Blunt Cerebrovascular Injury in Cervical Spine Fractures: Are More-Liberal Screening Criteria Warranted?

Abstract

Study Design Retrospective comparative study. Objective To compare strict Biffl criteria to more-liberal criteria for computed tomography angiography (CTA) when screening for blunt cerebrovascular injury (BCVI). Methods All CTAs performed for blunt injury between 2009 and 2011 at our institution were reviewed. All patients with cervical spine fractures who were evaluated with CTA were included; patients with penetrating trauma and atraumatic reasons for imaging were excluded. We then categorized the patients' fractures based on the indications for CTA as either within or outside Biffl criteria. For included subjects, the percentage of studies ordered for loose versus strict Biffl criteria and the resulting incidences of BCVI were determined. Results During our study period, 1,000 CTAs were performed, of which 251 met inclusion criteria. Of the injuries, 192 met Biffl criteria (76%). Forty-nine were found to have BCVIs (19.5%). Forty-one injuries were related to fractures meeting Biffl criteria (21.4%), and 8 were related to fractures not meeting those criteria (13.6%). The relative risk of a patient with a Biffl criteria cervical spine injury having a vascular injury compared with those imaged outside of Biffl criteria was 1.57 (p = 0.19). Conclusions Our data demonstrates that although cervical spine injuries identified by the Biffl criteria trend toward a higher likelihood of concomitant BCVI (21.4%), a significant incidence of 13.6% also exists within the non-Biffl fracture cohort. As a result, a more-liberal screening than proposed by Biffl may be warranted.

Keywords: Biffl criteria; blunt cerebrovascular injury; blunt trauma; cervical injury; cervical spine trauma; vertebral artery injury.

Fig. 1

Blunt cerebrovascular injury incidences for computed tomography angiography screening from December 2009 through December 2011.

Fig. 2

Blunt cerebrovascular injury (BCVI) grades for Biffl criteria cervical spine fractures determined by computed tomography angiography from December 2009 through December 2011.

Fig. 3

Blunt cerebrovascular injury (BCVI) grades for non-Biffl criteria cervical spine fractures determined by computed tomography angiography from December 2009 through December 2011.

Fig. 4

Biffl criteria cervical spine fracture breakdown for those patients who met Biffl Criteria and were found to have a blunt cerebrovascular injury from December 2009 through December 2011.