Tailored vertebral artery mobilisation in complex craniovertebral junction surgery- a blessing in disguise

Background: The surgical exposure of the complex craniovertebral junction (CVJ) requires manipulation of the neurovascular structures and the atlantoaxial joint (C1-C2 joint) to access the pathological region. To achieve adequate C1-C2 joint manipulation, the mobilization of the vertebral artery (VA) is mandatory. The present retrospective observational study aims to describe the surgical nuances and share the experience of tailored vertebral artery mobilization for efficient management of CVJ pathologies. Methodology: All the operated cases of CVJ anomalies from January 2019 to December 2023 were included. The clinico-radiological scan, including their three-dimensional computerized tomography (3-D CT), was recorded with a VA angiogram course. The intraoperative details of these patients were collected from the neurosurgery operative records. The patients' details were obtained either by the outpatient department or by telephone. Results: A total of 18 patients were analyzed with a mean age of 49.21±18.30 years. The median pre-operative Nurick's grade amongst the study population was 4 (IQR: 3,4 and Range: 3-5). Twelve patients underwent bilateral vertebral artery mobilization, whereas the remaining six underwent unilateral vertebral artery mobilization. After surgery, at three months of follow-up visit, the median post-operative Nurick's grade was 3 (IQR: 2,3 and Range: 2-5), which was statistically significant (P=0.002). The mean follow-up duration was 23.2 months without any procedure-related mortality. Conclusions: Tailored vertebral artery mobilisation (VAM) is an excellent surgical strategy for negotiating through the atlantoaxial joint in a specific group of patients. It offers safe access to managing CVJ anomalies, keeping in mind the principles of micro neurosurgery.