MDCT and MRI evaluation of cervical spine trauma

Value of MRI in the cervical spine imaging series of trauma patients: A state-of-the-art review

INTRODUCTION

Clinical decision protocols for evaluation and assessment of traumatic cervical spine injuries (TCSI) lean more towards the use of CT imaging. Investigation with MRI is therefore considered unnecessary following negative CT findings according to some local protocols. This review aims to explore what benefits MRI may offer in the clinical management of TCSI patients.

METHODS

A systematic search of the literature was conducted in the following databases: AMED, CINAHL, EMBASE and MEDLINE using defined key terms and synonyms optimised for each database. The eligible articles were subjected to data extraction and thematic synthesis.

RESULTS

The initial electronic search yielded 2527 articles. Of these, 15 articles remained following the application of a pre-defined inclusion criteria and full-text assessment. Four themes (mechanism of injury, type of patient, injuries detected on MRI, significance of injuries detected on MRI) were developed relating to the usage and value of MRI in the management of CSI.

DISCUSSION

Our findings indicate that MRI may be very valuable in some situations for the evaluation of TCSI, however, its usage must be cautiously considered on a case-by-case basis in light of additional clinical benefit, patient safety and resource availability following a normal CT scan or in conjunction with CT or projection radiography where appropriate.

IMPLICATIONS FOR PRACTICE

MRI may serve as a confirmatory test in the management pathway of TCSI based on individual clinical needs. Consideration for key limitations (e.g., patients' cooperation) and accessibility challenges (e.g., cost) against the clinical benefit to the patient must be noted. Development of centre-specific policies from standard trauma imaging protocols may be essential for the timely management of TCSI.

Diagnostic Accuracy of Dual-Layer Spectral CT Using Electron Density Images to Detect Post-Traumatic Prevertebral Hematoma of the Cervical Spine

PURPOSE

 To investigate the diagnostic value of dual-layer spectral detector computed tomography (SDCT) in detecting posttraumatic prevertebral hematoma of the cervical spine by including electron density images.

METHODS

 38 patients with post-traumatic imaging of the cervical spine were included in this study and received both SDCT and MRI examinations. MRI was set as the reference and combined conventional/electron density (C + ED) images were compared to conventional CT (CCT) images alone.

RESULTS

 A total of 18 prevertebral hematomas were identified. Reader 1 identified 14 of 18 and reader 2 15 of 18 prevertebral hematomas by using C + ED reconstructions. Readers 1 and 2 detected 6 and 9 of 18 hematomas on CCT, respectively. CCT showed a sensitivity of 33-50 % and a specificity of 75-80 %, while for C + ED reconstructed images the sensitivity was 77-83 % and the specificity was 85-90 %. Accuracy increased from 55-66 % to 84 % by using C + ED images. The minimum thickness for detecting hematoma on C + ED images was 3 mm. The sizes of prevertebral hematoma on CCT/C + ED were not significantly under- or overestimated compared to the MRI reference. There was a significant difference between the two readers for measuring hematoma sizes on CCT (p = 0.04). Readers showed an excellent inter-rater reliability (kappa = 0.82) for C + ED images and a moderative inter-rater reliability (kappa = 0.44) for CCT.

CONCLUSION

 With SDCT, the diagnostic accuracy for detecting post-traumatic prevertebral hematoma is improved by using combined conventional and electron density reconstructions compared to conventional images alone.

KEY POINTS

  · SDCT has a high potential for detecting post-traumatic prevertebral hematomas of the cervical spine by using combined conventional and electron density images.. · Prevertebral hematomas with a thickness of less than 3 mm cannot be reliably identified by SDCT.. · There is no discernible value of conventional SDCT images for diagnosing prevertebral hematoma..

CITATION FORMAT

· Sedaghat S, Langguth P, Larsen N et al. Diagnostic Accuracy of Dual-Layer Spectral CT Using Electron Density Images to Detect Post-Traumatic Prevertebral Hematoma of the Cervical Spine. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1529-7010.

Fractures of C2 (Axis) Vertebra: Clinical Presentation and Management

BACKGROUND

Injuries of the upper cervical spine are a major cause of morbidity and mortality due to associated spinal cord and head injuries. The injury patterns of the upper cervical spine are numerous, and the neurologic sequelae are diverse. The axis (C2) is the most commonly fractured vertebra in the upper cervical spine; its unique anatomy and architecture pose difficulties in the diagnosis and the management of its fractures.

