- Email: [email protected]
Vertebral Artery Loop—A Cause of Cervical Radiculopathy
Peer-review Short Reports
Vertebral Artery Loop—A Cause of Cervical Radiculopathy Salvatore Chibbaro1, Giuseppe Mirone1, Muneyoshi Yasuda2, Marco Marsella3, Paolo Di Emidio1, Bernard George1
Key words 䡲 Anterolateral approach 䡲 Cervical radiculopathy 䡲 Loop 䡲 Microvascular decompression 䡲 Vertebral artery Abbreviations and Acronyms CT: Computed tomography VA: Vertebral artery From the 1Department of Neurosurgery, Laribosiere University Hospital, Paris, France; 2Department of Neurosurgery, Aichi Medical University, Aichi, Japan; and 3Centre for Neurosciences, Tucson, Arizona, USA To whom correspondence should be addressed: Salvatore Chibbaro, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2012) 78, 3/4:375.e11-375.e13. DOI: 10.1016/j.wneu.2011.12.002 Supplementary digital content available online.
䡲 OBJECTIVE: To report a case of cervical radiculopathy caused by an anomalous vertebral artery (VA) and illustrate the efficacy of microvascular decompression by the anterolateral approach. 䡲 METHODS: A 50-year-old woman was referred because of an 8-year history of progressive left C6 radiculopathy refractory to other forms of treatment, including C5-6 anterior cervical discectomy. Clinical and radiologic evaluation showed an abnormally tortuous loop of V2 causing direct neurovascular compression. 䡲 RESULTS: A left cervical anterolateral approach was used to expose the anomalous loop. After a generous bony decompression, the loop was identified, and the artery was mobilized and ultimately separated from the C6 nerve root removing the direct pulsatile compression. 䡲 CONCLUSIONS: Cervical root compression by an aberrant or anomalous extracranial VA is a rare cause of radiculopathy. The best management of such lesions is the anterolateral approach with bony and direct microvascular decompression.
Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
and followed by conservative treatment because of the persistence of her symptoms. Neurologic examination was unremarkable INTRODUCTION except for left upper extremity severe paresthesias on head flexion and rotation. Plain Vertebral artery (VA) anomaly or tortuosity cervical x-ray showed enlargement of the is a rare cause of cervical radiculopathy (2, left C5-6 foramen, which was confirmed by 5, 6, 9, 11, 13, 14, 16, 17, 22, 33-38). It may be computed tomography (CT) scan (Figures 1 congenital or acquired, and it is usually deand 2). In addition, CT antected incidentally as part of giography and magnetic resoinvestigation for trauma or nance angiography (Figure 3) cervical pain. In cases of a of the neck documented the symptomatic cervical radicuVideo available at presence of a loop of left exlopathy caused by an anatomic WORLDNEUROSURGERY.org variation of the extracranial tracranial VA coming in direct VA, the best management (conservative vs. contact with the C6 nerve root. Cerebral ansurgical) is always a dilemma; it is often giography with left VA balloon occlusion hard to determine the actual pathogenesis test was performed and was well tolerated and the best form of management. by the patient. Surgical intervention was recommended, and a left cervical anterolateral approach (surgical technique has already been deCASE DESCRIPTION scribed by the senior author [4]) was choA 50-year-old, otherwise healthy woman sen to expose the anomalous loop. After a was referred to our institution because of an generous bony decompression, the loop 8-year history of progressive left C6 radicuwas identified, and the artery was mobilized lopathy refractory to other forms of treatand ultimately separated from the C6 nerve ment including C5-6 anterior cervical disroot removing the direct pulsatile comprescectomy performed in another institution 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
sion (Video 1 and Figures 4 and 5). Surgery was uneventful, and the patient experienced a complete resolution of pain by the third postoperative day. A neurologic examination performed at 12-month follow-up was unchanged, and the patient remains symptom-free.
