title: Vertebral artery injury associated with blunt cervical spine trauma: a multivariate regression analysis.
abstract: METHODS
  Retrospective analysis of prospective registry data.
  
  
  OBJECTIVE
  To determine the patient characteristics, risk factors, and fracture patterns associated with vertebral artery injury (VAI) in patients with blunt cervical spine injury.
  
  
  BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Hospital for Special Surgery, The Spine Care Institute, Spine & Scoliosis Surgery, New York, NY 10021, USA. drlebl@stanfordalumni.org
authors.forename: Darren R
authors.initials: DR
authors.lastname: Lebl
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Bono
authors.forename: George
authors.initials: G
authors.lastname: Velmahos
authors.forename: Umesh
authors.initials: U
authors.lastname: Metkar
authors.forename: Joseph
authors.initials: J
authors.lastname: Nguyen
authors.forename: Mitchel B
authors.initials: MB
authors.lastname: Harris
mesh_terms: D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae / Q000098:blood supply / Q000000981:diagnostic imaging / Q000293:injuries*; D005260:Female; D006801:Humans; D015576:Hyperostosis / Q000175:diagnosis / Q000209:etiology; D015601:Injury Severity Score; D004204:Joint Dislocations / Q000175:diagnosis / Q000209:etiology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography / Q000379:methods; D015999:Multivariate Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000209:etiology; D013124:Spinal Injuries / Q000150:complications* / Q000000981:diagnostic imaging; D013167:Spondylitis, Ankylosing / Q000175:diagnosis / Q000209:etiology; D020521:Stroke / Q000175:diagnosis / Q000209:etiology; D014193:Trauma Centers / Q000706:statistics & numerical data; D014711:Vertebral Artery / Q000000981:diagnostic imaging / Q000293:injuries*; D014949:Wounds, Nonpenetrating / Q000150:complications* / Q000000981:diagnostic imaging