Describes different traumatic injuries of the spine and their MRI appearance.

1. ROLE OF MAGNETIC
RESONANCE IMAGING IN ACUTE
SPINAL TRAUMA
HERRE TO ADD TEXT
Dr. Hazem Abu Zeid Yousef TO ADD TEXT

2. Trauma to the spinal column and spinal cord are
potentially devastating injuries.
Approximately half the spinal cord injuries occur
from motor vehicle crashes. Falls from height,
gunshot wounds, motorcycle crashes, crush
injuries, and medical/surgical complications
account for most of the remaining cases .

3. Imaging is a major pillar in the evaluation of
the trauma patient in addition to the history
and physical examination.

4. Who Should Undergo Cervical Spine
Imaging in the Acute Setting?

5. Only one third of spinal trauma patients present
initially with a neurological deficit
Moreover, important clinical features such as pain
from injury may be masked by other injuries,
medication, and drug and alcohol intoxication
Defining the group of subjects who are at risk for
cervical spine fracture and therefore in whom imaging
is appropriate remains challenging.

6. The NEXUS study indicates that cervical spine imaging is not necessary in
trauma patients who meet all of the following five criteria:
1. No midline cervical spine tenderness
2. No focal neurological deficit
3. Normal level of alertness
4. No intoxication
5. No painful distracting injury
NEXUS - National Emergency X-Ray Utilization Study, United States, published in 2000
Source: Hoffman J, Mower W, Wolfson A, et al. Validity of a set of clinical criteria to rule out
injury to the cervical spine in patients with blunt trauma. N Eng J Med. 2000;343:94–99.
sensitivity - 99.6%
specificity - 12.6%

7. Canadian C-Spine Rule for selective ordering of cervical spine imaging
Stiell, I. G et al. BMJ 2009;339:b4146
99.4% - sensitivity
45.1% - specificity

8. According to American College of Radiology (ACR)
appropriateness criteria, MRI of spine combined with CT scan is
appropriate in the setting of acute spinal trauma if :
1. NEXUS or Canadian Cervical-Spine Rule criteria are met and
there are clinical findings of myelopathy.
2.NEXUS or CCR criteria are met and there are clinical or
imaging findings to suggest ligamentous injury.
3.NEXUS or CCR criteria indicate imaging and the mechanically
unstable spine is anticipated.
Daffner RH, Hackney DB. ACR Appropriateness Criteria on suspected spine trauma. J Am Coll
Radiol. 2007;4:762–75.

9. RADIOGRAPHY for primary cervical spine
screening
• Minimum standard views
– Lateral through C7
– AP
– Odontoid
• Supplementary views
• Bilateral obliques
– Swimmer’s
– Flex ion and extension

13. 1 = anterior vertebral line
2 = posterior vertebral line
3 = spinolaminar line
4 = posterior spinous line
NORMAL CERVICAL SPINENORMAL CERVICAL SPINE
RP

14. Predental spacePredental space • 3mm or less
(4-5mm in children)
C2-C3 pseudosubluxationC2-C3 pseudosubluxation • 3mm or less
(4-5mm in children)
Retropharyngeal spaceRetropharyngeal space • < 6mm at C2
• < 22mm at C6
• For children 1/2 to 2/3
vertebral body distance
anteroposteriorly
Angulation of spinal column atAngulation of spinal column at
any single interspace levelany single interspace level
• < 11 degrees
Cord dimensionCord dimension • 10-13mm
Cervical Spines NormsCervical Spines Norms

15. GCS below 13 on initial assessment.
Has been intubated.
Plain film series is technically inadequate (for
example, desired view unavailable), suspicious or
definitely abnormal.
Continued clinical suspicion of injury despite a
normal X-ray.
The patient is being scanned for multi-region trauma.
Who gets CT

