title: Optimal measurement for "posterolateral protrusion" of the vertebral artery at the craniovertebral junction using computed tomography angiography.
abstract: OBJECTIVE
  Among extraosseous abnormalities of the vertebral artery (VA) at the craniovertebral junction (CVJ), available evidence regarding "posterolateral protrusion," the VA running distant from the groove over the superior surface of the posterior arch of the atlas, is limited. The purpose of this study was to determine the optimal measurement to indicate posterolateral protrusion of the VA.
  
  
  METHODS
  Computed tomography angiography (CTA) images of 40 consecutive patients with cervical disease were reviewed. Ultimately, 66 arteries were included in this study. Five parameters predicted to indicate posterolateral protrusion of the VA were defined (A-E) and measured by two surgeons twice over a 2-week interval. Intraclass correlation coefficients (ICC) were used to examine intra-observer reproducibility and inter-observer reliability. Receiver operating characteristic (ROC) curve analysis was performed to determine the most optimal parameter to predict posterolateral protrusion of the VA.
  
  
  RESULTS
  Excellent inter-observer reliability and intra-observer reproducibility were obtained for all parameters (ICC = 0.87-0.99). Among them, parameter A, defined as the maximal length from the outer surface of the VA to the outer surface of the posterior arch of the atlas, was most accurately described posterolateral protrusion of the VA. The optimal cut-off value of parameter A obtained with ROC curves was 8.3 mm (sensitivity 97.5%, specificity 100%).
  
  
  CONCLUSIONS
  The measurement in this study can quantitatively evaluate the posterolateral protrusion of the VA. Before posterior surgery at the CVJ, pre-operative CTA can help surgeons detect anomalous VA and reduce the risk of intra-operative VA injury.
authors.affiliation: Department of Orthopaedic surgery, Yokohama Rosai Hospital, Yokohama, Japan.
authors.forename: Junichi
authors.initials: J
authors.lastname: Ohya
authors.affiliation: Department of Orthopaedic surgery, Yokohama Rosai Hospital, Yokohama, Japan.
authors.forename: Kota
authors.initials: K
authors.lastname: Miyoshi
authors.affiliation: Department of Medical Reserch and Management for Musculoskeltal Pain 22 Century Medical and Reserch Center, The University of Tokyo, Tokyo, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Oka
authors.affiliation: Department of Medical Reserch and Management for Musculoskeltal Pain 22 Century Medical and Reserch Center, The University of Tokyo, Tokyo, Japan.
authors.forename: Ko
authors.initials: K
authors.lastname: Matsudaira
authors.affiliation: Department of Orthopaedic surgery, Yokohama Rosai Hospital, Yokohama, Japan.
authors.forename: Masayoshi
authors.initials: M
authors.lastname: Fukushima
authors.affiliation: Department of Orthopaedic surgery, Yokohama Rosai Hospital, Yokohama, Japan.
authors.forename: Kosei
authors.initials: K
authors.lastname: Nagata
keywords: Atlas; computed tomography angiography; posterolateral protrusion; vertebral artery