title: Risk stratification of vertebral artery vulnerability during surgery for congenital atlanto-axial dislocation with or without an occipitalized atlas.
abstract: BACKGROUND
  Variability in dimensions and course of vertebral artery (VA) makes it vulnerable to injury during surgery for congenital atlanto-axial dislocation (AAD) with or without an occipitalized atlas.
  
  
  OBJECTIVE
  This prospective study attempts to define anatomical variations that render VA at the craniovertebral junction (CVJ) vulnerable to injury during transoral decompression and posterior stabilization procedures; and, to propose a classification that helps in preoperative risk stratification.
  
  
  METHODS
  A prospective study.
  
  
  METHODS
  104 patients (65 with AAD; 39 controls) underwent a three-dimensional multiplanar computed tomographic angiogram to study anatomical variations in VA size, course, and anomalous medial deviation as well as in the type of axial isthmus and rotational deformity/tilt at the CVJ. The VA/foramen transversarium diameter; "stretched loop" sign of VA; and C1-2 facet joint angle were also assessed.
  
  
  METHODS
  A medial VA deviation that brought it in close proximity to the trajectory of the surgical approach was evaluated (P ≤ 0.05 significant).
  
  
  RESULTS
  An increased predisposition to VA injury was present in 23 (35.4%) patients (persistent first intersegmental artery [n = 20; 30%]; fenestrated VA [n = 1; 1.53%], and low-lying posterior inferior cerebellar artery [n = 2; 3.0%]) where VA crossed the C1-2 facet joint; 8 (12%) with an anomalous medial deviation; 12 (18%) with a high-riding VA at C2 and a narrow axial isthmus; and 13 (20%) with rotation/tilt at the CVJ. A normal score of 5 was obtained in 21 patients; and a score of 6-9 (that progressively indicated an increased vulnerability of VA to iatrogenic injury) in 44 patients. The "AAD with an occipitalized atlas" group was associated with a significant medial deviation of VA (right: P = 0.00 and left: P = 0.001).
  
  
  CONCLUSIONS
  A preoperative detailed risk assessment of anatomical variations in the size and course of VA at the CVJ significantly reduces chances of its iatrogenic injury.
authors.forename: Jayesh
authors.initials: J
authors.lastname: Sardhara
authors.affiliation: Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Behari
authors.forename: B Madan
authors.initials: BM
authors.lastname: Mohan
authors.forename: Awadhesh K
authors.initials: AK
authors.lastname: Jaiswal
authors.forename: Rabi N
authors.initials: RN
authors.lastname: Sahu
authors.forename: Arun
authors.initials: A
authors.lastname: Srivastava
authors.forename: Anant
authors.initials: A
authors.lastname: Mehrotra
authors.forename: Hira
authors.initials: H
authors.lastname: Lal