European Spine Journal

, Volume 27, Issue 6, pp 1278–1285 | Cite as

Variations of transverse foramina in cervical vertebrae: what happens to the vertebral artery?

  • Aristeidis Zibis
  • Vasileios Mitrousias
  • Nikolaos Galanakis
  • Nikoletta Chalampalaki
  • Dimitrios Arvanitis
  • Apostolos Karantanas
Original Article



The purpose of this study is to examine variations of the foramen transversarium and the vertebral artery in computed tomography angiographies (CTa) of the cervical spine, investigate their coexistence, and present possible considerations regarding such variations in spine surgical procedures.


Fifty CTa of the neck were retrospectively reviewed. Transverse and anteroposterior diameter of the foramen and diameter of the vertebral artery were measured. Variations of the foramen and the vertebral artery were detected.


Cervical CTa of 32 males and 18 females (mean age 66.4 ± 10.78 years), all belonging to the Indo-European race, were reviewed. Variations of the foramen transversarium were found in 17 vertebrae (4.85%) of 15 patients (30%). Duplication of the foramen was the most frequent variation, followed by the open foramen, the absence of the foramen, the triple foramen, and the hypoplastic foramen. Variations of the vertebral artery were found in 7 patients (14%) and asymmetry was found in 12 (24%) patients. Moreover, six patients presented with hypoplastic vertebral arteries (12%). When examining coexistence, 60% of patients exhibiting variations in the transverse foramen were also exhibiting variations or asymmetry in the vertebral artery, compared to 25.7% of patients with no foramen variations (p = 0.02).


Vertebral artery injury is not common but may be a disastrous complication during cervical spine surgery. Proper preoperative planning is essential for any surgeon and exact knowledge of the anatomy in each patient is essential. This study strongly recommends the preoperative use of a CTa when suspicion of a variation is present and implied by a foramen variation.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Spine cervical/vertebrae Transverse foramina Anatomic variants Computed tomography/angiography Vertebral arteries/variants 



There are no acknowledgements for this article.


There is no funding source for this article.

Compliance with ethical standards

Ethical approval

Approval of the local ethics committee was obtained, but no inform consents were collected due to the retrospective nature of the study.

Conflict of interest

Authors declare that they have no conflicts of interest.

Supplementary material

586_2018_5523_MOESM1_ESM.pptx (1.5 mb)
Supplementary material 1 (PPTX 1561 kb)


