Spinal trauma in DISH and AS: is MRI essential following the detection of vertebral fractures on CT?

The hidden value of MRI: modifying treatment decisions in C-spine injuries

BACKGROUND DATA

Computed Tomography (CT) is the gold standard for cervical spine (c-spine) evaluation. Magnetic resonance imaging (MRI) emerges due to its increasing availability and the lack of radiation exposure. However, MRI is costly and time-consuming, questioning its role in the emergency department (ED). This study investigates the added the value of an additional MRI for patients presenting with a c-spine injury in the ED.

METHODS

We conducted a retrospective monocenter cohort study that included all patients with neck trauma presenting in the ED, who received imaging based on the NEXUS criteria. Spine surgeons performed a full-case review to classify each case into "c-spine injured" and "c-spine uninjured". Injuries were classified according to the AO Spine classification. We assessed patients with a c-spine injury detected by CT, who received a subsequent MRI. In this subset, injuries were classified separately in both imaging modalities. We monitored the treatment changes after the additional MRI to evaluate characteristics of this cohort and the impact of the AO Spine Neurology/Modifier modifiers.

RESULTS

We identified 4496 subjects, 2321 were eligible for inclusion and 186 were diagnosed with c-spine injuries in the retrospective case review. Fifty-six patients with a c-spine injury initially identified through CT received an additional MRI. The additional MRI significantly extended (geometric mean ratio 1.32, p < 0.001) the duration of the patients' stay in the ED. Of this cohort, 25% had a change in treatment strategy and among the patients with neurological symptoms (AON ≥ 1), 45.8% experienced a change in treatment. Patients that were N-positive, had a 12.4 (95% CI 2.7-90.7, p < 0.01) times higher odds of a treatment change after an additional MRI than neurologically intact patients.

CONCLUSION AND RELEVANCE

Our study suggests that patients with a c-spine injury and neurological symptoms benefit from an additional MRI. In neurologically intact patients, an additional MRI retains value only when carefully evaluated on a case-by-case basis.

Rigid spine injuries - A comprehensive review on diagnostic and therapeutic challenges

Injuries to the rigid spine have a distinguished position in the broad spectrum of spinal injuries due to altered biomechanical properties. The rigid spine is more prone to fractures. Two ossification bone disorders that are of particular interest are Ankylosing Spondylitis (AS) and Diffuse Idiopathic Skeletal Hyperostosis (DISH). DISH is a non-inflammatory condition that leads to an anterolateral ossification of the spine. AS on the other hand is a chronic inflammatory disease that leads to cortical bone erosions and spinal ossifications. Both diseases gradually induce stiffening of the spine. The prevalence of DISH is age-related and is therefore higher in the older population. Although the prevalence of AS is not age-related the occurrence of spinal ossification is higher with increasing age. This association with age and the aging demographics in industrialized nations illustrate the need for medical professionals to be adequately informed and prepared. The aim of this narrating review is to give an overview on the diagnostic and therapeutic measures of the ankylosed spine. Because of highly unstable fracture configurations, injuries to the rigid spine are highly susceptible to neurological deficits. Diagnosing a fracture of the ankylosed spine on plain radiographs can be challenging. Moreover, since 8% of patients with ankylosing spine disorders (ASD) have multiple non-contagious fractures, a CT scan of the entire spine is highly recommended as the primary diagnostic tool. There are no consensus-based guidelines for the treatment of spinal fractures in ASD. The presence of neurological deficit or unstable fractures are absolute indications for surgical intervention. If conservative therapy is chosen, patients should be monitored closely to ensure that secondary neurologic deterioration does not occur. For the fractures that have to be treated surgically, stabilization of at least three segments above and below the fracture zone is recommended. These fractures mostly are treated via the posterior approach. Patients with AS or DISH share a significant risk for complications after a traumatic spine injury. The most frequent complications for patients with thoracolumbar burst fractures are respiratory failure, pseudoarthrosis, pneumonia, and implant failure.

Clinical Outcome Analysis of Robot-Assisted Pedicle Screw Insertion in the Treatment of Ankylosing Spondylitis Complicated with Spinal Fractures

BACKGROUND

Vague spinal anatomical landmarks in patients with ankylosing spondylitis (AS) make intraoperative insertion of pedicle screws difficult under direct vision. Currently, the clinical outcome is significantly improved with robot guidance. This study aims to explore the efficacy of robot-assisted pedicle screw insertion in treating AS combined with spinal fractures.

