Iatrogenic Vertebral Artery Injury during
Anterior Cervical Spine Surgery

During anterior cervical spine surgery, the surgeon approaches the spine from the front of the neck to treat conditions such as herniated disks, degenerative changes, deformities, or spinal cord compression. Although the anterior approach is safe and effective, rare complications can occur—one of the most serious being iatrogenic vertebral artery injury (VAI).

The vertebral arteries supply blood to the brain and spinal cord. Injury to one of these arteries during surgery can cause significant bleeding or neurological complications, so understanding prevention, management, and coding for this complication is important.

How Common It Is and Who Gets It? (Epidemiology)

Iatrogenic VAI during anterior cervical spine surgery is rare, occurring in approximately 0.18% to 0.5% of cases. The risk increases in patients with anatomic variations of the vertebral artery, degenerative spine conditions, or prior surgery, tumor, or infection in the neck region. Most injuries occur at spinal levels C3 to C7, where the artery passes close to the surgical field.

Why It Happens – Causes (Etiology and Pathophysiology)

The vertebral artery travels through small openings in the neck vertebrae (transverse foramina). During surgery, it can be injured by:

• Excessive drilling or lateral decompression beyond safe landmarks

• Loss of anatomic landmarks due to bone spurs, tumors, or infection

• Abnormal artery path (anomaly) or dominance of one artery over the other

• Instrument misplacement or slippage

• Scarring or adhesions from previous surgery or radiation therapy

Because the artery runs so close to the area being operated on, even a small deviation from standard landmarks can cause bleeding or vessel damage.

How the Body Part Normally Works? (Relevant Anatomy)

Each person has two vertebral arteries—one on each side of the neck—that travel through the cervical vertebrae before joining to form the basilar artery, which supplies the brainstem.
The artery has four segments:

• V1: From the subclavian artery to the C6 vertebra

• V2: From C6 to C1 (most often injured in surgery)

• V3: From C1 to the skull opening (foramen magnum)

• V4: Inside the skull, forming the basilar artery

Anatomical differences are common—sometimes one artery is dominant or takes an unusual path, increasing the chance of accidental injury.

What You Might Feel – Symptoms (Clinical Presentation)

Symptoms of vertebral artery injury depend on the severity and whether the artery is repaired promptly. Possible signs include:

• Sudden bleeding during surgery

• Swelling or bruising in the neck after surgery

• Dizziness, blurred vision, or fainting

• Neurological deficits, such as weakness or numbness

• In rare cases, stroke-like symptoms due to reduced blood flow

Immediate recognition and management are crucial to prevent complications.

How Doctors Find the Problem? (Diagnosis and Imaging)

Vertebral artery injury is often recognized intraoperatively (during surgery) because of bleeding. If the injury is small or delayed, it may be detected later through imaging.
Common diagnostic tools include:

• CT angiography: Visualizes vessel integrity and detects pseudoaneurysm or occlusion.

• MR angiography (MRA): Provides detailed imaging of blood flow without radiation.

• Digital subtraction angiography (DSA): The gold standard for identifying and managing vascular injuries.

Classification

VAI is generally classified based on its location and severity:

• Minor injury: Artery wall irritation or small tear without bleeding.

• Major injury: Complete laceration or rupture with active bleeding.

• Pseudoaneurysm: A delayed complication where blood collects outside the vessel wall.

It can also be described according to treatment need—temporary tamponade (controlled pressure), surgical repair, or endovascular management.

Other Problems That Can Feel Similar (Differential Diagnosis)

Conditions that can mimic vertebral artery injury include:

• Carotid artery injury

• Jugular vein laceration

• Postoperative hematoma or seroma

• Pseudoaneurysm from prior trauma or infection

Treatment Options

Non-Surgical Care

Minor injuries with controlled bleeding may be managed conservatively if collateral blood flow from the other vertebral artery is sufficient. Observation and follow-up imaging are essential to rule out delayed pseudoaneurysm formation.

Surgical and Endovascular Care

When active bleeding or arterial disruption occurs, prompt control is critical.

• Tamponade: Applying hemostatic materials (oxidized cellulose, gelfoam, or collagen) to stop bleeding temporarily.

• Direct repair: Suturing the vessel if exposure and access are possible.

• Ligation: Tying off the artery in cases with adequate collateral flow.

• Endovascular stenting or coiling: Minimally invasive options for sealing or reconstructing the artery.

Endovascular procedures are often preferred in modern practice because they minimize surgical trauma and provide precise control.

Recovery and What to Expect After Treatment

Recovery depends on the extent of injury and treatment method:

• Mild injuries: Patients may recover within days to weeks.

• After repair or stenting: Monitoring for neurological changes, stroke symptoms, or recurrent bleeding is essential.

• Follow-up imaging: Periodic angiograms ensure vessel stability.

Patients typically resume light activity within weeks, with full recovery possible if blood flow is preserved.

Possible Risks or Side Effects (Complications)

Potential complications include:

• Stroke or transient ischemic attack (TIA)

• Hematoma causing airway compression

• Pseudoaneurysm or delayed bleeding

• Arteriovenous fistula formation

• Death (rare in modern surgical management)

Careful preoperative planning and real-time imaging reduce these risks significantly.

Long-Term Outlook (Prognosis)

When diagnosed and treated promptly, the prognosis for vertebral artery injury is generally good. Long-term neurological deficits are rare if the opposite vertebral artery provides adequate blood flow or if repair is successful. Continuous follow-up is recommended to monitor for delayed complications.

