The Spine Journal 5 (2005) 508–514

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Iatrogenic vertebral artery injury during anterior cervical spine surgerJames P. Burke, MD, PhD, Peter C. Gerszten, MD, MPH, William C. Welch, MD, FACS*

Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA

Received 3 March 2004; accepted 23 November 2004

Abstract BACKGROUND CONTEXT: Iatrogenic injury to the vertebral artery during an anterior cervicaldecompression is a rarely mentioned but potentially catastrophic complication.PURPOSE: This study was designed to examine the incidence and management of iatrogenicvertebral artery injury (IVAI) in a large database.STUDY DESIGN/SETTING: This was a retrospective study performed at a large teaching institu-tion over a 7-year period (1994–2001).PATIENT SAMPLE: All anterior cervical spinal procedures performed for herniated or degenera-tive disc disease, or cervical spondylosis were identified, as were incidences of IVAI. Anteriorcervical procedures performed for trauma, neoplasia, or infection were excluded from this study.OUTCOME MEASURES: Neurological and associated morbidity as well as mortality wererecorded.METHODS: Data were accessed through an institution-wide electronic medical record searchthrough the operative reports of 10 spine surgeons. Hospital and clinical charts of IVAI cases weresubsequently reviewed. Demographic data and intraoperative strategies for repair were recorded.RESULTS: A total of 1,976 patients underwent anterior cervical spinal procedures in the reviewperiod. Six cases of IVAI were identified. In three of the six patients, arterial bleeding was controlledwith hemostatic agents. Of these three, two suffered complications. The initial management ofcontrolling arterial bleeding is by hemostatic agents; however, one must also consider repair orligation. The remaining three patients were treated with primary repair or ligation, and no complica-tions were noted.CONCLUSIONS: IVAI is a rare complication (0.3%) of anterior cervical procedures. The arterialbleeding can usually be controlled with topical hemostatic agents, but mortality may occur ininstances where it cannot be adequately addressed in a timely fashion.� 2005 Elsevier Inc. Allrights reserved.

Keywords: Vertebral artery; Anterior cervical spine; Cervical corpectomy; Anterior cervical discectomy and fusion(ACDF); Iatrogenic

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Introduction

The anterior approach for decompression of the cervicspinal cord and nerve roots is widely used for herniateintervertebral disc, spondylosis, trauma, tumor, and infetion. Although anterior approaches to the cervical spine aassociated with a lower incidence of neurologic complications[1,2], injury to the many vital structures encountered i

FDA device/drug status: not applicable.Nothing of value received from a commercial entity related to thi

research.* Corresponding author. Department of Neurological Surgery, Unive

sity of Pittsburgh, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 1521Tel.: (412) 647-0958; fax: (412) 647-0989.

E-mail address: welchwc@upmc.edu(W.C. Welch)

1529-9430/05/$ – see front matter� 2005 Elsevier Inc. All rights reserved.doi:10.1016/j.spinee.2004.11.015

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the anterior approach remains a risk. Potential complicatioinclude vocal cord paralysis, dysphagia, carotid artery injurHorner’s syndrome, esophageal perforation, and respirtory obstruction resulting from acute retropharyngeal edemor hematoma[1–7]. Despite these potential complications,anterior procedures have been successful and are popuAdditionally, most of the complications of the anterior ap-proach do not detract from the excellent long-term clinicaresults[8–12].

In contrast to this, iatrogenic injury to the vertebral arteryduring an anterior cervical decompression can be catstrophic[13–15]. Such injuries have been acknowledged inthe literature, but their incidence is rarely mentioned, exceto state that it is an unusual complication[3,8,15–22]. Verte-bral artery laceration is particularly grave because of th

J.P. Burke et al. / The Spine Journal 5 (2005) 508–514 509

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difficulty of controlling hemorrhage, and the uncertain neurological consequences, often resulting in significant neurlogical injuries[13,15,23,24].

