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.     

Pediatric care report of spinal cord injury without radiographic abnormality (SCIWORA): case report and literature review

STUDY DESIGN: Case report of SCIWORA following trivial trauma in childhood and review of the literature. OBJECTIVES: To describe a case of 'spinal cord injuries without radiographic abnormality (SCIWORA)', which was diagnosed 2 years after the event, and define its relevance from a differential diagnostic and medico-legal viewpoint. SETTING: An Austrian neuro-traumatological rehabilitation and workers' insurance appraisal center. METHODS: A 12-year-old patient is presented who suffered an ischemic spinal lesion of unknown origin on her way home from school. The patient was reinvestigated as part of an insurance appraisal 2 years later. The aim of this investigation was to elucidate the origin of the spinal cord lesion, in particular, whether it was because of accidental trauma or because of a preexisting condition (eg vascular malformation). RESULTS: SCIWORA due to a trivial trauma was diagnosed during the reinvestigation. This was of importance for the patient because of accident insurance coverage. CONCLUSION: In children developing a quadroparesis following a minor trauma, spinal cord injury without radiographic abnormality must be considered in the differental diagnosis.     

Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma

BACKGROUND: The purpose of this study was to better define the incidence and characteristics of patients with spinal cord injury without radiographic abnormality (SCIWORA), using the database of the National Emergency X-Radiography Utilization Study (NEXUS). METHODS: This was a prospective, observational study of blunt trauma patients in 21 U.S. medical centers undergoing plain cervical radiography. SCIWORA was defined as spinal cord injury demonstrated by magnetic resonance imaging, when a complete, technically adequate plain radiographic series revealed no injury. RESULTS: Of the 34,069 patients entered, there were 818 (2.4%) with cervical spine injury, including 27 (0.08%) patients with SCIWORA. Over 3,000 children were enrolled, including 30 with cervical spine injury, but none had SCIWORA. The most common magnetic resonance imaging findings among SCIWORA patients were central disc herniation, spinal stenosis, and cord edema or contusion. Central cord syndrome was described in 10 cases. CONCLUSION: In the large NEXUS cohort, SCIWORA was an uncommon disorder, and occurred only in adults.     

Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol

BACKGROUND: Prompt identification of cervical spine injuries has been a critical issue in trauma management. In 1998, the authors developed a new protocol to evaluate cervical spines in blunt trauma. This protocol relies on clinical clearance for appropriate patients and helical computed tomography instead of plain radiographs for patients who cannot be clinically cleared. The authors then prospectively collected data on all cervical spine evaluations to assess the sensitivity and specificity of their approach. METHODS: Any patient without clinical evidence of neurologic injury, alcohol or drug intoxication, or distracting injury underwent cervical spine evaluation by clinical examination. Patients who did not meet these criteria underwent helical computed tomographic scanning of the entire cervical spine. For patients who had neurologic deficits, a magnetic resonance image was obtained. If the patient was not evaluable secondary to coma, the computed tomographic scan was without abnormality, and the patient was moving all four extremities at arrival in the emergency department, the cervical spine was cleared, and spinal precautions were removed. Data were collected for all patients admitted to Santa Barbara Cottage Hospital trauma service between 1999 and 2002. The authors selected for analysis patients with blunt trauma and further identified those with closed head injuries (Glasgow Coma Scale score < 15 and loss of consciousness). In addition, all blunt cervical spine injuries were reviewed. RESULTS: During the period of study, 2,854 trauma patients were admitted, of whom 2,603 (91%) had blunt trauma. Of these, 1,462 (56%) had closed head injuries. One hundred patients (7% of patients admitted for blunt trauma) had cervical spine or spinal cord injuries, of which 99 were identified by the authors' protocol. Only one injury was not appreciated in a patient with syringomyelia. Fifteen percent of patients with spinal cord injury had no radiographic abnormality; all of these patients presented with neurologic deficits. The sensitivity for detecting cervical spine injury was thus 99%, and the specificity was 100%. The risk of missing a cervical spine injury in these blunt trauma patients was 0.04%. The authors missed no spine injuries in patients with head injuries. CONCLUSION: The use of the authors' protocol resulted in excellent sensitivity and specificity in detecting cervical spine injuries. In addition, it allowed early removal of spinal precautions.     

Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls

BACKGROUND: Cervical spine injuries are the most commonly missed severe injuries with serious implications for the patient and physician. The diagnosis of subluxations or spinal cord injuries in the absence of vertebral fractures, especially in unevaluable patients, poses a major challenge. The objective of this study was to study the incidence and type of cervical spine trauma according to mechanism of injury; identify problems and pitfalls in the diagnosis of nonskeletal cervical spine injuries. METHODS: Retrospective study of all C-spine injuries caused by traffic accidents or falls admitted over a 5-year period at a large Level I trauma center. Data were obtained from the trauma registry, review of patient charts, and radiology reports. RESULTS: During the study period, there were 14,755 admissions due to traffic injuries or falls who met trauma center criteria. There were 292 patients with C-spine injuries, for an overall incidence of 2.0% (3.4% in car occupants, 2.8% for pedestrians, 1.9% for motorcycle riders, and 0.9% for falls). The incidence of C-spine injuries in patients with a Glasgow Coma Scale score of 13 to 15 was 1.4%, 9 to 12 was 6.8%, and in < or =8 was 10.2% (p < 0.05). Of C-spine injuries, 85.6% (250 patients) were a vertebral fracture, 10.6% of the injuries (31 patients) were subluxation without fractures, and 3.8% (11 patients) were an isolated spinal cord injury without fracture or subluxation. Of the 31 patients with isolated subluxations, one-third required an early endotracheal intubation before clinical evaluation of the spine, because of associated severe head injury or hypotension. Adequate lateral C-spine films diagnosed or suspected 30 of the 31 subluxations (96.8%). The combination of plain films and computed tomographic (CT) scan diagnosed or suspected all injuries. Of the 11 patients with isolated cord injury, 27.3% required early intubation before clinical evaluation of the spine. The diagnosis of cord injury was made on admission in only five patients (45.5%). In three patients, the neurologic examination on admission was normal and neurologic deficits appeared a few hours later. In the remaining three patients (two intubated, one intoxicated), the diagnosis was missed clinically and radiologically. CONCLUSIONS: Isolated nonskeletal C-spine injuries are rare but potentially catastrophic because of the high incidence of neurologic deficits and missed diagnosis. In subluxations, the combination of an adequate lateral film and CT scan was reliable in diagnosing or highly suspecting the injury. A large prospective study is needed to confirm these findings, before a recommendation is made to remove the cervical collar if the findings of these investigations are normal. However, in isolated cord injuries, the diagnosis was often missed because of associated severe head trauma and the low sensitivity of the plain films and CT scans.     

The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography scan have a role?

BACKGROUND: Helical computed tomography (HCT) scan is the preferred modality for diagnosing fractures of the cervical spine in blunt trauma. We hypothesize that HCT can be used as a screening tool for isolated ligamentous injury (LI) in blunt trauma. METHODS: A prospective, consecutive series study design was used to include patients that could not have their cervical spine cleared clinically. All patients underwent HCT (occiput-T1) and plain radiographs (PR) with five views of the cervical spine. Patients with clinical or radiographic abnormalities without fracture underwent cervical magnetic resonance imaging (MRI). Demographic and outcome data were collected. The attending radiologist's interpretation was used for clinical management. Three neuroradiologists in a blinded fashion re-reviewed the studies (HCT, PR, and MRI) of the MRI subgroup. RESULTS: One thousand five hundred seventy-seven patients met the study criteria. Two hundred seventy-eight had 416 cervical spine fractures. PR failed to identify 299 of 416 (72%) cervical spine fractures in 208 of 278 (74.8%) patients. Of the 1,299 (82%) patients who had no fracture, 85 (6.5%) required an MRI. The mean time from admission to MRI was 3 days for the LI subgroup. Of these, 21 of 85 (25%) had LI by MRI. Seven of 21 (33.3%) patients had an abnormal HCT versus 3 of 21 (14.3%) patients who had an abnormal PR. Four of 85 (4.7%) patients had spinal cord injury without radiographic abnormality. One (1.2%) patient required surgical stabilization of LI, as seen on all studies performed (PR, HCT, and MRI). Sensitivities for PR and HCT for LI were 16% and 32%, respectively. Negative predictive values for PR and HCT for LI were 74% and 78%, respectively. Measurements of interrater reliability for MRI, HCT, and PR had kappa values of 0.60, 0.14, and 0.41, respectively. CONCLUSION: HCT is the most sensitive, specific, and cost-effective modality for screening the cervical spine bony injuries, but it is not an effective modality for screening for cervical LI. MRI is clearly superior to HCT for LI. The indications for MRI include abnormalities on HCT, neurologic deficits, cervical pain or tenderness on examination, or the inability to clear the cervical spine in the obtunded patient. With the current state of the art technology, we have redefined the definition of spinal cord injury without radiographic abnormality to include spinal cord injuries without boney injuries or LI.     

Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits

HYPOTHESIS: Trauma patients with normal motor examination results and normal cervical spine helical computed tomographic (CT) scans with sagittal reconstructions do not have significant cervical spine injury. DESIGN: Prospectively collected registry data. SETTING: Level II community-based trauma center. PATIENTS: All patients admitted to the trauma service from January 1, 1999, to December 31, 2003. MAIN OUTCOME MEASURES: Injury detected by CT and/or magnetic resonance imaging (MRI) of the cervical spine. Neurologic examination and need for surgery were secondary outcomes. RESULTS: During the study period, 2854 trauma patients were admitted, of whom 91.2% had blunt trauma. Of these patients, 56.2% had a closed head injury. One hundred patients had cervical spine and/or spinal cord injuries. Eighty-five patients had a cervical spine injury diagnosed by CT. Fifteen patients had admission neurologic deficits not seen on CT, and 7 of these patients had non-bony abnormalities on MRI. Ninety-three patients had a normal admission motor examination result, a CT result negative for trauma, and persistent cervical spine pain, and were examined with MRI. All MRI examination results were negative for clinically significant injury. Seventeen patients had MRIs that showed degenerative disc disease, and 6 had spinal canal stenosis secondary to ossification. Twelve comatose patients (Glasgow Coma Scale score, <9), moving all 4 extremities on arrival, with normal CT results of the cervical spine, were examined with MRI. All of these MRI examination results were negative for injury. None of the patients experienced neurologic deterioration. No patient required operative management of spinal injury. CONCLUSION: Blunt trauma patients with normal motor examination results and normal CT results of the cervical spine do not require further radiologic examination before clearing the cervical spine.     

Vertebral artery occlusion after acute cervical spine trauma

STUDY DESIGN: A retrospective study of vertebral artery injury diagnosed during the last 6 years in our institution. OBJECTIVES: To determine the clinical and radiologic features of vertebral artery injury. SUMMARY OF BACKGROUND DATA: Extracranial occlusion of the vertebral artery associated with cervical spine fracture is uncommon and can cause serious and even fatal neurologic deficit due to back lifting and cerebellar infarction. Magnetic resonance imaging and magnetic resonance angiography are extremely helpful in the examination of acute injuries of the cervical spine. METHODS: Magnetic resonance imaging and magnetic resonance angiography were performed at the time of injury. RESULTS: The authors reviewed six patients with cervical spine fractures who were diagnosed with a unilateral occlusion of the vertebral artery by means of magnetic resonance imaging/magnetic resonance angiography. One patient had signs of vertebrobasilar insufficiency and another with complete cord lesion had cerebellar and back lifting infarctions. Surgical anterior spinal fusion was performed in five patients, and one was treated by traction and orthosis. At the time of discharge, five patients had no vertebrobasilar symptoms, and the patient who experienced vertebrobasilar territory infarctions showed no progression of the neurologic damage. CONCLUSIONS: Vertebral artery injury should be suspected in cervical trauma patients with facet joint dislocation or transverse foramen fracture. Magnetic resonance imaging/magnetic resonance angiography is a helpful test to rule out vascular injury. Vertebral artery injury affects the extracranial segment at the same level as the cervical fracture. This is a retrospective review that did not permit drawing conclusions about the effects of early surgical stabilization in the treatment of cervical spine injuries with associated vertebral artery injury; however, surgical stabilization may avoid propagation and embolization of the clot located at the site of the lesion.     

