Vertebral artery injury in C1–2 transarticular screw fixation: results of a survey of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves

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Object. The 847 active members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Section on Disorders of the Spine and Peripheral Nerves were surveyed to quantitate the risk of vertebral artery (VA) injury during C1–2 transarticular screw placement.

Methods. This retrospective study elicited the number of patients treated with transarticular screws, the number of screws placed, the incidence of VA injury and subsequent neurological deficit, and the management of known or suspected VA injury.

Two hundred thirteen (25.1%) of the 847 surgeons responded. One hundred one respondents (47.4%) had placed a total of 2492 C1–2 transarticular screws in 1318 patients. Thirty-one patients (2.4%) had known VA injuries and an additional 23 patients (1.7%) were suspected of having injuries. However, only two (3.7%) of the 54 patients with known or suspected VA injuries exhibited subsequent neurological deficits and only one (1.9%) died of bilateral VA injury. Other iatrogenic complications included dural tears, screw fractures, screw breakout, fusion failure, infection, and suboccipital numbness.

Conclusions. Including both known and suspected cases, the risk of VA injury was 4.1% per patient or 2.2% per screw inserted. The risk of neurological deficit from VA injury was 0.2% per patient or 0.1% per screw, and the mortality rate was 0.1%. The choice of management of intraoperative VA injuries was evenly divided between placing the patient under observation and initiating immediate postoperative angiography with possible balloon occlusion.

Article Information

Address reprint requests to: Carl Lauryssen, M.D., Department of Neurosurgery, Washington University School of Medicine, Campus Box 8057, 660 South Euclid Avenue, St. Louis, Missouri 63110.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Lateral radiograph revealing atlantoaxial stabilization with bilateral transarticular screws supplemented by Sonntag's modified Gallie fusion.

  • View in gallery

    Anteroposterior radiograph demonstrating atlantoaxial stabilization with bilateral transarticular screws supplemented by Sonntag's modified Gallie fusion.

  • View in gallery

    Illustration (lateral perspective) of the atlantoaxial complex, with transarticular screws in place, showing the proximity of the screw to the transverse foramen of both the atlas and axis.

  • View in gallery

    Illustration (anteroposterior perspective) displaying the atlantoaxial complex. The transarticular screws are situated immediately medial to the VA groove.

References

  • 1.

    Apfelbaum RI: Screw fixation of the upper cervical spine: indications and techniques. Contemp Neurosurg 16:181994Apfelbaum RI: Screw fixation of the upper cervical spine: indications and techniques. Contemp Neurosurg 16:1–8 1994

  • 2.

    Aymard AGobin YPHodes JEet al: Endovascular occlusion of vertebral arteries in the treatment of unclippable vertebrobasilar aneurysms. J Neurosurg 74:3933981991Aymard A Gobin YP Hodes JE et al: Endovascular occlusion of vertebral arteries in the treatment of unclippable vertebrobasilar aneurysms. J Neurosurg 74:393–398 1991

  • 3.

    Böhler J: Anterior stabilization for acute fractures and non-unions of the dens. J Bone Joint Surg (Am) 64:18271982Böhler J: Anterior stabilization for acute fractures and non-unions of the dens. J Bone Joint Surg (Am) 64:18–27 1982

  • 4.

    Brooks ALJenkins EB: Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg (Am) 60:2792841978Brooks AL Jenkins EB: Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg (Am) 60:279–284 1978

  • 5.

    Coric DBranch CL JrWilson JAet al: Arteriovenous fistula as a complication of C1–2 transarticular screw fixation. Case report and review of the literature. J Neurosurg 85:3403431996Coric D Branch CL Jr Wilson JA et al: Arteriovenous fistula as a complication of C1–2 transarticular screw fixation. Case report and review of the literature. J Neurosurg 85:340–343 1996

  • 6.

