Korean J Neurotrauma.  2017 Apr;13(1):39-44. 10.13004/kjnt.2017.13.1.39.

Vertebral Artery Injury in C2-3 Epidural Schwannoma Resection: A Case Report and Literature Review

• Lee SB
• Rhim CH
• Roh SW
• Jeon SR
• Rhim SC

• KMID: 2378249
• DOI: http://doi.org/10.13004/kjnt.2017.13.1.39

Abstract

The incidence of vertebral artery (VA) injury (VAI) in posterior approach tumor resection surgery is extremely rare, but it can lead to serious complication. In this case, a 57-year-old man underwent surgery for resection of the tumor involving left epidural space and neural foramen at C2-3 level. Iatrogenic VAI occurred suddenly during tumor resection procedure using pituitary forceps. Immediate local hemostasis and maintaining of perfusion for reducing the risk of posterior circulation ischemia were performed. Intraoperative angiogram of both VA and emergent trapping embolization were done as well. It may reduce the risk of immediate postop complication, and further delayed occurrence. The patient had no complication after VAI by appropriate intraoperative management. Preoperative angiographic work up and preparation of endovascular team cooperation are positively necessary as well as a warning for the VAI during cervical spine surgery.

Keyword

Vertebral artery injury; Cervical spine surgery; Schwannoma; Embolization

MeSH Terms

Epidural Space
Hemostasis
Humans
Incidence
Ischemia
Middle Aged
Neurilemmoma*
Perfusion
Spine
Surgical Instruments
Vertebral Artery*

Figure

• 

  FIGURE 1 A 2.4-cm lobulated enhancing mass with internal cystic change involving left epidural space and neural foramen at C2-3 level, and widening of bony intervertebral foramen (Upper, magnetic resonance imaging). Left vertebral artery is pushed out to anterior lateral direction at C2-3 level by the tumor mass, and it is not encapsulated by tumor (Lower, computed tomography angio).

• 

  FIGURE 2 (A) Pituitary forceps resection in the lateral side of C2-3 left foramen for extensive tumor removal. (B) After sudden bleeding, immediately gauze packing and manual compression were began.

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  FIGURE 3 (A-C) Initial control angiogram: (A) Anterior posterior (AP) view of right vertebral artery (VA). Right dominant flow is filling retrograde left VA to C2 level. (B) AP view of left VA show posterior aspect pseudoaneurysm (black arrow) (C) Lateral view of left VA show pseudoaneurysm (black arrow) and focal spasm or narrowing due to extrinsic compression, leakage from direct arterial perforation (arrowhead). (D-F) Final control angiogram: (D) Segmental embolization from C2 level, successful trapping of the non-dominant left VA at C2-3 level. (E) Lateral view of left VA confirming antegrade flow interruption of left VA (arrow). (F) AP view of right VA confirming the retrograde filling of left VA.

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  FIGURE 4 Post-operative follow up magnetic resonance imaging: no definite enhancing lesions at left epidural space and neural foramen at C2-3 level means no gross evidence of residual mass.

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