Although vertebral artery trauma is uncommon, penetraing injuries to the neck can result in life-threatening hemorhage. In the general surgery literature, there are goaccounts of the surgical exposure of the artery and of tcontrol of bleeding caused by penetrating neck injuries[25–29]. However, little has been published to guide the spinsurgeon in the avoidance or intraoperative managementsuch an injury. While prevention of the problem is the betreatment, spine surgeons who perform anterior cervical dcompressions should be prepared to manage an inadverlaceration of the vertebral artery during the lateral extentthe decompression. The present study reviews the experieat a single institution with anterior cervical spine procedurecomplicated by vertebral artery injuries in terms of incidence, intraoperative strategies for repair, and postopetive outcome.

Methods

We present a retrospective review of six adult patienin whom an anterior cervical spinal procedure was compcated by iatrogenic vertebral artery injury (University oPittsburgh IRB #000565). An institution-wide electronicmedical record search through the operative reports ofspine surgeons (seven neurosurgeons, three orthopedicgeons) over the past 7 years (1994–2001) was conductAll procedures were performed for herniated or degeneratidisc disease, or spondylosis; procedures for trauma, neopsia, or infection were excluded from this study. Hospital anclinical charts subsequently were reviewed. Demographdata, intraoperative strategies for repair, and postoperatoutcome were recorded.

Results

Using an electronic search of medical records at oinstitution over the past 7 years, six adult patients weidentified who suffered iatrogenic vertebral artery injuryduring anterior cervical spine procedures for herniateddegenerative disc disease or spondylosis. A total of 1,9anterior cervical spine procedures were performed for theindications during this time (incidence of 0.3%); procedurefor traumatic, neoplastic, and infectious processes were ecluded from entry into this study. Of these six patients, onsingle-level and one three-level anterior cervical discectomand fusion, and one reexploration and three primary cerviccorpectomies and fusions were performed. Median patieage was 60 years; female to male ratio was 2:1. In fivesix cases presented, an operating microscope was usedall six patients with vertebral artery injury, the operation waperformed from the patient’s right side (Table 1).

In five cases, bright arterial bleeding was encounteretwo were repaired primarily; one was treated with arteria

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ligation; one was tamponaded with thrombin-soakeGelfoam (Pfizer, New York, NY). In each of these casesno neurological sequelae were noted postoperatively. Tduration of postoperative follow-up was approximately 3months. Only one postoperative cerebral angiogram wperformed; this demonstrated a mild defect in the arteriawall consistent with the intraoperative packing of the vertebral artery. In the final case in which bright arterial bleedingwas encountered, hemodynamic instability from hypovolemia resulted in intraoperative death.

In the sixth case of vertebral artery injury, no arterial oexcessive bleeding was encountered; however, thrombsoaked Gelfoam was placed laterally to tamponade epiduoozing. Postoperatively, the patient awoke with a lateramedullary infarct, and cerebral angiography demonstratedvertebral artery dissection with posterior inferior cerebellaartery occlusion (Fig. 1). Anticoagulation with heparin wasstarted immediately after the diagnosis of vertebral arterdissection was made.

Discussion

Vertebral artery injury is a serious complication of anterior spinal surgery. The possibility of severe hypotensioand cardiac arrest is present. If control of blood loss is noobtained carefully, the spinal cord and nerved roots may binjured. Control of the hemorrhage may be adequate initiallHowever, recurrent hemorrhage or the chronic problemsarterial injury (eg, arteriovenous fistula, pseudoaneurysmarterial thrombosis, and cerebrovascular emboli), are repossibilities[15,19,20,30].

The true incidence of iatrogenic injury to the vertebraartery during anterior decompressive surgery in the subaial spine is unknown. In a questionnaire survey of 82,11patients, Flynn[31] did not mention iatrogenic vertebralartery injury. Isolated reports include one by Cloward[17],in which he described a case of Wallenberg’s syndromresulting from thrombosis of the vertebral artery after thuse of a vertebral spreader. Additionally, Cloward reportepersonal communications from three surgeons, each withcase of vertebral artery injury that required only tamponad[3]. Weinberg and Flom[30] reported injury to the vertebralartery during cervical discectomy, resulting in an arteriovenous fistula. Cosgrove and The´ron [19] reported two caseswith “troublesome” and “difficult hemostasis,” in which de-layed vertebral arteriovenous fistulae were treated endovacularly. De los Reyes et al.[20] reported the direct repairof a pseudoaneurysm that developed 3 days after a drinjury to the vertebral artery during an anterior cervical vertebrectomy. Schweighofer et al.[24] reported injury tothe vertebral artery during vertebrectomy and reduction oa locked facet. In this case, the artery was ligated witclips, and no neurologic injury was observed. Smith et a[15] reviewed a 5-year experience and reported an incidenof vertebral artery laceration of 0.5% (10 of 1,195 operations); most of these occurred during vertebrectomy fo

