Vertebral Artery Injury Associated With Blunt Cervical Spine Trauma: A Multivariate Regression Analysis.
Lebl, Darren R. MD *; Bono, Christopher M. MD +; Velmahos, George MD, PhD ++; Metkar, Umesh MD [S]; Nguyen, Joseph MPH [P]; Harris, Mitchel B. MD ||
38(16):1352-1361, July 15, 2013.
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Study Design. Retrospective analysis of prospective registry data.
Objective. To determine the patient characteristics, risk factors, and fracture patterns associated with vertebral artery injury (VAI) in patients with blunt cervical spine injury.
Summary of Background Data. VAI associated with cervical spine trauma has the potential for catastrophical clinical sequelae. The patterns of cervical spine injury and patient characteristics associated with VAI remain to be determined.
Methods. A retrospective review of prospectively collected data from the American College of Surgeons trauma registries at 3 level-1 trauma centers identified all patients with a cervical spine injury on multidetector computed tomographic scan during a 3-year period (January 1, 2007, to January 1, 2010). Fracture pattern and patient characteristics were recorded. Logistic multivariate regression analysis of independent predictors for VAI and subgroup analysis of neurological events related to VAI was performed.
Results. Twenty-one percent of 1204 patients with cervical injuries (n = 253) underwent screening for VAI by multidetector computed tomography angiogram. VAI was diagnosed in 17% (42 of 253), unilateral in 15% (38 of 253), and bilateral in 1.6% (4 of 253) and was associated with a lower Glasgow coma scale (P < 0.001), a higher injury severity score (P < 0.01), and a higher mortality (P < 0.001). VAI was associated with ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis (crude odds ratio [OR] = 8.04; 95% confidence interval [CI], 1.30-49.68; P= 0.034), and occipitocervical dissociation (P < 0.001) by univariate analysis and fracture displacement into the transverse foramen 1 mm or more (adjusted OR = 3.29; 95% CI, 1.15-9.41; P= 0.026), and basilar skull fracture (adjusted OR = 4.25; 95% CI, 1.25-14.47; P= 0.021), by multivariate regression model. Subgroup analyses of neurological events secondary to VAI occurred in 14% (6 of 42) and the stroke-related mortality rate was 4.8% (2 of 42). Neurological events were associated with male sex (P= 0.024), facet subluxation/dislocation (crude OR = 9.00; 95% CI, 1.51-53.74; P= 0.004) and the diagnosis of ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis (OR = 40.67; 95% CI, 5.27-313.96; P < 0.001).
Conclusion. VAI associated with blunt cervical spine injury is a marker for more severely injured patients. High-risk patients with basilar skull fractures, occipitocervical dissociation, fracture displacement into the transverse foramen more than 1 mm, ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis, and facet subluxation/dislocation deserve focused consideration for VAI screening.
Level of Evidence: 2
(C) 2013 by Lippincott Williams & Wilkins