Blunt Cervical Spine Trauma Research Articles

Patient specific predictive factors of vertebral artery injury following blunt cervical spine trauma

ObjectiveDetermine patient and injury characteristics predictive of vascular injury (VAI) in blunt cervical spine (BCS) trauma to identify high-risk patients and propose an alternative screening protocol. MethodsPatients presenting between 2014 and 2018 with BCS injury and cervical spine CT imaging were included. Demographics and injury characteristics of BCS injuries were collected. Univariate and multivariate analyses to determine risk factors for VAI were performed. Once factors associated with greater odds of VAI were identified, this information was used to create an alternative protocol for indicating CTA in patients who sustained BCS injury. ResultsA total of 475 patients were included. CTA of the neck was performed in 55.5% patients. In patients who received CTA, 18.2% had a contraindication to receiving anti-platelet therapy, and 25% were already receiving anti-coagulation therapy as an outpatient medication. VAI was found in 13.2% patients. In patients with VAI, 48.5% were already receiving anti-coagulation as outpatient medication. Acute kidney injury was found in 10.5% patients who had received CTA.Factors associated with greater odds of having VAI included transverse foramen involvement(p = 0.0001), subluxation/displacement/dislocation of fracture(p = 0.03), high energy mechanism(p = 0.02), SLIC score > 4(p = 0.04), and concomitant lumbar spine injury(p = 0.03).Using Modified Hawkeye Protocol, 40.2% of patients were indicated to receive a CTA, and 17 VAI were identified. Compared to Denver Criteria, CTAs were performed in 73 less patients(p = 0.04). ConclusionsUpdated protocols utilizing evidence-based clinical parameters to predict chance of VAI may avoid unnecessary advanced imaging and contrast load to patients in the setting of BCS trauma.

257. Patient specific predictive factors of vertebral artery injury following blunt cervical spine trauma

<h3>BACKGROUND CONTEXT</h3> Computed topography angiography (CTA) is routinely used in evaluation for vascular injury in patients that have sustained blunt cervical spine trauma. Current screening criteria often leads to over utilization of imaging in patients who are already receiving antithrombic therapy or have clear contraindications due to concomitant injuries. <h3>PURPOSE</h3> This study sought to identify patient and injury characteristics predictive of vascular injury (VAI) in blunt cervical spine trauma in order to identify high-risk patients and propose alternative screening criteria. <h3>STUDY DESIGN/SETTING</h3> This was a retrospective cohort study collected from patients presenting for blunt cervical spine injury between 2014-2018 at a level I trauma tertiary care center. <h3>PATIENT SAMPLE</h3> A total of 475 patients over the age of 18 who sustained blunt cervical spine trauma and had available cervical spine CT were included in analysis. <h3>OUTCOME MEASURES</h3> 1) Incidence of vertebral artery injuries (VAI) in blunt cervical spine injury. 2) In patients with VAI, percentage of patients with contraindication to anti-platelet therapy OR receiving anti-platelet therapy prior to injury. 3) In patients with VAI, percentage of patients that developed acute kidney injury. 4) Injury and patient characteristics associated with higher risk of sustaining VAI. <h3>METHODS</h3> This was a retrospective cohort study collected from patients presenting for blunt cervical spine injury between 2014-2018. Patients were included who sustained a cervical spine injury and cervical spine CT was available. Demographics including age, gender, outpatient aspirin use, presence of kidney disease was recorded. Injury characteristics including mechanism of action, level of cervical spine injury, type of injury, concomitant thoracic and/or lumbar spine injury, if CTA was obtained, presence of VAI, operative interventions, and subaxial-cervical spine injury classification (SLIC) was collected. Data was evaluated using univariate and multivariate analyses to determine risk factors for VAI. <h3>RESULTS</h3> A total of 475 patients were included, average age 60.2 years. Motor vehicle accident was the most common cause of injury in 225 (47.4%) patients. CTA of the neck was performed in 264 (55.5%) patients. In patients who received CTA, 48 (18.2%) had a contraindication to receiving anti-platelet therapy and 66 (25%) were already receiving anti-platelet therapy as an outpatient medication. 26 (5.5%) patients were found to have VAI, and in patients with VAI, 4 (14.3%) patents were already receiving ASA as an outpatient medication, and no patients required secondary vascular interventions. Acute kidney injury was found in 28 (10.5%) patients who had received CTA. Factors associated with greater odds of having VAI included transverse foramen involvement (OR4.27, CI 2.05-8.89, p=0.0001), multilevel cervical spine fractures (OR2.09, CI 0.97-4.99), subluxation/displacement/dislocation of fracture (OR2.23, CI 1.08-4.59,p=0.03), high energy mechanism (OR2.38, CI 1.14-4.96), SLIC score >4 (OR2.65, CI 1.07-6.55,p=0.04), and concomitant lumbar spine injury (OR4.37, CI 1.13-16.9,p=0.03). <h3>CONCLUSIONS</h3> Updated protocols utilizing evidence-based clinical parameters to predict chance of VAI may avoid unnecessary advanced imaging and contrast load to patients in the setting of blunt cervical spine trauma. Further prospective studies are needed to determine if identified risk factors could be used as specific screening criteria to identify high-risk patients who would benefit most from further advanced imaging. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

