Vertebral Artery Injury during Routine Posterior Cervical Exposure: Case Reports and Review of Literature

Abstract

Study Design Case series. Objective We report the unusual occurrence of vertebral artery injury (VAI) during routine posterior exposure of the cervical spine. The importance of preoperative planning to identify the course of the bilateral vertebral arteries during routine posterior cervical spine surgery is emphasized. Methods VAI is a rare but potentially devastating complication of cervical spinal surgery. Most reports of VAI are related to anterior surgical exposure or screw placement in the posterior cervical spine. VAI incurred during posterior cervical spinal exposure surgery is not adequately addressed in the existing literature. Two cases of VAI that occurred during routine posterior exposure of the cervical spine in the region of C2 are described. Results VAI was incurred unexpectedly in the region of the midportion of the posterior C1–C2 interval during the initial surgical exposure phase of the operation. An aberrant vertebral artery course in the V2 anatomical section in the region between C1 and C2 intervals was identified postoperatively in both patients. A literature review demonstrates a relatively high incidence of vertebral artery anomalies in the upper cervical spine; however, the literature is deficient in reporting vertebral artery injury in this region. Recommendations for preoperative vertebral artery imaging also remain unclear at this time. Conclusions Successful management of this unexpected complication was achieved in both cases. This case report and review of the literature highlights the importance of preoperative vertebral artery imaging and knowledge of the course of the vertebral arteries prior to planned routine posterior exposure of the upper cervical spine. In both cases, aberrancy of the vertebral artery was present and not investigated or detected preoperatively.

Iatrogenic Acute Ischemic Necrosis Due to Emergent Bleeding Control in Ventral Foramen Magnum Meningioma with Spinal Instability

“…As the artery supplies oxygen and nutrients to the spinal cord, cerebellum, medulla, and neck musculature, significant blood loss is a major pitfall [14]. While vertebral artery injuries (VAIs) are rare in cervical spine surgeries (0.2-2%), intra-operative blood loss and hypotension can occur, requiring emergency arterial occlusion and repair, which were performed [15]. Most of the literature describing instances of VAI involves anterior and posterior approaches to the cervical spine, whereas this case illustrates its risk from the far lateral approach.…”

Posterior identification and exposure of the V3 segment of the vertebral artery

“…Molinari et al . [ 14 ] (two cases) and Yang et al . [ 15 ] (one case) reported cases of VAI in the C1–C2 level.…”

Use of O-arm With Intraoperative Arteriography for Localization and Stealth Navigation of the Vertebral Arteries During Posterior Cervical Spine Surgery

“…VAI has been reported to occur in the range of 0.07% to 8%. [1][2][3] Reports of neurologic deficit and death are reported as low as 0.14%, although the ranges have been estimated to be between 0 and 33%. 1,[4][5][6] The most commonly reported cause is that of abnormal vertebral artery anatomy, and the importance of preoperative planning and imaging of the vertebral arteries has been extolled in nearly every publication on VAI after cervical spine surgery.…”

“…1,[4][5][6] The most commonly reported cause is that of abnormal vertebral artery anatomy, and the importance of preoperative planning and imaging of the vertebral arteries has been extolled in nearly every publication on VAI after cervical spine surgery. [1][2][3][4][5][6] The use of intraoperative navigation on a preoperative or intraoperative basis has become routine in practices that have the technology available. This is true in spine surgery, especially with regard to high cervical instrumentation.…”