Development of a Standardized Algorithm for Iatrogenic Vertebral Artery Injury in Cervical Spine Surgery

Introduction: Iatrogenic vertebral artery injury (VAI) during cervical spine surgery, though uncommon, presents a serious hazard with potentially devastating consequences, such as stroke, paralysis, or death. The incidence of VAI varies by surgical approach, with the posterior approach contributing to 4-8% of injuries, compared to anterior subaxial procedures, which lead to 0.3-0.5% of injuries. Given the concerns about an occult injury, the true incidence may be higher. This study develops a comprehensive, multistage algorithm to minimize the risk of VAI during cervical spine surgery and guide prevention and management across different surgical approaches.

Methods: A detailed literature review was conducted using the PubMed and ScienceDirect databases covering literature from 2006-2024. Inclusion criteria focused on studies evaluating surgical techniques, patient anatomical considerations, and treating of iatrogenic VAI in spine surgery. Exclusion criteria ruled out non-surgical studies, studies with uncomplicated outcomes, or those evaluating VAI attributed to blunt trauma. Extracted data points included incidence rates, risk factors, imaging modalities, and management protocols for VAI. Analysis of surgical practices was used to inform the development of the proposed algorithm, which aims to identify and mitigate potential risk factors pre-, intra-, and postoperatively.

Results: Considering surgical techniques, anatomical variances, and perioperative imaging strategies, the algorithm incorporates comprehensive, multistage risk mitigation tactics that address potential VAI at all stages of care, tailored to individual patient anatomy. It uniquely integrates advanced imaging techniques, real-time navigation, and patient-specific protocols for VAI management, including immediate hemostasis, direct repair, and endovascular interventions. By differentiating guidance based on surgical approach (anterior vs. posterior), the algorithm aims to enhance safety and decision-making throughout the surgical process. Pending clinical validation, the algorithm has strong potential to improve patient outcomes and reduce VAI incidence during cervical spine surgery.

Conclusion : This study develops and proposes the VASIANT algorithm, a comprehensive tool for anterior and posterior surgical approaches to minimize the risk of VAI during cervical spine surgery.