颈椎骨折脱位合并椎动脉损伤

目的　探讨颈椎骨折脱位与椎动脉损伤的相关性。方法　 2 0例闭合性颈椎创伤患者 ,同时接受颈椎MRI和椎动脉磁共振血管成像 (MRA)检查。结果　 2 0例闭合性颈椎损伤中 ,5例无椎动脉血流成像 ,均为单侧 ,左侧 2例 ,右侧 3例。其中颈椎骨折 3例 ,单侧小关节脱位 1例 ,无放射影像的异常脊髓损伤 1例。 4例椎动脉损伤患者无任何症状 ,1例有轻度头昏、嗜睡。结论　颈椎骨折脱位可并发椎动脉损伤 ,由于缺乏特异性症状 ,前瞻性MRA检查是最重要的方法。     

Vertebral artery occlusion after acute cervical spine trauma

STUDY DESIGN: A retrospective study of vertebral artery injury diagnosed during the last 6 years in our institution. OBJECTIVES: To determine the clinical and radiologic features of vertebral artery injury. SUMMARY OF BACKGROUND DATA: Extracranial occlusion of the vertebral artery associated with cervical spine fracture is uncommon and can cause serious and even fatal neurologic deficit due to back lifting and cerebellar infarction. Magnetic resonance imaging and magnetic resonance angiography are extremely helpful in the examination of acute injuries of the cervical spine. METHODS: Magnetic resonance imaging and magnetic resonance angiography were performed at the time of injury. RESULTS: The authors reviewed six patients with cervical spine fractures who were diagnosed with a unilateral occlusion of the vertebral artery by means of magnetic resonance imaging/magnetic resonance angiography. One patient had signs of vertebrobasilar insufficiency and another with complete cord lesion had cerebellar and back lifting infarctions. Surgical anterior spinal fusion was performed in five patients, and one was treated by traction and orthosis. At the time of discharge, five patients had no vertebrobasilar symptoms, and the patient who experienced vertebrobasilar territory infarctions showed no progression of the neurologic damage. CONCLUSIONS: Vertebral artery injury should be suspected in cervical trauma patients with facet joint dislocation or transverse foramen fracture. Magnetic resonance imaging/magnetic resonance angiography is a helpful test to rule out vascular injury. Vertebral artery injury affects the extracranial segment at the same level as the cervical fracture. This is a retrospective review that did not permit drawing conclusions about the effects of early surgical stabilization in the treatment of cervical spine injuries with associated vertebral artery injury; however, surgical stabilization may avoid propagation and embolization of the clot located at the site of the lesion.     

颈椎闭合性创伤合并椎动脉损伤的机制及MRA诊断

目的探讨颈椎闭合性骨折脱位继发椎动脉损伤的机制及MRA诊断.方法本组95例颈椎闭合性创伤,男76例,女19例,年龄16～65岁,平均34岁.所有患者接受颈椎MRI和椎动脉MRA检查,当椎动脉预期位置完全无血流成像,MRI T2横断面上椎动脉内有高信号血栓影像时,即确诊为椎动脉阻塞.结果本组95例中,19例合并有椎动脉闭塞,均为单侧,左侧9例,右侧10例,其中颈椎骨折5例,双侧小关节突脱位6例,单侧小关节突脱位7例,无放射影像异常的脊髓损伤1例.18例椎动脉损伤患者无任何症状,1例有轻度头昏、嗜睡.结论椎动脉损伤易继发于有小关节突脱位的颈椎创伤,前瞻性MRA检查是首选的方法.     

Occlusion of the vertebral artery in cervical spine dislocations

We studied 12 consecutive patients with facet joint dislocation in the cervical spine to assess the incidence, site and clinical sequelae of occlusion of the extracranial vertebral artery. Intra-arterial digital subtraction angiography was performed after the orthopaedic management of the dislocations. This demonstrated vertebral artery occlusion (one bilateral) in five of the seven patients with bilateral dislocations and in four of the five patients with unilateral dislocations. Two of the nine patients with vertebral artery occlusion had neurological deficits above the level of the injury, all of which resolved spontaneously within two months. In our experience, a distraction-flexion injury appears to be the most common cause of closed traumatic vertebral artery occlusion.     

