Date of Award

January 2026

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jonathan Grauer

Abstract

Background and Scientific Premise: Cervical spine trauma is a common emergencydepartment presentation, and vertebral artery injury (VAI) is a potentially occult but serious complication associated with posterior circulation stroke. Identification of patients at risk remains challenging due to subtle presentations, variable screening practices, and limited prior data. Research Aims: The aims of this study were to characterize temporal trends in VAI detection among adult patients presenting to the emergency department with cervical spine fractures between 2010 and 2022, identify independent demographic, clinical, and injury-related predictors of VAI, and evaluate the association between VAI and ischemic stroke within ninety days of injury. Hypothesis or Research Question: It was hypothesized that VAI would be more frequently identified in patients with upper cervical spine fractures and high-energy injury mechanisms, and that VAI would be associated with an increased risk of ischemic stroke within ninety days. Methods and Approach: A retrospective cohort study was conducted using the PearlDiver Mariner administrative claims database from 2010 to 2022. Adults aged eighteen years and older who presented to the emergency department with acute cervical 2 spine fractures and had at least ninety days of follow-up were included. VAI and stroke outcomes were identified using ICD-9 and ICD-10 diagnostic codes. Multivariable logistic regression was used to identify independent predictors of VAI. Additionally, multivariate regression was applied to assess the association between VAI and ninety-day stroke, adjusting for age, sex, and Elixhauser Comorbidity Index (ECI). Results: Among 153,948 patients with cervical spine fractures, 777 (0.50%) were diagnosed with VAI, a proportion that rose from 0.33% in 2010 to 0.76% in 2022 (p < 0.001). Independent predictors of VAI in decreasing odds ratio (OR) included upper cervical fractures (OR 1.93), high-energy trauma (OR 1.87), insurance (relative to Medicare, commercial [OR 1.50]; Medicaid [OR 1.51]) higher comorbidity burden (ECI 1–2 [OR 1.77]; 3–4 [OR 1.38]; 5 or greater [OR 1.48]), male sex (OR 1.28), and younger age (OR 1.01 per decade decrease) (p < 0.05 for all). The ninety-day incidence of ischemic stroke was significantly higher for patients with VAI (6.95% vs. 2.19%, p < 0.001). After adjusting for age, sex, and ECI, VAI was associated with post-injury ischemic stroke (OR 3.62, p < 0.001). Scientific Impact and Relevance to Communities of Interest, Including Patients: VAI detection for cervical fractures in the emergency department increased over the study period. Several clinical and nonclinical factors were independent predictors of VAI in this patient population, and an over threefold higher odds of stroke within ninety days of VAI diagnosis was observed. These findings suggest that an early recognition of patients at high risk for such injuries may help advance more targeted screening approaches and reduce downstream cerebrovascular complications.

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This is an Open Access Thesis.

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