16. CT versus Radiography
Vandermark claimed:Vandermark claimed:
Well positioned and optimally exposed radiographs discloseWell positioned and optimally exposed radiographs disclose
95% of clinically significant C-spine fractures.95% of clinically significant C-spine fractures.
However –However – these high quality studies are often impossible tothese high quality studies are often impossible to
obtainobtain andand pt’s at highest risk are most likely to havept’s at highest risk are most likely to have
technically compromised imaging.technically compromised imaging.
1996 Nunez et al1996 Nunez et al 40% of Fx’s40% of Fx’s missed on radmissed on rad later revealed onlater revealed on
CTCT . One third of them had clinically significant or unstable. One third of them had clinically significant or unstable
Fx’sFx’s
Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls
and recommendations for improving efficiency and communication. AJR 1990;
155:465 –472

17. • Multidetector CT
– Faster.
– More Sensitive.
– Cost effective/more
expensive.
• Conventional Rad
– Slower.
– Less sensitive.
– Less expensive.
So, which do you choose?

18. Who Gets MRI?
1.Radiographic and/or CT scan findings suggestive of ligamentous
injury, such as prevertebral hematoma, spondylolisthesis,
asymmetric disc space widening, facet joint widening or
dislocations, and inter-spinous space widening.
2.To look for epidural hematoma or disc herniation before
attempting a closed reduction of cervical facet dislocations.
3.To identify spinal cord abnormalities in patients with impaired
neurological status.
4.To exclude clinically suspected ligamentous or occult bony
injuries in patients with negative radiographs.
5.To determine the stability of the cervical spine and assess the
need for cervical collar in obtunded trauma patients.
6.To differentiate between hemorrhagic and non-hemorrhagic
spinal cord injuries for the prognostic significance.

19. Kumar and Hayashi BMC Musculoskeletal Disorders (2016) 17:310
DOI 10.1186/s12891-016-1169-6

20. The typical MRI protocol for spinal
injury includes:
Sagittal T1W images for depiction of anatomy and osseous
fractures,
Sagittal T2W images for detecting the cord edema,
Sagittal T2*W (GRE) images to detect the hemorrhage in and
around the cord,
Sagittal STIR images which are very sensitive for detection
of edema and is helpful in diagnosing the soft tissue and
ligamentous injuries, particularly of the interspinous or
supraspinous ligaments,
And axial T2W and T2*W GRE sequences.

21. Mechanism of Fractures
Hyperflexion Hyperextension Axial compression

22. Classification
Type of Injury Fractures Stability
Flexion Anterior subluxation
Unilateral facet dislocation
Bilateral facet dislocation
Wedge compression fracture
Flexion teardrop fracture
Clay Shoveler's fracture
Odontoid
stable or delayed instability
stable
unstable
stable
unstable
stable
unstable
Extension Hangman's fracture unstable
Compression Jefferson fracture
Burst fracture
unstable
stable

23. Classification

24. Stable vs unstable fracture
The most important radiological finding to
suggest spinal instability is the involvement
of two columns, based on the Denis
classification as described above, which
includes middle column in most cases.

25. Other imaging findings of instability:
translation of greater than 2 mm
widening of the facet joints and interspinous space,
disruption of the posterior vertebral body line,
greater than 50 % loss of vertebral body height,
and greater than 20 degrees of kyphosis.
CT is sufficient to demonstrate most of these
findings, but is insensitive for the detection of
ligamentous injuries.

26. Types and mechanisms of ligamentous
injury
Spinal ligaments are very important to maintain the normal
alignment between vertebral segments under a physiologic load.
Normal ligaments of the spine appear as low signal intensity
bands on all the sequences .

28. Ligamentous tears can be partial or complete. Partial
tears are seen as high signal areas on STIR images with
varying degrees of intact fibers. Complete tears are seen
as complete lack of intact fibers. Types of ligamentous
injury is usually related to the mechanism of the trauma.
Hyperextension injuries usually result in damages to the
anterior column or combined anterior and posterior
columns and thus involving the ALL and PLL.
However, hyperflexion injuries can also result in
posterior column or combined posterior and middle
columns injuries characterized by damages to
ligamentum flavum, interspinous ligaments,
supraspinous ligaments, facet joint capsules, and PLL.

