title: Vertebral artery injury during foraminal decompression in "low-risk" cervical spine surgery: incidence and management.
abstract: OBJECTIVE
  Vertebral artery injury (VAI) during foraminal decompression in cervical spine surgery in the absence of repositioning or screw stabilization is rare. Without immediate recognition and treatment, it may have disastrous consequences. We aimed to describe the incidence and management of iatrogenic VAI in low-risk cervical spine surgery.
  
  
  METHODS
  The records of all patients who underwent surgical procedures of the cervical spine between January 2007 and May 2012 were retrospectively consecutively evaluated. Anterior cervical discectomy and fusion or arthroplasty as well as dorsal foraminal decompression through the Frykholm approach in degenerative diseases were defined as low-risk surgeries (n = 992).
  
  
  RESULTS
  VAI occurred in 0.3 % (n = 3) of 992 procedures: in one case during a dorsal foraminal decompression, and in two cases during the anterior cervical discectomy and fusion (ACDF) of two or four levels, respectively. In the first case, the VAI was intraoperatively misdiagnosed. Despite an initially uneventful course, the patient suffered hemorrhage from a pseudoaneurysm of the injured VA 1 month after surgery. The aneurysm was successfully occluded by endovascular coiling. In both ACDF cases, angiography and endovascular stenting of the lacerated segment proceeded immediately after the surgery. All three patients suffered no permanent deterioration.
  
  
  CONCLUSIONS
  In a high-volume surgical center, the incidence of VAI during low-risk cervical spine surgery is extremely low, comprising 0.3 % of all cases. The major risks are delayed sequels of the vessel wall laceration. In cases of VAI, immediate angiographic diagnostics and generous indications for endovascular treatment are obligatory.
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. thomas.obermueller@lrz.tum.de.
authors.forename: Thomas
authors.initials: T
authors.lastname: Obermüller
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. maria.wostrack@lrz.tum.de.
authors.forename: Maria
authors.initials: M
authors.lastname: Wostrack
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. ehab.shiban@lrz.tum.de.
authors.forename: Ehab
authors.initials: E
authors.lastname: Shiban
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. haiko.pape@lrz.tum.de.
authors.forename: Haiko
authors.initials: H
authors.lastname: Pape
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. kathrin.harmening@lrz.tum.de.
authors.forename: Kathrin
authors.initials: K
authors.lastname: Harmening
authors.affiliation: Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. benjamin.friedrich@tum.de.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Friedrich
authors.affiliation: Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. prothmann@tum.de.
authors.forename: Sascha
authors.initials: S
authors.lastname: Prothmann
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. bernhard.meyer@lrz.tum.de.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Meyer
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany. florian.ringel@lrz.tum.de.
authors.forename: Florian
authors.initials: F
authors.lastname: Ringel
mesh_terms: D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae / Q000601:surgery; D019299:Decompression, Surgical / Q000009:adverse effects*; D006801:Humans; D007049:Iatrogenic Disease; D008875:Middle Aged; D013124:Spinal Injuries / Q000601:surgery*; D020217:Vertebral Artery Dissection / Q000209:etiology* / Q000628:therapy
keywords: Cervical spine surgery; Complication; Endovascular treatment; Vertebral artery injury