The effect of axis pedicle and intra-axial vertebral artery on C<sub>2</sub> pedicle screw placement_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WU Fan , LI Hong , WAN Shengyu , GAO Tao , HU Haigang ,  LIN Xu , ZHONG Zeli , ZENG Jun , WU Chao , TAN Lun

Department of Spine and Trauma Surgery, Zigong Fourth People’s Hospital, Zigong Sichuan, 643000, P. R. China;

Corresponding?author：

LIN Xu, Email: med_linxu@163.com

Keywords：

Axis pedicle; intra-axial vertebral artery; pedicle screw placement; CT angiography

DOI：

10.7507/1002-1892.202202008

Video：

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Objective To investigate the influence of axis pedicle and intra-axial vertebral artery (IAVA) alignment on C₂ pedicle screw placement by measuring the data of head and neck CT angiography. Methods The axis pedicle diameter (D), isthmus height (H), isthmus thickness (T), and IAVA alignment types were measured in 116 patients (232 sides) who underwent head and neck CT angiography examinations between January 2020 and June 2020. Defined the IAVA offset direction by referencing the vertical line through the center of C₃ transverse foramen on the coronal scan, it was divided into lateral (L), neutral (N), and medial (M). Defined the IAVA high-riding degree by referencing the horizontal line through the outlet of the C₂ transverse foramen, it was divided into below (B), within (W), and above (A). The rate of pedicle stenosis, high-riding vertebral artery, and different IAVA types were calculated, and their relationships were analysed. Simulative C₂ pedicle screws were implanted by Mimics 19.0 software, and the interrelation among the rates of pedicle stenosis, high-riding vertebral artery, IAVA types, and vertebral artery injury were analyzed. Results The rate of C₂ pedicle stenosis was 33.6% (78/232), and the rate of high-riding vertebral artery was 35.3% (82/232). According to the offset direction and the degree of riding, IAVA was divided into 9 types, among which the N-W type (29.3%) was the most, followed by the L-W type (19.0%) and the L-B type (12.9%), accounting for 60.9%. The vertebral artery injury rate of simulative implanted C₂ pedicle screws was 35.3% (82/232). The vertebral artery injury rate in patients with pedicle stenosis and high-riding vertebral artery was significantly higher than that who were not (P<0.001). The rate of pedicle stenosis, high-riding vertebral artery, and vertebral artery injury were significantly different among IAVA types (P<0.001), and M-A type was the most common. Conclusion Vertebral artery injury is more common in pedicle stenosis and/or high-riding vertebral artery and/or IAVA M-A type. Preoperative head and neck CT angiography examination has clinical guiding significance.

Citation： WU Fan, LI Hong, WAN Shengyu, GAO Tao, HU Haigang, LIN Xu, ZHONG Zeli, ZENG Jun, WU Chao, TAN Lun. The effect of axis pedicle and intra-axial vertebral artery on C₂ pedicle screw placement. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(7): 866-872. doi: 10.7507/1002-1892.202202008 Copy