261. Outcomes in patients with vertebral injury after cervical spine trauma

<h3>BACKGROUND CONTEXT</h3> Vertebral artery injury (VAI) occurs in almost 1% of all blunt trauma hospital admissions. No large study has been conducted investigating outcomes of VAI in blunt cervical trauma. <h3>PURPOSE</h3> The objectives of this study were to evaluate 1-year outcomes in patients with blunt cervical spine trauma with vertebral artery injuries. <h3>STUDY DESIGN/SETTING</h3> Data from the National Trauma Data Bank (NTDB) in 2016 was analyzed. <h3>PATIENT SAMPLE</h3> Adult patients with cervical vertebral, ligamentous, or neurological trauma were included in the study. Patients who died within 3 days of admission were excluded. <h3>OUTCOME MEASURES</h3> Response variables collected included development of adverse events (DVT/PE, myocardial infarction (MI), stroke, hemorrhage, or neurological deficit) length of stay (LOS), intensive care unit (ICU) LOS, and unplanned ICU admission or surgical procedure. <h3>METHODS</h3> Demographic information (age, sex, race), injury specific information (mechanism, severity), patient health information, and a variable indicating the presence of vertebral artery injury were collected as explanatory variables. Multivariable regression was used to calculate the risk-adjusted effect of vertebral artery injury on the presence of adverse events and unplanned events as well as its relationship with LOS and ICU LOS. <h3>RESULTS</h3> A total of 64,662 patients with cervical trauma were reviewed, of which 2,310 had VAI. Of the patients with VAI, the 82 (3.6%) patients had a MI, 80 (3.5%) had a PE/DVT, 76 (3.3%) had a stroke, 36 (1.6%) had neurologic injury, and 94 (4.1%) had an unplanned operative procedure or ICU admission. After risk-adjustment, VAI was associated with an increased LOS and ICU LOS (p<0.001), as well as an increased risk of MI, PE/DVT, stroke, and neurologic injury (p<0.001). <h3>CONCLUSIONS</h3> Vertebral artery injury in cervical trauma leads to increase chance of adverse events and length of stay in the ICU and in the hospital. Trauma providers should be aware of these increased risks when treating patients with VAI in cervical trauma. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Risk of Vertebral Artery Injury and Stroke Following Blunt and Penetrating Cervical Spine Trauma: A Retrospective Review of 729 Patients

