Management of a penetrating vertebral artery injury in a peripheral hospital

Vertebral artery (VA) injuries in penetrating trauma are rare but can be life threatening. Management is often reliant on interventional radiology (IR), although such services may be lacking in peripheral centres. We report a case of a 22-year-old man who sustained a right VA injury from a stab wound to the posterolateral neck that was managed in a rural hospital. On presentation, the patient was initially haemodynamically stable but began exsanguinating heavily whilst undergoing imaging and was subsequently transferred to the operating theatre. Intraoperatively, bleeding was noted from the C5/C6 interforaminal space. Due to difficulty with exposure and lack of specialist surgical services, bimanual pressure was continuously applied to the wound whilst awaiting the arrival of a vascular surgeon and neuro-interventionalist who were transported by air from a tertiary hospital. At the time of angiography, bleeding had ceased and no further intervention was required. This case highlights the importance for surgeons in peripheral centres to be aware of some of the operative manouvres used in managing VA injuries including the utility of continued direct pressure. Moreover, it serves as a reminder that there remains a role for operative intervention in the unstable patient despite increasing reliance on radiological techniques to treat such injuries.