C1-C2 screw fixation in the patient with anomalous course of vertebral artery: Case report

Introduction. The atlantoaxial complex is a very complicated structure and open reduction of C1-C2 subluxation is very demanding. Atlantoaxial instability may result from the traumatic, inflammatory, neoplastic, congenital or degenerative disorders. Anatomy of the vertebral artery is essential for surgical approach and sometimes the placement of C2 pedicle screw is not possible. In these instances, the translaminar screw placement in C2 can provide an alternative fixation point in C2, without threatening injury to the vertebral artery. Case report. We presented 54- year-old patient with cervical myelopathy according to traumatic atlantoaxial subluxation. Computed tomography angiography showed a bilateral vertebral artery anomaly of ?high-riding? type. The patient was operated and the posterior C1-C2 screws fixation was used. Due to the vertebral artery anomaly C2 screws were translaminary inserted. Complete reduction of C1-C2 subluxation and excellent neurological improvement were achieved. Conclusion. Surgical treatment of C1-C2 subluxation is very challenging. Many techniques of atlantoaxial fixation have been developed. The use of C2 translaminar screw is an alternative method of fixation in the treatment of atlantoaxial instability, especially in cases with the vertebral artery anomaly.

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C2 Translaminar Screw Fixation (Wright`s Technique) Applicability in Atlantoaxial Instability

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v23i2.1163 ◽

2018 ◽

Vol 23 (2) ◽

pp. 152-156

Author(s):

Lucas Alves Aurich ◽

Jerônimo Buzetti Milano ◽

Erasmo Barros Da Silva Júnior ◽

Ricardo Ramina

Keyword(s):

Screw Fixation ◽

Atlantoaxial Instability ◽

Rigid Fixation ◽

Fixation Technique ◽

Advantages And Disadvantages ◽

Risks And Benefits ◽

Translaminar Screw Fixation ◽

Translaminar Screw ◽

Fixation Techniques ◽

Atlantoaxial Fixation

Atlantoaxial instability often requires surgical treatment. Several techniques are available to perform antlantoaxial stabilization, and all of these have their different advantages and disadvantages. In 2004, Wright described the C2translaminar screw fixation, which offers rigid fixation but without the technical demands of C2 pars placement and eliminates the risk of vertebral artery injury. The aim of this study is to review the C2 translaminar screw fixation technique, emphasizing operative details, risks and benefits comparing with the others atlantoaxial fixation techniques.

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Spontaneous recanalization of intracranial vertebral artery detected by carotid duplex ultrasonography in a patient with neurological improvement: a case report

Neurosonology ◽

10.2301/neurosonology.28.21 ◽

2015 ◽

Vol 28 (1) ◽

pp. 21-24

Author(s):

Hidetaka MITSUMURA ◽

Masako IKEDA ◽

Teppei KOMATSU ◽

Shinji MIYAGAWA ◽

Toshiaki HIRAI ◽

...

Keyword(s):

Case Report ◽

Vertebral Artery ◽

Duplex Ultrasonography ◽

Neurological Improvement ◽

Carotid Duplex ◽

Carotid Duplex Ultrasonography

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Atlantoaxial Fixation in a Patient with Bilateral Persistent First Intersegmental Vertebral Artery Anomaly Using an O-arm Navigation System: A Case Report

Spine Surgery and Related Research ◽

10.22603/ssrr.2018-0065 ◽

2019 ◽

Vol 3 (2) ◽

pp. 196-198 ◽

Cited By ~ 3

Author(s):

Hideaki Kashiro ◽

Keiji Wada ◽

Mitsuru Yui ◽

Ryo Tamaki ◽

Daisuke Numaguchi ◽

...

