Diagnostic capabilities of magnetic resonance imaging and computed tomography in acute cervical spinal column injury

Dynamic evaluation of the cervical spine by kinematic MRI in patients with cervical spinal cord injury without fracture and dislocation

BACKGROUND

The pattern of changes in the cervical spine and the spinal cord and their dynamic characteristics in patients with cervical spinal cord injury without fracture and dislocation remain unclear. This study aimed to evaluate the dynamic changes in the cervical spine and spinal cord from C2/3 to C7/T1 in different positions by using kinematic magnetic resonance imaging in patients with cervical spinal cord injury without fracture and dislocation. This study was approved by the ethics committee of Yuebei People's Hospital.

METHODS

Using median sagittal T2-weighted images for 16 patients with cervical spinal cord injury without fracture and dislocation who underwent cervical kinematic MRI, the anterior space available for the cord, spinal cord diameter, posterior space available for the cord from C2/3 to C7/T1, and Muhle's grade were determined. The spinal canal diameter was calculated by adding the anterior space available for the cord, spinal cord diameter, and posterior space available for the cord.

RESULTS

The anterior space available for the cord, posterior space available for the cord, and spinal canal diameters at C2/3 and C7/T1 were significantly higher than those from C3/4 to C6/7. Muhle's grades at C2/3 and C7/T1 were significantly lower than those at the other levels. Spinal canal diameter was lower in extension than in the neutral and flexion positions. In the operated segments, significantly lesser space was available for the cord (anterior space available for the cord + posterior space available for the cord), and the spinal cord diameter/spinal canal diameter ratio was higher than those in the C2/3, C7/T1, and non-operated segments.

CONCLUSION

Kinematic MRI demonstrated dynamic pathoanatomical changes, such as canal stenosis in different positions, in patients with cervical spinal cord injury without fracture and dislocation. The injured segment had a small canal diameter, high Muhle's grade, low space available for the cord, and high spinal cord diameter/spinal canal diameter ratio.

MRI has limited agreement with CT in the evaluation of vertebral fractures of the canine trauma patient

Complete assessment of vertebral trauma in dogs currently requires CT and MRI for evaluation of the osseous and soft tissue structures that contribute to vertebral stability. Some studies in people have suggested that MRI may be sensitive and specific at detecting vertebral fractures making this potentially a single modality that could be used in spinal trauma evaluation. This study aimed to assess the ability for observers to evaluate vertebral fractures using MRI when compared to CT, which was used as the reference standard. Twenty-nine dogs with previously diagnosed acute vertebral fractures and four dogs with no vertebral fracture that had undergone sequential CT and MRI were included into the study. One hundred twenty-eight vertebrae were evaluated for the presence of fractures. Imaging studies were read by two observers blinded to the history. While both observers had similarly high sensitivity and specificity for simple detection of any fractured vertebrae, interobserver agreement was only moderate (κ = 0.584). When evaluations were specifically limited to detection of structurally unstable fractured vertebrae both observers showed improved specificity and interobserver agreement became substantial (κ = 0.650). Complete agreement for exact fracture location between MRI and CT results was only achieved in 14.3-32.6% of fractured vertebra with up to 79% of fractures being missed in some vertebral structures. This suggests that although MRI may be able to detect the presence of fractured vertebrae, it is not able to replace CT for the complete evaluation of the traumatized spine and documentation of fracture morphology.

Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.

Marrow edema variability in acute spine fractures

BACKGROUND CONTEXT

The presence or absence of marrow edema is used in the assessment of fracture acuity in magnetic resonance imaging (MRI). We have observed variability in the degree of marrow edema in acute trauma. Our aim was to characterize the utility of marrow edema in fracture detection and fracture acuity on MRI. We hypothesized that only vertebral body compression injuries reliably generate marrow edema and that distraction injuries or fractures without compression do not reliably generate marrow edema and may give a false negative MRI examination.

PURPOSE

To characterize the utility of marrow edema in fracture detection and fracture acuity on MRI.