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Table 1Summary of demographic, operative, and outcome data in six patients with iatrogenic vertebral artery injury during anterior cervical spine surgery

Age (yr) Sex Operative procedure Complication Management Outcome

66 Female C5-6 corpectomy, C4-7 fusion, right side approach Left vertebral artery laceration Primary repair No sequelae53 Female C4-5, C5-6, C6-7 anterior cervical discectomy Left vertebral artery laceration Ligation No sequelae

and fusion, right side approach45 Male Redo C4-5 corpectomy and C3-6 fusion, right Left vertebral artery laceration Primary repair No sequelae

side approach62 Female C6 corpectomy, right side approach Left vertebral artery laceration Tamponade Intraoperative dea58 Male C4-5-6 corpectomy, C3-7 fusion, right side Right vertebral artery compression Tamponade No sequelae

approach66 Female C5-6 anterior cervical discectomy and fusion, Left vertebral artery dissection Tamponade with Posterior inferior

right side approach postoperative cerebellar arteryanticoagulation infarct, lateral

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spinal cord decompression. Management consisted of hemstatic packing in three cases, with direct exposure and ligtion of the artery in the remaining seven cases. In thestudy, three brainstem infarcts (from the ligated group) aone reversible cardiac arrest secondary to hemorrhage wnoted. The causes that they identified were: drill was omidline; excessive width of bone and disc removal; oabnormal softening of the lateral bone, resulting either frotumor or infection. Pfeifer et al.[32] reported a case inwhich the vertebral artery was entered when a trough wmade laterally during a C4-5 corpectomy. The artery wrepaired primarily, with no postoperative neurologic sequelae. Golfinos et al.[21] reviewed an 8-year experience anreported an incidence of 0.3% (4 in 1,215 anterior aproaches) of vertebral artery injury during anterior cervicdiscectomy or corpectomy. Three of the four arteries werepaired primarily at the time of injury; one artery waligated. No vertebrobasilar symptoms were noted postopetively (Table 2).

In this retrospective study, we identified six anterior cervcal spine procedures that were complicated by iatrogevertebral artery injury. This yielded an incidence of approxmately 0.3% (6 of 1,976). Our results are similar to thincidence reported in other studies[15,21]. In these six pa-tients, one intraoperative death and one vertebrobasstroke occurred.

Two scenarios may account for iatrogenic vertebral arteinjury during anterior cervical spine procedures. The firsttortuosity of the vertebral artery in which it has migrateinto the vertebral body. Careful attention to the preoperaticomputed tomographic and magnetic resonance imagstudies may reveal dilated or tortuous vertebral artery anomy, which can then be avoided intraoperatively. The secoscenario involves asymmetric and excessive far lateral boremoval. This injury is more likely to occur on the leftside during a right-sided approach.

Vertebral artery injury can occur during lateral exploration of the neural foramen after anterior cervical discectomand resection of uncovertebral joint osteophytes. The injuryusually minor and is readily controlled with small amounts o

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hemostatic packing. The segment of the extracranial vertbral artery that runs through the transverse foramen of the C6 vertebrae is surrounded by an extensive venous plexuExcellent postmortem studies have described the anatomrelationships of the vertebral artery to the vertebral bodieintervertebral foramina, and cervical roots[33,34]. The ver-tebral artery at the level of the disc space is usually founlateral to the midportion of the vertebral body and is normallyprotected during anterior cervical discectomy by the bonridge of the uncovertebral joint. However, during removaof laterally placed osteophytes or difficult reoperations, thevertebral artery or its venous plexus may be damaged.

