European Spine Journal

, Volume 20, Issue 12, pp 2202–2209 | Cite as

Vertebral artery injuries following cervical spine trauma: a prospective observational study

  • Christian-Andreas Mueller
  • Inga Peters
  • Martin Podlogar
  • Attila Kovacs
  • Horst Urbach
  • Karl Schaller
  • Johannes Schramm
  • Thomas Kral
Original Article

Abstract

Purpose

The purpose of this study was to report on the incidence, diagnosis and clinical manifestation of VAI following cervical spine injuries observed in a prospective observational study with a standardized clinical and radiographical protocol.

Methods

During a 16-year period, 69 (mean age: 43 ± 20.7 years; 25 female, 44 male) of 599 patients had cervical spine injury suspicious for VAI due to facet luxation and/or fractures extending into the transverse foramen. Diagnosis and management of these patients followed a previously published protocol (Kral in Zentralbl Neurochir 63:153–158, 2002). Digital subtraction angiography (DSA) was performed in all 69 patients. Injury grading of VAI was done according to Biffl et al. (Ann Surg 231:672–681, 2000). All patients with VAI were treated with anticoagulation (heparin followed by ASS) for 6 months.

Results

In cases suspicious for VAI, the incidence of VAI detected by DSA was 27.5% (n = 19 of 69 patients). VAI Grade I occurred in 15.8%, Grade II in 26.3%, Grade IV in 52.6% and Grade V in 5.2%. Of 19 patients, 4 (21%) had clinical signs of vertebrobasilar ischemia. Two patients died in hospital after 4 and 21 days respectively. Of 69 patients, 33 (47.8%) with suspected VAI had unstable spine injuries and were treated surgically.

Conclusion

In patients with cervical spine fractures or dislocations crossing the course of the vertebral artery, VAI are relatively frequent and may be associated with significant morbidity and mortality. VAI were identified by DSA in 27.5%. Despite anticoagulation therapy, 5.8% became clinically symptomatic and 2.9% died due to cerebrovascular ischemia.

Keywords

Vertebral artery injury Arteriography Cervical spine trauma CT-angiography MR-angiography 

