Intraoperative Doppler ultrasound as a means of preventing vertebral artery injury during Goel and Harms C1–C2 posterior arthrodesis: technical note

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Vertebral artery injury (VAI) is a potential catastrophic complication of Goel and Harms C1–C2 posterior arthrodesis. Meticulous study of preoperative spinal CT angiography together with neuronavigation plays a fundamental role in avoiding VAI. Doppler ultrasonography may be an additional intraoperative tool, providing real-time identification of the vertebral artery (VA) and thus helping its preservation.

Thirty-three consecutive patients with unstable odontoid fractures underwent Goel and Harms C1–C2 posterior arthrodesis. Surgery was performed with the aid of lateral fluoroscopic control in 16 cases (control group) that was supplemented by Doppler ultrasonography in 17 cases (Doppler group). Two patients in each group had a C1 ponticulus posticus. In the Doppler group, Doppler probing was performed during lateral subperiosteal muscle dissection, stepwise drilling, and tapping. Blood flow velocity in the V3 segment of the VA was recorded before and after posterior arthrodesis. All patients had a 12-month outpatient follow-up, and outcome was assessed using the Smiley-Webster Pain Scale. Neither VAI nor postoperative neurological impairments were observed in the Doppler group. In the control group, VAIs occurred in the 2 patients with C1 ponticulus posticus. In the Doppler group, 1 patient needed intra- and postoperative blood transfusions, and no difference in terms of Doppler signal or VA blood flow velocity was detected before and after C1–C2 posterior arthrodesis. In the control group, 3 patients needed intra- and postoperative blood transfusions.

Useful in supporting fluoroscopy-assisted procedures, intraoperative Doppler may play a significant role even during surgeries in which neuronavigation is used, reducing the chance of a mismatch between the view on the neuronavigation screen and the actual course of the VA in the operative field and supplying the additional data of blood flow velocity.

ABBREVIATIONS VA = vertebral artery; VAI = vertebral artery injury.
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Contributor Notes

Correspondence Giorgio Lofrese: “M. Bufalini” Hospital, Cesena, Italy. giorgio.lofrese@gmail.com.INCLUDE WHEN CITING Published online August 16, 2019; DOI: 10.3171/2019.5.SPINE1959.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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  • 1

    Abtahi AMBrodke DSLawrence BD: Vertebral artery anomalies at the craniovertebral junction: a case report and review of the literature. Evid Based Spine Care J 5:1211252014

    • Search Google Scholar
    • Export Citation
  • 2

    Anderson LDD’Alonzo RT: Fractures of the odontoid process of the axis. J Bone Joint Surg Am 56:166316741974

  • 3

    Bourdillon PPerrin GLucas FDebarge RBarrey C: C1-C2 stabilization by Harms arthrodesis: indications, technique, complications and outcomes in a prospective 26-case series. Orthop Traumatol Surg Res 100:2212272014

    • Search Google Scholar
    • Export Citation
  • 4

    Coric DBranch CL JrWilson JARobinson JC: Arteriovenous fistula as a complication of C1-2 transarticular screw fixation. Case report and review of the literature. J Neurosurg 85:3403431996

    • Search Google Scholar
    • Export Citation
  • 5

    Elgafy HPompo FVela RElsamaloty HM: Ipsilateral arcuate foramen and high-riding vertebral artery: implication on C1-C2 instrumentation. Spine J 14:135113552014

    • Search Google Scholar
    • Export Citation
  • 6

    Finn MAApfelbaum RI: Atlantoaxial transarticular screw fixation: update on technique and outcomes in 269 patients. Neurosurgery 66 (3 Suppl):1841922010

    • Search Google Scholar
    • Export Citation
  • 7

    Gautschi OPPayer MCorniola MVSmoll NRSchaller KTessitore E: Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management. Clin Neurol Neurosurg 123:1311352014

    • Search Google Scholar
    • Export Citation
  • 8

    Harms JMelcher RP: Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976) 26:246724712001

  • 9

    Hong JTLee SWSon BCSung JHYang SHKim IS: Analysis of anatomical variations of bone and vascular structures around the posterior atlantal arch using three-dimensional computed tomography angiography. J Neurosurg Spine 8:2302362008

    • Search Google Scholar
    • Export Citation
  • 10

    Igarashi TKikuchi SSato KKayama SOtani K: Anatomic study of the axis for surgical planning of transarticular screw fixation. Clin Orthop Relat Res 408:1621662003

    • Search Google Scholar
    • Export Citation
  • 11

    Jacobs CRoessler PPScheidt SPlöger MMJacobs CDisch AC: When does intraoperative 3D-imaging play a role in transpedicular C2 screw placement? Injury 48:252225282017

