Masking of vertebral artery dissection by severe trauma to the cervical spine

Association between cervical fracture patterns and blunt cerebrovascular injury when screened with computed tomographic angiography

BACKGROUND CONTEXT

Prior studies have demonstrated a close association between cervical spine fractures and blunt cerebrovascular injuries (BCVI). Undiagnosed BCVI is a feared complication because of the potentially catastrophic outcomes in a missed posterior circulation stroke. Computed tomography angiography (CTA) is commonly used to screen BCVI in the trauma setting. However, determining which cervical fracture patterns mandate screening is still not clearly known.

PURPOSE

The aim of this retrospective review is to further elucidate which fracture patterns are associated with BCVI when using CTA and may mandate screening.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

All patients that presented to our trauma and emergency departments with a blunt cervical spine fracture from January 2018 to December 2021. Inclusion criteria included blunt cervical trauma and the use of CTA for BCVI screening. Exclusion criteria included patients under the age of 18, penetrating cervical trauma, and use any imaging modality besides CTA for BCVI screening.

OUTCOME MEASURES

Patient demographics (age, gender, Glasgow coma scale, hospital length of stay (LOS), intensive care unit LOS, mechanism of energy of injury, polytrauma status), fracture location, fracture pattern (anterior arch, dens, dislocations/subluxations, facet, hangman, Jefferson, lamina, lateral mass, occipital condyle dissociation, occipital condyle, pedicle, posterior arch, spinous process, transverse process, transverse foramen, and vertebral body), and whether the patient sustained a BCVI or CVA.

METHODS

If a patient had multiple fracture levels or fracture patterns, each level and pattern was counted as a separate BCVI. Multilevel fractures were defined as any patient with fractures at two distinct cervical levels. Differences between the patients who had a BCVI and those who did not were analyzed using independent sample t-tests for continuous variables and the chi-square or Fisher exact test for categorical variables. Odds ratios and 95% confidence intervals were calculated to assess likelihood between patient characteristics/fracture characteristics and BCVI.

RESULTS

A total of 690 patients were identified as having a blunt cervical spine injury. A total of 453 patients (66%) underwent screening for BCVI with CTA. Among patients who underwent CTA, BCVI was diagnosed in 138 patients (30%), VAI in 119 patients (26%), CAI in 30 patients (7%), and 11 patients were diagnosed with both a VAI and CAI (2%). Overall, among all patients there were 9 strokes, all in patients identified with a BCVI (1%). No individual cervical level was associated with increased risk of BCVI, but when combined, OC-C3 fractures were associated with an increased risk (OR: 1.4, 95% CI: 1.0-1.9, p-value: .006). Multilevel fractures were also associated with an increased risk (OR: 1.7, 95% CI: 1.1-2.3, p-value: .01). The only fracture pattern associated with increased risk of BCVI were fractures associated with a dislocation/subluxation (OR: 3.8, 95% CI: 1.9-7.8, p-value = .0001).

CONCLUSIONS

The only fracture pattern associated with an increased risk of BCVI were fractures associated with dislocation/subluxation. The only fracture levels associated with BCVI were combined OC-C3 and multilevel fractures. We recommend that any upper cervical fracture (OC-C3), multilevel fracture, or fracture with dislocation/subluxation undergo screening for BCVI.

Cervical fracture patterns associated with blunt cerebrovascular injures when utilizing computed tomographic angiography: a systematic review and meta-analysis

BACKGROUND CONTEXT

Prior studies have demonstrated an association between cervical spine fractures and blunt cerebrovascular injuries (BCVI) due to the intimate anatomic relationship between the cervical spine and the vertebral arteries. Digital subtraction angiography (DSA) has historically been the gold standard, but computed tomography angiography (CTA) is commonly used to screen for BCVI in the trauma setting. However, there is no consensus regarding which fracture patterns mandate screening. Over aggressive screening may lead to increased radiation, increased false positives, and overtreatment of patients which can cause unnecessary patient harm, and increased healthcare costs.

PURPOSE

The aim of this meta-analysis is to analyze which cervical spine fracture patterns are most predictive of BCVI when utilizing CTA.

