Medical Management of Traumatic Vertebral Artery Injury Is Safe Regardless of the Severity of Injury.

BACKGROUND: Management of traumatic vertebral artery injury (VAI) remains under debate. Current consensus reserves surgical or endovascular management for high-grade injury in order to prevent stroke. We sought to evaluate the factors that influence posterior fossa stroke outcomes following traumatic VAI. METHODS: A search of the prospectively maintained PROOVIT trauma registry of patients older than 18 years of age with a diagnosis of VAI was performed at a level 1 trauma center from 2013 to 2019. Patient demographics, type of injury, the timing of presentation, Biffl Classification of Cerebrovascular Injury Grade score, medical management, procedural interventions, and stroke outcomes were analyzed. RESULTS: VAIs were identified in 66 trauma patients were identified out of 14,323 patients entered into the PROOVIT registry. The dominant mechanism was blunt injury (91.5% vs. 8.5%, blunt versus penetrating). Nine patients presented with symptomatic ipsilateral posterior circulation strokes visible on imaging. The average Biffl classification grade was similar between the stroke and nonstroke groups (2.0 vs. 1.5; P = 0.39). The average injury severity score (ISS) between stroke and nonstroke groups was also similar (9.0 vs. 14.0; P = 0.35). All 9 patients in the stroke group had magnetic resonance imaging verification of their infarct within an average of 21.2 hr from presentation. In the stroke group, 1 patient underwent diagnostic angiography but had no intervention. In the nonstroke group, all were treated with medical management alone and none underwent vertebral artery intervention. During a mean follow-up of 14.5 months, no patients experienced a new neurological deficit. CONCLUSIONS: The severity of VAI by Biffl grading and ISS are not associated with ischemic stroke at presentation following VAI. Medical management of VAI appears safe regardless of Biffl and ISS staging in this trauma population. Neurological changes related to embolic stroke were generally appreciated on presentation. Conservative medical management was sufficient to protect from secondary neurological deficit regardless of index vertebral injury.

Combined endovascular and skull base surgical management of pediatric craniocervical pathology: a case series.

OBJECTIVE: Pathological bony abnormalities of the craniocervical region in children sometimes require surgical intervention as part of their management. Rarely, abnormal skeletal or vascular anatomy can render traditional surgical techniques ineffective because of the risk of injury to the vertebral artery. To mitigate these risks, a combined endovascular and skull base approach was devised. The authors describe their experience using vertebral artery sacrifice as an adjunctive surgical method to reduce the risk of inadvertent vertebral artery injury during surgical correction of pediatric craniocervical deformity. METHODS: Three patients underwent vertebral artery sacrifice for structural craniocervical pathologies (1 male, 2 females; ages 12, 14, and 3 years). One patient presented with basilar invagination odontogenic brainstem compression, and the other 2 patients presented with congenital cervical fusion. All patients underwent endovascular left vertebral artery sacrifice after passing balloon test occlusion. RESULTS: No adverse effects from the vertebral artery sacrifice were observed. At the last follow-ups (35, 30, and 32 months), all 3 patients had a satisfactory outcome with no adverse effects as a result of their sacrificed artery. CONCLUSIONS: Endovascular vertebral artery sacrifice followed by skull base approaches can be used to effectively and safely treat craniocervical pathology from a variety of pediatric skeletal abnormalities.

Exploring the role of endovascular interventions in blunt carotid and vertebral artery trauma.

BACKGROUND: The role of endovascular interventions (EI) for blunt carotid and vertebral artery injuries (BCI and BVI) is poorly defined. The purpose of this study was to assess the efficacy of EI compared with antithrombotic therapy (AT) to inform future prospective study. METHODS: Retrospective review (2017-2022) of records at a Level I trauma center to determine injury, treatment, and outcome information. Primary outcome was stroke. RESULTS: 96 patients suffered 106 injuries (74 BVI, 32 BCI). 12 patients underwent 13 EI- 4 therapeutic, 9 prophylactic. Stroke occurred in 12 patients- 6 who had EI. In grade IV BVI, stroke rates are low with both EI and AT. Thrombectomy after stroke improved neurologic function in 4 (100%) of 4 patients. CONCLUSIONS: Most strokes occur prior to preventive therapy. Neither AT nor EI is 100% effective in preventing stroke. Thrombectomy may improve neurologic outcomes after stroke. Prospective multicenter study is imperative.

