Anterior Cervical Procedures Research Articles

Steroids and Risk Factors for Airway Compromise in Multilevel Cervical Corpectomy Patients

Prospective, randomized, double-blind study. To evaluate intravenous corticosteroids in preventing delayed extubation after multilevel corpectomy and strut graft reconstructive procedures and to identify risk factors for delayed extubation in these patients. We performed a prospective, randomized double-blind study in patients undergoing multilevel cervical corpectomy procedures. Our hypothesis was that high-dose perioperative steroids would decrease edema and thus decrease the incidence of delayed extubation. We studied patients undergoing 2- or 3-level anterior cervical corpectomy procedures with anterior strut graft reconstruction. Sixty-six patients were randomized to receive 3 doses of either intravenous dexamethasone (n = 35) or saline (n = 31). The first dose was given before the incision, with subsequent doses given 8 and 16 hours later. Patients remained intubated until postoperative day 1, at which time a cuff leak test was performed by the anesthesiology attending. If a leak was present, the patient was extubated. If not, the test was repeated each postoperative day until a leak was present, indicating a patent airway. Five of 35 (14%) in the steroid group and 6 of 31 (19%) in the saline group required delayed extubation (P = 0.22). There were no statistical differences in preoperative parameters of age, gender, diagnosis, smoking history, BMI, number of operative levels, or preoperative American Society of Anesthesiologists rating between the 2 groups. Similarly there were no differences between the groups for duration of anesthesia, intraoperative colloids or crystalloids, intraoperative blood loss, or intraoperative urine output. The data for both groups were pooled to evaluate risk factors for delayed extubation. The only statistically significant risk factor for delayed extubation in this study was female gender (P = 0.0001). Based on our data, we cannot recommend intravenous dexamethasone for prevention of delayed extubation after multilevel anterior cervical corpectomy and strut grafting procedures.

Adverse Events Associated With Anterior Cervical Spine Surgery

Anterior cervical procedures for neurologic decompression and fusion, including cervical diskectomy and cervical corpectomy, are commonly performed by orthopaedic surgeons and spinal neurosurgeons. These procedures are highly successful in treating most patients with persistent pain and neurologic symptoms that have not responded to nonsurgical methods. Adverse events occur infrequently, but several have been described, including esophageal injury, vertebral artery injury, dural tear, postoperative airway compromise, spinal cord injury, hematoma, dysphagia, dysphonia, and graft dislodgement. Newer procedures, such as cervical total disk replacement and the use of bone morphogenetic protein as a supplement to fusion, have raised unique concerns. Appropriate strategies must be utilized to avoid these adverse events, and the treating surgeon should have an understanding of how to detect and manage such events when they do arise.

Preoperative Laryngeal Nerve Screening for Revision Anterior Cervical Spine Procedures

Anterior cervical spine procedures carry an inherent risk of recurrent laryngeal nerve (RLN) injury. Patients with persistent RLN paresis may be asymptomatic because of compensation from the opposite side. If such patients undergo an opposite-side anterior approach for revision surgery, they are at risk for a second RLN injury, creating the potential for bilateral vocal fold paresis and possible need for tracheotomy. A program of routine screening for laryngeal paresis was implemented for these patients. This retrospective study reviews the results of this screening process. Patients referred for preoperative laryngeal nerve screening were identified. Their charts were reviewed for the results of the videolaryngoscopic examination, and for any recommendations made based on the findings. Relevant history and other physical findings were recorded. Fifty screening laryngeal examinations were performed in 47 patients, of whom 31 (66%) had previously undergone a single anterior cervical approach procedure, and 16 (34%) had undergone more than one. Thirteen of the examinations (26%) revealed abnormal laryngeal findings, including paresis or paralysis in 11 cases (22%), of which 5 were asymptomatic. The findings resulted in a recommendation of a cervical approach from the already-involved side. None of the revision procedures resulted in bilateral vocal fold paralysis. The risk of laryngeal nerve injury appears to increase as higher cervical levels are approached. Minimally symptomatic injuries of the laryngeal nerves from prior neck surgery create a potential serious risk of bilateral vocal fold paralysis with subsequent procedures. Preoperative laryngeal screening is a simple and effective method for reducing this risk.

