191. Cervical fracture patterns associated with blunt cerebrovascular injures: a systematic review and meta-analysis

• Published in: The spine journal Vol. 22; no. 9; pp. S101 - S102
• Main Authors: Du, Peter, Barton, Dane, Bridge, Nathaniel, Ganapathy, Venkatanarayanan
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.09.2022
• ISSN: 1529-9430; 1878-1632
• DOI: 10.1016/j.spinee.2022.06.210

There has been significant interest in the association between cervical spine injuries and blunt cerebrovascular injuries (BCVI) due to the intimate anatomic relationship between the cervical spine and the vertebral arteries. Digital subtraction angiography (DSA) has historically been the gold standard, but computed tomography angiography (CTA) is commonly used to screen for BCVI in the trauma setting. However, there is no consensus regarding which fracture patterns mandate screening. Overaggressive screening may lead to increased radiation, increased false positives and patient overtreatment which can cause unnecessary patient harm, and increased health care costs. The aim of this meta-analysis is to analyze which cervical spine fracture patterns are most predictive of BCVI when utilizing CTA. Systematic review and meta-analysis. Odds ratios for specific cervical fracture patterns and risk of developing a BCVI. A systematic literature review of all English language studies from 2000-2020 was conducted. The year 2000 was chosen as the cut-off because use of CTA prior to 2000 was rare. The Ovid MEDLINE®, Embase, Cochrane Central Register of Controlled Trials, Scopus, Global Index Medicus, and ClinicalTrials.gov were queried. Studies were included if they met the following inclusion criteria: 1) the diagnostic imaging modality was CTA; 2) investigated blunt cervical trauma; 3) noted specific cervical spine fracture patterns associated with BCVI; 4) odds ratios for specific cervical spine fracture patterns or the odds ratio could be calculated; 5) subjects were 18 years or older. Studies were excluded if they: 1) included DSA or magnetic resonance imaging; 2) included penetrating cervical trauma; 3) included pediatric patients < 18 years of age; 4) and were not written in English. All statistical analysis was performed using R Studio (RStudio, Boston, MA, USA). The initial search, after duplicates were removed, resulted in 10,940 articles for independent review. Six studies met the criteria for inclusion in the meta-analysis. Specific fracture patterns mentioned are isolated C1, C2, C3 fractures, any C1-C3 fracture, any C4-C7 fracture, two-level fractures, subluxation/dislocations, and transverse foramen (TF) fractures. Three studies were included in the meta-analysis for C1, C1-C3, subluxations/dislocations, and TF fractures. Two studies were included in the meta-analysis for C3, C4-C7, and two-level fractures. The pooled odds ratio with 95% confidence interval for: C1 fractures and BCVI is 1.3 (0.8-2.1); C2: 1.6 (0.9-2.8); C3: 1.8 (0.9-3.6); C1-C3: 2.2 (1.1-4.2); C4-C7: 0.7 (0.3-1.7); Two-level: 2.5 (1.4-4.6); Subluxation/Dislocation: 2.9 (1.8-4.5); TF: 3.6 (1.4-8.9). This study found that when utilizing CTA for screening of BCVI only fractures in the C1-C3 region, two-level fractures, subluxations/dislocations, and transverse foramen fractures were associated with increased incidence of a BCVI. Further refinement of protocols for CTA in the setting of blunt cervical trauma may help limit unnecessary patient harm and reduce health care costs. This abstract does not discuss or include any applicable devices or drugs.