Iatrogenic Vertebral Artery Injury during

Anterior Cervical Spine Surgery

A surgical technique called the anterior approach is utilized to address a range of conditions affecting the cervical spine, such as degenerative disorders, injuries, tumors, deformities, and infection.

The Smith-Robinson approach, which was first reported in 1955 and later modified by Southwick and Robinson in 1957 to reach C3 to T1, is likely the most commonly employed method. The anterior approach is a practical and convenient option for addressing pathologies originating from the anterior cervical spine.

It provides excellent exposure to multiple levels of the spine, allows thorough neural decompression, and enables solid reconstruction of the vertebral column. Anterior cervical procedures are frequently used to perform anterior cervical discectomy and fusion (ACDF) as well as anterior cervical corpectomy and fusion (ACCF).

It is essential to recognize the possibility of complications, even though most anterior approach procedures are executed with safety and efficacy. Possible complications of anterior approach procedures comprise incisional hematoma, dysphagia, esophageal perforation, injuries to the superior and recurrent laryngeal nerves, spinal cord and nerve root injury, as well as vertebral artery injury.

Due to its proximity to the surgical site, the vertebral artery (VA) is vulnerable to injury during anterior cervical spine surgery. Although iatrogenic vertebral artery injury (VAI) is uncommon, with an incidence rate of 0.18%–0.5%, it can cause significant intra- or postoperative bleeding, cardiac arrest, arteriovenous fistula, neurological complications, or even death.

Various factors that can elevate the risk of VAI have been identified:

      1. Coarse Drilling: The most commonly reported cause of VAI is drilling during the surgical procedure. When performing decompression during anterior cervical surgery, coarse drilling can cause excessive lateral movement, particularly when drilling through a vertebra, disc, or foramen. This is especially true in cases where the bone has been softened due to infection or tumor growth.
      2. Loss of Landmarks: In anterior cervical surgery, two significant landmarks are the midline and the uncinate process. The midline serves as a reference point to determine the safe extent of lateral exposure and decompression during the surgical procedure, as well as the precise placement of instrumentation.
        Accurately identifying the midline may be challenging in certain situations, such as when a large, eccentric osteophyte is present. Loss of this landmark can result in excessive lateral drilling, leading to VAI.
        Located medial to the transverse foramen, the uncinate process has a distinct sharp and tapered articular surface that creates an uncovertebral joint. During surgery, the medial uncovertebral joint serves as a boundary for lateral dissection or drilling. As the uncinate process flattens over time, it becomes less effective in preventing VAI.
      3. Status of VA: There are three sections that comprise the extracranial vertebral artery.
        • Section 1 (V1): It arises from the subclavian artery and travels to the transverse foramen of C6.
        • Section 2 (V2): It travels from the transverse foramen of C6 to the transverse foramen of C1.
        • Section 3 (V3): It extends from C1 to the foramen magnum.
        • Intracranial portion of the VA (V4): It travels from the foramen magnum to the basilar artery.

The segments of the VA that are most at risk are the anterior portion of C7, the lateral segments from C3 to C7, and the posterior segments of C2 and C1. The path of V2 is the longest and it travels through a canal that is formed by bone and muscle.

It is also surrounded by an extensive network of veins. As a result, the most common injury during anterior cervical surgeries occurs to V2, since these surgeries are primarily performed in the area between C3 and C7.

There is often a difference in the diameter of the left and right VAs. Approximately 6% to 26% of patients have VAs of the same size, and the left VA is usually larger and considered the dominant vessel.

A significant correlation exists between the diameter of the transverse foramen and VA blood volume. Usually, the side with the larger transverse foramen indicates the dominant VA. The normal course and structure of the VA are usually assumed in most anterior cervical surgery techniques.

Patients with abnormal VAs pose an increased risk of injury during anterior cervical surgery as the traditional landmarks become unusable. Not identifying an anomalous VA can lead to an elevated risk of injury, even if lateral decompression is performed within safe limits that are generally accepted.

Usually, anatomical variations in the VAs are present from birth or associated with degeneration and pathological conditions. Studies investigating anatomical variations of the VAs have reported abnormal entrance levels in approximately 7.0% of cases, and in 1%–2% of cases, the VA formed a medial loop either into an unusually large transverse foramen, whose internal border was medial to the uncovertebral joint, or into the intervertebral foramen.

Patients with degenerative osteoarthritis undergo a process of adaptation in the VA, resulting in the development of a tortuous course and erosion of the posterolateral vertebral bodies. Certain pathological conditions can alter the condition of the VA. The occurrence of VA abnormalities shows a significant difference between rheumatoid arthritis patients and healthy volunteers (34% vs. 2%).

Pre-operative irradiation can lead to scarring of the arterial adventitia, which may result in VA rupture when retracting the surrounding soft tissue during surgery. Infection can lead to erosion and weakening of the artery wall, making it more susceptible to injury.

Identifying anomalies of the VA on plain CT or MRI scans can be challenging. According to the literature, plain CT images are only able to detect about half of VA anomalies.