DISCUSSION Asymptomatic anatomic variations of the VA are usually detected incidentally during evaluation for cervical pain or trauma (2, 5, 6, 21, 28). Very rarely, a VA loop causes direct nerve root compression into the nerve root foramen, resulting in its dilation. The foramen may be normally wide (5, 6, 13, 15, 17, 33, 34); however, the differential diagnosis of a cervical radiculopathy in which magnetic resonance imaging or CT scan shows a widened foramen should include lesions such as aneurysms, arteriovenous malformations, and neoplastic or malformative processes (7, 8, 10, 12, 24, 29-31). The efficacy of microvascular decompression in managing other painful cranial nerve syndromes is well recognized (18-20).
WORLD NEUROSURGERY 78 [3/4]: 375.e11-375.e13, SEPTEMBER/OCTOBER 2012www.WORLDNEUROSURGERY.org
375.e11
PEER-REVIEW SHORT REPORTS SALVATORE CHIBBARO ET AL.
VERTEBRAL ARTERY LOOP
Figure 1. Preoperative color three-dimensional coronal computed tomography angiography scan showing the bony erosion “black dot” with enlargement of the left C5-6 foramen.
However, after analyzing the pathogenesis of peripheral nerve syndromes and microvascular compression, some authors expressed doubts and perplexities (1, 20). A systematic review of the international literature revealed other reports of neurovascular compression caused by anatomic anomalies of an extracranial VA. Most of the available reports concern traumatic and nontraumatic compression processes, such as pseudoaneurysms and true aneurysms, arteriovenous malformations, and arterial dissections (6-8, 10, 12, 24, 27, 29-31). There are very few reports describing symptomatic anomalous V2 in the literature. One of the best examples is the case of V3 not passing through the transverse foramen on
Figure 2. Preoperative coronal computed tomography angiography scan showing the vertebral artery loop with enlargement of the left C5-6 foramen.
375.e12
www.SCIENCEDIRECT.com
Figure 3. Preoperative axial magnetic resonance imaging scan showing the vertebral artery loop in the foramen with direct root compression.
C1 but entering the dura underneath the arch of C1 and causing C2 radiculopathy (Arnold neuralgia) (35). Other examples reported include a large and tortuous VA compressing multiple cervical roots (5) and an abnormal ectatic VA compressing both accessory nerves (25). Other authors have reported a megadolichovertebral V2 widening the C4-5 intervertebral foramen and compressing the C5 nerve root (15). The incidence of symptomatic extracranial VA anomaly is unknown, but the overall
Figure 4. Postoperative coronal computed tomography angiography scan showing disappearance of the vertebral artery loop.
Figure 5. Postoperative sagittal computed tomography angiography scan showing disappearance of the vertebral artery loop.
incidence of these anomalies is, in our opinion, quite relevant; in one series of 300 VA angiograms, it was estimated to be 2%–3% (23). In our case, we concluded that the patient’s cervical radicular symptoms disappeared likely by the same mechanism characterizing the removal of a pulsating and compressing mass. The clinical presentation of compressing anomalies of the VA changes in relation to the pathologic level; in other words, a VA anomaly present in the lower cervical spine manifests with a cervical radiculopathy (9, 11, 16, 32), whereas a compression occurring in the upper segment may produce glossopharyngeal or occipital neuralgia, spasmodic torticollis, Horner syndrome, or dysphagia (10, 31, 32). Various forms of management have been proposed and carried out, such as decompressive laminectomy, arterial occlusion, arterial revascularization or reconstruction, and direct microvascular decompression (3, 4, 10, 26, 31, 32, 37). Because of our large experience of VA surgery, we felt comfortable in proceeding with direct anterolateral decompression. During this operation, after bone removal and anomalous loop exposure and mobilization, we keep open the option of interposing inert material to avoid pulsatile compression whenever this is found. In the case reported here, we did not interpose any inert material because there was a large amount of fibrotic tissue around the VA and the nerve root as a
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.12.002
PEER-REVIEW SHORT REPORTS SALVATORE CHIBBARO ET AL.
result of a previous surgery. Dissection was difficult through the fibrotic tissue, and the complete separation of these elements was impossible.
