Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center

Traumatic Vertebral Artery Injury: Diagnosis, Natural History, and Key Considerations for Management

Vertebral artery injury (VAI) is a known complication of blunt cervical spine trauma with a potential risk of stroke. Factors including cervical bony injury, spinal cord injury, and overall trauma severity have been linked to an increased risk of VAI. Despite its prevalence, there is little consensus on various aspects of this pathology, including its initial screening, diagnostic approaches, and therapeutic strategies. A recent systematic review and meta-analysis from our group highlighted the dynamic nature of vertebral artery occlusion, revealing the underrecognized recanalization rates and potential stroke risks associated with delayed recanalization. While anticoagulant and/or antiplatelet therapy (ACAP) remains the cornerstone of VAI management, treatment is often complicated by co-existing injuries, such as intracranial hemorrhage or cervical trauma, which may preclude or delay ACAP usage or necessitate surgical intervention. This comprehensive narrative review synthesizes the latest evidence on VAI and associated ischemic sequelae, with the goal of elucidating its pathophysiology and natural history, summarizing current data on screening and diagnosis, and exploring key considerations for medical and endovascular management.

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.

Fractured cervical spine, dissected vertebral artery, and life-threatening stroke: A challenging case report and literature review

INTRODUCTION

Vertebral artery injury (VAI) following blunt trauma can lead to acute or delayed life-threatening posterior fossa ischemic stroke. Its management raises controversial issues and is still open to debate.

MATERIAL & METHOD

We report the case of a 48-year-old male who presented a life-threatening posterior circulation ischemic stroke, secondary to a vertebral artery dissection caused by a cervical spine fracture. This case was successfully managed through intravenous thrombolysis and endovascular thrombectomy followed by antiplatelet therapy and an anterior cervical discectomy and fusion. At the one-year follow-up, the patient had no persisting deficit and was back working as a policeman.

CONCLUSION

Rapid management of patients with dramatic clinical presentation can lead to full recovery. Implications include a systematic screening of blunt trauma VAI through computed tomography angiography when dealing with high-risk cervical spine fractures; patients harboring both a cervical spine fracture and a VAI must be transferred to a tertiary referral hospital able to deal both with strokes and cervical spine surgery to ensure responsiveness in case of stroke.

A Systematic Review and Meta-Analysis of Vertebral Artery Injury After Cervical Spine Trauma

STUDY DESIGN

Systematic Review and Meta-Analysis.

OBJECTIVE

Identify the incidence, mechanism of injury, investigations, management, and outcomes of Vertebral Artery Injury (VAI) after cervical spine trauma.

METHODS

A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines (PROSPERO-ID CRD42021295265). Three databases were searched (PubMed, SCOPUS, Google Scholar, CINAHL PLUS). Incidence of VAI, investigations to diagnose (Computed Tomography Angiography, Digital Subtraction Angiography, Magnetic Resonance Angiography), stroke incidence, and management paradigms (conservative, antiplatelets, anticoagulants, surgical, endovascular treatment) were delineated. Incidence was calculated using pooled proportions random effects meta-analysis.

RESULTS

A total of 44 studies were included (1777 patients). 20-studies (n = 503) included data on trauma type; 75.5% (n = 380) suffered blunt trauma and 24.5% (n = 123) penetrating. The overall incidence of VAI was .95% (95% CI 0.65-1.29). From the 16 studies which reported data on outcomes, 8.87% (95% CI 5.34- 12.99) of patients with VAI had a posterior stroke. Of the 33 studies with investigation data, 91.7% (2929/3629) underwent diagnostic CTA; 7.5% (242/3629) underwent MRA and 3.0% (98/3629) underwent DSA. Management data from 20 papers (n = 475) showed 17.9% (n = 85) undergoing conservative therapy, anticoagulation in 14.1% (n = 67), antiplatelets in 16.4% (n = 78), combined therapy in 25.5% (n = 121) and the rest (n = 124) managed using surgical and endovascular treatments.

