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Vertebral Artery in Relationship to C1-C2 Vertebrae: an Anatomical Study

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Vertebral Artery in Relationship to C1-C2 Vertebrae: an Anatomical Study Original Article Vertebral artery in relationship to C1-C2 vertebrae: An anatomical study Francesco Cacciola, Umesh Phalke, Atul Goel Department of Neurosurgery, Seth G. S. Medical College and King Edward Memorial Hospital, Parel, Mumbai, India. Background: Ten randomly selected adult cadaveric speci- course in relationship to the C2 vertebra, making it suscep- mens were dissected to analyse the anatomy of the verte- tible to injury during the surgical procedures in the region. bral artery during its course from the C3 transverse process The multiple loops of the artery and a buffer space within to its entry into the spinal dural canal at the level of C1. In the vertebral artery groove on the inferior surface of the su- addition, 10 dry cadaveric C1-C2 bones were studied. The perior facet of the C2 vertebra and over the posterior arch of course of the artery and the parameters relevant during sur- atlas provide the artery an extra length and space, probably gery in the region are evaluated. Methods: Ten adult ca- essential to avoid any stretch during neck movements. daveric specimens and 10 adult dry cadaveric C1 and C2 Key Words: Vertebral artery, C2-ganglion, atlas, axis, bones were studied. In five cadaveric specimens, the arter- craniovertebral junction ies and veins were injected with coloured silicon. The artery during its course from the transverse process of C3 to the transverse process of C2 was labelled as V1 segment, the artery during its course from the C2 transverse process to the C1 transverse process was labelled as V2 segment and Introduction the segment of the artery after its exit from the transverse foramen of C1 to the point of its dural entry was labelled as The anatomy of the vertebral artery in the region of the V3 segment. The relationship of the artery to the C1-2 joint craniovertebral junction is significantly different from the rela- and facets, distance of the location of the artery from the tively straightforward course in the transverse foramina of C6 midline, from the C2 ganglion and from the other surgery to C3 vertebrae. A three-dimensional understanding of the related landmarks were evaluated. The extent of occupancy anatomy is crucially important for any kind of surgery in the of the artery into the vertebral artery groove on the inferior craniovertebral region. Various authors have reported incidence surface of the superior facet of the C2 vertebra, and over of vertebral artery injury during transoral surgery, lateral mass the posterior arch of the atlas was studied. Results: The V1 and transarticular screw implantation for atlantoaxial fixation segment of the vertebral artery takes a varying degree of and during lateral approaches to the foramen magnum region.1,2 loop inside the vertebral artery foramen on the inferior as- The present study is designed to address a number of clinically pect of the superior facet of the C2 vertebra. The loop ex- relevant parameters pertaining to the vertebral artery in rela- tends towards the midline and was at an average distance tionship to the C1 and C2 vertebrae. The nomenclature of vari- of 14.6 mm from the midline of the vertebral body. The V2 ous bony components of the C2 vertebra has been used differ- segment of the artery takes an initial lateral loop after its exit ently by various authors.3-6 We followed the nomenclature clari- from the transverse process of the C2 vertebra. The aver- fied by Benzel.3 age distance of the artery from the lateral end of the C2 ganglion was 7.2 mm and from the dural tube was 15.3 mm. The vertebral artery groove in the superior facet of C2 and Material and methods the groove over the posterior arch of the atlas were com- pletely occupied by the vertebral artery only in six sides and Ten adult cadaveric specimens were examined using magnification (x 6-40). In five specimens coloured silicone was injected in the ar- in none respectively, suggesting the possibility of the dy- teries and veins. The microsurgical anatomy of the vertebral artery namic nature of the relationship of the artery to the bone. was evaluated along its course from the C3 transverse process to its Conclusions: The vertebral artery adopts a serpentine entrance into the spinal canal at the C0-C1 level with particular Atul Goel Department of Neurosurgery, King Edward Memorial Hospital, Parel, Mumbai, India. E-mail: [email protected] 178 Neurology India June 2004 Vol 52 Issue 2 178 CMYK Cacciola F, et al: Vertebral artery at C1-C2 vertebra attention to its relationship with