STUDY DESIGN

Two-year single-center retrospective review of marrow edema in patients evaluated by both computed tomography (CT) and MRI in acute trauma setting.

PATIENT SAMPLE

The final study cohort consisted of 163 patients (mean age, 54.5 years; standard deviation, 23.5 years; range, 8-94 years; 85 men and 78 women).

OUTCOME MEASURES

A physiologic measure of marrow edema as assessed by T2-signal hyperintensity on short tau inversion recovery sequence MRI examination.

METHODS

After institutional review board approval, we conducted a retrospective review of 1,215 patients who were evaluated at our hospital for suspected spine trauma with a combination of CT and MRI. Patients were assessed for fracture presence, location, type, and absence or degree of marrow edema.

RESULTS

The investigation identified 189/1,215 patients who had acute fractures on CT, subsequently imaged within 48 hours by MRI. A total of 94/288 acute fractures did not generate marrow edema. There were 63 patients (83 acute fractures) whose mechanism of injury resulted exclusively in acute fractures with no marrow edema. A statistically significant difference in marrow edema was observed with acute vertebral body compression fractures compared with acute fractures with distraction or fractures without compression. Moreover, certain fracture types were identified that often generate little or no marrow edema in acute trauma setting.

CONCLUSIONS

There is variability in the presence or degree of marrow edema on MRI evaluation after traumatic injury. Only fractures derived from vertebral body compression reliably generate marrow edema. Fractures without compression and/or fractures with distraction do not reliably generate marrow edema and can lead to a false negative MRI. An awareness of fracture types that produce more or less marrow edema can be beneficial when evaluating fractures by MRI.

Nuances in pediatric trauma

Pediatric trauma evaluation mimics adult stabilization in that it is best accomplished with a focused and systematic approach. Attention to developmental differences, anatomic and physiologic nuances, and patterns of injury equip emergency physicians to stabilize and manage pediatric injury.

Clearance of the cervical spine in clinically unevaluable trauma patients

STUDY DESIGN

Meta-analytic costeffectiveness analysis.

OBJECTIVE

Our goal was to compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries.

SUMMARY OF BACKGROUND DATA

We performed a structured literature review related to cervical spine trauma, radiographic clearance techniques (plain radiography, flexion/extension, CT, and MRI), and complications associated with semirigid collar use.

METHODS

Meta-analytic techniques were used to pool data from multiple sources to calculate pooled mean estimates of sensitivities and specificities of imaging techniques for cervical spinal clearance, rates of complications from various clearance strategies and from empirical use of semirigid collars. A decision analysis model was used to compare outcomes and costs among these strategies.

RESULTS

Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%-60%). Sensitivities for CT and MRI alone were 83% (82%-84%) and 87% (84%-89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low.

CONCLUSION

As currently used, neuroimaging studies for cervical spinal clearance in clinically unevaluable patients are not cost-effective compared with empirical immobilization in a semirigid collar.

Delayed presentation of cervical ligamentous instability without radiologic evidence

STUDY DESIGN

A case of delayed presentation of unstable cervical ligamentous injury without radiologic evidence is presented.

OBJECTIVES

To report a rare case of delayed presentation of cervical ligamentous injury without radiologic evidence, and to discuss diagnosis, initial management, and techniques of operative stabilization.

SUMMARY OF BACKGROUND DATA

The literature is reviewed.

METHODS

A 48-year-old man who sustained a nondisplaced unilateral C6 pillar fracture with no radiologic evidence of ligamentous injury returned for follow-up with radicular pain and bilateral perched facets at C5-C6.

RESULTS

Closed reduction of the cervical subluxation was performed via cervical traction, and subsequent surgical stabilization was undertaken with anterior cervical discectomy and instrumented arthrodesis of C5-C6 with structural interbody autograft. The patient wore a cervical brace for 6 weeks after surgery, and progressed to a stable fusion with pain resolution and no neurologic sequelae.

