Vertebral artery injuries in cervical spine surgery

BACKGROUND: Vertebral artery injuries during cervical spine surgery are rare, but potentially fatal. When performing cervical spine surgery, it is imperative that the surgeon has a systematic approach for avoiding, and if necessary, dealing with a vertebral artery injury. METHODS: This is a review paper. RESULTS: Upper posterior cervical spine surgeries put the vertebral artery at the highest risk, as opposed to anterior subaxial cervical spine procedures, which put the artery at the least risk. A thorough understanding of the complex anatomy of the vertebral artery is mandatory prior to performing cervical spine surgery, and since the vertebral artery can have a variable course, especially in the upper cervical spine, the surgeon must minimize the possibility of an arterial injury by preoperatively assessing the artery with a computed tomography (CT) scan or magnetic resonance imaging (MRI). Intraoperatively, the surgeon must be aware of when the vertebral artery is most at risk, and take precautions to avoid an injury. In the event of an arterial injury, the surgeon must have a plan of action to (1) Achieve control of the hemorrhage. (2) Prevent acute central nervous system ischemia. (3) Prevent postoperative complications such as embolism and pseudoaneurysm CONCLUSION: Prior to performing cervical spine surgery, one must understand the four A's of vertebral artery injuries: Anatomy, Assessment, Avoidance, and Action.