Microsurgical Treatment of Bowhunter's Syndrome: 3-Dimensional Operative Video

We present the case of a 56-yr-old previously healthy male who presented with an approximately 1-yr history of intermittent dizziness, near syncope, and holocephalic headaches when turning his head to the left side for a prolonged period of time. He had a distant history of a previous anterior cervical discectomy and fusion at the C6-7 level. He was neurologically intact. Static, dynamic, and vascular imaging confirmed hypoplasia of the right vertebral artery and dominance of the left vertebral artery that completely filled the posterior circulation. Dynamic imaging confirmed compression of the left vertebral artery just above the C5-6 disc space on full head rotation to the left. After an anterior cervical exposure, we dissected lateral to the C5-6 disc space to the transverse process. The anterior tubercle was identified, and a Doppler ultrasound was used to insonate the vertebral artery above the level of compression. The anterior wall of the transverse foramen was thinned with a high-speed drill under constant irrigation and Kerrison rongeurs used to expose the vertebral artery at the site of compression. Importantly, the fibrotic band at, above, and below the level of compression was also dissected and removed. The patient tolerated the procedure well, and was discharged from the hospital 2 d after surgery with no neurological deficits and with complete relief of his preoperative symptoms. Because his symptoms completely resolved and have not recurred, no postoperative imaging was performed. The etiology, presentation, and microsurgical treatment of this rare disease are discussed.All appropriate patient consents were obtained for this submission.© 2017 Department of Neurosurgery, Emory University Hospital. Used with permission.All Figures used with permission as above.