CONCLUSIONS

This is a rare reported case of delayed presentation of an unstable ligamentous injury in a nondisplaced cervical pillar fracture without initial radiologic evidence of instability. If any reason to suspect ligamentous injury exists, workup with upright cervical lateral radiographs, flexion/extension radiographs, or magnetic resonance imaging should be obtained. Awake, closed reduction with cervical traction followed by surgical stabilization with an anterior discectomy and instrumented arthrodesis with structural autograft achieved stable fixation.

Caring for the patients with cervical spine injuries: what have we learned?

PURPOSE

Anesthesiologists are often involved in the early management and resuscitation of patients who have sustained cervical spine injuries (CSIs). The most crucial step in managing a patient with suspected CSI is the prevention of further insult to the cervical spine (C-spine). In this review, important factors related to initial management, diagnosis, airway and anesthetic management of patients with CSI are presented.

SOURCE

Medline search was performed to seek out the English-language literature using the following phrases and keywords: spine trauma; cervical spine; airway management after CSI.

PRINCIPAL FINDINGS

Cervical spine injury occurs in up to 3% to 6% of all patients with trauma. The initial management of a patient with potential spine injury requires a high degree of suspicion for CSI so that early stabilization of the spine can be used to prevent further neurological damage. Diagnostic radiology has a critical role to play; however, clinical evaluation is equally important in excluding CSI in a conscious and cooperative patient. Although in-line stabilization reduces the movement at C-spine, traction causes clinically significant distraction and should be avoided.

CONCLUSION

A high level of suspicion and anticipation are the major components of decision making and management in a patient with CSI. Endotracheal intubation using the Bullard laryngoscope may have some advantages over other techniques as it causes less head and C-spine extension than the conventional laryngoscope, and this results in a better view. However, the current opinion is that oral intubation using a Macintosh blade after intravenous induction of anesthesia and muscle relaxation along with inline stabilization is the safest and quickest way to achieve intubation in a patient with suspected CSI. In summation caution, close care and maintenance of spinal immobilization are more important factors in limiting the risk of secondary neurological injury than any particular technique.

Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients

BACKGROUND

Spinal cord injury without radiographic abnormality (SCIWORA) is not uncommon among middle-aged and elderly people. It is less reported in adults as compared with children. This study was undertaken to find the incidence, magnetic resonance imaging (MRI) changes, and outcome of SCIWORA in adults and to demonstrate the prognostic value of MRI in SCIWORA.

MATERIALS AND METHODS

Forty adult patients who sustained SCIWORA for a period of 2 years (January 1999 to December 2000) were admitted to our hospital. Methylprednisolone was given in therapeutic doses, for a period of 24 hours, to those arriving within 6 hours of injury. Magnetic resonance imaging was performed within 72 hours of admission to the hospital. In all patients, sagittal, axial, and coronal T1, spin, and T2 images of MRI were obtained. Clinical status of the patient at the time of admission and discharge was correlated with MRI.

RESULTS

Four patients (10%), who were in Frankel grade D, with no demonstrable injury on MRI, improved to Frankel grade E at the time of discharge. Two patients (5%) with cord edema and extraneural injury improved to a useful neurological grade (Frankel grades D or E), whereas 13 patients (32.5%) with MRI features of cord contusion and hemorrhage did not achieve useful neurological function.

CONCLUSION

Spinal cord injury without radiographic abnormality contributes 12% of cases of spinal cord injury. Magnetic resonance imaging is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to pick up surgically correctable abnormality. Patients with minimal cord changes on MRI have the best outcome followed by those with cord edema. Patients with parenchymatous hemorrhage and contusion on MRI fare badly.

Spinal Cord Injury without Radiographic Abnormality in Children, 2 Decades Later

OBJECTIVE:

Much new research has emerged since1982, when the original description of spinal cord injury without radiographic abnormality (SCIWORA) as a self-contained syndrome was reported. This article reviews new and old data on SCIWORA, from the past 2 decades.

METHODS:

This article reviews what we have learned since 1982 about the unique biomechanical properties of the juvenile spine, the mechanisms of injuries, the profound influence of age on injury pattern and outcome, the magnetic resonance imaging (MRI) features, and management algorithms of SCIWORA.

