Does CT Angiography Matter for Patients with Cervical Spine Injuries?

Clinical characteristics and outcomes of patients with concomitant cervical spine trauma and vertebral artery injury: A literature review and retrospective analysis

Study Design

Retrospective review of a single institution cohort.

Objective

To assess the injury characteristics and outcomes in patients who suffered trauma to the cervical spine and vertebral artery injury (VAI).

Methods

This was a retrospective study of patients admitted to our trauma center with osseous or ligamentous cervical spine injury and VAI. Imaging findings were reviewed to classify the fracture types and fracture extension into transverse foramina was noted. Electronic medical records were reviewed to capture the mechanism of injury, discharge disposition, neurologic status, and mortality. Kaplan-Meier analysis was performed to determine the mean survival time and cumulative survival rate.

Results

Ultimately, 30 patients were included for the analysis. The mean age was 56 years old (range: 18-91 years). There were four major subgroups of cervical injuries: unilateral facet fractures (9 patients, 30%), occipital-cervical junction fractures (15 patients, 50%), translation or distraction injuries (3 patients, 10%), and injuries without extension into transverse foramina (20 patients, 67%). Left-sided VAIs were more common than right-sided (60% vs. 37%). Twelve patients (40%) initially presented with neurological symptoms. Nine patients (30%) died by final follow-up; the mean survival time for the cohort was 704.5 days (95% confidence interval: 440.1-968.9 days).

Conclusion

The laterality of facet fractures and fractures extending into the transverse foramina are associated with VAI sidedness. Various mechanisms may account for injury presentation, including rotation and hyperflexion. Given that patients may initially present without neurologic deficits, it is recommended that cervical trauma protocols integrate computed tomography angiography to reduce morbidity and mortality.

New Imaging Modalities for Degenerative Cervical Myelopathy

INTRODUCTION

Degenerative cervical myelopathy (DCM) is defined as dysfunction of the spinal cord as a result of compression from degenerative changes to surrounding joints, intervertebral disks, or ligaments. Symptoms can include upper extremity numbness and diminished dexterity, difficulty with fine manipulation of objects, gait imbalance, and incoordination, and compromised bowel and bladder function. Accurate diagnosis and evaluation of the degree of impairment due to degenerative cervical myelopathy remain a challenging clinical endeavor requiring a thorough and accurate history, physical examination, and assessment of imaging findings.

METHODS

A narrative review is presented summarizing the current landscape of imaging modalities utilized in DCM diagnostics and the future direction of research for spinal cord imaging.

RESULTS AND DISCUSSION

Current imaging modalities, particularly magnetic resonance imaging and, to a lesser extent, radiographs/CT, offer important information to aid in decision making but are not ideal as stand-alone tools. Newer imaging modalities currently being studied in the literature include diffusion tensor imaging, MR spectroscopy, functional magnetic resonance imaging, perfusion imaging, and positron emission tomography. These newer imaging modalities attempt to more accurately evaluate the physical structure, intrinsic connectivity, biochemical and metabolic function, and perfusion of the spinal cord in DCM. Although there are still substantial limitations to implementation, future clinical practice will likely be revolutionized by these new imaging modalities to diagnose, localize, surgically plan and manage, and follow patients with DCM.

Cervical Computed Tomography Angiography Rarely Leads to Intervention in Patients With Cervical Spine Fractures

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate the impact of computed tomography angiography (CTA) in the management of trauma patients with cervical spine fractures by identifying high-risk patients for vertebral artery injury (VAI), and evaluating how frequently patients undergo subsequent surgical/procedural intervention as a result of these findings.

METHODS

All trauma patients with cervical spine fractures who underwent CTA of the head and neck at our institution between January 2013 and October 2017 were identified. Patients were indicated for CTA according to our institutional protocol based on the modified Denver criteria, and included patients with cervical fractures on scout CT. Those with positive VAI were noted, along with their fracture location, and presence or absence of neurological deficit on physical examination. Statistical analysis was performed and odds ratios were calculated comparing the relationship of cervical spine fracture with presence of VAI.