1.	Xu S, Ruan S, Song X, et al. Evaluation of vertebral artery anomaly in basilar invagination and prevention of vascular injury during surgical intervention: CTA features and analysis. Eur Spine J, 2018, 27(6): 1286-1294.
2.	Wang Y, Wang C, Yan M. Clinical outcomes of atlantoaxial dislocation combined with high-riding vertebral artery using C₂ translaminar screws. World Neurosurg, 2019, 122: e1511-e1518.
3.	Vaněk P, Bradá? O, de Lacy P, et al. Vertebral artery and osseous anomalies characteristic at the craniocervical junction diagnosed by CT and 3D CT angiography in normal Czech population: analysis of 511 consecutive patients. Neurosurg Rev, 2017, 40(3): 369-376.
4.	Shimizu T, Koda M, Abe T, et al. Correlation between osteoarthritis of the atlantoaxial facet joint and a high-riding vertebral artery. BMC Musculoskelet Disord, 2021, 22(1): 406. doi: 10.1186/s12891-021-04275-9.
5.	Wright NM, Lauryssen C. Vertebral artery injury in C_1-2 transarticular screw fixation: results of a survey of the AANS/CNS section on disorders of the spine and peripheral nerves. American association of neurological surgeons/congress of neurological surgeons. J Neurosurg, 1998, 88(4): 634-640.
6.	Madawi AA, Casey AT, Solanki GA, et al. Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg, 1997, 86(6): 961-968.
7.	王建華, 尹慶水, 夏虹, 等. 樞椎椎動脈孔解剖分型與椎弓根置釘關系的研究. 中國脊柱脊髓雜志, 2006, 16(9): 677-680.
8.	Lee SH, Park DH, Kim SD, et al. Analysis of 3-dimensional course of the intra-axial vertebral artery for C₂ pedicle screw trajectory: a computed tomographic study. Spine (Phila Pa 1976), 2014, 39(17): E1010-E1014.
9.	Klepinowski T, Pala B, Cembik J, et al. Prevalence of high-riding vertebral artery: A meta-analysis of the anatomical variant affecting choice of craniocervical fusion method and its outcome. World Neurosurg, 2020, 143: e474-e481.
10.	黃學良, 朱雙芳, 林雨聰, 等. 三維重建CT血管造影在C_1-2水平椎動脈變異診斷中的價值. 中國脊柱脊髓雜志, 2018, 28(4): 315-319.
11.	Chen Q, Brahimaj BC, Khanna R, et al. Posterior atlantoaxial fusion: a comprehensive review of surgical techniques and relevant vascular anomalies. J Spine Surg, 2020, 6(1): 164-180.
12.	Maki S, Koda M, Iijima Y, et al. Medially-shifted rather than high-riding vertebral arteries preclude safe pedicle screw insertion. J Clin Neurosci, 2016, 29: 169-172.
13.	Neo M, Matsushita M, Iwashita Y, et al. Atlantoaxial transarticular screw fixation for a high-riding vertebral artery. Spine (Phila Pa 1976), 2003, 28(7): 666-670.
14.	Bloch O, Holly LT, Park J, et al. Effect of frameless stereotaxy on the accuracy of C_1-2 transarticular screw placement. J Neurosurg, 2001, 95(1 Suppl): 74-79.
15.	Wakao N, Takeuchi M, Nishimura M, et al. Vertebral artery variations and osseous anomaly at the C_1-2level diagnosed by 3D CT angiography in normal subjects. Neuroradiology, 2014, 56(10): 843-849.
16.	Chin KR, Mills MV, Seale J, et al. Ideal starting point and trajectory for C₂ pedicle screw placement: a 3D computed tomography analysis using perioperative measurements. Spine J, 2014, 14(4): 615-618.
17.	Chiapparelli E, Bowen E, Okano I, et al. Spinal cord medial safe zone for C₂ pedicle instrumentation: An MRI measurement analysis. Spine (Phila Pa 1976), 2022, 47(3): E101-E106.
18.	吳益奇, 黃春輝, 盧海川, 等. 福建閩西地區頸寰椎同側弓狀孔和椎動脈高跨的發生率及其臨床意義. 中外醫療, 2017, 36(17): 87-89.
19.	張艷, 劉溢, 王曉華. 椎動脈CT血管造影多平面重組在樞椎椎弓根置釘中的價值. 中國脊柱脊髓雜志, 2014, (3): 217-221.
20.	Li T, Yin YH, Qiao GY, et al. Three-dimensional evaluation and classification of the anatomy variations of vertebral artery at the craniovertebral junction in 120 patients of basilar invagination and atlas occipitalization. Oper Neurosurg (Hagerstown), 2019, 17(6): 594-602.
21.	Klepinowski T, ?y?ka N, Pala B, et al. Prevalence of high-riding vertebral arteries and narrow C₂ pedicles among Central-European population: a computed tomography-based study. Neurosurg Rev, 2021, 44(6): 3277-3282.
22.	趙國權, 姚書眈, 陸廷盛, 等. 樞椎椎板螺釘固定技術在椎動脈高跨手術患者中的應用. 齊齊哈爾醫學院學報, 2020, 41(14): 1770-1772.
23.	Lau SW, Sun LK, Lai R, et al. Study of the anatomical variations of vertebral artery in C₂ vertebra with magnetic resonance imaging and its application in the C₁-C₂ transarticular screw fixation. Spine (Phila Pa 1976), 2010, 35(11): 1136-1143.
24.	Sanelli PC, Tong S, Gonzalez RG, et al. Normal variation of vertebral artery on CT angiography and its implications for diagnosis of acquired pathology. J Comput Assist Tomogr, 2002, 26(3): 462-470.
25.	田野, 張嘉男, 陳浩, 等. 3D打印導板輔助椎動脈高跨患者C₂椎弓根螺釘置入的臨床研究. 中國脊柱脊髓雜志, 2020, 30(4): 323-330.
26.	高延征, 高坤, 余正紅, 等. “in-out-in”多皮質樞椎椎弓根螺釘在寰樞椎脫位或不穩后路手術中的應用. 中國脊柱脊髓雜志, 2017, 27(1): 55-60.
27.	Goel A, Prasad A, Shah A, et al. Transarticular fixation following mobilization of “high-riding” vertebral artery. Oper Neurosurg (Hagerstown), 2021, 20(4): E322-E325.
28.	吳超, 鄧佳燕, 譚倫, 等. 逐級擴大型3D打印導板系統輔助寰樞椎椎弓根植釘準確性分析及臨床應用. 中國修復重建外科雜志, 2019, 33(2): 212-218.
29.	王華棟, 何達, 劉波, 等. 術中即時三維導航輔助寰樞椎經關節螺釘固定治療寰樞椎不穩定. 中華骨科雜志, 2019, 39(21): 1311-1319.
30.	田偉, 王晉超, 劉亞軍, 等. 上頸椎手術方式回顧及應用機器人輔助上頸椎手術的體會. 中國醫療器械信息, 2017, 23(7): 9-13.
31.	Kothari MK, Dalvie SS, Gupta S, et al. The C₂ pedicle width, pars length, and laminar thickness in concurrent ipsilateral ponticulus posticus and high-riding vertebral artery: A radiological computed tomography scan-based study. Asian Spine J, 2019, 13(2): 290-295.
32.	Goel A, Rangnekar R, Shah A, et al. Mobilization of the vertebral artery-surgical option for C₂ screw fixation in cases with “high riding” vertebral artery. Oper Neurosurg (Hagerstown), 2020, 18(6): 648-651.
33.	Salunke P, Singh A, Karthigeyan M. Technique of C₂ subfacetal screw in patients with high-riding vertebral artery. World Neurosurg, 2020, 144: 59. doi: 10.1016/j.wneu.2020.08.045.