Trauma mechanisms and patterns of blunt cervical vascular injury: A descriptive study using a nationwide trauma registry.

OBJECTIVE: Blunt cervical vascular injury (BCVI) is a non-penetrating trauma to the carotid and/or vertebral vessels following a direct injury to the neck or by the shearing of the cervical vessels. Despite its potentially life-threatening nature, important clinical features of BCVI such as typical patterns of co-occurring injuries for each trauma mechanism are not well known. To address this knowledge gap, we described the characteristics of patients with BCVI to identify the pattern of co-occurring injuries by common trauma mechanisms. METHODS: This is a descriptive study using a Japanese nationwide trauma registry from 2004 through 2019. We included patients aged ≥13 years presenting to the emergency department (ED) with BCVI, defined as a blunt trauma to any of the following vessels: common/internal carotid artery, external carotid artery, vertebral artery, external jugular vein, and internal jugular vein. We delineated characteristics of each BCVI classified according to three damaged vessels (common/internal carotid artery, vertebral artery, and others). In addition, we applied network analysis to unravel patterns of co-occurring injuries among patients with BCVI by four common trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height). RESULTS: Among 311,692 patients who visited the ED for blunt trauma, 454 (0.1%) patients had BCVI. Patients with common/internal carotid artery injuries presented to the ED with severe symptoms (e.g., the median Glasgow Coma Scale was 7) and had high in-hospital mortality (45%), while patients with vertebral artery injuries presented with relatively stable vital signs. Network analysis showed that head-vertebral-cervical spine injuries were common across four trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height), with co-occurring injuries of the cervical spine and vertebral artery being the most common injuries due to falls. In addition, common/internal carotid artery injuries were associated with thoracic and abdominal injuries in patients with car accidents. CONCLUSIONS: Based on analyses of a nationwide trauma registry, we found that patients with BCVI had distinct patterns of co-occurring injuries by four trauma mechanisms. Our observations provide an important basis for the initial assessment of blunt trauma and could support the management of BCVI.

[Dissection technique for organs of the neck in hanging]. / Tekhnika sektsionnogo issledovaniya organokompleksa shei pri poveshenii.

The aim of this study is to develop a comprehensive dissection technique to examine the deep structures of the neck in hanging, including extraction of the cervical spine and investigation of the removed segment with access to vertebral arteries and spinal cord. Its advantages include the unnecessity of any special instruments usage, the short period of time, which is necessary for performing dissection techniques, as well as the possible detailed examination of the spine, spinal cord and vertebral arteries. The improved dissection technique simplifies the diagnosis of injuries and increases the objectivity of the forensic medical examination in hanging.

Ultrasonography is an effective tool for the evaluation of traumatic vertebral artery injuries distal to fourth cervical vertebra in the emergency room.

BACKGROUND: This study aimed to determine the feasibility of ultrasonography in the assessment of cervical vertebral artery (VA) injury as an alternative to computed tomography angiography (CTA) in the emergency room. METHODS: We analyzed 50 VAs from 25 consecutive patients with cervical spine injury that had been admitted to our emergency room. Ultrasonography and CTA were performed to assess the VA in patients with cervical spine injury. We examined the sensitivity and specificity of ultrasonography compared with CTA. RESULTS: Among these VAs, six were occluded on CTA. The agreement between ultrasonography and CTA was 98% (49/50) with 0.92 Cohen's Kappa index. The sensitivity, specificity, and positive and negative predictive values of ultrasonography were 100%, 97.7%, 85.7%, and 100%, respectively. In one case with hypoplastic VA, the detection of flow in the VA by ultrasonography differed from detection by CTA. Meanwhile, there were two cases in which VAs entered at C5 transverse foramen rather than at C6 level. However, ultrasonography could detect the blood flow in these VAs. CONCLUSIONS: Ultrasonography had a sensitivity of 100% compared with CTA in assessment of the VA. Ultrasonography can be used as an initial screening test for VA injury in the emergency room.

