Cervical arterial injury after blunt trauma in children: characterization and advanced imaging

Stephen R Tolhurst, Kelly L Vanderhave, Michelle S Caird, Hugh L Garton, Gregory P Graziano, Cormac O Maher, Robert N Hensinger, Frances A Farley
Journal of Pediatric Orthopedics 2013, 33 (1): 37-42

BACKGROUND: The incidence of cervical vascular injury (CVI) after blunt cervical trauma in children and adolescents is low. Potential harm from missed injury is high. Screening for CVI has increased with advances in noninvasive angiography, including computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). We attempt to characterize CVI in children and adolescents and evaluate the utility of advanced imaging in CVI screening in this patient population.

METHODS: Clinical and radiographic records of consecutive patients aged 4 to 18 years with blunt cervical spine trauma from 1998 to 2008 were reviewed. Patient demographics, injury pattern, neurological findings, and treatment were recorded.

RESULTS: Sixty-one patients were identified. Nineteen underwent screening to evaluate for CVI, including 12 males and 7 females, mean age 13.5 years. The most common mechanism of injury was motor vehicle collision (n=11). Seven patients underwent MRA, 7 CTA, 3 had both studies, and 2 had traditional angiography. Seven patients had CVI, with an overall incidence of 11.5%. High-risk criteria (fracture extension to transverse foramina, fracture/dislocations or severe subluxations, or C1-C3 injury) were associated with increased rates of CVI. Neurological injury was found in 12/19 patients screened and 6/7 patients with CVI. Two of 7 patients underwent anticoagulation due to documented CVI. No delayed-onset ischemic neurological events occurred.

CONCLUSIONS: After blunt cervical spine trauma, certain fracture patterns increase the risk of CVI. CVI is common, with a minimum incidence of 7/61 or >10% of pediatric patients with blunt cervical spine injury. Over 1/4 of patients studied on the basis of high-risk criteria had injury. Advanced imaging with noninvasive angiography (CTA/MRA) should be strongly considered in pediatric patients with cervical spine trauma. The presence of CVI may prompt a change in management.

LEVEL OF EVIDENCE: Level IV-retrospective diagnostic study.

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