    Coyne TJFehlings MGWallace MCet al: C1–C2 posterior cervical fusion: long-term evaluation for results and efficacy. Neurosurgery 37:6886931995Coyne TJ Fehlings MG Wallace MC et al: C1–C2 posterior cervical fusion: long-term evaluation for results and efficacy. Neurosurgery 37:688–693 1995

  • 7.

    Dickman CASonntag VKHPapadopoulos SMet al: The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg 74:1901981991Dickman CA Sonntag VKH Papadopoulos SM et al: The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg 74:190–198 1991

  • 8.

    Dull STToselli RM: Preoperative oblique axial computed tomographic imaging for C1–C2 transarticular screw fixation: technical note. Neurosurg 37:1501521995Dull ST Toselli RM: Preoperative oblique axial computed tomographic imaging for C1–C2 transarticular screw fixation: technical note. Neurosurg 37:150–152 1995

  • 9.

    Fried LC: Atlanto-axial fracture-dislocations. Failure of posterior C.1 to C.2 fusion. J Bone Joint Surg (Br) 55:4904961973Fried LC: Atlanto-axial fracture-dislocations. Failure of posterior C.1 to C.2 fusion. J Bone Joint Surg (Br) 55:490–496 1973

  • 10.

    Gallie WE: Fractures and dislocations of the cervical spine. Am J Surg 46:4954991939Gallie WE: Fractures and dislocations of the cervical spine. Am J Surg 46:495–499 1939

  • 11.

    Golfinos JGDickman CAZabramski JMet al: Repair of vertebral artery injury during anterior cervical decompression. Spine 19:255225561994Golfinos JG Dickman CA Zabramski JM et al: Repair of vertebral artery injury during anterior cervical decompression. Spine 19:2552–2556 1994

  • 12.

    Golueke PSclafani SPhillips Tet al: Vertebral artery injury—diagnosis and management. J Trauma 27:8568651987Golueke P Sclafani S Phillips T et al: Vertebral artery injury—diagnosis and management. J Trauma 27:856–865 1987

  • 13.

    Grob DCrisco JJ IIIPanjabi MMet al: Biomechanical evaluation of four different posterior atlantoaxial fixation techniques. Spine 17:4804901992Grob D Crisco JJ III Panjabi MM et al: Biomechanical evaluation of four different posterior atlantoaxial fixation techniques. Spine 17:480–490 1992

  • 14.

    Grob DJeanneret BAebi Met al: Atlanto-axial fusion with transarticular screw fixation. J Bone Joint Surg (Br) 73:9729761991Grob D Jeanneret B Aebi M et al: Atlanto-axial fusion with transarticular screw fixation. J Bone Joint Surg (Br) 73:972–976 1991

  • 15.

    Halbach VVHigashida RTDowd CFet al: Endovascular treatment of vertebral artery dissections and pseudoaneurysms. J Neurosurg 79:1831911993Halbach VV Higashida RT Dowd CF et al: Endovascular treatment of vertebral artery dissections and pseudoaneurysms. J Neurosurg 79:183–191 1993

  • 16.

    Hanson PBMontesano PXSharkey NAet al: Anatomic and biomechanical assessment of transarticular screw fixation for atlantoaxial instability. Spine 16:114111451991Hanson PB Montesano PX Sharkey NA et al: Anatomic and biomechanical assessment of transarticular screw fixation for atlantoaxial instability. Spine 16:1141–1145 1991

  • 17.

    Higashida RTHalbach VVTsai FYet al: Interventional neurovascular treatment of traumatic carotid and vertebral artery lesions: results in 234 cases. AJR 153:5775821989Higashida RT Halbach VV Tsai FY et al: Interventional neurovascular treatment of traumatic carotid and vertebral artery lesions: results in 234 cases. AJR 153:577–582 1989

  • 18.

