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Observational study with retrospective computerized tomography (CT) angiography analysis.The purpose of this study is to examine the vertebral artery’s course in the V2 segment and define the anatomic variations in the adult population using CT angiography.The V2 segment of the vertebral artery (VA) usually extends from the transverse processes of C6–C2; however, the presence of abnormal VA course has been reported. These variations may predispose a patient to higher risk of iatrogenic vascular injury during anterior cervical surgery.Retrospectively, 700 vertebral arteries on 350 three-dimensional CT angiographies were analyzed. Measurements were taken describing the relationship between the extraosseous portions of the VA to surgical landmarks. In addition, the diameter of the transverse foramen was measured on axial CT images.The VA entered the C6 transverse process in 94.9% of the specimens (664 out of 700 VA courses). Abnormal VA entrance was observed in 5.1% of the specimens (36 VA courses), with entrance into the C4, C5, or C7 transverse foramen 1.6%, 3.3%, and 0.3%, respectively.In 2 of 36 cases (5.6%) of abnormal VA entrance, the extraosseous VA formed an unusual medial loop, and the center of VA was positioned medial to the longus colli muscle. Furthermore, transverse foramens filled with VA were significantly larger than unfilled foramens (P < 0.01), but there was no significant difference between the C7 unfilled foraminal area and unfilled foraminal area above C7 (P = 0.768).The present study confirms the presence of anomalous VA routes in the V2 segment. A preoperativethree-dimensional computerized tomography (CT) angiography with axial images may be useful to identify the presence of an anomalous V2 route when suspected on magnetic resonance imaging or CT. Delineation of this anomaly may reduce the risk of intraoperative VA injury.