RESULTS

A total of 144 patients were included in our study. Of those, 25 patients (17.4%) were found to have VAI. Two patients (1.4%) with VAI underwent subsequent surgical/procedural intervention. Of the 25 cervical fractures with a VAI, 20 (80%), were found to involve the upper cervical region (4.2 OR, 95% CI 1.5-12.0; P = .007). Of the 25 who had a VAI, 9 were unable to undergo reliable neurologic examination. Of the remaining 16 patients, 5 (31.3%) had motor or sensory deficits localized to the side of the VAI, with no other attributable etiology.

CONCLUSIONS

Cervical spine fractures located in the region of the C1-C3 vertebrae were more likely to have an associated VAI on CTA. VAI should also be considered in cervical trauma patients who present with neurological deficits not clearly explained by other pathology. Despite a finding of VAI, patients rarely underwent subsequent surgical or procedural intervention.

Interobserver reliability of the Gehweiler classification and treatment strategies of isolated atlas fractures: an internet-based multicenter survey among spine surgeons

Purpose

Atlas (C1) fractures are commonly rated according to the Gehweiler classification, but literature on its reliability is scarce. In addition, evaluation of fracture stability and choosing the most appropriate treatment regime for C1-injuries are challenging. This study aimed to investigate the interobserver reliability of the Gehweiler classification and to identify whether evaluation of fracture stability as well as the treatment of C1-fractures are consistent among spine surgeons.

Methods

Computed tomography images of 34 C1-fractures and case-specific information were presented to six experienced spine surgeons. C1-fractures were graded according to the Gehweiler classification, and the suggested treatment regime was recorded in a questionnaire. For data analyses, SPSS was used, and interobserver reliability was calculated using Fleiss’ kappa (κ) statistics.

Results

We observed a moderate reliability for the Gehweiler classification (κ = 0.50), the evaluation of fracture stability (κ = 0.50), and whether a surgical or non-surgical therapy was indicated (κ = 0.53). Type 1, 2, 3a, and 5 fractures were rated stable and treated non-surgically. Type 3b fractures were rated unstable in 86.7% of cases and treated by surgery in 90% of cases. Atlas osteosynthesis was most frequently recommended (65.4%). Overall, 25.8% of type 4 fractures were rated unstable, and surgery was favoured in 25.8%.

Conclusion

We found a moderate reliability for the Gehweiler classification and for the evaluation of fracture stability. In particular, diverging treatment strategies for type 3b fractures emphasise the necessity of further clinical and biomechanical investigations to determine the optimal treatment of unstable C1-fractures.

Cervical Spine Fractures: Who Really Needs CT Angiography?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Compare a novel two-step algorithm for indicating a computed tomography angiography (CTA) in the setting of a cervical spine fracture with established gold standard criteria.

SUMMARY OF BACKGROUND DATA

As CTA permits the rapid detection of blunt cerebrovascular injuries (BCVI), screening criteria for its use have broadened. However, more recent work warns of the potential for the overdiagnosis of BCVI, which must be considered with the adoption of broad criteria.

METHODS

A novel two-step metric for indicating CTA screening was compared with the American College of Surgeons guidelines and the expanded Denver Criteria using patients who presented with cervical spine fractures to a tertiary-level 1 trauma center from January 1, 2012 to January 1, 2016. The ability for each metric to identify BCVI and posterior circulation strokes that occurred during this period was assessed.

