Vertebral artery cervical spondylotic vertebralartery (CSV) 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 insufficient blood supply to the brain due to the 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. Zhang Qiang, Department of Orthopedics, Beijing Ditan Hospital There are few reports on the typology of vertebral artery cervical spondylosis, and there is no uniform typology at present. 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 cervical spondylosis are of wide origin and complex, and can be seen in the inner ear, brainstem, cerebellum, mesencephalon, occipital lobe of the brain, temporal lobe and spinal cord. It may include occipital pain and episodes of vertigo, nausea, tinnitus and deafness, etc. Sudden collapse may occur at the same time, and the above symptoms occur every time 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 can 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 upper cervical spine or other cervical spine at the back of the neck with displacement, swelling and pressure pain in the corresponding joint capsule can also be one of the diagnostic criteria. 2. Auxiliary examination 2.1 X-ray radiography Orthopantomographs can show degenerative changes of the hook vertebral joint, such as the hook protrusion, and the joint space is blurred and narrowed. Lateral radiographs can show changes in the physiological curvature of the cervical spine, such as straightening of the curvature, retroflexion, hyperbolicity, etc., narrowing of the intervertebral foramen and lacunar sign, i.e. hyperplastic and hypertrophied crooked processes projected 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, among which the X-ray displacement changes of cervical 3, 4 and cervical 4, 5 are the most diagnostic. 2.2 CT scan shows that the osteophytes of the hook vertebral joint develop anteriorly and externally and protrude into the bony transverse foramen, with degenerative stenosis and deformation of the bilateral transverse foramina.CT vertebral artery angiography (CTA) was first applied to the intracranial spine, but due to the slow speed of conventional CT scan and the inseparable iodine-containing contrast agent for vascular enhancement scan, the development of CTA was limited and delayed the development of enhanced nuclear magnetic angiography (MRA). development. 2.3 Trancranial Color Doppler (TCD) TCD is an ultrasound spectral Doppler method to detect the hemodynamics and flow parameters of the major arteries at the skull base, which has the advantages of non-invasive, small size, low cost, repeatability and dynamic observation. It can also be used as a basis for simple typing of cervical spondylosis and can exclude VA itself to facilitate 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 in 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 artery angiography 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, 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, tortuosity 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, course and lumen internal conditions in two dimensions and measures the vertebral artery internal diameter, and 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, each display segment of the vertebral artery The positive manifestations of CSA on ultrasound: (1) two-dimensional images: vertebral artery stenosis, internal diameter <3 mm, and curvature of vertebral artery travel, which is obvious in the vertebral segment; (2) spectral Doppler: vertebral artery PI (2) Spectral Doppler: increased PI and RI of vertebral artery (PI>1.50 and RI>0.74 in cervical segment, PI>1.30 and RI>0.72 in vertebral segment), decreased flow velocity of vertebral artery when the blood supply of vertebral artery is obviously insufficient, mainly in vertebral segment, PSV<35 cm/s, Vm<20 cm/s and EDV<10 cm/s, abnormal spectral pattern of vertebral artery; (3) Color Doppler: color flow bundle of vertebral artery (3) color Doppler: thinning, reduced 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 resolved, which may not be positive. 3, Diagnostic points of vertebral artery cervical spondylosis: ① sudden collapse with cervical vertigo; ② positive rotational neck test; ③ X-rays show segmental instability or osteophytes of the hook vertebral joint; ④ sympathetic symptoms; ⑤ insufficient blood supply to the vertebral basilar artery caused by compression of the vertebral artery segment I and segment III, except for ophthalmogenic and otogenic vertigo.