VERTEBRAL
ARTERY
DECOMPRESSION A
OF
RETROSPECTIVE
MICHAEL
D.
KENNETH
From
Ten
SMITH,
Minnesota
patients
who
viewed
to assess
Center,
EMERY,
subsequent body
electrocoagulation (1), or open Five patients
but
most
exposure
of
(4),
tumour
them
vertebral
ossification
The final control of (3), direct exposure
(2), open
suture
We
or tumour,
of
direct
found
arterial
to be safe, quick and reliable. Careful particularly in pathologically weakened
by a thorough
relationships
(2),
transosseous
resolved.
as in infection avoided
All had been for spondylitic
ligament (1), nonunion of a (1). The use of an air drill had
(1),
and control
is best
DUDLEY,
placement of a haemostatic clip (3). had postoperative neurological deficits,
use of the air drill,
bone,
ALBERT
USA
outcome. resection
been responsible for most injuries. haemorrhage had been by tamponade and
is essential. knowledge
artery,
the
the
injury
Arterial
of the anatomical canal,
spinal
and
the
1993; 75-B :410.-S. Accepted3O
July
The anterior spinal cord neoplastic,
1992
approach and nerve infective,
potential paralysis,
complications dysphagia,
syndrome,
oesophageal
obstruction haematoma
due to (Smith
1978,
Graham
1989;
for decompression roots is widely used or post-traumatic
reported include vocal cord to the carotid artery, Homer’s
injury
perforation, acute and 1989;
S. E. Emery, MD Department of Orthopaedics, Abington Road, Cleveland, A. Dudley, Four East Baltimore,
MD Madison Maryland
nerve
root
exposure or nerve relief
Emery,
Greater
M. Leventhal, MD Department of Orthopaedics, Clinic, 869 Madison Avenue, Correspondence ©I993 British 030l-620X/93/3522
410
should
South,
Suite
be sent
Editorial Society $2.00
Surgery,
3091
Baltimore
University Memphis, to Dr M. of Bone
Medical
602,
Minneap-
University,
1074
Centre,
Avenue,
Baltimore,
of Tennessee and Campbell Tennessee 38103, USA. D. Smith. and
Joint
Surgery
and
Bohlman
or
spinal
canal
decompression
without
of the dura or manipulation of the spinal cord roots. It results in little epidural fibrosis. Direct
of anterior The
compression
use
is assured,
and
incision
gives
of a transverse
Sepic 1984; In contrast
the uncertain accounts control little
Greenspring
Smith
or
arthrodesis a cosmetic
and often imperceptible scar, and most of the complications of the anterior approach do not detract from the excellent long-term clinical results (Williams, Allen and Harkess 1968; White et al 1973; Bohlman 1977; Gore and
Case Western Reserve Ohio 44106, USA.
Orthopaedic 2121 1, USA.
K. J. Murray, MD, PhD NeurosurgicalOncology, Maryland 21204, USA.
Avenue
respiratory
Despite these theoretical complications, anterior procedures have been successful and are popular. The approach allows for anterior discectomy and thorough
McAfee to this,
et al 1987). laceration of the
Vertebral artery because of the difficulty 24th
and
retropharyngeal oedema Robinson 1958 ; Whitecloud
during an anterior decompression complication. Such injuries have in the literature, probably because
M. D. Smith, MD Minnesota Spine Centre, 606 ohs, Minnesota 55454, USA.
of the cervical for spondylitic, problems. The
1991).
is easy.
body.
J Bone Joint Surg [Br] Received 18 June 1992;
SPINE
PATIENTS
iatrogenic injury to a vertebral decompression were rethe mechanisms of injury, their operative
or myelopathy
suture
TEN
Minneapolis,
posterior longitudinal (2), or osteomyelitis
of the fracture
CERVICAL
cervical
the
ANTERIOR
LEVENTHAL
a partial vertebral
radiculopathy
DURING
suffered
and
undergoing
E.
MARVIN
anterior
management,
OF
SANFORD
Spine
during
THE
REVIEW
J. MURRAY,
artery
INJURY
has
been
the avoidance injury. Spinal decompressions inadvertent We sources
published
to guide
or intraoperative surgeons who should be
had
an
grave and are good
There
exposure of the artery and of the to penetrating neck injuries, but
laceration have reviewed who
particularly haemorrhage,
consequences.
of the surgical of bleeding due
artery
is a very serious received little attention they are infrequent.
