Multimodality Management of Vertebral Artery Injury Sustained During Cervical or Craniocervical Surgery BACKGROUND: Iatrogenic vertebral artery (VA) injury is a rare but potentially devas- tating complication associated with cervical and craniocervical surgery. OBJECTIVE: To retrospectively evaluate treatment modalities and outcomes associated with iatrogenic VA injury. METHODS: Our institutional surgical database was queried for patients who under- went cervical or craniocervical surgery from January 1997 to August 2012. RESULTS: During this time period, 8213 patients underwent cervical or craniocervical surgery, and 17 (0.2%) cases of VA injury were identified. Eight (47%) of these injuries occurred during C1-2 instrumentation procedures. Primary microsurgical repair of the VA was performed in 5 patients. Other cases were managed by either surgical or en- dovascular VA occlusion. Of the 17 patients, 15 underwent immediate angiography, 9 of whom were ultimately treated by the use of endovascular techniques. CONCLUSION: VA injury is an uncommon complication of cervical and/or skull base surgery. Standardized management recommendations may help reduce complications associated with these rare but potentially devastating injuries. KEY WORDS: Cervical, Complications, Craniocervical, Endovascular pseudoaneurysm, Iatrogenic injury, Ver- tebral artery Neurosurgery 73[ONS Suppl 2]:ons271–ons282, 2013 DOI: 10.1227/01.neu.0000431468.74591.5f V ertebral artery (VA) injuries are rare com- plications associated with cervical or cra- niocervical surgery. VA injury can result in severe blood loss, intradural or extradural hem- orrhage, and the development of arteriovenous fistulae or pseudoaneurysms. 1-4 These complica- tions may be asymptomatic, or may result in severe neurological morbidity or mortality. 5-7 The management of iatrogenic VA injuries remains controversial. We retrospectively re- viewed the treatment modalities and outcomes associated with VA injuries following craniocer- vical surgery at our institution over a 15-year period. PATIENTS AND METHODS This study was approved by the Institutional Review Board of St. Joseph’s Hospital and Medical Center. Surgical databases and medical records were reviewed to identify VA injuries that occurred during cervical and craniocervical surgery at our institution from January 1997 to August 2012. Of 8213 surgeries, 17 cases (10 females and 7 males, mean age 49.4 years, range 3-74 years) were identified. One of these cases was reported previously. 8 RESULTS Incidence of VA Injury The overall incidence of VA injury related to craniocervical surgery was 0.2% (17/8213). The VA was most often injured during C1-2 instru- mentation (1.2%) and odontoid screw placement (0.7%, Table 1) and less frequently during far- lateral craniotomies (0.5%), anterior cervical corpectomy (0.5%), and anterior cervical dis- cectomy with fusion and plating (ACDFP) (0.08%). No such injuries were sustained during Peter Hanks Maughan, MD Andrew F. Ducruet, MD Ali M. Elhadi, MD Nikolay L. Martirosyan, MD Mark Garrett, MD Raza Mushtaq, BA Felipe C. Albuquerque, MD Nicholas Theodore, MD, FACS Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospi- tal and Medical Center, Phoenix, Arizona Correspondence: Nicholas Theodore, MD, FACS, c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ 85013, E-mail: Neuropub@dignityhealth.org Received, November 28, 2012. Accepted, April 23, 2013. Published Online, May 29, 2013. Copyright ª 2013 by the Congress of Neurological Surgeons ABBREVIATIONS: ACDFP, anterior cervical discec- tomy with fusion and plating; CTA, computed tomography angiography; PICA, posterior inferior cerebellar artery; POD, postoperative day; SAH, subarachnoid hemorrhage; VA, vertebral artery SPINE Complication NEUROSURGERY VOLUME 73 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2013 | ons271 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.