References

  1. 1.
    Auer A, Felber S, Schmidauer C, Waldenberger P, Aichner F (1998) Magnetic resonance angiographic and clinical features of extracranial vertebral artery dissection. J Neurol Neurosurg Psychiatry 64:474–481PubMedCrossRefGoogle Scholar
  2. 2.
    Auer RN, Krcek J, Butt JC (1994) Delayed symptoms and death after minor head trauma with occult vertebral artery injury. J Neurol Neurosurg Psychiatry 57:500–502PubMedCrossRefGoogle Scholar
  3. 3.
    Berne JD, Reuland KS, Villarreal DH, McGovern TM, Rowe SA, Norwood SH (2006) Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury. J Trauma 60:1204–1209 (discussion 1209–1210)PubMedCrossRefGoogle Scholar
  4. 4.
    Biffl WL, Egglin T, Benedetto B, Gibbs F, Cioffi WG (2006) Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries. J Trauma 60:745–751 (discussion 751–752)PubMedCrossRefGoogle Scholar
  5. 5.
    Biffl WL, Moore EE, Elliott JP, Ray C, Offner PJ, Franciose RJ, Brega KE, Burch JM (2000) The devastating potential of blunt vertebral arterial injuries. Ann Surg 231:672–681PubMedCrossRefGoogle Scholar
  6. 6.
    Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM (1999) Blunt carotid arterial injuries: implications of a new grading scale. J Trauma 47:845–853PubMedCrossRefGoogle Scholar
  7. 7.
    Biffl WL, Ray CE Jr, Moore EE, Franciose RJ, Aly S, Heyrosa MG, Johnson JL, Burch JM (2002) Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg 235:699–706 (discussion 706–707)PubMedCrossRefGoogle Scholar
  8. 8.
    Biffl WL, Ray CE Jr, Moore EE, Mestek M, Johnson JL, Burch JM (2002) Noninvasive diagnosis of blunt cerebrovascular injuries: a preliminary report. J Trauma 53:850–856PubMedCrossRefGoogle Scholar
  9. 9.
    Bub LD, Hollingworth W, Jarvik JG, Hallam DK (2005) Screening for blunt cerebrovascular injury: evaluating the accuracy of multidetector computed tomographic angiography. J Trauma 59:691–697PubMedGoogle Scholar
  10. 10.
    Carpenter S (1961) Injury of neck as cause of vertebral artery thrombosis. J Neurosurg 18:849–853PubMedCrossRefGoogle Scholar
  11. 11.
    Cogbill TH, Moore EE, Meissner M, Fischer RP, Hoyt DB, Morris JA, Shackford SR, Wallace JR, Ross SE, Ochsner MG et al (1994) The spectrum of blunt injury to the carotid artery: a multicenter perspective. J Trauma 37:473–479PubMedCrossRefGoogle Scholar
  12. 12.
    Cothren CC, Biffl WL, Moore EE, Kashuk JL, Johnson JL (2009) Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents. Arch Surg 144:685–690PubMedCrossRefGoogle Scholar
  13. 13.
    Cothren CC, Moore EE (2005) Blunt cerebrovascular injuries. Clinics (Sao Paulo) 60:489–496Google Scholar
  14. 14.
    Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE Jr, Johnson JL, Moore JB, Burch JM (2004) Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg 139:540–545 (discussion 545–546)PubMedCrossRefGoogle Scholar
  15. 15.
    Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE Jr, Johnson JL, Moore JB, Burch JM (2003) Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 55:811–813PubMedCrossRefGoogle Scholar
  16. 16.
    Cothren CC, Moore EE, Ray CE Jr, Ciesla DJ, Johnson JL, Moore JB, Burch JM (2005) Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits. Arch Surg 140:480–485 (discussion 485–486)PubMedCrossRefGoogle Scholar
  17. 17.
    Cothren CC, Moore EE, Ray CE Jr, Ciesla DJ, Johnson JL, Moore JB, Burch JM (2005) Screening for blunt cerebrovascular injuries is cost-effective. Am J Surg 190:845–849PubMedGoogle Scholar
  18. 18.
    Fabian TC, Patton JH Jr, Croce MA, Minard G, Kudsk KA, Pritchard FE (1996) Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg 223:513–522 (discussion 522–525)PubMedCrossRefGoogle Scholar
  19. 19.
    Fassett DR, Dailey AT, Vaccaro AR (2008) Vertebral artery injuries associated with cervical spine injuries: a review of the literature. J Spinal Disord Tech 21:252–258PubMedCrossRefGoogle Scholar
  20. 20.
    Giacobetti FB, Vaccaro AR, Bos-Giacobetti MA, Deeley DM, Albert TJ, Farmer JC, Cotler JM (1997) Vertebral artery occlusion associated with cervical spine trauma. A prospective analysis. Spine (Phila Pa 1976) 22:188–192CrossRefGoogle Scholar
  21. 21.
    Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC, Mielke DH (2002) Guidelines for the management of acute cervical spine and spinal cord injuries. Clin Neurosurg 49:407–498PubMedGoogle Scholar
  22. 22.
    Hinse P, Thie A, Lachenmayer L (1991) Dissection of the extracranial vertebral artery: report of four cases and review of the literature. J Neurol Neurosurg Psychiatry 54:863–869PubMedCrossRefGoogle Scholar
  23. 23.
    Kerwin AJ, Bynoe RP, Murray J, Hudson ER, Close TP, Gifford RR, Carson KW, Smith LP, Bell RM (2001) Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 51:308–314PubMedCrossRefGoogle Scholar
  24. 24.
    Kral T, Schaller C, Urbach H, Schramm J (2002) Vertebral artery injury after cervical spine trauma: a prospective study. Zentralbl Neurochir 63:153–158. doi:10.1055/s-2002-36433 PubMedCrossRefGoogle Scholar
  25. 25.
    Louw JA, Mafoyane NA, Small B, Neser CP (1990) Occlusion of the vertebral artery in cervical spine dislocations. J Bone Joint Surg Br 72:679–681PubMedGoogle Scholar
  26. 26.
    Menon DK, Peden CJ, Hall AS, Sargentoni J, Whitwam JG (1992) Magnetic resonance for the anaesthetist. Part I: physical principles, applications, safety aspects. Anaesthesia 47:240–255PubMedCrossRefGoogle Scholar
  27. 27.
