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  • Title: Utility of the analysis of intracranial venous sinuses using preoperative computed tomography venography for safe occipital screw insertion.
    Author: Izeki M, Neo M, Fujibayashi S, Takemoto M, Otsuki B, Watanabe M, Koizumi K, Matsuda A, Nagai K, Matsuda S.
    Journal: Spine (Phila Pa 1976); 2013 Aug 15; 38(18):E1149-55. PubMed ID: 23698573.
    Abstract:
    STUDY DESIGN: Prospective descriptive study. OBJECTIVE: To verify the feasibility and utility of evaluating venous sinuses (VSs) using computed tomography venography (CTV) concomitant with preoperative CT angiography (CTA) for safe occipital screw fixation. SUMMARY OF BACKGROUND DATA: Preoperative evaluation of the vertebral artery by CTA is indispensable in occipitocervical spinal instrumentation surgery. Despite accumulating evidence showing the potential of CTV, no studies have reported the usefulness of concomitant use of CTV and CTA before placement of occipital plate-screw constructs. METHODS: We analyzed 30 consecutive patients who underwent CTV simultaneously with CTA. First, we investigated VS anatomy in individual cases and classified the continuity patterns of relevant VSs. Subsequently, we evaluated the probable risk zones for VS injury, from the viewpoint of occipital screw insertion. RESULTS: VSs can be clearly visualized using CTV simultaneously with CTA examination without significant increase of radiation exposure or extra workload for radiographical technicians. VS continuity was classified into 4 categories: the confluence type (n = 9), bifurcation type (n = 8), transverse type (n = 11), and others (n = 2). The confluence of sinuses and their relevant VSs were greatly variable between individuals, and occasionally, some cases with high-risk morphology for VS injury in occipital screw placement were observed. CONCLUSION: Our findings indicate that there is no universal position for safe insertion of occipital screws that is applicable to all individuals. It is risky to determine optimal screw placement, only on the basis of traditional cadaveric information such as occipital bone thickness and several external bony landmarks. Spine surgeons must recognize that VS injury may occasionally lead to life-threatening complications. The detailed information on VSs obtained by preoperative CTV examination combined with CTA in individual cases can be useful in preoperative planning and can contribute greatly to the improvement of surgical safety. LEVEL OF EVIDENCE: 2.
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