Helical CT in the primary trauma evaluation of the cervical spine: an evidence-based approach

This review provides a summary of the cost-effectiveness, clinical utility, performance, and interpretation of screening helical cervical spine CT for trauma patients. Recent evidence supports the use of helical CT as a cost-effective method for screening the cervical spine in high-risk trauma patients. Screening cervical spine CT can be performed at the time of head CT to lower the cost of the evaluation, and when all short- and long-term costs are considered, CT may actually save money when compared with traditional radiographic screening. In addition to having higher sensitivity and specificity for cervical spine injury, CT screening also allows more rapid radiological clearance of the cervical spine than radiography. Patients who are involved in high-energy trauma, who sustain head injury, or who have neurological deficits are candidates for CT screening. Screening with CT may enhance detection of other potentially important injuries of the cervical region. Received: 17 March Revision requested: 14 April 2000 Revision received: 19 July 2000 Accepted: 19 July 2000     

Cervical spine injury in the very elderly

Background: Elderly patients are known to be at increased risk of cervical spine injuries. This propensity for injury becomes more important as the population of mobile elderly individuals increases. The present study seeks to examine the incidence and spectrum of spine injury among patients aged 80 years or greater, and to examine the efficacy of a decision rule for obtaining cervical spine radiography in this extreme age group. The decision rule would determine whether imaging could be avoided in patients who have none of the following: (1) posterior midline cervical spine tenderness; (2) focal neurological deficit; (3) abnormal level of alertness; (4) evidence of intoxication; or (5) clinically apparent distracting painful injury. Methods: All blunt trauma victims presenting to participating emergency departments underwent clinical evaluation prior to radiographic imaging. The elements of the decision rule were assessed and documented in each patient prior to radiographic imaging. The presence or absence of cervical spine injury was subsequently based on the final interpretation of all radiographic studies supplemented by a review of neurosurgical and risk management logs from each participating hospital. Data on all patients aged 80 years or greater were sequestered from the main database for separate analysis. Results: The study enrolled 34,069 individuals, including 818 patients (2.4 %) with cervical spine injuries. This population contained 1,070 patients (3.1 % of all cases) aged 80 or greater, 50 of whom (4.7 %) sustained cervical spine injuries. Injuries to the craniocervical junction (particularly C2 and the odontoid) accounted for 47.3 % of the injuries in the elderly, but only 28.6 % of injuries in younger patients. Older fracture victims were also likely to have more injuries (2.54 injuries/patient) than their younger counter parts (1.78 injuries/patient). The decision rule correctly identified all very elderly cervical spine injury victims [sensitivity 100.0 %; confidence interval (CI) 92.9–100.0 %], and designated 132 patients as “low-risk,” yielding a negative predictive value of 100.0 % (CI 97.3–100.0 %). Conclusions: The very elderly are at increased risked of cervical spine injury, particularly injury to the craniocervical junction. They also tend to have more extensive injuries than younger patients. Despite the increased risk of injury, the decision rule performed well in the very elderly, and allowed correct identification of all cervical spine injury victims.     

Calcification of the alar ligament of the cervical spine: imaging findings and clinical course

Ligamentous calcification of the cervical spine has been reported in the yellow ligament, anterior and posterior longitudinal ligaments and interspinous ligament. Calcification in the upper cervical spine is rare, although some cases with calcification of the transverse ligament of the atlas have been reported. Two patients with calcification of the alar ligament with an unusual clinical presentation and course are described. Examination by tomography and computed tomography (CT) showed calcification of the alar ligament and the transverse ligament of the atlas. CT documented decreased calcification as symptoms resolved. There may be a role for CT in the search for calcifications in the upper cervical spine in patients presenting with neck pain and pharyngodynia if radiographs are normal. Received: 13 October 2000 Revision requested: 17 November 2000 Revision received: 18 December 2000 Accepted: 19 December 2000     

MRI of acute spinal trauma

The clinician managing patients who have suffered trauma to the spine requires several questions answered from imaging studies. In the acute stage, a full assessment of the complete injury to the bony, ligamentous, disc and neural tissues will determine the stability of the injury and help decide the nature of clinical management, either conservative or surgical, and also help in determining the surgical approach. Magnetic resonance imaging (MRI) is established as a vital imaging technique and can answer many of the questions posed above. The purpose of this article is to review the current status of MRI in the assessment of acute spinal trauma. Received: 24 August 2000 Revision requested: 13 December 2000 Revision received: 31 January 2001 Accepted: 15 February 2001     

MRI of the cervical spine: rheumatoid arthritis compared with cervical spondylosis

This study is a comparison of the cervical spine MR images from 26 patients with rheumatoid arthritis of the cervical spine with those from an age and sex matched group suffering from cervical spondylosis. Erosion of bone and major atlanto-axial subluxation were confined to rheumatoid arthritis. Soft tissue changes revealed by MRI included distortion of normal ligaments and bursae around the dens, particularly in rheumatoid arthritis. Abnormal masses of soft tissue were found in both groups, but those suggesting acute inflammation were much more frequent in rheumatoid arthritis than in cervical spondylosis. Neural compression was well demonstrated, and in rheumatoid arthritis was usually caused by bony structures whereas in cervical spondylosis it was usually due to disc material. It is concluded that MRI should be used as the first investigation to follow plain films in rheumatoid arthritis of the cervical spine. Bone and soft tissue changes are clearly shown, but interpretation of the images requires the recognition that some observed abnormalities may be due to coincidental cervical spondylosis.     

