Subaxial Fracture-dislocation with Vertebral Artery Injury and Cerebellar Infarction: Case Report

Abstract

Introduction

Vertebral artery injuries (VAI) following blunt cervical trauma are uncommon but potentially severe. Their detection is often challenging due to asymptomatic presentation.

Objective

To present a case of symptomatic VAI following subaxial fracture-dislocation and surgical stabilization, highlighting diagnostic and therapeutic considerations.

Methods

Clinical and radiographic findings of a patient with cervical trauma were analyzed. A literature review was conducted.

Case Report

A 29-year-old woman sustained a C5–C6 facet fracture-dislocation with vertebral artery dissection and pseudoaneurysm. Anterior cervical arthrodesis was performed. Postoperatively, she developed vertigo and nystagmus. Brain MRI confirmed a right cerebellar infarction. Aspirin was prescribed for 3 months. She remained asymptomatic during five years of follow-up with a stable pseudoaneurysm.

Conclusion

VAI should be suspected in cervical fractures involving the transverse foramen. Medical treatment and careful surgical planning are essential to prevent neurological complications.

Keywords

cervical trauma - vertebral artery - arterial dissection - cerebellar infarction - cervical arthrodesis

Introduction

Vertebral artery injury (VAI) is a rare but potentially serious complication of blunt cervical trauma. Computed Tomography Angiography occurs in between 0.5% and 2% of all blunt trauma cases, although it can reach up to 39% in patients with high-risk cervical fractures, depending on the imaging modality and screening protocol used.[1] [2] The systematic implementation of computed tomography angiography (CTA) has allowed for greater detection of these injuries, especially in high-complexity trauma centers.[3] [4]

Various cervical fracture patterns have been associated with an increased risk of VAI, such as those involving the transverse foramina, cervical dislocations or subluxations, and cervical fractures.[5] [6] [7] Despite this, controversies persist regarding which patients should be screened, what the most appropriate initial management is, and whether treatment should include anticoagulation, antiplatelet therapy, or endovascular interventions, depending on the type of injury.[8] [9] [10]

For this reason, it is essential for spine surgeons to recognize these injuries and understand their clinical implications, as there is still debate regarding the initial diagnosis, follow-up, and optimal treatment of these injuries. This article presents the case of a 29-year-old patient who developed a cerebellar infarction secondary to a traumatic vertebral artery dissection. The purpose of this article is to review the literature and discuss current controversies regarding the diagnostic, therapeutic, and surgical approach to these injuries.

Clinical Case

A 29-year-old, previously healthy woman was involved in a traffic accident in October 2011 when she was rear-ended by another vehicle. She was evaluated the following day in the emergency department for progressive neck pain and sudden onset of paresthesias in her right hand. Physical examination revealed midline cervical tenderness and hypoesthesia in the C6 dermatome of the right upper extremity. A cervical computed tomography (CT) scan revealed a unilateral fracture-dislocation of the right C5–C6 facet joint, associated with anterolisthesis of C5, a fracture of the right transverse process of C6, and a 50% stenosis of the ipsilateral transverse foramen secondary to a displaced bone fragment ([Fig. 1]).

Fig. 1 Anteroposterior (a) and lateral (b) radiographs of the cervical spine, and CT scans of the cervical spine in right parasagittal (c), coronal (d), and axial (e and f) sections, showing a luxation-fracture of the right C5–C6 articular facet, anterolisthesis of C5, fracture of the right transverse process of C6, and a 50% stenosis of the transverse foramen.

The study was completed with an CTA, which confirmed a dissection of the right vertebral artery extending from the upper border of C6 to the C4–C5 level (segment V2), with an associated pseudoaneurysm in that path ([Fig. 2]). In addition, cervical magnetic resonance imaging (MRI) was performed to rule out an associated disc herniation ([Fig. 3]).

Fig. 2 Cervical CTA in right (a) and left (b) parasagittal sections, showing dissection of the right vertebral artery from the upper border of C6 up to C4–C5, with an associated pseudoaneurysm.

Fig. 3 Cervical MRI in sagittal sections with T2 (a), T1 (b), and STIR (c) sequences, and axial sections at the C5–C6 level in MERGE (d) and T2 (e) sequences.

According to the AO Spine Subaxial Cervical classification, the injury corresponds to type C due to the translational mechanism, with modifiers F2 (right unilateral facet fracture dislocation), M2 (vertebral artery involvement), and N1 (C6 radicular hypoesthesia), findings that support the indication for urgent surgical management.