Vertebral Artery Injury During Cervical Spine Surgery

Retrospective survey. To clarify the present incidence and management of iatrogenic vertebral artery injury (VAI) during cervical spine surgery. VAI is a rare complication of cervical spine surgery, but it may be catastrophic. Anterior cervical decompression (ACD) and posterior atlantoaxial transarticular screw fixation (Magerl fixation) have been the main causes, with reported incidences of 0.3% to 0.5% and 0% to 8.2%, respectively. Popular new surgical techniques, such as cervical pedicle screw or C1 lateral mass screw fixation, also entail the potential risk of VAI. A questionnaire was sent to our affiliated hospitals requesting information regarding iatrogenic VAI during cervical spine surgery. Seven spine surgeon groups and 25 general orthopedist groups responded to the questionnaire, with a response rate of 89%. The overall incidence of VAI was 0.14% (8 cases among 5641 cervical spine surgeries). The incidence in anterior cervical decompression procedures was 0.18% and that in Magerl fixation was 1.3%. Inexperienced surgeons tended to commit VAI more frequently. One case of VAI during C1 lateral mass screw fixation was included, whereas there was no case of VAI caused by cervical pedicle screw fixation. In the case of "VAI in the screw hole," hemostasis was obtained by tamponade or screw insertion, whereas "VAI in the open space" sometimes caused uncontrollable bleeding, in which embolization eventually stopped the bleeding. There were no deaths or apparent neurologic sequelae. The incidence of VAI during cervical spine surgery from this survey was similar to or slightly less than that in the literature. Tamponade was effective in many cases, but prompt consultation with an endovascular team is recommended if the bleeding is uncontrollable. Preoperative careful evaluation of the vertebral artery seems to be most important to prevent iatrogenic VAI and to avoid postoperative neurologic sequelae.

Esophageal injury associated with anterior cervical spine surgery

Background Anterior cervical spinal surgery has been used to treat a variety of conditions including spondylosis, fracture, tumor, infection, trauma, and instability. Esophageal perforation, a rare and unusual complication of anterior cervical procedures, has been largely relegated to only incidental case reports with few large retrospective studies performed to determine true incidence, treatment, etiology, and outcome. Methods More than 3000 anterior cervical spine surgeries conducted over a 30-year period by 5 active practicing surgeons were reviewed. There were 3 cases of esophageal injury identified with subsequent critical evaluation to determine presentation, diagnosis, risk factors, management, and outcomes. In addition, incidence rates were calculated based on overall occurrence and antecedent risk factors. Results Two of the patients with esophageal injury had predisposing risk factors, including diverticula or cervical spine trauma. The third patient had no antecedent risk factors. Symptoms included axial spine pain, odynophagia, dysphagia, purulent spondylitis, and sepsis. Treatment consisted of one or more of the following: reoperation with exploration and repair, esophageal diversion, esophageal rest, antibiotic administration, and wound drainage. Functional outcomes were achieved in all cases with no deaths. Conclusions Esophageal injury incidence based on overall occurrence in this study was 0.1%. Patients with no antecedent risk factors had an incidence of 0.03%. Our results compare favorably with those of the Cervical Spine Research Society survey from 1989, which predicted an incidence of 0.25% based on questionnaires filed by surgeons, representing 1 of only 2 reports that included more than 1000 patients.

Correlation of cervical endplate strength with CT measured subchondral bone density

Cervical interbody device subsidence can result in screw breakage, plate dislodgement, and/or kyphosis. Preoperative bone density measurement may be helpful in predicting the complications associated with anterior cervical surgery. This is especially important when a motion preserving device is implanted given the detrimental effect of subsidence on the postoperative segmental motion following disc replacement. To evaluate the structural properties of the cervical endplate and examine the correlation with CT measured trabecular bone density. Eight fresh human cadaver cervical spines (C2-T1) were CT scanned and the average trabecular bone densities of the vertebral bodies (C3-C7) were measured. Each endplate surface was biomechanically tested for regional yield load and stiffness using an indentation test method. Overall average density of the cervical vertebral body trabecular bone was 270 +/- 74 mg/cm3. There was no significant difference between levels. The yield load and stiffness from the indentation test of the endplate averaged 139 +/- 99 N and 156 +/- 52 N/mm across all cervical levels, endplate surfaces, and regional locations. The posterior aspect of the endplate had significantly higher yield load and stiffness in comparison to the anterior aspect and the lateral aspect had significantly higher yield load in comparison to the midline aspect. There was a significant correlation between the average yield load and stiffness of the cervical endplate and the trabecular bone density on regression analysis. Although there are significant regional variations in the endplate structural properties, the average of the endplate yield loads and stiffnesses correlated with the trabecular bone density. Given the morbidity associated with subsidence of interbody devices, a reliable and predictive method of measuring endplate strength in the cervical spine is required. Bone density measures may be used preoperatively to assist in the prediction of the strength of the vertebral endplate. A threshold density measure has yet to be established where the probability of endplate fracture outweighs the benefit of anterior cervical procedure.

