The segmentation of the vertebral artery: An ambiguous anatomical concept

The course of the vertebral artery from its subclavian artery origin up to its termination at the vertebrobasilar junction is divided into four segments (V1–V4). This segmentation, based on schemes that have evolved since the late nineteenth century, should be a consistent and reproducible anatomical concept. However, the current literature offers conflicting definitions of that scheme, not infrequently within a single article or monograph. The principal inconsistency found in modern publications concerns the termination of the V2 segment, which is either set at the C2 or C1 transverse foramen depending on the scheme considered. Consequently, the portion of the vertebral artery extending between C2 and C1—a frequent site of pathological involvement—either belongs to the V2 or V3 segment. This discrepancy can affect the validity of studies evaluating the diagnosis and management of vertebral artery disorders. A V3 segment extending from the transverse foramen of C2 to the posterior atlanto-occipital membrane and subdivided into vertical, horizontal, and oblique subsegments—a pattern suggested by Barbieri in 1867 and adopted in some modern publications—would provide a simple, precise, and reliable solution without significantly altering the widely accepted division of the vertebral artery into four segments (V1–V4).