J Korean Neurosurg Soc.  2012 Mar;51(3):177-181. 10.3340/jkns.2012.51.3.177.

Intraoperative Vertebral Artery Angiography to Guide C1-2 Transarticular Screw Fixation in a Patient with Athetoid Cerebral Palsy

• Chung JC
• Jung SS
• Park KS
• Ha HG

• KMID: 2018196
• DOI: http://doi.org/10.3340/jkns.2012.51.3.177

Abstract

We present a case of an athetoid cerebral palsy with quadriparesis caused by kyphotic deformity of the cervical spine, severe spinal stenosis at the cervicomedullary junction, and atlantoaxial instability. The patient improved after the first surgery, which included a C1 total laminectomy and C-arm guided righ side unilateral C1-2 transarticular screw fixation. C1-2 fixation was not performed on the other side because of an aberrant and dominant vertebral artery (VA). Eight months after the first operation, the patient required revision surgery for persistent neck pain and screw malposition. We used intraoperative VA angiography with simultaneous fluoroscopy for precise image guidance during bilateral C1-2 transarticular screw fixation. Intraoperative VA angiography allowed the accurate insertion of screws, and can therefore be used to avoid VA injury during C1-2 transarticular screw fixation in comorbid patients with atlantoaxial deformities.

Keyword

Atlantoaxial instability; Transarticular screw fixation; Vertebral artery; Intraoperative angiography; Athetoid cerebral palsy

MeSH Terms

Angiography
Cerebral Palsy
Congenital Abnormalities
Fluoroscopy
Humans
Laminectomy
Neck Pain
Quadriplegia
Spinal Stenosis
Spine
Vertebral Artery

Figure

• 

  Fig. 1 Preoperative images obtained in a static 54-year-old female with torticollis. Lateral flexion (A) and extension (B) cervical radiographs showing atlantoaxial instability and severe kyphotic deformity. Initial 3D CT angiography shows hypoplastic right vertebral artery (C). Sagittal plane MRI (D) demonstrating marked spinal cord compression at cervicomedullary junction.

• 

  Fig. 2 Images obtained after 8 months of the initial operation. Follow-up sagittal plane MRI (A) showing enough decompression of stenosis at cervicomedullary junction. However, serial CT scans (B) reveal malposition of screw and encroachment of VA. VA : vertebral artery.

• 

  Fig. 3 Intraoperative lateral fluoroscopic image obtained during vertebral angiography and insertion of the drill (A). Illustration for layout of the operation room (B) suitable for transpopliteal intraoperative VA angiography with fluoroscopy during atlantoaxial screw fixation. VA : vertebral artery.

• 

  Fig. 4 Last follow-up three-dimensional CT scans obtained after 4 years of the second operation showing completely fused atlantoaxial joint (A). 3D CT scans (B) demonstrate head of atlantoaxial screws at inferior facet of C2 (white arrow) and right vertebral artery is not visible due to the violation. Individual screws on transparent 3D reconstruction (C and D)show extraordinary trajectory caused by spinal deformity but both of them thoroughly pass atlantoaxial joints.

Reference

1. Azuma S, Seichi A, Ohnishi I, Kawaguchi H, Kitagawa T, Nakamura K. Long-term results of operative treatment for cervical spondylotic myelopathy in patients with athetoid cerebral palsy : an over 10-year follow-up study. Spine (Phila Pa 1976). 2002; 27:943–948. discussion 948. PMID: 11979166.

2. Duan S, He H, Lv S, Chen L. Three-dimensional CT study on the anatomy of vertebral artery at atlantoaxial and intracranial segment. Surg Radiol Anat. 2010; 32:39–44. PMID: 19707709.

3. Duruflé A, Pétrilli S, Le Guiet JL, Brassier G, Nicolas B, Le Tallec H, et al. Cervical spondylotic myelopathy in athetoid cerebral palsy patients : about five cases. Joint Bone Spine. 2005; 72:270–274. PMID: 15851002.