STUDY DESIGN/SETTING

Systematic review and meta-analysis.

OUTCOME MEASURES

Odds ratios for specific cervical fracture patterns and risk of developing a BCVI.

METHODS

A systematic literature review of all English language studies from 2000-2020 was conducted. The year 2000 was chosen as the cut-off because use of CTA prior to 2000 was rare. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Scopus, Global Index Medicus, and ClinicalTrials.gov were queried. Studies were included if they met the following criteria: (1) the diagnostic imaging modality was CTA; (2) investigated blunt cervical trauma; (3) noted specific cervical spine fracture patterns associated with BCVI; (4) odds ratios for specific cervical spine fracture patterns or the odds ratio could be calculated; (5) subjects were 18 years old or older. Studies were excluded if they: (1) included DSA or magnetic resonance imaging; (2) included penetrating cervical trauma; (3) included pediatric patients less than 18 years of age; (4) were not written in English. All statistical analysis was performed using R Studio (RStudio, Boston, MA, USA).

RESULTS

The initial search, after duplicates were removed, resulted in 10,940 articles for independent review. Six studies met the criteria for inclusion in the meta-analysis. Specific fracture patterns mentioned are isolated C1, C2, C3 fractures, any C1-C3 fracture, any C4-C7 fracture, two-level fractures, subluxation/dislocations, and transverse foramen (TF) fractures. Three studies were included in the meta-analysis for C1, C2, C1-C3, subluxations/dislocations, and TF fractures. Two studies were included in the meta-analysis for C3, C4-C7, and two-level fractures. The pooled odds ratio with 95% confidence interval for: C1 fractures and BCVI is 1.3 (0.8-2.1); C2: 1.6 (0.9-2.8); C3: 1.8 (0.9-3.6); C1-C3: 2.2 (1.1-4.2); C4-C7: 0.7 (0.3-1.7); Two-level: 2.5 (1.4-4.6); Subluxation/Dislocation: 2.9 (1.8-4.5); TF: 3.6 (1.4-8.9).

DISCUSSION/CONCLUSION

This study found that when utilizing CTA for screening of BCVI only fractures in the C1-C3 region, two-level fractures, subluxations/dislocations, and transverse foramen fractures were associated with increased incidence of a BCVI. Further refinement of protocols for CTA in the setting of blunt cervical trauma may help limit unnecessary patient harm from overtreatment and reduce healthcare costs.

Massive Brainstem and Cerebellum Infarction Due to Traumatic Extracranial Vertebral Artery Dissection in a Motor Traffic Accident: An Autopsy Case Report

ABSTRACT

Traumatic unilateral vertebral artery (VA) injury can cause focal thrombosis and may block the basilar artery which can further lead to ischemic stroke and massive cerebral infarction and subarachnoid hemorrhage and even rapid death. Here, we present an autopsy case with a traumatic extracranial VA dissection in a motor traffic accident, and the identification of cause of death underwent 2 autopsies. A 62-year-old male pedestrian collided with the right rearview mirror of a car and fell down to the ground. He complained pains in the head and neck. Head computed tomography (CT) showed a right linear temporal bone fracture and a small left temporal subdural hematoma. Neck CT and magnetic resonance imaging (MRI) examination showed left transverse process fracture of the sixth cervical vertebra (C6) and left extracranial VA injury. After 6 days of hospitalization, the left temporal subdural hematoma had been nearly absorbed, and the man was discharged home. On day 15 after the traffic accident, the man suffered sudden unconsciousness accompanied by frequent vomiting at home. The man was taken to hospital, and there were no obvious abnormal findings by head CT examination. However, the man soon fell into a coma state and died 2 days later. The first autopsy was performed 7 days after death and confirmed a left transverse process fracture of C6 and that the deceased died of cerebral infarction and secondary subarachnoid hemorrhage caused by blunt force in the motor traffic accident. In the civil lawsuit, the traffic accident wrecker put forward the objection whether the deceased had fatal diseases. The second autopsy (84 days after the death) findings verified the left extracranial VA injury. Histopathological examination further showed intimal dissection and thrombus formation of the left extracranial VA and secondary basal arterial thromboembolism. Massive infarction of the brainstem and cerebellum was disclosed. Therefore, the deceased died of delayed massive brainstem and cerebellum infarction because of left extracranial VA dissection in the motor traffic accident.

