Fri., 10/14/11 Pelvis & Spine, Paper #41, 10:06 am OTA-2011
Vertebral Artery Injury Associated With Blunt Cervical Spine Trauma: A Multicenter Study
Darren R. Lebl, MD1; Kirkham B. Wood, MD2; George Velmahos, MD2; Umesh Metkar, MD3; Christopher M. Bono, MD4; Mitchel B. Harris, MD4;
1Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA;
2Massachusetts General Hospital, Boston, Massachusetts, USA;
3Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA;
4Brigham and Women’s Hospital, Boston, Massachusetts, USA
Background: Vertebral artery injury (VAI) in the blunt trauma patient may be clinically silent or have catastrophic neurologic sequelae. The optimal screening process for VAI associated with cervical spine injury has yet to be clearly defined.
Purpose: We sought to define the incidence, patient characteristics, and the independent predictors for VAI from blunt cervical spine trauma.
Methods: We conducted a retrospective review of prospectively collected patient data from the American College of Surgeons (ACS) institutional trauma registries at 3 Level 1 trauma centers over a 3-year period. Patients screened for VAI by CTA were identified, studied, and logistic regression analysis was performed.
Results: 1204 patients sustained a cervical spine injury during the study period; 253 patients (21.0%) underwent screening for VAI by CT angiography. VAI was diagnosed in 42 patients (3.5% incidence), 38 with unilateral VAI (3.2%) and 4 with bilateral (0.3%). Fracture displacement into the transverse foramen >1 mm (odds ratio [OR] = 3.66; 95% confidence interval [CI], 1.32-10.18; P <0.01), basilar skull fracture (OR = 5.18; 95% CI, 2.07-12.98; P <0.001), occipital-cervical dissociation (P <0.001), and ankylosing spondylitis (AS)/diffuse iodiopathic skeletal hyperostosis (DISH) (OR = 8.05; 95% CI, 1.30-49.69; P <0.01) were found to be independent predictors for VAI. Patients with VAI had a significantly lower GCS (P <0.001), higher ISS (P <0.01), and higher mortality rate (P <0.001). There was no significant difference in age, gender, hospital length of stay or ICU length of stay between patients with VAI and those without. The stroke rate for VAI was 6 out of 42 patients (14%) and the stroke-related mortality rate was 2 of 42 patients (4.8%). Any injury from the occiput to C2 (P = 0.89), multiple transverse process fractures (P = 0.43), fractures entering the transverse foramen (P = 0.46), atlas fractures (P = 0.84), C2 fractures (hangman’s [P = 0.99] or dens [P = 0.12], and facet subluxations/dislocations (P = 0.28) were not associated with an increased likelihood of VAI. Fractures undergoing operative stabilization (P = 0.40) and patients with a high-energy mechanism of injury (P = 0.19) were not independently predictive of VAI. A minimum of 1 contraindication to antiplatelet or anticoagulation treatment for VAI was present in 100 (39.5%) of the screened patients. 30 of 42 patients (71%) diagnosed with VAI did not receive any new medication or treatment subsequent to the diagnosis of VAI during their hospitalization.
Conclusions: In the more severely injured patient population with VAI, anticoagulation or antiplatelet therapy is often not feasible. Routine, obligatory CT angiography screening for VAI in the asymptomatic cervical spine trauma patient should be avoided. Patients with a basilar skull fracture, occipital-cervical dissociation, AS/DISH, or transverse process fracture displaced into the transverse foramen >1 mm should be strongly considered for VAI screening.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.