Vertebral Artery Injury in Cervical Spine Surgery: Anatomy, Risk Factors, and Modern Management Strategies

Background Vertebral artery injury is a rare but potentially catastrophic complication of cervical spine surgery. Its low incidence belies its importance, given the risk of severe neurological outcomes or death. As surgical techniques evolve and the complexity of cervical procedures increases, a comprehensive understanding of vertebral artery injury is essential for safe practice. Objective To provide an in-depth review of vertebral artery anatomy, radiologic evaluation, preoperative planning, and intra and postoperative management of vertebral artery injuries, with a focus on current techniques to mitigate complications and improve patient outcomes. Methods A narrative literature review was conducted with articles selected based on relevance to cervical spine surgery, including anatomical considerations, incidence, mechanisms of injury, clinical consequences, diagnostic approaches, treatment strategies, and preventive measures. Results Vertebral artery injury most commonly occurs at high-risk anatomical locations, particularly at C1–C2. Prompt recognition and appropriate imaging are critical for diagnosis. Management strategies vary from conservative anticoagulation to endovascular repair or surgical ligation, depending on severity and risk for developing complications. Preoperative planning with imaging is important to reducing the risk of iatrogenic vertebral artery injury. Conclusion Vertebral artery injury remains a significant concern in cervical spine surgery. Early identification, appropriate imaging, and individualized management are essential to minimizing morbidity and improving surgical outcomes.