Intersegmental Artery Research Articles

Anatomic variation of the vertebral artery: a case involving a persistent first intersegmental artery at C1-C2.

We observed a rare anatomical variation of a persistent first intersegmental vertebral artery in the C1-C2 region in an elderly Chinese male cadaver at Changzhi Medical College. In this case, the vertebral artery, rather than passing through the transverse foramen of the atlas, exits the transverse foramen of C2 and enters the spinal canal at the lower portion of the C1 posterior arch. The original transverse foramen of C1 was filled with connective tissue. This report details the anatomical characteristics of this abnormal vertebral artery and discusses its anatomical, surgical, and developmental implications. We describe the detailed morphological features of a rare VA variant and discuss the anatomical, clinical, and developmental aspects of this case. A case of head dissection. The anatomical characteristics of the VA were studied and documented, and anatomical measurements were collected. In this case, the vertebral artery, rather than passing through the transverse foramen of the atlas, exits the transverse foramen of C2 and enters the spinal canal at the lower portion of the C1 posterior arch. The original transverse foramen of C1 was filled with connective tissue. The anomalous development of segmental arteries in our case is linked to failures in the embryonic sclerotome reconstruction during development and failure.

Commentary: Bilateral High-Riding Persistent First Cervical Intersegmental Arteries in a Case of Klippel-Feil Syndrome: The Technique of Vertebral Artery Mobilization for C1-C2 Reduction and Fusion for Atlantoaxial Dislocation and Basilar Invagination: 2-Dimensional Operative Video

Commentary: Bilateral High-Riding Persistent First Cervical Intersegmental Arteries in a Case of Klippel-Feil Syndrome: The Technique of Vertebral Artery Mobilization for C1-C2 Reduction and Fusion for Atlantoaxial Dislocation and Basilar Invagination: 2-Dimensional Operative Video

Commentary: Bilateral High-Riding Persistent First Cervical Intersegmental Arteries in a Case of Klippel-Feil Syndrome: The Technique of Vertebral Artery Mobilization for C1-C2 Reduction and Fusion for Atlantoaxial Dislocation and Basilar Invagination: 2-Dimensional Operative Video

Commentary: Bilateral High-Riding Persistent First Cervical Intersegmental Arteries in a Case of Klippel-Feil Syndrome: The Technique of Vertebral Artery Mobilization for C1-C2 Reduction and Fusion for Atlantoaxial Dislocation and Basilar Invagination: 2-Dimensional Operative Video

Fetal premature excess vertebral linear calcification: a case series.

During embryogenesis, the vertebrae begin development during the 6th week of gestation via two lateral chondrification centers per segment. It was assumed that when disruptions occur in the process of somitogenesis during membranous vertebral body formation, chondrification and ossification will follow the anomalous membranous vertebral body scaffolding, resulting in an anomalous vertebral formation, such as a hemivertebra. Another hypothesis is that hemivertebra may result from anomalous distribution of intersegmental arteries of the vertebral column. There is no description in the medical literature of "excess linear calcifications" of part of the fetal vertebra, characterized by the presence of linear calcifications in the vertebrae of a developing fetus. In the first two trimesters of pregnancy, the fetal vertebrae usually show three calcified points in an axial section: the vertebral body and two transverse processes. Premature linear vertebral calcification was defined as an anterior or posterior echogenic connection between two of the points (Fig. 1). In this study, we describe seven cases of premature fetal linear vertebral calcification.

Bilateral High-Riding Persistent First Cervical Intersegmental Arteries in a Case of Klippel-Feil Syndrome: The Technique of Vertebral Artery Mobilization for C1-C2 Reduction and Fusion for Atlanto-Axial Dislocation and Basilar Invagination: 2-Dimensional Operative Video.

Bilateral High-Riding Persistent First Cervical Intersegmental Arteries in a Case of Klippel-Feil Syndrome: The Technique of Vertebral Artery Mobilization for C1-C2 Reduction and Fusion for Atlanto-Axial Dislocation and Basilar Invagination: 2-Dimensional Operative Video.