Fatal basilar artery thrombosis after traumatic cervical facet dislocation. Case report

The authors detail a rare case of basilar artery thrombosis in a patient with traumatic cervical spine facet dislocation. Although the patient's deficits could initially be explained by the spinal injury, deterioration to a "locked-in-state" could not. In addition to vertebral artery injuries, the basilar artery can also be indirectly involved in cases of cervical spine trauma. In the rare viable patient, immediate reduction of cervical spine dislocation may allow endovascular thrombolysis, if not otherwise contraindicated.     

Lateral cervical spine dislocation and vertebral artery injury.

Although anterior and posterior traumatic displacement of cervical vertebrae are commonly noted, and the devastating neurological deficits associated with these injuries have been amply defined, lateral displacement with fractures has been rarely recognized, and the clinical significance of this injury has been overlooked. This report describes five cases of cervical spine fractures with lateral dislocation. All patients had lateral and anteroposterior cervical spine radiographs as well as cervical angiography or postmortem study demonstrating either complete occlusion or significant impairment of flow of the vertebral arteries. Two cases had traumatic vertebral artery occlusion with secondary medullary and cerebellar infarction resulting in the patient's death. Vertebral artery injury apparently is not uncommon in this particular type of fracture. The diagnosis of these vascular injuries may require angiography or magnetic resonance angiography. A vertebral occlusion or dissection is a problem of considerable complexity, requiring individualized management depending on the patient's symptomatology, location and nature of the injury, and time lapsed since the injury.     

Poor surgical technique in cervical plating leading to vertebral artery injury and brain stem infarction--case report

BACKGROUND: Lateral mass plating is a safe fixating system for lower cervical fractures. Brain stem infarction after cervical lateral mass screw plating has not been reported in previous literature. We report a case of poor surgical technique leading to vertebral artery injury and brain stem infarction after cervical lateral mass plating. CASE DESCRIPTION: A 41-year-old male patient was transferred to our hospital because of hemiparesis and dysarthria immediately after lateral mass plating for fracture and dislocation of the fifth and sixth cervical vertebrae. Brain magnetic resonance imaging showed infarction of the left posterior inferior cerebellar artery territory, and the vertebral artery angiography showed complete occlusion of the left vertebral artery. The cervical computed tomography revealed a left screw of the fifth and sixth cervical vertebrae penetrating the central portion of the transverse foramen. The patient was managed with anticoagulant and supportive therapy only, with subsequent improvement of hemiparesis and dysarthria. CONCLUSIONS: Poor surgical technique of lateral mass plating in the cervical spine could lead to vertebral artery injury and even brain stem infarction. Postoperative brain infarction in cervical fusion could be a complication of the usually safe lateral mass plating of the cervical spine.     

Operative treatment for cervical fracture and dislocation with blunt unilateral vertebral artery injury

Objective： To investigate risks and clinical effects of operative treatment for cervical vertebral fracture and dislocation associated with unilateral vertebral artery injury. Methods： This group consisted of 76 cases of closed cervical spine trauma combined with unilateral vertebral artery injury （23 cases of bilateral facet dislocation, 28 unilateral facet dislocation and 25 fracture）. All patients underwent prospective examination of cervical spine MRI and vertebral artery two-dimensional time-of-flight （2D TOF） magnetic resonance angiography （MRA）, and anterior cervical decompression. The healthy vertebral artery paths were evaluated before the surgery, and were protected during the surgery according to the anatomical signs. Results： There were no acute or chronic clinical dam- age symptoms in 76 cases after surgery. No neural damage symptoms were observed in patients with normal neural functions. The neural functions of incomplete paralyzed patients were improved in different grades. Conclusions： Reliable anterior operation can produce good results for cervical fracture and dislocation with unilateral vertebral artery injury. Detecting the course of uninjured vertebral artery before operation and locating the anatomical site during operation are effective to avoid damaging vertebral artery of uninjured side.     

闭合性椎动脉损伤的临床诊断和治疗

目的探讨闭合性椎动脉损伤的MRA诊断及临床治疗。方法本组319例闭合性颈椎创伤患者,颈椎骨折261例,双侧小关节突脱位24例,单侧小关节突脱位22例,无放射影像异常的脊髓损伤12例。全部患者接受前瞻性颈椎MRI及椎动脉MRA检查,对继发椎动脉损伤患者,常规行抗凝、溶栓及改善微循环治疗。结果本组319例闭合性颈椎创伤患者,52例继发有椎动脉损伤,单侧51例,双侧1例;其中34例为颈椎小关节脱位,16例为颈椎骨折,2例为无放射影像异常的脊髓损伤。51例单侧椎动脉损伤患者,44例无脑神经症状,7例有头昏、嗜睡,1例视物模糊,经治疗后症状均消失;1例双侧椎动脉损伤患者于伤后1周死亡。结论2DTOFMRA是诊断闭合性椎动脉损伤的有效方法,抗凝、溶栓及改善微循环治疗是降低缺血性损害风险的可行措施。     