Antiplatelet versus Anticoagulation for Asymptomatic Patients with Vertebral Artery Injury during Anterior Cervical Surgery-Two Case Reports and Review of Literature

Vertebral Artery Injury (VAI) while performing cervical spinal reconstruction surgery is rare, but it can lead to catastrophic events. Treatment for this injury with regard to antiplatelet versus anticoagulation therapy is controversial. The purpose of this report is to discuss two cases of VAI that occurred during the performance of cervical reconstruction surgery and provide a guideline based on a literature review about whether to use anticoagulant or antiplatelet therapy for treatment of asymptomatic VAI. In case 1, iatrogenic injury occurred to the left C5 vertebral artery (VA) during high speed burr removal of an osteophyte on the left C5/6 uncovertebral joint, resulting in VAI. This patient was treated with Heparin resulting in respiratory complication. Case 2 encountered VAI while using the kerrison rongeur to perform a right sided C5/6 foraminotomy. Antiplatelet therapy was administered. Fourteen publications relevant to Antiplatelet versus Anticoagulation treatment were reviewed. Anticoagulation has similar results to antiplatelet therapy. Studies are limited; there were no common guidelines or parameters concerning the utilization of Antiplatelets versus Anticoagulants. Anticoagulation achieved similar results as Antiplatelet therapy; based on the limited relevant data, the superiority of one treatment over the other cannot be concluded in VAI after cervical spinal reconstruction surgery.

A Case of Delayed Traumatic Vertebral Artery Dissection

Vertebral artery dissection is of special clinical importance because of its often-delayed presentation and the risk of potentially permanent neurological deficit, or even death, as a result of injury. Once a rarely discovered injury, the better availability and use of computed tomography and magnetic resonance imaging have contributed to an increased incidence. Early diagnosis and treatment can almost eliminate the threat of acute cerebral vascular injury and save lives. In this report, we review a case of delayed traumatic vertebral artery dissection and discuss the key clinical findings and management strategies.

An interesting case report of vertebral artery dissection following polytrauma

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Routine/regular screening is not undertaken in polytrauma patients.

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Vertebral artery dissection can be clinically challenging to detect and diagnose due to its diverse presentation and the lack of uniform screening/guidelines.

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The pathological process is more common in polytrauma and therefore there needs to be a high index of suspicion in this group of patients.

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CT angiogram and/or Doppler and duplex ultrasonography should be used as a non-invasive screening tool in patients with significant traumatic injuries.

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Early anticoagulation should ideally be the treatment, however, in traumatic injuries it is seldom used.

Introduction

The authors present an interesting case of a 19-year-old male who presented as a polytrauma patient following a fall from a height.

Presentation of case

He was initially managed on the intensive care unit with intracranial pressure bolt monitoring after being intubated and sedated and having his other traumatic injuries stabilized. Upon attempting to wean sedation and extubation a repeat CT scan of the head was undertaken and showed a new area suggested of cerebral infarction, this was a new finding. Further imaging found that he had a cervical vertebral artery dissection following this polytrauma mode of injury.

Discussion

The incidence of vertebral artery dissection following generalized or local trauma is rising but routine imaging/screening in these patients is not undertaken.

Conclusion

Our report displays select images related to this case report and emphasizes the consideration of routine imaging in head and neck traumatic injuries to diagnose internal carotid and/or vertebral artery dissections much earlier.

Diagnostic vascular ultrasonography with the help of color Doppler and contrast-enhanced ultrasonography

The use of ultrasonography and especially of contrast-enhanced ultrasonography (CEUS) in the diagnosis of vascular pathologies before and after interventions has significantly increased over the past years due to the broader availability of modern ultrasound systems with CEUS capabilities and more trained user experience in this imaging modality. For the preinterventional and postinterventional work-up of carotid diseases, duplex ultrasound as well as CEUS have been established as the standard-of-care examination procedures for diagnosis, evaluation, and follow-up. In addition to its use for carotid arterial diseases, ultrasonography has also become the primary modality for the screening of vascular pathologies. This review describes the most common pathologies found in ultrasonography of the carotid arteries, the abdominal aorta, and the femoral arteries.