the bony structures. For this pur- side of the facet. Anteroposterior dimension (mean 19.73 mm) pose the bony groove of the artery on the inferior surface of the was more than transverse dimension (mean 11.12 mm) in all superior facet of C2 was unroofed. In addition, 10 dry C1 and C2 superior facets of the atlas. None of the superior facets of atlas bones were studied. All measurements were made using a digital was found to be exactly symmetrical to that on the contralat- calliper and a goniometer. The findings were then corroborated with measurements on the images loaded on the computer (Figures 1-5). eral side. Both superior and inferior facets of the atlas always faced medially towards the spinal canal. The inferior facet of Results the atlas was almost circular in most of the vertebrae without any significant difference in the mean anteroposterior (15.76 Anatomical considerations mm) and transverse (15.22 mm) dimensions. The thickness of Osseous anatomy (Figure 5): The superior facet of the atlas the inferior facet under the posterior arch of the atlas was 1.7 was of oval shape with a groove on either side (76%) and was mm to 5.2 mm (average 3.5 mm). The thickness of the poste- kidney shaped in 24 facets, wherein the groove was only on one rior arch of the atlas separating the vertebral artery groove (a) (c) (b) (d) (e) (f) Figure 1: Stages of dissection as seen through the transoral approach: (a) Specimen prior to incision of the posterior pharyngeal wall. The uvula and soft palate can be identified. The artery on the left side is hypoplastic. (b) Incision on the posterior pharyngeal wall is taken and the flaps are retracted apart. The C2 vertebra and the anterior arch of the atlas can be identified. A thin film of bone is covering the anterior aspect of the osseous segment of V1 segment of the vertebral artery on the right side. (c) Soft palatal incision is taken and the two components are retracted apart. The uvula is retracted on the right side. The clivus is now seen. (d) Unroofing of the anterior bony shell of the osseous segment of V1 segment of the vertebral artery. The loop of the V1 segment and its course towards the midline can now be appreciated. The vertebral artery on the right side almost completely occupies the vertebral artery groove on the inferior surface of the superior articular facet of the C2. On the other hand, the left side artery does not completely occupy the vertebral artery groove. Note the relationship of the artery to the articular surfaces of the C1-2 joint. (e) The vertebral artery loop is elevated off the vertebral artery groove. The deep groove can be appreciated. (f) The specimen is seen from the right side in its lateral aspect. Note the loops of the V2 and V3 segment of the artery. Neurology India June 2004 Vol 52 Issue 2 179 CMYK 179 Cacciola F, et al: Vertebral artery at C1-C2 vertebra from the inferior facet was 2.2 mm to 4.8 mm (average 3.8 rior to these. The shape of the articular surface of the superior mm). The vertebral artery foramen was in the transverse proc- facet of the axis varied. In 54% facets it was oval with antero- ess lateral to the lateral mass of the C1 vertebra (Fig. 5). The posterior dimension more than transverse, in 27% facets it was groove for the vertebral artery on the superior surface of the oval with transverse dimension more than anteroposterior di- posterior arch of the atlas was converted into a complete bony mension and in 19% facets it was circular. It was convex in the foramen in one of the twenty sides examined. The distance from sagittal plane and was directed laterally to articulate with infe- the midline to the medial-most edge of the vertebral artery groove rior facet of C1. The average depth of the vertebral artery groove on the outer cortex of the posterior arch was 14.3 mm to 19.7 on the inferior surface of the superior facet was 4.36 mm (range mm (average 18.2 mm). 2-8.2 mm). The vertebral artery groove extended in the supe- The axis vertebral body has a thick and conical superior pro- rior facet up to its medial third in 10 cases, middle third in 18 jection of the dens. The dens is flanked by two large, superior cases and up to its lateral third in 12 cases. In none of the facets, extending laterally on to the adjoining pars- specimens did the vertebral artery groove extend in to the body interarticularis and articulating with the inferior atlantal fac- of axis vertebra or into the pars interarticularis. The vertebral ets. Unlike superior facets of all other vertebrae, they do not artery groove was located 2.2 mm to 3.4 mm (average 2.8 mm) form a pillar with the inferior facets, being considerably ante- anterior to the anterior limit of pars interarticularis.
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