• Vincent J Miele, John C France, and Charles L Rosen.
• Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, WV 26506-9183, USA.
• Spine. 2008 May 15;33(11):E366-70.

Study DesignA rare case of subaxial vertebral artery (VA) positional occlusion is reviewed and treatment methods discussed.ObjectiveThe decision process involved in treating subaxial VA positional occlusion is reviewed.Summary Of Background DataBow Hunter stroke is a symptomatic vertebrobasilar insufficiency caused by stenosis or occlusion of the VA with physiologic head rotation. It most commonly occurs at the junction of C1 and C2 and less commonly as the VA enters the C6 transverse foramen. Rotational stenosis of the VA is quite rare during its passage through the foramen transversarium of C3-C6.MethodsA 48-year-old gentleman presented describing syncopal episodes when he turns his head to the left side. Imaging revealed a congenitally narrowed right foramen transversarium and high-grade stenosis of the left VA when the head was turned to the left. A routine anterior cervical discectomy and fusion was performed with the addition of decompression of the left transverse foramen.ResultsVascular imaging should be performed with the patient's head in both the neutral position and in the symptomatic position. Surgical treatment may be chosen if conservative therapies fail and generally has 1 of 2 goals-decompression of the VA or elimination of rotational movement at the affected level. Decisions between anterior and posterior decompressions may be influenced by the surgeon's comfort level with the approach and if the transverse foramen stenosis is caused mainly by an anterior (osteophytes at the uncinate process) or posterior (facet joint hypertrophy) process. The patient remains symptom-free after treatment.ConclusionThis report demonstrates the condition in the subaxial spine and describes successful treatment by fusion of the affected level combined with decompression of the foramen transversarium-a combination of previously described therapies.

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