RESULTS:

The increasing use of MRI in SCIWORA has yielded ample evidence of damage in virtually all nonbony supporting tissues of the juvenile vertebral column, including rupture of the anterior and posterior longitudinal ligaments, intervertebral disc disruption, muscular and interspinal ligament tears, tectorial membrane rupture, and shearing of the subepiphyseal growth zone of the vertebral endplates. These findings provide the structural basis for the postulated “occult instability” in the spine of a patient after SCIWORA. MRI also demonstrated five classes of post-SCIWORA cord findings: complete transection, major hemorrhage, minor hemorrhage, edema only, and normal. These “neural” findings are highly predictive of outcome: patients with transection and major hemorrhage had profoundly poor outcome, but 40% with minor hemorrhage improved to mild grades, whereas 75% with “edema only” attained mild grades and 25% became normal. All patients with normal cord signals made complete recovery.

The large pool of clinical data from our own and other centers also lends statistical power to uphold most of our original assertions regarding incidence, causes of injury, pathophysiology, age-related changes in the malleability of the spine, vectors of deformation, and the extreme vulnerability of young children to severe cord injury, particularly high cervical cord injury. Thoracic SCIWORA has been identified as an important subset, comprising three subtypes involving high-speed direct impact, distraction from lap belts, and crush injury by slow moving vehicles. Computation of the sensitivities of MRI and somatosensory evoked potentials in detecting SCIWORA shows that both tests were normal in 12 to 15% of children with definite, persistent myelopathy; all of these children were nevertheless braced for 3 months because of their clinical syndrome. Children with transient deficits but abnormal MRI and/or somatosensory evoked potentials were also braced, but the 60% with transient deficits and normal MRI and somatosensory evoked potentials were not braced. This is a change from our original policy in 1982 of bracing all children with persistent or transient deficits, brought on by our new MRI and electrophysiology data.

CONCLUSION:

Injury prevention, prompt recognition, use of MRI and electrophysiological verification, and timely bracing of SCIWORA patients remain the chief measures to improve outcome.

Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing

STUDY DESIGN

A retrospective review of medical records and imaging studies of children diagnosed with spinal cord injury without radiographic abnormality (SCIWORA) or SCIWORA-like symptoms at Children's Hospital of Pittsburgh between 1965 and 1999 was undertaken.

OBJECTIVES

To evaluate the existence of occult segmental spinal instability and a role for bracing as treatment for SCIWORA, we contrasted the Children's Hospital of Pittsburgh experience with literature reports on SCIWORA.

SUMMARY OF BACKGROUND DATA

There is a great deal of confusion and conflicting evidence regarding pediatric SCIWORA in the literature. Previous reports from our institution reported unique findings, including the only description of serious, recurrent SCIWORA in the literature. These findings have frequently been cited as the justification for long-term immobilization in all cases of SCIWORA.

METHODS

All records on patients coded as spinal cord injury without fracture or dislocation (ICD-9 code 952.xx) were reviewed. Children 17 years of age or younger with traumatic spinal cord injury and normal plain radiographic findings were included. Penetrating trauma, infection, or metabolic diseases were excluded.

RESULTS

A total of 189 patients were diagnosed with SCIWORA at our institution over the 35-year review period. These patients differed from those reported in the literature with respect to a higher incidence, older age, less involved neurologic injury, and more low-energy mechanisms, such as sports and falls. There were no cases of a patient with SCIWORA who deteriorated and developed a permanent neurologic deficit after having either recovered or plateaued from an initial SCIWORA. All recurrent SCIWORA recovered to normal neurologic function. Bracing did not demonstrate any benefit in preventing these minor recurrent SCIWORAs.

CONCLUSION

We identified no cases of serious, recurrent SCIWORA at our institution from 1965 to 1999. A case-by-case evaluation is required for the treatment of spinal cord injury without apparent spinal column injury, and bracing is not uniformly indicated.

Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries

OBJECTIVE

The purpose of this study was to describe the performance of adjunctive radiologic imaging in patients with cervical spine injury.

