Ankylosis of the cervical spine increases the incidence of blunt cerebrovascular injury (BCVI) in CTA screening after blunt trauma

Mika P. Koivikko,Frank V. Bensch,Riku M. Vierunen,Ville V. Haapamäki

doi:10.1007/s10140-022-02022-8

Mika P. Koivikko, Frank V. Bensch

Open Access

https://doi.org/10.1007/s10140-022-02022-8

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Abstract

PurposeTo examine the incidence, location, and grade of blunt cerebrovascular injury (BCVI), as well as associated strokes in patients with ankylosis of the cervical spine, imaged with CT angiography (CTA) after blunt trauma. The related etiologies of ankylosis had an additional focus.Materials and methodsAltogether of 5867 CTAs of the craniocervical arteries imaged after blunt trauma between October 2011 and March 2020 were manually reviewed for a threshold value of ankylosis of at least three consecutive cervical vertebrae. BCVI was the primary outcome and associated stroke as the secondary outcome. Variables were craniofacial and cervical spine fractures, etiology and levels of ankylosis, traumatic brain injury, spinal hematoma, spinal cord injury, and spinal cord impingement, for which correlations with BCVI were examined.ResultsOf the 153 patients with ankylosis and blunt trauma of the cervical spine, 29 had a total of 36 BCVIs, of whom two had anterior and 4 posterior circulation strokes. Most of the BCVIs (n = 32) were in the vertebral arteries. Injuries were graded according to the Biffl scale: 17 grade II, 4 grade III, 14 grade IV, and 1 grade V. A ground-level fall was the most common trauma mechanism. Cervical spine fracture was the only statistically significant predictor for BCVI (OR 7.44). Degenerative spondylosis was the most prevalent etiology for ankylosis.ConclusionAnkylosis of the cervical spine increases the incidence of BCVI up to sevenfold compared to general blunt trauma populations, affecting especially the vertebral arteries.

Highlights

High-energy deceleration forces from blunt trauma resulting in hyperflexion, hyperextension, or rotation of the neck can cause cervical arteries to stretch over or shear against adjacent structures, in addition to the direct impact caused by fractured bones
Patients in our study with an ankylosed cervical spine of at least three consecutive vertebrae had an incidence of 19% for blunt cerebrovascular injury (BCVI), more than seven times as high as non-specified blunt trauma patient populations, and twice as high as those with traumatic brain injury (TBI) [3, 5, 28]
Most injuries were located in the vertebral arteries, leading to a vertebral artery injuries (VAIs) incidence of 17%, 34 times higher than the incidence of 0.5% in general blunt trauma populations [29–31]

Summary

Introduction

High-energy deceleration forces from blunt trauma resulting in hyperflexion, hyperextension, or rotation of the neck can cause cervical arteries to stretch over or shear against adjacent structures, in addition to the direct impact caused by fractured bones. The resulting intimal damage can affect both carotid and vertebral arteries and is defined as blunt cerebrovascular injury (BCVI) [1]. BCVI has an incidence of 1% to 2.7% in blunt trauma [2–4] and up to 9.2% in hospitalized patients with severe trauma and traumatic brain injury (TBI) [5]. BCVI can cause cerebral or cerebellar infarction via thromboembolism or vessel occlusion, which can be prevented by timely instituted anticoagulation [5–7]. Spinal ankylosis carries a risk for unstable fractures, even from low-energy trauma, usually localized in the lower While digital subtraction angiography is still considered the gold standard for the diagnosis of BCVI, CTA is the de facto standard of imaging, thanks to its speed, reliability, and cost-effectiveness [5, 7–12].

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