Surgery Involving the Vertebral Artery at the Cranio-vertebral Junction

Abstract

The vertebral artery (VA) at the cranio-vertebral junction is in its third segment (V3) and has a complex course between the transverse foramen (TF) of C2 and the foramen magnum (FM) dura. There are two main routes which permit to safely expose and control the VA: the posterolateral and the anterolateral approaches. The most important technical trick for a safe exposure of the VA is the preservation of the periosteal sheath surrounding the VA and its venous plexus. The access to the VA gives the possibility of release of extrinsic intermittent VA compression (Bow Hunter syndrome) and of course to revascularize the vertebro-basilar system by a venous graft bypassing an occlusive lesion, an aneurysm, or a tumor. The VA control gives also a better access to FM tumors through the posterolateral approach or to CVJ tumors through the anterolateral approach, or to jugular foramen (JF) tumors through the juxtacondylar approach, which is an anterolateral approach extension. Mortality and morbidity related to the VA exposure should be very limited, including only painful stiffness of the sterno-mastoid muscle due to overstretching of the accessory nerve.