Neurophysiological detection of iatrogenic C-5 nerve deficit during anterior cervical spinal surgery

The incidence of postoperative C-5 spinal nerve root palsy following decompressive cervical spinal surgery has been reported to be as high as 12% for anterior procedures and 30% for posterior procedures. The present study was conducted to document the prevalence of iatrogenic C-5 nerve root deficit during anterior cervical spinal surgery, as well as to evaluate the sensitivity and specificity of intraoperative transcranial electrical stimulation (TES)-induced motor evoked potentials (MEPs) and spontaneous electromyographic (EMG) activity for identifying evolving C-5 nerve root impairment. The authors conducted a retrospective study of 238 consecutive anterior cervical spinal procedures performed by a single surgeon at Christiana Care Hospital within a 48-month period. Techniques used to monitor spinal nerve root function included TES-induced MEPs and spontaneous EMG activity from deltoid, biceps, triceps, wrist extensor, and hand intrinsic muscles innervated by the C5-T1 spinal nerve roots. Spinal cord function was monitored by recording TES-induced MEPs from upper- and lower-extremity muscles as well as somatosensory evoked potentials from stimulation of the ulnar and posterior tibial nerves. Transcranial electrical stimulation-induced MEPs and spontaneous EMG activity offer complementary information about evolving iatrogenic C-5 spinal nerve root impairment during anterior cervical spinal surgery. The TES-induced MEPs provide prognostic information and show increased sensitivity to C-5 deficit compared with spontaneous EMG activity alone. Monitoring of spinal nerve root function using only EMG activity carries a risk of false-negative findings; without timely warning of impending neurological impairment, timely intervention to prevent permanent deficit cannot occur.

In vivo evaluation of biomechanical anterior cervical plate failure

Anterior cervical plate (ACP) failure is rarely addressed in the literature. In this retrospective, observational, longitudinal, cohort study, the objectives were to (1) identify incidences of in vivo biomechanical failure in commercially available, US Food and Drug Administration-approved ACP systems, (2) describe modes of failure, (3) suggest structural explanations for system failure, and (4) discuss complications and treatment of patients with failed ACP systems. Investigators retrospectively identified patients who underwent anterior cervical procedures followed by use of ACP as a fusion adjunct and showed evidence of ACP failure on plain radiographs. Components of the ACP system that led to failure were identified and examined. A total of 240 patients received ACP supplementation of anterior cervical fusion constructs during the 9.5-y study period. Evidence of ACP failure was noted in 7 patients (3.3%), and an eighth patient was referred for evaluation after ACP failure. Screw-plate interface failure occurred in all 8 cases. The biomechanical method by which the bone screw head was secured into the vertebral body, or against the ACP, the use of hybrid systems, the surgical technique selected, and host factors were used to determine the rate of failure. Concern for esophageal or other tissue injury often necessitated ACP removal. Screw-plate interface failure, which was found to be the most common mode of biomechanical ACP failure, may occur in hybrid constructs and in systems that do not create a rigid interface between the screw head and the ACP. Surgical technique and patient host factors may also influence the rate of biomechanical construct failure.