Persistent Primitive Arteries

Primitive anastomotic arteries temporarily exist between the future internal carotid and vertebrobasilar arteries during the early embryonic period(between 28 and 32 days of life). The primitive trigeminal, otic, hypoglossal, and proatlantal intersegmental arteries serve as major blood channels to the developing vertebrobasilar circulation at this stage. These arteries are replaced by the posterior communicating and vertebral arteries, and the primitive anastomotic arteries rapidly regress following the development of the definitive vertebrobasilar circulation. Occasionally, these primitive anastomoses persist and are incidentally discovered after birth. Physicians who treat cerebrovascular diseases should be familiar with the anatomy and functions of these vessels. In this review, we discuss the embryonic basis of the carotid-vertebrobasilar anastomoses and the clinical significance of their persistent forms in adults.

Unusual vascular cause of syncope in an adult patient: type 2 proatlantal intersegmental artery.

A proatlantal intersegmental artery anomaly may present with symptoms such as dizziness and syncope. Because it has the risk of damage in surgical and interventional radiological procedures, to know the presence of this unusual vascular anomaly is very important.

Dysplastic aberrant left subclavian artery originating from a thoracic intersegmental artery associated with a right aortic arch.

A right aortic arch (RAA) is a rare vascular anomaly that often coexists with an aberrant left subclavian artery (ALSA). Due to the rarity of RAA, the development of an ALSA is not well understood. We describe a case in which a 58-year-old man who was scheduled to undergo posterior decompression and fusion surgery for thoracic ossification of the posterior longitudinal ligament from Th1 to Th3 was found to have a RAA and an ALSA. Preoperative computed tomography angiography demonstrated a RAA and an ALSA. The ALSA was extremely tortuous and ran in the paraspinal muscles behind the thoracic laminae, which meant it was in the surgical field. The ALSA arose from the descending aorta and bifurcated into the left segmental arteries of Th1 and Th2, and also bifurcated into the left vertebral artery, which had a normal subsequent course. The dysplastic ALSA was considered to have developed from the thoracic intersegmental artery. Based on preoperative examination findings, we performed spinal surgery without vessel injury. We report a rare case of a dysplastic ALSA that developed from the thoracic intersegmental artery with a RAA. The knowledge of this anomaly provides safety in spinal surgery of the cervicothoracic junction.

Environmentally relevant concentrations of fipronil selectively disrupt venous vessel development in zebrafish embryos/larvae

The pesticide fipronil is widely dispersed in aquatic environments and frequently detected in the general population. Although the adverse effects on embryonic growth by fipronil exposure have been extensively documented, the early responses for its developmental toxicity are largely unknown. In the present study, we explored the sensitive targets of fipronil, focusing on vascular injury using zebrafish embryos/larvae and cultured human endothelial cells. Exposure to 5–500 μg/L fipronil at the early stage impeded the growth of sub-intestinal venous plexus (SIVP), caudal vein plexus (CVP), and common cardinal veins (CCV). The damages on venous vessels occurred at exposure to the environmentally relevant concentration as low as 5 μg/L fipronil, whereas no significant change was observed in general toxicity indexes. In contrast, vascular development of the dorsal aorta (DA) or intersegmental artery (ISA) was not affected. In addition, the mRNA levels of vascular markers and vessel type-specific function genes exhibited significant decreases in venous genes, including nr2f2, ephb4a, and flt4, but no appreciable change in arterial genes. Likewise, the more pronounced changes in cell death and cytoskeleton disruption were shown in human umbilical vein endothelial cells as compared with human aortic endothelial cells. Furthermore, molecular docking supported a stronger affinity of fipronil and its metabolites to the proteins correlated with venous development, such as BMPR2 and SMARCA4. These results reveal the heterogeneity in developing vasculature responsive to fipronil's exposure. The preferential impacts on the veins confer higher sensitivity, allowing them to be appropriate targets for monitoring fipronil's developmental toxicity.

Radiological Assessment of Extracranial Vertebral Artery Variations: A Computed Tomography Angiography Study

