Vertebral artery cervical spondylosis is the most controversial type in recent years, and there is no uniform standard for diagnosis, although the etiology and pathology of CSA are complex and diverse, eventually leading to a series of symptoms due to insufficient blood supply to the vertebrobasilar artery. It mainly refers to those who have inadequate cerebral blood supply due to stimulation and compression of the vertebral artery by secondary pathological changes such as osteophytes and lateral disc herniation triggered by degenerative changes of the cervical hook vertebral joint.
There are few reports on the typology of vertebral artery cervical spondylosis, and there is no uniform typology. Professor Yang Keqin et al. divided it into three types: ① vertebral artery cervical spondylosis; ② vertebral artery-nerve root type; ③ vertebral artery-sympathetic type.
1. Symptoms and signs.
The clinical symptoms of vertebral artery-type cervical spondylosis are of wide origin and complex performance, and can be seen in the inner ear, brainstem, cerebellum, mesencephalon, occipital lobe of the brain, temporal lobe and spinal cord. There may be occipital pain and episodes of vertigo, nausea, tinnitus and deafness, etc. Sudden collapse may occur at the same time, and the above symptoms appear whenever the head is overextended or rotated. After vertebral artery thrombosis, lateral medullary syndrome may appear, which is characterized by ataxia, difficulty in swallowing, abnormal sensation of the diseased side, soft palate paralysis and Horner’s syndrome, as well as contralateral limb pain and disturbance of temperature sensation. There may be visual confusion, posterior cranial fossa neurological symptoms, hoarseness, numbness, difficulty in swallowing, and some cases may have motoneurological symptoms and diplopia. There may also be symptoms such as memory loss, forgetfulness, poor sleep and dreaminess, and easy to be frightened.
Burke believes that turning the head and neck to the opposite side will aggravate the stenosis or obstruction of the vertebral artery between C1 and 2 and cause symptoms. If neck movement can induce or aggravate general symptoms, or if it is accompanied by neck and shoulder, occipital disease and nerve root symptoms, or if there are other manifestations of brainstem damage, and if there is a typical positive vertebral artery twist test on examination, this is the initial diagnosis. Some scholars also believe that palpation of the posterior cervical region with displacement of the upper cervical spine or other cervical vertebrae, swelling of the corresponding joint capsule and pressure pain can also be one of the diagnostic criteria.
2.Auxiliary examination.
2.1 X-ray plain film examination.
The orthopantomograph can show degenerative changes of the hook vertebral joint such as the hook protrusion, and the joint space is blurred and narrowed. The lateral film can have changes in the physiological curvature of the cervical spine, such as curvature straightening, retroflexion, hyperbolicity, etc., narrowing of the intervertebral foramen and lacunar sign, i.e., hyperplastic and hypertrophied crooks projecting on the superior vertebral body, osteophytes and sclerosis at the transverse foramen and interarticular sulcus, narrowing of the small joint space, etc. Other scholars have observed that the disease is triggered by the displacement caused by cervical degeneration and instability of the cervical spine, in which the X-ray displacement changes of cervical 3, 4 and cervical 4, 5 have the most diagnostic significance.
2.2 CT manifestations.
CT scan shows that the osteophytes of the hook vertebral joint develop anterolaterally and protrude into the bony transverse foramen, with degenerative stenosis and deformation of the transverse foramen bilaterally.CT vertebral artery angiography (CTA) was first applied to the intracranial spine, and because of the slow speed of conventional CT scan and the inseparability of the vascular enhancement scan with iodine-containing contrast agent, the development of CTA was limited and delayed the development of enhanced nuclear magnetic angiography (MRA).
2.3 Transcranial Color Doppler (TCD).
The TCD technique is an examination method that uses ultrasound spectral Doppler to detect the hemodynamics of the main arteries at the skull base and each flow parameter, which has the advantages of non-invasive, small size of the instrument, low examination cost, repeatability and dynamic observation, etc. TCD can directly obtain the hemodynamic index of the vertebrobasilar artery (VBA) and determine the blood supply status of VBA more accurately, and has the potential to replace vertebral artery (VA) angiography, and can be used as It can be used as a basis for simple classification of cervical spondylosis, and can also exclude VA itself for differential diagnosis of cervical spondylosis. Many authors have concluded that peak systolic flow velocity, mean flow velocity, and end-diastolic flow velocity are significantly slower in patients with CSA during episodes. Some authors also found that the TCD in the head-turned state in the CSA group showed altered VBA insufficiency of blood supply, suggesting that testing with different head positions is needed for CSA patients, and that the neck-turn test is important for the diagnosis of VBA ischemia and the characterization of microsurgical treatment.