Morphology analysis of the C2 pediculoisthmic component and feasibility of safe C2 pedicle screw placement: comparison of multiplanar reconstruction versus traditional radiographic methods.

BACKGROUND: Preoperatively evaluating the feasibility of safe C2 pedicle screw placement is the key to avoiding iatrogenic vertebral artery injury. However, it has not been verified whether the conventional CT measurements of C2 pediculoisthmic component (PIC) are reliable and accurate, and the results may lack validity. The purpose of this study is to analyze the evaluative performance of conventional CT measurements and to create an accurate predictor of morphometrics of C2 PIC. METHODS: A total of 304 C2 PICs were measured in 152 consecutive patients who underwent CT examination of the cervical spine between April 2020 and December 2020. We obtained the morphometric parameters of C2 PIC by measuring minimum PIC diameter (MPD) in CT multiplanar reconstruction versus conventional measurements of transverse PIC width (TPW), oblique PIC width (OPW) and definition of high-riding vertebral artery (HRVA). The outer diameter measured less than 4 mm in MPD was regarded as the standard of precluding safe C2 pedicle screw insertion. The evaluative performance of the conventional CT measurements was assessed, and the correlation between conventional CT measurements and measurements in CT multiplanar reconstruction was calculated. RESULTS: The parameters in OPW and MPD were measured significantly larger than those in TPW, and the preclusion of C2 pedicle screw placement evaluated from TPW and HRVA was significantly higher than that evaluated from OPW and MPD. The sensitivity of TPW was 93.09%, and the specificity was 79.31%. The sensitivity and specificity of OPW were 97.82% and 82.76%. The sensitivity of HRVA was 88.36%, and the specificity was 96.55%. Strong agreement with the highest correlation coefficient (0.879) and determination coefficient (0.7720) suggested that the outer diameter of OPW could be useful for the precise prediction of MPD. CONCLUSIONS: CT MPR allows accurate measurement of the narrowest section of the C2 PIC. The outer diameter of OPW could be simply measured and be useful for precise prediction of MPD, which makes C2 pedicle screw placement more safely than the conventional measurement of TPW and HRVA.

VertebralArtery Injury with Anterior Cervical Spine Operations: A Systematic Review of Risk Factors, Clinical Outcomes, and Management Strategies.

OBJECTIVE: Anterior cervical spine operations are commonly performed on cervical spine pathologies and to a large extent are safe and successful. However, these surgical procedures expose the vertebral artery, posing a risk of harm to it. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to critically assess primary articles discussing treatment strategies "vertebral artery injury" AND "anterior cervical spine" and develop a management strategy based on our experience and meta-analysis of the literature. In addition, we present an illustrative case of iatrogenic vertebral artery injury presenting with 6 to 7 months' history of progressive dysphagia was transferred to our care from an outside institution. RESULTS: Included and analyzed were 43 articles that detailed 75 cases involving vertebral artery injury (VAI) in anterior cervical spine operations. Preoperatively, frequent clinical findings reported were sensory deficit (26 patients [63.41%]), motor deficit (20 patients [48.78%]), and pain (17 patients [41.46%]). In total, 32 patients (50.00%) endured injury of their left VA, and 30 patients had a right VAI. The 2 common causes of VAI were drilling (24 patients [40.00%]) and instrumentation (8 patients [13.33%]). CONCLUSIONS: Altogether, our review recommends repair or tamponade packing with a hemostatic agent for primary management. Should tamponade packing with a hemostatic agent be used for primary management, secondary management should entail either repair, stenting occlusion, embolization, anticoagulants, or ligation. Further examination of this treatment strategy based on a larger cohort is necessary.

Application of C2 subfacetal screws for the management of atlantoaxial dislocation in patients with Klippel-Feil syndrome characterized by a narrow C2 pedicle and high-riding vertebral artery.

