What structure is at risk with lateral dissection of the atlas

The vertebral artery lies lateral to the ring of the atlas (Fig. 25-2); therefore, the dissection should not be carried more than 1.5 cm lateral to the posterior midline and 8 to 10 mm laterally along the superior C1 border to avoid injury to the vertebral artery. Once the greater occipital nerve is encountered and the fragile venae comitantes of the paravertebral venous plexus are exposed, further lateral dissection endangers the vertebral artery. If bleeding is encountered from disruption of the venous plexus between C1 and C2, packing and hemostatic agents are usually adequate to control bleeding. If vertebral artery injury occurs, direct repair, manual pressure, and ligation are options for control of hemorrhage.

Figure 25-1. Ligamentum nuchae. (From Winter R, Lonstein J, Denis F, et al. Posterior upper cervical procedures: Atlas of Spinal Surgery. Philadelphia: Saunders; 1995. p. 21.)
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