    Miller PR, Fabian TC, Bee TK, Timmons S, Chamsuddin A, Finkle R, Croce MA (2001) Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma 51:279–285 (discussion 285–286)PubMedCrossRefGoogle Scholar
  28. 28.
    Miller PR, Fabian TC, Croce MA, Cagiannos C, Williams JS, Vang M, Qaisi WG, Felker RE, Timmons SD (2002) Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 236:386–393 (discussion 393–395)PubMedCrossRefGoogle Scholar
  29. 29.
    Neau JP, Petit E, Gil R (2001) Dissection of cervical arteries. Presse Med 30:1882–1889PubMedGoogle Scholar
  30. 30.
    Parbhoo AH, Govender S, Corr P (2001) Vertebral artery injury in cervical spine trauma. Injury 32:565–568PubMedCrossRefGoogle Scholar
  31. 31.
    Peden CJ, Menon DK, Hall AS, Sargentoni J, Whitwam JG (1992) Magnetic resonance for the anaesthetist. Part II: anaesthesia and monitoring in MR units. Anaesthesia 47:508–517PubMedCrossRefGoogle Scholar
  32. 32.
    Pelkonen O, Tikkakoski T, Leinonen S, Pyhtinen J, Lepojarvi M, Sotaniemi K (2003) Extracranial internal carotid and vertebral artery dissections: angiographic spectrum, course and prognosis. Neuroradiology 45:71–77PubMedGoogle Scholar
  33. 33.
    Prall JA, Brega KE, Coldwell DM, Breeze RE (1998) Incidence of unsuspected blunt carotid artery injury. Neurosurgery 42:495–498 (discussion 498–499)PubMedCrossRefGoogle Scholar
  34. 34.
    Provenzale JM, Sarikaya B (2009) Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol 193:1167–1174PubMedCrossRefGoogle Scholar
  35. 35.
    Rodriguez M, Tyberghien A, Matge G (2001) Asymptomatic vertebral artery injury after acute cervical spine trauma. Acta Neurochir (Wien) 143:939–945CrossRefGoogle Scholar
  36. 36.
    Sawlani V, Behari S, Salunke P, Jain VK, Phadke RV (2006) “Stretched loop sign” of the vertebral artery: a predictor of vertebrobasilar insufficiency in atlantoaxial dislocation. Surg Neurol 66:298–304 (discussion 304)PubMedCrossRefGoogle Scholar
  37. 37.
    Sheth TN, Winslow JL, Mikulis DJ (2001) Rotational changes in the morphology of the vertebral artery at a common site of artery dissection. Can Assoc Radiol J 52:236–241PubMedGoogle Scholar
  38. 38.
    Sim E, Vaccaro AR, Berzlanovich A, Pienaar S (2000) The effects of staged static cervical flexion-distraction deformities on the patency of the vertebral arterial vasculature. Spine (Phila Pa 1976) 25:2180–2186CrossRefGoogle Scholar
  39. 39.
    Stringaris K, Liberopoulos K, Giaka E, Kokkinis K, Bastounis E, Klonaris EC, Balas P (1996) Three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography in carotid artery dissections. Int Angiol 15:20–25PubMedGoogle Scholar
  40. 40.
    Taneichi H, Suda K, Kajino T, Kaneda K (2005) Traumatically induced vertebral artery occlusion associated with cervical spine injuries: prospective study using magnetic resonance angiography. Spine (Phila Pa 1976) 30:1955–1962CrossRefGoogle Scholar
  41. 41.
    Torina PJ, Flanders AE, Carrino JA, Burns AS, Friedman DP, Harrop JS, Vacarro AR (2005) Incidence of vertebral artery thrombosis in cervical spine trauma: correlation with severity of spinal cord injury. AJNR Am J Neuroradiol 26:2645–2651PubMedGoogle Scholar
  42. 42.
    Utter GH, Hollingworth W, Hallam DK, Jarvik JG, Jurkovich GJ (2006) Sixteen-slice CT angiography in patients with suspected blunt carotid and vertebral artery injuries. J Am Coll Surg 203:838–848PubMedCrossRefGoogle Scholar
  43. 43.
    Vaccaro AR, Klein GR, Flanders AE, Albert TJ, Balderston RA, Cotler JM (1998) Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography. Spine (Phila Pa 1976) 23:789–794 (discussion 795)CrossRefGoogle Scholar
  44. 44.
    Veras LM, Pedraza-Gutierrez S, Castellanos J, Capellades J, Casamitjana J, Rovira-Canellas A (2000) Vertebral artery occlusion after acute cervical spine trauma. Spine (Phila Pa 1976) 25:1171–1177CrossRefGoogle Scholar
  45. 45.
    Wei CW, Montanera W, Selchen D, Lian J, Stevens C, de Tilly LN (2010) Blunt cerebrovascular injuries: diagnosis and management outcomes. Can J Neurol Sci 37:574–579PubMedGoogle Scholar
  46. 46.
    Weller SJ, Rossitch E Jr, Malek AM (1999) Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography. J Trauma 46:660–666PubMedCrossRefGoogle Scholar
  47. 47.
    Willis BK, Greiner F, Orrison WW, Benzel EC (1994) The incidence of vertebral artery injury after midcervical spine fracture or subluxation. Neurosurgery 34:435–441 (discussion 441–442)PubMedCrossRefGoogle Scholar
  48. 48.
    Woodring JH, Lee C (1992) The role and limitations of computed tomographic scanning in the evaluation of cervical trauma. J Trauma 33:698–708PubMedCrossRefGoogle Scholar
  49. 49.
    Woodring JH, Lee C, Duncan V (1993) Transverse process fractures of the cervical vertebrae: are they insignificant? J Trauma 34:797–802PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Christian-Andreas Mueller
    • 1
    • 2
  • Inga Peters
    • 1
  • Martin Podlogar
    • 1
  • Attila Kovacs
    • 3
  • Horst Urbach
    • 3
  • Karl Schaller
    • 1
    • 4
  • Johannes Schramm
    • 1
  • Thomas Kral
    • 1
    • 5
  1. 1.Department of NeurosurgeryRheinische Friedrich-Wilhelms Universität BonnBonnGermany
  2. 2.Department of NeurosurgeryUniversity Hospital of the Aachen University (RWTH)AachenGermany
  3. 3.Department of Radiology and NeuroradiologyRheinische Friedrich-Wilhelms Universität BonnBonnGermany
  4. 4.Department of Neurosurgery, Faculty of Medicine, Geneva University Medical CenterUniversity of GenevaGenevaSwitzerland
  5. 5.Department of NeurosurgeryGemeinschaftskrankenhausHerdecke, RuhrGermany

Personalised recommendations