Bow hunter's syndrome secondary to lateral and posterior spondylosis: illustrative case

Bow hunter's syndrome (BHS) is a rare form of rotational vertebral artery (VA) insufficiency, most commonly attributed to osteophytic compression at the subaxial cervical spine. While single-segment compression is frequently reported, dual-segment involvement remains exceedingly rare.

The authors report the case of an 82-year-old male who presented with recurrent vertigo triggered by head rotation. Dynamic imaging revealed rotational occlusion of the left VA secondary to simultaneous lateral and posterior compression at both C4-5 and C5-6 levels, caused by osteophytes of the uncovertebral and facet joints. The patient underwent successful anterior cervical discectomy and fusion from C4 to C6, along with targeted resection of the osteophytes. Postoperatively, rotational symptoms resolved completely, and follow-up imaging confirmed restoration of VA patency.

This case highlights the importance of considering multilevel, multidirectional osteophytic compression in the evaluation of BHS. To the authors' knowledge, this represents the first documented instance of BHS resulting from concurrent lateral and posterior compression at two adjacent cervical levels, emphasizing the need for comprehensive vascular and bony assessment in atypical presentations. https://thejns.org/doi/10.3171/CASE25718.