We evaluated the incidence of intraforaminal and extraforaminal variations of the vertebral artery (VA) in the Omani population using computed tomography angiography (CTA). CTA results of 579 consecutive Omani patients (1158 VAs) were reviewed retrospectively for the analysis of unusual entrance transverse foramen (UE-V2), midline migration (MM), persistent first intersegmental artery (PFIA), and paracondylar process (PP) variations of VA. The anomalous origin and VA dominance were also determined. The sex and side differences in the incidence of these variations were analyzed using the Chi-square test. The incidence of UE-V2 was observed in 10.44% (121 out of 1158) of cases. The incidence of UE-V2 at different vertebral levels was observed in the sequence of C5 (71%) > C4 (20.7%) > C7 (7.43%) > C3 (0.8%). The incidence of MM variation was 1.29%. PFIA and PP variations were found in 0.17% and 0.60% of cases, respectively. Left-dominant VA was identified in 44.7% (259 out of 579) of subjects. The incidence of VA variations was not significantly associated with either sex or side. Anomalous VA origin from arch aorta (3.5%) and right common carotid artery (CCA) (0.08%) was identified. The incidence of UE-V2 in Omani subjects is comparatively higher than that reported in other Asian populations. A rare case of VA originating from the right CCA was also identified.

Abstract Number ‐ 86: Intracranial Angioplasty via Type II Proatlantal Intersegmental Artery

Introduction A proatlantal intersegmental artery (PIA) is an exceedingly rare primitive anastomosis between the carotid and vertebrobasilar circulations. PIA’s may be accompanied by ipsilateral or bilateral vertebral artery (VA) agenesis and can originate from the cervical internal carotid artery (ICA, type I) or external carotid artery (ECA, type II) before eventually joining the vertebrobasilar system. Several authors have described this anomaly in different clinical scenarios, but to our knowledge, there are no studies documenting intracranial vertebral artery angioplasty through a type II PIA in the setting of a vertebrobasilar stroke. Methods Single case study Results A 62‐year‐old male presented to the ED with slurred speech that began one hour prior to arrival. Computer tomography (CT) of the head revealed a small right posterior acute parietal subdural hematoma, and CT perfusion scan revealed ischemia of the cerebellar hemispheres bilaterally with small areas of core infarction and a moderate‐to‐large surrounding penumbra. Magnetic resonance imaging (MRI) of the brain was positive for bilateral acute ischemic strokes of the cerebellar and pontine arteries. CT angiogram of the head and neck revealed high grade stenosis of the right intracranial VA and narrowing of the left V1, V2, and V3 segments. The proximal left V4 segment was occluded with distal reconstitution. Catheter angiogram of the ICAs and ECAs showed that the patient’s right VA did not originate from the right subclavian artery but instead from the right ECA. The patient was subsequently determined to have a type II PIA with critical stenosis. We proceeded with right VA submaximal angioplasty via the type II PIA. The procedure went without complications and resulted in restoration of vertebrobasilar blood flow, with only moderate stenosis following the submaximal angioplasty. On day 5 postoperatively, the patient reported resolution of his symptoms and was subsequently discharged. Conclusions We presented a case of vertebrobasilar stroke in which the right VA did not originate from the right subclavian artery but instead from the ECA, with a subsequent diagnosis of a type II PIA. The only option for management was to perform the right VA angioplasty via the PIA, which we believe to be the first documented case of intracranial vertebral angioplasty through a type II PIA. This case serves as a reminder of the very rare cases of persistent fetal circulation and the importance of performing a catheter angiogram of both the ICA and ECA. Evaluation of the ECA and subsequent observation of a PIA can completely change both the management and outcomes of the patient. This case underscores the complexity of the intracranial atherosclerotic disease, the beneficial role of endovascular intervention, and the necessity of future studies to identify the optimal treatment methods for vertebrobasilar stroke.

Normal and Abnormal Development of Left Vertebral Artery and Its Implications in Cervical Region Surgery

Aortic arch (AA) anomalies occur in approximately 3-5% of cadavers, but these atypical branches remain a point of discussion in cervical region surgery. This case report describes a 73-year-old Caucasian female who died of renal failure following a complicated urinary tract infection whose left vertebral artery (LVA) originated from the AA between the left common carotid and subclavian arteries. The preforaminal part of the LVA was 5 mm in diameter and entered the C6 transverse foramen while the right vertebral artery (RVA) arose from the right subclavian was 6.5 mm in diameter and entered the C5. Embryologically, VAs are formed during weeks four through eight by development of longitudinal anastomoses linking the cervical intersegmental arteries (ISA). The ISA regress except the seventh, which becomes the proximal subclavian artery, the point of origin of the adult VA. Persons with LVA that arises from the AA may be asymptomatic; however, secondary dilatation of the RVA may be implicated in the development of cerebrovascular disorders and atherosclerotic changes due to increased blood flow. Additionally, the anatomical positioning of a left vertebral artery is important when considering an anterior approach for cervical spine surgery and other head-neck procedures when soft structures arteries, veins and muscles are retracted to reach the cervical spine. KEY WORDS: Vertebral artery anomaly, Developmental error, Cervical region surgery, Cerebral circulation, Clinical correlation.

