J. Neurosurg. / Volume 32 / May, 1970 Surgical Treatment of Vertebral Artery Insufficiency Caused by Cervical Spondylosis* CHIKAO NAGASHIMA, M.D.t Department of Neurosurgery, University of Tokyo, School of Medicine, and the Department of Neurosurgery, Moro General Hospital, Tokyo, Japan ERVICAL spondylosis accompanied by mina at two levels above and below the inter- arthritic bony spurs that compress the space, so that the artery can be adequately C vertebral artery is not uncommon in freed and straightened. ~Fhe operations were older people, ~,21,23,2~ and is often most se- carried out on several cadavers until the tech- vere during rotation and hyperextension of nical details of the procedure were perfected. the neck. The most common site of forma- Since 1967, this method has been used tion of these osteophytes is on the uncinate successfully in 20 consecutive cases in the portion of the vertebrae, which in embryonic department of neurosurgery at the Moro stages is the junction of the centrum and lat- General Hospital associated with Professor eral masses, called the "neurocentral," "un- Sano's neurosurgical department, University covertebral," or "Luschka's" joint. There is of Tokyo. This report describes the opera- disagreement on whether this is a true joint tive technique and gives a brief summary of or not. 3,m1,18 It has been suggested that the clinical and surgical results. compression and displacement of one or both vertebral arteries may interfere with cir- Operative Technique culation in the vertebrobasilar arterial sys- Endotracheal general anesthesia is used tem. To date, few attempts have been made routinely. The patient is placed in the supine to correct this condition by surgical mea- position with the head turned to the side op- sures. posite to the lesion. Before making the inci- The surgical procedure presented here sion, it is necessary to localize by roentgen- evolved from observations of cadavers with ography the interspace to be operated on. displaced vertebral arteries due to severe The incision in the skin, 6 to 7 cm long, is osteophytes on the uncinate portion of the made transversely extending from the mid- vertebrae. The ease with which those lateral line to the posterior border of the sternoclei- osteophytes could be exposed and removed domastoid muscle. A longitudinal incision through the anterior approach with excision along the anterior border of the sternocleido- of the longus colli muscle led us to develop a mastoid muscle is used in cases with multiple simple method of removing the hypertro- lesions. The plane of cleavage between the phied uncovertebral joint (uncectomy) with- carotid sheath and the lateral border of the out making a burr hole or performing an in- thyroid and larynx is separated down to the terbody fusion as described by Bakay and anterolateral surface of the vertebral bodies. Leslie? Even after the spurs and fibrocarti- A lateral plain film taken with a needle in- laginous masses had been removed, the ver- serted into a disc space confirms the level to terbral artery was still kinked due to marked be attacked. Protrusion of the lateral osteo- perivascular fibrosis; a crease remained in the phyte and transverse processes can be pal- adventitia, with evidence of chronic irrita- pated individually through the longus colli tion of the vertebral nerve. I therefore advo- muscle. The longus colli muscle is cauterized cate excision of the fibrosis including the along its medial border and is separated sub- adventitia and periarterial vertebral nerve, periosteally from the spine on the side to be following unroofing of the transverse fora- exposed. Sectioning and partial excision of Received for publication August 6, 1969. the longus colli muscle greatly facilitates ex- * Presented at the 26th annual meeting of the Ja- posure of the uncinate portion and the trans- pan Neurosurgical Society, Gifu City, lapan, Octo- ber 8, 1967. verse process. Care should be taken to avoid "tAddress: 15 Minami-Enoki-Cho, Shinjiku-Ku, injury to the sympathetic trunk running on Tokyo 162, Japan. the lateral aspect of the longus colli muscle. 512 Spondylotic Vertebral Insufficiency 513 Uncectomy is done with electric drills or extreme rotation to the right, and one in the Hall air drill. The bulk of the lateral os- hyperextension plus extreme rotation to the teophyte is removed initially, then the un- left); two projections of the neck in neutral covertebral joint up to the depth of the floor position (one anteroposterior and one lat- of the transverse foramen, cephalad and cau- eral); and one with a Towne projection to dad to the transverse processes (Figs. 1-3). visualize the basilar artery and its branches. Curettes are used to clean the lateral aspect The patient was asked if any given position of the vertebral bodies. The anterior roots or had exacerbated the symptoms, and an at- costal element of the transverse processes are tempt was then made to simulate this posi- removed laterally to the tip of the anterior tu- tion. A 30 cc bolus of 60% Conray was used bercle with a Kerrison punch. Two trans- for each injection. The procedure was well verse foramina above and below the inter- tolerated. Carotid arteriography was added space are open. on the left side. The vertebral artery, thus freed from its Clinical Data. The clinical data on these compromised bony canal, appears still to be 20 patients are summarized in Table 1. Two kinked due to adhesions and perivascular fib- patients having a resting blood pressure over rosis at the site where the compression had 160/90 mm Hg were judged to be hyperten- been the most severe. Procaine solution is sive, and six having a resting blood pressure inserted locally into the arterial wall to pre- below 110/70 mm Hg were iudged to be hy- vent arterial spasm and to minimize bleeding potensive; two others had postural hypoten- from periarterial venous plexuses; this facili- sion. tates periarterial stripping. A dural hook is Vertigo, Dizziness, and Fainting. The inserted into the thickened area of adventi- most common complaint was the episodes of tia, which is incised longitudinally, and the vertigo or dizziness that occurred in 15 of area removed (Fig. 2). Venous bleeding, if the 20 cases; 10 had severe rotatory vertigo encountered, is arrested by application of and five had dizziness. The dizziness was not pieces of Gelfoam inserted in thrombin solu- a sensation of rotation but rather a feeling of tion with gentle pressure. The deep struc- instability. Four patients had fainting attacks. tures of the wound are permitted to fall to- These episodes were elicited upon turning gether, and the platysma muscle, subcuta- the head abruptly to look over the shoulder, neous layer, and skin are closed in layers. on looking upward at the ceiling, or on aris- No drain is used. ing from bed and on changing their posture. Convalescence from this operation is sur- These episodes were rarely an isolated symp- prisingly uneventful. Since no interbody fu- tom but frequently found in association with sion is done, no supporting collar or restric- visual disturbances, sensations of numbness tion of neck movement is needed. As a rule, in the arms or legs, cold sweating, nausea patients are ready to leave the hospital and vomiting, but seldom tinnitus or audi- within 7 days after operation. tory loss. One patient out of the 20 had bi- lateral tinnitus accompanying a severe rota- Summary of 20 Cases tory vertigo. Visual disturbances took the During the 2 years after this operation form of blurred vision, diplopia, or transient was devised, 20 patients were operated on. amblyopia. Headache, shoulder and neck There were 12 men and eight women, rang- pain were common. ing in age from 32 to 71 years. All patients Neurological Signs. The most commonly had initial and follow-up plain films of the observed neurological signs were a positive cervical spine. Romberg, and vertical or diagonal nystag- Arteriography. In all cases, arteriography mus seen through the Frenzel glass during of both the vertebral and carotid arteries the positioning tests of Dix and Hallpike ~ was undertaken by the percutaneous trans- and Stenger. z4 These were noted in all 20 brachial retrograde technique first described cases. It has been suggested that this kind of by Gould, et al.? ~ utilizing a Teflon catheter nystagmus indicates vestibular disorder of a needle and a pressure injecter. Six films were central nature; "~'~ thus, it is very important to taken: three anteroposterior projections of differentiate it from the vertigo due to a pe- the neck in hyperextension (one in plain hy- ripheral disorder of the vestibular end organ perextension, one in hyperextension plus such as M6ni~re's disease and the positional .