OBJECTIVE: This study aims to investigate the clinical application and feasibility of C2 subfacetal screws in patients with Klippel-Feil syndrome (KFS), narrow C2 pedicles, and high-riding vertebral arteries (HRVAs). METHODS: The clinical data of seven patients with KFS, atlantoaxial dislocation, narrow C2 pedicles, and HRVAs treated with C2 subfacetal screws were analyzed in this retrospective study. The internal height, isthmus height, and pedicle width of C2 vertebra were measured using preoperative computed tomography (CT). Subfacetal screws were inserted for 7 patients (12 sides). The position and length of the screws were observed using postoperative CT. Intraoperative dura mater and vertebral artery (VA) injuries were recorded. Bone fusion was observed using follow-up CT. RESULTS: The internal height was 10.5 ± 3.2 mm, the isthmus height was 3.7 ± 1.8 mm, the pedicle width was 3.0 ± 1.4 mm, and the screw length was 19.7 ± 1.5 mm. All patients had HRVAs and narrow pedicles. No injury to the dura mater and vertebral artery (VA) occurred in this group of patients. Bone fusion was achieved in all patients during follow-up. CONCLUSIONS: In patients with KFS, HRVA, and a narrow C2 pedicle, there is sufficient space below the C2 articular surface for screw insertion. When the pedicle is narrow and the C2 pedicle screw is not suitable for placement due to possible injury to the VA, subfacetal screws are a feasible alternative.

Vision Loss Following Vertebral Artery Injury during Surgery for Atlantoaxial Instability.

Background: A number of complications following surgery aimed at atlantoaxial fixation have been reported. However, there is no report in the literature describing visual loss following vertebral artery injury. Objective: Vision loss as a complication of vertebral artery injury during surgery for atlantoaxial fixation is reported. Material and Methods: This is a report of two patients who were operated for atlantoaxial instability by the Goel technique of atlantoaxial fixation. During surgery, there was an injury to the vertebral artery and the artery had to be sacrificed. Results: Both patients suffered severe visual loss following surgery. One patient had a partial visual recovery that started within few days of surgery while the other patient remained completely blind. Conclusions: Although rare, visual loss can be a complication of vertebral artery sacrifice during surgery for atlantoaxial stabilization.

Accuracy of Axis Drill Guides in the Cases of Atlantoaxial Instabilities Associated With High-Riding Vertebral Arteries, Narrow Pedicles, and Complex Deformities: Comparison of 3 Fixation Methods.

OBJECTIVE: To contrast the accuracy of C2 navigation template-assisted versus freehand pedicle and/or pars screw fixation in high-risk cases where a high-riding vertebral artery (VA) or narrow pedicle and complex deformities were associated. METHODS: In our hospital, computed tomography (CT) data of 30 patients with pathology on C0-1-2, who had risk factors for VA injury, that were complex cervical deformities, atlantoaxial instabilities with narrow C2 pedicle and/or HRVA variations were retrospectively reviewed. Using computer-aided design software and desktop printer we printed 3 sets of high cervical models per case. We divided them into 3 groups using 3 different C2 screw fixation techniques: the freehand pars screw fixation group, the freehand pedicle screw fixation group, and the navigation template-assisted pedicle screw fixation group. After 180 screw placements were finished, the parts underwent a CT scan. Then the breach rates on postoperative scans were measured. RESULTS: Our results showed that the accurate placement rate is not noticeably different between navigation template-assisted and freehand pedicle screws, where the high-riding vertebral artery and narrow pedicles were associated, but was better in the navigational template group with complex deformities. Pars screws were found to be superior in terms of accuracy. CONCLUSIONS: The current study suggests that navigational template-assisted pedicle screws are risky for high-risk individuals with abnormal anatomy, such as those with a high-riding vertebral artery, a narrow pedicle, and complex abnormalities, and alternative C2 pars screws may be a reliable option for such individuals.

[The effect of axis pedicle and intra-axial vertebral artery on C 2 pedicle screw placement].