Multiple Cerebral Infarctions due to Unilateral Traumatic Vertebral Artery Dissection after Cervical Fractures

We report a case of multiple symptomatic cerebral infarctions from a traumatic vertebral artery dissection (VAD) after cervical fractures. A 73-year-old man was admitted with stuporous mentality and left hemiparesis after a motor-vehicle accident. A brain computed tomography (CT) scan at admission showed a traumatic subarachnoid hemorrhage on the left parietal lobe. A cervical CT scan showed left lateral mass fractures on C2, C5, and C6, involving the transverse foramen. Cervical spine magnetic resonance imaging (MRI) revealed loss of signal void on the left vertebral artery. Neck CT angiography showed left VAD starting at the C5 level. Brain MRI revealed acute, multiple cerebral infarctions involving the pons, midbrain, thalamus, corpus callosum, and parietal and frontal lobes on diffusion weighted images. The patient was treated conservatively at the intensive care unit in the acute stage to prevent extent of stroke. Aspirin was started for antiplatelet therapy in the chronic stage. The possibility of symptomatic cerebral infarctions due to traumatic VAD following cervical fracture should be considered.

The role of contrast-enhanced ultrasound in imaging carotid arterial diseases

The standard of care for the initial diagnosis of carotid artery bifurcation diseases is carotid duplex ultrasound. Carotid abnormalities or difficult examinations may represent a diagnostic challenge in patients with clinical symptoms as well as in the follow-up after carotid endarterectomy, carotid artery stenting or other interventions. A promising new method in the diagnosis and follow-up of pathologic carotid diseases is contrast-enhanced ultrasound (CEUS). In comparison with magnetic resonance imaging or computed tomography, the contrast agents used for CEUS remain within the vascular space and hence can be used to study vascular disease and could provide additional information on carotid arterial diseases. This review describes the current carotid duplex ultrasound examination and compares the pathologic findings with CEUS.

Perfil do cirurgião de coluna brasileiro

OBJETIVO: Realizar estudo transversal identificando o perfil do cirurgião de coluna no Brasil. MÉTODOS: Foram coletados dados por meio de questionários com múltiplas alternativas, em dois eventos de relevância para a cirurgia de coluna no âmbito nacional em 2011, o Congresso da Sociedade Brasileira de Coluna (SBC) e o Simpósio Internacional de Coluna (SINCOL). Os dados foram submetidos a análise estatística comparando e estratificando as informações obtidas conforme o perfil encontrado. RESULTADOS: Obtivemos 182 questionários respondidos por ortopedistas e neurocirurgiões com particularidades e semelhanças em suas condutas médicas. CONCLUSÕES: Os dados obtidos nessa pesquisa podem ser importantes para o desenvolvimento de políticas de saúde na área de cirurgia de coluna no Brasil.

Vertebral artery injury in destabilized midcervical spine trauma; predisposing factors and proposed mechanism

BACKGROUND

By now it has been well established that vertebral artery injury (VAI) is associated with unstable cervical spine injuries resulting from blunt trauma. A more complete understanding of predisposing factors and the mechanism of injury in VAI should result in improved outcomes and reduced risk for patients with VAI associated with unstable cervical spine injury following blunt trauma. The authors report statistical outcome and hypothesis to more thoroughly examine the predisposing factors for VAI, of which management is controversial, in destabilized midcervical spine trauma.

METHODS

Ninety-one of 131 consecutive patients who underwent surgery for a traumatically destabilized subaxial cervical spine were included, and results were analyzed statistically by logistic regression.

