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 » Objective
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Table of Contents    
VIDEO SECTION: STEP BY STEP: OPERATIVE NUANCES
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 315-317

Anomalous Vertebral Artery During Cranio Vertebral Junction Surgery Using DCER (Distraction, Compression, Extension, and Reduction): Approach. and Its Repair


Department of Neurosurgery, AIIMS, New Delhi, India

Date of Submission08-Mar-2021
Date of Decision08-Mar-2021
Date of Acceptance13-Mar-2021
Date of Web Publication24-Apr-2021

Correspondence Address:
P Sarat Chandra
Professor and Head of Unit 1, Room 7, 6th Floor, CN Center, Department of Neurosurgery, AIIMS, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.314543

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 » Abstract 


Introduction: Vertebral artery (VA) may run an anomalous course in congenital craniovertebral junction anomalies. Anomalous VA, though rare, is challenging to handle. An anomalous VA can get injured during exposure of craniovertebral junction, even in the experienced hands.
Objective: The objective of this article was to describe the technique of repairing the VA in case of its damage during exposure in the craniovertebral junction (atlantoaxial dislocation [AAD] with basilar invagination [BI]).
Procedure: The authors describe a case of VA artery injury in a case of severe BI & AAD, which was anomalous and coursing over the joints. Following the repair of injured VA, we proceeded with the surgery (distraction, compression, extension, and reduction [DCER]).
Conclusion: To avoid injury, it is important to always perform a CT 3-D angiogram, perform meticulous dissection under the microscope while exposing the joints, use variable impedance bipolar to control venous bleeding and always expose the side with non-dominant VA first.


Keywords: Atlanto-axial dislocation, basilar invagination, C1–C2 spacers, cranio-vertebral junction, distraction, compression, vertebral artery injury, vertebral artery repair
Key Message: The vertebral artery may run an anomalous course in congenital CV junction anomalies and one has to be careful during the exposure to prevent vertebral artery injury. However, if injured, the vertebral artery can be repaired using meticulous microsurgical techniques.


How to cite this article:
Chandra P S, Ghonia R, Singh S, Garg K. Anomalous Vertebral Artery During Cranio Vertebral Junction Surgery Using DCER (Distraction, Compression, Extension, and Reduction): Approach. and Its Repair. Neurol India 2021;69:315-7

How to cite this URL:
Chandra P S, Ghonia R, Singh S, Garg K. Anomalous Vertebral Artery During Cranio Vertebral Junction Surgery Using DCER (Distraction, Compression, Extension, and Reduction): Approach. and Its Repair. Neurol India [serial online] 2021 [cited 2021 May 15];69:315-7. Available from: https://www.neurologyindia.com/text.asp?2021/69/2/315/314543




Craniovertebral junction (CVJ) anomalies is a commonly encountered neurosurgical pathology in certain parts of the world. The treatment of CVJ anomalies has witnessed significant transition from transoral decompression to C1-C2 joint manipulation and atlantoaxial (or occipitocervical) fixation in the past two decades.[1],[2],[3],[4],[5],[6],[7],[8] One of the biggest challenges in the posterior approach is to handle the vertebral artery (VA), which runs a high risk of injury due to its anomalous course in patients with congenital CVJ anomaly. VA injury can be devastating in some patients and can result in massive blood loss intraoperatively and neurological deficits.[9],[10] Identification of VA anomaly preoperatively on radiological imaging is an important step in avoiding VA injury.[11],[12] However, the VA can still get injured despite all precautions, even inexperienced hands.


 » Objective Top


The objective of this article was to describe the technique of repairing the VA in case of its damage during exposure in the CVJ (atlantoaxial dislocation [AAD] with basilar invagination [BI]). We describe the successful management of VA injury using microsurgical techniques.

Case description

The patient is a 40-year-old man with severe BI and AAD. The course of the left VA was anomalous and it was coursing over the C1-C2 joint on the left side.

Procedure/Surgical technique

The patient was planned for DCER (distraction, compression, extension and reduction). The VA got injured during exposure of the joint on the left side as it had an anomalous course. It was planned to repair the injured VA. C2 ganglion was cut after tamponade over the injured VA with cotton to get adequate exposure for the microsurgical repair of the injured VA. VA was then repaired primarily. DCER procedure was completed by retracting the repaired VA away from the joint.

Video Link: https://youtu.be/t85WJG_ Qux8

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Video timeline with audio transcript (Minutes):

0.02: We present a case of the anomalous VA during CV junction surgery (DCER), its injury and subsequent repair.[1],[2],[3],[4],[5]

0.10: This is a 40-year-old man with severe BI and AAD, and as you can see the VA was over the joint on the left side and was anomalous in nature.