laceration is of controlling
neurological
vertebral
of the ten iatrogenic
artery. We aimed to controlling haemorrhage,
the
vertebral patients
THE JOURNAL
surgeon
in
artery. from a variety
injury
determine to discover
risk factors, and to develop guidelines for the avoidance
spinal
management of such an perform anterior cervical prepared to manage an
of
the
the best means the mechanism
anatomical of such injuries. OF BONE
AND
of
vertebral of and
and
surgical
JOINT
SURGERY
VERTEBRAL Table
1. Details
ARTERY
of ten patients
with
INJURY
iatrogenic
DURING
injury
ANTERIOR
to a vertebral
DECOMPRESSION
OF
THE
CERVICAL
411
SPINE
artery S
Case
Age (yr)
Follow-up (mth)
Diagnosis
Procedure bone
10
43
Aneurysmal
Corpectomy
CS, C6
Right
Right
24
Spondylitic
myelopathy
Corpectomy
C3, C4, CS
Left
Right
Coarse
air drill
3
52
18
Old nonunion Spondylosis
of a dens fracture with myelopathy
Corpectomy
C2
Right
Left
Coarse
air drill
4
38
2
Corpectomy
C6, C7
Right
Right
Instrumentation
Discectomy
C5-6
Right
Left
Instrumentation
Corpectomy
C4, CS, C6
Right
Left
Coarse
air drill
Corpectomy
CS, C6
Right
Right
Coarse
drill
Corpectomy
C3
5
52
34
Spondylitic
6
55
12
OPLL
7
86
67
Spondylitic
abscess
radiculopathy with
cervical
C5, C6
Cause
68
epidural
myelopathy
Injury
I
and
with
Arterial
2
Osteomyelitis myelopathy
cyst
Approach
with
C6 myelopathy
myelopathy
Metastatic
cancer
C3
Instrumentation
8
75
2
Right
Right
Cavitron
9
67
31
Pseudarthrosis
C6-7
Hemicorpectomy
C6, C7
Right
Right
Diamond
10
43
12
Pseudarthrosis
C5-6
Hemicorpectomy
CS, C6
Right
Right
Coarse
burr burr
Estimated Case
Level
ofinjury
bked (ml)
Management
I
Mid
third
Avitene,
2
Mid
third
Direct
electrocoagulation
3
Lower
third
Direct clips
electrocoagulation,
4
Lower
third
Avitene,
5
Upper
third
Direct distal
exposure vascular exposure,
6
Mid
third
Direct
gelatin
gelatin
sponge
proximal
sponge
Mid
third
Transosseous
ligation
Mid
third
Transosseous
ligation,
9
Disc
space
Exposure
10
Disc
space
Gelatin
incision,
and
proximal
distal
vascular
None
Artery
None
No
3
Upper airway tracheostomy. later
4
Immediate embolisation None
5
6
OPLL* dural absence, dural patch and graft
Emergency fusion Cl to CS one week angiography
CSF fistula. reinsertion
Reoperation
None
for
fossa
intact
Posterior
fossa
intact
with
dysphagia circulation at 6 months
Severe Marked
CS root damage None
1000
CS root damage which resolved
cranial
with signs
with
mild deltoid
with
deltoid
No pain
posterior
or functional
No pain difficulty
limitations
II myelopathy,
or functional
chronic
limitations,
Persistent
mild
needs
central
ofdaily
cord
syndrome,
No pain,
No
Death
at 2 months
9
None
No
Death
due to unrelated
causes
10
None
No
No pain
or functional
limitations
75-B,
No. 3, MAY
1993
minor
deltoid
lost to follow-
no pain,
weakness : disseminated
disease
swallowing
living
No
VOL.
renal
Drug abuser, left hospital against advice, up Overhead activities increase vertigo meet
ligament
weakness
Comments
None
longitudinal
paralysis
None
None
of the posterior
paralysis
hemiplegia.
and biceps
8
ossification
palsies
Persistent Vocal cord
prominent
7
0
nerve
and dysarthria. insufficiency.
quadraparesis cerebellar
No pain, Nurick with dialysis
Posterior
No
infarction
1000
no pseudoaneurysm
Collateral flow present, fossa intact
and
None Cerebellar
Transient posterior resolved
angiogram
patent,
complications
None
1700
300
Postoperative
Neurological
4500
2300
tamponade
I
postoperative
clips
ligation
2
obstruction. Posterior
and
2000
500
complications
Non-neurological
vascular
electrocoagulation
by vertebrectomy, sponge
and distal
tamponade
proximal
7
2300 400
by separate clips
8
Case
tamponade
km
cancer at 33 months
able
to
M. D. SMITH,
412
PATIENTS We
AND
made
S. E. EMERY,
A. DUDLEY,
METHODS
a retrospective
review
of medical
records
at
K. J. MURRAY,
M. LEVENTHAL
provided prompt temporary control, but in case 6, severe hypovolaemia led to cardiac arrest before temporary control of the haemorrhage allowed adequate restoration
the authors’ four medical centres, all being referral centres for complex and tertiary spinal care, and identified ten patients who had had vertebral artery
of blood volume. Methods of definitive
laceration during an anterior operation of the cervical spine (C2 to C7). We with congenital vascular malformations,
an extended waiting period. In these bleeding had ceased, but blood loss had (2300 ml and 4500 ml) and the operations
arterial shows
injuries or aneurysmal the details of the ten
surgeons surgeons). of one patients
involved Four
on the lower part excluded patients post-traumatic
vascular patients.
