Vertebral artery injury associated with a Jefferson fracture

Vertebral Artery Injury in the Cervical Spine: Anatomy, Diagnosis, and Management

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Although rare, injury to the vertebral artery (VA) can occur after blunt trauma or iatrogenically during surgery. Clinicians should be aware of the anatomic variants of the VA, the presence of which may increase the risk of iatrogenic VA injury (VAI).

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If VAI is suspected following blunt trauma, rapid identification via advanced imaging modalities, such as computed tomography angiography, can help clarify the site of injury and guide management.

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VAI can be classified according to the Denver grading scale for blunt cerebrovascular injury, ranging from grade I to grade V, which includes intimal narrowing, pseudoaneurysm formation, complete occlusion, and arterial transection.

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Treatment modalities remain controversial and include anticoagulation, endovascular interventions, surgical tamponade, ligation, and microvascular repair. The choice of treatment is influenced by the setting of the injury (iatrogenic injury in the operating room versus blunt trauma in the field) and the laterality of the dominant VA with respect to brain perfusion.

Cerebellar infarction after posterior direct reduction and fixation to treat an unstable Jefferson fracture: a case report

A 42-year-old man had an unstable Jefferson type IV atlas fracture with unilateral vertebral artery occlusion after a diving accident. We performed C1-ring reconstruction with a crosslink rod and C2 fixation to directly reduce the fracture fissure. Within 6 h, cerebellar hemisphere infarction developed. After decompressive craniectomy, duroplasty, and release of the vertebral artery occlusion caused by the transfixing rod, a postoperative computed tomography angiogram showed that blood flow in the right vertebral artery improved. We suggest cautiously inserting screws into the fractured C1 lateral mass and gently tightening the crosslink rod to prevent distal migration of a thrombus.

Resolution of traumatic vertebral artery dissection and occlusion after repositioning and posterior C1-ring osteosynthesis of a displaced Jefferson burst fracture

A 70-year-old male sustained a Jefferson burst fracture with unilateral vertebral artery dissection and occlusion by displaced fragments. We performed reduction and posterior C1-ring osteosynthesis. We present a description of the intraoperative manual assessment of atlantoaxial stability. The vertebral artery was found with a good anterograde flow posteroperatively, and MRA showed reperfusion of the vessel. The patient was free of pain with preserved C1-C2 rotation after 6 weeks. Function-preserving posterior C1-ring osteosynthesis after reduction in a displaced Jefferson burst fracture complicated by vertebral artery dissection and occlusion may restore blood flow.

Bilateral cerebellar and brain stem infarction resulting from vertebral artery injury following cervical trauma without radiographic damage of the spinal column: a case report

Vertebral artery injury can be a complication of cervical spine injury. Although most cases are asymptomatic, the rare case progresses to severe neurological impairment and fatal outcomes. We experienced a case of bilateral cerebellar and brain stem infarction with fatal outcome resulting from vertebral artery injury associated with cervical spine trauma. A 69-year-old male was admitted to our hospital because of tetraplegia after falling down the stairs and hitting his head on the floor. Marked bony damage of the cervical spine was not apparent on radiographs and CT scans, so the injury was initially considered to be a cervical cord injury without bony damage. However, an intensity change in the intervertebral disc at C5/C6, and a ventral epidural hematoma were observed on MRI. A CT angiogram of the neck showed the right vertebral artery was completely occluded at the C4 level of the spine. Forty-eight hours after injury, the patient lapsed into drowsy consciousness. The cranial CT scan showed a massive low-density area in the bilateral cerebellar hemispheres and brain stem. Anticoagulation was initiated after a diagnosis of the right vertebral artery injury, but the patient developed bilateral cerebellar and brain stem infarction. The patient's brain herniation progressed and the patient died 52 h after injury. We considered that not only anticoagulation but also treatment for thrombosis would have been needed to prevent cranial embolism. We fully realize that early and appropriate treatment are essential to improve the treatment results, and constructing a medical system with a team of orthopedists, radiologists, and neurosurgeons is also very important.