CONCLUSIONS VA anomalous loops may produce symptomatic compression of the adjacent nerve root. The current report supports the concept of peripheral nerve microvascular compression. In our opinion, the best management of a VA loop is the anterolateral approach with bony and direct microvascular decompression.
REFERENCES
VERTEBRAL ARTERY LOOP
12. Fournier JY, Amsler U, Weder B, Heilbronner R, Hildebrandt G: Extracranial vertebral artery dissection causing cervical root lesion. J Neuroimaging 10:125-128, 2000.
28. Lindsey RW, Piepmeier J, Burkus JK: Tortuosity of the vertebral artery: an adventitious finding after cervical trauma. A case report. J Bone Joint Surg (Am) 67:806-808, 1985.
13. Freilich M, Virapongse C, Kier EL, Sarwar M, Bhimani S: Foramen transversarium enlargement due to tortuosity of the vertebral artery: computed tomographic appearance. Spine 11:95-98, 1986.
29. Lot G, George B: Cervical neuromas with extradural components: surgical management in a series of 57 patients. Neurosurgery 41:813-822, 1997.
14. Ganiyusufoglu K, Kantarci M, Sirvanci M, Sildiroglu O, Alparslan L: Cervical radiculopathy caused by vertebral artery loop formation: multislice computed tomography angiography findings. J Comput Assist Tomogr 29:133-135, 2005. 15. Gatti JM, Juan LH, Bironne P, Glowinski J: Elargissement d’un trou de conjugaison cervical par une megadolichoartere vertebrale. Presse Med 12:2056, 1983. 16. Horgan MA, Hsu FP, Frank EH: Cervical radiculopathy secondary to a tortuous vertebral artery. Case illustration. J Neurosurg 89:489, 1998.
1. Adams CBT: Microvascular compression: an alternative view and hypothesis. J Neurosurg 57:1-12, 1989.
17. Hyyppä SE, Laasonen EM, Halonen V: Erosion of cervical vertebrae caused by elongated and tortuous vertebral arteries. Neuroradiology 7:49-51, 1974.
2. Anderson RE, Shealy CN: Cervical pedicle erosion and rootlet compression caused by a tortuous vertebral artery. Radiology 96:537-538, 1970.
18. Jannetta PJ: Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. J Neurosurg 26:159-162, 1967.
3. Barratt JG: Enlargement of cervical intervertebral foramina by coiling of the vertebral artery. Australas Radiol 18:171-174, 1974.
19. Jannetta PJ: Neurovascular compression in cranial nerve and systemic disease. Ann Surg 192:518-525, 1980.
4. Bruneau M, Cornelius JF, George B: Microsurgical cervical nerve root decompression by anterolateral approach. Neurosurgery 58(1 Suppl):ONS108ONS113, 2006.
20. Jannetta PJ: Trigeminal neuralgia: treatment by microvascular decompression. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. New York: McGrawHill; 1996:3961-3968.
5. Cooper DF: Bone erosion of the cervical vertebrae secondary to tortuosity of the vertebral artery. Case report. J Neurosurg 53:106-108, 1980.
21. Jarmundowicz W: Pathological changes and their sequelae in the spinal nerve roots, spinal cord and vertebral artery in cervical spondylosis [in Polish]. Neurol Neurochir Pol 20:59-63, 1986.