Cervical spine trauma (CST) may result in vertebral artery injury (VAI), increasing the risk of developing stroke. Stroke risk following CST is poorly reported. In total, 729 patients with CST were retrospectively analyzed, including rates of VAI, age at injury, cause of injury, cardiovascular history, smoking history, substance abuse history, embolization therapy, and antiplatelet or anticoagulant therapy prior or after injury. VAIs were identified and graded following the Modified Denver Criteria for Blunt Cerebrovascular Injury using magnetic resonance angiography and computed tomography angiography. Brain scans were reviewed for stroke rates and statistically significant variations. Thirty-three patients suffered penetrating trauma, whereas 696 patients experienced blunt trauma. In total, 81 patients met the criteria for analysis with confirmed VAI. VAI was more common in penetrating injury group compared with blunt injury group (64% vs. 9%, P < 0.0005). However, low-grade VAI (less than grade III) was more common in blunt injury group versus penetrating group (37% vs. 14%, P < 0.05). The frequency of posterior circulation strokes did not vary significantly between groups (26.3% vs. 13.8%, P= 0.21). Cardiovascular comorbidities were significantly more common in the blunt group (50%, P= 0.0001) compared with the penetrating group (0%). VAI occurs with a high incidence in penetrating CST. Although stroke risk following penetrating and blunt CST did not vary significantly, they resulted in serious complications in a group of patients. Further study of this patient population is required to provide high-level, evidence-based preventions for VAI complications.

Role of cervical spine MRI in the setting of negative cervical spine CT in blunt trauma: Critical additional information in the setting of clinical findings suggestive of occult injury

Background and purposeCervical spine injury is common in the setting of blunt trauma and there is consensus that cervical spine CT (CSCT) is the image modality of choice for initial evaluation for blunt trauma related injuries of the cervical spine. However, there is disagreement in the literature with regards to further evaluation of blunt trauma patients with cervical spine MRI (CSMRI) after negative CSCT when there is persistent clinical concern for occult trauma related injury. The purpose of this study is to examine the utility of CSMRI for detection of occult injury in blunt trauma patients after negative CSCT. Materials and methodsWe reviewed records for 7,301 patients admitted for blunt trauma (November 2007–December 2013) and identified 259 who underwent CSMRI after a negative CSCT. These CSMRIs were reviewed to determine the number and type of significant CT occult injuries identified and clinical indications that led to CSMRI acquisition. Results and conclusionsCSMRI detected significant injuries following negative CSCT in 31% (81/259) of patients. There were 15 cord contusions/infarcts, 9 bone contusions/fractures, 7 spinal canal hemorrhages and 66 soft tissue injuries. Upper extremity neurological deficit had greatest positive predictive value (PPV) for detection of CT-occult injury on CSMRI of 43% (23/53), followed by equivocal CSCT findings (38%, 18/47), presence of extra-cervical injuries (34%, 20/58), midline cervical tenderness (20%, 17/85), and isolated lower extremity neurological deficit (0%, 0/16). CSMRI is recommended following negative CSCT in the evaluation of blunt cervical spine trauma when appropriate clinical concerns are present.

Clinical Features and Treatment Strategy of Vertebral Artery Injury Associated with Cervical Spine Trauma

Vertebral artery injury(VAI)associated with cervical spine trauma has the potential to cause catastrophic vertebrobasilar stroke. However, there are no well-defined treatment recommendations for VAI. The purpose of this study was to identify an effective treatment strategy for VAI following cervical spine trauma. Ninety-seven patients with blunt cervical spine trauma were treated at Hyogo Prefectural Kakogawa Medical Center between January 2013 and September 2017. Of these patients, 49 underwent computed tomographic angiography or magnetic resonance angiography for evaluation of the vertebral artery. Eighteen patients(36.7%)had a diagnosis of VAI. We retrospectively analyzed the clinical features, treatment, and outcomes in these 18 patients. Seven patients(38.9%)had bilateral VAI, 16(88.9%)had cervical dislocation, and 2(11.1%)had transverse process fractures extending into the transverse foramen. Surgical reduction was performed in 14 patients. Five patients with either bilateral or unilateral occlusion underwent parent artery occlusion before reduction. There were no complications after this procedure. Two patients with bilateral VAI had a stroke before treatment. There were no infarctions in the distribution of the vertebrobasilar artery after intervention. The perioperative stroke rate was relatively good, and almost all Glasgow Outcome Scale scores were related to the degree of spinal cord injury. Aggressive screening for VAI is important in patients with cervical spine trauma in order to ensure adequate treatment. Although the treatment strategy described here could yield good results, it may require modification according to the needs of the individual patient.