The Effect of Anterior Cervical Fusion on Neck Motion

Prospective cohort study. To precisely measure the effect of anterior cervical fusion on neck motion. Anterior cervical decompression and stabilization procedures are successful in treating recalcitrant cervical radiculopathy and cervical myelopathy. Most assume that these "fusion" procedures result in a loss of neck motion, although changes in overall motion following anterior cervical fusion have never been precisely quantified. Twenty-five consecutive patients undergoing anterior cervical fusion of one to four levels underwent cervical range of motion testing in three planes using an unconstrained instrumented linkage before surgery and more than 3 months after surgery. These data were compared with that of 10 volunteers with no prior history of neck complaints. Motion data were compared between patients and volunteers, and between the patients before surgery and at last follow-up, using RMANOVA and Fisher's PLSD post hoc test. Before surgery, the patients had significantly less motion than the volunteers in all directions. Following surgical fusion, patients gained a statistically significant amount of motion in all planes, although they did not achieve the motion seen among the volunteers. Gains in motion were seen among all patients, including those undergoing four-level fusions, and there was no correlation between postoperative motion and the number of levels fused. Patients undergoing anterior cervical fusion have diminished neck motion compared with normal volunteers. Following surgery, they may be expected to gain motion, even when undergoing multilevel fusions. However, these patients are unlikely to regain the neck motion seen among normal individuals without neck complaints.

Advances in the surgical management of cervical degenerative disease

Purpose of review: Contemporary surgical management of cervical degenerative disk disease is evolving towards maintaining segmental motion at the operative levels. Anterior cervical surgery, including discectomy or corpectomy and fusion procedures, is considered as the gold standard in surgical management of cervical radiculopathy and myelopathy. Posterior cervical procedures, including foraminotomy, are employed and cervical intervertebral disk prostheses are studied in prospective patient cohorts. This paper reviews the potential benefit of cervical intervertebral disk prostheses compared with anterior cervical discectomy procedures. Recent findings: It has been demonstrated that fusion procedures may result in future segmental degeneration. To decrease segmental breakdown, there has been a trend toward eliminating fusion. This led to developing intervertebral disk arthroplasty. Cervical intervertebral disk arthroplasty represents a potential technique that preserves motion and decreases segmental stresses. Recent studies have shown the benefits of preserving segmental motion. Summary: Prior to lumbar disk arthroplasty, various technologies had been utilized, such as intradiscal electrothermal therapy and artificial nucleus pulposus replacements. None of these has yet been employed in the cervical spine. Lumbar intervertebral disk arthroplasty has been implanted in patients throughout Europe and the United States with fairly good outcomes. Cervical intervertebral disk arthroplasty is being implemented in the United States. Whether this will provide long-lasting outcomes will be validated with long-term studies.

Iatrogenic vertebral artery injury during anterior cervical spine surgery

Background context Iatrogenic injury to the vertebral artery during an anterior cervical decompression is a rarely mentioned but potentially catastrophic complication. Purpose This study was designed to examine the incidence and management of iatrogenic vertebral artery injury (IVAI) in a large database. Study design/setting This was a retrospective study performed at a large teaching institution over a 7-year period (1994–2001). Patient sample All anterior cervical spinal procedures performed for herniated or degenerative disc disease, or cervical spondylosis were identified, as were incidences of IVAI. Anterior cervical procedures performed for trauma, neoplasia, or infection were excluded from this study. Outcome measures Neurological and associated morbidity as well as mortality were recorded. Methods Data were accessed through an institution-wide electronic medical record search through the operative reports of 10 spine surgeons. Hospital and clinical charts of IVAI cases were subsequently reviewed. Demographic data and intraoperative strategies for repair were recorded. Results A total of 1,976 patients underwent anterior cervical spinal procedures in the review period. Six cases of IVAI were identified. In three of the six patients, arterial bleeding was controlled with hemostatic agents. Of these three, two suffered complications. The initial management of controlling arterial bleeding is by hemostatic agents; however, one must also consider repair or ligation. The remaining three patients were treated with primary repair or ligation, and no complications were noted. Conclusions IVAI is a rare complication (0.3%) of anterior cervical procedures. The arterial bleeding can usually be controlled with topical hemostatic agents, but mortality may occur in instances where it cannot be adequately addressed in a timely fashion.

P155. Intraesophageal retraction pressure during anterior cervical plating vs. cervical disc replacement

BACKGROUND CONTEXT: Dysphagia is a well-recognized complication following anterior cervical discectomy and fusion, observed as high as 50% by videofluoroscopic evaluation postoperatively. Esophageal injury due to surgical retraction is one mechanism by which swallowing difficulties may ensue. There are limited published data evaluating the effect of soft tissue retraction on intra-esophageal pressures during anterior cervical instrumentation procedures.

