CLASSIC CASES

Vertebral artery injury following cervical spine fracture

Augustin Luna Tovar, MD
Antillas, Mexico

Case Presentation
43 year old male injured in a motor vehicle crash in which his car rolled over. The patient was first managed in a County hospital and was transferred to our hospital (Level 1) 48hrs later. On arrival in the emergency department he was fully conscious (Glasgow Coma Score 15) and complaining of headache. Physical examination revealed skin lesions on the left showlder and vertical nystagmus. Lateral cervical spine X-ray film showed a C2 fracture, confirmed on CT scan.

CT scan of the brain was suggestive of cerebellar infarction and this was confirmed on magnetic resonance imaging.

At that point it was clear our patient had an ipsilateral vertebral artery injury, thus we asked for an MR angiography that reveals nonopacification of the left vertebral artery consistent with occlusion. A neurosurgical consult was warranted, the patient recived treatment with steroids and cervical collar and finally nine days later was discharged without dizziness or headache.

Discussion
Karim Brohi (London, UK):
The association between cervical spine fractures and vertebral artery injury is well documented, although the true incidence of the condition and its significance remains unclear. Imaging of the vertebral artery is not routine in cervical spine trauma, so those case reports in the literature tend to report only those patients presenting with neurologic deficits, as with this patient. Four studies have prospectively evaluated cervical spine injuries using conventional or magnetic resonance angiography. The incidence of vertebral artery injury with cervical spine fracture ranged between 24% and 46%. However only about one quarter of these patient will have neurological deficits.

Young asymptomatic patients are probably at low risk for neurologic sequelae of unilateral vertebral artery injury due to the presence of a contralateral normal vertebral. However older patients may be at increased risk if the contralateral artery is already stenosed or occluded. Unlateral complete occlusion is probably more innocent than a dissection or false aneurysm as these injuries may be more likely to lead to distal embolization. Magnetic resonance angiography is non-invasive and reputed to have an accurracy of approximately 80%. However it may be less sensitive than conventional angiography, and the role of duplex ultrasound is also unclear.

Patients with cervical spine fracture who have neurological deficits suggestive of vertebral artery injury, or those with high-risk fractures (involving the foramen transversarium) should undergo either conventional or magnetic resonance angiography.

References
1. Giacobetti FB; Vaccaro AR; Bos Giacobetti MA et al. 'Vertebral artery occlusion associated with cervical spine trauma. A prospective analysis' Spine 1997;22:188-92

2. Willis BK, Greiner F, Orrison WW et al. 'The incidence of vertebral artery injury after midcervical spine fracture or subluxation' Neurosurgery 1994;34:435-442

3. Friedman D; Flanders A; Thomas C; Millar W. 'Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences' Am J Roentgenol 1995;164:443-447; discussion 448-449

4. Weller SJ; Rossitch E Jr; Malek AM ' Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography' J Trauma 1999;46:660-666

5. Vaccaro AR; Klein GR; Flanders AE et al. 'Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography' Spine 1998;23:789-794; discussion 795

trauma.org (5:6) June 2000