颈椎小关节脱位与闭合性椎动脉损伤的相关性研究

[目的]探讨颈椎小关节脱位与闭合性椎动脉损伤的相关性。[方法]本组319仍颈椎创伤患者，颈椎骨折261例；小关节脱位46例，其中单侧小关节脱位22例，双侧小关节脱位24例；无放射影像异常的脊髓损伤12例。所有患者接受了颈椎MRI和椎动脉2DTOF MRA的前瞻性检查。动物实验建立犬颈椎小关节脱位的撞击模型，撞击后摄颈椎X线片，24—36h后行椎动脉2DTOF MRA检查。[结果]临床319例颈椎创伤患者，52例继发有椎动脉损伤，单侧51例，双侧1例。发现有椎动脉损伤的患者中，34例（65．4％）原始损伤为颈椎小关节脱位，16例为颈椎骨折，2例为无放射影像异常的颈髓损伤。动物实验14只犬撞击后发生颈椎小关节脱位，12只犬无小关节脱位。14只发生小关节脱位犬中，8只继发有单侧椎动脉损伤，12只无小关节脱位犬均无椎动脉损伤。[结论]闭合性椎动脉损伤最常继发于颈椎小关节脱位，瞬间位移使椎动脉受到过度牵张是主要的致伤因素。     

A case of basilar artery occlusion of traumatic vertebral artery dissection successfully managed by endovascular treatment

The author describes a case of basilar artery occlusion caused by vertebral artery dissection with vertebral fracture. A 61-year-old man was admitted with neck pain after a traffic accident. His symptoms suddenly deteriorated and cerebral angiography revealed an occlusion of the right vertebral artery, and complete occlusion of the basilar artery. Local-arterial fibrinolysis with urokinase for basilar artery occlusion and angioplasty with the use of a self-expandable stent for the site of the vertebral artery dissection was performed, and the basilar artery was partially recanalized. The patient's symptoms gradually improved. It should be emphasized that in cases of acute cervical spine injury after major trauma, vertebral artery dissection should be considered. Local-arterial fibrinolysis and angioplasty using a self-expandable stent was regarded as a useful treatment for basilar artery occlusion caused by vertebral artery dissection, in the acute stage.     

Masking of vertebral artery dissection by severe trauma to the cervical spine

STUDY DESIGN: A prospective case study was performed. OBJECTIVES: To illustrate the association of cervical trauma with vertebral artery dissection, and to propose a diagnostic and therapeutic algorithm for suspected traumatic vertebral artery dissection. SUMMARY OF BACKGROUND DATA: Vertebral artery dissection is a recognized but underdiagnosed complication of trauma to the cervical spine. Symptoms of spinal cord injury, however, may obscure those of vertebral artery dissection, presumably causing gross underdiagnosis of this complication. METHODS: All patients with vertebral artery dissection admitted to the authors' facility between 1992 and 1997 were screened for cervical trauma. RESULTS: This article presents four patients with severe trauma to the cervical spine, defined as luxation, subluxation, or fracture, in whom symptoms of vertebral artery dissection developed after a delay ranging from several hours to weeks. The traumatic vertebral artery dissection typically was located at the site of vertebral injury or cranial to it. One patient with fracture of the odontoid process survived symptom free without ischemic brain infarctions. Another patient survived with traumatic quadriplegia in addition to large cerebellar and posterior cerebral artery infarctions. Two patients died as a result of fulminant vertebrobasilar infarctions, both with only moderate impairment from the primary spinal cord injury. CONCLUSIONS: Early signs of vertebral artery dissection include head and neck pain, often localized to the site of intimal disruption, which may be disguised by the signs of the spinal injury. Early Doppler ultrasound and duplex sonography as a noninvasive screening method should be performed for patients with severe trauma to the cervical spine. In cases of vertebral artery dissection, immediate anticoagulation should be initiated. Traumatologists should be aware of this complication in evaluating patients with severe trauma of the cervical spine, and also for a variety of forensic reasons.     

Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography

BACKGROUND: We prospectively describe the incidence, magnetic resonance-based diagnosis, and treatment of vertebral artery (VA) injury resulting from closed cervical spine trauma. METHODS: Patients with fracture or dislocation on plain radiographic studies underwent computed tomography. Among these patients, the subset with computed tomographic evidence of foramen transversarium (FT) fracture underwent magnetic resonance angiography as early as possible. RESULTS: During a 16-month period, 38 patients with closed cervical trauma were treated. Twelve patients demonstrated fracture extension through at least one FT by computed tomography. Among these patients, four showed unilateral VA injury by magnetic resonance angiography, all ipsilateral to the fractured FT. Three cases of VA occlusion and one of focal narrowing were demonstrated. All four patients were initially treated with aspirin, and two were systemically anticoagulated. None developed irreversible neurologic deficits from the VA compromise. CONCLUSION: Our data suggest that the incidence of VA injury in closed cervical spine trauma is significant and that FT fractures warrant flow-sensitive magnetic resonance imaging.     

Vertebral artery complications in anterior approaches to the cervical spine: report of two cases and review of literature

BACKGROUND: Cases of lesions to either the carotid artery or the vertebral artery in anterior approaches to the cervical spine are rarely found in medical literature. Two cases of vertebral artery injury in anterior approaches as well as a review of the pertinent literature are presented. In cases of arterial injury, appropriate management strategies are necessary to avoid or minimize harm to the patient. CASE REPORTS: In the first case, the vertebral artery was injured during decompression of a cervical spinal stenosis while drilling the neuroforamen. Local compression provided sufficient control of hemorrhage. Nevertheless, rebleeding from a pseudoaneurysm occurred 2 days later. After removal of the hematoma, the pseudoaneurysm was treated successfully with coils by an endovascular approach. In the second case, misplacement of one screw in screw-fixation of a type II odontoid fracture caused a pseudoaneurysm of the vertebral artery. This led to a fatal subarachnoid hemorrhage 4 days later. CONCLUSIONS: In ventral approaches to the cervical spine, precise preoperative planning and a detailed knowledge of the surgical anatomy are mandatory. In cases of injury to the vertebral arteries, direct surgical repair is most appropriate to prevent complications arising from fistulas, late-onset hemorrhages, pseudoaneurysms, thrombosis, and emboli. Alternatively, endovascular techniques or even clipping or ligation of the affected artery should be considered.     

Basilar artery thrombosis after reduction of cervical spondyloptosis: a cautionary report

Traumatic cervical spondyloptosis is a rare clinical entity typically associated with complete neurological deficit. The inherent mechanics of this fracture-dislocation pattern contorts the vertebral arteries in such a way that it may result in dissection or compromised flow through those vessels. Thus, intimal injury or thrombus from stasis of flow may result. Reduction of the spondyloptosis restores flow to the vertebral arteries, but it also may mobilize thrombus or propagate an intimal dissection within the previously contorted vessel. The authors review their experience in the care of a 43-year-old man who sustained C4-5 spondyloptosis while riding an all-terrain vehicle. On arrival, the patient demonstrated no motor function below C-4 but had sensation to the nipple line (American Spinal Injury Association Spinal Cord Injury Classification B). The patient's cranial nerve examination was unremarkable. Computed tomography of the cervical spine demonstrated complete spondyloptosis at C4-5. The patient was immediately placed in cervical traction and taken to the operating room for open reduction of the fracture dislocation, decompression of the spinal cord, and stabilization with an interbody graft and cervical plate. Preoperative cervical traction was successful in only partial reduction of the fracture dislocation. Open reduction was achieved with exposure of the C-4 and C-5 bodies and sequential distraction. After anatomical alignment was achieved, an interbody graft was placed and a cervical plate secured. A subsequent decline in the patient's level of consciousness prompted CT of the head, which showed evidence of a basilar artery thrombosis. A CT angiographic study demonstrated patency of the vertebral arteries, but a mid-basilar artery thrombosis. The patient progressed to brain death 24 hours after reduction of the fracture dislocation. The degree of contortion of the vertebral arteries in cervical spondyloptosis in the upper cervical spine may result in stasis of flow with subsequent formation of thrombus or intimal injury. After anatomical reduction, restoration of flow within the vertebral arteries may mobilize the thrombus or propagate an intimal dissection and result in subsequent embolic events. Endovascular evaluation may be warranted immediately after anatomical reduction of a high cervical spondyloptosis for evaluation of the vertebral arteries and possible thrombus dissolution or retrieval.     