4. Haid RW Jr. C1-C2 transarticular screw fixation : technical aspects. Neurosurgery. 2001; 49:71–74. PMID: 11440462.

5. Haro H, Komori H, Okawa A, Shinomiya K. Surgical treatment of cervical spondylotic myelopathy associated with athetoid cerebral palsy. J Orthop Sci. 2002; 7:629–636. PMID: 12486465.

6. Hirose G, Kadoya S. Cervical spondylotic radiculo-myelopathy in patients with athetoid-dystonic cerebral palsy : clinical evaluation and surgical treatment. J Neurol Neurosurg Psychiatry. 1984; 47:775–780. PMID: 6470718.

7. Hue YH, Chun HJ, Yi HJ, Oh SH, Oh SJ, Ko Y. Unilateral posterior atlantoaxial transarticular screw fixation in patients with atlantoaxial instability : comparison with bilateral method. J Korean Neurosurg Soc. 2009; 45:164–168. PMID: 19352478.

8. Kawaguchi Y, Ishihara H, Ohmori K, Kanamori M, Kimura T. Computer-assisted Magerl's transarticular screw fixation for atlantoaxial subluxation. J Orthop Sci. 2002; 7:131–136. PMID: 11819145.

9. Laherty RW, Kahler RJ, Walker DG, Tomlinson FH. Stereotactic atlantoaxial transarticular screw fixation. J Clin Neurosci. 2005; 12:62–65. PMID: 15639416.

10. Lang SS, Eskioglu E, A Mericle R. Intraoperative angiography for neurovascular disease in the prone or three-quarter prone position. Surg Neurol. 2006; 65:283–289. discussion 289. PMID: 16488250.

11. Madawi AA, Casey AT, Solanki GA, Tuite G, Veres R, Crockard HA. Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg. 1997; 86:961–968. PMID: 9171174.

12. Mihara F, Yoshiura T, Noguchi T, Togao O, Morioka T, Sasaki T, et al. A method to reduce saline and heparin in intraoperative cerebral angiography : a preliminary report. Radiat Med. 2005; 23:588–589. PMID: 16555571.

13. Neo M, Matsushita M, Yasuda T, Sakamoto T, Nakamura T. Use of an aiming device in posterior atlantoaxial transarticular screw fixation. Technical note. J Neurosurg. 2002; 97:123–127. PMID: 12120635.

14. Onari K, Kondo S, Mihara H, Iwamura Y. Combined anterior-posterior fusion for cervical spondylotic myelopathy in patients with athetoid cerebral palsy. J Neurosurg. 2002; 97:13–19. PMID: 12120637.

15. Richter M, Mattes T, Cakir B. Computer-assisted posterior instrumentation of the cervical and cervico-thoracic spine. Eur Spine J. 2004; 13:50–59. PMID: 14634850.

16. Schievink WI, Vishteh AG, McDougall CG, Spetzler RF. Intraoperative spinal angiography. J Neurosurg. 1999; 90:48–51. PMID: 10413125.

17. Song GS, Theodore N, Dickman CA, Sonntag VK. Unilateral posterior atlantoaxial transarticular screw fixation. J Neurosurg. 1997; 87:851–855. PMID: 9384394.

18. 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; 27:410–413. PMID: 4058734.

19. Tsirikos AI, Chang WN, Shah SA, Miller F. Acquired atlantoaxial instability in children with spastic cerebral palsy. J Pediatr Orthop. 2003; 23:335–341. PMID: 12724596.

20. 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. American Association of Neurological Surgeons/Congress of Neurological Surgeons. J Neurosurg. 1998; 88:634–640. PMID: 9525707.

21. Yamazaki M, Koda M, Aramomi MA, Hashimoto M, Masaki Y, Okawa A. Anomalous vertebral artery at the extraosseous and intraosseous regions of the craniovertebral junction : analysis by three-dimensional computed tomography angiography. Spine (Phila Pa 1976). 2005; 30:2452–2457. PMID: 16261125.

22. Yoshida M, Neo M, Fujibayashi S, Nakamura T. Comparison of the anatomical risk for vertebral artery injury associated with the C2-pedicle screw and atlantoaxial transarticular screw. Spine (Phila Pa 1976). 2006; 31:E513–E517. PMID: 16816753.