Normal and Abnormal Development of Left Vertebral Artery and its Implications in Cervical Region Surgery

Anomalies occur in branches arising from the aortic arch (AA) in approximately 3‐5% of cadaveric cases (Lazaridis et al. 2018; Natsis et al. 2021), and these atypical branches remain a point of discussion in cervical neck surgery. Here, we describe a 73‐year‐old Caucasian female who died of renal failure following a complicated urinary tract infection whose left vertebral artery (VA) originated from the AA between the left common carotid and subclavian arteries. The preforaminal part of the left VA was 3.5 mm in diameter and entered the C5 transverse foramen while the right VA arising from the right subclavian artery was 4.2 mm in diameter and entered the C5 transverse foramen normally. Embryologically, the VAs are formed during weeks 4 through 8 by development of longitudinal anastomoses linking the cervical intersegmental arteries (ISA). The ISA regresses except the seventh, which becomes the proximal subclavian artery, the point of origin of the adult VA. Persons with left VAs that arise from the AA may be asymptomatic; however, secondary dilatation of the right VA may be implicated in the development of cerebrovascular disorders and atherosclerotic changes due to increased blood flow. Additionally, the recognition of the anomalous origin and anatomical positioning of a left VA is important when considering an anterior approach for cervical spine surgery (Tardieu et al. 2017) and other head‐neck procedures when soft structures such as arteries, veins and muscles are retracted to reach the cervical spine.

Aberrant right subclavian artery with right type 1 proatlantal artery and segmental dysplasia of the right internal carotid artery: a case report

We present a case of an aberrant right subclavian artery (ARSA) with extremely rare vascular anomalies. A 69-year-old woman was suspected to have right internal carotid artery (ICA) stenosis. Computed tomography angiography demonstrated an ARSA and hypoplasia of the right ICA. The proximal segment of the right vertebral artery (VA) was aplasia, and a right type 1 proatlantal artery (PA) arose from the right common carotid artery. Cerebral angiography demonstrated segmental dysplasia of the right ICA. The ascending intrapetrous segment and the ascendingforamen lacerum-horizontal intracavernous segment of the right ICA demonstrated hypoplasia. The collateral pathways promoted reconstitution of each of the distal segments. Left internal carotid angiography demonstrated anterior communicating artery aneurysm and sufficient cross flow to the contralateral middle cerebral artery via the AcomA. A type 1 PA with an ARSA may result in the regression of the right dorsal aorta with persistence of the first cervical intersegmental artery. Although there are few findings of a relationship between an ARSA and intracranial artery anomalies, a developmental error of the right dorsal aorta may cause such complex vascular anomalies. Knowledge of anatomical variations in patients with ARSA is useful when performing angiography or endovascular therapy, as well as during clinical follow-up.

Proper migration of lymphatic endothelial cells requires survival and guidance cues from arterial mural cells.

The migration of lymphatic endothelial cells (LECs) is key for the development of the complex and vast lymphatic vascular network that pervades most tissues in an organism. In zebrafish, arterial intersegmental vessels together with chemokines have been shown to promote lymphatic cell migration from the horizontal myoseptum (HM). We observed that emergence of mural cells around the intersegmental arteries coincides with lymphatic departure from HM which raised the possibility that arterial mural cells promote LEC migration. Our live imaging and cell ablation experiments revealed that LECs migrate slower and fail to establish the lymphatic vascular network in the absence of arterial mural cells. We determined that mural cells are a source for the C-X-C motif chemokine 12 (Cxcl12a and Cxcl12b), vascular endothelial growth factor C (Vegfc) and collagen and calcium-binding EGF domain-containing protein 1 (Ccbe1). We showed that chemokine and growth factor signalling function cooperatively to induce robust LEC migration. Specifically, Vegfc-Vegfr3 signalling, but not chemokines, induces extracellular signal-regulated kinase (ERK) activation in LECs, and has an additional pro-survival role in LECs during the migration. Together, the identification of mural cells as a source for signals that guide LEC migration and survival will be important in the future design for rebuilding lymphatic vessels in disease contexts.

