Bow Hunter's Syndrome Caused by Compression of the Subaxial Vertebral Artery: Surgical Technique of Anterolateral Decompression (video)

ABSTRACT Objective Bow hunter’s syndrome (BHS) is a rare clinical condition. It is caused by dynamic com-pression of the vertebral artery either at the level of the transverse foramina (V2 segment) or at the atlanto-axial level (V3 segment). Case report Here we report a male patient (54 years) with typical BHS caused by compression at the level of C6/ C7. He was successfully treated by antero-lateral vertebral artery decompression without need for stabilization. We present pre-operative imaging (MRI, CTA and dynamic angiography), a high-quality intraoperative video detailing each step of the surgical technique (high definition video (HD) with annotations and audio-track of the Doppler ultrasound used as intraoperative control). Furthermore post-operative imaging and a video of clinical outcome are presented. Discussion Adequate management of BHS requires good patho-physiological understanding of the disease and careful clinical examination. Dynamic angiography confirms the exact site of vertebral artery compression. Surgical decompression is the causal treatment. Surgical techniques include vertebral artery decompression by antero-lateral approach (V2 or V3) or posterior approach (V3). Some authors advocate stand-alone stabilization which is however only an indirect treatment and results in significant loss of head motion. Other non-surgical treatments such as orthesis, medical therapy or endovascular stenting have only been anecdotically reported. Conclusion Bow hunter’s syndrome is best treated by vertebral artery decompression. This may safely be achieved by good anatomical knowledge and straightforward surgical technique. Here, the antero-lateral approach is presented in detail in a high definition surgical instruction video.