6. Danziger J, Bloch S: The widened cervical intervertebral foramen. Radiology 116:671-674, 1975. 7. De Bray JM, Penisson-Besnier I, Giroud M, Klein J, Tanguy JY, Pasco A, Dubas F: Cervical deficit radiculopathy in 3 cases of vertebral artery dissection [in French]. Rev Neurol (Paris) 154:762-766, 1998. 8. Decker RE, San Augustin W, Epstein JA: Spinal epidural venous angioma causing foraminal enlargement and erosion of vertebral body. Case report. J Neurosurg 49:605-606, 1978. 9. Detwiler PW, Porter RW, Harrington TR, Sonntag VK, Spetzler RF: Vascular decompression of a vertebral artery loop producing cervical radiculopathy. Case report. J Neurosurg 89:485-488, 1998. 10. Detwiler K, Godersky JC, Gentry L: Pseudoaneurysm of the extracranial vertebral artery. Case report. J Neurosurg 67:935-939, 1987. 11. Duthel R, Tudor C, Motuo-Fotso MJ, Brunon J: Cervical root compression by a loop of the vertebral artery. Case report. Neurosurgery 35:140-142, 1994.
30. Rahimizadeh A, Sabouri-Daylami M, Amir-Moezi N, Haddadian K: Traumatic aneurysm of the extracranial vertebral artery. Neurosurgery 19:628-629, 1986. 31. Reyes RA, Moser FG, Sachs DP, Boehm FH: Direct repair of an extracranial vertebral artery pseudoaneurysm: case report and review of the literature. Neurosurgery 26:528-533, 1990. 32. Ross DA, Olsen WL, Halbach V, Rosegay H, Pitts LH: Cervical root compression by a traumatic pseudoaneurysm of the vertebral artery. Case report. Neurosurgery 22:414-417, 1988. 33. Salvador MR, Solé-Llenas J, Quera Salvá MA: Bilateral bone erosion of the cervical vertebrae caused by tortuosity of the vertebral arteries. Neurochirurgia 24:212-213, 1981. 34. Schima W, Stiglbauer R, Trattnig S, Heimberger K, Kramer J, Imhof H: Case report: cervical intervertebral foramen widening caused by vertebral artery tortuosity— diagnosis with MR and colour-coded Doppler sonography. Br J Radiol 66:165-167, 1993. 35. Sharma RR, Parekh HC, Prabhu S, Gurusinghe NT, Bertolis G: Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report. J Neurosurg 78:669-672, 1993. 36. Tokuda K, Miyasaka K, Abe H, Abe S, Takei H, Sugimoto S, Tsuru M: Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:410-413, 1985.
22. Kalkan E, Paksoy Y, Reisli R, Topatan H: Distress triggered cervical root compression pain by looped vertebral artery. Neurol India 53:367-368, 2005.
37. Vincentelli F, Caruso G, Rabehanta PB, Rey M: Surgical treatment of a rare congenital anomaly of the vertebral artery: case report and review of the literature. Neurosurgery 28:416-420, 1991.
23. Kauppila LI, Penttilä A: Postmortem angiographic study of degenerative vascular changes in arteries supplying the cervicobrachial region. Ann Rheum Dis 53:94-99, 1994.
38. Yousry TA, Seelos K, Widenka DC, Steiger HJ: Vertebral artery loop causing cervical compression. AJNR Am J Neuroradiol 17:1800-1801, 1996.
24. Kikuchi K, Kowada M: Nontraumatic extracranial aneurysm of the vertebral artery. Surg Neurol 19: 425-427, 1983. 25. Kitagawa M, Nakagawa Y, Kitaoka K, Kobayashi N, Ishikawa T, Nagashima M: Accessory nerve paralysis due to compression of the fenestrated vertebral artery [in Japanese]. No Shinkei Geka 16:1173-1177, 1988. 26. Kiwerski J: Anterior operations in cervicarthrosis and vertebral artery compression. Clin Orthop Relat Res (272):95-99, 1991. 27. Korinth MC, Mull M: Vertebral artery loop causing cervical radiculopathy. Surg Neurol 67:172-173, 2007.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 2 April 2011; accepted 01 December 2011; published online 10 December 2011 Citation: World Neurosurg. (2012) 78, 3/4:375.e11-375.e13. DOI: 10.1016/j.wneu.2011.12.002 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY 78 [3/4]: 375.e11-375.e13, SEPTEMBER/OCTOBER 2012www.WORLDNEUROSURGERY.org
375.e13
Vertebral Artery Loop—A Cause of Cervical Radiculopathy Salvatore Chibbaro1, Giuseppe Mirone1, Muneyoshi Yasuda2, Marco Marsella3, Paolo Di Emidio1, Bernard George1
Key words 䡲 Anterolateral approach 䡲 Cervical radiculopathy 䡲 Loop 䡲 Microvascular decompression 䡲 Vertebral artery Abbreviations and Acronyms CT: Computed tomography VA: Vertebral artery From the 1Department of Neurosurgery, Laribosiere University Hospital, Paris, France; 2Department of Neurosurgery, Aichi Medical University, Aichi, Japan; and 3Centre for Neurosciences, Tucson, Arizona, USA To whom correspondence should be addressed: Salvatore Chibbaro, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2012) 78, 3/4:375.e11-375.e13. DOI: 10.1016/j.wneu.2011.12.002 Supplementary digital content available online.