(three neurosurgeons, of the authors had
4, the
lesions. Table I There were nine
six orthopaedic personal experience
by four other associates with this paper.
All
the operations had been similar technique with anterolateral the common carotid neurovascular the trachea nine right the surgeon.
performed using exposure, medial sheath and lateral
a to to
and oesophagus. The side of the approach, and one left, was based on the preference of During the study period from January 1986
to May 1990, about 1 195 tions had been performed were unable to determine
anterior cervical spine operaby the five authors, but we the other four surgeons’ case
loads. The approximate incidence was 0.5%. The first author (MDS) studied records and the operative notes
in the
authors’
(7 hours
and
followed
by
controlled In
case each ; the fifth of two cases. Thus, six of the were under the direct care of one of the authors;
the other four were managed who did not wish to be involved
packing
cases
radiographs for risk factors, intraoperative errors, and neurological sequelae. Follow-up reports were obtained at the various centres, usually by the responsible operating surgeon, and included a physical examination and radiographs.
despite
Follow-up
averaged
24 months,
with
never returned for patient (case 8) died metastases. Neither apparent complication.
two
patients
having
abuser (case 4) at two months and
removal of halo fixation, and one after two months from disseminated of these had paralysis or any other The other eight patients were
followed for at least one year, and none needed further operations for the cervical spine disorder that prompted the index operation. None had late worsening of any neurological complications at the time of discharge, and all with
iatrogenic
neurological
least some recovery. Findings. In all cases, unaware vertebral unexpected gelatin (Avitene
of the
close
the
injuries operating
proximity
of his
artery : the first indication and profuse bleeding. sponges, ; Medchem
bone
wax, Products,
have surgeon
shown had
dissection
In cases
gently
removed
had
placement,
patients,
either
or there
severe postoperative of arterial control
been
and
this
bleeding
had
had
after
two patients the been considerable were prolonged
10 tamponade
bone-graft
1 and
been
had concern
haemorrhage, and been undertaken,
probably caused later. A separate necessary There
the spinal longitudinal
in case were
clinically
5 to provide no
detectable
arterial
embolisation patients
only
or
patients one alone.
had
of them Because
soon had
a direct
after the operation. postoperative neurological
four
Case nerve
3 suffered a Wallenberg’s and bulbar dysfunction al
Four
postoperative haemorrhage, this an uncomplicated prophylactic
lems,
et
diagnosed had been
adequate exposure. of recurrent bleeding
cases
angiography, but treated by tamponade
possibility of had undergone
as
injuries incision
pseudoaneurysm.
of the patient Five
nerve root left-sided
complication
1980).
An
of
the
prob-
arterial
injury.
syndrome (lower cranial with cerebellar findings: MRI
scan
showed
a large
infarction (Fig. 1), but the patient’s speech, swallowing have improved over the 18-month One patient (case 5) had persistent ataxia and
vertigo with positional changes of the head, which were thought to be due to impaired posterior circulation; resolution has been slow and incomplete. Cases 7 and 9 had root injuries due to blind suture placement, and had rapid and nearly complete recovery. The fifth patient, case 6, had a severe quadraparesis, which is still dense but recovering slowly one year later. This patient had ossification of the posterior longitudinal ligament and a grade 4 myelopathy (Nurick 1972). She had absence ofthe dura and a postoperative cerebrospinal fluid fistula. postoperative
These other problems quadraparesis.
could
have
caused
her
been to the
of trouble Tamponade
and fibrillated Woburn, Mass)
at
In case
varied.
by suture ligation in cases 7, 8 and 9, by metallic clips in cases 3, 5 and 6 and by exposure and electrocoagulation in case 2. In cases 7 and 8 the sutures had been passed blindly through bone using a stout curved needle above and below the area of the arterial injury ; these sutures
cerebellar gait and follow-up.