  1. 1.
    Kimura K, Konishi M, Hu SY (1985) Shape and size of the transverse foramina in Japanese. Okajimas Folia Anat Jpn 62:123–131CrossRefPubMedGoogle Scholar
  2. 2.
    Murlimanju BV, Prabhu LV, Shilpa K et al (2011) Accessory transverse foramina in the cervical spine: incidence, embryological basis, morphology and surgical importance. Turk Neurosurg 21:384–387. PubMedGoogle Scholar
  3. 3.
    Zibis AH, Mitrousias V, Baxevanidou K et al (2016) Anatomical variations of the foramen transversarium in cervical vertebrae: findings, review of the literature, and clinical significance during cervical spine surgery. Eur Spine J 25:4132–4139. CrossRefPubMedGoogle Scholar
  4. 4.
    Taitz C, Nathan H, Arensburg B (1978) Anatomical observations of the foramina transversaria. J Neurol Neurosurg Psychiatry 41:170–176CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Wakao N, Takeuchi M, Kamiya M et al (2014) Variance of cervical vertebral artery measured by CT angiography and its influence on C7 pedicle anatomy. Spine (Phila Pa 1976) 39:228–232. CrossRefGoogle Scholar
  6. 6.
    Kim JT, Lee HJ, Kim JH, Hong JT (2016) Quantitative analysis of unusual entrance of the vertebral artery into the cervical foramen (V2 segment) and its clinical implications. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 25:4188–4194. CrossRefGoogle Scholar
  7. 7.
    Bernard TJ, Mull BR, Handler MH et al (2007) An 18-year-old man with fenestrated vertebral arteries, recurrent stroke and successful angiographic coiling. J Neurol Sci 260:279–282. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Giannopoulos S, Markoula S, Kosmidou M et al (2007) Lateral medullary ischaemic events in young adults with hypoplastic vertebral artery. J Neurol Neurosurg Psychiatry 78:987–989. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Ahn S-H, Oh S-J, Yook J-W et al (2008) Recurrent isolated vertigo from hypoplastic vertebral artery. Eur J Neurol 15:e51–e52. CrossRefPubMedGoogle Scholar
  10. 10.
    Furumoto T, Nagase J, Takahashi K et al (1996) Cervical myelopathy caused by the anomalous vertebral artery. A case report. Spine (Phila Pa 1976) 21:2280–2283CrossRefGoogle Scholar
  11. 11.
    Zhou R, Liu D, Yu K et al (2015) Carotid and vertebral arterial variations in Alzheimer’s disease. Curr Alzheimer Res 12:368–376CrossRefPubMedGoogle Scholar
  12. 12.
    Johnson SA, Ducruet AF, Bellotte JB et al (2017) Rotational vertebral artery dissection secondary to anomalous entrance into transverse foramen. World Neurosurg 108:998.e1–998.e5. CrossRefGoogle Scholar
  13. 13.
    Smith MD, Emery SE, Dudley A et al (1993) Vertebral artery injury during anterior decompression of the cervical spine. A retrospective review of ten patients. J Bone Jt Surg Br 75:410–415CrossRefGoogle Scholar
  14. 14.
    Lunardini DJ, Eskander MS, Even JL et al (2014) Vertebral artery injuries in cervical spine surgery. Spine J 14:1520–1525. CrossRefPubMedGoogle Scholar
  15. 15.
    Neo M, Fujibayashi S, Miyata M et al (2008) Vertebral artery injury during cervical spine surgery: a survey of more than 5600 operations. Spine (Phila Pa 1976) 33:779–785. CrossRefGoogle Scholar
  16. 16.
    Sano A, Hirano T, Watanabe K et al (2013) Preoperative evaluation of the vertebral arteries and posterior portion of the circle of Willis for cervical spine surgery using 3-dimensional computed tomography angiography. Spine (Phila Pa 1976) 38:E960–E967. CrossRefGoogle Scholar
  17. 17.
    Puchner S, Haumer M, Rand T et al (2007) CTA in the detection and quantification of vertebral artery pathologies: a correlation with color Doppler sonography. Neuroradiology 49:645–650. CrossRefPubMedGoogle Scholar
  18. 18.
    Eskander MS, Drew JM, Aubin ME et al (2010) Vertebral artery anatomy: a review of two hundred fifty magnetic resonance imaging scans. Spine (Phila Pa 1976) 35:2035–2040. CrossRefGoogle Scholar
  19. 19.
    Nagar Y, Taitz C, Reich R (1999) What can we make of these fragments? Excavation at “Mamilla” Cave, Byzantine period, Jerusalem. Int J Osteoarchaeol 38:29–38CrossRefGoogle Scholar
  20. 20.
    Rathnakar P, Remya K, Swathi B (2013) Study of accessory foramen transversaria in cervical vertebrae. Nitte Univ J Health Sci 3:97–99Google Scholar
  21. 21.
    Katikireddi RS, Nageswara S, Sundara R (2014) A study of double foramen transversarium in dried cervical vertebra. Int J Health Sci Res 4:59–61Google Scholar
  22. 22.
    Jovanovic MS (1990) A comparative study of the foramen transversarium of the sixth and seventh cervical vertebrae. Surg Radiol Anat 12:167–172CrossRefPubMedGoogle Scholar
  23. 23.
    Metin Tellioglu A, Durum Y, Gok M et al (2017) Evaluation of morphologic and morphometric characteristic of foramen transversarium on 3-dimensional multidetector computed tomography angiography (MDCTA). Turk Neurosurg. PubMedGoogle Scholar
  24. 24.
    Jeng J-S, Yip P-K (2004) Evaluation of vertebral artery hypoplasia and asymmetry by color-coded duplex ultrasonography. Ultrasound Med Biol 30:605–609. CrossRefPubMedGoogle Scholar
  25. 25.
    Francke JP (1971) Contribution à l’étude des artères vertébrales. Recherche anatomique. LilleGoogle Scholar
  26. 26.
    Argenson C, Francke JP, Sylla S et al (1979) Les artères vertébrales (segments V1 et V2). Anat Clin 2:29–41CrossRefGoogle Scholar
  27. 27.
    Zhou M, Zheng H, Gong S et al (2015) Vertebral artery hypoplasia and vertebral artery dissection: a hospital-based cohort study. Neurology 84:818–824. CrossRefPubMedGoogle Scholar
  28. 28.
    Park J-H, Kim J-M, Roh J-K (2007) Hypoplastic vertebral artery: frequency and associations with ischaemic stroke territory. J Neurol Neurosurg Psychiatry 78:954–958. CrossRefPubMedGoogle Scholar
  29. 29.
    Mitsumura H, Miyagawa S, Komatsu T et al (2016) Relationship between vertebral artery hypoplasia and posterior circulation ischemia. J Stroke Cerebrovasc Dis 25:266–269. CrossRefPubMedGoogle Scholar
  30. 30.
    Kotil K, Kilincer C (2014) Sizes of the transverse foramina correlate with blood flow and dominance of vertebral arteries. Spine J 14:933–937. CrossRefPubMedGoogle Scholar
  31. 31.
    Russo VM, Graziano F, Peris-Celda M et al (2011) The V(2) segment of the vertebral artery: anatomical considerations and surgical implications. J Neurosurg Spine 15:610–619. CrossRefPubMedGoogle Scholar
  32. 32.
    Grabowski G, Cornett CA, Kang JD (2012) Esophageal and vertebral artery injuries during complex cervical spine surgery—avoidance and management. Orthop Clin N Am 43:63–74. (viii) CrossRefGoogle Scholar
  33. 33.
    Nagahama K, Sudo H, Abumi K et al (2014) Anomalous vertebral and posterior communicating arteries as a risk factor in instrumentation of the posterior cervical spine. Bone Jt J 96–B:535–540. CrossRefGoogle Scholar
  34. 34.
    Maughan PH, Ducruet AF, Elhadi AM et al (2013) Multimodality management of vertebral artery injury sustained during cervical or craniocervical surgery. Neurosurgery 73:ons271–ons281. (discussion ons281–2) CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Anatomy, School of Health SciencesUniversity of ThessalyLarissaGreece
  2. 2.Department of Medical ImagingUniversity HospitalHeraklionGreece
  3. 3.Department of RadiologyMedical School-University of CreteHeraklionGreece

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