METHODS

All patients undergoing cervical spine radiography were prospectively enrolled at 16 diverse emergency departments. We recorded the imaging modalities and radiographic interpretations rendered by unblinded faculty radiologists at each center. Only patients with cervical spine injury were included in this analysis. Findings revealed by individual modalities were compared with the final diagnosis (after all evaluations) in each patient.

RESULTS

Six hundred eighty-eight patients with 1,302 separate cervical spine injuries were enrolled. Four hundred seventy-six (69%) patients had magnetic resonance imaging (MRI) and/or computed tomography (CT) of the cervical spine. MRI identified the following injuries among 124 imaged patients: osseous fractures, 85 of 154 (55%); spinal cord injury, 69 of 69 (100%); vertebral subluxation/dislocation, 37 of 43 (86%); ligamentous injury, 38 of 38 (100%); and unilateral/bilateral locked facets, 14 of 18 (78%). Among 418 patients undergoing CT, the following injuries were identified: osseous fractures, 721 of 740 (97%); spinal cord injury, 0 of 30 (0%); vertebral subluxation/dislocation, 76 of 88 (86%); ligamentous injury, 9 of 36 (25%); and unilateral/bilateral locked facets, 34 of 35 (97%). CT identified 29 patients with fractures who had normal plain radiographs. Cervical myelograms were obtained in two patients and cervical tomograms in seven patients.

CONCLUSION

The majority of patients with cervical spine injury undergo MRI and/or CT imaging. In clinical practice, MRI is superior at identifying soft tissue injuries, whereas CT performs better in identifying bony injuries. Cervical myelograms and tomograms are rarely obtained.

Impact of age on the injury pattern and survival of people with cervical cord injuries

STUDY DESIGN

A retrospective, follow-up study.

OBJECTIVES

To differentiate the injury pattern and survival of people with cervical cord injuries with onset at different ages.

SETTING

Rehabilitation wards of a university hospital that is a tertiary referral center in Taipei, Taiwan.

METHODS

The records of acute and traumatic cervical cord injury patients hospitalized from 1989 to 1997 were reviewed. All subjects received comprehensive rehabilitation programs during hospitalization. Their survival status at the end of follow-up was studied.

RESULTS

Forty-seven of 109 (43.1%) people with cervical cord injuries were 50 years or older at onset. Older patients were more frequently injured by minor falls, resulting in more incomplete quadriplegia. They also showed fewer spinal fractures, and more demonstrated associated spondylosis and ossification of the posterior longitudinal ligament. Eleven (10.2%) subjects were deceased, found by a linkage to a death registration database at the end of follow-up. The significant predictor of survival status at follow-up was older age at injury using Cox proportional hazards model.

CONCLUSION

Spinal cord injured patients had different injury patterns, demanding different preventative strategies. Those injured at older ages were at higher risk of mortality according to our study.

SPONSORSHIP

This study was supported in part by grants from the National Taiwan University Hospital (89S2005), Taipei, Taiwan.

Use of magnetic resonance imaging in spinal trauma: indications, techniques, and utility

Magnetic resonance (MR) imaging of acute spinal injury provides excellent visualization of neurologic and soft-tissue structures in a noninvasive format. Advances in imaging-sequence techniques have made possible more rapid acquisition of images with greater spatial resolution. Appropriate selection of imaging sequences allows improved imaging and contrast of the pathologic processes involved in acute spinal trauma, including spinal cord, soft-tissue, and ligamentous injury. Three patterns of spinal cord injury have been identified. Type I is representative of acute cord hemorrhage. Type II represents spinal cord edema. Type III is a mixed hemorrhagic-edematous presentation. Correlation of MR findings with experimental and clinical spinal cord injury has given a relative predictive value to spinal cord injury patterns on MR images indicative of long-term neurologic outcome. Magnetic resonance imaging is useful in delineating soft-tissue injuries associated with spinal column trauma. Despite the improved spatial resolution of MR imaging, plain radiography and computed tomography remain the standard modalities for visualizing spinal fractures.