CONCLUSION

VAI in cervical spine trauma has an approximate posterior circulation stroke risk of 9%. Optimal management paradigms for the prevention and management of VAI are yet to be standardized and require further research.

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.

Massive Hemorrhage Associated With Upper Cervical Vertebral Fracture Treated Successfully With Transcatheter Arterial Embolization: A Case Report

Blunt vertebral artery injuries (BVAI) associated with cervical spine fractures are often problematic due to symptoms of occlusion. Denver grade V cases, in which the vertebral artery is transected, are rare but often fatal, and treatment has rarely been reported. We encountered a case of hemorrhagic shock due to an injury to a branch of the vertebral artery associated with an upper cervical spine fracture. Transcatheter arterial embolization was performed successfully to achieve hemostasis, requiring superselective arterial embolization to preserve the main trunk of the vertebral artery. It is important to be aware that vascular injuries to the branch vessels as well as the main trunk can cause complications.

The Incidence, Characteristics and Outcomes of Vertebral Artery Injury Associated with Cervical Spine Trauma: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

Vertebral Artery Injury (VAI) is a potentially serious complication of cervical spine fractures. As many patients can be asymptomatic at the time of injury, the identification and diagnosis of VAI can often prove difficult. Due to the high rates of morbidity and mortality associated with VAI, high clinical suspicion is paramount. The purpose of this review is to elucidate incidence, diagnosis, treatment and outcomes of VAI associated with cervical spine injuries.

METHODS

A systematic search of electronic databases was performed using 'PUBMED', 'EMBASE','Medline (OVID)', and 'Web of Science, for articles pertaining to traumatic cervical fractures with associated VAI.

RESULTS

24 studies were included in this systematic review. Data was included from 48 744 patients. In regards to the demographics of the focus groups that highlighted information on VAI, the mean average age was 46.6 (32.1-62.6). 75.1% (169/225) were male and 24.9% (56/225) were female. Overall incidence of VAI was 596/11 479 (5.19%). 190/420 (45.2%) of patients with VAI had fractures involving the transverse foramina. The right vertebral artery was the most commonly injured 114/234 (48.7%). V3 was the most common section injured (16/36 (44.4%)). Grade I was the most common (103/218 (47.2%)) injury noted. Collective acute hospital mortality rate was 32/226 (14.2%), ranging from 0-26.2% across studies.

CONCLUSION

VAI secondary to cervical spine trauma has a notable incidence and high associated mortality rates. The current available literature is limited by a low quality of evidence. In order to optimise diagnostic protocols and treatment strategies, in addition to reducing mortality rates associated with VAI, robust quantitative and qualitative studies are needed.

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.

Vertebral artery dissection in acute cervical spine trauma

Objective:

The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST).

Methods:

A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of fracture and subluxation were studied in detail with respect to the presence or absence of VAD.

Results:

Patients were divided in subsets of axial spine injury and subaxial spine injury. Subgroup and group analysis was performed and computerized tomography angiogram, MR angiogram and T1/T2 axial scans were studied to identify VAD, an incidence of 14.1% was found. Patients having infarcts in posterior circulation were also identified.

Conclusion:

There is a significant contribution of biomechanics of CST and evolution of VAD. This is an important consideration to prevent significant morbidity and mortality. Hence, a diagnostic algorithm which can be applied in any hospital setup is the need of the hour.

Vertebral artery occlusion associated with blunt traumatic cervical spine injury

Aim

Vertebral artery injury associated with blunt traumatic cervical spine injury sometimes causes severe cerebellar and brain stem infarction. No treatment guidelines for vertebral artery injury aimed at preventing stroke have been decided. We have conducted endovascular embolization in patients with up to Denver grade IV cerebrovascular injury complicated by unstable cervical spine injury before open reduction and fixation surgery. The purpose of this study was to validate the clinical course of vertebral artery injury and especially endovascular treatment for grade IV patients in our hospital.

Methods

Participants comprised of patients diagnosed as having traumatic cervical spine injury in our hospital between January 2015 and April 2018. Among these patients, we selected those with vertebral artery injury and retrospectively examined the background characteristics of the patients, details of treatment, and complications with or without stroke.

