The Incidence, Characteristics and Outcomes of Vertebral Artery Injury Associated with Cervical Spine Trauma: A Systematic Review

Abstract

Study design: Systematic Review.

Objectives: Vertebral Artery Injury (VAI) is a potentially serious complication of cervical spine fractures. As many patients can be asymptomatic at the time of injury, the identification and diagnosis of VAI can often prove difficult. Due to the high rates of morbidity and mortality associated with VAI, high clinical suspicion is paramount. The purpose of this review is to elucidate incidence, diagnosis, treatment and outcomes of VAI associated with cervical spine injuries.

Methods: A systematic search of electronic databases was performed using 'PUBMED', 'EMBASE','Medline (OVID)', and 'Web of Science, for articles pertaining to traumatic cervical fractures with associated VAI.

Results: 24 studies were included in this systematic review. Data was included from 48 744 patients. In regards to the demographics of the focus groups that highlighted information on VAI, the mean average age was 46.6 (32.1-62.6). 75.1% (169/225) were male and 24.9% (56/225) were female. Overall incidence of VAI was 596/11 479 (5.19%). 190/420 (45.2%) of patients with VAI had fractures involving the transverse foramina. The right vertebral artery was the most commonly injured 114/234 (48.7%). V3 was the most common section injured (16/36 (44.4%)). Grade I was the most common (103/218 (47.2%)) injury noted. Collective acute hospital mortality rate was 32/226 (14.2%), ranging from 0-26.2% across studies.

Conclusion: VAI secondary to cervical spine trauma has a notable incidence and high associated mortality rates. The current available literature is limited by a low quality of evidence. In order to optimise diagnostic protocols and treatment strategies, in addition to reducing mortality rates associated with VAI, robust quantitative and qualitative studies are needed.

Keywords: blunt trauma; cervical spinal trauma; spinal orthopaedics; vertebral artery injury.

Figure 1.

Denver Grading Scale for blunt cerebrovascular injuries. Grabowski G, Robertson RN, Barton BM, Cairns MA, Webb SW. Blunt Cerebrovascular Injury in Cervical Spine Fractures: Are More-Liberal Screening Criteria Warranted? Global Spine J. 2016 Nov;6 (7):679-685.

Figure 2.

PRISMA flowchart outlining the systematic search process.

Figure 3.

Incidence of VAI. VAI: Vertebral artery injury.

Figure 4.

Location of VAI. VA: vertebral artery.

Figure 5.

Grades of VAI. VA: vertebral artery.

Figure 6.

Diagnostic Imaging Modality Utilised and corresponding publications. DSA: Digital Subtraction Angiography, CTA: Computed Topography Angiography. MRA: Magnetic Resonance Angiography, MDCTA: multidetector computed tomographic angiography.

Figure 7.

In-Hospital Mortality Associated with VAI. VAI: vertebral artery injury.

Figure 8.

Type 4 left vertebral artery injury with acute ischemic stroke following corrective spinal surgery. A) CTA demonstrating a cervical spine fracture/subluxation with occlusion of the left vertebral artery (arrow). B) CTA demonstrating occlusion of the left vertebral artery (arrow). C) DWI sequence obtained after corrective cervical spine surgery with evidence of an acute ischemic stroke. D) MRA demonstrating restored patency of the previously occluded vertebral artery (1).

Figure 9.

Type A dissecting aneurysm. A) DSA of the left vertebral artery showing a fusiform dilation. b, c, d Consecutive angiograms of the right vertebral artery during balloon test occlusion showing that the site of dissection is opacified distal to proximal (2). Type B dissecting aneurysm. A) DSA of the left vertebral artery showing a fusiform dilation. b, c, d Consecutive angiograms of the right vertebral artery during balloon test occlusion showing that the site of dissection is opacified proximal to distal (2).