Recurrent spinal cord injury without radiographic abnormalities in children

Spinal cord injury without radiographic abnormality is a well-known entity in the pediatric age group. Age-related elasticity of the vertebral ligaments as well as immaturity of the osseous structures in the pediatric spine allow momentary subluxation in response to deforming forces. The resultant neurological injuries range from transient dorsal column dysfunction to complete cord transection. Between 1960 and 1985, 42 such injuries were treated at the Children's Hospital of Pittsburgh. Management of these radiographically occult spinal cord injuries consisted of cervical immobilization for 2 months in a hard collar and restriction of contact sports. Recurrent cord injury occurred in eight cases during the 2-month immobilization period. A clearly defined traumatic episode was identified in seven of the eight patients, although in four children the recurrent trauma to the spine was trivial. Five of the children removed their collars briefly before the second injury, and two children incurred reinjury with the hard collar in place. The remaining child was too young for hard-collar immobilization, and recurrent neurological deterioration occurred during sleep. Serial flexion-extension films failed to detect frank instability in any of the eight cases. The children most susceptible to reinjury were those who sustained mild or transient neurological deficits from an initial cord injury and who rapidly resumed normal activities. Radiographically occult spinal instability resulting from the initial injury to the vertebral and paravertebral soft tissues presumably made these children vulnerable to recurrent spinal cord injury, often from otherwise insignificant trauma. During the last 21 months, 12 additional children have been managed with a more stringent protocol combining neck immobilization in a rigid cervical brace for 3 months and restriction of both contact and noncontact sports, together with a major emphasis on patient compliance. With this new protocol, no recurrent cord injuries have been documented.     

Adult spinal cord injury with no radiographic bone lesion: analysis of nine consecutive patients

Background

Spinal cord injury with no radiographic bone lesion described as spinal cord injury without radiographic abnormality (SCIWORA) in childhood is less often reported in adults than in children. This study was undertaken to report our experience in the management of nine cases over 25 years.

Patients and methods

This was a retrospective study from 1985 to 2009 concerning nine adult patients who sustained spinal cord injury with no radiographic abnormality. The ratio among all cervical spine traumas for the same period was 2.21%. Magnetic resonance imaging (MRI) was performed in all the patients. The patients’ clinical status at the time of admission and discharge was evaluated using the Frankel's grading system. We report the results based on the clinical, epidemiologic and radiological findings and outcomes.

Results

The mean age of our population was 37.43 years, ranging from 18 to 60 years. All the patients were men. The main etiology was falls (5/9) followed by road traffic accidents (4/9). According to the Frankel's grading system, four patients (44.45%) were grade A, four were grade B (44.45%), and one was grade C (11.11%). On MRI, medullar lesions were: contusion, non-compressive cervical disc herniation, cervical spine stenosis, and two cases of normal cervical spine. Four patients were operated on via the posterior cervical spine approach (laminectomy, C3-C7 in three cases and C1-C3 in one case). The other five patients were treated orthopaedically for 6 to 8 weeks. Three patients (3/9), who were Frankel's grade B and C with no demonstrable injury on MRI, improved to Frankel a useful neurological grade (Frankel's grades D or E) at the time of discharge. One patient evaluated as Frankel's grade A died from cardiovascular disturbance.

Conclusion

Spinal cord injury with no radiographic abnormality accounted for 2.21% of cases of spinal cord injury in our series. MRI is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to identify surgically correctable abnormalities.     

