End-to-End Anastomosis of an Unanticipated Vertebral Artery Injury during C2 Pedicle Screwing

Abstract

J Korean Neurosurg Soc 48 : [363][364][365][366] 2010 Vertebral artery (VA) injury is a rare and serious complication of cervical spine surgery; this is due to difficulty in controlling hemorrhage, which can result in severe hypotension and cardiac arrest, and uncertain neurologic consequences. The authors report an extremely rare case of a 56-year-old woman who underwent direct surgical repair by end-to-end anatomosis of an unanticipated VA injury during C2 pedicle screwing. Postoperatively, the patient showed no neurological deterioration and computed tomography angiography of the VA demonstrated normal blood flow. Although direct occlusion of an injured VA by surgical ligation or endovascular embolization has been used for management of an unanticipated VA injury during surgery, these methods may be associated with significant morbidity and mortality. However, despite its technical demand, microvascular primary repair can restore normal blood flow and minimizes the risk of immediate or delayed ischemic complications. Here we report an iatrogenic VA injury during C2 pedicle screwing, which was successfully treated by end-to-end anastomosis. KEY WORDS :Vertebral artery injury˙ End-to-end anastomosis˙ Atlantoaxial complex.

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

“…This step should help prevent immediate vertebrobasilar ischemia. Some surgeons advocate direct primary repair of the injured vessel as an optimal management strategy if it is technically feasible [9,17,19,24,29]. Primary repair could restore normal blood flow and minimize the risk of hemorrhagic or ischemic complications; therefore, it should especially be considered when injury occurs in the dominant VA [9,19,20,24,29].…”

“…However, direct exposure and suture repair of a VA laceration is not always feasible because of copious bleeding within the bony canal and surrounding venous plexus and hemodynamic instability [13,17]. If the VA is lacerated or perforated with good margin, it can be repaired by primary suture [24]. Direct tamponade followed by endovascular investigation can help assess the patency of the vessel and also permits repair during the same procedure [17].…”

“…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].…”

Anatomical Features and Clinical Importance of the Vertebral Artery

“…Although some patients may remain asymptomatic due to adequate collateral circulation, other patients may sustain devastating vertebrobasilar ischemia or fatal bleeding [41].…”

“…Considering unrecognized and underreported cases, the true incidence of VA injury will probably remain unknown and underestimated, and will increase with the increasing popularity of cervical instrumentation techniques [41].…”