Awareness of traumatic occult lateral mass fracture of the cervical spine triggered by the presence of unilateral vertebral artery occlusion: a case report.

We present an unusual case of traumatic occult lateral mass fracture of the cervical spine with unilateral occlusion of the vertebral artery (VA), that was missed by plain X-ray and magnetic resonance imaging (MRI), but identified by computed tomography (CT) after suspecting high-energy trauma as the underlying cause. A 67-year-old male was injured in a car accident and came to our institute on foot 4 days after injury with complaints of neck pain and numbness in the right hand. Although, no specific bone injury was visible on plain X-ray, the absence of flow voids in the right VA was confirmed on axial T2-weighted MRI. We suspected high-energy trauma of the cervical spine at that point and performed CT for a more detailed assessment. Consequently, a fracture was detected in the right lateral mass of C6 and we speculated that spontaneous reduction of the fracture-dislocation had occurred. One-stage surgery with posterior fixation was subsequently performed for instability. The patient's preoperative symptoms were improved and neither recanalization of the occlusion nor another VA occlusion was observed after surgery. VA injury occurs frequently as a complication of blunt cervical spine trauma. In the present case, however, the lateral mass fracture was not seen on MRI and missed until the unilateral VA injury was detected. When high-energy trauma of the cervical spine is suspected, it is important to evaluate damage to the spinal cord, bone, soft-tissue, and VA by MRI and CT.

Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT.

To determine the utility of cervical spine MRI in blunt trauma evaluation for instability after a negative non-contrast cervical spine CT. A review of medical records identified all adult patients with blunt trauma who underwent CT cervical spine followed by MRI within 48 h over a 33-month period. Utility of subsequent MRI was assessed in terms of findings and impact on outcome. A total of 1,271 patients with blunt cervical spine trauma underwent both cervical spine CT and MRI within 48 h; 1,080 patients were included in the study analysis. Sixty-six percent of patients with a CT cervical spine study had a negative study. Of these, the subsequent cervical spine MRI had positive findings in 20.9%; 92.6% had stable ligamentous or osseous injuries, 6.0% had unstable injuries and 1.3% had potentially unstable injuries. For unstable injury, the NPV for CT was 98.5%. In all 712 patients undergoing both CT and MRI, only 1.5% had unstable injuries, and only 0.42% had significant change in management. MRI for blunt trauma evaluation remains not infrequent at our institution. MRI may have utility only in certain patients with persistent abnormal neurological examination. • MRI has limited utility after negative cervical CT in blunt trauma. • MRI is frequently positive for non-specific soft-tissue injury. • Unstable injury missed on CT is infrequent.

Cervical spine clearance in adults following blunt trauma: a national survey across major trauma centres in England

To assess current practice in cervical spine clearance across major trauma centres in England and review current guidelines. An electronic survey was sent to lead trauma clinicians at 22 major trauma centres in England. This assessed the clinical decision tools used, the choice of initial imaging technique, and the methods used to clear the cervical spine in alert and obtunded patients without focal neurology, and where initial imaging was normal. British Orthopaedic Association Standards for Trauma (BOAST) 2 and Eastern Association for Surgery for Trauma (EAST) guidelines were used as standards. Eighteen out of the 22 (82%) centres responded by completing the survey. Most (71%) centres used the Canadian C-Spine Rule for clearing the cervical spine clinically. Seventy-two percent of centres preferred computed tomography (CT) as the first-line imaging technique, the choice based on age of patient and mechanism of injury. If the initial CT imaging was normal, magnetic resonance imaging (MRI) was performed in 52% of centres to clear the cervical spine, with half of these centres stating that they would discuss further imaging with a radiologist first. The practice across centres was highly variable for the obtunded patient, with most centres preferring continuing immobilisation or MRI to clear the cervical spine, with a small minority removing spinal precautions when a high-quality multidetector CT was normal. Multidetector CT is the preferred initial imaging technique across most major trauma centres in England when blunt cervical spine trauma is suspected. There is widespread reliance on MRI to clear the cervical spine in both alert and obtunded patients, if initial CT imaging is normal and there is no focal neurology on clinical assessment. This calls for greater awareness of the reliability of a high-quality normal multidetector CT examination in clearing the cervical spine in the absence of focal neurology.

