential risk of neurovascular injuries. The purpose of this study was to evaluate the accuracy and safety of cervical pedicle screw insertion to the deformed, fragile, and small RA spine lesions using computer-assisted image-guidance systems. A frameless, stereotactic image-guidance system that is CT-based, and optoelectronic was used for correct screw placement. A total of 21 patients (16 females, 5 males) with cervical disorders due to RA were surgically treated using the image-guidance system. Postoperative computerized tomography and plane X-ray was used to determine the accuracy of the screw placement. Neural and vascular complications associated with screw insertion and postoperative neural recovery were evaluated. Postoperative radiological evaluations revealed that only 1 (2.1%; C4) of 48 screws inserted into the cervical pedicle had perforated the vertebral artery canal more than 25% (critical breach). However, no neurovascular complications were observed. According to Ranawat's classification, 9 patients remained the same, and 12 patients showed improvement. Instrumentation failure, loss of reduction, or nonunion was not observed at the final followup (average 49.5 months; range 24-96 months). In this study, the authors demonstrated that image-guidance systems could be applied safely to the cervical lesions caused by RA. Image-guidance systems are useful tools in preoperative planning and in transarticular or transpedicular screw placement in the cervical spine of RA patients.

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Section: Discussionmentioning

confidence: 99%

Computer-assisted screw insertion for cervical disorders in rheumatoid arthritis

et al. 2006

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“…VA injury is a rare but profound complication of ACSO [2,17,25,35]. The reports included in this study presented several mechanisms or risk factors of VA injury in ACSO.…”

Section: Causesmentioning

confidence: 97%

“…Unrecognized VA tortuosity or other anomalies, such as a VA located anterior to the transverse process, may also result in intraoperative injury [4,15,17,39]. The presence of a softened lateral cortex due to tumor or infection has been implicated in VA injury during operation [4,5,19,35]. In addition, a VA weakened by radiation or infection is also at risk for injury [5,19].…”

Section: Causesmentioning

confidence: 99%

“…Although anterior cervical spine operations (ACSO) are generally considered to be safe and effective, the vertebral artery (VA) is at risk during the procedure because of its location adjacent to the neural foramen [5,38]. The largest series of these injuries cite the incidence of injury as approximately 0.3-0.5 % [4,35]. Although VA injury is uncommon, the consequences can be catastrophic as it is associated with serious complications such as arteriovenous fistula (AVF), pseudoaneurysm, late-onset hemorrhage, thrombosis, embolism, cerebral ischemia, and death [20,25,28].…”

Section: Introductionmentioning

confidence: 99%

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The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases

Park

Jho

2012

Eur Spine J

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Purpose Anterior cervical spine operations (ACSO) are generally considered to be safe and effective, but the vertebral artery (VA) is at risk during the procedure. Because the consequences of VA injury can be catastrophic, properly managing a VA injury is very important. However, due to the rarity of these injuries, there is no agreed upon treatment strategy. Methods Studies were identified for inclusion in the review via sensitive searches of electronic databases through 31 December 2011. All cases included in the review were qualitatively analyzed to explore the relationship between type of VA injury management and neurological complications. Results Seventeen articles describing 39 cases of VA injury during ACSO were included in this study. Seven patients (17.9 %) had neurological complications followed by VA insufficiency. Two patients (5.1 %) had root damage due to ligation. One case (2.6 %) resulted in intraoperative death due to fatal bleeding. Delayed vascular complications were identified in nine (45.0 %) of the 20 patients that underwent only tamponade or hemostatic agent during the operation. Four patients underwent intraoperative endovascular treatment, and three of these patients had a cerebral infarction. All three patients who underwent clipping also had neurological complications. The five patients treated by direct repair did not have any complications. Conclusion Our review suggests the management of VA injury should be considered in order listed: (1) performing tamponade with a hemostatic agent, (2) direct repair, (3) postoperative endovascular procedures to prevent delayed complications. If tamponade fails to achieve proper hemostasis, additional procedures as endovascular embolization, clipping and ligation should be considered but carry the risk of neurological complications. Because of the limitations of this review, further studies are recommended with larger sample sizes.

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“…The incidence of iatrogenic VA injury in anterior cervical decompression procedures has been reported to range from 0.18 to 2.78 % [1,[19][20][21][22]. James et al [19] reported that VA injury can occur if decompression is asymmetric or overly aggressive.…”

Section: Discussionmentioning

confidence: 99%

Alterations in axial curvature of the cervical spine with a combination of rotation and extension in the conventional anterior cervical approach

et al. 2013

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Purpose Alterations of three-dimensional cervical curvature in conventional anterior cervical approach position are not well understood. The purpose of this study was to evaluate alignment changes of the cervical spine in the position. In addition, simulated corpectomy was evaluated with regard to sufficiency of decompression and perforation of the vertebral artery canal. Methods Fifty patients with cervical spinal disorders participated. Cervical CT scanning was performed in the neutral and supine position (N-position) and in extension and right rotation simulating the conventional anterior approach position (ER-position). Rotation at each vertebral level was measured. With simulation of anterior corpectomy in a vertical direction with a width of 17 mm, decompression width at the posterior wall of the vertebrae and the distance from each foramen of the vertebral artery (VA) were measured. Results In the ER-position, the cervical spine was rotated rightward by 37.2°± 6.2°between the occipital bone and C7. While the cervical spine was mainly rotated at C1/2, the subaxial vertebrae were also rotated by several degrees. Due to the subaxial rotation, the simulated corpectomy resulted in smaller decompression width on the left side and came closer to the VA canal on the right side. Conclusions In the ER-position, the degrees of right rotation of subaxial vertebrae were small but significant. Therefore, preoperative understanding of this alteration of cervical alignment is essential for performing safe and sufficient anterior corpectomy of the cervical spine.

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Vertebral artery injury during anterior decompression of the cervical spine. A retrospective review of ten patients

Cited by 214 publications

References 18 publications

Computer-assisted screw insertion for cervical disorders in rheumatoid arthritis

Computer-assisted screw insertion for cervical disorders in rheumatoid arthritis

The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases

Alterations in axial curvature of the cervical spine with a combination of rotation and extension in the conventional anterior cervical approach

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