Vertebrobasilar Insufficiency Syndrome in Extension: Insights into Surgical Treatment.

BACKGROUND AND IMPORTANCE: Rotational vertebrobasilar artery syndrome, or bow hunter syndrome, is a rare but well described pathology. We present the surgical treatment of a latent presentation of dynamic, extension only, bilateral co-dominant vertebral artery compression in the V3 segment. A fall year prior resulted in Jefferson Fracture and craniocervical instability. This was further complicated by concurrent central canal stenosis due to degenerative pannus at C1-2. In this report, we describe a case and surgical technique and discussion of multidisciplinary approach to safe and effective treatment. To our knowledge, this is the first documented report of Vertebrobasilar Insufficiency Syndrome in Extension with multidisciplinary team management.

CLINICAL PRESENTATION: We present the treatment of positional vertigo resulting from complete left and high grade right vertebral artery stenosis with neck extension only, diagnosed with formal angiogram under provocative maneuver and treated surgically with multidisciplinary approach. This included intraoperative angiogram before and after positioning to confirm patent vertebral arteries prior to craniocervical fusion. We highlight in this article the rare presentation of extension alone provocation and multidisciplinary approach to treatment of bilateral vertebrobasilar syndrome in the setting of craniocervical instability with C1 Jefferson fracture from a fall 2 years prior with C1-2 pannus causing central canal stenosis.

CONCLUSION: We present the treatment of a patient who presented with non-union of C1 Jefferson Fracture from prior injury resulting in extension only vertebrobasilar syndrome complicated by C1-2 pannus and craniocervical instability who underwent successful surgical treatment via multidisciplinary approach. In the setting of positional vertigo or other transient neurological complaints with a history of injury, vertebral artery dynamic stenosis should be considered. If failing conservative treatment including bracing, avoidance of positional triggers and treatment with aspirin or other antiplatelet medication, surgical stabilization should be considered if instability renders decompression alone inadequate with special care to evaluate pre- and post-surgical positioning to confirm patency of the vertebral arteries and posterior vasculature.