METHODS

Forty patients (341 screws) who underwent pedicle screw insertion with AS complicated with spinal fractures were included. According to different surgical methods, 16 patients (135 screws) were classified into the robot group and 24 (206 screws) into the free-hand group. Intraoperative blood loss, operative duration, and adverse events were compared between the 2 groups. Gertzbein and Robbins classification was used to classify the accuracy of screw position. Clinical outcomes were evaluated by Visual Analog Scale, Japanese Orthopedic Association, and Oswestry Disability Index.

RESULTS

No statistically significant differences between baseline data of the groups. The difference in the blood loss between groups wasn't significant, nor was the operative duration. No severe adverse events related to pedicle screw insertion were reported in either group. Notably, the accuracy of screw insertion was significantly higher in the robot group (129/135) than in the free-hand group (182/206). The lateral perforation prevalence didn't differ among groups. Visual Analog Scale in the third month postoperatively was lower in the robot group than in the free-hand group, with a significant difference.

CONCLUSIONS

The study demonstrates statistically superior accuracy and surgical outcome of robot-assisted pedicle screw insertion in the treatment of AS complicated with spinal fractures compared with the traditional free-hand operation.

Post-traumatic spinal hematoma in diffuse idiopathic skeletal hyperostosis (DISH)

OBJECTIVES

To determine the incidence of spinal hematoma and its relation to neurological deficit after trauma in patients with spinal ankylosis from diffuse idiopathic skeletal hyperostosis (DISH).

MATERIALS AND METHODS

A retrospective review of 2256 urgent or emergency MRI referrals over a period of 8 years and nine months revealed 70 DISH patients who underwent CT and MRI scans of the spine. Spinal hematoma was the primary outcome. Additional variables were spinal cord impingement, spinal cord injury (SCI), trauma mechanism, fracture type, spinal canal narrowing, treatment type, and Frankel grades during injury, before and after treatment. Two trauma radiologists reviewed MRI scans blinded to initial reports.

RESULTS

Of 70 post-traumatic patients (54 men, median age 73, IQR 66-81) with ankylosis of the spine from DISH, 34 (49%) had spinal epidural hematoma (SEH) and 3 (4%) had spinal subdural hematoma, 47 (67%) had spinal cord impingement, and 43 (61%) had SCI. Ground-level fall (69%) was the most common trauma mechanism. A transverse, AO classification type B spine fracture (39%) through the vertebral body was the most common injury type. Spinal canal narrowing (p < .001) correlated and spinal cord impingement (p = .004) associated with Frankel grade before treatment. Of 34 patients with SEH, one, treated conservatively, developed SCI.

CONCLUSIONS

SEH is a common complication after low-energy trauma in patients with spinal ankylosis from DISH. SEH causing spinal cord impingement may progress to SCI if not treated by decompression.

CLINICAL RELEVANCE STATEMENT

Low-energy trauma may cause unstable spinal fractures in patients with spinal ankylosis caused by DISH. The diagnosis of spinal cord impingement or injury requires MRI, especially for the exclusion of spinal hematoma requiring surgical evacuation.

KEY POINTS

• Spinal epidural hematoma is a common complication in post-traumatic patients with spinal ankylosis from DISH. • Most fractures and associated spinal hematomas in patients with spinal ankylosis from DISH result from low-energy trauma. • Spinal hematoma can cause spinal cord impingement, which may lead to SCI if not treated by decompression.

Diagnostic Value of Magnetic Resonance Imaging Scan, Multislice Spiral Computed Tomography Three-Dimensional Reconstruction Combined with Plain Film X-Ray in Spinal Injuries

Objective

The main objective is to explore the diagnostic value of magnetic resonance imaging (MRI) scan, multislice spiral computed tomography (MSCT) three-dimensional reconstruction combined with plain film X-ray in spiral injuries.

Methods

By means of retrospective study, the data of 100 patients with spiral injury treated in our hospital from January 2020 to December 2021 were retrospectively analyzed, and all patients received MRI scan, MSCT three-dimensional reconstruction, and plain film X-ray examination, and by taking the operation results as the reference, the diagnostic results of different diagnostic modalities were analyzed, and the accordance rates (diagnostic result/surgical result × 100%) of the three diagnostic modalities and their combination were calculated, respectively.