䡲 OBJECTIVE: To report a case of cervical radiculopathy caused by an anomalous vertebral artery (VA) and illustrate the efficacy of microvascular decompression by the anterolateral approach. 䡲 METHODS: A 50-year-old woman was referred because of an 8-year history of progressive left C6 radiculopathy refractory to other forms of treatment, including C5-6 anterior cervical discectomy. Clinical and radiologic evaluation showed an abnormally tortuous loop of V2 causing direct neurovascular compression. 䡲 RESULTS: A left cervical anterolateral approach was used to expose the anomalous loop. After a generous bony decompression, the loop was identified, and the artery was mobilized and ultimately separated from the C6 nerve root removing the direct pulsatile compression. 䡲 CONCLUSIONS: Cervical root compression by an aberrant or anomalous extracranial VA is a rare cause of radiculopathy. The best management of such lesions is the anterolateral approach with bony and direct microvascular decompression.
Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
and followed by conservative treatment because of the persistence of her symptoms. Neurologic examination was unremarkable INTRODUCTION except for left upper extremity severe paresthesias on head flexion and rotation. Plain Vertebral artery (VA) anomaly or tortuosity cervical x-ray showed enlargement of the is a rare cause of cervical radiculopathy (2, left C5-6 foramen, which was confirmed by 5, 6, 9, 11, 13, 14, 16, 17, 22, 33-38). It may be computed tomography (CT) scan (Figures 1 congenital or acquired, and it is usually deand 2). In addition, CT antected incidentally as part of giography and magnetic resoinvestigation for trauma or nance angiography (Figure 3) cervical pain. In cases of a of the neck documented the symptomatic cervical radicuVideo available at presence of a loop of left exlopathy caused by an anatomic WORLDNEUROSURGERY.org variation of the extracranial tracranial VA coming in direct VA, the best management (conservative vs. contact with the C6 nerve root. Cerebral ansurgical) is always a dilemma; it is often giography with left VA balloon occlusion hard to determine the actual pathogenesis test was performed and was well tolerated and the best form of management. by the patient. Surgical intervention was recommended, and a left cervical anterolateral approach (surgical technique has already been deCASE DESCRIPTION scribed by the senior author [4]) was choA 50-year-old, otherwise healthy woman sen to expose the anomalous loop. After a was referred to our institution because of an generous bony decompression, the loop 8-year history of progressive left C6 radicuwas identified, and the artery was mobilized lopathy refractory to other forms of treatand ultimately separated from the C6 nerve ment including C5-6 anterior cervical disroot removing the direct pulsatile comprescectomy performed in another institution 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
sion (Video 1 and Figures 4 and 5). Surgery was uneventful, and the patient experienced a complete resolution of pain by the third postoperative day. A neurologic examination performed at 12-month follow-up was unchanged, and the patient remains symptom-free.
