Chapter 9 Operative Exposure in Neck Trauma: Exposure of the Vertebral Artery in the Neck

This chapter will discuss exposure of actual or suspected injuries to the vertebral arteries in the neck. Though the major emphasis of this lab experience is operative exposure, a general review of the principles of diagnosis and management will also be presented.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Describe the four zones of the vertebral artery.
2. Demonstrate surgical exposure of the first portion of the vertebral artery in the neck.

Considerations

• Injuries to the vertebral arteries can occur from either blunt or penetrating mechanisms, with penetrating (e.g., gunshot wounds) being the most common.
• Blunt traumatic mechanisms that can result in vertebral artery injury include basilar skull fractures, axial injuries to the spine, ligamentous disruption, direct blows to the neck, chiropractic manipulation, yoga exercises, central line insertion, angiography, and spine operations.
• Except for its first portion, the vertebral artery is protected by the cervical vertebrae and the skull, so it is not easily exposed surgically (Figure 1). As such, the primary method for diagnosing and controlling bleeding is endovascular.
• Paired veins follow the course of the arteries, and multiple small bridging veins are present. As arterial injuries are frequently associated with venous injury, an arteriovenous fistula may occur.

Surgical Exposure

• There are two main options to expose the most proximal portion (segment V-1) of the vertebral artery: the transverse supraclavicular approach and the vertical anterior cervical approach.
• The supraclavicular approach is perhaps the easiest and provides excellent exposure of the vertebral artery at its origin. This exposure is also used to expose the subclavian artery above the clavicle (see chapter 14). Once the subclavian artery is identified, it is followed medially to expose and identify the origin and first portion of the vertebral artery (Figure 2).

• The vertical anterior cervical approach can also be used for exposure of segment V-1 of the vertebral artery. It is initially similar to the standard incision for neck exploration made along the anterior border of the sternocleidomastoid muscle (see chapter 7). The carotid sheath is retracted medially and the scalene fat pad laterally. This exposes the anterior scalene muscle, which is then retracted or divided to allow exposure of the vertebral artery.
• Injuries to segment V-2 are technically accessible, but the bony canal must be unroofed to expose it, and such exposure is best left to surgeons with appropriate specialty experience.
• Acute hemorrhage from segment V-2, as seen from a stab wound to the posterior triangle of the neck (Figure 3), can be extremely challenging to control and can be temporized with a Foley balloon placed in the wound as a bridge to endovascular control (Figure 4).
• Exposure of segments V-3 and V-4 also requires specialty expertise and is beyond the scope of this course.