The differential for
vertebrobasilar insufficiency is wide and can be caused by posterior circulation
infarcts, steal-type phenomena, or other systemic causes. In the absence of imaging findings explaining symptomology, the utility of appropriate history gathering and dynamic angiography cannot be understated in identifying Bow
Hunter's syndrome, a rare cause of dynamic
vertebrobasilar insufficiency. We present a case of a 69-year-old man who complained of
presyncope and severe
dizziness when turning his head towards the right. On examination he had no
radiculopathy but did have objective evidence of
myelopathy as well. CT imaging and dynamic angiography demonstrated C3-C4 right uncovertebral joint
hypertrophy and near complete
stenosis of the right vertebral artery with dynamic head position towards the right. Given
vertebrobasilar insufficiency and
myelopathy he was taken to the operating room for C3-C4 anterior cervical
discectomy and fusion with vertebral artery
decompression. The patient provided consent for the procedure. Standard anterior cervical
neck dissection was undertaken with additional platysmal undermining to facilitate exposure of the right uncovertebral joint and transverse processes. The vertebral artery was first decompressed above and below the area of most significant
stenosis at the respective transverse foramina before the hypertrophied uncovertebral joint was removed. Next,
discectomy and posterior
osteophyte removal were completed in typical fashion followed by graft, plate, and screw placement. Postoperatively the patient had immediate resolution of symptoms and continued so at 8-month follow-up. Imaging demonstrated return to normal caliber of the right vertebral artery and successful
decompression.