Vertebral artery injuries associated with cervical spine injuries: a review of the literature

Objective: To determine the incidence of vertebral artery injuries (VAIs) in association with cervical spine trauma and investigate the optimum diagnostic and treatment protocols. Summary of Background Data: VAIs may result from cervical spine trauma and have the potential to cause cerebral, brainstem, and even spinal cord ischemia. Screening and treatment for traumatic VAI are very controversial, with conflicting recommendations within the trauma and spine literature. Methods: A literature review was performed to identify publications pertaining to VAIs associated with cervical spine trauma. These publications were evaluated to determine the incidence, radiographic evaluation, and treatment options of VAIs. Results: Approximately 0.5% of all trauma patients will have a VAI, and 70% of all traumatic VAIs will have an associated cervical spine fracture. Cervical spine translation injuries and transverse foramen fractures are most commonly cited as having a significant association with VAIs. The incidence of neurologic deficits secondary to VAI ranges from 0% to 24% in published series that incorporate a screening protocol for asymptomatic patients. Catheter angiography has been the gold standard for the diagnosis of VAIs; however, new 16-slice computed tomography angiography seems to have sensitivity and specificity close to that of catheter angiography. Treatment options include observation, antiplatelet agents, anticoagulation, and endovascular treatments. Although some authors have advocated antithrombotic therapy for most asymptomatic VAIs, there is a lack of class I evidence to support any strong guidelines for treatment. Conclusions: VAIs can occur in association with cervical spine trauma and have the potential for neurological ischemic events. Screening for and treatment of asymptomatic VAIs may be considered, but it is unclear based on the current literature whether these strategies improve outcomes.