title: Vertebral artery injury in cervical spine surgery: anatomical considerations, management, and preventive measures.
abstract: BACKGROUND
  Vertebral artery (VA) injury can be a catastrophic iatrogenic complication of cervical spine surgery. Although the incidence is rare, it has serious consequences including fistulas, pseudoaneurysm, cerebral ischemia, and death. It is therefore imperative to be familiar with the anatomy and the instrumentation techniques when performing anterior or posterior cervical spine surgeries.
  
  
  OBJECTIVE
  To provide a review of VA injury during common anterior and posterior cervical spine procedures with an evaluation of the surgical anatomy, management, and prevention of this injury.
  
  
  METHODS
  Comprehensive literature review.
  
  
  METHODS
  A systematic review of Medline for articles related to VA injury in cervical spine surgery was conducted up to and including journal articles published in 2007. The literature was then reviewed and summarized.
  
  
  RESULTS
  Overall, the risk of VA injury during cervical spine surgery is low. In anterior cervical procedures, lateral dissection puts the VA at the most risk, so sound anatomical knowledge and constant reference to the midline are mandatory during dissection. With the development and rise in popularity of posterior cervical stabilization and instrumentation, recognition of the dangers of posterior drilling and insertion of transarticular screws and pedicle screws is important. Anomalous vertebral anatomy increases the risk of injury and preoperative magnetic resonance imaging and/or computed tomography (CT) scans should be carefully reviewed. When the VA is injured, steps should be taken to control local bleeding. Permanent occlusion or ligation should only be attempted if it is known that the contralateral VA is capable of providing adequate collateral circulation. With the advent of endovascular repair, this treatment option can be considered when a VA injury is encountered.
  
  
  CONCLUSIONS
  VA injury during cervical spine surgery is a rare but serious complication. It can be prevented by careful review of preoperative imaging studies, having a sound anatomical knowledge and paying attention to surgical landmarks intraoperatively. When a VA injury occurs, prompt recognition and management are important.
authors.affiliation: Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY 10003, USA. chanpeng99@gmail.com
authors.forename: Chan W
authors.initials: CW
authors.lastname: Peng
authors.forename: Benedict T
authors.initials: BT
authors.lastname: Chou
authors.forename: John A
authors.initials: JA
authors.lastname: Bendo
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Spivak
mesh_terms: D002574:Cervical Vertebrae / Q000601:surgery*; D006801:Humans; D019637:Orthopedic Procedures / Q000009:adverse effects*; D013124:Spinal Injuries / Q000601:surgery*; D014711:Vertebral Artery / Q000293:injuries*