The aim of this study is to characterize the anatomy of vertebral arteries using magnetic resonance imaging scans of 250 consecutive patients.

To document the prevalence of midline vertebral artery (VA) migration in a subgroup of patients presenting with neck pain, radiculopathy, or myelopathy and to identify the course of the VA through the TFs.

Knowledge of VA anomalies and their respective prevalence may help surgeons decrease the incidence of iatrogenic injury to this artery.

In this retrospective review of 281 consecutive patients, who had an magnetic resonance imaging for axial neck pain, radiculopathy, or myelopathy, anatomic measurements were obtained from C2 to C7.

The observed VA anomalies can be classified into following 3 main groups: (1) intraforaminal anomalies-midline migration, (2) extraforaminal anomalies, and (3) arterial anomalies. Midline migration of the VA was identified in 7.6% (19/250) of patients. The etiology can be degenerative or traumatic. It is important to note that the pattern of medial migration was clockwise rotation from caudal to cephalad and was present in all of our patients with anomalous arteries. Additionally, at C6, only 92% (460/500) of VAs were located within their respective transverse foramens and hypoplastic VAs were identified in 10% (25/250) of patients.

Anomalies that must be considered before surgery include interforamenal anomalies, extraforamenal anomalies, and arterial anomalies. The intraforaminal anomalies involve midline migration, which places the VA at direct risk during corpectomy. Extraforaminal anomalies are related to VAs entering the transverse foramen at a level other than C6, which can increase the risk of injury during the anterior approach to the cervical spine. Arterial anomalies can be fenestrated, hypoplastic, or absent. These raise concern with the ability to maintain cerebral perfusion in the setting of damage to one of the VAs with the presence of contralateral arterial abnormality.