DISCUSSION Asymptomatic anatomic variations of the VA are usually detected incidentally during evaluation for cervical pain or trauma (2, 5, 6, 21, 28). Very rarely, a VA loop causes direct nerve root compression into the nerve root foramen, resulting in its dilation. The foramen may be normally wide (5, 6, 13, 15, 17, 33, 34); however, the differential diagnosis of a cervical radiculopathy in which magnetic resonance imaging or CT scan shows a widened foramen should include lesions such as aneurysms, arteriovenous malformations, and neoplastic or malformative processes (7, 8, 10, 12, 24, 29-31). The efficacy of microvascular decompression in managing other painful cranial nerve syndromes is well recognized (18-20).
WORLD NEUROSURGERY 78 [3/4]: 375.e11-375.e13, SEPTEMBER/OCTOBER 2012www.WORLDNEUROSURGERY.org
375.e11
PEER-REVIEW SHORT REPORTS SALVATORE CHIBBARO ET AL.
VERTEBRAL ARTERY LOOP
Figure 1. Preoperative color three-dimensional coronal computed tomography angiography scan showing the bony erosion “black dot” with enlargement of the left C5-6 foramen.
However, after analyzing the pathogenesis of peripheral nerve syndromes and microvascular compression, some authors expressed doubts and perplexities (1, 20). A systematic review of the international literature revealed other reports of neurovascular compression caused by anatomic anomalies of an extracranial VA. Most of the available reports concern traumatic and nontraumatic compression processes, such as pseudoaneurysms and true aneurysms, arteriovenous malformations, and arterial dissections (6-8, 10, 12, 24, 27, 29-31). There are very few reports describing symptomatic anomalous V2 in the literature. One of the best examples is the case of V3 not passing through the transverse foramen on
Figure 2. Preoperative coronal computed tomography angiography scan showing the vertebral artery loop with enlargement of the left C5-6 foramen.
375.e12
www.SCIENCEDIRECT.com
Figure 3. Preoperative axial magnetic resonance imaging scan showing the vertebral artery loop in the foramen with direct root compression.
C1 but entering the dura underneath the arch of C1 and causing C2 radiculopathy (Arnold neuralgia) (35). Other examples reported include a large and tortuous VA compressing multiple cervical roots (5) and an abnormal ectatic VA compressing both accessory nerves (25). Other authors have reported a megadolichovertebral V2 widening the C4-5 intervertebral foramen and compressing the C5 nerve root (15). The incidence of symptomatic extracranial VA anomaly is unknown, but the overall
Figure 4. Postoperative coronal computed tomography angiography scan showing disappearance of the vertebral artery loop.
Figure 5. Postoperative sagittal computed tomography angiography scan showing disappearance of the vertebral artery loop.
incidence of these anomalies is, in our opinion, quite relevant; in one series of 300 VA angiograms, it was estimated to be 2%–3% (23). In our case, we concluded that the patient’s cervical radicular symptoms disappeared likely by the same mechanism characterizing the removal of a pulsating and compressing mass. The clinical presentation of compressing anomalies of the VA changes in relation to the pathologic level; in other words, a VA anomaly present in the lower cervical spine manifests with a cervical radiculopathy (9, 11, 16, 32), whereas a compression occurring in the upper segment may produce glossopharyngeal or occipital neuralgia, spasmodic torticollis, Horner syndrome, or dysphagia (10, 31, 32). Various forms of management have been proposed and carried out, such as decompressive laminectomy, arterial occlusion, arterial revascularization or reconstruction, and direct microvascular decompression (3, 4, 10, 26, 31, 32, 37). Because of our large experience of VA surgery, we felt comfortable in proceeding with direct anterolateral decompression. During this operation, after bone removal and anomalous loop exposure and mobilization, we keep open the option of interposing inert material to avoid pulsatile compression whenever this is found. In the case reported here, we did not interpose any inert material because there was a large amount of fibrotic tissue around the VA and the nerve root as a
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.12.002
PEER-REVIEW SHORT REPORTS SALVATORE CHIBBARO ET AL.
result of a previous surgery. Dissection was difficult through the fibrotic tissue, and the complete separation of these elements was impossible.