Objective: To investigate the influence of axis pedicle and intra-axial vertebral artery (IAVA) alignment on C 2 pedicle screw placement by measuring the data of head and neck CT angiography. Methods: The axis pedicle diameter (D), isthmus height (H), isthmus thickness (T), and IAVA alignment types were measured in 116 patients (232 sides) who underwent head and neck CT angiography examinations between January 2020 and June 2020. Defined the IAVA offset direction by referencing the vertical line through the center of C 3 transverse foramen on the coronal scan, it was divided into lateral (L), neutral (N), and medial (M). Defined the IAVA high-riding degree by referencing the horizontal line through the outlet of the C 2 transverse foramen, it was divided into below (B), within (W), and above (A). The rate of pedicle stenosis, high-riding vertebral artery, and different IAVA types were calculated, and their relationships were analysed. Simulative C 2 pedicle screws were implanted by Mimics 19.0 software, and the interrelation among the rates of pedicle stenosis, high-riding vertebral artery, IAVA types, and vertebral artery injury were analyzed. Results: The rate of C 2 pedicle stenosis was 33.6% (78/232), and the rate of high-riding vertebral artery was 35.3% (82/232). According to the offset direction and the degree of riding, IAVA was divided into 9 types, among which the N-W type (29.3%) was the most, followed by the L-W type (19.0%) and the L-B type (12.9%), accounting for 60.9%. The vertebral artery injury rate of simulative implanted C 2 pedicle screws was 35.3% (82/232). The vertebral artery injury rate in patients with pedicle stenosis and high-riding vertebral artery was significantly higher than that who were not ( P<0.001). The rate of pedicle stenosis, high-riding vertebral artery, and vertebral artery injury were significantly different among IAVA types ( P<0.001), and M-A type was the most common. Conclusion: Vertebral artery injury is more common in pedicle stenosis and/or high-riding vertebral artery and/or IAVA M-A type. Preoperative head and neck CT angiography examination has clinical guiding significance.

Safety of early posterior fusion surgery without endovascular embolization for asymptomatic vertebral artery occlusion associated with cervical spine trauma.

PURPOSE: Vertebral artery occlusion (VAO) is an increasingly recognized complication of cervical spine trauma. However, the management strategy of VAO remains heavily debated. Therefore, the aim of this retrospective study was to investigate the safety of early fusion surgery for traumatic VAO. METHODS: This study included a total of 241 patients (average age 64.7 years; 201 men) who underwent early surgical treatment for acute cervical spine injury between 2012 and 2019. The incidence of VAO, cerebral infarction rates, the recanalization rates, and cerebral thromboembolism after recanalization were retrospectively analyzed. RESULTS: VAO occurred in 22 patients (9.1%). Of the 22 patients with VAO, radiographic cerebral infarction was detected in 4 patients (21.1%) at initial evaluation, including 1 symptomatic medullar infarction (4.5%) and 3 asymptomatic cerebrum infarctions. A patient who experienced right medullar infarction showed no progression of the neurologic damage. Follow-up imaging revealed that the VAOs of 9 patients (40.9%) were recanalized, and the recanalization did not correlate with clinical adverse outcomes. The arteries of the remaining 13 (59.1%) patients remained occluded and clinically silent until the final follow-up (mean final follow-up 33.0 months). CONCLUSION: Despite the lack of a concurrent control group with preoperative antiplatelet therapy or endovascular embolization for VAO, our results showed low symptomatic stroke rate (4.5%), high recanalization rate (40.9%), and low mortality rate (0%). Therefore, we believe that the indication for early stabilization surgery as management strategy of asymptomatic VAO might be one of the safe and effective treatment options for prevention of symptomatic cerebral infarction.

Vertebral arteriovenous fistula due to blunt neck trauma: A case report.

The arteriovenous fistulas (AVFs) of the vertebral artery are usually caused by iatrogenic and penetrating traumas. Vertebral AVF is rarely seen after blunt cervical trauma. A 65-year-old male patient applied to the emergency clinic due to falling from a height of about 3 m. In his neurological examination, he had weakness in the left upper limb and tinnitus in the left ear. The cervical computed tomog-raphy examination showed a Hangman's fracture, a C3 vertebra corpus compression fracture, and a C1 anterior arch fracture. There was a separation on the C1-2 transverse foramen due to the fracture, and there was a fracture in the left C3-4 transverse foramen. In cervical magnetic resonance imaging (MRI), the presence of a contusion in the spinal cord at the C2 corpus level was observed. Through an MRI angiography examination of the vertebral artery, it was determined that the left vertebral artery had developed an AVF at the V2-3 segment level. Stabilization surgery was performed with a posterior approach for unstable vertebrae. Then, vertebral AVF was then closed endovascularly using a stent coil. Improvement in neurological deficit was seen after surgery and endovascular treatment. There were no complications related to the procedure. Transverse foramen should be carefully evaluated, especially in the upper cervical trauma. Vertebral artery imaging should be performed before instability surgery in the presence of a separation in the fracture line to determine whether the damage to the vertebral artery is iatrogenic.