Cervical Spinal Cord Injury without Computed Tomography Evidence of Trauma in Adults: Magnetic Resonance Imaging Prognostic Factors.

Spinal cord injury (SCI) without computed tomography evidence of trauma is underreported in adults and is considered a subtype of SCI with relatively good outcome. Despite this, few studies have been performed to determine specific imaging-related prognostic factors. Our objective is to describe the imaging characteristics of patients experiencing blunt cervical spine trauma with neurologic deficits, but without radiologic abnormalities and associated prognostic factors. A retrospective review of all adult patients with cervical SCI admitted to the emergency room of 2 university hospitals from January 2004 to December 2013 was performed. Only patients with a magnetic resonance imaging (MRI) performed within 72 hours after trauma were included for further analysis. All patients with bony injury or traumatic malalignment were excluded. Data gathered on the remaining patients included demographics, mechanism of injury, severity of SCI, long-term patient outcome, improvement in neurologic condition, and MRI results. There were 48 patients who met the inclusion and exclusion criteria, and 40 who demonstrated improvement in the neurologic examination at follow-up. Disruption of either the anterior longitudinal ligament or ligamentum flavum and larger lesions in the MRI were predictors of lack of neurologic improvement. Early MRI has prognostic value in patients suffering SCI without computed tomography evidence of trauma. Lesion length is a powerful predictor of outcome in this subgroup of patients. Soft tissue injury plays a role in the severity of injury and the ability to recover in this subgroups of patients.

Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis.

To quantify the rate of unstable injuries detected by MRI missed on CT in blunt cervical spine (CS) trauma patients and assess the utility of MRI in CS clearance. We undertook a systematic review of worldwide evidence across five major medical databases and performed a meta-analysis. Studies were included if they reported the number of unstable injuries or gave enough details for inference. Variables assessed included severity, CT/MRI specifications, imaging timing, and outcome/follow-up. Pooled incidences of unstable injury on follow-up weighted by inverse-of-variance among all included and obtunded or alert patients were reported. Of 428 unique citations, 23 proved eligible, with 5,286 patients found, and 16 unstable injuries reported in five studies. The overall pooled incidence is 0.0029%. Among studies reporting only obtunded patients, the pooled incidence is 0.017%. In alert patients, the incidence is 0.011%. All reported positive findings were critically reviewed, and only 11 could be considered truly unstable. There is significant heterogeneity in the literature regarding the use of imaging after a negative CT. The finding rate on MRI for unstable injury is extremely low in obtunded and alert patients. Although MRI is frequently performed, its utility and cost-effectiveness needs further study. • There were 16 unstable injuries on follow-up MRI among 5286 patients. • The positive finding rate among obtunded patients was 0.12 %. • The positive finding rate among alert, awake patients was 0.72 %. • MRI has a high false-positive rate; its utility mandates further studies. • The use and role of "confirmatory" tests shows wide variations.