Keyword(s):

Case Report ◽

Vertebral Artery ◽

Navigation System ◽

System A ◽

Atlantoaxial Fixation

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Posterior atlantoaxial fixation with new subfacetal axis screw trajectory avoiding vertebral artery with customized variable screw placement plate and screws to enhance biomechanics of fixation

Neurosurgical Focus: Video ◽

10.3171/2020.4.focusvid.20168 ◽

2020 ◽

Vol 3 (1) ◽

pp. V10

Author(s):

Sushil Patkar

Keyword(s):

Vertebral Artery ◽

Facet Joint ◽

Articular Surface ◽

Standard Of Care ◽

Screw Placement ◽

Atlantoaxial Instability ◽

Technological Advances ◽

Atlantoaxial Fixation ◽

Screw Position ◽

Developed World

Fixation for atlantoaxial dislocation is a challenging issue, and posterior C1 lateral mass and C2 pars–pedicle screw plate–rod construct is the standard of care for atlantoaxial instability. However, vertebral artery injury remains a potential complication. Recent literature has focused on intraoperative navigation, the O-arm, 3D printing, and recently use of robots for perfecting the trajectory and screw position to avoid disastrous injury to the vertebral artery and enhance the rigidity of fixation. These technological advances increase the costs of the surgery and are available only in select centers in the developed world.Review of the axis bone anatomy and study of the stress lines caused by weight transmission reveal that the bone below the articular surface of the superior facet is consistently dense as it lies along the line of weight transmission A new trajectory for the axis screw 3–5 mm below the midpoint of the facet joint and directed downward and medially avoids the course of the vertebral artery and holds the axis rigidly. Divergent screw constructs are biomechanically stronger. Variable screw placement (VSP) plates with long shaft screws permit manipulation of the vertebrae and realignment of the facets to the correct reduced position with fixation in the compression mode.The video can be found here: https://youtu.be/E1msiKjM-aA

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Mobilization of the Vertebral Artery—Surgical Option for C2 Screw Fixation in Cases With “High Riding” Vertebral Artery

Operative Neurosurgery ◽

10.1093/ons/opz289 ◽

2019 ◽

Vol 18 (6) ◽

pp. 648-651 ◽

Cited By ~ 5

Author(s):

Atul Goel ◽

Ranjit Rangnekar ◽

Abhidha Shah ◽

Survendra Rai ◽

Ravikiran Vutha

Keyword(s):

Vertebral Artery ◽

Screw Fixation ◽

Basilar Invagination ◽

Os Odontoideum ◽

Safe Procedure ◽

Screw Insertion ◽

Atlantoaxial Fixation ◽

Atlantoaxial Stabilization ◽

C2 Vertebra

Abstract BACKGROUND Mobilization of intraosseous course of vertebral artery for safe screw insertion into pedicle of axis in cases with high riding vertebral artery is discussed. OBJECTIVE To show drilling, exposure, and mobilization of the “high-riding” vertebral artery loop during its course in relationship with superior facet/pedicle of C2 vertebra can provide safety to techniques of atlantoaxial fixation that involve insertion of screws in the pars/pedicle/facet of C2. METHODS During the period June 2016 to April 2018, 15 patients operated for atlantoaxial stabilization underwent vertebral artery exposure and mobilization using the technique discussed. The ages of the patients ranged from 6 to 48 yrs. Four patients had mobile and reducible atlantoaxial dislocation. Seven patients had basilar invagination. Four patients had os-odontoideum. Gentle and precise drilling of bone that covers the “high-riding” vertebral artery can lead to its safe and wide surgical exposure. The arterial loop can then be either completely or partially mobilized out of the vertebral artery groove such that C2 screw insertion can be conducted under direct surgical visualization of the vertebral artery. RESULTS During the average follow-up period of 14 mo, there have been no complications related to the surgical procedure, metal implant, or vertebral artery. CONCLUSION Vertebral artery exposure and mobilization is rather simple and safe procedure and is remarkably effective in providing a space for C2 screw implantation.