RESULTS

Eighteen patients (19.8 % of 91 patients) had a VAI associated with midcervical spine trauma (C2-C6). In univariate statistical analysis, transverse foramen fracture (P = 0.002), facet dislocation (P = 0.014), and facet fracture (P = 0.001) were significant risk factors. However, only facet fracture was determined to be significant risk factor after multivariate analysis (P = 0.006, odds ratio 20.98). It is hypothesized that a VAI occurs in a midcervical spine injury when a facet fracture allows the bony compartment to impinge on the relatively narrow free space of the intervertebral foramen, which is also occupied by the cervical root.

CONCLUSION

A facet fracture is the most important risk factor for VAI in patients with a destabilized midcervical spine injury. Patients with a C2-C6 facet fracture may require a definitive evaluation with vertebral artery imaging.

[Brown-Sequard syndrom complicating a C6 teardrop fracture associate with an occult vertebral artery dissection: case report]

CASE REPORT

We report the case of a 27-year-old man, presenting a C6 tear-drop fracture associated to medullar contusion with a Brown-Sequard syndrome. An asymptomatic right vertebral artery dissection in its V2 portion was also discovered by the radiologic investigations. A surgical treatment and antiplatelet therapy were performed. The patient outcome was quite satisfactory.

Multi-detector row CT angiography of the neck in blunt trauma

Blunt cerebrovascular injury (BCVI) is uncommon but potentially catastrophic; 80% are caused by vehicle collisions. Ischemic events secondary to untreated BCVI are common, with high injury-specific mortality. This has led to implementation of screening programs based on mechanism of injury, clinical presentation, and injury patterns identified on noncontrast computed tomography (CT) imaging. The standard of reference for diagnosis is four-vessel digital subtraction angiography. Given its availably in trauma service institutions, use of multidetector CT angiography has increased. This article presents the evidence and the controversies surrounding its use. Available protocols, injury description, and grading, as well as potential pitfalls are reviewed.

Pediatric traumatic carotid, vertebral and cerebral artery dissections: a review

Traumatic cerebral dissections are rare but potentially dangerous conditions that through improved diagnostics have recently gained increased interest. However, there is still a significant lack of knowledge on the natural history, as well as on the best treatment options. Most of the literature on this topic consists of case reports and retrospective studies with no prospective randomized controlled studies. In our review, we highlight the fact that there is no level 1 evidence for the natural history of cerebral dissections or for the best treatment. We present 26 case studies derived from 70 pediatric patients affected by dissections, occlusions, and pseudoaneurysms.

Imaging of carotid arterial diseases with contrast-enhanced ultrasound (CEUS)

Carotid duplex ultrasound is the standard of care for the initial diagnosis of carotid artery bifurcation diseases. But in difficult examinations, carotid abnormalities are commonly encountered and may represent a diagnostic challenge in patients with clinical symptoms as well as in the follow up after carotid endarterectomy or carotid artery stenting. Contrast enhanced ultrasound (CEUS) with low mechanical index (low MI) is a promising new method in the diagnosis and follow up of pathological carotid diseases. Unlike most contrast agents used for magnetic resonance imaging or computed tomography, the microbubbles used in CEUS with SonoVue(®) remain within the vascular space and hence can be used to study vascular disease. In addition to improving current carotid structural scans, CEUS has potential to improve or add extra information on carotid arterial diseases. This review describes the current carotid duplex ultrasound examination and compares the pathological findings with CEUS.

Management and outcomes of patients undergoing surgery for traumatic cervical fracture-subluxation associated with an asymptomatic vertebral artery injury

STUDY DESIGN

Retrospective clinical series.

OBJECTIVE

To evaluate the management and outcomes of patients with unilateral, asymptomatic vertebral artery occlusion (VAO) undergoing surgery for cervical fractures associated with subluxation.

SUMMARY OF BACKGROUND DATA

The management of VAO is controversial with several treatment options available, including observation alone, antiplatelet therapy, or anticoagulation therapy.

METHODS

A chart review inclusive of the years 2004 to 2006 was performed to include patients who presented after nonpenetrating trauma with cervical fracture associated with subluxation requiring surgery. An associated asymptomatic VAO was also required for inclusion. Eight patients were identified.

