A rare complication of a unilateral vertebral artery occlusion, which resulted in a basilar emboli after a C5–C6 bifacet dislocation in a professional rugby player: case study

Evaluation for Vertebral Artery Injury with Cervical Dislocated Fracture and Optimal Treatment before Reduction

“…5) However, even unilateral development causes serious sequelae or death when a scattering thrombus causes basilar artery occlusion (BAO). 7,8,9,12) On the contrary, even in bilateral VAO, when BAO is absent, symptoms are mild because of collateral circulation in rare cases 5,8) ; therefore, avoiding embolism of the cerebral major arteries, including BAO, may be the most important factor for the reduction of dislocation in patients with VAO. Thus, we searched for reports on treatment before the reduction of dislocation in patients with VAO.…”

“…6) VAI complication rate with facet dislocation, subluxation, and fracture of the transverse foramen were reported in 80%, 75%, and 46% of cases, respectively. 1,3,[7][8][9] However, for treatment, reports of course observation, antithrombotic drug administration, and parent artery occlusion (PAO) of the affected vertebral artery are mixed with no consensus, as the pathology and complicating injury differ among patients. 1,2,9,10) In patients requiring reduction of dislocation and fusion, there is a risk of fatal cerebral embolism due to scattering of the thrombus formed in the VAI lesion after restoration of the vertebral artery by reduction.…”

Traumatic, high-cervical, coronal-plane spondyloptosis with unilateral vertebral artery occlusion: treatment using a prophylactic arterial bypass graft, open reduction, and instrumented segmental fusion

“…39 This cautionary report highlights the importance of studying vascular anatomy closely in spondyloptosis, which can otherwise cause mobilization of a thrombus or propagation of dissection leading to catastrophic posterior circulation ischemia. 8,10,19,23,26,29,32,33,40 Vertebral artery injury is a rare but well recognized catastrophic iatrogenic complication of cervical spine surgery with a reported incidence of 0.3%-0.5%. 6,7,13,14,25,28,30 In the case presented in this report, the left VA was at risk during the exposure, osteotomies, and bone reduction for 2 reasons: 1) proximity of the artery to the partially autofused C2-3 vertebral bodies with potential for injury during osteotomy; and 2) anticipated significant alteration in its course that would occur with successful realignment, placing the vessel at risk for shear injury or kinking during translation.…”

“…Iatrogenic VA injury during cervical spine surgery has been documented to produce fistulas, late hemorrhages, pseudoaneurysm, thrombosis, and death. 8,10,19,23,26,29,32,33,40 Common techniques to reduce the risk of VA injury include the following: 1) partial excision of the longus colli muscle, allowing exposure of the uncinate processes and transverse processes; 2) careful uncectomy and removal of lateral osteophytes followed by uncovertebral joint resection up to the depth of the floor of the transverse foramen cephalad and caudal to the transverse process; 3) exposure large enough for proximal and distal control of the VA should inadvertent arterial injury be encountered while working on the fusion mass; and 4) use of neuronavigation and Doppler probe ultrasonography to more clearly identify the vessel near the fu sion mass.…”

“…In the trauma literature, there are several reported cases of symptomatic vertebral and basilar artery thrombosis, with and without surgical reduction of cervical spine injury. 8,10,23,26,27,31,34,39,43,44 Once a patient develops a symptomatic basilar artery occlusion, the prognosis is generally ominous, although a case report of successful mechanical and pharmacological thrombolysis does exist in the literature. 37 …”