Anatomical relationships between the V2 segment of the vertebral artery and the cervical nerve roots

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During surgical procedures focused on the cervical nerve roots, the surgeon works in proximity to the V2 segment of the vertebral artery (VA). Depending on the specific surgical approach, it may be necessary to identify, expose, or mobilize the artery. In most cases, the artery may be left undisturbed. To reduce the risk of iatrogenic injury to the V2 segment during anterior and anterolateral approaches to the cervical spine, the authors analyzed the relationship between the V2 segment and the proximal segment of the C3–6 nerve roots.


Six cadaveric cervical spines (12 sides) were fixed with formalin, injected with red and blue latex, and investigated intraoperatively using different magnifications (× 3–40).

The VA rested on the anteromedial surface of the cervical nerve roots at the level of each intertransverse space. The exiting nerve roots intersected the VA at a distance ranging from 4.5 to 8.1 mm (mean 6.3 ± 1.06 mm) from the dural sac. The distance was slightly shorter at cephalad levels, suggesting that the artery is more posteriorly and medially situated at those levels. Arterial pedicles anchored the VA to the cervical nerve roots at various levels. These arteries gave rise to purely radicular, ligamentous, and medullary branches without a predictable pattern. After reaching the nerve roots on their lower margin, the nonligamentous branches pierced the radicular dural sheath within the neural foramen at a distance of 2 to 4 mm from the VA.


Proximal-to-distal dissection of a cervical nerve root may proceed with relative safety for at least 4 mm. The V2 segment of the VA gives rise to at least one radicular arterial pedicle between C-4 and C-6. These trunks give rise to purely radicular, ligamentous, and medullary branches in an unpredictable pattern.

Abbreviations used in this paper:VA = vertebral artery; VB = vertebral body.

Article Information

Address reprint requests to: Giuseppe Lanzino, M.D., Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine at Peoria, 530 Northeast Glen Oak, Peoria, Illinois 61637. email:

© AANS, except where prohibited by US copyright law.



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    Fig. 1. Intraoperative photographs. A: A cadaveric specimen showing the relationship between the V2 segment of the VA and cervical nerve roots after complete unroofing of these structures. Because of the oblique direction of the proximal nerve roots, the posterolateral aspect of the VA rests on the anteromedial aspect of the nerve roots. A radiculomedullary trunk (Rad. Tr.) arises at the C-5 nerve root. At the C-6 nerve root, a purely radicular branch (Rad. Br.) is present. At the C-3 nerve root in this specimen, as in most, there is a typical pair of facing branches: a medial ligamentous branch supplying the retroodontoid arterial arch (Med. R.Od. Br.) and a lateral recurrent branch (Lat. Rec. Br.) for the first nerve roots. B: The V2 segment and cervical nerve roots after partial unroofing. This view highlights the relationship of these structures with the VBs and the neighboring osteomuscular boundaries. The interval between the dural sac and the VA was measured in all the specimens along each nerve root (dotted arrows). C: The cervical neural foramen after selective unroofing. A radicular trunk bifurcates into a ligamentous branch (Lig. Br.) that leads to the posterior longitudinal ligament (PLL) and a radicular branch, which immediately pierces the radicular dural sheath. The radicular trunk originates below the nerve root (N.R.) and enters the neural foramen in an ascendant course. A.Tub = anterior tubercle; I.M. = intertransversarii muscles; L.Cap.M. = longus capitis muscle; Tr.B. = transverse bar; VP = venous plexus.


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