RESULTS

Seven patients were male and the mean age was 26.8 years. Six patients suffered an associated spinal cord injury. Three patients underwent closed reduction before surgical stabilization. Five patients underwent open reduction with stabilization. No patient received treatment for VAO before reduction. Postoperative treatment for VAO was variable, with 5 of 8 patients undergoing observation alone. The remaining 3 patients were treated with aspirin therapy, although 1 patient received heparin intravenously for 1 day. None of the patients experienced an ischemic complication.

CONCLUSIONS

Reduction of a fracture, whether closed or open, without treatment of an associated asymptomatic VAO seems safe. Postoperative management of VAO consisting of either observation alone or aspirin therapy also seems to be a safe option.

Traumatic vertebral artery dissection and Wallenberg syndrome after a motorcycle collision

Wallenberg syndrome is also called lateral medullary syndrome or posterior inferior cerebellar artery syndrome. The clinical presentations include ipsilateral Horner syndrome, ipsilateral cerebellar signs, and the hypalgesia of ipsilateral face and contralateral body. A considerable number of cases of Wallenberg syndrome were reported to be associated with vertebral artery dissection (VAD). Nowadays, the preferred imaging tool comes down to magnetic resonance imaging because it provides high spatial resolution, which is especially important for assessment of lesions in posterior fossa. The optimal treatment of VAD remains controversial. Most patients receive conservative treatments with anticoagulants or antiplatelet drugs. Overall, most cases have good prognosis. However, the rarity and various presentations of VAD may challenge emergency physicians in making correct diagnosis in the emergency department. Hence, maintaining a high index of suspicion is needed for an early diagnosis, especially in young people without risk factors attributing to cerebrovascular accident.

Vertebral artery injuries associated with cervical spine injuries: a review of the literature

STUDY DESIGN

Literature review.

OBJECTIVE

To determine the incidence of vertebral artery injuries (VAIs) in association with cervical spine trauma and investigate the optimum diagnostic and treatment protocols.

SUMMARY OF BACKGROUND DATA

VAIs may result from cervical spine trauma and have the potential to cause cerebral, brainstem, and even spinal cord ischemia. Screening and treatment for traumatic VAI are very controversial, with conflicting recommendations within the trauma and spine literature.

METHODS

A literature review was performed to identify publications pertaining to VAIs associated with cervical spine trauma. These publications were evaluated to determine the incidence, radiographic evaluation, and treatment options of VAIs.

RESULTS

Approximately 0.5% of all trauma patients will have a VAI, and 70% of all traumatic VAIs will have an associated cervical spine fracture. Cervical spine translation injuries and transverse foramen fractures are most commonly cited as having a significant association with VAIs. The incidence of neurologic deficits secondary to VAI ranges from 0% to 24% in published series that incorporate a screening protocol for asymptomatic patients. Catheter angiography has been the gold standard for the diagnosis of VAIs; however, new 16-slice computed tomography angiography seems to have sensitivity and specificity close to that of catheter angiography. Treatment options include observation, antiplatelet agents, anticoagulation, and endovascular treatments. Although some authors have advocated antithrombotic therapy for most asymptomatic VAIs, there is a lack of class I evidence to support any strong guidelines for treatment.

CONCLUSIONS

VAIs can occur in association with cervical spine trauma and have the potential for neurological ischemic events. Screening for and treatment of asymptomatic VAIs may be considered, but it is unclear based on the current literature whether these strategies improve outcomes.

[Asymptomatic blunt vertebral artery injury after cervical spine nonpenetrating trauma]

OBJECTIVE

To show the possibility of vertebral injury after cervical spine trauma.

METHOD

We observed 2 cases of asymptomatic thrombosis of the vertebral artery after cervical fracture.

DISCUSSION

Thrombosis of the vertebral artery is acute in 20% of cases of cervical trauma. It may be asymptomatic. Magnetic resonance angiography is the best noninvasive investigation for such cases to systematically detect the complication. Treatment with anticoagulants or antiaggregants should be initiated.