More significant injuries can be created during cervicacorpectomy if the decompression is taken too far laterallyThe injuries are usually incurred when drilling is asymmetricor overly aggressive and can be avoided if the drill is noallowed to penetrate the deep bony cortex. The vertebra cbe eggshelled out with the drill, leaving only a thin bonycortex to be avulsed with a fine curette or thin-footed Kerrison rongeur.

Maintaining the midline orientation is key to adequatedecompression of the neural structures, as well as to avoinjury to the vertebral artery. Marking the midline withthe monopolar cautery or a marking pen before dissecting thlongus colli, and then frequently confirming orientation byreferring to the midline markings is often helpful. The mediauncovertebral joint should be a guide as to the lateral exteof any dissection or drilling. One must use caution with thedissection and drilling of pathologically softened bones fromtumor or infection. The use of a measuring standard, eg,standard 13-mm-wide cottonoid patty, is also useful to confirm orientation. Several anatomic clues to maintain the midline are the curvature of the vertebral body and thecal sathe location of epidural veins and fat, visualization of thenerve roots, palpation of the pedicle, and the location othe sternomanubrial notch.

Surgical adjuncts may be considered in selected casespatients requiring anterior cervical approaches. The operating microscope does aid in visualization and may reducthe risk of vertebral artery and neurological structure injury

J.P. Burke et al. / The Spine Journal 5 (2005) 508–514 511

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Fig. 1. Case 6. (A) Cerebral angiogram demonstrating dissection of the left vertebral artery (arrow). (B) Cerebral angiogram demonstrating taperedof the left vertebral artery (arrow), with no flow in left posterior inferior cerebellar artery. (C) T2-weighted magnetic resonance imaging study showininfarction and edema in the left cerebellar hemisphere and medulla (Wallenberg infarct).

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Table 2Summary of treatment options and associated complications ofstudy site compared with observations from other institutions

Treatment option and incidence of complications(Number of complications/Number ofsubjects treated)

Primary author andreference number Tamponade Ligation Primary repair

Our study site 2/3 0/1 0/2Cloward[3] 0/3Smith [15] 0/3 3/7Cosgrove[19] 0/2de los Reyes[20] 0/1Golfinos[21] 0/1 0/3Weinberg[30] 0/2Pfeifer [32] 0/1

Interestingly, the microscope was used in five of the scases described above. One potential shortcoming ofmicroscope is that surgeons tend to become highly focuson a small area and may lose their larger surgical perspectiShould the operating surgeon choose to use the micscope, we would recommend lowering the magnification oan intermittent basis and reestablishing surgical orientatio

Fluoroscopy may also be used to aid in maintaining midline orientation. This adjunct is readily available in mosoperating rooms and might enable the surgeon to confirmregain midline orientation in difficult cases. Intraoperativecomputed tomographic scans were not used in any of thecases presented here. Intraoperative computed tomograpscanning has been used to assess the adequacy of surdecompression during anterior cervical procedures, andwould be a logical step to use this adjunct should the surgehave concerns about orientation[35]. Computed tomo-graphic scanning or the use of image guidance techniqucould be especially helpful in cases with severe patho-antomic anomalies or reoperations, and this would seem toa reasonable surgical adjunct if it is readily available.

Intraoperative angiography may be an appropriate adjunto help identify and potentially treat the bleeding sourcshould vertebral artery injury occur. The endovascular teamay be able to place a stent into the vertebral artery acrothe injury. Alternatively, they may be able to temporarilyocclude the artery with close observation of intraoperativneurophysiological monitoring. Should temporary occlusiobe tolerated, either the surgeon or the endovascular tecan directly occlude the vessel.

Prevention of iatrogenic vertebral artery injury remainthe best treatment. However, when laceration of a vertebartery has occurred, generous use of thrombostatic agealong with direct pressure and suction over cotton pattishould be used initially to control the bleeding. The anesthsia team should be immediately informed of the event, anblood products should be made readily available. The patieshould be fluid-resuscitated and, if possible, appropriate sgical assistance should be gathered, including vascusurgery. Basic vascular principles, including proximal andistal control of the bleeding vessel, should be employed

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possible. Management options at this time include continuetamponade, microvascular repair of the injured artery, and lgation of the vertebral artery. Endovascular embolizationhas also been described as a postoperative adjunct[19].