Magnetic resonance imaging of acute cervical spine trauma. Correlation with severity of neurologic injury

Prior to the advent of computer-assisted imaging techniques, conventional radiographic studies did not accurately depict the severity of soft tissue injury (spinal cord and paravertebral tissue) attending severe spinal trauma. Computed tomography scanning is clearly superior to plain radiography in the demonstration of osseous fractures and impactions, but this modality does not clearly depict ligamentous or disc injuries and does not image the spinal cord directly. The authors' preliminary experience indicates that magnetic resonance imaging (MRI) more accurately defines the extent of soft tissue damage in the zone of injury. In this study, the authors correlate these objective imaging techniques with findings on neurologic exam. Seventy-eight patients with cervical spine injuries admitted to the Regional Spinal Cord Injury Center of the Delaware Valley between August 1987 and January 1989 were evaluated with surface-coil MRI on a 1.5-Tesla unit. Fifty-nine patients were studied within 7 days of injury. Image sequences consisting of T1-, proton density, and T2-weighted images were obtained in saggital views. Axial gradient recalled acquisitions in the steady state (GRASS) images were obtained from most patients. We learned that certain patterns of MRI signal were associated with severe neurologic deficit. These include: 1) intramedullary hematoma and 2) spinal cord contusion associated with edema encompassing more than one spinal segment. Magnetic resonance imaging findings also correlated with less severe injury and include 1) normal spinal cord signal and 2) small focal contusions associated with edema encompassing one spinal segment or less.     

颈椎闭合性创伤合并椎动脉损伤的机制及MRA诊断

目的探讨颈椎闭合性骨折脱位继发椎动脉损伤的机制及MRA诊断.方法本组95例颈椎闭合性创伤,男76例,女19例,年龄16～65岁,平均34岁.所有患者接受颈椎MRI和椎动脉MRA检查,当椎动脉预期位置完全无血流成像,MRI T2横断面上椎动脉内有高信号血栓影像时,即确诊为椎动脉阻塞.结果本组95例中,19例合并有椎动脉闭塞,均为单侧,左侧9例,右侧10例,其中颈椎骨折5例,双侧小关节突脱位6例,单侧小关节突脱位7例,无放射影像异常的脊髓损伤1例.18例椎动脉损伤患者无任何症状,1例有轻度头昏、嗜睡.结论椎动脉损伤易继发于有小关节突脱位的颈椎创伤,前瞻性MRA检查是首选的方法.     

闭合性椎动脉损伤的临床诊断和治疗

目的探讨闭合性椎动脉损伤的MRA诊断及临床治疗。方法本组319例闭合性颈椎创伤患者,颈椎骨折261例,双侧小关节突脱位24例,单侧小关节突脱位22例,无放射影像异常的脊髓损伤12例。全部患者接受前瞻性颈椎MRI及椎动脉MRA检查,对继发椎动脉损伤患者,常规行抗凝、溶栓及改善微循环治疗。结果本组319例闭合性颈椎创伤患者,52例继发有椎动脉损伤,单侧51例,双侧1例;其中34例为颈椎小关节脱位,16例为颈椎骨折,2例为无放射影像异常的脊髓损伤。51例单侧椎动脉损伤患者,44例无脑神经症状,7例有头昏、嗜睡,1例视物模糊,经治疗后症状均消失;1例双侧椎动脉损伤患者于伤后1周死亡。结论2DTOFMRA是诊断闭合性椎动脉损伤的有效方法,抗凝、溶栓及改善微循环治疗是降低缺血性损害风险的可行措施。     

