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

Background Vertebral artery injury (VAI) can be a devastating complication during cervical spine surgery. Although considered a rare occurrence overall, incidences of VAI have been reported in the ranges of 0.07% to 8%. Such injuries have the potential for catastrophic consequences, including blood loss, permanent morbid neurologic injury, and even death. The introduction of intraoperative navigation using either preoperative or intraoperative imaging has now been widely adopted in current practice so as to try and minimize adverse outcomes while giving real-time, dynamic information of the operative field. The use of the O-arm Surgical Imaging System during cervical spine surgery allows one to obtain high-resolution, accurate intraoperative imaging, and when used in concert with forms of intraoperative navigation, it can help with instrumentation and safety. However, patients undergoing cervical spine surgery do not routinely undergo preoperative vascular imaging, particularly with regard to anterior cervical or posterior high-cervical surgeries, where the incidence of VAI, in comparison with other cervical surgeries, has been reported to be the highest.

Methods Here we present the use of intraoperative O-arm–based arteriography for integration with navigation for vertebral artery localization during C1 to C3 posterior instrumentation and fusion of an unstable C2 fracture in a 54-year-old man.

Results The patient did not experience any intraoperative VAI and was subsequently discharged with no focal neurologic deficits.

Conclusions Detailed in our report is our protocol and procedure for obtaining and using intraoperative angiographic images.

Clinical Relevance Case report detailing O arm for intraoperative identification of vertebral arteries during C1-C3 posterior instrumentation and fusion with pre-operative unilateral vertebral artery injury.