31. Acute traumatic disc herniation
Traumatic disc herniations are most commonly
associated with vertebral fracture dislocations and
hyperextension injuries of the spine, and are caused
by injuries to annulus fibrosus with nucleus pulposus
herniation.
Axial GRE can differentiate herniated disk material
(which is hyperintense on GRE) and osteophytes
(which are hypointense) .

33. Extra medullary hemorrhage
Extradural hematoma is the most common type of
extra medullary collections in trauma patients.
Subdural hematoma and subarachnoid hemorrhage
are uncommon. Epidural hematomas usually appear
isointense to slightly hyperintense on T1W images
and hyperintense on T2W images. In GRE images
epidural hematoma has low signal intensity .

35. Vascular injuries
Vascular injuries can be caused by both blunt and
penetrating trauma. In blunt vascular injuries in the
neck, vertebral arteries are more commonly
involved than carotid arteries. The Denver
screening criteria has been used to identify the
patients at risk for vascular injuries and includes
C1–C3 fractures, fracture of the cervical spine
extending into a foramen transversarium, cervical
spine subluxation, Le Fort II or III facial fractures,
basilar skull base fractures involving the carotid
canal, diffuse axonal injury, and expanding neck
hematoma.

36. The imaging findings of vascular injuries include
minimal intimal injury, visualization of intimal flap,
pseudoaneurysm, dissection with intramural
hematoma, complete occlusion, active extravasation,
and arteriovenous fistula formation. Most of the
vascular injuries can be seen as irregularity or loss
of normal flow void on long TE sequences such as
T2W images. In equivocal cases, CT angiography or
catheter angiography can be used for further
evaluation of vascular injuries.

38. Spinal cord injuries
In MRI assessment of spinal cord injury, the axial and
sagittal T2W images, and T2*W GRE images are
particularly useful. Most common MRI findings of
cord trauma include abnormal hyperintense T2 signal
suggesting cord edema, hypointense signal depicting
hemorrhage “best seen on GRE images”, and a
mixture of edema and hemorrhage. Although
neurological function at the presentation remains the
single best predictive factor for long term prognosis,
presence of cord hemorrhage has been described as the
most important findings associated with poor
prognosis.

41. Other osseous and soft tissue injuries
Osseous injuries with little apparent morphologic
changes such as compression and cortical break are
difficult to be diagnosed with CT. MRI is very sensitive
for detection of these occult osseous injuries by showing
marrow edema as hyperintense signal on STIR images.
Prevertebral soft tissue injuries can occur and may
demonstrate abnormal thickening. Paraspinal muscles
injuries can also occur with trauma, either in isolation or
associated with other injuries.

44. Old vs acute vertebral fracture
Compression vertebral fractures are very common,
especially in the elderly, and are usually osteoporotic .
MRI can be very helpful by showing the bone marrow
edema “low signal on T1W images and high signal on
T2W and STIR images”. Soft tissue edema associated
with acute compression fractures can also be an
important differentiating clue. The chronic fractures
will show fatty marrow as high signal on T1W and
T2W images without marrow edema.

46. Benign osteoporotic fracture vs malignant
fracture
Differentiating acute osteoporotic fractures from acute
pathological fractures caused by metastases and other
primary malignancies is a commonly encountered
dilemma in the clinical practice.

47. MRI findings favouring acute osteoporotic
compression fractures:
1) horizontal band of abnormal signal intensity
separated by a straight line from the normal fatty
marrow,
2) relative lack of involvement of posterior
elements,
3) and angulated and concave appearance of the
posterior vertebral margin.

49. Pathological fractures due to malignancy on MRI
are characterized by
1) involvement of the entire vertebral body by
abnormal bone marrow edema,
2) extension into posterior elements,
3) convex appearance of the posterior vertebral
wall,
4) involvement of the surrounding soft tissue,
5) and the presence of other bony lesions.

51. Diffusion weighted imaging also has been shown to be
useful in differentiating these two by showing restricted
diffusion in malignant pathological fractures. This has
been attributed to the high cellularity and high
nucleocytoplasmic ratio in rapidly dividing tumor cells.

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