Surgical Decompression of the Vertebral Artery in a Patient with Ponticulus Posticus: a Case Report

Ponticulus posticus (PP) of the cervical vertebrae is an anatomical variant that, in some cases, can result in the obstruction of the vertebral artery (VA) by an osseous ponticle or calcified ligament at C1. Surgical decompression may be required to restore vertebrobasilar blood flow and relieve associated symptoms; however, few reports have described surgical treatment for tethering of the VA due to PP. A 41-year-old man presented with severe unilateral neck pain and dizziness with lightheadedness brought on by head turning to the left. MRI and CT of the cervical spine revealed the VA to be traveling through a complete bony ring on the right side at the C1 level. The patient was initially managed conservatively, but his symptoms persisted, and surgical decompression of the VA was offered. Surgical decompression of the artery was successfully performed and well tolerated without complications. At 3-month follow-up, the patient reported significant improvement of his preoperative symptoms with only mild residual local tenderness in the region. We describe a case of PP in which the VA was tethered in a complete bony ring at C1 producing symptoms, which resolved in large part with surgical decompression. PP anatomical variants may cause debilitating symptoms if vertebrobasilar flow is obstructed, requiring surgical decompression in select cases.