1. Xu S, Ruan S, Song X, et al. Evaluation of vertebral artery anomaly in basilar invagination and prevention of vascular injury during surgical intervention: CTA features and analysis. Eur Spine J, 2018, 27(6): 1286-1294.
2. Wang Y, Wang C, Yan M. Clinical outcomes of atlantoaxial dislocation combined with high-riding vertebral artery using C₂ translaminar screws. World Neurosurg, 2019, 122: e1511-e1518.
3. Vaněk P, Bradá? O, de Lacy P, et al. Vertebral artery and osseous anomalies characteristic at the craniocervical junction diagnosed by CT and 3D CT angiography in normal Czech population: analysis of 511 consecutive patients. Neurosurg Rev, 2017, 40(3): 369-376.
4. Shimizu T, Koda M, Abe T, et al. Correlation between osteoarthritis of the atlantoaxial facet joint and a high-riding vertebral artery. BMC Musculoskelet Disord, 2021, 22(1): 406. doi: 10.1186/s12891-021-04275-9.
5. Wright NM, Lauryssen C. Vertebral artery injury in C_1-2 transarticular screw fixation: results of a survey of the AANS/CNS section on disorders of the spine and peripheral nerves. American association of neurological surgeons/congress of neurological surgeons. J Neurosurg, 1998, 88(4): 634-640.
6. Madawi AA, Casey AT, Solanki GA, et al. Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg, 1997, 86(6): 961-968.
7. 王建華, 尹慶水, 夏虹, 等. 樞椎椎動脈孔解剖分型與椎弓根置釘關系的研究. 中國脊柱脊髓雜志, 2006, 16(9): 677-680.
8. Lee SH, Park DH, Kim SD, et al. Analysis of 3-dimensional course of the intra-axial vertebral artery for C₂ pedicle screw trajectory: a computed tomographic study. Spine (Phila Pa 1976), 2014, 39(17): E1010-E1014.
9. Klepinowski T, Pala B, Cembik J, et al. Prevalence of high-riding vertebral artery: A meta-analysis of the anatomical variant affecting choice of craniocervical fusion method and its outcome. World Neurosurg, 2020, 143: e474-e481.
10. 黃學良, 朱雙芳, 林雨聰, 等. 三維重建CT血管造影在C_1-2水平椎動脈變異診斷中的價值. 中國脊柱脊髓雜志, 2018, 28(4): 315-319.
11. Chen Q, Brahimaj BC, Khanna R, et al. Posterior atlantoaxial fusion: a comprehensive review of surgical techniques and relevant vascular anomalies. J Spine Surg, 2020, 6(1): 164-180.
12. Maki S, Koda M, Iijima Y, et al. Medially-shifted rather than high-riding vertebral arteries preclude safe pedicle screw insertion. J Clin Neurosci, 2016, 29: 169-172.
13. Neo M, Matsushita M, Iwashita Y, et al. Atlantoaxial transarticular screw fixation for a high-riding vertebral artery. Spine (Phila Pa 1976), 2003, 28(7): 666-670.
14. Bloch O, Holly LT, Park J, et al. Effect of frameless stereotaxy on the accuracy of C_1-2 transarticular screw placement. J Neurosurg, 2001, 95(1 Suppl): 74-79.
15. Wakao N, Takeuchi M, Nishimura M, et al. Vertebral artery variations and osseous anomaly at the C_1-2level diagnosed by 3D CT angiography in normal subjects. Neuroradiology, 2014, 56(10): 843-849.
16. Chin KR, Mills MV, Seale J, et al. Ideal starting point and trajectory for C₂ pedicle screw placement: a 3D computed tomography analysis using perioperative measurements. Spine J, 2014, 14(4): 615-618.