Dens fracture with concurrent subaxial cervical spine injury in patients with ankylosing spondylitis

Odontoid process fractures in patients with ankylosing spondylitis (AS) are rare and their finding together with subaxial cervical spine injury is a great exception. Neither the mechanism of such a combined cervical spine injury nor its surgical treatment has so far been reported in the relevant literature (MEDLINE). The authors present two such cases, one in a 30- and the other in a 74-year-old man. Both AS patients showed a common mechanism of injury sustained in a car accident, which involved hitting a solid barrier at 60 to 70 kilometres per hour, resulting in hyperextension of the cervical spine. In both patients the fractures were stabilised from the anterior approach: the dens fractures with one or two screws by the Magerl-B?hler method and the subaxial fractures with long-plate and screw fixation. At 2 post-operative years complete bone union of the subaxial spine was recorded in both patients; complete healing of the dens fracture was achieved in one patient while in the other partial fibrous union of the dens fracture occurred.     

Kinematics of cervical spine injury

Summary This paper, based on functional radiological knowledge of normal cervical spine kinematics, develops the hypothesis that compressive vertebral injury can be produced by abrupt reversal of curve between hyperflexed and hyperextended parts of the cervical spine. Reversal of curve occurs when the main vector of a compressive force passes between two centers of flexion-extension motion. The hypothesis more clearly explains reverse dislocation of fractured vertebrae than the current concept of Whitley and Forsyth of motion of the head through an arc. The mechanism of injuries with characteristics of hyperflexion of one segment and hyperextension of an adjacent segment, e.g., in certain types of hangman's fractures, is better understood. The hypothesis is expected to be helpful in guiding experimental cervical spine injury, as it relates direction of force to level and type of the resulting vertebral injury.     

Subintimal dissection of the vertebral artery in subluxation of the cervical spine.

The vertebral arteries appear to be particularly susceptible to injury in trauma of the cervical spine because of their close anatomical relationship to the spine; however, traumatic subintimal dissection of the vertebral artery is rare judging from the paucity of cases reported in the literature. The case of a patient who developed a visual field defect secondary to a fracture-subluxation of the cervical spine is reported. Angiography demonstrated an intimal dissection of the vertebral artery at the site of the fracture-subluxation resulting in thrombus formation and subsequently in emboli occluding the posterior temporal branch of the posterior cerebral artery. Early angiography is recommended if extracranial injury of the vertebral artery is suspected, and the institution of heparin therapy is necessary if a subintimal dissection is demonstrated.     

Forty-three cases of vertebral artery trauma

Forty-three cases of injury to the vertebral artery are reviewed. Trauma to these cervical vessels requires deep tissue penetration, most often as a result of gunshot or stabwounds. The majority of patients are hemodynamically stable, although serious hemorrhage and death may result from injury to this artery alone. Injury to the vertebral artery was frequently associated with cervical spine fracture and local neural damage. However, no patient presented with or developed neurologic sequelae attributable to vertebral-basilar ischemia. Arteriography accurately identified the site of injury, but the specific arteriographic diagnosis can be unreliable. Two of 13 patients (15%) treated by proximal vascular control alone had postoperative vascular complications. While direct surgical intervention with proximal and distal arterial ligation is the appropriate treatment of acute injuries, in some cases there may be a role for conservative treatment of minimal injuries. In this series, mortality related to a vertebral artery injury was low (4.7%), likely as a result of accurate diagnosis and prompt operative intervention.     

颈椎横突孔骨折合并椎动脉损伤

目的：研究颈椎横突孔骨折患者椎动脉损伤的发生率及椎动脉损伤的临床特征。方法：选择2000年8月-2003年6月，CT证实的25例急性颈椎横突孔骨折患者进行颈部动脉磁共振血管造影(MRA)检查。结果：12例患者发生椎动脉损伤(48％)，其中8例为单侧损伤，4例为双侧损伤；椎动脉损伤的发生率在横突孔骨折伴小关节绞锁脱位组与横突孔骨折无小关节绞锁脱位组之间有统计学差异(P=0．03)。2例椎动脉损伤患者出现椎基底动脉缺血症状。结论：急性颈椎横突孔骨折患者椎动脉损伤的发生率较高，尤其伴小关节绞锁脱位者；大多数椎动脉损伤患者无特异性临床表现。