Management Protocol for Cervical Foramen Transversarium Fracture with Vertebral Artery Involvement
All patients with cervical foramen transversarium fractures should undergo immediate vascular imaging (CT angiography or MR angiography) to detect vertebral artery injury, followed by anticoagulation therapy if injury is confirmed, regardless of symptoms. 1, 2
Initial Assessment and Imaging Protocol
Immediate Diagnostic Workup
- Obtain CT imaging of the cervical spine to identify fracture pattern, displacement, and foramen transversarium involvement 3
- Perform vascular imaging urgently in all patients with foramen transversarium fractures or facet joint subluxation/dislocation, as vertebral artery injury (VAI) occurs in 16-46% of these cases 1, 4
- CT angiography is preferred for acute evaluation as it provides rapid assessment of both bony and vascular structures 2, 5
- MR angiography can be performed within 2 days if CT angiography is unavailable, though it may miss subtle intimal flaps 1, 2
- Digital subtraction angiography remains the gold standard but is typically reserved for cases where non-invasive imaging is inconclusive 1
Critical Pitfall
Radiological diagnosis is more sensitive than clinical findings - patients with vertebral artery occlusion or stenosis are frequently asymptomatic initially, with symptoms manifesting within 24 hours or developing catastrophically later 1, 5, 6. Do not rely on absence of vertebrobasilar symptoms to rule out VAI.
Vertebral Artery Injury Management
Anticoagulation Protocol
- Initiate anticoagulation immediately upon diagnosis of vertebral artery injury (occlusion, stenosis, dissection, or pseudoaneurysm) 1, 2
- Begin with aspirin as initial therapy, with consideration for systemic anticoagulation (heparin followed by warfarin) in cases of occlusion or dissection 7, 1, 2
- Continue anticoagulation to prevent thromboembolic complications including brainstem ischemia and cerebellar infarction 1, 5, 6
Specific VAI Patterns and Treatment
- Unilateral vertebral artery occlusion: Anticoagulation with aspirin or systemic anticoagulation 1, 2
- Intimal flap or dissection: Systemic anticoagulation preferred 1
- Pseudoaneurysm: Anticoagulation with consideration for endovascular intervention if expanding 1
- Bilateral vertebral artery involvement: Extremely high risk for fatal brainstem infarction; requires aggressive anticoagulation and may warrant endovascular consultation 5
Cervical Spine Fracture Management
Stability Assessment
- Apply the Subaxial Injury Classification (SLIC) System to grade instability and determine surgical need 3, 8
- SLIC score ≥5 indicates surgical intervention is required 3, 8
- Assess discoligamentous complex integrity with MRI if ligamentous injury is suspected, as this significantly impacts stability 3
Surgical Timing with Concurrent VAI
- Perform surgical stabilization within 4 days if spine is unstable, even in presence of vertebral artery injury 1
- Early surgical stabilization may prevent clot propagation and embolization from the injury site 6
- Maintain anticoagulation perioperatively unless contraindicated by other injuries 1
Immobilization Considerations
- Minimize cervical spine movement during all transfers and procedures 3, 5
- Multiple transportation events are high-risk for worsening subluxation and vertebral artery compromise 5
- Proper immobilization with attention to neck position based on mechanism of injury is mandatory 5
Monitoring and Follow-up
Neurological Surveillance
- Monitor closely for vertebrobasilar insufficiency symptoms: vertigo, nausea, visual disturbances, syncope, ataxia, or altered consciousness 7
- Symptoms typically manifest within 24 hours but can occur later 5, 6
- Watch for signs of brainstem or cerebellar infarction: diplopia, dysarthria, dysphagia, limb ataxia, or decreased level of consciousness 5, 6
High-Risk Features Requiring Intensive Monitoring
- Bilateral vertebral artery involvement (extremely high mortality risk) 5
- Dominant vertebral artery occlusion with contralateral hypoplasia 6
- Progressive subluxation or displacement on serial imaging 5
- Facet joint dislocation combined with foramen transversarium fracture 4, 6
Evidence Limitations and Clinical Approach
The evidence base for specific cervical fracture subtypes with vertebral artery injury is limited, with few comparative studies providing level II evidence or higher 7, 3. Given this limitation and the catastrophic consequences of missed VAI (brainstem infarction, death), err on the side of aggressive screening and anticoagulation in all patients with foramen transversarium fractures 5.
The incidence of VAI in foramen transversarium fractures ranges from 16-46% across studies, with most injuries being asymptomatic initially 1, 4. This high incidence combined with potential for delayed catastrophic deterioration mandates routine vascular imaging rather than selective screening based on symptoms 1, 5.