RESULTS
been
tamponade
possible methods
Schellhas
less than one year. One intravenous-drug left hospital against medical advice
8 hours). immediate
had postoperative (case 4) had been
in detail the medical with all pertinent
had
the bleeding. another seven
recurred about direct
control
material
was with
collagen usually
DISCUSSION Before
200 these
this patients occurred
study,
we would
would during
have
not
have
arterial
anticipated
vertebrectomy
THE JOURNAL
that
lacerations.
OF BONE
for AND
Most spinal JOINT
1/ of
cord
SURGERY
VERTEBRAL
ARTERY
INJURY
DURING
ANTERIOR
DECOMPRESSION
OF
THE
CERVICAL
SPINE
413
Case 3. A 52-year-old man with an old upper cervical spine fracture and progressive myelopathy. During decompression of the lateral aspect ofthe spinal canal with a motorised burr, the left vertebral artery was lacerated. A haemorrhagic cerebellar infarction resulted. Axial MRI of the skull shows an ischaemic area in the distribution of the posterior inferior cerebellar artery.
decompression anterior
a more
-
discectomy.
extensive
use
complex
procedure
Vertebrectomy
of motorised
burrs
in tight
three common reasons for the apparent : the motorised dissection width of the bone and disc removal bone of the pathologically
lateral softened
Anatomy.
The
subclavian
or
transversarium
lateral
to
through the base
vertebral
of the infection
artery
the sixth
the
surgical
originates and
and
enters
Before
teal
this,
of C7, but usually The
artery
passes
foramina until it reaches level it curves posteriorly to
enter the foramen transversarium part of the ring of the atlas and
in the perforates
posterolateral the posterior
membrane to pass through the foramen It then joins the opposite vertebral artery to basilar artery, which supplies most of the and cerebellum. The artery is most vulnerable C7, laterally at C3 to C7, and posteriorly at
Cl andC2. Operative
technique.
With
the
anatomy must wide.
in
mind,
the
be performed To deviate
in from
the midline or to remove bone wider than is necessary risks a laceration, particularly if there is ectasia of the vertebral artery (Fig. 2). The location of the insertions of longus colli may help to maintain orientation. SubperiosVOL.
75-B,
No. 3, MAY
1993
dissection
the anterior posteriorly.
cervical spine of a patient injury. It is apparent that The corpectomy defect is of the fibular strut graft.
of their
the
defect needed 3). The bone and straight anteroposterior tomy
cortex,
then
medial
borders
is performed
surface of the vertebral body The width between the two
represents
usually
any
removed Kerrison
atlantoaxial magnum. form the brainstem anterior to
removal of bone and disc material the midline and not be excessively
Case 2. Anteroposterior radiograph of the who sustained a right-sided vertebral artery the surgeon lost his midline orientation. eccentric as shown by the lateral placement
was
from the the foramen
vertebra.
process
dissection.
a series of transverse of the axis. At this
the
confines,
spinal canal or tumour.
cervical
to the transverse
a simple
requires
lacerations became was off midline ; the was excessive ; or the
artery
innominate of
it is anterior
part from
than
usually
appropriate
width
osteophytes,
be extended
of the
corpec-
for spinal canal decompression (Fig. disc material is then removed in a direction. The posterior vertebral and
the
using a diamond burr, punches as needed.
needed, using The vertebral
until
begins to curve dissected flaps
laterally
to the
small diamond artery should
(Raynor 1983). We verified the safety by studying 25 preoperative, axial CT scans of patients
disc
fine The
material
are
curettes, and decompression
also
microcan
uncovertebral
joints,
burrs or Kerrison be above this
punches. dissection
as
ofthis technique of dissection myelographically enhanced, who were about to undergo
anterior decompression and fusion. We measured the distances from the floor of the spinal canal to the artery, from the anticipated lateral wall of the decompression to the artery, and the necessary width of through the middle portion of the vertebral CS and
C6 (Fig.
3). The
average
width
decompression bodies at C4,
of the spinal
cord
414
M. D. SMITH,
Fig.
