gms | German Medical Science

Objective: Vertebral artery injuries (VAI) due to spine injuries are thought to be rarely symptomatic and can be easily overlooked. VAI have the potential to cause cerebral and spinal cord ischemia. In this prospective observational study VAI following cervical spinal injuries were diagnosed and managed according to a standardized protocol, as described previously by Kral et al. (Zentralbl Neurochir, 2002).

Methods: During a 16 year period 69 (mean age: 43y, SD±20.71; 25 female, 44 male, p<0.05) of 599 patients with blunt cervical spine injury were suspicious for VAI due to facet luxation and/or fractures extending in the transverse foramen, and were subjected to a predefined radiological work-up. Digital subtraction angiography (DSA) was performed in all patients. Additionally, 15 magnetic resonance angiographies (MRA) and 7 computed tomography angiographies (CTA) were performed. Injury grading of VAI was done according to Biffl et al. (Ann Surg, 2000).

Results: In cases suspicious for VAI the incidence of VAI detected by DSA was 27.5% (n=19 of 69). VAI Grade I occurred in 15.8% (n=3), Grade II in 26.31% (n=5), Grade IV in 52.6% (n=10), and in one case Grade V with a rupture of one VA. MRA failed to detect a VAI (Grade I) in one patient, while CTA detected the VAI in all cases. 4 of 19 patients (21%) had clinical signs of vertebrobasilar insufficiency. Two patients with unilateral PICA and PCA infarctions became comatose and ultimately died after several days. One patient had vertigo and headache due to unilateral PICA Infarction, and one patient had vertigo due to unilateral VA occlusion. All patients with VAI were treated with anticoagulation (Heparin followed by ASS) for 6 month without adverse effects. 33 of 69 patients (47.8%) with VAI had unstable spine injuries and were treated surgically.

Conclusions: In patients with cervical spine fractures or dislocations crossing the course of the vertebral artery, VAI are frequent and are associated with significant morbidity and mortality. VAI were indentified by DSA in every fourth case. Despite anticoagulation therapy, every fifth patient becomes clinically symptomatic due to cerebrovascular insufficiency that leads to death in every tenth patient.