Lang Vertebral Artery Decompression

Preop imaging

Right subclavian artery injection. A) neutral head position, opacification of vertebral artery is noted. B) head turned to the right. Vertebral artery no longer opacifies shortly after its take off from the subclavian. 

Neuromonitoring

SSEPs and brainstem auditory evoked potentials. 

Positioning

Same as for CEA, which is itself same as for ACDF just with the head turned to the side opposite the pathology. 

Patient is prone, shoulder at the break in the bed. Place an arterial line pressure bag between the shoulder blades, oriented longitudinally with the bulb oriented towards the head. 

Incision