Flexion/extension cervical spine views in blunt cervical trauma

ObjectiveTo examine the contribution of flexion and extension radiographs in the evaluation of ligamentous injury in awake adults with acute blunt cervical spine trauma, who show loss of cervical lordosis and neck pain. MethodsAll patients who presented to our emergency department following blunt trauma were enrolled in this study, except those with schiwora, neurological deficits or fracture demonstrated on cross-table cervical spine X-rays, and those who were either obtunded or presented after cervical spine surgery. Adequacy of flexion and extension views was checked by the neurosurgery and radiology team members. All these patients underwent cross-table cervical spine view followed by flexion/extension views based on the loss of lordosis on cross-table imaging and the presence of neck pain. ResultsA total of 200 cases were reviewed, of whom 90 (45%) underwent repeat X-rays because of either inadequate exposure or limited motion. None of the patients with loss of lordosis on cross-table view had positive flexion and extension views of cervical spine for instability. ConclusionsOur results show that in patients who underwent acute radiographic evaluation of blunt cervical spine trauma, flexion and extension views of the cervical spine are unlikely to yield positive results in the presence of axial neck pain and/or loss of cervical lordosis. We can also hypothesize that performing flexion and extension views will be more useful once the acute neck pain has settled.

Multidetector CT of Blunt Cervical Spine Trauma in Adults

A number of new developments in cervical spine imaging have transpired since the introduction of 64-section computed tomographic (CT) scanners in 2004. An increasing body of evidence favors the use of multidetector CT as a stand-alone screening test for excluding cervical injuries in polytrauma patients with obtundation. A new grading scale that is based on CT and magnetic resonance (MR) imaging findings, the cervical spine Subaxial Injury Classification and Scoring (SLIC) system, is gaining acceptance among spine surgeons. Radiographic measurements described for the evaluation of craniocervical distraction injuries are now being reevaluated with the use of multidetector CT. Although most patients with blunt trauma are now treated nonsurgically, evolution in the understanding of spinal stability, as well as the development of new surgical techniques and hardware, has driven management strategies that are increasingly favorable toward surgical intervention. It is therefore essential that radiologists recognize findings that distinguish injuries with ligamentous instability or a high likelihood of nonfusion that require surgical stabilization from those that are classically stable and can be treated with a collar or halo vest alone. The purpose of this article is to review the spectrum of cervical spine injuries, from the craniocervical junction through the subaxial spine, and present the most widely used grading systems for each injury type.

Spinal Cord Injury after Blunt Cervical Spine Trauma: Correlation of Soft-Tissue Damage and Extension of Lesion

In patients with spinal cord injury after blunt trauma, several studies have observed a correlation between neurologic impairment and radiologic findings. Few studies have been performed to correlate spinal cord injury with ligamentous injury. The purpose of this study was to retrospectively evaluate whether ligamentous injury or disk disruption after spinal cord injury correlates with lesion length. We retrospectively reviewed 108 patients diagnosed with traumatic spinal cord injury after cervical trauma between 1990-2011. Plain films, CT, and MR imaging were performed on patients and then reviewed for this study. MR imaging was performed within 96 hours after cervical trauma for all patients. Data regarding ligamentous injury, disk injury, and the extent of the spinal cord injury were collected from an adequate number of MR images. We evaluated anterior longitudinal ligaments, posterior longitudinal ligaments, and the ligamentum flavum. Length of lesion, disk disruption, and ligamentous injury association, as well as the extent of the spinal cord injury were statistically assessed by means of univariate analysis, with the use of nonparametric tests and multivariate analysis along with linear regression. There were significant differences in lesion length on T2-weighted images for anterior longitudinal ligaments, posterior longitudinal ligaments, and ligamentum flavum in the univariate analysis; however, when this was adjusted by age, level of injury, sex, and disruption of the soft tissue evaluated (disk, anterior longitudinal ligaments, posterior longitudinal ligaments, and ligamentum flavum) in a multivariable analysis, only ligamentum flavum showed a statistically significant association with lesion length. Furthermore, the number of ligaments affected had a positive correlation with the extension of the lesion. In cervical spine trauma, a specific pattern of ligamentous injury correlates with the length of the spinal cord lesion in MR imaging studies. Ligamentous injury detected by MR imaging is not a dynamic finding; thus it proved to be useful in predicting neurologic outcome in patients for whom the MR imaging examination was delayed.

