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