Current Concepts in Imaging Diagnosis and Screening of Blunt Cerebrovascular Injuries.

Blunt cerebrovascular injury (BCVI) is an often underrecognized injury occurring in the carotid or vertebral arteries, associated with a risk of ischemic stroke and potential for poor neurological outcome or death. Computed tomographic angiography (CTA) is the most common modality for initial screening and diagnosis. Vessel wall intimal injuries, intraluminal thrombus, dissection, intramural hematoma, pseudoaneurysm, vessel transection, and arteriovenous fistula, are potential findings to be considered in approach to imaging. Identification of high-risk trauma patients based on clinical and radiological risk factors can determine patients at risk of BCVI for targeted screening.

Iatrogenic Vascular Injury Associated with Cervical Spine Surgery: A Systematic Literature Review.

BACKGROUND: Iatrogenic vascular injury is an uncommon complication of anterior and/or posterior surgical approaches to the cervical spine. Although the results of this injury may be life-threatening, mortality/morbidity can be reduced by an understanding of its mechanism and proper management. METHODS: We conducted a literature review to provide an update of this devastating complication in spine surgery. A total of 72 articles including 194 cases of vascular lesions following cervical spine surgery between 1962 and 2021 were analyzed. RESULTS: There were 53 female and 41 male cases (in addition to 100 cases with unreported sex) with ages ranging from 3 to 86 years. The vascular injuries were classified according to the spinal procedures, such as anterior or posterior cervical spine surgery. The interval between the symptom of the vascular injury and the surgical procedure ranged from 0 to 10 years. Only two-thirds of patients underwent intra- or postoperative imaging and the most frequently injured vessel was the vertebral artery (86.60%). Laceration was the most common lesion (41.24%), followed by pseudoaneurysm (16.49%) and dissection (5.67%). Vascular repair was performed in 114 patients. The mortality rate was 7.22%, and 18.04% of patients had 1 or more other complications. Most presumed causes of vascular lesions were by instrumentation/screw placement (31.44%) or drilling (20.61%). Sixteen patients had an anomalous artery. Direct microsurgical repair was achieved in only 15 cases. CONCLUSIONS: Despite increased anatomical knowledge and advanced imaging techniques, we need to consider the risk of vascular injury as a surgical complication in patients with cervical spine pathologies.

Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study.

BACKGROUND: Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS: An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS: Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION: Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, Level IV.

Penetrating injuries to the vertebral artery: interventions and outcomes from US Trauma Centers.

