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.
ABBREVIATIONSVA = vertebral artery; VAI = vertebral artery injury.
Correspondence Giorgio Lofrese: “M. Bufalini” Hospital, Cesena, Italy. firstname.lastname@example.org.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.
BourdillonPPerrinGLucasFDebargeRBarreyC: C1-C2 stabilization by Harms arthrodesis: indications, technique, complications and outcomes in a prospective 26-case series. Orthop Traumatol Surg Res100:221–2272014
CoricD, BranchCLJr, WilsonJA, RobinsonJC: Arteriovenous fistula as a complication of C1-2 transarticular screw fixation. Case report and review of the literature. 85:340–343, 199610.3171/jns.1996.85.2.03408755766)| false
GautschiOPPayerMCorniolaMVSmollNRSchallerKTessitoreE: Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management. Clin Neurol Neurosurg123:131–1352014
GautschiOP, PayerM, CorniolaMV, SmollNR, SchallerK, TessitoreE: Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management. 123:131–135, 201410.1016/j.clineuro.2014.05.02025012025)| false
HongJTLeeSWSonBCSungJHYangSHKimIS: Analysis of anatomical variations of bone and vascular structures around the posterior atlantal arch using three-dimensional computed tomography angiography. J Neurosurg Spine8:230–2362008
HongJT, LeeSW, SonBC, SungJH, YangSH, KimIS, : Analysis of anatomical variations of bone and vascular structures around the posterior atlantal arch using three-dimensional computed tomography angiography. 8:230–236, 20081831207410.3171/SPI/2008/8/3/230)| false
JacobsC, RoesslerPP, ScheidtS, PlögerMM, JacobsC, DischAC, : When does intraoperative 3D-imaging play a role in transpedicular C2 screw placement?48:2522–2528, 20172891202210.1016/j.injury.2017.09.008)| false
LauSWSunLKLaiRLukMSNgYSWongNM: 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)35:1136–11432010
LauSW, SunLK, LaiR, LukMS, NgYS, WongNM, : 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. 35:1136–1143, 201010.1097/BRS.0b013e3181bb4f2120118834)| false
MuellerCA, RoesselerL, PodlogarM, KovacsA, KristofRA: Accuracy and complications of transpedicular C2 screw placement without the use of spinal navigation. 19:809–814, 20102014046510.1007/s00586-010-1291-3)| false
PatkarSV: New entry point for C2 screw, in posterior C1-C2 fixation (Goel-Harm’s technique) significantly reducing the possibility of vertebral artery injury. 38:93–97, 201610.1080/01616412.2015.110558227118605)| false
RashimK, Verma PawanK, SinhaVD: Increasing the safety of surgical treatment for complex cranio-vertebral anomalies using customized 3D printed models. 48:203–208, 201810.1016/j.jocn.2017.10.06129129522)| false
TerterovSTaghvaAKhalessiAAHsiehPC: 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:E678–E6812011
TerterovS, TaghvaA, KhalessiAA, HsiehPC: Symptomatic vertebral artery compression by the rod of a C1-C2 posterior fusion construct: case report and review of the literature. 36:E678–E681, 201110.1097/BRS.0b013e3181faa6de)| false
VaněkPBradáčOde LacyPKonopkováRLacmanJBenešV: 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 Rev40:369–3762017
VaněkP, BradáčO, de LacyP, KonopkováR, LacmanJ, BenešV: 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. 40:369–376, 20172762378310.1007/s10143-016-0784-x)| false
WhitmoreRGSimonSLHurstRWNisenbaumHLKasnerSEZagerEL: Bow hunter’s syndrome caused by accessory cervical ossification: posterolateral decompression and the use of intraoperative Doppler ultrasonography. Surg Neurol67:169–1712007