Vertebral artery injury in cervical spine surgery: anatomical considerations, management, and preventive measures

Peng, Chan Wearn Benedict; Chou, Benedict T.; Bendo, John A.; Spivak, Jeffrey M.

doi:10.1016/j.spinee.2008.03.006

Cited by 149 publications

(133 citation statements)

References 48 publications

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“…The therapeutic goals for treating VA injury are threefold and progressive: (1) obtain control of local hemorrhage, (2) prevent immediate vertebrobasilar ischemia, and (3) prevent cerebrovascular complications [20,28]. When VA injury occurs, there usually is a sudden, copious bright red bleeding, which is different from bone bleeding [28].…”

Section: Managementmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

“…When VA injury occurs, there usually is a sudden, copious bright red bleeding, which is different from bone bleeding [28]. VA bleeding should be controlled with direct tamponade followed by hemostatic agents, although an effort should be made to accomplish a more effective means of control [8,20,25,28]. Control of hemorrhage by direct hemostatic tamponade can be effective and easy, but this review showed that there remains a potential risk of cerebral ischemia due to VA occlusion, hypovolemic shock due to insufficient hemostasis, or delayed hemorrhage due to pseudoaneurysm or AVF formation.…”

Section: Managementmentioning

confidence: 99%

“…This type of management can decrease the risk of delayed hemorrhage and insufficient hemostasis related to tamponade. However, it should only be attempted if the patient has a patent contralateral VA or sufficient collateral posterior circulation [14,20,24,28]. The left VA is hypoplastic in 5.7 % and absent entirely in 1.8 % of the general population, while the right VA is hypoplastic in 8.8 % and absent in 3.1 % [14].…”

Section: Managementmentioning

confidence: 99%

“…The largest series of these injuries cite the incidence of injury as approximately 0.3-0.5 % [4,35]. Although VA injury is uncommon, the consequences can be catastrophic as it is associated with serious complications such as arteriovenous fistula (AVF), pseudoaneurysm, late-onset hemorrhage, thrombosis, embolism, cerebral ischemia, and death [20,25,28]. Advances in ACSO and VA injury management should make an effort to reduce these complications.…”

Section: Introductionmentioning

confidence: 99%

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The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases

Park

Jho

2012

Eur Spine J

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Purpose Anterior cervical spine operations (ACSO) are generally considered to be safe and effective, but the vertebral artery (VA) is at risk during the procedure. Because the consequences of VA injury can be catastrophic, properly managing a VA injury is very important. However, due to the rarity of these injuries, there is no agreed upon treatment strategy. Methods Studies were identified for inclusion in the review via sensitive searches of electronic databases through 31 December 2011. All cases included in the review were qualitatively analyzed to explore the relationship between type of VA injury management and neurological complications. Results Seventeen articles describing 39 cases of VA injury during ACSO were included in this study. Seven patients (17.9 %) had neurological complications followed by VA insufficiency. Two patients (5.1 %) had root damage due to ligation. One case (2.6 %) resulted in intraoperative death due to fatal bleeding. Delayed vascular complications were identified in nine (45.0 %) of the 20 patients that underwent only tamponade or hemostatic agent during the operation. Four patients underwent intraoperative endovascular treatment, and three of these patients had a cerebral infarction. All three patients who underwent clipping also had neurological complications. The five patients treated by direct repair did not have any complications. Conclusion Our review suggests the management of VA injury should be considered in order listed: (1) performing tamponade with a hemostatic agent, (2) direct repair, (3) postoperative endovascular procedures to prevent delayed complications. If tamponade fails to achieve proper hemostasis, additional procedures as endovascular embolization, clipping and ligation should be considered but carry the risk of neurological complications. Because of the limitations of this review, further studies are recommended with larger sample sizes.

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Section: Managementmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases

Park

Jho

2012

Eur Spine J

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Anatomic study of the suboccipital artery of Salmon with surgical significance

D’Antoni¹,

Battaglia²,

DiLandro³

et al. 2010

Clinical Anatomy

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The anatomy of the muscular branches of the vertebral arteries has clinical relevance during surgical procedures, suboccipital injections, and manual therapies. Each vertebral artery is divided into four segments. Segment V3, found in the suboccipital triangle, courses posteromedially around the lateral mass to lie in a groove on the posterior arch of the atlas, ultimately coursing beneath the posterior atlanto-occipital membrane to enter the skull. Although not always present, any muscular branch that emanates from this segment to supply the suboccipital muscles is called the suboccipital artery of Salmon. There is a paucity of literature on this artery despite its clinical relevancy. We found the suboccipital artery of Salmon in 10 (67%) of 15 embalmed adult cadavers. This frequency is considerably higher than that in previous reports. Two (20%) of the 10 cadavers demonstrated bilateral and symmetrical suboccipital arteries of Salmon (one artery on each side). Four (40%) of the 10 cadavers had an arrangement of two parallel suboccipital arteries of Salmon on one side, and one on the contralateral side. Three (30%) of the 10 cadavers displayed an asymmetrical unilateral arrangement (only one artery). One (10%) of the 10 cadavers displayed the unique arrangement of three arteries of Salmon on one side and one artery on the contralateral side. This study adds to a limited, but growing, body of knowledge by providing photographic evidence of the course and arrangement of these arteries and, therefore, can be of value to surgeons and other clinicians whose procedures focus on the suboccipital region.

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Aortic arch origin of the left vertebral artery

et al. 2017

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Complications from anterior approaches to the cervical spine are uncommon with normal anatomy. However, variant anatomy might predispose one to an increased incidence of injury during such procedures. We hypothesized that left vertebral arteries that arise from the aortic arch instead of the subclavian artery might take a more medial path in their ascent making them more susceptible to iatrogenic injury. Fifty human adult cadavers were examined for left vertebral arteries having an aortic arch origin and these were dissected along their entire cervical course. Additionally, two radiological databases of CTA and arteriography procedures were retrospectively examined for cases of aberrant left vertebral artery origin from the aortic arch over a two-year period. Two cadaveric specimens (4%) were found to have a left vertebral artery arising from the aortic arch. The retrospective radiological database analysis identified 13 cases (0.87%) of left vertebral artery origin from the aortic arch. Of all cases, vertebral arteries that arose from the aortic arch were much more likely to not only have a more medial course (especially their preforaminal segment) over the cervical vertebral bodies but also to enter a transverse foramen that was more cranially located than the normal C6 entrance of the vertebral artery. Spine surgeons who approach the anterior cervical spine should be aware that an aortic origin of the left vertebral artery is likely to be closer to the midline and less protected above the C6 vertebral level. Clin. Anat. 30:811-816, 2017. © 2017Wiley Periodicals, Inc.

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Vertebral artery injury in cervical spine surgery: anatomical considerations, management, and preventive measures

Cited by 149 publications

References 48 publications

The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases

The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases

Anatomic study of the suboccipital artery of Salmon with surgical significance

Aortic arch origin of the left vertebral artery

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