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Table of Contents    
Year : 2015  |  Volume : 63  |  Issue : 6  |  Page : 1012

Authors' reply

Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication20-Nov-2015

Correspondence Address:
Sanjay Behari
Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Sardhara J, Behari S. Authors' reply. Neurol India 2015;63:1012

How to cite this URL:
Sardhara J, Behari S. Authors' reply. Neurol India [serial online] 2015 [cited 2022 Jul 1];63:1012. Available from: https://www.neurologyindia.com/text.asp?2015/63/6/1012/170117


We thank Salunke et al., for their insightful comments that have gone a long way in clarifying the management of these vertebral artery (VA) anomalies and has served to further highlight the clinical situations where the proposed classification will be useful.

It has been our experience that VA injury usually occurs during the soft tissue dissection for Cervical (C)1-2 joint exposure especially in the presence of torticollis and VA anomalies. It usually occurs when an additional effort has not been made to track its preoperative course using computed tomographic angiography or magnetic resonance imaging with angiography. It seldom occurs during the placement of pars/lateral mass/pedicle screws in the occipital-C1-C2 joints, as by the time that stage is reached, the location of VA is relatively known and one is usually taking special care to avoid injury to it. Therefore, the predetermined choice of the surgical procedure for stabilization usually has no bearing on the vulnerability of VA to be injured during a procedure.

The proposed classification is an objective checklist that provides a numerical assessment of risk stratification of the vulnerability of VA to injury during both the initial dissection of the occipito-C1-C2 region as well as during the procedure of stabilization.[1] It highlights the fact that the surgeon has to preoperatively focus on tracing the pathway of the VA, study its anomalous course if present, and assess its proximity to the C1-2 joint. This is especially useful in case one-sided VA is dominant or there is a co-existent torticollis, neck rotation or tilt, and significant facet joint asymmetry in the region.[2-5] It also highlights the anomalies prevalent in the VA size, course, dominance and luminal characteristics, and other anatomical characteristics (e.g. the C2 isthmic and C1-2 facet joint features). It emphasizes the need to focus on the soft tissue dissection between C1-2 and not between occipito-C1 space; and, to remain medial to the lateral margin of the lateral mass of the  Atlas More Details/C2-3 facet joints during the surgical exposure in order to avoid encountering the VA traversing its normal course. [3,4] It provides special craniometric measurements that assess the vulnerability of VA to injury due to its proximity to the C1-2 joints and its propensity to loop towards the midline at different levels that may increase the risk of its injury both during transoral surgery and posterior fusion. Finally, it also provides a unique technique to trace the entire course of VA at the craniovertebral junctional region, especially its intracranial course in the presence of an occipitalised atlas that has not been sufficiently addressed in the preexisting literature but nevertheless, has significant clinical significance.

The ever-increasing awareness amongst surgeons operating in this region of the need to focus on the course of VA (apart from the existing bony anomalies) prior to surgery for the management of congenital atlanto-axial dislocation needs to be lauded.

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Conflicts of interest

There are no conflicts of interest.

 » References Top

Sardhara J, Behari S, Mohan BM, Jaiswal AK, Sahu RN, Srivastava A, et al. Risk stratification of vertebral artery vulnerability during surgery for congenital atlanto-axial dislocation with or without an occipitalized atlas. Neurol India 2015;63:382-91.  Back to cited text no. 1
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Salunke P, Behari S, Sharma MS, Jaiswal AS, Jain VK. Pediatric congenital atlantoaxial dislocation: Focusing on the differences between the irreducible and reducible varieties. J Neurosurg Pediatrics 2006;104:115-22.  Back to cited text no. 2
Sawlani V, Behari S, Jain VK, Phadke RV: Stretched loop sign of vertebral artery: A predictor of vertebrobasilar insufficiency in atlantoaxial dislocation. Surgical Neurol 2006;66:298-304.  Back to cited text no. 3
Jain VK, Behari S. Management of congenital atlantoaxial dislocation. Some lessons learnt. Neurol India 2002;50:386-97.  Back to cited text no. 4
Behari S, Jain VK, Phadke RV, Banerji D, Kathuria M, Chhabra DK. C1-C2 rotary subluxation following posterior stabilization for congenital atlantoaxial dislocation. Neurol India 2000;48:164.  Back to cited text no. 5
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