    • Search Google Scholar
    • Export Citation
  • 12

    Lau SWSun LKLai RLuk MSNg YSWong NM: 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) 35:113611432010

    • Search Google Scholar
    • Export Citation
  • 13

    Molinari RWChimenti PCMolinari R JrGruhn W: Vertebral artery injury during routine posterior cervical exposure: case reports and review of literature. Global Spine J 5:5285322015

    • Search Google Scholar
    • Export Citation
  • 14

    Mueller CARoesseler LPodlogar MKovacs AKristof RA: Accuracy and complications of transpedicular C2 screw placement without the use of spinal navigation. Eur Spine J 19:8098142010

    • Search Google Scholar
    • Export Citation
  • 15

    Patkar SV: New entry point for C2 screw, in posterior C1-C2 fixation (Goel-Harm’s technique) significantly reducing the possibility of vertebral artery injury. Neurol Res 38:93972016

    • Search Google Scholar
    • Export Citation
  • 16

    Rashim KVerma Pawan KSinha VD: Increasing the safety of surgical treatment for complex cranio-vertebral anomalies using customized 3D printed models. J Clin Neurosci 48:2032082018

    • Search Google Scholar
    • Export Citation
  • 17

    Rath SAMoszko SSchäffner PMCantone GBraun VRichter HP: Accuracy of pedicle screw insertion in the cervical spine for internal fixation using frameless stereotactic guidance. J Neurosurg Spine 8:2372452008

    • Search Google Scholar
    • Export Citation
  • 18

    Roy-Camille RSaillant GJudet Tde Botton GMichel G: [Factors of severity in the fractures of the odontoid process (author’s transl).] Rev Chir Orthop Reparatrice Appar Mot 66:1831861980 (French)

    • Search Google Scholar
    • Export Citation
  • 19

    Sahoo SSalunke PGarg R: Unusual case of C2 subisthmic vertebral artery with atlantoaxial dislocation: persistent second cervical intersegmental artery. World Neurosurg 115:1541562018

    • Search Google Scholar
    • Export Citation
  • 20

    Schulz RMacchiavello NFernández ECarredano XGarrido ODiaz J: Harms C1-C2 instrumentation technique: anatomo-surgical guide. Spine (Phila Pa 1976) 36:9459502011

    • Search Google Scholar
    • Export Citation
  • 21

    Terterov STaghva AKhalessi AAHsieh PC: Symptomatic vertebral artery compression by the rod of a C1-C2 posterior fusion construct: case report and review of the literature. Spine (Phila Pa 1976) 36:E678E6812011

    • Search Google Scholar
    • Export Citation
  • 22

    Uchino ASaito NWatadani TOkada YKozawa ENishi N: Vertebral artery variations at the C1-2 level diagnosed by magnetic resonance angiography. Neuroradiology 54:19232012

    • Search Google Scholar
    • Export Citation
  • 23

    Vaněk PBradáč Ode Lacy PKonopková RLacman JBeneš V: 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 40:3693762017

    • Search Google Scholar
    • Export Citation
  • 24

    Wang XEichbaum EJian FChou D: Two-stage en bloc resection of multilevel cervical chordomas with vertebral artery preservation: operative technique. Oper Neurosurg (Hagerstown) 14:5385452018

    • Search Google Scholar
    • Export Citation
  • 25

    Weidner AWähler MChiu STUllrich CG: Modification of C1-C2 transarticular screw fixation by image-guided surgery. Spine (Phila Pa 1976) 25:266826742000

    • Search Google Scholar
    • Export Citation
  • 26

    Whitmore RGSimon SLHurst RWNisenbaum HLKasner SEZager EL: Bow hunter’s syndrome caused by accessory cervical ossification: posterolateral decompression and the use of intraoperative Doppler ultrasonography. Surg Neurol 67:1691712007

    • Search Google Scholar
    • Export Citation
  • 27

    Wong CWPoon WS: Far lateral approach with intraoperative ultrasound Doppler identification of the vertebral artery. Clin Neurol Neurosurg 101:2642671999

    • Search Google Scholar
    • Export Citation
  • 28

    Yeom JSBuchowski JMKim HJChang BSLee CKRiew KD: Risk of vertebral artery injury: comparison between C1-C2 transarticular and C2 pedicle screws. Spine J 13:7757852013

    • Search Google Scholar
    • Export Citation
  • 29

    Yeom JSBuchowski JMPark KWChang BSLee CKRiew KD: Undetected vertebral artery groove and foramen violations during C1 lateral mass and C2 pedicle screw placement. Spine (Phila Pa 1976) 33:E942E9492008

    • Search Google Scholar
    • Export Citation
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