Magnetic resonance imaging: utilization in the management of central nervous system trauma

OBJECTIVE

To determine the availability, use, and perceived value of magnetic resonance imaging (MR) in the management of acute central nervous system (CNS) trauma in United States Level I (or equivalent) trauma centers (TCs).

DESIGN, MATERIALS, AND METHODS

One hundred sixty-nine American College of Surgeons, state or locally designated Level I (or equivalent) TCs were identified using compiled lists and telephone contacts. Surveys about MR use in CNS trauma were mailed to each institution. Follow-up telephone calls were made to nonresponding institutions. Data were analyzed using frequency distribution.

MEASUREMENTS

Using returned questionnaires from trauma directors and follow-up telephone contacts, data on the physical location, technologist availability, and patient monitoring capabilities were accrued. The questionnaire addressed the perceived value and cost-effectiveness of MR for acute CNS trauma in general, distinguishing between spinal cord and traumatic brain injury, using a Likert-type rating scale.

MAIN RESULTS

One hundred nine (65%) of identified TCs responded by mail. Sixty (33%) required contact by telephone. One hundred fifty-two (93%) reported MR scanners "on site." Five of seven TCs without on-site MR had facilities within 5 miles. No TC reported the inability to obtain MR scans. Seventy-four percent of TCs reported MR angiography capabilities. Ninety-seven percent of MR facilities were staffed 24 hours per day, 83% by on-call, out-of-hospital technologists at night and on weekends. TCs reported patient monitoring capabilities including cardiac monitoring (83%) and pulse oximetry (91%). Seventy-one percent reported the ability to scan intubated patients. Forty-five percent of TCs "rarely" use MR, 51% report "occasional" use, and 4% "frequently" use MR for acute trauma. Ninety-four percent of trauma directors agreed or strongly agreed that MR directed management and was cost-effective for spinal cord trauma. Fifty-four percent agreed or strongly agreed that MR directed management and was cost-effective for traumatic brain injury. No correlation existed between perceptions of MR applicability in CNS trauma and the number of trauma admissions or on-site availability.

CONCLUSIONS

Most trauma directors consider MR important in the acute evaluation of spinal trauma and, to a lesser extent, for traumatic brain injury. Despite these opinions, the vast majority of these centers reported only "rare" to "occasional" use of MR in the setting of acute CNS trauma. Our results show that most TCs have on-site and continuously available MR facilities capable of cardiac and pulmonary monitoring. Other factors such as the higher relative cost of MR may be responsible for the discrepancy between the perceived value and the actual utilization of MR imaging in the setting of CNS trauma.

Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children

Seven children aged birth to 17 years with spinal cord injury without radiographic abnormality (SCIWORA) were studied with magnetic resonance imaging (MRI) between 3 hours and 16 days after the injury. There were six cervical cord injuries and one thoracic cord injury. The MRI findings were divided into two groups: extraneural and neural. The extraneural findings included one case of anterior longitudinal ligament disruption and anterior C6-C7 disc herniation associated with hyperextension; one case of posterior longitudinal ligament disruption and C2-C3 disc herniation associated with lateral flexion; and one case of C6-C7 disc abnormality consistent with increased water content occurring with hyperflexion. These ligament and disc injuries did not correlate with late instability. The neural MRI findings included one case of cord transection with rostral cord stump hemorrhage and one case of hemorrhage involving the majority of the cord's transverse diameter, both associated with permanent complete cord injuries; one case of hemorrhage involving a minor portion of the cord and of the brain stem's transverse diameter associated with a severe partial cord injury but subsequent incomplete improvement; one case of edema without hemorrhage associated with Brown-Séquard syndrome and subsequent incomplete improvement; and three cases of normal cord signal and outline. Two of the latter patients had mild cord injuries that recovered completely. In the third, a child with complete T12 sensorimotor paralysis at presentation, the normal MRI findings predicted the subsequent complete recovery. No extraaxial compressive lesion was demonstrated in these seven children.(ABSTRACT TRUNCATED AT 250 WORDS)