Unilateral C-1 lateral mass sagittal split fracture: an unstable Jefferson fracture variant

Object

The object of this study was to describe an unusual fracture subtype within C-1 injuries with a propensity to result in late deformity and pain. Most patients with C-1 injuries are nonsurgically treated using external immobilization unless there is an injury of the transverse atlantal ligament. The authors describe an unusual variant involving a unilateral sagittal split with a high tendency to late deformity and pain. They also review the literature and treatment of C-1 fractures.

Methods

A retrospective review of 12,671 CT scans from a Level I trauma center over a 6-year period yielded 54 patients with C-1 fractures. Among these patients, 6 had an unusual unilateral lateral mass sagittal split, which resulted in a late cock-robin deformity in all survivors and thus a surgical deformity correction with occipital-cervical instrumented fusions. Patient charts and radiographs were reviewed, this fracture subtype is described, and its treatment discussed.

Results

Radiographic studies in 6 patients with C-1 fractures demonstrated a unilateral sagittal split of the lateral mass but an intact transverse atlantal ligament. In the 3 surviving patients, a late cock-robin deformity, significant loss of neck rotation, and severe neck pain developed. Vertebral artery occlusion, as revealed on CT angiography, occurred in 1 patient. All patients were placed in traction and underwent successful occipital-cervical fusion and deformity correction. At the final follow-up, all patients had satisfactory pain relief and improved head alignment.

Conclusions

Patients with a unilateral sagittal split of the C-1 lateral mass have unstable injuries and must be carefully monitored, with a low threshold for surgical reconstruction or prolonged traction. Patients with late deformity can be successfully treated with occipital-cervical instrumented fusions.

Vertebral artery injury after blunt cervical trauma: an update

BACKGROUND

Vertebral artery injury (VAI) after blunt cervical trauma has been considered to be rare. The incidence of VAI has increased dramatically within the last decade after a heightened awareness of this entity on the part of spine surgeons. Diagnostic or therapeutic guidelines for VAI have not been established fully, however.

METHODS

A review of the literature published between 1990 and 2004 was conducted.

RESULTS

The incidence of VAI among total blunt trauma admissions ranged from 0.20% to 0.77%. Most VAI patients remained asymptomatic, but sudden unexpected deterioration was often reported. Distraction/extension, distraction/flexion, and lateral flexion injuries were the major mechanisms of injury. Dissection and occlusion were the frequent vascular injury patterns. Facet joint dislocations and the fractures extending into the transverse foramen were the spine injury patterns closely associated with VAI. Digital subtraction angiography was the most sensitive imaging study, but because of invasiveness, its role as a screening study remained questionable. Neuroradiological intervention was used successfully to treat hemorrhagic VAI and progressing vertebrobasilar stroke. Systemic anticoagulation with heparin was the preferred treatment for mild ischemia. Treatment of asymptomatic patients has been controversial because the natural history of VAI has not been elucidated. Prophylactic anticoagulation with heparin or the use of antiplatelet agents was advocated in recent studies.

CONCLUSIONS

Preemptive treatment may be reasonable in selected patients considering the devastating potentials of VAI. The potential risks of heparin or antiplatelet agents in relation to early cervical spine surgery have not been addressed fully, however, and spine surgeons have to weigh the risk and benefit of such treatment cautiously.

A lateral mass fracture of C1 associated with left vertebral artery and mid-basilar artery occlusion

Extreme acceleration and deceleration forces as well as axial loading are exerted at the occipito-cervical junction of drivers involved in high-velocity motor vehicle accidents, especially with fastened seatbelts. Injury at this level, usually lethal, can go unrecognized despite modern emergency management of the unconscious patient. A precise neurologic and radiographic workup of damage to this area is often not possible or overlooked in the initial phase of such severe trauma. We describe a patient with multiple injuries who sustained a left vertebral artery occlusion associated with a left-sided lateral mass fracture of C1 and a basilar artery occlusion resulting in a locked-in syndrome after an automobile accident.