Bilateral C5 motor paralysis following anterior cervical surgery—a case report

Numerous authors have reported C5 root palsies following posterior cervical surgery, and several mechanisms of injury have been proposed. Similar deficits after anterior cervical procedures are considered to occur less commonly. We report on a 48-year-old male who underwent multi-level anterior discectomy and fusion for cervical spondylotic myelopathy. Bilateral C5 nerve root deficits were noticed in the immediate postoperative period, and treated non-operatively. A postoperative magnetic resonance imaging (MRI) scan showed an increase in cervical lordosis accompanied by a posterior shifting of the spinal cord. Potential mechanisms of nerve root injury in this situation are discussed, and the literature on postoperative C5 root deficits is reviewed. The patient returned to his preoperative occupation as an operating room nurse 6 months following surgery, with complete neurologic recovery occurring over an 11-month period. C5 deficits following anterior cervical surgery occur more frequently than generally assumed. Improved lordosis and longitudinal lengthening of the cervical spinal column in multilevel anterior decompression and interbody fusion can paradoxically result in a traction injury to the spinal cord and C5 nerve roots.

Dysphagia, aspiration, and dysphonia related to cervical surgery

The intent of this article is to review the postoperative complications of dysphagia and dysphonia after cervical surgery. The focus is on prevention, early identification, and initial treatment. Anterior cervical procedures have become commonplace in spine surgery. Within the past year the incidence of postoperative dysphagia and dysphonia has been estimated to be as much as 47%. Recent studies have implicated damage to the recurrent laryngeal, hypoglossal, or superior laryngeal nerves as a causative factor. Damage may occur from direct injury during surgery or as a result of extrinsic pressure from retractors and the endotracheal tube. A recent study has shown no increase in the incidence of nerve injury when right-sided and left-sided approaches are compared. Diagnostic modalities include physical examination, plain radiographs, and endoscopy. Advances in treatment use diet modification, therapy, and autologous and allogeneic substance injection into the vocal cords. Operative modalities for the cervical spine continue to evolve. As techniques progress efforts must be made to prevent, identify, and treat complications that may arise.

Development of Adjacent-Level Ossification in Patients with an Anterior Cervical Plate

It has been our experience that ossification occurs adjacent to anterior cervical plates. Our hypothesis was that the closer the plate is to the adjacent disc space, the greater the ossification. We retrospectively reviewed the lateral radiographs of the cervical spine of 118 patients who had a solid fusion following an anterior cervical arthrodesis with a plate for the treatment of a degenerative cervical condition; none of the patients had had cervical spine surgery prior to the index arthrodesis. The plate-to-disc distance was measured on the postoperative lateral radiograph and was used to divide the patients into two groups for each of the two adjacent disc spaces. In group A the plate-to-disc distance was <5 mm, and in group B it was >/=5 mm. The mean duration of follow-up was 25.7 months. The severity of the ossification at the two adjacent disc spaces was classified on a scale ranging from grade 0 (no ossification) to grade 3 (complete bridging). Eighteen patients were excluded from the measurement of the severity of the caudal ossification because overlapping by the bone of the shoulder precluded adequate visualization of the caudal level. Ossification developed in seventy (59%) of the 118 cephalad adjacent disc spaces and twenty-nine (29%) of the 100 caudal adjacent disc spaces (p < 0.001). The mean cephalad plate-to-disc distance was shorter than the mean caudal plate-to-disc distance (p < 0.001). The rate of ossification was higher in group A than in group B, both at the cephalad adjacent disc spaces (67% compared with 24%) and at the caudal adjacent disc spaces (45% compared with 5%) (both p < 0.001). In addition, 93% (twenty-six) of the twenty-eight cases of moderate-to-severe ossification developed in group A. We found a positive association between adjacent-level ossification following anterior cervical plate procedures and the plate-to-disc distance. We now strive to place anterior cervical plates at least 5 mm away from the adjacent disc spaces in order to decrease the likelihood of moderate-to-severe adjacent-level ossification.