0.27: Here, we show you that the VA was already injury while I was attempting to cut the C2 ganglion.

0.36: Here, I place cotton with a suction directly over the VA with suction.

0.40: I continue exposing the C2 ganglion, because it comes in way of repairing the VA. Under microscope, the C2 ganglia are cut completely. The ends are retracted. Here, when I remove the cotton, I see profound bleeding coming from the VA. It is very important to identify the bleeding from artery as well as from veins. The bleeding from veins can be controlled by using a variable impedance bipolar. I prefer a variable impedance from Sutter, which provides excellent hemostasis from venous bleeding.

1.30: Now, you can see the cut ends of VA very well. So, we release the proximal clip, to see that there is adequate backflow.

1.40: Now, we repair using 8-0 prolene, in this case, there was a circumferential tear, which is taking up almost three-fourth of the circumference. And I had to use three uninterrupted sutures. It is important that in all these cases, the vascular set should be kept ready in case of inadvertent injury to the VA.

2.02: That is the second suture being applied. I had told earlier in one of the earlier captions that it is important to understand that the anomalous VA is anterior to the C2 ganglia, so when you are exposing the anomalous VA, you would come across the C2 ganglia first. So, you should cut it cautiously as the VA would be in front of that.

2.30: The proximal clip the first. And you can see that the sutures are holding well. Now, I remove the distal clip. The sutures are holding very well. Now, my assistant retracts the VA using Penfield's dissector no. 4, and I continue drilling the joint to perform the technique of distraction, compression, extension and reduction. So, the joint is prepared well.

3.03: Here, I am introducing a trial implant, while my assistant is retracting the VA. And then this is the final spacer, the core of which is filled with bone graft and hydroxyl-apatite.

3.19: So, you can see that both the spacers are in situ. This is the final reduction performed and you can see that the BI has been reduced very satisfactorily, and as you can see that there were bilateral pseudo-joints and the spacers were placed within the bilateral pseudo-joints.

3.36: Few Tips, always perform a 3D CT angiogram, to look for anomalous VA. Presence of anomalous VA is not a contraindication for posterior approach, the VA many are mobilized before placing spacers. A vascular set should always be kept ready. The side with non-dominant VA should be exposed first.

3.58: This is an example of a 27-year-old woman with BI and severe cord compression with bilateral pseudo-joints. And you can that the VA is right over the joint on the left side. So, in this case, we performed a successful mobilization of the VA and performed the placement of the spacer, and the technique of DCER and this CT scan again shows the images before and after surgery showing successful mobilization of the VA away from the joint.[5],[6]

Thank you very much.


 » Discussion Top


VA injury is a rare event in cervical spine surgery, with reported incidence varying from 0.3% to 0.5% following anterior cervical surgery to as high as 4.1% to 8.2% following C1C2 transarticular screws.[13],[14],[15] The chances of VA injury increase when the course of VA is anomalous. It has been estimated that the incidence of VA anomaly in the atlantoaxial region is 2.3%.[16] However, few recent radiological studies have estimated this incidence to be much higher, near 20%.[15] One must take all precautions to avoid VA injury. It is important to always perform a CT 3D angiogram preoperatively to check the course of VA. Meticulous dissection under the microscope should be done while exposing the joints. Use of variable impedance bipolar to control venous bleeding can be helpful as well. One should always expose the side with non-dominant VA first.

VA artery injury results in a sudden, pulsatile, and copious bright red bleeding. It can be confused with venous bleeding if there is a coexistent injury to the venous plexus.[13],[17] The goals of management of VA injury are prevention of excessive blood loss and prevention of vertebrobasilar ischemia and embolism.[18] The intraoperative steps to achieve these goals include fluid resuscitation, hemostatic tamponade, microsurgical repair, and VA ligation. Direct hemostatic tamponade can be achieved by a variety of hemostatic agents like gel foam or bone wax. This can be effective to control bleeding from VA injury; however, there is risk of delayed hemorrhage and formation of pseudoaneurysm. These risks are prevented by the direct repair of VA; however, it is surgical challenging. Experience in microsurgical techniques is required to repair injured VA. However, VA can be successfully repaired using meticulous microsurgical technique, as demonstrated in our case.


 » Conclusion Top


VA can get injured during exposure for posterior C1C2 surgeries like joint manipulation and C1C2 transartricular screws. Certain steps can prevent VA injury like performing a CT 3-D angiogram, performing meticulous dissection under the microscope while exposing the joints and using variable impedance bipolar to control venous bleeding. One must expose the non-dominant VA first.

Patient's consent

Patient consent was obtained for this video.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Copyright notice

Authors retain copyright for the video and accompanying printed matter that appears on the JNSPG website.

