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Researchers identify severe injuries associated with vertebral artery injuries
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 Mitchel B. Harris |
SAN ANTONIO — Researchers at Brigham and Women’s Hospital in Boston found that vertebral artery injury occurred in 3.5% of patients with blunt cervical spine trauma and discovered independent predictors of vertebral artery injury.
“In about 1% of all blunt trauma patients, we see have an incidence of cerebrovascular injuries, and if you look at all the vertebral artery injuries that are identified, there is a strong association with cervical injuries,” study author Mitchel B. Harris, MD, said during his presentation at the 2011 Annual Meeting of the Orthopaedic Trauma Association.
Harris and colleagues performed a retrospective multi-center study at three level 1 trauma centers in Boston and analyzed the data of 1,204 patients who sustained cervical spine fractures during a 3-year period. Of these patients, 243 underwent screening for vertebral artery injury (VAI). Of the group who underwent screening, 42 patients (3.5%) had a VAI.
“One of the more interesting findings was the relatively random nature of the screening of each patient at each institution,” Harris said. “Comparing the screened to unscreened patients, recognizing that there were not strictly adhered to protocols, the ones that were screened were generally younger with a lower Glasgow Severity Score (GCS), higher Injury Severity Score (ISS) and high-energy mechanism of injury.”
Of the 243 screened patients, 100 had at least one contraindication to antiplatelet or anticoagulation treatment. Subsequently, 71% of patients identified with VAIs were not treated.
“Often, anticoagulation and antiplatelet agents are transiently contraindicated in this patient population,” Harris said.
Patients with VAI showed a lower GCS, a higher ISS and higher mortality rates compared to those without VAI. The team found that fracture displacement of 1 mm into the foramen, basilar skull fracture, occipital-cervical dissociation fracture and ankylosing spondylitis/diffuse idiopathic skeletal hyperostosis (DISH) were independent risk factors for VAI.
The investigators found no significant differences between patients with and without VAI regarding age, gender and hospital or ICU length of stay. Injuries from the occiput to C2, multiple (non-displaced) transverse process fractures entering the transverse foramen, C2 fractures or facet subluxations/dislocations were not associated with an increased incidence of VAI. Operative stabilization for fractures or high-energy mechanism of injury did not correlate with the incidence of VAI.
“We should probably start funneling down who we are actually screening at the time of initial presentation to those who have a high risk injury such as basilar skull fracture, occipital-cervical dissociation, the presence of ankylosing spondylitis or DISH and displacements into the foramen of greater than 1 mm,” Harris said. “Most importantly, delayed screening may actually be the answer in that if you have a patient that has one of these injury predictors and cannot be initially screened, a screening performed about a week out will allow you to make a good decision as to what you need to do for treatment. About 50% of patients who present with VAI can be watched for the first week and then treated at a regular time if necessary.” – by Renee Blisard
References:
- Lebl DR, Wood KB, Velmahos G, Metkar U, et al. Vertebral artery injury associated with cervical spine trauma: A multi-center study. Paper #41. Presented at the 2011 Annual Meeting of the Orthopaedic Trauma Association. Oct. 12-15. San Antonio.
- Mitchel B. Harris, MD, can be reached at Brigham and Women’s Hospital, 75 Francis St., Boston, MA.; 617-732-5385; email: mbharris@partners.org.
- Disclosure: Harris has no relevant financial disclosures.