Preventing Iatrogenic Injury to the Vertebral Artery in Cervical Spine Surgery

Abstract

Summary of Background Data: Iatrogenic injury of the vertebral artery (VA) in the context of surgical approaches to the cervical spine has been cited as a relatively rare complication with varying degrees of severity ranging from minimal injury to acute stroke and can result in death. It is estimated that ~50% of cases of iatrogenic VA injury are preventable after postoperatively examining a patient’s preoperative imaging. Despite the low incidence (<2%) of this complication, the potential associated morbidity demonstrates the importance of meticulous preoperative vascular consideration. Objective: This study aims to emphasize the importance of preoperative vascular screening during anterior cervical access planning visualized through a rare case of a VA aberration in a 47-year-old patient. Study Design: This study is designed as a retrospective case report. Methods: A thorough chart review was performed for this subject including all prior medical records, imaging studies, imaging reports, operative notes, and communication records. Results: The subject was found to have a history of patent foramen ovale (PFO) repair with a rare vertebral artery malformation described as a medial transposition of the vertebral artery out of the vertebral artery foramen between C3 and C4. Conclusions: Consideration of cervical anatomy, particularly the VA, is key to minimizing the risk of adverse surgical outcomes in both anterior and posterior approaches to the cervical spine. During the workup process, the patient’s primary care providers, radiologists, and surgeons should be aware of the potential variations of the VA with particular attention given to the course of the VA on MR imaging. Level of Evidence: Level IV.