2.4 Vertebral arteriography.
Including general angiography and digital subtraction angiography (DSA) is not only a reliable test for this disease. It can also provide a reliable basis for the development of surgical plans. Especially, the latter is more accurate and clearer. It has been promoted and has now become a routine test. The DSA technology developed in recent years in combination with automatic computer analysis technology has greatly improved the accuracy of detection, and is also more conducive to the development of interventional therapy. Compared with traditional angiography, this method has the advantages of better contrast, immediate visualization, safety and convenience, and fewer complications. With the rise of DSA and interventional radiology, this method has become an important part of clinical diagnosis and treatment of CSA. DSA has high accuracy and clarity, and can accurately detect the site and extent of vertebral artery stenosis and torsion, clarify the relationship with surrounding tissues, determine the cause of vertebral artery stenosis and torsion, and provide a reliable basis for the development of surgical plans. The rate of diagnosis can be improved if the results are also compared with the results of the neck rotation test. Turning the neck is an important tool for diagnosing CSA. Turning the neck can cause stenosis of the vertebral artery or aggravate this lesion, and the positive rate is generally high when turning to the affected side.
2.5 Magnetic resonance (MR).
Its advantages can directly show the involvement of the vertebral artery: vertebral artery compression, displacement, tortuosity, obstruction, deformity or atherosclerosis, without contrast, non-invasive non-invasive examination, and free from ionizing radiation, safe and reliable, simple operation, can be in any direction line video dynamic observation of the vertebral artery situation, avoid overlap and artifact interference, clear imaging, short time. The disadvantages are: expensive, not easy to locate, longer examination time, higher technical requirements, some subtle lesions may be missed, the grassroots units are not equipped to use. MRI axial can show the vertebral artery canal diameter thinning, bilateral asymmetry, determine the compression originated from the transverse foramen or the hook synapse. The coronal view can show whether the involvement of the vertebral artery is bony or tumor compression, and directly shows the compression of the vertebral artery itself, making it easy to localize the involved segment preoperatively. Magnetic resonance angiography (MRA) of the vertebral artery has been clinically used since the early nineties, and unlike DSA and CTA, MRA can be used to examine vertebral artery injury and lesions without injecting iodine-containing contrast, without allergy or radiation damage, and can be performed simultaneously with cranial and cervical MRI to obtain more information. MRA can clearly display the entire vertebral artery and can show changes such as compression, stenosis, torsion and abnormalities in the course of the vertebral artery in patients with CSA, which is of high diagnostic value for CSA caused by soft tissue hyperplasia and degeneration. The literature reports that its sensitivity is 97% and specificity is 98.9% for the diagnosis of vertebrobasilar artery (VBA). However, some authors believe that MRA is, after all, a kind of reconstructed vascular imaging, and some unavoidable factors, such as the selection of imaging parameters, movement artifacts, limitations of the maximum density (MIP) reconstruction method itself, and the influence of the direction of vascular travel, may affect the quality of the images and even the analysis results, but in severe obstructive cases, MRA combined with color Doppler ultrasound can be used instead of vertebral arteriography. MRA has a higher positive diagnostic rate than DSA for manifestations such as tortuous deformation of the vertebral artery in cervical instability, and it is easy to diagnose diffuse, long-segment stenosis and occlusion, and has a low diagnostic rate for stenosis or non-occlusive lesions in local microsites.
2.6 Color Doppler flow imaging (CDFI).
CDFI is a noninvasive diagnostic technique that not only displays the flow spectrum like TCD, but also dynamically displays the vertebral artery vascular morphology, alignment and lumen interior in two dimensions, and measures the vertebral artery internal diameter. Color Doppler can display the color flow filling of the vertebral artery and the width of the flow beam, and according to the guidance of color Doppler, pulse spot sampling of each display segment of the vertebral artery and acquisition of the Doppler spectrum. Positive ultrasound findings of CSA: (1) 2D images: vertebral artery stenosis, internal diameter <3 mm, vertebral artery curvature, evident in the vertebral segment; (2) spectral Doppler: increased PI and RI in the vertebral artery (PI>1.50 in the cervical segment, RI>0.74 in the vertebral artery) (2) Spectral Doppler: increased PI and RI of the vertebral artery (PI>1.50, RI>0.74 in the cervical segment, PI>1.30, RI>0.72 in the vertebral segment), decreased flow velocity of the vertebral artery when the blood supply is significantly inadequate, mainly in the vertebral segment, PSV<35 cm/s, Vm<20 cm/s and EDV<10 cm/s, and abnormal spectral pattern of the vertebral artery; (3) Color Doppler: thinning of the color flow beam, decreased flow velocity and curvature of the vertebral artery. In patients with unilateral vertebral artery stenosis with progressively increasing stenosis, the contralateral (healthy) vertebral artery internal diameter may gradually widen, flow velocity increase, and PI and RI decrease to increase the blood supply into the cranium. Therefore, color Doppler can not only detect the degree of unilateral vertebral artery spasm or stenosis, but also clarify whether the contralateral vertebral artery is compensated and its degree of compensation, and determine the side of vertebral artery involvement and its different etiologies and manifestations. However, ultrasound Doppler has a certain detection rate for CSA, especially for those whose vertebral artery spasm has been relieved, and there may be no positive performance.
3. Diagnostic points of vertebral artery type cervical spondylosis.
(1) previous episodes of sudden collapse with cervical vertigo; (2) positive rotational neck test; (3) X-rays showing segmental instability or osteophytes of the hook vertebral joint; (4) mostly accompanied by sympathetic symptoms; (5) insufficient blood supply to the vertebral basilar artery caused by compression of vertebral artery segment I and vertebral artery segment III, except for ophthalmogenic and otogenic vertigo.