颈椎小关节脱位与闭合性椎动脉损伤的相关性研究

[目的]探讨颈椎小关节脱位与闭合性椎动脉损伤的相关性。[方法]本组319仍颈椎创伤患者，颈椎骨折261例；小关节脱位46例，其中单侧小关节脱位22例，双侧小关节脱位24例；无放射影像异常的脊髓损伤12例。所有患者接受了颈椎MRI和椎动脉2DTOF MRA的前瞻性检查。动物实验建立犬颈椎小关节脱位的撞击模型，撞击后摄颈椎X线片，24—36h后行椎动脉2DTOF MRA检查。[结果]临床319例颈椎创伤患者，52例继发有椎动脉损伤，单侧51例，双侧1例。发现有椎动脉损伤的患者中，34例（65．4％）原始损伤为颈椎小关节脱位，16例为颈椎骨折，2例为无放射影像异常的颈髓损伤。动物实验14只犬撞击后发生颈椎小关节脱位，12只犬无小关节脱位。14只发生小关节脱位犬中，8只继发有单侧椎动脉损伤，12只无小关节脱位犬均无椎动脉损伤。[结论]闭合性椎动脉损伤最常继发于颈椎小关节脱位，瞬间位移使椎动脉受到过度牵张是主要的致伤因素。     

Clinical indications for cervical spine radiographs in the traumatized patient

During a 4 1/2 year period, 4,941 trauma patients were admitted to a hospital, and details of their injuries and treatment were entered in a computerized trauma registry. Using that database, patients with cervical spine injury were studied. Of the 4,941 patients, 1,823 (38 percent) had radiographs of the cervical spine. Ninety-four patients (5 percent) of these patients had injuries of the cervical spine or spinal cord. Sixty five of the 94 patients with cervical spine injury were alert. All had either neck pain or neck tenderness. We do not recommend screening cervical spine radiographs for the alert trauma patient without neck pain; however, we do recommend screening for all patients with decreased levels of consciousness and an injury that could have conceivably injured the cervical spine, for all patients with neurologic deficits compatible with a cervical origin, and for all patients with neck pain or tenderness. Lateral cervical spine radiographs were obtained in all injured patients. They demonstrated cervical spine injury in 70 patients (74 percent) and missed the injury in the remaining 24, which resulted in an unacceptable false-negative rate of 26 percent. We believe that all patients at risk for cervical spine injuries must have complete radiographic examinations of the cervical spine. Computerized axial tomography was the most useful modality to confirm a cervical spine injury in those patients whose lateral cervical spines appeared normal radiographically, especially in patients with associated head injury requiring computerized axial tomography of the brain. Computerized axial tomography diagnosed the injury in 14 of the 24 patients requiring study beyond initial screening. Also presented herein is a radiologic screening algorithm for cervical spine injuries in trauma patients.     

Transient neurologic deficits associated with thoracic and lumbar spine trauma without fracture or dislocation

Two categories of persistent posttraumatic neurologic deficits of the spinal cord without evidence of a spinal fracture or dislocation have been described previously. Spinal cord injury without radiographic abnormality (SCI-WORA) is seen in children. In the elderly, hyperextension injuries causing neurologic deficits without bony injury have also been described. The purpose of this report is to review mechanisms by which transient neurologic deficits occur in the absence of bony disruption. The authors describe four cases in which transient neurologic deficits occurred after blunt trauma to the thoracic or lumbar spine. Their experience indicates that, when neurologic deficits after trauma occur without fracture or dislocation, there is often an underlying structural susceptibility of the axial skeleton.     

Herniated intervertebral discs associated with unstable spinal injuries

To examine the occurrence of traumatic herniated intervertebral discs associated with unstable spinal injuries, the authors reviewed the records of all patients with spinal cord level unstable spine injuries managed at their institution over a 26-month period. Ninety-three patients were identified. All patients had roentgenographic and computed tomographic (CT) evaluation. Magnetic resonance imaging was performed in 48 patients, and revealed the presence of a herniated intervertebral disc in 16, with the highest incidence being in the cervical spine. In the patients who had only plain film and CT scans, no disc pathology was identified. Magnetic resonance imaging provides a noninvasive means of examining intervertebral disc damage in unstable spinal injuries that might otherwise be unidentified and result in spinal cord injury at the time of surgery.     

