Vertebral Artery Injury in the Cervical Spine: Anatomy, Diagnosis, and Management

Serious adverse events associated with conservative physical procedures directed towards the cervical spine: A systematic review

BACKGROUND

Previous reviews on serious adverse events (SAEs) following physical interventions involving the neck have focused on vascular SAEs or those related to cervical manipulation.

OBJECTIVE

To review the evidence for all serious adverse events associated with any physical cervical procedures and describe SAE characteristics.

METHODS

Searches were conducted in PubMed, EMBASE, CINAHL, Scopus, Cochrane, Web of Science and Index to Chiropractic Literature from inception to May 2023 for studies reporting characteristics of SAE following any neck intervention and patient demographics.

RESULTS

Two hundred and thirty-three studies describing 334 SAE cases were identified. Forty-one were reported in the last 5 years. The results confirmed findings of past reviews with most events being vascular (58%) and mainly arterial dissection or vertebral artery related and the majority involving manipulation (75%). However lesser-known SAES ie neurological (25%), combined vascular/neurological (12%) and others (5%) which included cases such as cerebrospinal fluid leaks, phrenic nerve palsies and retinal detachments were identified. Further, some followed procedures such as vestibular testing, gentle mobilization, exercises, acupuncture or even massage. Initial symptoms included sharp increases in headache/neck pain, nausea, vomiting, dizziness and altered sensation, during treatment or within 48 h, often preceding neurological signs. Most recovered favourably (62%), 16% with disability, 6% died, the rest were unspecified.

CONCLUSION

Most SAEs were vascular and associated with manipulation but awareness of potential neurological and orthopaedic injuries and other procedures should be raised. Monitoring for early signs of SAEs for up to 48 h post-intervention is advisable if a SAE is suspected.

Is Vertebral Artery Injury After Blunt Cervical Spine Trauma an Incidental Finding?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To understand the associations between vertebral artery injury (VAI) and adverse events in patients sustaining blunt cervical spine trauma.

SUMMARY OF BACKGROUND DATA

To date, the impact of VAI on adverse events, and by extension, clinical outcomes has been extracted from small patient cohorts and have not allowed definitive conclusions.

METHODS

Adult patients with cervical vertebral, ligamentous, or neurological trauma in the National Trauma Data Bank from 2016 to 2017 were included in the study. Demographic information (age, sex, and race), injury-specific information (mechanism, severity), patient health information, and presence of a VAI were collected as explanatory variables. Response variables included development of adverse events [DVT/PE, myocardial infarction (MI), stroke, hemorrhage, or neurological deficit] length of stay (LOS) and unplanned ICU admission or surgical procedure. Multivariable regression was used to calculate the risk-adjusted effect of vertebral artery injury on the presence of adverse and unplanned events as well as its relationship with LOS.

RESULTS

Totally, 128,908 patients with cervical trauma were reviewed, of which 5300 had VAI. Of the patients with VAI, 187 (3.5%) patients had a MI, 156 (2.9%) had a PE/DVT, 196 (3.7%) had a stroke, 1392 (26.3%) had neurological injury, and 443 (8.4%) had an unplanned operative procedure or ICU admission. After risk-adjustment, VAI was associated with a >2-fold increased risk of increased LOS and ICU LOS (P<0.001), as well as greater than a 2-fold increased risk of MI, PE/DVT, stroke, and neurological injury (P<0.001).

CONCLUSIONS

Our study documented a higher rate of concomitant VAI in blunt cervical trauma than previously reported. VAI is a hallmark of a more severe or higher energy mechanism of injury and is associated with increased adverse events and LOS in the hospital/ICU. In addition, these data suggest that, in older patients, concomitant VAI is associated with adverse outcomes independent of mechanism of injury.

LEVEL OF EVIDENCE

Step II-diagnostic study.

Intraoperative Vertebral Artery Injury: Evaluation, Management, and Prevention

Vertebral artery injury (VAI) is a serious and potentially life-threatening injury that is encountered with trauma to the cervical spine and less frequently during surgery. VAI can occur during either anterior or posterior cervical approaches or instrumentation and often involves anomalous courses of the artery. Although the incidence is rare, serious consequences including fistula formation, thrombosis, pseudoaneurysm development, cerebral ischemia, hemorrhage, and death may occur. Management of VAI can be divided into prevention, including review of preoperative imaging with knowledge of the anatomic course, utilization of surgical landmarks intraoperatively, and prompt recognition and management when injury is encountered.