Vertebral Artery Injury Associated With Blunt Cervical Spine Trauma

Retrospective analysis of prospective registry data. To determine the patient characteristics, risk factors, and fracture patterns associated with vertebral artery injury (VAI) in patients with blunt cervical spine injury. VAI associated with cervical spine trauma has the potential for catastrophical clinical sequelae. The patterns of cervical spine injury and patient characteristics associated with VAI remain to be determined. A retrospective review of prospectively collected data from the American College of Surgeons trauma registries at 3 level-1 trauma centers identified all patients with a cervical spine injury on multidetector computed tomographic scan during a 3-year period (January 1, 2007, to January 1, 2010). Fracture pattern and patient characteristics were recorded. Logistic multivariate regression analysis of independent predictors for VAI and subgroup analysis of neurological events related to VAI was performed. Twenty-one percent of 1204 patients with cervical injuries (n = 253) underwent screening for VAI by multidetector computed tomography angiogram. VAI was diagnosed in 17% (42 of 253), unilateral in 15% (38 of 253), and bilateral in 1.6% (4 of 253) and was associated with a lower Glasgow coma scale (P < 0.001), a higher injury severity score (P < 0.01), and a higher mortality (P < 0.001). VAI was associated with ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis (crude odds ratio [OR] = 8.04; 95% confidence interval [CI], 1.30-49.68; P = 0.034), and occipitocervical dissociation (P < 0.001) by univariate analysis and fracture displacement into the transverse foramen 1 mm or more (adjusted OR = 3.29; 95% CI, 1.15-9.41; P = 0.026), and basilar skull fracture (adjusted OR = 4.25; 95% CI, 1.25-14.47; P= 0.021), by multivariate regression model. Subgroup analyses of neurological events secondary to VAI occurred in 14% (6 of 42) and the stroke-related mortality rate was 4.8% (2 of 42). Neurological events were associated with male sex (P = 0.024), facet subluxation/dislocation (crude OR = 9.00; 95% CI, 1.51-53.74; P = 0.004) and the diagnosis of ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis (OR = 40.67; 95% CI, 5.27-313.96; P < 0.001). VAI associated with blunt cervical spine injury is a marker for more severely injured patients. High-risk patients with basilar skull fractures, occipitocervical dissociation, fracture displacement into the transverse foramen more than 1 mm, ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis, and facet subluxation/dislocation deserve focused consideration for VAI screening.

Cervical Arterial Injury After Blunt Trauma in Children

The incidence of cervical vascular injury (CVI) after blunt cervical trauma in children and adolescents is low. Potential harm from missed injury is high. Screening for CVI has increased with advances in noninvasive angiography, including computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). We attempt to characterize CVI in children and adolescents and evaluate the utility of advanced imaging in CVI screening in this patient population. Clinical and radiographic records of consecutive patients aged 4 to 18 years with blunt cervical spine trauma from 1998 to 2008 were reviewed. Patient demographics, injury pattern, neurological findings, and treatment were recorded. Sixty-one patients were identified. Nineteen underwent screening to evaluate for CVI, including 12 males and 7 females, mean age 13.5 years. The most common mechanism of injury was motor vehicle collision (n=11). Seven patients underwent MRA, 7 CTA, 3 had both studies, and 2 had traditional angiography. Seven patients had CVI, with an overall incidence of 11.5%. High-risk criteria (fracture extension to transverse foramina, fracture/dislocations or severe subluxations, or C1-C3 injury) were associated with increased rates of CVI. Neurological injury was found in 12/19 patients screened and 6/7 patients with CVI. Two of 7 patients underwent anticoagulation due to documented CVI. No delayed-onset ischemic neurological events occurred. After blunt cervical spine trauma, certain fracture patterns increase the risk of CVI. CVI is common, with a minimum incidence of 7/61 or >10% of pediatric patients with blunt cervical spine injury. Over 1/4 of patients studied on the basis of high-risk criteria had injury. Advanced imaging with noninvasive angiography (CTA/MRA) should be strongly considered in pediatric patients with cervical spine trauma. The presence of CVI may prompt a change in management. Level IV-retrospective diagnostic study.