Misplaced or displaced instruments: Rubbing or abutting of the artery wall can result in VAI, which may manifest as delayed symptoms or an abrupt hemorrhage.

There is currently no agreement on the best approach for managing VAI. In cases of VAI, prompt intervention is necessary to stop bleeding. Hemostasis can be achieved through tamponade using various hemostasis agents, including oxidized cellulose, matrix sealant, microfibrillar collagen, or gelfoam.

The application of tamponade can provide urgent hemostasis, which can be followed by immediate definitive treatment. This treatment may involve artery reconstruction, repair, or stent placement. Alternatively, the artery may be occluded using ligation, clipping, or endovascular coiling. In certain cases, tamponade is used as the primary treatment instead of a temporary measure for achieving hemostasis.

Emergent intubation and volume replacement may be required for neck swelling, dyspnea, and hypotension caused by delayed rupture and pseudoaneurysm hemorrhage.

Achieving restoration of blood flow through direct repair or endovascular stenting can yield excellent outcomes, however, both procedures are considered technically demanding. Additional muscle dissection and partial removal of the anterior transverse foramen rim are required to create sufficient space for direct repair.

This can be a challenging task, especially when the VAI is located on the opposite side of the original surgical approach, which may necessitate an extension of the existing incision or a separate incision. Additionally, obtaining sufficient space for direct repair may require further lateral dissection of muscles and partial removal of the anterior rim of the transverse foramen.

Prompt intraoperative or postoperative angiography may be a reasonable approach after VAI, particularly when the occlusion of the injured VA is a possibility, given that collateral circulation is seldom known beforehand. This can help assess the status of the bilateral VA before definitive treatment.

Performing artery occlusion without prior evaluation of VA status may pose a high risk of ischemic complications to the patient. Techniques such as tamponade, ligation, vascular clips, or endovascular occlusion should be avoided until the status of the VA has been determined through prompt intra-operative or postoperative angiography.

However, a postoperative angiography revealing a normal state of a damaged VA does not eliminate the possibility of a delayed hemorrhage or the formation of a pseudoaneurysm, which may occur days to years later. The postoperative period may be without complications until symptoms associated with pseudoaneurysm arise.

In cases where the injured VA is dominant, it is highly recommended to restore blood flow through repair or endovascular stent placement to minimize the risk of both immediate and delayed ischemic neurological complications. In patients who have sufficient collateralization and perfusion through the ipsilateral posteroinferior cerebral artery, sacrificing the injured VA may be a safe option.

If the VA is occluded through direct ligation or vascular clips, it is recommended to ligate or clip it both proximally and distally to prevent the possibility of delayed complications such as embolic or hemorrhagic issues, or the formation of arteriovenous fistula if only proximal ligation or clipping is performed.

Recent Advances

An alternative to direct exposure and suture repair is the use of endovascular stents, especially in cases of massive bleeding, hemodynamic instability, or lacerations on the posterior or posteromedial walls of the vessel.

Additionally, procedures such as stent-assisted angioplasty, embolization of pseudoaneurysm, and endovascular occlusion using coiling or balloons have been reported to yield favorable outcomes. Having a skilled endovascular team can facilitate the successful completion of these procedures.

Prevention is considered the optimal approach to managing VAI. Thorough evaluation of the cervical spine and VA for abnormalities or pathological alterations pre-operatively is crucial, particularly in patients with conditions such as degeneration, RA, tumors, or infections, to prevent VAI.

Angiography can be utilized to visualize both VAs and any anomalies present for evaluation purposes. If anomalies such as tortuous or dilated arteries that are displaced are detected, it is important to consider dominance. If anomalies are detected prior to surgery, alternative or innovative surgical techniques, or a posterior approach, may be considered.

Real-time image guidance, intraoperative CT, or 3D fluoroscopy-based navigation systems can be helpful during surgery to accurately determine anatomy and assist with decompression and instrument placement, especially when landmarks are not visible. Precise and controlled drilling can minimize the risk of injury compared to using coarse drilling techniques, thereby promoting stability during the procedure.

VAI, which can occur during anterior cervical surgery, is an infrequent yet potentially severe complication. The risk of VAI during anterior cervical surgery is increased by factors such as extensive lateral decompression, loss of landmarks, and anatomical variations or pathologic conditions of the VA. While tamponade can be effective in urgent cases, it is not a recommended definitive treatment due to a high risk of pseudoaneurysm formation.

It is necessary to identify collateralization before treatment and restore blood flow through direct repair or endovascular stenting when the dominant VA is injured. Precise pre-operative assessment and careful intra-operative manipulation with real-time radiographic guidance can also decrease the likelihood of VAI.

If you are interested in knowing more about Iatrogenic VAI During Anterior Cervical Spine Surgery a you have come to the right place!

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00:52 30 May 23
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00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
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19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
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15:02 02 Mar 23
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21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
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20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
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16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
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21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
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19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
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21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
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23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
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17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
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19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
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00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
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23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
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19:37 09 May 22
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19:54 05 May 22
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20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
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19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
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03:25 09 Apr 22
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Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
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14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
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21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
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18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
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17:26 17 Nov 20
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16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
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04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

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