The patient underwent surgery the same day using an anterior cervical approach. A C5–C6 discectomy with interbody fusion was performed, using a cage with autologous bone graft and a 14 mm anterior cervical plate with four locking screws ([Fig. 4]). No attempt was made to correct the narrowing of the compromised transverse foramen, and special care was taken to avoid a wide dissection to the left side in order to protect the contralateral VA from iatrogenic injury.

Fig. 4 Postoperative anteroposterior (a) and lateral (b) cervical radiographs showing C5–C6 discectomy with interbody arthrodesis using a cage with autologous bone graft and an anterior cervical plate.

In the immediate postoperative period, the patient presented no neurological symptoms and reported significant improvement in neck pain. However, after 24 hours of observation, she developed severe vertigo of progressive onset, with right horizontal nystagmus noted on physical examination. Cervical MRI was performed ([Fig. 5]), and a cerebral diffusion image, which confirmed the dissection of the right AV and an acute right cerebellar infarction ([Fig. 6]).

Fig. 5 Cervical MR angiography showing dissection of the right vertebral artery.

Fig. 6 Brain diffusion MRI showing an acute right cerebellar infarct in axial (a) and coronal (b) sections.

Treatment with aspirin at a dose of 100 mg/day was indicated, with progressive improvement of symptoms from the following day. The patient was discharged five days after surgery. Antiplatelet therapy was continued for 3 months, after which a follow-up CTA was performed, which showed persistence of the AV pseudoaneurysm and a reduction in luminal caliber between the upper border of C6 and the C4–C5 level. The patient remained asymptomatic to date from a neurological and cervical spine perspective, completing a 14-year follow-up.

Discussion

VAI in the context of blunt cervical trauma represents a diagnostic and therapeutic challenge, especially when it presents asymptomatic or subclinically. Although its incidence has been widely documented, its clinical and surgical management continues to generate debate. The case presented demonstrates how an initially undetected VAI can progress to a cerebellar infarction, underscoring the importance of recognizing associated fracture patterns, applying appropriate screening criteria, and carefully planning surgical treatment in patients with high-risk cervical injuries.

VAI is found in approximately 3% to 39% of cervical fractures, depending on the type of fracture pattern and the screening protocol used.[1] [2] Most unilateral lesions are asymptomatic, thanks to the convergence of both vertebral arteries in the basilar artery and the circle of Willis, which allows compensation from the contralateral or anterior circulation.[3] This compensatory capacity is one of the main reasons for underdiagnosis, as there are often no obvious clinical manifestations in the acute phase. However, when the lesion occurs in a dominant artery or there is bilateral involvement, neurological symptoms related to posterior circulation infarction may appear, such as headache, vertigo, ataxia, dysarthria, visual disturbances, or loss of consciousness.[4] [5]

Fractures involving the transverse foramen, facet dislocations, and injuries of the upper cervical spine (C1-C3) have traditionally been associated with an increased risk of VAI. Studies in literature have sought more specific risk patterns. Lebl et al. (2013) identified independent risk factors for VAI in a cohort of 253 patients, including basal skull fractures, occipitocervical dissociation, fractures in patients with ankylosing spondylitis, facet subluxations, and displaced fractures ≥1 mm at the transverse foramen.[6] Lockwood et al. (2016), in a retrospective analysis of 732 patients with CTA, found that the patterns most frequently associated with VAI were combined C2 fractures, transverse foramen fractures, and subluxations of adjacent levels.[7] In a series of 67 patients with isolated C2 fracture, Roberts et al. (2013) found an incidence of VAI of 37.3%, with the most significant patterns being type III fractures of the odontoid and those with intraforaminal fragments, although isolated involvement of the transverse foramen was not associated as an independent predictor.[8]

Despite this evidence, the optimal screening protocol and its cost-effectiveness remain a matter of debate. Digital subtraction angiography (DSA) is considered the gold standard, but its invasiveness, limited availability, and higher cost have led to a preference for other modalities such as CTA and MR angiography. While DSA can detect subtle intimal irregularities, CTA has demonstrated high specificity (up to 99%) but variable sensitivity (around 69%) for detecting VAI, depending on the center and the technology used.[9] Multiple studies have supported the use of CTA as a useful tool in patients with a high pre-test probability, especially in the context of trauma, due to its speed, lower cost, and wide availability.[10] [11]

Currently, there is no universal consensus on how to perform screening. Most centers use protocols based on the modified Denver criteria, which indicate performing CTA in the presence of unstable cervical fractures, transverse foramen involvement, atlanto-occipital dislocations, or associated neurological symptoms.[12] However, these criteria have been questioned due to their limited sensitivity, as recent studies indicate that up to 20% of VAIs may go undetected if applied strictly.[13] Furthermore, its universal application could lead to overuse of radiation and intravenous contrast in patients who ultimately do not present with clinically relevant injuries.