RESULTS

A total of 721 patients with cervical fractures were included, of whom 417 underwent CTAs (57.8%). Sixty-eight BCVIs and seven strokes were diagnosed in this cohort. All algorithms detected an equivalent number of BCVIs (52 with the novel metric, 54 with the ACS and Denver Criteria, P = 0.84) and strokes (7/7, 100% with the novel metric, 6/7, 85.7% with the ACS and Denver Criteria, P = 1.0). However, 63% fewer scans would have been needed with the proposed screening algorithm compared with the ACS or Denver Criteria (261/721, 36.2% of all patients with our criteria vs. 413/721, 57.3% with the ACS standard and 417/721, 57.8%) with the Denver Criteria, P < 0.0002 for each).

CONCLUSION

A two-step criterion based on mechanism of injury and patient factors is a potentially useful guide for identifying patients at risk of BCVI and stroke after cervical spine fractures. Further prospective analyses are required prior to widespread clinical adoption.

LEVEL OF EVIDENCE

4.

Treatment of Atlas Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Narrative review and expert recommendation.

OBJECTIVES

To establish treatment recommendations for atlas fractures based on the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma.

METHODS

Neither high-level evidence studies comparing conservative and operative management nor studies matching different operative treatment strategies exist. This recommendation summarizes the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma with regard to the treatment of atlas fractures.

RESULTS

Most atlas fractures are the result of compression forces. A valuable morphological classification system has been described by Gehweiler. For an adequate diagnosis, a computed tomography is mandatory. To distinguish between stable and unstable type 3 injuries, it is necessary to evaluate the integrity of the transverse atlantal ligament (TAL) with magnetic resonance imaging and to classify the TAL lesions. The majority of atlas fractures are stable and will be successfully managed conservatively. Unstable atlas fractures (type 3b and sagittal split type 4 fractures) should be treated by surgical stabilization. Unstable atlas fractures (type 3b) with a midsubstance ligamentous disruption or severely dislocated ligamentous bony avulsions of the TAL can successfully be treated by a C1/2 fusion. Unstable atlas fractures (type 3b) with a moderately dislocated ligamentous bony avulsion of the TAL and sagittal split type 4 fractures may be treated by atlas osteosynthesis only.

CONCLUSIONS

Whereas the majority of atlas fractures can be managed conservatively, in specific fracture patterns surgical treatment strategies have become the standard of care.

Atlas Fractures and Atlas Osteosynthesis: A Comprehensive Narrative Review

Most atlas fractures are the result of compression forces. They are often combined with fractures of the axis and especially with the odontoid process. Multiple classification systems for atlas fractures have been described. For an adequate diagnosis, a computed tomography is mandatory. To distinguish between stable and unstable atlas injury, it is necessary to evaluate the integrity of the transverse atlantal ligament (TAL) by magnetic resonance imaging and to classify the TAL lesion. Studies comparing conservative and operative management of unstable atlas fractures are unfortunately not available in the literature; neither are studies comparing different operative treatment strategies. Hence all treatment recommendations are based on low level evidence. Most of atlas fractures are stable and will be successfully managed by immobilization in a soft/hard collar. Unstable atlas fractures may be treated conservatively by halo-fixation, but nowadays more and more surgeons prefer surgery because of the potential discomfort and complications of halo-traction. Atlas fractures with a midsubstance ligamentous disruption of TAL or severe bony ligamentous avulsion can be treated by a C1/2 fusion. Unstable atlas fractures with moderate bony ligamentous avulsion may be treated by atlas osteosynthesis. Although the evidence for the different treatment strategies of atlas fractures is low, atlas osteosynthesis has the potential to change treatment philosophies. The reasons for this are described in this review.

Pearls for Interpreting Computed Tomography of the Cervical Spine in Trauma

The high morbidity and mortality associated with cervical spine injuries makes identification and classification essential. It is important to have a systematic approach to evaluation, especially in the trauma setting with other distracting injuries. Understanding the anatomy and biomechanics enables rapid and accurate interpretation of images. In severe trauma and in patients with rigid spinal disease, the classic patterns of injury may be difficult or impossible to recognize. This article provides an approach to acquiring and interpreting cervical spine images in the setting of acute trauma and reviews the classic patterns of injury.