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Vertebral artery injury is a rarely described complication of anterior cervical decompression. The authors performed a retrospective review of their operative database for the purposes of defining the optimal management of this complication and its avoidance.Four of 1,215 (0.3%) patients undergoing anteior cervical operation sustained arterial injuries. In three cases, primary repair of the artery was succesful; in one case, the artery was exposed and ligated. There were no postoperative ischemic compllcations. Artery laceration occurred during decompression (n=2), screw tapping (n=1), and during soft tissue retraction (n=1).Injury to the vertebral artery during anterior approaches can be avoided by preoperative identification of anomalous arteries and by intraoperative attention to the midline. When the artery is injured, primary repair may be the optimal management strategy.