Elsevier

The Spine Journal

Volume 9, Issue 1, January 2009, Pages 70-76
The Spine Journal

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

https://doi.org/10.1016/j.spinee.2008.03.006Get rights and content

Abstract

Background context

Vertebral artery (VA) injury can be a catastrophic iatrogenic complication of cervical spine surgery. Although the incidence is rare, it has serious consequences including fistulas, pseudoaneurysm, cerebral ischemia, and death. It is therefore imperative to be familiar with the anatomy and the instrumentation techniques when performing anterior or posterior cervical spine surgeries.

Purpose

To provide a review of VA injury during common anterior and posterior cervical spine procedures with an evaluation of the surgical anatomy, management, and prevention of this injury.

Study design

Comprehensive literature review.

Methods

A systematic review of Medline for articles related to VA injury in cervical spine surgery was conducted up to and including journal articles published in 2007. The literature was then reviewed and summarized.

Results

Overall, the risk of VA injury during cervical spine surgery is low. In anterior cervical procedures, lateral dissection puts the VA at the most risk, so sound anatomical knowledge and constant reference to the midline are mandatory during dissection. With the development and rise in popularity of posterior cervical stabilization and instrumentation, recognition of the dangers of posterior drilling and insertion of transarticular screws and pedicle screws is important. Anomalous vertebral anatomy increases the risk of injury and preoperative magnetic resonance imaging and/or computed tomography (CT) scans should be carefully reviewed. When the VA is injured, steps should be taken to control local bleeding. Permanent occlusion or ligation should only be attempted if it is known that the contralateral VA is capable of providing adequate collateral circulation. With the advent of endovascular repair, this treatment option can be considered when a VA injury is encountered.

Conclusions

VA injury during cervical spine surgery is a rare but serious complication. It can be prevented by careful review of preoperative imaging studies, having a sound anatomical knowledge and paying attention to surgical landmarks intraoperatively. When a VA injury occurs, prompt recognition and management are important.

Introduction

Although vertebral artery (VA) injury is uncommon in cervical spine surgeries, the consequences may be catastrophic as it is associated with serious complications such as fistulas, pseudoaneurysm, late-onset hemorrhage, thrombosis, embolism, cerebral ischemia, and death.

For anterior cervical spine surgery, the reported rates of VA injury range from 0.3% to 0.5% [1], [2], [3], [4]. For posterior spine surgeries, the reported rates are variable depending on the instrumentation techniques used and range from 4.1% to 8.2% for C1C2 transarticular screws to no reported VA injury for subaxial lateral mass screws [5], [6], [7], [8], [9], [10], [11].

The purpose of this review was to provide an understanding of VA injury associated with cervical spine surgery with a detailed discussion of the surgical anatomy, management, and prevention of this injury.

Section snippets

Surgical anatomy of the VA

The VA can be divided into four segments [12], [13]. V1 extends from the subclavian artery, anterior to C7 transverse process, to the entry point of C6 foramen transversarium. V2 lies within C6–C1 transverse foramina. V3 is from the superior aspect of the arch of the atlas to the foramen magnum. V4 extends intradurally from the foramen magnum to unite with the contralateral VA to form the basilar artery. The artery is most vulnerable anterior to C7, laterally at C3 to C7, and posteriorly at C1

Anatomical anomalies

In the presence of anomalous VA anatomy, injuries can occur even when standard anterior or posterior techniques are used [4], [24], [39], [40], [41], [42].

The incidence of anomalous VA associated with anterior cervical surgery has been documented as 2.7% [18]. The tortuous VA causes erosions of the vertebral bodies and pedicles [18], [39], [41] and in such cases, Curylo et al. found that the transverse foramen is either medial to or less than 1.5 mm from the uncovertebral joint [18]. Epstein

Complications of VA injury

Complications of VA injury include arteriovenous fistulae, late-onset hemorrhage, pseudoaneurysm and thrombosis with embolic incidents, cerebral ischemia, stroke, and even death [1], [3], [20], [22], [23], [45], [46]. The vascular complications might occur days to years later [1], [47], [48], [49]. Ischemia occurring immediately postoperation could be the result of complete occlusion of the vessel, whereas those occurring much later could be the result of emboli from a partially occluded VA [8]

Management

When VA injury occurs, there usually is a sudden, nonpulsatile, copious bright red bleeding, which is different from bone bleeding [23]. Occasionally, the blood may be dark because of injury of the surrounding plexus of veins [23].

There is still no consensus for the management of VA injury. Management should achieve three goals: 1) hemorrhage should be locally controlled, 2) immediate vertebrobasilar ischemia must be prevented, and 3) cerebral embolic complications must be avoided [2]. The

Prevention of VA injury

All preoperative imaging studies should be carefully reviewed. On the preoperative CT or magnetic resonance imaging scans, the position of the VA and its relation to bony and surrounding structures should be noted. It is also possible to determine if the artery is ecstatic, tortuous, or involved in tumor or infection [39]. Additional imaging such as vertebral angiography, magnetic resonance angiography, or CT angiography should be considered to further delineate the anatomy [39], [40]. This is

Conclusion

Overall, the risk of VA injury during cervical spine surgery is low but may be associated with serious complications. A sound knowledge of the surgical anatomy and recognition of any anomalous vasculature is important to prevent injury. In the event of an injury, steps should be taken to control local bleeding and to obtain immediate postoperative angiogram, followed by endovascular repair, if necessary. Permanent occlusion or ligation should only be attempted if it is known that the

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