When tamponade does not control the hemorrhage,small, high-speed bone cutting tool then should be used texpose the vertebral artery proximal and distal to the injuryThe artery can then be temporarily occluded and carefullrepaired. For this reason, the head must be returned to tmidline position to avoid kinking the contralateral arteryand producing vertebrobasilar insufficiency.

The therapeutic goal is the elimination of the injury withpreservation of the normal flow in the patent vertebral arteryand the management of vertebral artery lacerations neeto be based on 1) controlling the hemorrhage locally, 2preventing immediate vertebrobasilar ischemia, and 3) preventing cerebrovascular complications. Without angiography, one cannot predict in advance the risks of ischemideficits from vertebral artery sacrifice. Therefore, one musweigh the options of vertebral artery ligation versus repairThe majority of patients tolerate unilateral vertebral ligationwell [25,36–38]. A small number of patients, however, willhave an isolated vertebral artery terminating in the posterioinferior cerebellar artery, an atretic, stenotic, or previouslyoccluded vertebral artery, or inadequate collateralization othe circle of Willis. Ligation of the vertebral artery in thesecircumstances can result in cerebellar or brainstem infarction. Shintani and Zervas[14] found a 12% mortalityrate after acute vertebral artery ligation. The anatomy othe vertebral artery in the general public should also bconsidered. The left vertebral artery is hypoplastic in 5.7%and absent entirely in 1.8% of cases. On the right sidethe artery is hypoplastic in 8.8%, and absent in 3.1%[39].In an older population, the adequacy of collateral circulationis further compromised by atherosclerosis in the circle oWillis and in the posterior circulation. In an autopsy studyand review of the literature, Thomas et al.[40] indicatedthat the predictable incidence of brainstem infarction is3.1% of cases when the left vertebral artery is ligated, an1.8% when the right vertebral artery is ligated. Because thstatus of the vertebral artery anatomy is unlikely to be knownpreoperatively and because the long-term consequenceseven a successful vertebral artery ligation are unclear, eveeffort should be made to preserve arterial patency whenever possible.

Prior studies also conclude that direct repair is the preferred management, when possible, with clean ligation aa second choice[15,20,21,32,41,42]. Several cases in theliterature have reported delayed complications from packinthe injured vessels rather than directly repairing or cleanlligating the vessels[15,19,20].

When not possible to perform microvascular repair, exposure of the artery with ligation proximally and distally isrecommended[21], because experience in the trauma population reveals a risk of delayed embolic complications, hemorrhagic complications, and a risk of fistula formation in

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those patients treated with packing or proximal ligation alon[36,43]. In patients in whom hemorrhage can only be controlled by packing, this may have to suffice, although theremains a risk of delayed hemorrhage and fistula formati[19,20]. Smith’s 3 patients treated with packing alone had nneurologic complications. However, the mean estimatblood loss was 2370 cc in these three patients[15].

Once the decision has been made to proceed with micvascular repair or ligation, the anterior bony foramen tranversarium immediately beneath the laceration, as wellregions above and below, needs to be unroofed. Once promal and distal control are obtained, the laceration can oftbe reapproximated. If ligation is to be performed, both proxmal and distal ends of the artery are to be ligated to reducerisk of delayed complications. The patient should be admittto an intensive care unit postoperatively for close monitorinof neurologic function. Additionally, a confirmatory radio-graphic study should be performed (either magnetic reonance angiogram or conventional angiogram) to rule oarterial pathology. Further management would be based upthe etiology of the abnormality detected by these studi(consider reoperation, embolization, or anticoagulation).

Anticoagulation is generally indicated when neurologicadeficits occur due to thromboembolic phenomena. Hepais immediately started and then an antiplatelet agent is usfor 3 months postoperatively. Anticoagulation carries somrisk of local rebleeding or conversion of a recent brain infarto a hemorrhagic infarct requiring evacuation. Consultatioby a stroke neurologist would be appropriate in this settinWe would recommend postoperative angiography when fesible so as to identify the extent of the injury, and to identifany evidence of vertebral artery dissection. The collatecirculation to the brain should also be confirmed. This studmay influence the extent and duration of postoperatianticoagulation.

