Intraoperative Vertebral Artery Injury: Evaluation, Management, and Prevention
Location
LSUHSC-NO Center for Advanced Learning and Simulation
Document Type
Presentation
Start Date
21-6-2025 8:45 AM
End Date
21-6-2025 9:05 AM
Publication Date
June 2025
Description
Introduction: Vertebral artery injury (VAI) is the most common vascular injury during cervical spine surgery and makes up 86.6% of iatrogenic cervical spine vascular injuries. The typical mechanism of VAI in cervical spine surgery is laceration. The most common causes are drilling (anterior approach) and instrumentation (posterior approach). Delayed complications from arterial laceration include recurrent bleeding, pseudoaneurysm development, and arteriovenous fistula (AVF) formation. Neurologic complications from VAI are rare (5%) but can result in potentially devastating ischemia or cerebral infarct due to thrombosis with subsequent emboli. The risk of these complications depends on VA dominance, baseline health of the patient, and management of the injury. Once hemorrhage is controlled patients may frequently be asymptomatic from these injuries, but the possibility of late neurologic sequelae cannot be ignored. The authors would highlight the primary importance of prevention in knowledge of individual patient anatomy, careful selection of procedure choice, and instrumentation techniques to reduce the likelihood of VAI.
Summary: Iatrogenic VAI is a rare but potentially catastrophic complication. Advanced imaging techniques and increased anatomic knowledge are crucial to the prevention of these complications during cervical spine surgeries performed for various cervical spine disorders. Regardless of the surgical approach, surgeons must be aware of the potential for VAI and take the necessary steps for prevention of complications by understanding a patient’s vascular anatomy, recognizing anatomic anomalies, undertaking proper surgical planning, and maintaining close monitoring during the perioperative period. Surgeons must be aware of the appropriate management strategies for VAI and be prepared to perform hemostatic tamponade, microvascular repair, or anastomosis as needed. VA dominance and collateral circulation must be known preoperatively before surgical ligation or permanent clipping is attempted. Recent advancements in endovascular treatment have provided increased intervention options in iatrogenic VAI. In the event of VAI, local control of bleeding is the first concern followed by immediate angiography, serial endovascular treatment, and close monitoring of the patient.
Clinical Care Points: Iatrogenic vertebral artery injury (VAI) is a rare but potentially devastating complication of cervical spine surgery. Surgeons should be aware of anatomic variants of the vertebral artery, the presence of which can be detected on meticulous review of preoperative imaging. Prevention is key to avoiding any injury through knowledge of patient anatomy, procedure and instrumentation selection, care in dissection, and meticulous surgical technique. Initial management of VAI includes tamponade and enlistment of anesthesia assistance in addition to neurointerventional radiology/surgery or vascular surgery if available. Treatment modalities remain controversial and include tamponade, direct repair, ligation, or endovascular interventions. Surgeons must be aware of late complications of VAI such as delayed hemorrhage, pseudoaneurysm, and arteriovenous fistula in addition to management options.
Recommended Citation
Redlich, Nathan MD, "Intraoperative Vertebral Artery Injury: Evaluation, Management, and Prevention" (2025). Dept. of Orthopaedics: Robert D. D’Ambrosia Lectureship & Research Day. 4.
https://digitalscholar.lsuhsc.edu/ortho_rd/2025/presentation1/4
Intraoperative Vertebral Artery Injury: Evaluation, Management, and Prevention
LSUHSC-NO Center for Advanced Learning and Simulation
Introduction: Vertebral artery injury (VAI) is the most common vascular injury during cervical spine surgery and makes up 86.6% of iatrogenic cervical spine vascular injuries. The typical mechanism of VAI in cervical spine surgery is laceration. The most common causes are drilling (anterior approach) and instrumentation (posterior approach). Delayed complications from arterial laceration include recurrent bleeding, pseudoaneurysm development, and arteriovenous fistula (AVF) formation. Neurologic complications from VAI are rare (5%) but can result in potentially devastating ischemia or cerebral infarct due to thrombosis with subsequent emboli. The risk of these complications depends on VA dominance, baseline health of the patient, and management of the injury. Once hemorrhage is controlled patients may frequently be asymptomatic from these injuries, but the possibility of late neurologic sequelae cannot be ignored. The authors would highlight the primary importance of prevention in knowledge of individual patient anatomy, careful selection of procedure choice, and instrumentation techniques to reduce the likelihood of VAI.
Summary: Iatrogenic VAI is a rare but potentially catastrophic complication. Advanced imaging techniques and increased anatomic knowledge are crucial to the prevention of these complications during cervical spine surgeries performed for various cervical spine disorders. Regardless of the surgical approach, surgeons must be aware of the potential for VAI and take the necessary steps for prevention of complications by understanding a patient’s vascular anatomy, recognizing anatomic anomalies, undertaking proper surgical planning, and maintaining close monitoring during the perioperative period. Surgeons must be aware of the appropriate management strategies for VAI and be prepared to perform hemostatic tamponade, microvascular repair, or anastomosis as needed. VA dominance and collateral circulation must be known preoperatively before surgical ligation or permanent clipping is attempted. Recent advancements in endovascular treatment have provided increased intervention options in iatrogenic VAI. In the event of VAI, local control of bleeding is the first concern followed by immediate angiography, serial endovascular treatment, and close monitoring of the patient.
Clinical Care Points: Iatrogenic vertebral artery injury (VAI) is a rare but potentially devastating complication of cervical spine surgery. Surgeons should be aware of anatomic variants of the vertebral artery, the presence of which can be detected on meticulous review of preoperative imaging. Prevention is key to avoiding any injury through knowledge of patient anatomy, procedure and instrumentation selection, care in dissection, and meticulous surgical technique. Initial management of VAI includes tamponade and enlistment of anesthesia assistance in addition to neurointerventional radiology/surgery or vascular surgery if available. Treatment modalities remain controversial and include tamponade, direct repair, ligation, or endovascular interventions. Surgeons must be aware of late complications of VAI such as delayed hemorrhage, pseudoaneurysm, and arteriovenous fistula in addition to management options.
Comments
Chief Resident Presentation