17. Chiapparelli E, Bowen E, Okano I, et al. Spinal cord medial safe zone for C₂ pedicle instrumentation: An MRI measurement analysis. Spine (Phila Pa 1976), 2022, 47(3): E101-E106.
18. 吳益奇, 黃春輝, 盧海川, 等. 福建閩西地區頸寰椎同側弓狀孔和椎動脈高跨的發生率及其臨床意義. 中外醫療, 2017, 36(17): 87-89.
19. 張艷, 劉溢, 王曉華. 椎動脈CT血管造影多平面重組在樞椎椎弓根置釘中的價值. 中國脊柱脊髓雜志, 2014, (3): 217-221.
20. Li T, Yin YH, Qiao GY, et al. Three-dimensional evaluation and classification of the anatomy variations of vertebral artery at the craniovertebral junction in 120 patients of basilar invagination and atlas occipitalization. Oper Neurosurg (Hagerstown), 2019, 17(6): 594-602.
21. Klepinowski T, ?y?ka N, Pala B, et al. Prevalence of high-riding vertebral arteries and narrow C₂ pedicles among Central-European population: a computed tomography-based study. Neurosurg Rev, 2021, 44(6): 3277-3282.
22. 趙國權, 姚書眈, 陸廷盛, 等. 樞椎椎板螺釘固定技術在椎動脈高跨手術患者中的應用. 齊齊哈爾醫學院學報, 2020, 41(14): 1770-1772.
23. Lau SW, Sun LK, Lai R, et al. Study of the anatomical variations of vertebral artery in C₂ vertebra with magnetic resonance imaging and its application in the C₁-C₂ transarticular screw fixation. Spine (Phila Pa 1976), 2010, 35(11): 1136-1143.
24. Sanelli PC, Tong S, Gonzalez RG, et al. Normal variation of vertebral artery on CT angiography and its implications for diagnosis of acquired pathology. J Comput Assist Tomogr, 2002, 26(3): 462-470.
25. 田野, 張嘉男, 陳浩, 等. 3D打印導板輔助椎動脈高跨患者C₂椎弓根螺釘置入的臨床研究. 中國脊柱脊髓雜志, 2020, 30(4): 323-330.
26. 高延征, 高坤, 余正紅, 等. “in-out-in”多皮質樞椎椎弓根螺釘在寰樞椎脫位或不穩后路手術中的應用. 中國脊柱脊髓雜志, 2017, 27(1): 55-60.
27. Goel A, Prasad A, Shah A, et al. Transarticular fixation following mobilization of “high-riding” vertebral artery. Oper Neurosurg (Hagerstown), 2021, 20(4): E322-E325.
28. 吳超, 鄧佳燕, 譚倫, 等. 逐級擴大型3D打印導板系統輔助寰樞椎椎弓根植釘準確性分析及臨床應用. 中國修復重建外科雜志, 2019, 33(2): 212-218.
29. 王華棟, 何達, 劉波, 等. 術中即時三維導航輔助寰樞椎經關節螺釘固定治療寰樞椎不穩定. 中華骨科雜志, 2019, 39(21): 1311-1319.
30. 田偉, 王晉超, 劉亞軍, 等. 上頸椎手術方式回顧及應用機器人輔助上頸椎手術的體會. 中國醫療器械信息, 2017, 23(7): 9-13.
31. Kothari MK, Dalvie SS, Gupta S, et al. The C₂ pedicle width, pars length, and laminar thickness in concurrent ipsilateral ponticulus posticus and high-riding vertebral artery: A radiological computed tomography scan-based study. Asian Spine J, 2019, 13(2): 290-295.
32. Goel A, Rangnekar R, Shah A, et al. Mobilization of the vertebral artery-surgical option for C₂ screw fixation in cases with “high riding” vertebral artery. Oper Neurosurg (Hagerstown), 2020, 18(6): 648-651.
33. Salunke P, Singh A, Karthigeyan M. Technique of C₂ subfacetal screw in patients with high-riding vertebral artery. World Neurosurg, 2020, 144: 59. doi: 10.1016/j.wneu.2020.08.045.

Chinese Journal of Reparative and Reconstructive Surgery

The effect of axis pedicle and intra-axial vertebral artery on C₂ pedicle screw placement

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The effect of axis pedicle and intra-axial vertebral artery on C₂ pedicle screw placement