Vertebral artery dissection (VAD) is rare in children but is increasingly recognized as a cause of stroke in the pediatric population. Traditionally, VAD was thought to be attributable to either trauma or spontaneous dissections. Recently, several underlying causes, such as bony cervical abnormalities, connective tissue diseases, and infection, have been determined to account for spontaneous VAD or those cases associated with only minor trauma. Two pediatric cases of VAD are presented, both caused by bony cervical abnormalities and each treated with different surgical procedures for symptom resolution. The first case required suboccipital decompression and endovascular sacrifice of the vertebral artery. The second case was treated with surgical decompression of the foramen transversarium at C-1 and C-2. The treatment of both of these patients required accurate diagnosis via cervical spine CT to define the bone anatomy and delineate a cause for what was originally theorized to be spontaneous VAD.