CONCLUSIONS VA anomalous loops may produce symptomatic compression of the adjacent nerve root. The current report supports the concept of peripheral nerve microvascular compression. In our opinion, the best management of a VA loop is the anterolateral approach with bony and direct microvascular decompression.
REFERENCES
VERTEBRAL ARTERY LOOP
12. Fournier JY, Amsler U, Weder B, Heilbronner R, Hildebrandt G: Extracranial vertebral artery dissection causing cervical root lesion. J Neuroimaging 10:125-128, 2000.
28. Lindsey RW, Piepmeier J, Burkus JK: Tortuosity of the vertebral artery: an adventitious finding after cervical trauma. A case report. J Bone Joint Surg (Am) 67:806-808, 1985.
13. Freilich M, Virapongse C, Kier EL, Sarwar M, Bhimani S: Foramen transversarium enlargement due to tortuosity of the vertebral artery: computed tomographic appearance. Spine 11:95-98, 1986.
29. Lot G, George B: Cervical neuromas with extradural components: surgical management in a series of 57 patients. Neurosurgery 41:813-822, 1997.
14. Ganiyusufoglu K, Kantarci M, Sirvanci M, Sildiroglu O, Alparslan L: Cervical radiculopathy caused by vertebral artery loop formation: multislice computed tomography angiography findings. J Comput Assist Tomogr 29:133-135, 2005. 15. Gatti JM, Juan LH, Bironne P, Glowinski J: Elargissement d’un trou de conjugaison cervical par une megadolichoartere vertebrale. Presse Med 12:2056, 1983. 16. Horgan MA, Hsu FP, Frank EH: Cervical radiculopathy secondary to a tortuous vertebral artery. Case illustration. J Neurosurg 89:489, 1998.
1. Adams CBT: Microvascular compression: an alternative view and hypothesis. J Neurosurg 57:1-12, 1989.
17. Hyyppä SE, Laasonen EM, Halonen V: Erosion of cervical vertebrae caused by elongated and tortuous vertebral arteries. Neuroradiology 7:49-51, 1974.
2. Anderson RE, Shealy CN: Cervical pedicle erosion and rootlet compression caused by a tortuous vertebral artery. Radiology 96:537-538, 1970.
18. Jannetta PJ: Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. J Neurosurg 26:159-162, 1967.
3. Barratt JG: Enlargement of cervical intervertebral foramina by coiling of the vertebral artery. Australas Radiol 18:171-174, 1974.
19. Jannetta PJ: Neurovascular compression in cranial nerve and systemic disease. Ann Surg 192:518-525, 1980.
4. Bruneau M, Cornelius JF, George B: Microsurgical cervical nerve root decompression by anterolateral approach. Neurosurgery 58(1 Suppl):ONS108ONS113, 2006.
20. Jannetta PJ: Trigeminal neuralgia: treatment by microvascular decompression. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. New York: McGrawHill; 1996:3961-3968.
5. Cooper DF: Bone erosion of the cervical vertebrae secondary to tortuosity of the vertebral artery. Case report. J Neurosurg 53:106-108, 1980.
21. Jarmundowicz W: Pathological changes and their sequelae in the spinal nerve roots, spinal cord and vertebral artery in cervical spondylosis [in Polish]. Neurol Neurochir Pol 20:59-63, 1986.
