Endovascular Management of Iatrogenic Vertebral Artery Transection During Anterior Cervical Spine Surgery: A Case Report

Abstract

Anterior surgical approaches to the cervical spinal pathology have become a frequently used technique. Anterior cervical spine surgeries are generally considered to be safe with low incidence of neurological complications. Vertebral artery (VA) injuries are infrequent during an anterior cervical spine approach but can be devastating. A retrospective review of these injuries documents an incidence of 0.3%-0.5%. However, there is no established strategy or guidelines for managing iatrogenic VA injuries. We describe a case of iatrogenic VA injury at C5 vertebral level during an anterior cervical approach for C5 cervical osteoblastoma; successful managed by endovascular coiling using detachable coils achieving complete occlusion. The patient had a good clinical outcome, with no symptoms of vertebrobasilar insufficiency at 2-year follow-up. There is a paradigm shift in the management of the VA injury after introduction of the interventional angiography. Endovascular embolization is a safe and effective treatment option, which offers certain advantages over open surgery such as minimal invasion, lower risk of neurological injury, lower morbidity, and recurrence rates.

Horner’s Syndrome and Vertebral Artery Occlusion Concomitant With Brachial Plexus Injury in a Patient With Anterior Approach Cervical Disc Herniation Surgery

“…However, iatrogenic VA injury is a rare complication of anterior approach cervical spine surgery [11]. Paghi et al reported VA injury at the same level as our report in a young male patient with cervical osteoblastoma who had undergone anterior approach cervical surgery [11]. Yunoki et al reported that repeated use of a spreader in two consecutive intervertebral space may have triggered VA occlusion after anterior cervical discectomy in a 50year-old patient [10].…”

“…It is known that VA is vulnerable to injury and occlusion of VA can be seen as a result of cervical fracture and sharp head movements and can occur even with chiropractic manipulation [10]. However, iatrogenic VA injury is a rare complication of anterior approach cervical spine surgery [11]. Paghi et al reported VA injury at the same level as our report in a young male patient with cervical osteoblastoma who had undergone anterior approach cervical surgery [11].…”

Two Different Cases of Stroke in Young

“…Management consists intravenous heparin followed by oral oral anticoagualtion for all patients with acute dissections of the vertebral artery, regardless of the type of symptoms, unless there are contraindications such as the presence of a large infarct with associated mass effect, hemorrhagic transformation of the infarcted area, an intracranial aneurysm, and intracranial extension of the dissection with or without SAH [8].Endovascular therapy can be reserved for cases with recurrent neurological events despite on antithrombotics and who are all not a canditate for surgical therapy.Surgical therapy consists of insitu interposition of graft or extracranial intracranial bypass only for patients with persisting symptoms refractory to maximal non invasive management and who are not candidates for endovascular therapy.Continuation of anticoagulation therapy may be guided by MRA or ultrasound.Persisting irregularity or stenosis at 3rd month necessitates continuation of therapy for another 3 months. If features of stenosis persist beyond 6 months, it is advisable to shift the patient on antiplatelet agents [8,9]. Nearly 75% of patients make excellent recovery and overall death rate is less than 5%.Risk of spontaneous dissection approximates 2% in the first month and decreases to about 1% per year.Dissection usually does not recur in the same vascular territory [10].By conclusion we emphasise the clinical history elicitation of neck movement related trivial trauma are most important even without predisposing conditions for vertebral artery dissection in stroke management.…”

Epidemiology and Management of Iatrogenic Vertebral Artery Injury Associated With Cervical Spine Surgery

“… 30 37 46) Destructive intervention, complete occlusion of VA with coil has benefits in bleeding control, reduces recurrence and emboli, compared with other VA saving endovascular techniques. 37 43) However, insufficient blood flow of the contralateral VA can lead to ischemic strokes in brain stem and cerebellum. 44) Therefore, permanent VA occlusion with coil should be considered carefully to uncontrolled bleeding, in patients with tolerable collateral flow in posterior circulation and patent contralateral VA.…”