Conclusions

Iatrogenic vertebral artery injury during anterior cervicaspine procedures is an infrequent, yet potentially catastropcomplication. Initial management of vertebral artery injuris immediate tamponade; either primary repair or arteriligation may be required if this maneuver is unsuccessfAppreciation for the local, “hidden” anatomic structures malimit the incidence of vertebral artery injury during lateraexploration of the neural foramen after discectomy and ucovertebral joint osteophytes or during the lateral decompression of a cervical corpectomy. Injuries need to be readidentified and controlled with either direct tamponade, mcrosurgical repair, or vessel occlusion.

References

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COMMEN

Gregory J. Przybylski, M

The authors describe the management of six patients witvertebral artery injuries sustained during anterior cervicasurgery in the largest retrospective series of patients examined for this complication. There is limited publication aboutthis complication secondary to the infrequency of this iatro-genic injury. Consequently, the authors’ analysis of the management options available can prove exceedingly helpful fothe surgeon who encounters this rare intraoperative problem

Several useful recommendations for avoidance of vertebral artery injury during anterior cervical surgery were given.Review of preoperative imaging to identify anomalous ortortuous vertebral arteries, careful identification of the mid-line, and recognition of the lateral extent of decompressionare important ways to prevent vertebral injury. Althoughone might assume that the illumination and magnification ofan operating microscope would be a useful adjunct, themicroscope was actually used in five of their six patients.

In managing a patient once a vertebral artery injuryoccurs, the authors observed no neurological consequencin the three patients treated with direct repair or ligation,whereas two of three treated with tamponade had serioucomplications. Although the reader might conclude thatdirect repair is the preferred treatment, one of the two patients died from intraoperative hemorrhage with inadequatetamponade. Others have observed successful treatmewith tamponade. Given the limited data available, it becomesdifficult to recommend a particular treatment among theoptions of tamponade, ligation, or repair at the time of sur-gery. While obtaining control of bleeding with tamponade,the authors recognize the importance of communicating with

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[35] Freidberg SR, Pfeifer BA, Dempsey PK, et al. Intraoperative computerized tomography scanning to assess the adequacy of decompressin anterior cervical spine surgery. J Neurosurg (Spine 1) 2001;94:8–1

[36] Golueke P, Sclafani S, Phillips T, et al. Vertebral artery injury: diagno-sis and management. J Trauma 1987;27:856–65.

[37] McCormick WF. Trauma. In: Resenber RN, ed. The clinical neurosciences. Vol. III. New York: Churchill Livingstone, 1983:241–4.

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the anesthesiologist the potential need for fluid resuscitationincluding blood products. In addition, one should also em-phasize to the anesthesia team the importance of maintainingperfusion pressure to reduce the risk of posterior circulationischemia. Postoperative monitoring of neurological status islikewise important as delayed symptoms may arise. Post-operative imaging with magnetic resonance, computed to-mographic, or conventional angiography may help guidesubsequent additional treatment if a fistula or pseudoaneu-rysm is present.

However, the management of cerebral ischemia or in-farction after control of bleeding with either tamponade,ligation, or repair remains unclear. In examining the publica-tions concerning traumatic nonpenetrating vertebral arteryinjury in acute cervical spine injury, anticoagulation withheparin was recommended in patients sustaining a stroke[1]. However, patients with only symptoms of ischemiacould be alternatively managed with observation. Becausehemorrhagic complications from heparin anticoagulationwere observed, observation alone was recommended inasymptomatic patients. Although patients with iatrogenicpenetrating vertebral artery injuries may respond differently,the published data remain inadequate to offer evidence-based recommendations.

Reference

[1] Hadley MN, Walters BC, Grabb PA, et al. Management of vertebralartery injuries after nonpenetrating cervical trauma. Neurosurgery2002;50:S173–8.

doi:10.1016/j.spinee.2005.01.001