Prevalence of Vertebral artery anomaly in upper cervical and its surgical implications: a systematic review.

The presence vertebral artery (VA) abnormalities in the upper cervical may be a potential cause of catastrophic complication in the posterior approach of the upper cervical spine surgery. The aim of this study was to demonstrate the real incidence of the V3 segment anomaly in patients who need upper cervical surgery, and tried to find out the risk factors of V3 segment anomaly to evaluate the necessary of computed tomographic angiography (CTA) for upper cervical surgery. This systematic review was conducted following the preferred reporting items for systematic reviews and meta-Analyses (PRISMA). Retrospective studies and reports of case series involving human subjects with data on anomalies of vertebral artery in upper cervical spine were included. Data on the prevalence of persistent first intersegmental artery (PIA), fenestration of the VA (FA), posterior inferior cerebellar artery (PICA) were extracted. A total of 16 articles involving 5927 subjects met the inclusion criteria. The total incidence of V3 segment anomaly in the patients with bony abnormalities was 25.9% (74/286): PIA was 17.5%, FA was 6.6% and PICA was 1.8%. The total incidence of V3 segment anomaly in the patients without bony abnormalities was 2.7% (152/5671): PIA was 1.76%, FA was 0.4% and PICA was 0.5%. The total incidence of V3 segment anomaly in Asian population without bony abnormalities was 5.8%, while in European and American population was 0.8 and 0.6%, respectively. Patients with bone abnormalities are high risk factor for VA abnormalities, CTA is of paramount importance to evaluate the variant VA anatomy. However, regarding to the low incidence of V3 variation in normal population, we do not recommend preoperative CT angiography as mandatory part of preoperative.

The association between atlantoaxial instability and anomalies of vertebral artery and axis

BACKGROUND CONTEXTA screw-rod system is the most widely used technique for atlantoaxial instability (AAI). However, neglecting anomalies of the vertebral artery and axis could lead to fatal complications. Whether or not the presence of AAI is associated with a more complicated anatomy for instrumentation is unclear. PURPOSETo analyze the association between AAI and anomalies of the vertebral artery and axis in patients with and without AAI. STUDY DESIGNA retrospective comparative study. PATIENT SAMPLEOne hundred and twenty patients who underwent preoperative 3-dimensional computed tomography with vertebral angiography of the cervical spine at our institution from 2012 to 2020. OUTCOME MEASURESThe C2 isthmus height, internal height of the C2 lateral mass, and C2 pedicle width were radiologically assessed. METHODSA case control study with matched cohort analysis was conducted. One hundred and twenty patients were divided into 2 groups according to presence of AAI, and the presence of high-riding vertebral artery (HRVA) and a narrow pedicle for insertion of the C2 pedicle screw was assessed, as was the prevalence of extraosseous vertebral artery anomaly. RESULTSThe C2 isthmus height, C2 internal height, and C2 pedicle width were significantly narrower in the AAI group (p<.01, <.01, and <.01, respectively). A significantly greater proportion of patients with AAI had HRVA and a narrow pedicle than those without (p<.01 and < 0.01, respectively). Among patients with AAI, the C2 internal height was significantly narrower in patients with rheumatoid arthritis (p<.01). Five patients (8.3%) with AAI had vertebral artery anomaly (3 fenestration, 2 persistent first intersegmental artery), while there were no vertebral artery anomalies in patients without AAI (p<.01). CONCLUSIONSVertebral artery anomalies are more common in patients with AAI. Furthermore, posterior instrumentation in patients with AAI has a narrower safe zone compared to that in patients without AAI, which may be caused by a long-lasting deformity rather than a congenital deformity. Therefore, more thorough preoperative evaluation of the anatomy should be performed in these patients.

Endothelial Semaphorin 3fb regulates Vegf pathway-mediated angiogenic sprouting.