Another controversy is the clinical relevance of incidentally diagnosed VAIs. Many cases are asymptomatic and do not alter the therapeutic approach for cervical trauma. Furthermore, antithrombotic treatment may be contraindicated due to associated injuries, and in some studies, the discovery of a VAI has not changed the surgical indication or the patient's functional outcomes.[14] [15] This has led some centers to individualize the use of CTA, considering screening only in cases with high-risk fracture patterns or suggestive symptoms, rather than routinely applying the Denver criteria.

The initial management of confirmed VAI also remains a matter of debate. Early detection is important to initiate timely medical treatment and coordinate it with possible cervical trauma surgery. Options include observation, systemic anticoagulation, antiplatelet therapy, and endovascular treatment. In patients with confirmed infarction, measures should be taken to prevent secondary hypoperfusion, maintaining elevated mean arterial pressure, blood glucose between 100–140 mg/dL, and adequate oxygen saturation.[16]

Regarding pharmacological treatment, the American Association of Neurological Surgeons (AANS) guidelines recommend systemic anticoagulation with heparin for symptomatic lesions. However, recent studies have shown no significant differences between anticoagulation and antiplatelet therapy in preventing ischemic events, with a lower risk of bleeding complications in the antiplatelet group.[11] [17] [18] For this reason, current practice tends to prefer aspirin as the initial treatment for grade I and II injuries, reserving heparin for cases with higher risk or neurological symptoms.

The timing of this treatment should also consider the patient's general condition. Up to one-third of cases have contraindications to anticoagulation, usually due to concomitant trauma with a risk of bleeding. If there are no contraindications, and cervical surgery is required, unfractionated heparin may be chosen due to its rapid reversibility compared to other heparins or antiplatelet agents.[19]

Surgical options for treating VAI are primarily endovascular: stenting, arterial occlusion, or pseudoaneurysm embolization. These are reserved for symptomatic or progressive lesions, and their indication depends on the type, location, and laterality of the lesion. Surgical treatment has not been shown to be superior to medical treatment in the absence of symptoms or progression.[17] [20]

Once the VAI is stabilized, surgical fixation of the cervical fracture must be carefully planned. The presence of a preexisting VAI makes it critical to avoid iatrogenic injury to the contralateral artery, as this can lead to infarction or even death, as has been reported in up to 12% of cases with bilateral involvement.[21] It is essential to analyze the images for anatomical variations of the vertebral artery, which are often not described in radiological reports. These include medial migration (up to 7.6%), unilateral hypoplastic artery (6–10%), and high-course vertebral artery at the craniocervical junction (10–14.5%).[22] [23] [24]

In anterior surgery, the procedures most associated with iatrogenic VAI are discectomies and corpectomies, especially when resected laterally or with electrosurgical resection under the longus colli muscle. Lesions with lateral resection less than 8 mm from the median plane have been described, so it is recommended to remain medial to the uncovertebral joint and limit bone resection to a width less than 15 mm.[25] [26] In posterior surgery, the risk increases when using pedicle screws in the subaxial spine, as these can penetrate the transverse foramen. Therefore, their use should be avoided on the side of the healthy artery. In C1-C2, transarticular fixation has a higher rate of VAI compared to the Harms technique, although both have similar rates of neurological complications.[27] [28]

The imaging follow-up protocol after VAI is another controversial aspect. The natural history of these lesions depends on the grade: low-grade lesions usually resolve spontaneously, while high-grade lesions can persist for months. Longitudinal studies have shown that more than 95% of changes in VAI occur within the first 90 days, and that follow-up beyond this period rarely changes the outcome.[29] [30] Therefore, many current guidelines recommend performing a follow-up CTA at 7–10 days and another at 3 months. In asymptomatic cases and with grade I–II lesions that show early resolution, some centers have opted to omit the second image, while grade III–IV lesions require closer monitoring and even evaluation for endovascular treatment if they persist or progress.[31] [32] [33]

This clinical case exemplifies the importance of considering VAI in patients with high-risk cervical fractures. A timely diagnosis allows for the initiation of preventive treatment and avoidance of major complications, such as the cerebellar infarction observed in this patient. Optimal management of these injuries requires systematic evaluation, detailed anatomical knowledge, careful surgical planning, and targeted follow-up. Although medical treatment remains the cornerstone, it is essential for surgical teams to be aware of the clinical, surgical, and outcome implications of these injuries to avoid serious neurological consequences.

Conflict of Interest

None.

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Publication History

Received: 26 June 2025

Accepted: 11 September 2025

Article published online:
22 December 2025