Results

Traumatic cervical spine injury was diagnosed in 89 patients. Among these patients, 15 (16.7%) showed a complicating vertebral artery injury. Mean age was 62.6 years, and almost 50% of the patients were injured in falls. Three types of cervical spine injury caused vertebral artery injury: subluxation, Jefferson fracture, and fracture involving the foramen transversarium. Vertebral artery injury was classified as grade IV in 12 patients, of whom nine required spinal surgery. All patients who needed spinal surgery underwent endovascular therapy before surgery, and none experienced a stroke.

Conclusion

Endovascular embolization of the vertebral artery occlusion in patients with unstable cervical spine injury before open reduction and fixation surgery can be a treatment option to prevent stroke.

Antithrombotic choice in blunt cerebrovascular injuries: Experience at a tertiary trauma center, systematic review, and meta-analysis

BACKGROUND

Blunt cerebrovascular injuries (BCVIs) may occur following trauma and lead to ischemic stroke if untreated. Antithrombotic therapy decreases this risk; however, the optimal agent has yet to be determined in this population. The aim of this study was to compare the risk-benefit profile of antiplatelet (AP) versus anticoagulant (AC) therapy in rates of ischemic stroke and hemorrhagic complications in BCVI patients.

METHODS

We performed a retrospective review of BCVI patients at our tertiary care Trauma hospital from 2010 to 2015, and a systematic review and meta-analysis of the literature. The OVID Medline, Embase, Web of Science, and Cochrane Library databases were searched from inception to September 16, 2019. References of included publications were searched manually for other relevant articles. The search was limited to articles in humans, in patients 18 years or older, and in English. Studies that reported treatment-stratified clinical outcomes following AP or AC treatment in BCVI patients were included. Exclusion criteria included case reports, case series with n < 5, review articles, conference abstracts, animal studies, and non-peer-reviewed publications. Data were extracted from each study independently by two reviewers, including study design, country of origin, sex and age of patients, Injury Severity Score, Biffl grade, type of treatment, ischemic stroke rate, and hemorrhage rate. Pooled estimates using odds ratio (OR) were combined using a random-effects model using a Mantel-Hanzel weighting. The main outcome of interest was rate of ischemic stroke due to BCVI, and the secondary outcome was hemorrhage rate based on AC or AP treatment.

RESULTS

In total, there were 2044 BCVI patients, as reported in the 22 studies in combination with our institutional data. The stroke rate was not significantly different between the two treatment groups (OR, 1.27; 95% confidence interval, 0.40-3.99); however, the hemorrhage rate was decreased in AP versus AC treated groups (OR, 0.38; 95% confidence interval, 0.15-1.00).

CONCLUSION

Based on this meta-analysis, both AC and AP seem similarly effective in preventing ischemic stroke, but AP is better tolerated in the trauma population. This suggests that AP therapy may be preferred, but this should be further assessed with prospective randomized trials.

LEVEL OF EVIDENCE

Review article, level II.

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.

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.

Best practice guidelines for blunt cerebrovascular injury (BCVI)

Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1-2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed.

The Clinical Implications of Adding CT Angiography in the Evaluation of Cervical Spine Fractures: A Propensity-Matched Analysis

BACKGROUND

Advanced-imaging screening for asymptomatic blunt cerebrovascular injury is controversial. Vertebral artery injury (VAI) is most commonly associated with cervical spine fracture, and many guidelines advocate indiscriminate screening for all cervical spine fractures. The purpose of this study was to determine whether the addition of computed tomographic angiography (CTA) results in a change in management for patients with cervical spine fractures.

METHODS

Adult patients treated for acute cervical spine fractures after blunt trauma during the period of 2000 to 2015 were retrospectively identified. Patients who sustained a penetrating trauma or who had a history of neoplasm or prior cervical spine surgery were excluded. The following variables were recorded: age, biologic sex, race, medical comorbidities, Injury Severity Score (ISS), mechanism of injury, whether CTA of the neck was obtained in addition to computed tomography (CT), cervical spine fracture characteristics and treatment, and the presence of VAI. Recommendation for a change in management with antithrombotic therapy was the primary outcome measure. Detection of stroke and of VAI were secondary outcomes. Propensity-score matching was performed to negate the significant differences in baseline demographic and clinical characteristics.

