背景:先前的研究表明颈椎骨折与钝性脑血管损伤(BCVI)密切相关。未确诊的BCVI是一种令人恐惧的并发症,因为在错过的后循环中风中可能会产生灾难性后果。计算机断层扫描血管造影(CTA)通常用于在创伤环境中筛查BCVI。然而,确定哪些颈椎骨折类型需要筛查仍不清楚.
目的:本回顾性综述的目的是进一步阐明使用CTA时哪些骨折类型与BCVI相关,可能需要进行筛查。
方法:回顾性队列研究患者样本:所有2018年1月至2021年12月因颈椎钝性骨折到我们的创伤和急诊科就诊的患者。纳入标准包括宫颈钝性外伤和使用CTA进行BCVI筛查。排除标准包括18岁以下的患者,宫颈穿透伤,并使用除CTA外的任何成像方式进行BCVI筛查。
方法:患者人口统计(年龄,性别,格拉斯哥昏迷量表,住院时间(LOS),重症监护室LOS,损伤的能量机制,多发性创伤状态),骨折位置,骨折模式(前弓,dens,脱位/半脱位,facet,Hangman,杰斐逊,椎板,侧块,枕骨髁离解,枕骨髁,椎弓根,后弓,棘突,横突,横孔,和椎体),以及患者是否患有BCVI或CVA。
方法:如果患者有多个骨折级别或骨折类型,每个级别和模式都作为单独的BCVI计数.多水平骨折被定义为在两个不同的颈椎水平骨折的任何患者。使用连续变量的独立样本t检验以及分类变量的卡方或Fisher精确检验来分析患有BCVI的患者与未患有BCVI的患者之间的差异。计算赔率比和95%置信区间以评估患者特征/骨折特征与BCVI之间的可能性。
结果:总共690名患者被确定为颈椎钝性损伤。453例患者(66%)接受了CTA筛查BCVI。在接受CTA的患者中,138例患者(30%)诊断为BCVI,119例患者(26%)的VAI,30例患者(7%)的CAI,11例患者同时诊断为VAI和CAI(2%)。总的来说,在所有患者中有9次中风,所有确定为BCVI的患者(1%)。没有单独的宫颈水平与BCVI风险增加相关,但是当结合时,OC-C3骨折与风险增加相关(OR:1.4,95%CI:1.0-1.9,p值:0.006)。多节段骨折也与风险增加相关(OR:1.7,95%CI:1.1-2.3,p值:0.01)。与BCVI风险增加相关的唯一骨折类型是与脱位/半脱位相关的骨折(OR:3.8,95%CI:1.9-7.8,p值=0.0001)结论:与BCVI风险增加相关的唯一骨折类型是与脱位/半脱位相关的骨折。与BCVI相关的唯一骨折级别是OC-C3和多级别骨折。我们建议任何上颈椎骨折(OC-C3),多级骨折,或有脱位/半脱位的骨折接受BCVI筛查。
Prior studies have demonstrated a close association between cervical spine fractures and blunt cerebrovascular injuries (BCVI). Undiagnosed BCVI is a feared complication because of the potentially catastrophic outcomes in a missed posterior circulation stroke. Computed tomography angiography (CTA) is commonly used to screen BCVI in the trauma setting. However, determining which cervical fracture patterns mandate screening is still not clearly known.
The aim of this retrospective review is to further elucidate which fracture patterns are associated with BCVI when using CTA and may mandate screening.
Retrospective cohort study.
All patients that presented to our trauma and emergency departments with a blunt cervical spine fracture from January 2018 to December 2021. Inclusion criteria included blunt cervical trauma and the use of CTA for BCVI screening. Exclusion criteria included patients under the age of 18, penetrating cervical trauma, and use any imaging modality besides CTA for BCVI screening.
Patient demographics (age, gender, Glasgow coma scale, hospital length of stay (LOS), intensive care unit LOS, mechanism of energy of injury, polytrauma status), fracture location, fracture pattern (anterior arch, dens, dislocations/subluxations, facet, hangman, Jefferson, lamina, lateral mass, occipital condyle dissociation, occipital condyle, pedicle, posterior arch, spinous process, transverse process, transverse foramen, and vertebral body), and whether the patient sustained a BCVI or CVA.
If a patient had multiple fracture levels or fracture patterns, each level and pattern was counted as a separate BCVI. Multilevel fractures were defined as any patient with fractures at two distinct cervical levels. Differences between the patients who had a BCVI and those who did not were analyzed using independent sample t-tests for continuous variables and the chi-square or Fisher exact test for categorical variables. Odds ratios and 95% confidence intervals were calculated to assess likelihood between patient characteristics/fracture characteristics and BCVI.
A total of 690 patients were identified as having a blunt cervical spine injury. A total of 453 patients (66%) underwent screening for BCVI with CTA. Among patients who underwent CTA, BCVI was diagnosed in 138 patients (30%), VAI in 119 patients (26%), CAI in 30 patients (7%), and 11 patients were diagnosed with both a VAI and CAI (2%). Overall, among all patients there were 9 strokes, all in patients identified with a BCVI (1%). No individual cervical level was associated with increased risk of BCVI, but when combined, OC-C3 fractures were associated with an increased risk (OR: 1.4, 95% CI: 1.0-1.9, p-value: .006). Multilevel fractures were also associated with an increased risk (OR: 1.7, 95% CI: 1.1-2.3, p-value: .01). The only fracture pattern associated with increased risk of BCVI were fractures associated with a dislocation/subluxation (OR: 3.8, 95% CI: 1.9-7.8, p-value = .0001).
The only fracture pattern associated with an increased risk of BCVI were fractures associated with dislocation/subluxation. The only fracture levels associated with BCVI were combined OC-C3 and multilevel fractures. We recommend that any upper cervical fracture (OC-C3), multilevel fracture, or fracture with dislocation/subluxation undergo screening for BCVI.