Common peroneal nerve palsy as a complication of anterior cervical operation: a case report

Background Common peroneal nerve palsy is a well-recognized complication following orthopedic procedure in and around the knee region. In neurosurgical practice, however, this kind of injury with regard to the patients' position is seldom reported. Case description We describe an immediately developed common peroneal nerve palsy in a 53-year-old slender man who underwent anterior cervical operative procedure. He suffered incomplete common peroneal nerve injury for about 8 months and during this period, he underwent 2 electromyographic examinations suggesting demyelinating injury. He received conservative treatment including physiotherapy and rigid foot orthosis and finally made a favorable but incomplete recovery. Conclusion We propose that such palsy may result from immobilization in a certain position instead of direct compression or traction of the corresponding nerve, although this is not proven. In this report, we suggest the possible risk factors, preventive measures, therapeutic options, and relevant outcome of this unwanted result.

Estudio comparativo de la artrodesis cervical con injerto óseo roscado e implante de titanio

The authors conducted a prospective and randomized study in 44 consecutive patients requiring cervical interbody fusion following anterior cervical discectomy to compare the efficacy of heterologous threaded cylindrical bone (Unilab Surgibone) versus titanium implant (Bak-C; Spine-Tech, Minneapolis ). The patients were evaluated between two and five years postoperatively and the objectives of the study were to assess the potential differences in implant shifting, interespace collapse, angulation, maintenance of cervical alignment and lordosis, and clinical and radiographic fusion success rates between the two fusion substrates. Clinical results were satisfactory with both types of implant. However the threaded cylindrical titanium implant was found to be superior to the heterologous threaded cylindrical bone as an interbody substrate after single -and multiple- level anterior cervical decompression procedures with respect to maintenance of cervical interspace height, interspace angulation and radiographic fusion success rates.

Intraoperative cervical epidurography: a simple modality for assessing the adequacy of decompression during anterior cervical procedures

Intraoperative cervical epidurography (ICE) was used during anterior cervical procedures to assess the success of bone resection and indicate the need for immediate correction in the event of inadequate decompression. The adequacy of decompression was assessed by the operating neurosurgeon who performed ICE after anterior microdiscectomy with exposure of the dura mater. If the decompression was deemed inadequate, additional bone was removed using a high-speed drill. Epidurography was conducted after each subsequent decompression until adequate bone removal was achieved. This was undertaken in 39 patients undergoing anterior cervical procedures. Nine patients underwent corpectomy, 21 one-level, and nine two-level discectomy. The ICE revealed insufficient resections requiring additional bone removal in 14 (36%) of the 39 patients. The goal of ICE is to ensure adequate decompression, and if such has not been achieved, to allow for additional immediate bone excision. Furthermore, ICE provides additional real-time control of the position of cages and screws to avoid dural tear or spinal cord compression. Because of this immediate feedback, the success rate of anterior cervical procedures can be improved. The advantages of this modality include real-time assessment, low cost, simplicity, and speed.

Airway complications associated with surgery on the anterior cervical spine.

Retrospective chart review of 311 anterior cervical procedures. To assess the incidence and variables that predispose to an airway complication in a large series of anterior cervical surgical procedures. A rare but potentially lethal complication after anterior cervical spine surgery is respiratory compromise and airway obstruction. Some risk factors are thought to include two-level corpectomy in myelopathic patients with a history of heavy smoking and asthma. No previous study in the literature has been directed at examining the factors specifically related to airway complications after anterior cervical spine surgery. Each chart was examined for patient characteristics and pathology, anesthetic parameters and problems, operative procedure, and postoperative course and management. Statistical analysis was performed. Nineteen patients (6.1%) had an airway complication and six (1.9%) required reintubation. One patient died. Symptoms developed on average 36 hours postoperatively. All complications except for two were attributable to pharyngeal edema. Variables that were found to be statistically associated with an airway complication (P < 0.05) were exposing more than three vertebral bodies, a blood loss >300 mL, exposures involving C2, C3, or C4, and an operative time >5 hours. A history of myelopathy, spinal cord injury, pulmonary problems, smoking, anesthetic risk factors, and the absence of a drain did not correlate with an airway complication. Patients with prolonged procedures (i.e., >5 hours) exposing more than three vertebral levels that include C2, C3, or C4 with more than 300-mL blood loss should be watched carefully for respiratory insufficiency.

Iatrogenic vertebral artery injury during anterior cervical spine surgery

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.