Vessel growth integrates diverse extrinsic signals with intrinsic signaling cascades to coordinate cell migration and sprouting morphogenesis. The pro-angiogenic effects of Vascular Endothelial Growth Factor (VEGF) are carefully controlled during sprouting to generate an efficiently patterned vascular network. We identify crosstalk between VEGF signaling and that of the secreted ligand Semaphorin 3fb (Sema3fb), one of two zebrafish paralogs of mammalian Sema3F. The sema3fb gene is expressed by endothelial cells in actively sprouting vessels. Loss of sema3fb results in abnormally wide and stunted intersegmental vessel artery sprouts. Although the sprouts initiate at the correct developmental time, they have a reduced migration speed. These sprouts have persistent filopodia and abnormally spaced nuclei suggesting dysregulated control of actin assembly. sema3fb mutants show simultaneously higher expression of pro-angiogenic (VEGF receptor 2 (vegfr2) and delta-like 4 (dll4)) and anti-angiogenic (soluble VEGF receptor 1 (svegfr1)/ soluble Fms Related Receptor Tyrosine Kinase 1 (sflt1)) pathway components. We show increased phospho-ERK staining in migrating angioblasts, consistent with enhanced Vegf activity. Reducing Vegfr2 kinase activity in sema3fb mutants rescues angiogenic sprouting. Our data suggest that Sema3fb plays a critical role in promoting endothelial sprouting through modulating the VEGF signaling pathway, acting as an autocrine cue that modulates intrinsic growth factor signaling.

Arterial Vascular Structures Running Through Retrotransverse Foramen and Retrotransverse Groove of the Atlas Vertebrae

Retrotransverse foramen (RTF) and retrotransverse groove (RTG) are anatomic variations of the atlas (C1) vertebrae. RTF contains an anastomotic vein connecting atlanto-occipital and atlanto-axodian venous sinuses. The purpose of this study was to analyze the arterial vascular structures running though the RTF and RTG. Three-dimensional volume rendered computed tomography angiography (3D VR CTA) images of 427 patients (264 men, 163 women; age 17-87 years) were reviewed and evaluated using the RadiAnt DICOM Viewer (version 5.0.2; Medixant, Poznan, Poland). The incidence of RTF or RTG, the incidence of the V3 segment of vertebral artery variants, and the artery vascular structures inside the RTF and RTG anatomic variation of C1 were analyzed. Fifty (11.7%) atlases presented RTF anatomical variant; 113 (26.5%) atlases presented RTG anatomical variants. The incidence of the V3 segment of vertebral artery variants was 0.94% (4 of 427). Three (0.7%) were persistent first intersegmental artery and 1 (0.2%) was the fenestration of the vertebral artery on left side. In 4 cases of C1 vertebral artery V3 segmental variants, there were no RTF and RTG. No artery vascular structure was found in RTF or RTG. The RTF or RTG of C1 was a common anatomical variant. No arterial vascular structure runs though the RTF or RTG. The presence of C1 RTF and RTG variants had no effect on the V3 segmental course of the vertebral artery. Preoperative understanding of these variations using 3D CTA are helpful for the safe execution of the upper cervical posterior approach surgeries.

Anatomical Variations of the Vertebral Artery: Analysis by Three-Dimensional Computed Tomography Angiography in Chinese Population.

ObjectiveTo analyze the anatomical variations of V3 and V2 segments of the vertebral artery in the Chinese population.MethodsThe current retrospective study was an observational, anatomical, radiological research. Between 1 January 2018 to 31 December 2019, the data of 589 continuous head‐and‐neck three‐dimensional computed tomography angiography were observed and analyzed using the open‐source software of Horos. There were 415 males and 174 females with an average age of 44.63 ± 2.5(18–74) years. The variations of the V3 segment were defined as persistent first intersegmental artery (PFIA) and paracondylar processes (PP). The variations of V2 segments were unusual vertebral artery entrance transverse foreman (UE‐V2S) and midline migration (MM). The incidences of all variations were summarized and the gender, side characters were compared.ResultsAmong the patients, 4.34% (18/415) males and 4.60% (8/174) females were with the variation of PFIA. Meanwhile, 12.29% (51/415) males and 10.92% (19/174) females were with the variation of PP. Then 18.80% (78/415) males and 16.67% (29/174) females were with UE‐V2S. All the variations above were not different in genders. As for the variation of MM, 3.86% (16/415) males and 8.62% (15/174) females were identified, and the difference of genders was significant for this type of variation (P < 0.05). The differences between each side were also observed and analyzed for all variations and no differences were found.ConclusionThere are several variations of V3 and V2 segments of the vertebral artery are associated with the cervical surgeries, most were without differences in genders and sides, except the variation of MM.