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Published on: July 24, 2012
Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury
C Clay Cothren1, Ernest E Moore, Charles E Ray
1University of Colorado Health Sciences Center and the Department of Surgery, Denver Health Medical Center, CO 80204, USA. clay.cothren@dhha.org
Insights
Specific cervical spine fractures, including subluxation, C1-C3 fractures, or extension into the foramen transversarium, are associated with blunt cerebrovascular injury (BCVI). Prompt screening for BCVI is recommended for patients with these complex fractures.
Area of Science:
- Trauma Surgery
- Vascular Surgery
- Neurosurgery
Background:
- Aggressive screening for blunt cerebrovascular injury (BCVI) and prompt anticoagulation reduce ischemic neurologic events.
- Current guidelines screen all cervical spine fractures for BCVI, leading to unnecessary imaging.
- Specific cervical spine fracture patterns associated with vertebral artery injuries (VAIs) have been suggested.
Purpose of the Study:
- To identify specific cervical spine fracture patterns associated with BCVI.
- To limit unwarranted diagnostic imaging by refining screening criteria for BCVI.
Main Methods:
- Prospective follow-up of patients undergoing BCVI screening based on injury patterns and mechanism since January 1996.
- Analysis of 17,007 blunt trauma admissions from January 1996 to January 2005.
- Review of screening angiography results and associated cervical spine fracture patterns.
Main Results:
- 258 of 766 screened patients (34%) were diagnosed with BCVI.
- 125 patients with BCVI had cervical spine fractures, including isolated carotid artery injuries (CAIs), isolated VAIs, or combined injuries.
- The study identified three key fracture patterns associated with BCVI: subluxations (48%), C1-C3 fractures (36%), and fractures extending into the foramen transversarium (16%).
Conclusions:
- Blunt cerebrovascular injury is significantly associated with complex cervical spine fractures.
- Specific fracture patterns, including subluxation, C1-C3 fractures, and extension into the foramen transversarium, warrant prompt BCVI screening.
- Refining screening criteria based on these fracture patterns can reduce unnecessary diagnostic imaging.
Background:
Aggressive screening for blunt cerebrovascular injury (BCVI) and prompt anticoagulation for documented injuries has resulted in a significant reduction in ischemic neurologic events. An association between vertebral artery injuries (VAIs) and specific cervical spine fracture patterns has been suggested; however, current screening guidelines would subject all patients with cervical spine fractures to imaging because no distinction has been made for carotid artery injuries (CAIs). We hypothesized that specific cervical spine fracture patterns that warrant screening evaluation exist, hence limiting unwarranted diagnostic imaging.
Methods:
Patients undergoing screening for BCVI on the basis of injury patterns and mechanism have been prospectively followed at our regional trauma center since January 1996.
Results:
During the study period from January 1996 to January 2005, there were 17,007 blunt trauma admissions. Twenty-three patients presented with symptoms of BCVI. Screening angiography was performed in 766 patients (4.5%), and diagnosed 258 (34%) patients with BCVI. One hundred twenty-five patients with BCVI had cervical spine fractures; 18 patients had isolated CAI; 84 had isolated VAI, and 23 had combined CAI and VAI. Eight patients with VAI had minor cervical fractures but underwent screening for other injury patterns. Fractures in the remaining patients with BCVI were 1 of 3 patterns. Subluxations in 56 (48%) patients, C1 to C3 cervical spine fractures in 42 (36%), or extension of the fracture through the foramen transversarium in 19 (16%). Cervical spine fractures were the sole indication for screening in 90% of the study population. Screening yield of all patients admitted with 1 of these 3 fracture patterns was 37%.
Conclusions:
Blunt cerebrovascular injury is associated with complex cervical spine fractures that include subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Patients sustaining such cervical fractures should undergo prompt screening.