MRI of cervical spine injuries complicating ankylosing spondylitis

OBJECTIVE: The objective was to study characteristic MRI findings in cervical spine fractures complicating ankylosing spondylitis (AS). Technical issues related to MRI are also addressed. MATERIALS AND METHODS: A review of 6,774 consecutive cervical spine multidetector CT (MDCT) scans obtained during 6.2 years revealed 33 ankylosed spines studied for suspected acute cervical spine injury complicating AS. Of these, 20 patients also underwent MRI. RESULTS: On MRI, of these 20 patients, 19 had a total of 29 cervical and upper thoracic spine fractures. Of 20 transverse fractures traversing both anterior and posterior columns, 7 were transdiskal and exhibited less bone marrow edema than did those traversing vertebral bodies. One Jefferson's, 1 atlas posterior arch (Jefferson's on MDCT), 2 odontoid process, and 5 non-contiguous spinous process fractures were detectable. MRI showed 2 fractures that were undetected by MDCT, and conversely, MDCT detected 6 fractures not seen on MRI; 16 patients had spinal cord findings ranging from impingement and contusion to complete transection. CONCLUSION: Magnetic resonance imaging can visualize unstable fractures of the cervical and upper thoracic spine. Paravertebral hemorrhages and any ligamentous injuries should alert radiologists to seek transverse fractures. Multiple fractures are common and often complicated by spinal cord injuries. Diagnostic images can be obtained with a flexible multipurpose coil if the use of standard spine array coil is impossible due to a rigid collar or excessive kyphosis.     

MRI detection of unsuspected vertebral injury in acute spinal trauma: incidence and significance

Objective. Multilevel spinal injury is well recognised. Previous studies reviewing the radiographs of spinal injury patients have shown an incidence of 15.2% of unsuspected spinal injury. It is recognised that magnetic resonance imaging (MRI) can identify injuries that are not demonstrated on radiographs. The objective of this study was to determine the incidence and significance of spinal injuries using MRI in comparison with radiographs. Design and patients. The radiographs and MR images of 110 acute spinal injury patients were reviewed independently of each other and the findings were then correlated to determine any unsuspected injury. Results. MRI detected vertebral body bone bruises (microtrabecular bone injury) in 41.8% of spinal injury patients which were not seen on radiographs. These bone bruises were best appreciated on sagittal short tau inversion recovery MR sequences and seen at contiguous and non-contiguous levels in relation to the primary injury. Conclusion. This level of incidence of bone bruises has not previously been appreciated. We recommend that patients undergoing MRI for an injured segment of the spine are better assessed by MRI of the entire spine at the same time to exclude further injury. Received: 17 April 2000 Revision requested: 19 June 2000 Revision received: 6 September 2000 Accepted: 27 November 2000     

Cervical myelography: survey of modes of practice and major complications

A total of 68 major complications of cervical myelography were reported by 220 neuroradiologists in a mail survey. Two-thirds of the complications were attributed to cervical spine hyperextension and one-third to lateral C1-2 puncture. Narrow sagittal diameter of the spinal canal and severe cervical spondylosis were frequent contributing factors to hyperextension injury of the cervical spinal cord. Clinical and radiographic premyelography screening is suggested, with magnetic resonance imaging performed first in patients with spinal canal stenosis, severe spondylosis, and/or myelopathy of any cause. Neck extension should be minimal during myelography. All C1-2 punctures should be monitored with lateral fluoroscopy for accurate needle positioning and prevention of contrast medium injection into the spinal cord.     

颈椎前路手术中相关神经损伤并发症的常见原因及治疗

目的 回顾颈椎前路手术中相关神经损伤的常见原因及治疗方法.方法 2008年1月-2009年12月手术治疗859例颈椎病、颈椎后纵韧带骨化症及颈椎外伤行颈椎前路手术患者,对术后出现脊髓损伤症状加重及相关神经损伤的7例患者的临床资料进行回顾性分析.结果 859例患者中共5例发生脊髓损伤,发生率为0.58%;1例发生喉返神经损伤,发生率为0.12%;1例发生喉上神经损伤,发生率为0.12%.术后血肿发生脊髓损伤4例,经过清除血肿、甲基强的松龙等药物、高压氧及时治疗,均逐渐恢复至正常;术后发生脊髓损伤症状加重1例,经气管切开、呼吸机支持治疗及激素、高压氧治疗后脊髓损伤症状逐渐恢复至原有水平.术后发生喉返神经、喉上神经损伤患者2例经过激素、脱水等药物保守治疗,术后3个月内均恢复至正常.结论 颈椎病、颈椎后纵韧带骨化症及颈椎外伤患者行颈椎前路手术中均可能发生脊髓损伤及相关神经损伤,如能注意预防和及时治疗,预后较好.

