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Vertebral Artery Injuries Associated with Cervical Spine Trauma

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Vertebral Artery Injuries Associated with Cervical Spine Trauma Vertebral Artery Injuries Associated with Cervical Spine Trauma Scott D. Daffner, M.D. Associate Professor Department of Orthopaedics West Virginia University School of Medicine Morgantown, WV USA Introduction a. Incidence of vertebral artery injury (VAI) i. 0.5% of all trauma patients ii. 70% of VAI in blunt trauma has associated cervical fracture iii. 33%-39% of all cervical spine fractures b. Impact of VAI difficult to predict i. Not all patients symptomatic ii. Variable symptomatology II. Anatomy a. 4 segments i. Most injuries from cervical trauma in V2 (foraminal segment) b. Types of injury i. Intimal tear ii. Dissection iii. Pseudoaneurysm iv. Occlusion v. Transection Cloud G , and Markus H QJM 2003;96:27-54 III. Injury Patterns a. V2 segment (foraminal) most commonly injured b. Mechanism i. Direct trauma (bone fragments) ii. Stretching (dislocation / subluxation) c. Most common fracture / injury i. Transverse foramen ii. Subluxation or dislocation iii. Upper cervical injury (C1-C3) d. Associated conditions i. Basilar skull fracture ii. Occipitocervical dissociation iii. Ankylosing Spondylitis / DISH Woodring Vaccaro Miller Kral Cothren Ding Even (1993) (1998) (2002) (2002) (2003) (2010) (2012) TP / Foramen Transversarium 88% 25% 48% 8% \ - 17% Facet Subluxation / Dislocation - 40% 44% 21% 33% - 63% Upper Cervical (C1-C3) - - - - / 18% 25% I. Screening a. Modalities i. Digital subtraction angiography (gold standard) ii. CT Angiography iii. MR Angiography b. Criteria i. No definite established Criteria for Ordering CTA (Head & Neck) criteria West Virginia University ii. Varies by institution Unexplained or incongruous central or lateralizing neurologic deficit iii. East & West Trauma Evidence of acute cerebral infarct on Head CT Assoc.’s criteria Glasgow Coma Scale score ≤ 8 1. Includes Evidence of diffuse axonal injury evaluation for Facial fracture or Lefort type II or III fracture o Basilar skull fracture carotid, o Petrous fracture intracranial o Complex mandible fracture injuries Cervical spine injuries o Subluxation / dislocation 2. Includes o C1, C2, or C3 fracture extraspinal o Extension through foramen indications transversarium Cervical spinal cord injury iv. Screening all trauma Hanging injuries patients not encouraged Major thoracic injury or 1st rib fracture 1. Cost o Thoracic aorta or major vessel injury o Sternal fracture 2. Complications o Scapula fracture 3. Low yield II. Treatment a. Symptomatic VAI i. Anticoagulation / antiplatelet Rx ii. Thrombolysis iii. Endovascular procedures iv. Open procedures b. Asymptomatic VAI i. Anticoagulation / antiplatelet Rx 1. Low dose heparin, ASA 325mg, Clopidogrel ii. Observation c. Repeat imaging i. 7-10 days ii. 3 months III. Outcomes a. Highly variable i. Many clinically silent ii. Delayed presentation iii. Does not correlate with presenting symptoms or fracture b. Vertebrobasilar insufficiency i. Bilateral VAI c. Embolic stroke i. Posterior circulation (brainstem, cerebellum, posterior hemispheres, thalamus) ii. Nonocclusive injuries (dissection, pseudoaneurysm) d. PICA stroke i. Lateral medullary syndrome (Wallenberg syndrome) e. Spinal cord ischemia i. Anterior spinal artery ii. Intersegmental arteries f. Mortality rates 0-33% g. Impact on surgical treatment of cervical injury References Alterman DM, Heidel RE, Daley BJ, et al. Contemporary outcomes of vertebral artery injury. J Vasc Surg 2013;57:741-746. Biffl WL, Moore EE, Elliott JP, et al. The devastating potential of blunt vertebral arterial injuries. Ann Surg 2000;231:672-681. Cothren CC, Moore EE, Biffl WL, et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 2003;55:811-813. Ding T, Maltenfort M, Yang H, et al. Correlation of C2 fractures and vertebral artery injury. Spine 2010;35:E520-E524. Even J, McCullough K, Braly B, et al. Clinical indications for arterial imaging in cervical trauma. Spine 2012;37:286-291. Fassett DR, Dailey AT, Vaccaro AR. Vertebral artery injuries associated with cervical spine injuries: a review of the literature. J Spinal Disord Tech 2008;21:252-258. Hagedorn JC, Emery SE, France JC, Daffner SD. Does CT angiography matter for patients with cervical spine injuries? J Bone Joint Surg Am 2014;96:951-955. Harshavardhana NS, Dabke HV. Risk factors for vertebral artery injuries in cervical spine trauma. Orthop Rev 2014;6:128-130. Kral T, Schaller C, Urbach H, et al. Vertebral artery injury after cervical spine trauma: a prospective study. Zentralbl Neurochir 2002;63:153-158. Lebl DR, Bono CM, Velmahos G, et al. Vertebral artery injury associated with blunt cervical spine trauma: a multivariate regression analysis. Spine 2013;38:1352-1361. Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 2002; 236:386-395. Mitha AP, Kalb S, Ribas-Nijkerk, et al. Clinical outcome after vertebral artery injury following blunt cervical spine trauma. World Neurosurg 2013;80:399-404. Mueller CA, Peters I, Podlogar M, et al. Vertebral artery injuries following cervical spine trauma: a prospective observational study. Eur Spine J 2011;20:2202-2209. Scott WW, Sharp S, Figueroa SA, et al. Clinical and radiological outcomes following traumatic grade 1 and 2 vertebral artery injuries: a 10-year retrospective analysis from a level 1 trauma center. J Neurosurg 2014;121:450-456. Vaccaro AR, Klein GR, Flanders AE, et al. Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography. Spine 1998;23:789-795. Wang AC, Charters MA, Thawani JP, et al. Evaluating the use and utility of noninvasive angiography in diagnosing traumatic blunt cerebrovascular injury. J Trauma Acute Care Surg 2012;72:1599-1608. Woodring JH, Lee C, Duncan V, et al. Transverse process fractures of the cervical vertebra: are they significant? J Trauma 1993;34:797-782. .
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