PURPOSE: Penetrating injuries to the vertebral artery are rare and incompletely studied. Operative, angioembolic, and nonoperative strategies are management options, although the association between management strategy and outcomes is unknown. This study endeavored to define the epidemiology, management strategy, and outcomes after penetrating injuries to the vertebral artery presenting to trauma centers nationwide. METHODS: Patients with veterbral artery injuries were identified from the National Trauma Data Bank (NTDB) (2016-2017) using ICD-10-CM codes. Only those with penetrating mechanisms of injury were included in the study. Transferred patients were excluded. Study groups were defined by management strategy (Operative management, OM; angioembolization, AE; and nonoperative management, NOM). Patient demographics, injury characteristics, and outcomes were compared between groups using univariate analysis. Multivariate analysis with logistic regression was used to examine independent risk factors for mortality and stroke. RESULTS: Penetrating injuries to the vertebral artery were rare (n = 476, < 1% of NTDB patient population). Median age was 28 [IQR 21-37] years and 81% (n = 385) of patients were male. Interpersonal violence was the most common injury intent (n = 374, 79%). Most patients were managed with NOM (n = 409, 86%), with AE and OM utilized less frequently (8% and 6%, respectively). Stab wounds were the most frequent mechanism of injury among patients managed with OM (62%), while gunshot wounds were most common among patients managed with NOM (84%) or AE (79%). Multivariate analysis of risk factors for stroke revealed only associated carotid artery injury (OR 4.236, 95% CI 1.284-13.970, p = 0.018) and AE (OR 6.342, 95% CI 1.417-28.399, p = 0.016) were independent predictors. Independent risk factors for mortality were advanced age (OR 1.026, 95% CI 1.001-1.052, p = 0.044); elevated ISS (OR 1.030, 95% CI 1.008-1.052, p = 0.006); and associated traumatic brain injury (OR 3.020, 95% CI 1.333-6.843, p = 0.008). Higher ED GCS was independently associated with reduced mortality (OR 0.788, 95% CI 0.731-0.849, p < 0.001). CONCLUSIONS: Vertebral artery injuries after penetrating mechanisms are infrequent in the United States. Patients with these injuries tend to be young adult men who were injured by gunshot wounds as a result of interpersonal violence. The majority of these injuries were managed nonoperatively, with operative intervention required most commonly for patients injured by stab wounds. Risk factors for both stroke and mortality were principally due to patient factors and associated injuries. Increased risk of stroke among patients managed with angioembolization will need to be further investigated with future study to determine if this risk is imparted from the management strategy itself or from underlying injury characteristics.

Prevención, manejo y seguimiento de las lesiones de la arteria vertebral. Conocimiento actual de los cirujanos de columna de la Argentina / Prevention, management and monitoring of vertebral artery injuries. Current state of knowledge of spine surgeons in Argentina

Introducción: La lesión de la arteria vertebral es un evento grave. El objetivo del estudio fue evaluar el grado de conocimiento de los cirujanos de columna en la Argentina sobre las medidas diagnósticas y terapéuticas de la lesión de la arteria vertebral. Materiales y métodos: Se realizó un estudio descriptivo observacional mediante una encuesta difundida a través de la AANC y la SAPCV. Resultados: Se recibieron 157 respuestas. El 47,4% considera relevante evaluar la anatomía de la arteria vertebral en todo tipo de patología mediante métodos angiográficos. La mitad de los encuestados diagnosticó una variante anatómica de la arteria. El 29,2% manifestó haber tenido en su práctica una lesión de la arteria. Solo el 35% tiene un protocolo de acción para el manejo de este evento adverso. El 77% adopta como primera medida el taponamiento. En el seguimiento posquirúrgico, la mayoría estudia el estado final mediante métodos angiográficos. Alrededor del 10% procuraría instaurar alguna medida de profilaxis antitrombótica. El 76,6% dispone de Servicio de Hemodinamia con cirujano endovascular. Conclusión: Esta complicación está subestimada. Menos de la mitad de los cirujanos utiliza, como rutina, herramientas de diagnóstico de posibles alteraciones anatómicas. No se han observado protocolos de manejo ni seguimiento de estas lesiones. Nivel de Evidencia: IV

Introduction: Vertebral artery injury is a serious event. The objective of this work is to evaluate the degree of knowledge of spinal surgeons in Argentina regarding the diagnostic and therapeutic measures of vertebral artery injury. Materials and methods: An observational descriptive study was carried out through a survey transmitted through AANC and SAPCV. Results: Of 157 responses, 47.4% consider it relevant to evaluate the anatomy of the vertebral artery in all types of pathology by angiographic methods. Half of those surveyed diagnosed an anatomical variant of the artery, 29.2% reported having encountered an artery injury during their practice and only 35% had an action protocol for the management of this adverse event. 77% adopted tamponade as their first measure. In the postoperative follow-up, the majority of surgeons studied the final state of the situation using angiographic methods. Around 10% would try to establish some measure of antithrombotic prophylaxis. 76.6% have an hemodynamics service with an endovascular surgeon. Conclusion: We found an underestimation of this complication. Less than half of surgeons routinely use diagnostic tools for possible anatomical changes. Management or monitoring protocols for these injuries have not been observed. Level of Evidence: IV