Vertebral artery injury after blunt cervical trauma: an update

BACKGROUND

Vertebral artery injury (VAI) after blunt cervical trauma has been considered to be rare. The incidence of VAI has increased dramatically within the last decade after a heightened awareness of this entity on the part of spine surgeons. Diagnostic or therapeutic guidelines for VAI have not been established fully, however.

METHODS

A review of the literature published between 1990 and 2004 was conducted.

RESULTS

The incidence of VAI among total blunt trauma admissions ranged from 0.20% to 0.77%. Most VAI patients remained asymptomatic, but sudden unexpected deterioration was often reported. Distraction/extension, distraction/flexion, and lateral flexion injuries were the major mechanisms of injury. Dissection and occlusion were the frequent vascular injury patterns. Facet joint dislocations and the fractures extending into the transverse foramen were the spine injury patterns closely associated with VAI. Digital subtraction angiography was the most sensitive imaging study, but because of invasiveness, its role as a screening study remained questionable. Neuroradiological intervention was used successfully to treat hemorrhagic VAI and progressing vertebrobasilar stroke. Systemic anticoagulation with heparin was the preferred treatment for mild ischemia. Treatment of asymptomatic patients has been controversial because the natural history of VAI has not been elucidated. Prophylactic anticoagulation with heparin or the use of antiplatelet agents was advocated in recent studies.

CONCLUSIONS

Preemptive treatment may be reasonable in selected patients considering the devastating potentials of VAI. The potential risks of heparin or antiplatelet agents in relation to early cervical spine surgery have not been addressed fully, however, and spine surgeons have to weigh the risk and benefit of such treatment cautiously.

Traumatically induced vertebral artery occlusion associated with cervical spine injuries: prospective study using magnetic resonance angiography

STUDY DESIGN

A prospective study using magnetic resonance angiography (MRA) on a consecutive cohort of patients with cervical spine injuries.

OBJECTIVE

To investigate clinical and radiographic features of vertebral artery injury/occlusion associated with nonpenetrating cervical spine trauma.

SUMMARY OF BACKGROUND DATA

With the popularization of MRA, vertebral artery injury has been a common complication of cervical spine trauma. However, detailed clinical features such as restoration of blood flow in occluded vessels and collateral circulation have not been fully evaluated.

METHODS

During a 2-year period, 64 consecutive patients with cervical spine fractures and/or dislocations were prospectively evaluated for patency of the vertebral artery and collateral circulation. Extracranial and intracranial MRAs were conducted at initial injury and follow-up.

RESULTS

Vertebral artery occlusion occurred in 11 patients, including 10 with unilateral and 1 with bilateral. Only the patient with bilateral occlusion was symptomatic but had no permanent neurologic deficit as a result of brain ischemia. He had complete circle of Willis, which provides sufficient collateral blood supply from anterior circulation. Follow-up MRAs revealed restoration of blood flow in occluded vessel(s) in 3 patients. All of them had compressive injuries.

CONCLUSIONS

The incidence of traumatically induced vertebral artery occlusion was 17.2%. The potential for blood flow restoration was higher in compressive injuries than in distractive injuries. The mechanism of occlusion in compressive injuries is likely to be vasospasm or minor artery dissection, which may cause reversible occlusion because vessels are subjected to relatively minor stretching in compressive injuries. Vertebral artery occlusion was rarely symptomatic because of sufficient collateral blood supply through not only contralateral vertebral artery but also the circle of Willis.

Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty

Growing evidence supports the effectiveness of manual therapy interventions in patients with neck pain; however, considerable attention has also been afforded to the potential risks such as vertebrobasilar insufficiency (VBI). Despite the existence of guidelines advocating specific screening procedures, research does not support the ability to accurately identify patients at risk. The logical question becomes, "How does one proceed in the absence of certainty?" Given the lack of clear direction for decision making in the peer-reviewed literature, this commentary discusses the uncertainties that exist regarding the ability to identify patients at risk for VBI. The authors hope that this commentary adds additional perspective on manual therapy decision-making strategies in the presence of uncertainty.

