The anterior operative approach to the cervical vertebral artery

BACKGROUND: Vertebral arterial trauma continues to be a perplexing diagnostic and therapeutic challenge. Operative management is often required despite improved radiologic interventions for these injuries. Accounts of the operative approaches to anterior cervical vertebral artery injuries have been limited. STUDY DESIGN: We reviewed our experience with anterior cervical vertebral arterial trauma in 53 consecutive patients requiring operative management during a 14-year period. In seven patients, the vertebral arterial injury was identified at urgent surgical intervention either for an expanded cervical hematoma or active bleeding. The remaining injuries were identified by arteriographic investigation of penetrating cervical trauma. The injuries were equally distributed between the three anatomic zones of the anterior cervical vertebral artery. The general features of the operative approaches that were used to manage these injuries were the emphasis of the study. RESULTS: The anterior approaches to patients with vertical arterial trauma were effective in controlling injuries in all cases. Proximal and distal ligation of the artery adjacent to the injury site was accomplished in 95 percent of the patients. Associated major cervical injuries in 43 percent of the patients (carotid artery, eight patients; pharyngoesophageal, six patients; and neurologic, nine patients) contributed to the postoperative morbidity rate and the overall mortality rate of 10 percent. CONCLUSIONS: The surgeon approaching vertebral arterial trauma should have a clear appreciation of the deep anterior cervical anatomy to expedite the operative management and avoid unnecessary complications related to a misdirected surgical dissection. The descriptions of the operative techniques used in this clinical experience can aid the surgeon in managing patients with vertebral vascular trauma.