Disclosures

  1. This is to confirm that the abstract and video are original, and have not been submitted elsewhere in part or in whole
  2. The DCER technique is registered with US Patent US 14/897,156
  3. UNIVERSAL CV JUNCTION REDUCER is being developed R&D project with Medtronics**
  4. PSC spacers are being developed as an R&D project with Department of Science and Technology, India*.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Chandra PS, Kumar A, Chauhan A, Ansari A, Mishra NK, Sharma BS. Distraction, compression, and extension reduction of basilar invagination and atlantoaxial dislocation: A novel pilot technique. Neurosurgery 2013;72:1040-53; discussion 1053.  Back to cited text no. 1
    
2.
Chandra PS, Prabhu M, Goyal N, Garg A, Chauhan A, Sharma BS. Distraction, compression, extension, and reduction combined with joint remodeling and extra-articular distraction: Description of 2 new modifications for its application in basilar invagination and atlantoaxial dislocation: Prospective study in 79 cases. Neurosurgery 2015;77:67-80; discussion 80.  Back to cited text no. 2
    
3.
Sarat Chandra P, Bajaj J, Singh PK, Garg K, Agarwal D. Basilar invagination and atlantoaxial dislocation: Reduction, deformity correction and realignment using the dcer (distraction, compression, extension, and reduction) technique with customized instrumentation and implants. Neurospine 2019;16:231-50.  Back to cited text no. 3
    
4.
Goel A. Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine 2004;1:281-6.  Back to cited text no. 4
    
5.
Chandra PS, Goyal N, Chauhan A, Ansari A, Sharma BS, Garg A. The severity of basilar invagination and atlantoaxial dislocation correlates with sagittal joint inclination, coronal joint inclination, and craniocervical tilt: A description of new indexes for the craniovertebral junction. Neurosurgery 2014;10(Suppl 4):621-9; discussion 629-630.  Back to cited text no. 5
    
6.
Chandra PS. In reply: Different facets in management of congenital atlantoaxial dislocation and basilar invagination. Neurosurgery 2015;77:E987-8.  Back to cited text no. 6
    
7.
Chandra PS, Singh P. In reply: Distraction, compression, extension, and reduction combined with joint remodeling and extra-articular distraction: Description of 2 new modifications for its application in basilar invagination and atlantoaxial dislocation: Prospective study in 79 Cases. Neurosurgery 2017;80:231-5.  Back to cited text no. 7
    
8.
Joaquim AF, Tedeschi H, Chandra PS. Controversies in the surgical management of congenital craniocervical junction disorders - A critical review. Neurol India 2018;66:1003-15.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Wright NM, Lauryssen C. 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. J Neurosurg 1998;88:634-40.  Back to cited text no. 9
    
10.
Lunardini DJ, Eskander MS, Even JL, Dunlap JT, Chen AF, Lee JY, et al. Vertebral artery injuries in cervical spine surgery. Spine J 2014;14:1520-5.  Back to cited text no. 10
    
11.
Abtahi AM, Brodke DS, Lawrence BD. Vertebral artery anomalies at the craniovertebral junction: A case report and review of the literature. Evid Based Spine Care J 2014;5:121-5.  Back to cited text no. 11
    
12.
Su C, Chen Z, Wu H, Jian F. Computed tomographic angiography to analyze dangerous vertebral artery anomalies at the craniovertebral junction in patients with basilar invagination. Clin Neurol Neurosurg 2021;200:106309.  Back to cited text no. 12
    
13.
Peng CW, Chou BT, Bendo JA, Spivak JM. Vertebral artery injury in cervical spine surgery: Anatomical considerations, management, and preventive measures. Spine J 2009;9:70-6.  Back to cited text no. 13
    
14.
Burke JP, Gerszten PC, Welch WC. Iatrogenic vertebral artery injury during anterior cervical spine surgery. Spine J 2005;5:508-14.  Back to cited text no. 14
    
15.
Madawi AA, Casey ATH, Solanki GA, Tuite G, Veres R, Crockard HA. Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg 1997;86:961-8.  Back to cited text no. 15
    
16.
Tokuda K, Miyasaka K, Abe H, Abe S, Takei H, Sugimoto S, et al. Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 1985;27:410-3.  Back to cited text no. 16
    
17.
Prabhu VC, France JC, Voelker JL, Zoarski GH. Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation: Case report. Surg Neurol 2001;55:29-33.  Back to cited text no. 17
    
18.
Golfinos JG, Dickman CA, Zabramski JM, Sonntag VKH, Spetzler RF. Repair of vertebral artery injury during anterior cervical decompression. Spine 1994;19:2552-6.  Back to cited text no. 18
    




 

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