Antiplatelet versus Anticoagulation for Asymptomatic Patients with Vertebral Artery Injury during Anterior Cervical Surgery-Two Case Reports and Review of Literature

Crimping technique to treat iatrogenic vertebral artery injury during spinal fusion

Iatrogenic arterial injuries may occur during neurosurgical procedures. Particularly, the vertebral artery may be injured in a high-level cervical spinal fusion case, either during the initial exposure or when placing screws.1- 3 If such an injury occurs, obtaining hemostatic control and repairing the laceration are of paramount importance.4, 5 In this technical video, we describe the case of a patient who was undergoing a posterior C1-C2 cervical fusion when the right vertebral artery was injured due to variant anatomy. Using sutures to repair the injury was unsuccessful. Thus, we employed a technique known as crimping, which involves the use of vascular clips to pinch off the site of the tear. This technique is an improvement over existing methods given how quickly and easily it can be performed. In our technical video, we explain how to perform the crimping technique and discuss indications for its use. The patient consented to the procedure.

Intraoperative Vertebral Artery Injury: Evaluation, Management, and Prevention

Vertebral artery injury (VAI) is a serious and potentially life-threatening injury that is encountered with trauma to the cervical spine and less frequently during surgery. VAI can occur during either anterior or posterior cervical approaches or instrumentation and often involves anomalous courses of the artery. Although the incidence is rare, serious consequences including fistula formation, thrombosis, pseudoaneurysm development, cerebral ischemia, hemorrhage, and death may occur. Management of VAI can be divided into prevention, including review of preoperative imaging with knowledge of the anatomic course, utilization of surgical landmarks intraoperatively, and prompt recognition and management when injury is encountered.

VertebralArtery Injury with Anterior Cervical Spine Operations: A Systematic Review of Risk Factors, Clinical Outcomes, and Management Strategies

OBJECTIVE

Anterior cervical spine operations are commonly performed on cervical spine pathologies and to a large extent are safe and successful. However, these surgical procedures expose the vertebral artery, posing a risk of harm to it.

METHODS

A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to critically assess primary articles discussing treatment strategies "vertebral artery injury" AND "anterior cervical spine" and develop a management strategy based on our experience and meta-analysis of the literature. In addition, we present an illustrative case of iatrogenic vertebral artery injury presenting with 6 to 7 months' history of progressive dysphagia was transferred to our care from an outside institution.

RESULTS

Included and analyzed were 43 articles that detailed 75 cases involving vertebral artery injury (VAI) in anterior cervical spine operations. Preoperatively, frequent clinical findings reported were sensory deficit (26 patients [63.41%]), motor deficit (20 patients [48.78%]), and pain (17 patients [41.46%]). In total, 32 patients (50.00%) endured injury of their left VA, and 30 patients had a right VAI. The 2 common causes of VAI were drilling (24 patients [40.00%]) and instrumentation (8 patients [13.33%]).

CONCLUSIONS

Altogether, our review recommends repair or tamponade packing with a hemostatic agent for primary management. Should tamponade packing with a hemostatic agent be used for primary management, secondary management should entail either repair, stenting occlusion, embolization, anticoagulants, or ligation. Further examination of this treatment strategy based on a larger cohort is necessary.

Surgery for Spine Disease and Intractable Pain

Painful conditions, particularly due to head pain, spinal disease, and neuropathic pain, are highly prevalent in modern society, resulting in a significant impact on the individual due to the disability of the condition and the direct cost of associated treatments [...].