METHODS

All cases of acute spinal injuries at Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia, were screened for fractures of C2 vertebrae. These patients underwent computerized tomography (CT) imaging of the cervical spine with special attention paid to the cranio-cervical junction. Magnetic resonance imaging (MRI) and angiography of the neck were performed to exclude ligamentous tears and vascular injuries. Unstable fractures were fixed surgically. In the remaining cases, a conservative trial was given. All patients were followed up once every 3 months for a period of 1 year. During follow-up, some patients underwent additional CT imaging of the cervical spine to monitor the healing of fractures.

RESULTS

Out of 230 spinal trauma patients, 43.5% suffered from cervical spine injury. C2 fractures were recorded in 26% cases, and fractures of the C2 vertebral body, including pedicles, laminae, lateral masses, and articular processes, were found in many cases, followed by odontoid fractures (50%). No case of atlanto-axial or atlanto-occipital dislocation was recorded. Road traffic accidents were found to be responsible for 92% of cases. The majority of patients were young males, and 96% of patients had no neurological deficit. Only 15% of the patients required surgery for their unstable fractures. Half of the patients attended outpatient follow -up appointments, all of whom underwent CT scanning of the cervical spine 9 months after the accident or operation.

CONCLUSIONS

The axis (C2) is the most commonly affected vertebra in cervical spine trauma, and odontoid fractures make up 50% of all C2 fractures. C2 fractures rarely cause any neurological deficit or vascular injury, and the majority of affected patients can be managed conservatively; only a small proportion requires surgical intervention. Surgical intervention leads to early and complete healing.

Cervical Disc and Ligamentous Injury in Hyperextension Trauma: MRI and Intraoperative Correlation

BACKGROUND AND PURPOSE

To identify and evaluate diagnostic magnetic resonance imaging (MRI) features in patients with suspicion of discoligamentous cervical injury after hyperextension trauma of the cervical spine.

METHODS

MR images with a standard protocol (1.5 T, including sagittal T2‐weighted images and short tau inversion recovery [STIR]) in 21 patients without any sign of fracture or instability on multidetector computed tomography of the cervical spine were assessed. Among other structures we evaluated the following: prevertebral hematoma, anterior longitudinal ligament (ALL), intervertebral disc, and spinal cord. Presence and the anatomic level of injury were identified and recorded. Results were then compared with intraoperative findings as a reference standard. Simple descriptive statistical analysis, agreement coefficients (given by calculating the percent agreement), and the determination of Gwet's AC1 coefficient were used to analyze our results.

RESULTS

The overall percent agreement between STIR and intraoperative findings was 90.9% (AC1 = .881) and for T2 69.7% (AC1 = .498). For the ALL, the overall agreement was 87.9% (AC1 = .808) and for the intervertebral disc 78.8% (AC1 = .673), in which STIR always showed a higher agreement. Prevertebral hematoma was found in 20 of 21 patients with the maximum thickness at the same anatomic level as the intraoperatively proven lesion in 12 of 18 patients (67%). Edema and/or hemorrhage of the spinal cord was shown in 16 of 21 being at the same anatomic level as the intraoperatively confirmed pathology in 16 of 16 patients (100%).

CONCLUSIONS

MRI is a reliable tool for the evaluation of discoligamentous injuries in the cervical spine, with ancillary features proven as helpful information.

Occult subaxial cervical disco-ligamentous injuries in computer tomography negative trauma patients

PURPOSE

Due to lack of cervical clearance consensus in literature and the devastating consequences of missed cervical injuries, Magnetic resonance imaging (MRI) of the neurologically intact symptomatic patient with negative CT scan is frequently done to rule out disco-ligamentous injuries. This study retrospectively evaluates occult disco-ligamentous injuries detected by MRI in patients with no abnormalities detected by modern multi-detector CT scanning and postulates a new theory of ligamentous stability of cervical spine.

METHODS

Cervical spine injury patients treated at a spinal trauma referral centre from 2010 to 2013 were retrospectively identified. Available clinical records and radiographic imaging were reviewed to find neurologically intact symptomatic patients with no identifiable acute cervical spine injury on CT scan but MRI evidence of isolated subaxial disco-ligamentous injuries. Patient demographics, injury profile, and treatment details were extracted. Subaxial Cervical Spine Injury Classification (SLIC) and Denis three-column spinal stability theory were adopted to assess stability of injuries.

