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The Clinical Implications of Adding CT Angiography in the Evaluation of Cervical Spine Fractures: A
Daniel G Tobert1, Hai V Le1, Justin A Blucher1
1Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Insights
Computed tomographic angiography (CTA) for blunt cerebrovascular injury screening in cervical spine fractures increases vertebral artery injury detection but not stroke prevention. Selective screening is recommended over nonselective approaches.
Area of Science:
- Trauma Surgery
- Vascular Surgery
- Emergency Medicine
- Radiology
Background:
- Screening for blunt cerebrovascular injury using advanced imaging is debated.
- Vertebral artery injury (VAI) is often linked to cervical spine fractures, leading to recommendations for universal screening.
- The utility of adding computed tomographic angiography (CTA) to standard computed tomography (CT) for cervical spine fractures requires further investigation.
Purpose of the Study:
- To evaluate if incorporating CTA into the imaging protocol for cervical spine fractures alters patient management.
- To assess the impact of CTA on the detection of vertebral artery injury (VAI) and subsequent treatment recommendations.
Main Methods:
- Retrospective analysis of adult patients with acute cervical spine fractures from blunt trauma (2000-2015).
- Exclusion of patients with penetrating trauma or history of neoplasm/prior cervical spine surgery.
- Propensity-score matching compared patients who received CT + CTA versus CT alone, analyzing VAI detection, antithrombotic therapy recommendations, stroke occurrence, and bleeding events.
Main Results:
- Of 2,831 eligible patients, propensity-score matching created comparable cohorts of 644 patients each (CT + CTA vs. CT alone).
- CTA identified VAI in 113 patients, leading to antithrombotic recommendations for 62, versus 11 VAI cases and 8 recommendations in the CT-alone group.
- No preventable strokes occurred in either group; however, 2 major bleeding events were linked to antithrombotic therapy in the CT + CTA group.
Conclusions:
- Adding CTA to CT for cervical spine fractures significantly increases VAI detection and antithrombotic therapy recommendations.
- The study found no evidence of preventable strokes, but identified a risk of major bleeding events associated with CTA-guided therapy.
- Nonselective screening for VAI in all cervical spine fractures is not supported; screening should be reserved for high-risk patients.
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.
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