Disc herniation in cervical fracture subluxation

Previous reports of computed tomographic scan with contrast myelography in cervical spinal cord injury have shown a rate of disc herniation of less than 5%. We hypothesized that injuries associated with forces adequate to cause bone or ligamentous injury in the region of the disc space could be associated with higher and more significant rates of disc herniation. Thirty-seven consecutive traumatic midcervical fracture subluxations were reviewed. Fracture subluxation was defined by fracture of the facet joints, pedicles, or vertebral bodies or more than 3.5 mm subluxation from C2-C3 to C7-T1. Reduction was achieved in 97% and was not associated with neurological deterioration. On the basis of plain films, tomograms, and plain computed tomographic scans, the injuries were classified as flexion dislocation, flexion compression, compression burst, or extension injuries. Twenty-five computed tomographic scans with contrast myelograms and one magnetic resonance imaging scan were obtained. All patients with partial neurological deficits were studied. A herniated disc was defined as that which deformed the thecal sac and/or nerve roots. Retrospectively, a neuroradiologist reviewed the studies for the presence of herniated disc. Disc herniation was seen at the level of injury in 9 (35%) patients and not seen in other patients. Forty-seven percent of the patients with partial deficits had herniated discs. Herniated disc was seen most frequently in flexion dislocation and flexion compression injuries. Three patients (20%) with partial deficits underwent discectomy. Patients with partial spinal cord injury and discectomy, on average, improved more than other patients with partial spinal cord injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Blunt traumatic hematuria in children. Is a simplified algorithm justified?

PURPOSE: We determined whether radiographic evaluation is indicated in all children with traumatic hematuria. MATERIALS AND METHODS: We retrospectively reviewed the records of 110 children from 1992 to 1999 diagnosed with blunt trauma and hematuria. It is routine practice at our emergency department to perform radiographic evaluation in all children with hematuria regardless of the degree. Each chart was evaluated for the mechanism of injury, degree of hematuria, hypotension, imaging studies, renal injury, renal anomalies, associated injuries and outcome. RESULTS: A total of 110 patients 1 to 18 years old (mean age 9) were identified. The most common mechanism of injury was motor vehicle accident in 37 children (34%), followed by a fall in 32 (29%). Grades I to V renal injury was present in 5, 6, 6, 6 and 1 cases, respectively (22%), while 1 (0.9%) involved ureteropelvic junction avulsion. No child had renal pedicle injury. In 9 patients renal anomalies were detected incidentally. Of the 110 patients 101 underwent radiographic evaluation, including computerized tomography in 97 (88%). The 24 patients (22%) with significant renal injury and all with incidentally diagnosed renal anomalies had 50 or greater red blood cells per high power field on urinalysis, while 1 with ureteropelvic junction avulsion presented without hematuria. Hypotension was present in only 3 patients (2.7%), who also had associated injuries, including 2 who presented with renal injury. All 3 with associated injuries. Associated injuries were identified in 11 of 25 patients (44%). The 9 patients (8%) who did not undergo radiographic imaging had negative results on repeat urinalysis with an excellent outcome. CONCLUSIONS: We recommend that radiological evaluation consisting of abdominal and pelvic computerized tomography should be performed only in patients with 50 or greater red blood cells on urinalysis, hypotension at presentation to the emergency room or based on the severity of mechanism of injury, for example high speed motor vehicle accident deceleration injuries. The patient who presented with ureteropelvic junction avulsion without hematuria would have undergone imaging considering the mechanism of injury and number of associated injuries.     

Subarachnoid-pleural and subarachnoid-mediastinal fistulae

Subarachnoid-pleural fistula and subarachnoid-mediastinal fistula are rare complications of chest trauma. One case each of subarachnoid-mediastinal fistula and subarachnoid-pleural fistula is described. Both patients were young children who suffered severe longitudinal distraction injuries to their thoracic spine and exhibited complete cord transection without radiographic evidence of vertebral column injury. Progressive mediastinal widening and enlarging pleural effusion in the absence of angiographic evidence of aortic injury suggested the diagnosis of an intrathoracic cerebrospinal fluid fistula. Myelograms identified the site of spinal cord rupture and cerebrospinal fluid leakage. The diagnosis, management, and outcome of these rare fistulae are discussed.