Results

Among the 100 patients, 52 cases (52%) had a fracture at the anterior column of the spine, 28 cases (28%) had a fracture at the middle column of the spine, and 20 cases (20%) had a fracture at the posterior column of spine; 24 cases (24%) had simple flexion compression fracture, 60 cases (60%) had burst fracture, 6 cases (6%) had seat belt fracture, and 10 cases (10%) had fracture dislocation. The accordance rate of combined diagnosis for fracture site was 100%, and that for fracture type was 98.0%; MRI could visualize bone marrow injuries, ligamentous injuries, soft tissue injuries, and nerve root injuries that could not be visualized on X-ray plain films, and 3D reconstruction with MSCT could clearly demonstrate the 3D relationship of spinal fracture displacement, fracture line orientation, and spinal injury.

Conclusion

Plain film X-ray is the basic method for diagnosing spinal injuries, while MRI and MSCT have their unique advantages in this regard, and patients with a negative result of X-ray plain film can be examined by MRI and MSCT to observe the spinal injury comprehensively.

Future of Low-Dose Computed Tomography and Dual-Energy Computed Tomography in Axial Spondyloarthritis

Purpose of Review

Recent technical advances in computed tomography (CT) such as low-dose CT and dual-energy techniques open new applications for this imaging modality in clinical practice and for research purposes. This article will discuss the latest innovations and give a perspective on future developments.

Recent Findings

Low-dose CT has increasingly been used for assessing structural changes at the sacroiliac joints and the spine. It has developed into a method with similar or even lower radiation exposure than radiography while outperforming radiography for lesion detection. Despite being incompatible with low-dose scanning, some studies have shown that dual-energy CT can provide additional information that is otherwise only assessable with magnetic resonance imaging (MRI). However, it is unclear whether this additional information is reliable enough and if it would justify the additional radiation exposure, i.e. whether the performance of dual-energy CT is close enough to MRI to replace it in clinical practice.

Summary

While the role of dual-energy CT in patients with axial spondyloarthritis remains to be established, low-dose CT has developed to an appropriate modality that should replace radiography in many circumstances and might supplement MRI.

Epidural hematoma in patients with ankylosing spondylitis requiring surgical stabilization: a single-institution retrospective review with literature analysis

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the sacroiliac joints and axial spine that is closely linked with human leukocyte antigen-B27. There appears to be an increased frequency of associated epidural hematomas in spine fractures in patients with AS. The objective was to review the incidence within the literature and a single-institution experience of the occurrence of epidural hematoma in the context of patients with AS requiring spine surgery.

METHODS

Deep 6 AI software was used to search the entire database of patients at a single level I trauma center (since the advent of the institution's modern electronic health record system) to look at all patients with AS who underwent spinal surgery and who had a diagnosis of epidural hematoma. Additionally, a systemic literature review was performed of all papers evaluating the incidence of epidural hematoma in patients with spine fractures.

RESULTS

A single-institution, retrospective review of records from 2009 to 2020 yielded a total of 164 patients with AS who underwent spine surgery. Of those patients, 17 (10.4%) had epidural hematomas on imaging, with the majority requiring surgical decompression. These spine fractures occurred close to the cervicothoracic or thoracolumbar junction. The patients ranged in age from 51 to 88 years, and there were 14 males and 3 females in the cohort. Eight patients were administered an antiplatelet and/or anticoagulant agent, and the rest were not. All patients required surgical stabilization, with 64.7% of patients also requiring decompressive laminectomies for evacuation of the hematoma and spinal cord decompression. Only 1 death was reported in the series. There was a tendency toward neurological improvement after surgical intervention.

CONCLUSIONS

AS has been a well-described pathologic process that leads to an increased risk of three-column injury in spine fracture, with an increased incidence of symptomatic epidural hematoma compared with patients without AS. Early recognition of this entity is important to ensure that appropriate surgical management includes addressing compression of the neural elements in addition to surgical stabilization.

Imaging update in spondyloarthropathy

Although our understanding of axial spondyloarthropathy (axSpA) has increased recently, there has not been a concurrent improvement in patient diagnosis with delays contributing to patient morbidity. Imaging findings of axSpA can be subtle and may be dismissed often due to lack of understanding by reporters and importantly clinicians who do not suspect the disease. Recognition of the importance of imaging has led to the inclusion of MRI as part of the diagnostic criteria for axSpA. With this in mind, a number of advancements have been made in an attempt to increase our diagnostic accuracy on imaging. This article will give an overview of these techniques as well as a recap of the imaging features of axSpA.