Traumatic vertebral artery dissection in a child with brachial plexus injury

Traumatic vertebral artery dissection is an unusual event in children, but early recognition and treatment are important to prevent neurological deficits. The authors present a case of a 4-year-old boy with a traumatic extracranial vertebral artery dissection, who suffers from left arm monoplegia due to brachial plexus injury.

Higher calpastatin levels correlate with resistance to calpain-mediated proteolysis and neuronal apoptosis in juvenile rats after spinal cord injury

While the average age for patients admitted with spinal cord injury is 32 years, patients under the age of 16 account for 5% of spinal cord injured persons. For these younger patients, an increased mortality up to 24 h post-injury has been reported, however, survivors may regain more function than their adult counterparts, suggesting that age may play a role in injury tolerance. While the use of growth factors as a therapy for spinal cord injury is well researched, the response of the developing cord to secondary injury has not been thoroughly investigated. Following spinal cord injury, Ca(2+) influx can activate enzymes such as calpain, a Ca(2+)-dependent protease, which plays a role in the pathogenesis of spinal cord injury in rats. The present investigation revealed that following spinal cord injury, calpain upregulation was significantly less (15.3%) in the 21-day-old rats than in either 45-day-old (70%) or 90-day-old (99.6%) rats, as shown by Western blot and in situ immunofluorescent studies. Expression of the endogenous calpain inhibitor, calpastatin, was significantly higher in juvenile rats than adult rats. Juvenile rats with spinal cord injury also showed a reduced Bax:Bcl-2 ratio (4:1 vs. 6:1), reduced caspase-3 staining, reduced myelin loss (3% vs. 18%), and less neuronal DNA damage, as compared to older rats. These results suggest that increased calpastatin levels found in juvenile rats muted calpain activity and neuronal apoptosis, following spinal cord injury.

Herniation of a calcified cervical disc into the foramen transversarium in an 8-year-old child

STUDY DESIGN

Herniation of a calcified C3-C4 disc into the left foramen transversarium in a child is reported.

OBJECTIVE

To discuss the natural history and management of a calcified disc herniation into the foramen transversarium.

SUMMARY OF BACKGROUND DATA

Cervical disc calcification in children usually follows a benign course. Herniation of the calcified disc into the spinal canal has already been described. However, herniation into the foramen transversarium has never been reported.

METHODS

An 8-year-old girl presented with progressive neck pain and torticollis. Her neurologic examination was normal. She was treated using a head halter traction, analgesics, and muscle relaxants for 3 days, followed by the use of a soft cervical collar for 2 weeks.

RESULTS

Computed tomography scan showed a calcified C3-C4 disc with herniation into the C3 left foramen transversarium. Her symptoms subsided and she rapidly regained full range of motion of her neck after 3 days of conservative treatment. Magnetic resonance angiography done after 2 months did not show any residual compression of the left vertebral artery. After 3 months, the herniation had completely disappeared, whereas only a small central calcification remained in the C3-C4 disc space.

CONCLUSION

The natural history of cervical disc calcification is usually benign. A computed tomography scan can be performed for patients in whom a calcified disc herniation is suspected on the plain films. In this case of herniation into the foramen transversarium, magnetic resonance angiography was useful to evaluate the integrity of the vertebral arteries. Spontaneous resolution of the herniated disc and return to normal function can be expected with conservative treatment.

Management of vertebral artery injuries after nonpenetrating cervical trauma

DIAGNOSTIC

STANDARDS

There is insufficient evidence to support diagnostic standards.

GUIDELINES

There is insufficient evidence to support diagnostic guidelines.

OPTIONS

Conventional angiography or magnetic resonance angiography is recommended for the diagnosis of vertebral artery injury after nonpenetrating cervical trauma in patients who have complete cervical spinal cord injuries, fracture through the foramen transversarium, facet dislocation, and/or vertebral subluxation.

TREATMENT

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Anticoagulation with intravenous heparin is recommended for patients with vertebral artery injury who have evidence of posterior circulation stroke. Either observation or treatment with anticoagulation in patients with vertebral artery injuries and evidence of posterior circulation ischemia is recommended. Observation in patients with vertebral artery injuries and no evidence of posterior circulation ischemia is recommended.