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, Bradáč 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.	王建华, 尹庆水, 夏虹, 等. 枢椎椎动脉孔解剖分型与椎弓根置钉关系的研究. 中国脊柱脊髓杂志, 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.	黄学良, 朱双芳, 林雨聪, 等. 三维重建CT血管造影在C_1-2水平椎动脉变异诊断中的价值. 中国脊柱脊髓杂志, 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.	吴益奇, 黄春辉, 卢海川, 等. 福建闽西地区颈寰椎同侧弓状孔和椎动脉高跨的发生率及其临床意义. 中外医疗, 2017, 36(17): 87-89.
19.	张艳, 刘溢, 王晓华. 椎动脉CT血管造影多平面重组在枢椎椎弓根置钉中的价值. 中国脊柱脊髓杂志, 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, Żyłka 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.	赵国权, 姚书眈, 陆廷盛, 等. 枢椎椎板螺钉固定技术在椎动脉高跨手术患者中的应用. 齐齐哈尔医学院学报, 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, 张嘉男, 陈浩, 等. 3D打印导板辅助椎动脉高跨患者C₂椎弓根螺钉置入的临床研究. 中国脊柱脊髓杂志, 2020, 30(4): 323-330.
26.	高延征, 高坤, 余正红, 等. “in-out-in”多皮质枢椎椎弓根螺钉在寰枢椎脱位或不稳后路手术中的应用. 中国脊柱脊髓杂志, 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.	吴超, 邓佳燕, 谭伦, 等. 逐级扩大型3D打印导板系统辅助寰枢椎椎弓根植钉准确性分析及临床应用. 中国修复重建外科杂志, 2019, 33(2): 212-218.
29.	王华栋, 何达, 刘波, 等. 术中即时三维导航辅助寰枢椎经关节螺钉固定治疗寰枢椎不稳定. 中华骨科杂志, 2019, 39(21): 1311-1319.
30.	田伟, 王晋超, 刘亚军, 等. 上颈椎手术方式回顾及应用机器人辅助上颈椎手术的体会. 中国医疗器械信息, 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, Bradáč 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. 王建华, 尹庆水, 夏虹, 等. 枢椎椎动脉孔解剖分型与椎弓根置钉关系的研究. 中国脊柱脊髓杂志, 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. 黄学良, 朱双芳, 林雨聪, 等. 三维重建CT血管造影在C_1-2水平椎动脉变异诊断中的价值. 中国脊柱脊髓杂志, 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. 吴益奇, 黄春辉, 卢海川, 等. 福建闽西地区颈寰椎同侧弓状孔和椎动脉高跨的发生率及其临床意义. 中外医疗, 2017, 36(17): 87-89.
19. 张艳, 刘溢, 王晓华. 椎动脉CT血管造影多平面重组在枢椎椎弓根置钉中的价值. 中国脊柱脊髓杂志, 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, Żyłka 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. 赵国权, 姚书眈, 陆廷盛, 等. 枢椎椎板螺钉固定技术在椎动脉高跨手术患者中的应用. 齐齐哈尔医学院学报, 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, 张嘉男, 陈浩, 等. 3D打印导板辅助椎动脉高跨患者C₂椎弓根螺钉置入的临床研究. 中国脊柱脊髓杂志, 2020, 30(4): 323-330.
26. 高延征, 高坤, 余正红, 等. “in-out-in”多皮质枢椎椎弓根螺钉在寰枢椎脱位或不稳后路手术中的应用. 中国脊柱脊髓杂志, 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. 吴超, 邓佳燕, 谭伦, 等. 逐级扩大型3D打印导板系统辅助寰枢椎椎弓根植钉准确性分析及临床应用. 中国修复重建外科杂志, 2019, 33(2): 212-218.
29. 王华栋, 何达, 刘波, 等. 术中即时三维导航辅助寰枢椎经关节螺钉固定治疗寰枢椎不稳定. 中华骨科杂志, 2019, 39(21): 1311-1319.
30. 田伟, 王晋超, 刘亚军, 等. 上颈椎手术方式回顾及应用机器人辅助上颈椎手术的体会. 中国医疗器械信息, 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