RESULTS

A total of 3,943 patients were screened for eligibility, and 2,831 patients met the inclusion criteria. Propensity-score matching yielded 1 cohort who underwent CT + CTA and 1 cohort who underwent CT alone, both with 644 patients and equivalent demographic and clinical characteristics. CTA identified definite or indeterminate VAI in 113 patients, and for 62 patients, antithrombotic therapy was recommended. In the CT-alone cohort, VAI was identified in 11 patients incidentally through other imaging, and antithrombotic therapy was recommended for 8 patients. Two patients in the CT + CTA group had major adverse bleeding events as a result of the initiation of antithrombotic therapy. There were no preventable strokes in either group.

CONCLUSIONS

The addition of CTA increased detection of VAI and the recommendation for antithrombotic therapy. There were no preventable strokes in either cohort and 2 major adverse bleeding events attributable to the recommended pharmacologic antithrombotic therapy. Nonselective screening is not warranted and should be limited to a high-risk subset of patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

STUDY DESIGN

Narrative literature review and expert recommendation.

OBJECTIVE

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

METHODS

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 axis ring fractures based on a narrative literature review.

RESULTS

Typical "hangman's fractures" with bilateral separation of the neural arch from C2 and atypical "hangman's fractures" with irregular fracture morphology are described. Computed tomography is the "gold" standard used to detect and analyse these fractures adequately. Furthermore, the detection of vertebral artery integrity is necessary. To classify axis ring fractures, the Levine-Edwards or Josten classification is recommended. In particular, the integrity of the C2/3 disc and the integrity of the anterior longitudinal ligament are used to determine the treatment strategy. While Levine-Edwards type I and type IIA (Josten type 1 and 2) fractures should be treated conservatively, Levine type II and type III (Josten type 3 and 4) fractures should be treated operatively. Levine-Edwards type II fractures will be predominately treated by anterior C2/3 fusion. Levine-Edwards type III fractures have to be primary reduced, if an anterior fusion is planned (anterior cervical discectomy and fusion [ACDF] C2/3). If a closed reduction of a type III fracture is impossible, an open reduction and posterior fixation/fusion is the treatment of choice.

CONCLUSION

Conservative treatment is predominantly reserved for Levine-Edwards I and IIA fractures. Operative treatment should be performed in case of Levine-Edwards II and III fractures.

Temporary vertebral artery occlusion after C3 fracture dislocation injury and spontaneous resolution following reduction and instrumented fusion: case report and literature review

Vertebral artery injuries as a result of blunt trauma can result in vertebrobasilar strokes. Typical treatment of such an injury includes early anticoagulation to prevent cerebral ischemic events due to vessel occlusion or embolism. We present a case of cervical fracture-dislocation injury and compression/occlusion of the right vertebral artery, which spontaneously resolved following surgical reduction and fusion. Postoperative cerebral angiography showed no evidence of vertebral artery stenosis, and systemic anticoagulation was discontinued. This case shows that vertebral artery occlusion can resolve spontaneously after fracture reduction, and cerebral angiography should play a role in assessing these complicated traumatic injuries.

Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated

BACKGROUND

We implemented expanded screening criteria for blunt cerebrovascular injuries (BCVIs) in an attempt to capture the remaining 20% of patients not historically identified with earlier protocols. We hypothesized that these expanded criteria would capture the additional 20% of BCVI patients not previously identified.

METHODS

Screening criteria for BCVI were expanded in 2011 after identifying new injury patterns. The study population included 4 years prior (2007 to 2010; classic) and following (2011 to 2014; expanded) implementation of expanded criteria.

RESULTS

BCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms.

CONCLUSIONS

There was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries. Expanded criteria should be adopted when screening for BCVI.