    Holness ROHuestis WSHowes WJet al: Posterior stabilization with an interlaminar clamp in cervical injuries: technical note and review of the long term experience with the method. Neurosurgery 14:3183221984Holness RO Huestis WS Howes WJ et al: Posterior stabilization with an interlaminar clamp in cervical injuries: technical note and review of the long term experience with the method. Neurosurgery 14:318–322 1984

  • 19.

    Jeanneret BMagerl F: Primary posterior fusion C1–2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord 5:4644751992Jeanneret B Magerl F: Primary posterior fusion C1–2 in odontoid fractures: indications technique and results of transarticular screw fixation. J Spinal Disord 5:464–475 1992

  • 20.

    Madawi AACasey ATHSolanki GAet al: Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg 86:9619681997Madawi AA Casey ATH Solanki GA et al: Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg 86:961–968 1997

  • 21.

    Magerl FSeemann PS: Stable posterior fusion of the atlas and axis by transarticular screw fixation in Kehr PWeidner A (eds): Cervical Spine I. Vienna: Springer-Verlag1987 pp 322327Magerl F Seemann PS: Stable posterior fusion of the atlas and axis by transarticular screw fixation in Kehr P Weidner A (eds): Cervical Spine I. Vienna: Springer-Verlag 1987 pp 322–327

  • 22.

    Marcotte PDickman CASonntag VKHet al: Posterior atlantoaxial facet screw fixation. J Neurosurg 79:2342371993Marcotte P Dickman CA Sonntag VKH et al: Posterior atlantoaxial facet screw fixation. J Neurosurg 79:234–237 1993

  • 23.

    Mixter SJOsgood RB: Traumatic lesions of the atlas and axis. Ann Surg 51:1932071910Mixter SJ Osgood RB: Traumatic lesions of the atlas and axis. Ann Surg 51:193–207 1910

  • 24.

    Panjabi MDvorak JDuranceau Jet al: Three-dimensional movements of the upper cervical spine. Spine 13:7267301988Panjabi M Dvorak J Duranceau J et al: Three-dimensional movements of the upper cervical spine. Spine 13:726–730 1988

  • 25.

    Paramore CGDickman CASonntag VKH: The anatomic suitability of the C1–2 complex for transarticular screw fixation. J Neurosurg 85:2212241996Paramore CG Dickman CA Sonntag VKH: The anatomic suitability of the C1–2 complex for transarticular screw fixation. J Neurosurg 85:221–224 1996

  • 26.

    Steinberg GKDrake CGPeerless SJ: Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients. J Neurosurg 79:1611731993Steinberg GK Drake CG Peerless SJ: Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients. J Neurosurg 79:161–173 1993

  • 27.

    Stillerman CBWilson JA: Atlanto-axial stabilization with posterior transarticular screw fixation: technical description and report of 22 cases. Neurosurgery 32:9489551993Stillerman CB Wilson JA: Atlanto-axial stabilization with posterior transarticular screw fixation: technical description and report of 22 cases. Neurosurgery 32:948–955 1993

  • 28.

    Taveras JMWood EH: Diagnostic Neuroradiologyed 2. Baltimore: Williams & Wilkins1976Taveras JM Wood EH: Diagnostic Neuroradiology ed 2. Baltimore: Williams & Wilkins 1976

  • 29.

    Tokuda KMiyasaka KAbe Het al: Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:4104131985Tokuda K Miyasaka K Abe H et al: Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:410–413 1985

  • 30.

    Welch WCSubach BRPollack IFet al: Frameless stereotactic guidance for surgery of the upper cervical spine. Neurosurgery 40:9589641997Welch WC Subach BR Pollack IF et al: Frameless stereotactic guidance for surgery of the upper cervical spine. Neurosurgery 40:958–964 1997

  • 31.

    Yee LFOlcott EWKnudson MMet al: Extraluminal, transluminal, and observational treatment for vertebral artery injuries. J Trauma 39:4804861995Yee LF Olcott EW Knudson MM et al: Extraluminal transluminal and observational treatment for vertebral artery injuries. J Trauma 39:480–486 1995

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