Multiple Myeloma Treatment Challenges: A Case Report of Vertebral Artery Pseudoaneurysm Complicating Occipitocervical Arthrodesis and a Review of the Literature

Multiple myeloma is a hematological neoplasm that frequently affects the spinal column. Less than a fifth of this vertebral involvement corresponds to the cervical spine and cranio-cervical junction. When there is instability or neurological involvement due to compression or deformity, approaches for anterior decompression and occipitocervical stabilization are required. The correct managment of vertebral artery aneurysm associated with occipitocervical arthrodesis requires extensive knowledge of anatomy and pathology. We present a case of a vertebral pseudoaneurysm that occurred late after the resection of a C1-C2 vertebral body multiple myeloma lesion managed with endonasal endoscopic approach and posterior occipitocervical arthrodesis as well as a systematic review of the related literature. The patient recovered well, without major neurological deficits.

Delayed Hemorrhage Followed by Vertebral Artery Injury during Cervical Anterior Controllable Antedisplacement and Fusion Surgery: Case Report and Literature Review

Background

Vertebral artery injury (VAI) during cervical spine surgery is rare. Anterior controllable ante‐displacement and fusion (ACAF) surgery is a novel technique for treating degenerative cervical spine disorders, especially ossification of the posterior longitudinal ligament. To date, there have been no reports of VAI during cervical ACAF surgery. Here, we report a rare case of perioperative complication of VAI during ACAF surgery. The available English literature that provides treatment instructions were reviewed.

Case Presentation

A patient diagnosed with mixed ossification of the posterior longitudinal ligament (OPLL) underwent ACAF surgery from C2–C6. Two level transverse foramina were ruptured, and severe bleeding was encountered during ACAF osteotomy. Hemostatic tamponade was performed using bone waxes. The patient had delayed hemorrhage on postoperative day 6. Emergence angiography revealed two vertebral artery pseudoaneurysms in the ruptured transverse foramina. A balloon‐expandable covered stent was deployed to treat the pseudoaneurysm. The patient recovered without complications.

Conclusion

ACAF surgery is a good choice for multiple‐level OPLL disease, but special attention should be paid to VAI in the perioperative period. Intraoperative tamponade with bone wax and postoperative digital subtraction angiography (DSA) are effective in preventing disaster‐related hemorrhage.

Efficiency of Long Lateral Mass Screws

Introduction: Lateral mass screws (LMS) have been widely used for the posterior fusion of the cervical spine. Even though LMS are safe, the screws are short and postoperative fixation is uncertain. Therefore, we measured and reported a technique using long lateral mass screws (LLMS), a new method of screw insertion, using a Zed spine from LEXI (Tokyo, Japan). Materials and Methods: In this study, we evaluated the outcomes of 35 patients who underwent surgery using LLMS at our hospital from 2019 to 2021. Operative time, blood loss, complications, inserted screw length, screw length based on gender differences, and screw deviation rate were evaluated. The Mann−Whitney U test was used to determine the gender differences in screw length. Screw deviation was evaluated by postoperative CT and a Zed spine to determine the screw insertion angle. Results: The mean operative time was 185 ± 51 min (120−327 min), and the mean blood loss was 236 ± 316 g (10−1720 g). The total number of screws was 183. The screw length was 22.2 (16−28) mm for males and 20.8 (16−28) mm for females, with an average length of 21 ± 2.7 mm. No gender differences were observed in terms of screw length (p > 0.01 NS). The number of deviated screws above G3 was one in the third cervical vertebra, three in the fourth cervical vertebra, one in the fifth cervical vertebra, and one in the sixth cervical vertebra. The number of deviated screws was 6 out of 183, and the deviation rate was 3.2%. Conclusions: In this study, the LLMS deviation rate was 3.2%, and strong fixation was possible without any complications. We measured the screw length and screw deviation rate in cases in which LLMS were actually inserted.

Penetrating vertebral artery injury treated by combining the "zone" approach and imaging tests: A case report

Patients with vertebral artery injury from penetrating neck trauma may not present with signs of vascular injury because of anatomical characteristics and concomitant conditions, such as hypothermia and shock. If patients are hemodynamically stable, imaging tests should be performed to examine the posterior components, including the vertebral artery.