6. Danziger J, Bloch S: The widened cervical intervertebral foramen. Radiology 116:671-674, 1975. 7. De Bray JM, Penisson-Besnier I, Giroud M, Klein J, Tanguy JY, Pasco A, Dubas F: Cervical deficit radiculopathy in 3 cases of vertebral artery dissection [in French]. Rev Neurol (Paris) 154:762-766, 1998. 8. Decker RE, San Augustin W, Epstein JA: Spinal epidural venous angioma causing foraminal enlargement and erosion of vertebral body. Case report. J Neurosurg 49:605-606, 1978. 9. Detwiler PW, Porter RW, Harrington TR, Sonntag VK, Spetzler RF: Vascular decompression of a vertebral artery loop producing cervical radiculopathy. Case report. J Neurosurg 89:485-488, 1998. 10. Detwiler K, Godersky JC, Gentry L: Pseudoaneurysm of the extracranial vertebral artery. Case report. J Neurosurg 67:935-939, 1987. 11. Duthel R, Tudor C, Motuo-Fotso MJ, Brunon J: Cervical root compression by a loop of the vertebral artery. Case report. Neurosurgery 35:140-142, 1994.
30. Rahimizadeh A, Sabouri-Daylami M, Amir-Moezi N, Haddadian K: Traumatic aneurysm of the extracranial vertebral artery. Neurosurgery 19:628-629, 1986. 31. Reyes RA, Moser FG, Sachs DP, Boehm FH: Direct repair of an extracranial vertebral artery pseudoaneurysm: case report and review of the literature. Neurosurgery 26:528-533, 1990. 32. Ross DA, Olsen WL, Halbach V, Rosegay H, Pitts LH: Cervical root compression by a traumatic pseudoaneurysm of the vertebral artery. Case report. Neurosurgery 22:414-417, 1988. 33. Salvador MR, Solé-Llenas J, Quera Salvá MA: Bilateral bone erosion of the cervical vertebrae caused by tortuosity of the vertebral arteries. Neurochirurgia 24:212-213, 1981. 34. Schima W, Stiglbauer R, Trattnig S, Heimberger K, Kramer J, Imhof H: Case report: cervical intervertebral foramen widening caused by vertebral artery tortuosity— diagnosis with MR and colour-coded Doppler sonography. Br J Radiol 66:165-167, 1993. 35. Sharma RR, Parekh HC, Prabhu S, Gurusinghe NT, Bertolis G: Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report. J Neurosurg 78:669-672, 1993. 36. Tokuda K, Miyasaka K, Abe H, Abe S, Takei H, Sugimoto S, Tsuru M: Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:410-413, 1985.
22. Kalkan E, Paksoy Y, Reisli R, Topatan H: Distress triggered cervical root compression pain by looped vertebral artery. Neurol India 53:367-368, 2005.
37. Vincentelli F, Caruso G, Rabehanta PB, Rey M: Surgical treatment of a rare congenital anomaly of the vertebral artery: case report and review of the literature. Neurosurgery 28:416-420, 1991.
23. Kauppila LI, Penttilä A: Postmortem angiographic study of degenerative vascular changes in arteries supplying the cervicobrachial region. Ann Rheum Dis 53:94-99, 1994.
38. Yousry TA, Seelos K, Widenka DC, Steiger HJ: Vertebral artery loop causing cervical compression. AJNR Am J Neuroradiol 17:1800-1801, 1996.
24. Kikuchi K, Kowada M: Nontraumatic extracranial aneurysm of the vertebral artery. Surg Neurol 19: 425-427, 1983. 25. Kitagawa M, Nakagawa Y, Kitaoka K, Kobayashi N, Ishikawa T, Nagashima M: Accessory nerve paralysis due to compression of the fenestrated vertebral artery [in Japanese]. No Shinkei Geka 16:1173-1177, 1988. 26. Kiwerski J: Anterior operations in cervicarthrosis and vertebral artery compression. Clin Orthop Relat Res (272):95-99, 1991. 27. Korinth MC, Mull M: Vertebral artery loop causing cervical radiculopathy. Surg Neurol 67:172-173, 2007.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 2 April 2011; accepted 01 December 2011; published online 10 December 2011 Citation: World Neurosurg. (2012) 78, 3/4:375.e11-375.e13. DOI: 10.1016/j.wneu.2011.12.002 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY 78 [3/4]: 375.e11-375.e13, SEPTEMBER/OCTOBER 2012www.WORLDNEUROSURGERY.org
375.e13