Repair of V2 Vertebral Artery Injuries Sustained During Anterior Cervical Diskectomy

Abstract

The V2 segment of the vertebral artery (VA) typically runs through the transverse foramen of C2-C6. V2 injury may occur during anterior approaches to the cervical spine and can cause significant morbidity. We describe landmarks and microsurgical V2 repair techniques through the standard anterolateral cervical diskectomy approach. Five silicone-injected cadaveric heads (necks-C7) were dissected bilaterally. An anterolateral approach with C3-4, C4-5, and C5-6 diskectomies and an ipsilateral VA injury were simulated. VA approach and repair were performed using microdissection techniques. Landmarks to the VA were identified, and distances from landmarks to the VA were measured in horizontal and vertical planes. Operative photographs of stepwise approach and repair techniques were processed for stereoscopic illustration. An illustrative case describes microsurgery to successfully repair an inadvertent VA injury during a C3-C6 diskectomy and fusion procedure. The anatomic landmarks delineated were the intervertebral disk, uncinate apices, and anterior tubercles of C4-C6 transverse processes. After temporary hemostasis with packing, VA exposure and repair included dissection of the longus colli muscle, removal of the anterior root of the transverse processes above and below the injury level, intertransversarii muscle removal, vertebral plexus opening, VA handling, and microsuturing. In 30 dissected cadaver intertransverse intervals, 13 medial, 7 lateral, and 3 anterior branches of the V2 were encountered at C3-C6 levels. Familiarity with relevant vascular surgical anatomy allows neurosurgeons to be prepared in cases of VA injury and may facilitate repair when the VA is injured during anterior cervical spine surgery.