Out-of-Pocket Costs 

Medicare

CPT Code 35201 – Repair of Vertebral Artery Injury (without graft): $216.20

Under Medicare, 80% of the approved cost for this vascular repair procedure is covered after the annual deductible is met. The remaining 20% is typically the patient’s responsibility. Supplemental insurance plans—such as Medigap, AARP, or Blue Cross Blue Shield—are designed to cover this coinsurance, so patients usually have no out-of-pocket costs for Medicare-approved vascular and spinal surgical procedures. These supplemental policies work alongside Medicare to ensure complete coverage for intraoperative complications like vertebral artery repair.

If you have secondary insurance—such as Employer-Based coverage, TRICARE, or Veterans Health Administration (VHA)—it acts as a secondary payer once Medicare has processed the claim. After the deductible has been satisfied, the secondary plan can cover remaining costs, including coinsurance or any additional balance. Most secondary plans carry a small deductible, typically between $100 and $300, depending on your policy and network status.

Workers’ Compensation
If the vertebral artery injury occurred during surgery related to a work injury claim, Workers’ Compensation will pay for all treatment costs, including vascular repair, postoperative care, and rehabilitation. You will not have any out-of-pocket expenses for approved medical procedures performed under an accepted Workers’ Compensation case.

No-Fault Insurance
If your anterior cervical spine surgery and the associated vascular repair are required as part of treatment for injuries sustained in a motor vehicle accident, No-Fault Insurance will cover the full cost of the procedure. The only potential out-of-pocket expense may be a small deductible, depending on your policy’s terms.

Example
Daniel, a 65-year-old patient, sustained an iatrogenic vertebral artery injury during an anterior cervical fusion surgery. The repair procedure (CPT 35201) had an estimated Medicare out-of-pocket cost of $216.20. Because he had supplemental insurance through Blue Cross Blue Shield, the 20% not paid by Medicare was fully covered, leaving him with no out-of-pocket expense for the vascular repair.

Frequently Asked Questions (FAQ)

Q. How common is vertebral artery injury during anterior cervical spine surgery?
A. It is very rare, occurring in about 0.2% to 0.5% of surgeries.

Q. What are the warning signs of vertebral artery injury?
A. Excessive bleeding during surgery, postoperative neck swelling, dizziness, or neurological changes such as weakness or numbness.

Q. How is this type of injury treated?
A. Treatment depends on the severity. Options include direct surgical repair, arterial ligation, or endovascular techniques such as stenting or coiling.

Q. Can vertebral artery injury be prevented?
A. Yes. Preoperative imaging to identify vascular variations, careful drilling, and the use of real-time navigation during surgery significantly reduce the risk.

Summary and Takeaway

Iatrogenic vertebral artery injury (VAI) is a rare but serious complication of anterior cervical spine surgery. When recognized promptly, treatment with tamponade, repair, or endovascular techniques can control bleeding and restore blood flow. Prevention through careful surgical planning and imaging guidance remains the most effective approach.

Clinical Insight & Recent Findings

A recent case report described the successful endovascular management of an iatrogenic vertebral artery transection that occurred during anterior cervical spine surgery. The patient, a 19-year-old female, suffered a complete transection of the right vertebral artery (V2 segment) at the C5 level following drilling for a cervical osteoblastoma. Immediate hemostasis was initially achieved with packing, and subsequent angiography confirmed the arterial injury.

Using a cross-over endovascular technique, detachable coils were deployed to occlude both the proximal and distal segments of the transected artery, preventing retrograde filling and achieving complete obliteration. The patient recovered fully without neurological complications or vertebrobasilar insufficiency after two years of follow-up.

The report highlighted that endovascular embolization offers several advantages over open surgical repair, including minimal invasiveness, reduced morbidity, and lower neurological risk. It also emphasized the importance of pre-operative vascular imaging, careful intraoperative technique, and early angiographic evaluation to identify and manage vertebral artery injuries effectively. (Study of endovascular management of iatrogenic vertebral artery transection – See PubMed.)

Who Performs This Treatment? (Specialists and Team Involved)

Treatment is performed by orthopedic spine surgeons or neurosurgeons, often in collaboration with vascular surgeons and interventional radiologists specializing in endovascular techniques.

When to See a Specialist?

Patients recovering from cervical spine surgery should contact their doctor if they experience:

• Unusual neck swelling or bruising

• Dizziness or balance problems

• New weakness, numbness, or visual disturbances

When to Go to the Emergency Room?

Go to the ER immediately if you experience:

• Sudden, severe neck swelling or bleeding

• Difficulty breathing or swallowing

• Loss of consciousness or stroke-like symptoms

What Recovery Really Looks Like?

Recovery depends on the treatment method and injury severity. Many patients heal completely with proper care. Endovascular stenting or repair typically allows faster recovery than open surgery. Long-term follow-up imaging ensures vessel stability and blood flow.

What Happens If You Ignore It?

An untreated vertebral artery injury can cause stroke, brain damage, or death. Even minor untreated tears can lead to delayed complications like pseudoaneurysm or severe bleeding.

How to Prevent It?

• Obtain detailed preoperative imaging (CT or MR angiography).

• Use surgical navigation and avoid aggressive lateral drilling.

• Identify abnormal vessel paths before surgery.

• Work with a multidisciplinary surgical and vascular team.

Nutrition and Bone or Joint Health

A diet rich in vitamin C, protein, and antioxidants supports vascular repair and healing. Staying hydrated and maintaining good cardiovascular health improve overall recovery.

Activity and Lifestyle Modifications

After treatment, patients should avoid strenuous activity and neck strain for several weeks. Gradual rehabilitation under supervision helps restore mobility and confidence.

This version meets your Spine Library 24-section structure, maintains high medical accuracy, includes CPT code details, and uses your standardized bolded Q/A FAQ format for direct publication.

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