S. E. EMERY,
A. DUDLEY,
K. J. MURRAY,
M. LEVENTHAL
3
Diagram of the landmarks used to measure the width of the corpectomy needed for adequate spinal canal decompression. The vertical lines are based on the medial borders of the longus colli muscles. The horizontal line is at the most anterior aspect of the dissection on the floor of the canal showing the lateral position of the arterial foramina.
at these levels was The average lateral needed
to
1 3.7, 1 3.8 and 1 3.3 mm respectively. dissection ofthe longus colli insertion
provide
decompression at all levels,
thus
a
ical landmarks margin of safety.
motorised burr. can be performed
that we A small
irrigation,
foramina. Preoperatively, the
for
an
vertebral
the
should the
angiography
note
CT
should
artery is prophylactic
displaced, measures
such placement
as its exposure for of encircling vascular
sion,
precautions (Fig. 4). In the exposure difficult exposure effective, inflatable compression
would
or
the position
MRI
scans
presence
been
of vigorous
dilated, before
;
bleeding
if the
in cases the
,
9
unplanned
of the vertebral artery presents a serious and problem. Our best results were with direct of the artery ; blind placement of sutures was but caused nerve root palsies. The use of an balloon catheter of the vessel
to provide temporary within the foramen
external transver-
1988).
foramen or complete allow the muscles ; retracted
also
distal These
1 4 and
laterally operation
severe of the
haemorrhage interferes artery (Hatzitheofilou
et
the arterial injury is on the same side as the original approach, exposure may be facilitated by further lateral dissection of the longus colli and longus capitus beyond the transverse process to expose the
al
When
transversarium. In these circumstances partial transection of the sternocleidomastoid may surgeon easier retraction laterally of the other the carotid sheath could also be mobilised and medially or laterally as necessary (Riley 1989).
Partial removal ofthe rim of the foramen
additional decompres-
the proximal and loops or sutures.
valuable
to
in the Burkus Fig. 4).
be considered
tortuous, or may be needed
have
sarium is possible when with the orderly exposure
safely used to perform a of the lateral recesses of the risk of entering the arterial
on
cyst extends after the anteriorly.
a
be
surgeon
arteries
4
Axial preoperative CT scan. An aneurysmal bone around the foramen transversarium. An angiogram revealed that the artery was tortuous and displaced
with a 5 mm with continuous
determine if the arteries are ectatic or are involved tumour or infection (Lindsey, Piepmeier and 1985; Bohlman et al 1986; Born et al 1988: Preoperative
Fig.
adequate
This shows that using the anatom-
have described, diamond burr,
then
can
generous decompression canal with very small
of
guide
of the central canal was less than 3 mm leaving at least S mm of bone between
the artery and the central corpectomy
saline
lateral
allow
wider
longus colli transversarium exposure
muscle and the anterior with rongeurs will
(Verbiest
sternocleidomastoid
muscle
has
be re-approximated
at the
time
been
1969). divided,
of wound
If
the
it should
closure,
and
the cosmetic results should be acceptable (Southwick and Robinson 1957). If the injury is on the contralateral side and adequate visualisation is not obtained through the initial incision, the operating surgeon could either extend the present incision beyond the midline and expose the artery beyond the contralateral sternocleidomastoid (as described Some one
above) other
vertebral
or make published artery THE
a separate incision. work supports the
can JOURNAL
be
ligated OF BONE
without AND
JOINT
idea
that
serious SURGERY
VERTEBRAL
(McCormick
consequences
of
ARTERY
our
ligated posterior
seven
related
to the
INJURY
1983;
Perry
patients had circulation.
DURING
1989),
neurological This rate
ANTERIOR
but
three
deficits is greater
that reported by Golueke et al (1987) (six of 23) or Hatzitheofilou et al (1988) (four of 20). These authors were reporting the results of traumatic lacerations in
DECOMPRESSION Golueke P,Sclafani and management. Gore
than
younger tolerate
patients unilateral
who were more likely to be able to ligation. An additional factor is arterial
dominance.
In patients
with
sided artery part of the
is usually the blood supply
asymmetry,
arterial
the left-
larger and provides to the hindbrain.
the greater Ligation or
prolonged
OF
THE
CERVICAL
S, PhilllpsT, J Trauma
DR, Sepic SB. Anterior protruded discs : a review 1984; 9:667-71.
et al. Vertebral artery 1987; 27:856-65.
C, Demetriades approaches
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cervical fusion for of one hundred forty-six
Graham JJ. Complications of cervical spine. Second ed. Philadelphia, etc: Hatzitheofilou Surgical
415
SPINE
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degenerated patients.
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M, Franklin
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McCormick
We would prefer repair rather than ligation artery (Perry 1989 ; De Los Reyes et al 1990), and
Nurick S. The natural history and results of surgical treatment spinal cord disorder associated with cervical spondylosis.
Reyes absence vein
et al (1990) of the left grafting
describe vertebral
after
an
a patient with a congenital artery who required bypass right vertebral lacera-
iatrogenic
tion. This was not possible in any of our patients. anterior exposure does not allow for direct repair laceration of the posterior or posteromedial arterial No benefits commercial article.
in any party
form have been related directly
An of a wall.
received or will be received or indirectly to the subject
from a of this
J. 1988;
Br J Surg
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