RESULT

316/566 cervical spinal admissions had CT and MRI scans. 11 (3.5%) CT negative patients were found to have occult discoligamentous injuries on MRI. The average age (51.1 years) was not significantly different to all cervical trauma admissions (p = 0.09). Eight had flexion type and three had extension type injuries. The most common mechanisms were sports and fall on flat surface. The average SLIC score was 3.1. Four patients were classified as having unstable or potentially unstable injuries (two patients each) and three of these patients were surgically managed. Subtle CT changes to indicate discoligamentous injury could be retrospectively identified in all four of these patients.

CONCLUSION

CT scans alone may be inadequate for clearing occult disco-ligamentous injuries of the subaxial cervical spine in trauma. Denis three-column stability theory may be beneficial in determining stability and guiding treatment along with the SLIC system for occult discoligamentous injuries of the subaxial cervical spine.

Multidetector Computed Tomography and Magnetic Resonance Imaging Evaluation of Craniovertebral junction Abnormalities

BACKGROUND

Craniovertebral junction (CVJ) abnormalities constitute an important group of treatable neurological disorders with diagnostic dilemma. Their precise diagnosis, identification of probable etiology, and pretreatment evaluation significantly affects prognosis and quality of life of patients.

AIMS

The study was to classify various craniovertebral junction disorders according to their etiology and to define the importance of precise diagnosis for pretreatment evaluation with multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

This is a prospective observational study of 62 patients referred to our department between October 2012 and September 2014. All patients suspected to have a craniovertebral junction disorder were included in the study, from all age groups and both genders. Detailed clinical history was taken. Radiographs of cervical spine were collected if available. All patients were subjected to MDCT and/or MRI.

RESULTS

In our study of 62 patients; 39 were males and 23 were females, with male to female ratio of 1.6:1. Most common age group was 2(nd) -3(rd) decade (19 patients, 30.64%). Developmental anomalies (33 patients, 53.22%) were the most common etiology group followed by traumatic (10 patients, 16.12%), degenerative (eight patients, 12.90%), infective (four patients, 6.45%), inflammatory and neoplastic (three patients each, 4.8%), and no cause found in one patient.

CONCLUSIONS

CVJ abnormalities constitute an important group of treatable neurological disorders, especially in certain ethnic groups and are approached with much caution by clinicians. Thus, it is essential that radiologists should be able to make a precise diagnosis of craniovertebral junction abnormalities, classify them into etiological group, and rule out important mimickers on MDCT and/or MRI, as this information ultimately helps determine the management of such abnormalities, prognosis, and quality of life of patients.

Ohio physical therapists' accuracy in identifying abnormalities on diagnostic images with and without a clinical vignette

BACKGROUND

A strong understanding of diagnostic imaging has been advocated for physical therapists. There have been recent changes in physical therapy curricula and increased opportunities to utilize imaging during clinical practice.

PURPOSE

The aim of this study was to explore the ability of practicing clinicians to accurately identify selected musculoskeletal conditions on plain-film radiograph (X-ray), magnetic resonance imaging (MRI), and computed tomography scan (CT scan). Further, to determine whether improvements in identification of pathology occur when the clinical scenario is added to the imaging and whether there are related training/exposure factors.

METHODS

A cross- sectional electronic survey was sent out to physical therapists in the state of Ohio. Participants were asked to identify conditions (cervical fracture, anterior cruciate ligament tear, and avascular necrosis of the femoral head) first given diagnostic images only, and then given the images and a clinical scenario.

RESULTS

Eight hundred sixty-six surveys of the 7537 sent out were eligible for analysis. With clinical scenarios, 61.3% of respondents were correct with the ACL injury identified on MRI, 36.4% for identification of the cervical spine fracture on CT and 25.6% for identification of avascular necrosis on plain film. The accuracy significantly improved (p<0.01) with the addition of the clinical information for all three of the diagnoses. The most remarkable improvement was seen with the AVN diagnosis on plain film radiograph (365.5% improvement), followed by the ACL injury on MRI (27.2% improvement) and cervical fracture diagnosis on CT scan (17.8% improvement). Finally, formal and informal training, board certification through the APTA and to a lesser extent, degree level, all improved diagnostic accuracy.

CONCLUSIONS

A clinical scenario paired with images notably improved identification of pathology. Physical therapists were better at identifying the ACL pathology that was presented on MRI. This is a common diagnosis to physical therapists and was paired with a relatively common imaging modality. This study suggests that physical therapists can improve accuracy with identifying pathologies on diagnostic images through a physical therapy curriculum or post-graduation through certifications and continuing education.

LEVEL OF EVIDENCE

Level 4.