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Risk to the vertebral artery during C-2 translaminar screw placement: a thin-cut computerized tomography angiogram–based morphometric analysis

Journal of Neurosurgery Spine ◽

10.3171/2013.5.spine12790 ◽

2013 ◽

Vol 19 (2) ◽

pp. 217-221 ◽

Cited By ~ 3

Author(s):

Ron I. Riesenburger ◽

G. Alexander Jones ◽

Marie Roguski ◽

Ajit A. Krishnaney

Keyword(s):

Vertebral Artery ◽

Screw Fixation ◽

Buffer Zone ◽

Screw Placement ◽

Lamina Thickness ◽

Axial Angle ◽

Vertebral Arteries ◽

Screw Length ◽

Translaminar Screw ◽

Translaminar Screws

Object The goal of this study was to characterize the anatomy relevant to placement of crossing C-2 translaminar screws, including morphometric data, and to evaluate the risk of violating the vertebral artery (VA) during the screw placement. Placement of bilateral crossing C-2 translaminar screws has become an increasingly popular method for dorsal C-2 instrumentation as it is felt to avoid the known risk of VA injury associated with C1–2 transarticular screw fixation and C-1 lateral mass–C-2 pars screw fixation. Methods The source images from 50 CT angiograms of the neck obtained from October to November 2007 were studied. Digital imaging software was used to measure lamina thickness and maximum screw length, perform angulation of screw trajectories in the axial plane, and evaluate the potential for VA injury. In cases where the VA could be injured, the distance between the maximal screw length and artery was measured. Logistic regression was performed to evaluate lamina width, axial angle, and screw length for predicting the potential for VA injury. Results Mean lamina thickness, axial angle, and maximal screw length were determined for 100 laminae, and a potential for VA injury was noted in 55 laminae. The anatomically defined ideal screw length was longer in laminae with potential for VA injury than in laminae with no apparent risk (35.2 vs 33.6 mm, p = 0.0131). Only increasing optimal screw length was noted to be a statistically significant predictor of potential VA injury (p = 0.0159). The “buffer zone” (the distance between an optimally placed screw and the VA) was 5.6 ± 1.9 mm (mean ± SD, range 1.8–11.4 mm). A screw limited to 28 mm in length appeared to be safe in all laminae studied. Conclusions Crossing C-2 translaminar screws have been reported to be safe and effective. In addition to morphometric characteristics, the authors have found that screws placed in this trajectory could jeopardize the vertebral arteries in the foramen transversarium or the C1–2 interval. A C-2 translaminar screw limited to 28 mm in length appeared to be safe in all 100 screw trajectories studied in this series.

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Arteriovenous fistula as a complication of C1–2 transarticular screw fixation

Journal of Neurosurgery ◽

10.3171/jns.1996.85.2.0340 ◽

1996 ◽

Vol 85 (2) ◽

pp. 340-343 ◽

Cited By ~ 99

Author(s):

Domagoj Coric ◽

Charles L. Branch ◽

John A. Wilson ◽

James C. Robinson

Keyword(s):

Vertebral Artery ◽

Arteriovenous Fistula ◽

Screw Fixation ◽

Atlantoaxial Instability ◽

Unusual Complication ◽

Venous Plexus ◽

Fixation Technique ◽

Transarticular Screw ◽

Content Type ◽

Transarticular Fixation

✓ A case is reported of a vertebral artery-to-epidural venous plexus fistula as a complication of posterior atlantoaxial facet screw fixation. The use of transarticular screws to stabilize the C1–2 joint has become an increasingly popular fixation technique, most notably for atlantoaxial instability due to trauma or rheumatoid disease. Despite the fact that this approach is technically challenging, there have been few reports of complications associated with C1–2 transarticular fixation. Although damage to the vertebral artery is a documented hazard of transarticular fixation at this level, a symptomatic arteriovenous fistula resulting from the procedure has not been described previously. The etiology, presentation, and treatment of this unusual complication are discussed.

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