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.

A Systematic Review and Meta-Analysis of Vertebral Artery Injury After Cervical Spine Trauma

“…Other less frequently reported fracture types included burst fractures, Hangman fractures, Jefferson fractures, subaxial fractures, lateral mass fractures, lamina fractures, pedicle fractures, arch fractures, and ligamentous injuries. 3 , 46 …”

“…Other less frequently reported fracture types included burst fractures, Hangman fractures, Jefferson fractures, subaxial fractures, lateral mass fractures, lamina fractures, pedicle fractures, arch fractures, and ligamentous injuries. 3,46 Studies have shown that a significant percentage (70%) of cases involving VAI after cervical spine trauma exhibit neurological symptoms within the first 24 hours. However, there have been instances where there was a delay of up to 18 hours between the injury and the onset of neurological symptoms in 44% of cases.…”

“…Thus, the use of conventional angiography is strongly recommended once bleeding control via direct tamponade is achieved. 3 Nevertheless, suturing a damaged VA presents technical challenges due to the extensive injury site. The requirement for sharp margins when suturing the damaged VA, coupled with factors such as substantial bleeding, VAI within the bony canal, and surrounding venous plexus, can impede the management process.…”

“…Hence, microvascular primary repair or connection is suggested if technically feasible, particularly in cases of dominant VAI involving hemodynamically stable patients without interference from neighbouring structures. 3,11 Endovascular Management. Modern advancements have greatly improved endovascular approaches for treating vertebral artery injuries (VAI).…”

“…Notably, fractures involving the transverse foramen have been associated with VAI rates as high as 88%. 3 Unstable vertebral body fractures, such as tear-drop fractures, and fractures with anterolisthesis of 3 mm or more, are particularly prone to causing VAI. It's important to note that the absence of visible fractures on imaging does not explicitly rule out the possibility of VAI.…”