Iatrogenic vertebral artery injury during anterior cervical spine surgery

Abstract

James P. Burke, MD, PhD, Peter C. Gerszten, MD, William C. Welch, MD, Pittsburgh, PA, USAIntroduction: The anterior surgical approach to the cervical spine has become a commonly used procedure for the treatment of a number of conditions, including degenerative disc disease, spondylosis, fractures, neoplasms and infections. Intraoperative complications of anterior cervical spine surgery after the anterior soft tissue has been dissected include injury to the nerve root, the spinal cord and the vertebral artery. Injuries to the vertebral artery during anterior cervical spine surgery are infrequent but can be catastrophic, frequently resulting in significant ischemic neurological injuries. The present study reviews the experience at a single institution with anterior cervical spine procedures complicated by vertebral artery injuries in terms of incidence, intraoperative strategies for repair and postoperative outcome.Methods: We present a retrospective review of six adult patients in whom an anterior cervical spinal procedure was complicated by iatrogenic vertebral artery injury. An institution-wide electronic medical record search through the operative reports of ten spine surgeons (seven neurosurgeons, three orthopedic surgeons) over the past 7 years was conducted. All procedures were performed for herniated or degenerative disc disease or spondylosis; procedures for trauma, neoplasia or infection were excluded from this study. Hospital and clinical charts subsequently were reviewed. Demographic data, intraoperative strategies for repair and postoperative outcome were recorded.Results: Using an electronic search of medical records at our institution over the past 7 years, six adult patients were identified who had iatrogenic vertebral artery injury during anterior cervical spine procedures for herniated or degenerative disc disease or spondylosis. A total of 1,976 anterior cervical spine procedures were performed for these indications during this time; procedures for traumatic, neoplastic and infectious processes were excluded from entry into this study. One single-level and one three-level anterior cervical discectomy and fusion, and one re-exploration and three fresh cervical corpectomies and fusions were performed. In five cases, bright arterial bleeding was encountered; two were repaired primarily, one was treated with arterial ligation and one was tamponaded with thrombin-soaked Gelfoam. In each of these cases, no neurological sequelae were noted postoperatively. Only one postoperative cerebral angiogram was performed; this demonstrated a mild defect in the arterial wall consistent with the intraoperative packing of the vertebral artery. In the final case in which bright arterial bleeding was encountered, hemodynamic instability from hypovolemia resulted in intraoperative death. In the sixth case of vertebral artery injury, no arterial or excessive bleeding was encountered. However, thrombin-soaked Gelfoam was placed laterally to tamponade epidural oozing. Postoperatively, the patient awoke with a lateral medullary infarct, and cerebral angiography demonstrated a vertebral artery dissection with posterior inferior cerebellar artery occlusion.Conclusion: Iatrogenic vertebral artery injury during anterior cervical spine procedures is an infrequent, yet potentially catastrophic complication. The initial management of vertebral artery injury is immediate tamponade. Either primary repair or arterial ligation may be required if this maneuver is unsuccessful. Appreciation for the local, “hidden” anatomic structures may limit the incidence of vertebral artery injury during lateral exploration of the neural foramen after discectomy and uncovertebral joint osteophytes or during the lateral decompression of a cervical corpectomy.