Erect Radiographs to Assess Clinical Instability in Patients with Blunt Cervical Spine Trauma

Computed tomography (CT) and magnetic resonance imaging (MRI) are sensitive modalities for the assessment of the spine, but certain injuries remain poorly assessed with supine radiographs. We describe four cases in which cervical spine injuries were proven as unstable with erect radiographs after being previously evaluated with supine radiographs and CT scans. A retrospective review of medical records and images was used to identify four patients who presented to a teaching hospital from April to December 2010 with unstable cervical spine injuries that were only demonstrated on erect radiographs. All four patients sustained either C4-C5 or C5-C6 injuries. Prior to diagnosis, each had been evaluated with supine radiographs that did not demonstrate instability. Computed tomography identified the osseous injuries that were present but did not provide suitable assessment of stability. Three patients successfully underwent anterior cervical discectomy and fusion. The fourth was managed with a Halo jacket because of major comorbidities. Despite major advances in imaging, these cases highlight the importance of physiological loading and radiographs. The controlled use of erect radiographs to test for clinical instability in patients with cervical spine injuries should be considered except in cases in which instability is already evident on other imaging modalities and/or surgical treatment is already indicated.

To Screen or Not to Screen: Vertebral Artery Injuries in Blunt Cervical Spine Trauma

To present operative details and clinical follow-up of a series of patients with thoracic disk herniation treated with the minimally invasive technique of thoracic microendoscopic diskectomy (TMED).TMED was performed in 16 consecutive patients (age range, 18–79 years old) with 18 thoracic disk herniations. One patient with a calcified herniation in a direct ventral location was not included in this series. Patients were positioned prone, and a tubular retractor system was placed through a muscle dilating approach. The procedure was performed with endoscopic visualization. Outcomes were assessed using modified McNab criteria.There were no complications, and no case required conversion to an open procedure. The mean operative time was 153 minutes per level, and mean blood loss was 69 mL per level. Mean hospital stay was 21 hours. At a mean follow-up of 24 months (median, 22 months), 13 patients (81%) had excellent or good outcomes, 1 patient (6%) had a fair outcome, and 2 patients (13%) had poor outcomes. The two patients with poor outcomes had neurologic diagnoses (multiple sclerosis and multiple systems atrophy) that were ultimately found to be responsible for their symptoms and deficits.TMED is a safe and effective minimally invasive posterolateral approach for the treatment of thoracic disk herniations that lacks the morbidity associated with traditional approaches.

Blunt Cervical Spine Trauma and Distracting Injuries: Konstantinidis A, Demetriades D, Plurad D, et al. J Trauma 2011;71:528–32.

Blunt Cervical Spine Trauma and Distracting Injuries: Konstantinidis A, Demetriades D, Plurad D, et al. J Trauma 2011;71:528–32.

Evaluation of acute cervical spine imaging based on ACR Appropriateness Criteria®

The objectives of this study were to determine the rate of acute blunt cervical spine injury at an academic urban level 1 trauma center and to evaluate the utilization of cervical spine imaging based on the established American College of Radiology (ACR) Appropriateness Criteria®. We retrospectively reviewed all radiography and CT imaging of the cervical spine performed over a year period in adult patients presenting with acute blunt cervical spine trauma. Exclusion criteria were children ≤17years, non-acute trauma of ≥72h, and penetrating trauma. Any fracture, dislocation, or ligamentous instability demonstrated by diagnostic imaging and requiring stabilization or specialized follow-up was defined as clinically significant cervical spine injury. A total of 1,325 cervical spine studies were reviewed in 1,245 patients; 32.7% (433/1,325) were cervical spine radiographs and 67.3% (892/1,325) were CT examinations. Approximately 1.5% (19/1,245) of the patients demonstrated clinically significant acute cervical spine injury. There were 6.4% (80/1,245) patients who received both cervical spine radiographs and CT as imaging evaluation. Based on the ACR Appropriateness Criteria®, all of the cervical spine radiographs performed (433) were determined to be "inappropriate" imaging in the setting of acute cervical spine injury.