The V3 segment of the vertebral artery: Surgery around the craniocervical junction

Abstract

Exposure of the third segment (V3) of the vertebral artery (VA) is more challenging than at lower levels because of its complex course around the craniocervical junction. Surgical control of the VA may be useful in treating lesions in close relation with the VA and inducing a more or less important compression. Like compression at lower levels, compression at V3 may be intermittent or permanent. Intermittent compression is usually related to bony or ligamentous anomalies or to a rotational mechanical obstruction (bow hunter's syndrome). Permanent compression is typically caused by neuromeningeal or bone tumors. Surgical exposure of the VA with or without transposition allows different areas to be accessed. The intradural foramen magnum can be reached via the posterolateral approach, and the jugular foramen and the anterior part of the craniocervical junction (CCJ) can be reached via the juxtacondylar approach. At the CCJ the elements that help stabilize the CCJ must be respected when they are intact. Preoperative planning requires choosing the surgical route that provides access to the lesion without compromising stability.