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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§; Nguyen, Joseph, MPH; Harris, Mitchel B., MD

doi: 10.1097/BRS.0b013e318294bacb
Cervical Spine

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

Vertebral artery injury (VAI) associated with cervical trauma has potential for catastrophical sequelae yet associated injury patterns and patient characteristics remain to be determined. A review of 1024 fractures at 3 level-1 trauma centers revealed VAI to be associated with more severely injured patients, a higher mortality, and distinct fracture patterns.

*Hospital for Special Surgery, The Spine Care Institute, Spine & Scoliosis Surgery, New York, NY

Brigham and Women's Hospital, Department of Orthopaedic Surgery, Boston, MA

Massachusetts General Hospital, Boston MA

§Beth Israel Deaconess Medical Center, Department of Orthopaedic Surgery, Boston, MA

Hospital for Special Surgery, Epidemiology and Biostatistics, New York, NY; and

Brigham and Women's Hospital, Department of Orthopaedic Surgery, Boston, MA.

Address correspondence and reprint requests to Darren R. Lebl, MD, Hospital for Special Surgery, The Spine Care Institute, Spine & Scoliosis Surgery, 523 East 72nd St, New York, NY 10021; E-mail:

Acknowledgment date: April 30, 2012. First revision date: December 22, 2012. Second revision date: February 4, 2013. Acceptance date: March 15, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, royalties, other.

© 2013 by Lippincott Williams & Wilkins