Abstract：

Objective To review the relevant causes for and treatment of nerve injuries in the anterior cervical surgery. Methods From January 2008 to December 2009,859 cages of cervical spondylosis,ossification of cervical posterior longitudinal ligament and cervical spine trauma were treated by anterior cervical surgery.This study retrospectively analyzed the clinical data of seven cases who were with worsened symptoms of spinal cord injury and related nerve injury. Results Of 859 cases,five cases(0.58%)were with spinal cord injury,one(0.12%)with recurrent laryngeal nerve injury and one (0.12%)with laryngeal nerve injury.Hematoma occurred in four cases after surgery caused spinal cord injury and all the four patients recovered to normal after removal of the hematoma and timely treatment with mythylprednisolone and hyperbaric oxygen.Cervical spine trauma was worsened in one patient after the anterior cervical surgery.The patient restored to its original level of spinal cord gradually through some measures such as tracheotomy,ventilator support,hormone therapy and hyperbaric oxygen treatment.Laryngeal nerve injuries in two cases recovered to normal after conservative treatment with hormone,dehydration and other drugs within three months after surgery. Conclusions Anterior cervical surgery of cervical spondylosis,ossification of cervical posterior longitudinal ligament and cervical spine trauma are likely to induce the related nerve damage.The good prognosis can be obtained under timely prevention and treatment.     

Imaging in spinal trauma

Because it may cause paralysis, injury to the spine is one of the most feared traumas, and spinal cord injury is a major cause of disability. In the USA approximately 10,000 traumatic cervical spine fractures and 4000 traumatic thoracolumbar fractures are diagnosed each year. Although the number of individuals sustaining paralysis is far less than those with moderate or severe brain injury, the socioeconomic costs are significant. Since most of the spinal trauma patients survive their injuries, almost one out of 1000 inhabitants in the USA are currently being cared for partial or complete paralysis. Little controversy exists regarding the need for accurate and emergent imaging assessment of the traumatized spine in order to evaluate spinal stability and integrity of neural elements. Because clinicians fear missing occult spine injuries, they obtain radiographs for nearly all patients who present with blunt trauma. We are influenced on one side by fear of litigation and the possible devastating medical, psychologic and financial consequences of cervical spine injury, and on the other side by pressure to reduce health care costs. A set of clinical and/or anamnestic criteria, however, can be very useful in identifying patients who have an extremely low probability of injury and who consequently have no need for imaging studies. Multidetector (or multislice) computed tomography (MDCT) is the preferred primary imaging modality in blunt spinal trauma patients who do need imaging. Not only is CT more accurate in diagnosing spinal injury, it also reduces imaging time and patient manipulation. Evidence-based research has established that MDCT improves patient outcome and saves money in comparison to plain film. This review discusses the use, advantages and disadvantages of the different imaging techniques used in spinal trauma patients and the criteria used in selecting patients who do not need imaging. Finally an overview of different types of spinal injuries is given.     

益脑推拿法对椎动脉型颈椎病患者颈椎生理曲度的影响

目的:观察益脑推拿法对椎动脉型颈椎病患者颈椎生理曲度的影响。方法:160例患者随机分为益脑推拿组(80例)和常规推拿组(80例),采用Borden氏法测量颈椎生理曲度,疗程结束后对两组患者颈椎生理曲度值的变化进行对照分析。结果:治疗后益脑推拿组、常规推拿组的颈椎生理曲度值分别为4.30±1.23 mm、3.55±1.82 mm,两组差别有显著性意义(t′=3.0309,P<0.05)。结论:改善或重建颈椎生理曲度可能是益脑推拿法治疗椎动脉型颈椎病的作用机制之一。     

椎动脉型颈椎病的MRI分析

目的 探讨椎动脉型颈椎病的ＭＲＩ诊断价值及其限度。材料与方法 选取我院近２年来经临床诊断为椎动脉型颈椎病患者４２例,全部行颈部ＭＲＡ检查,其中２３例同时行颈椎ＭＲＩ,观察椎动脉全段ＭＲＡ表现及颈椎横突孔以及钩椎关节的变化情况。选择２６例正常人作为对照组。全部行颈椎ＭＲＩ及椎动脉ＭＲＡ检查,方法条件和观察内容同病例组。结果 （１）４２例中７例椎动脉ＭＲＡ正常,其余３５例（３５／４２）分别显示不同程度     

Improving the imaging diagnosis of cervical spine injury in the very elderly: implications of the epidemiology of injury

Purpose: To enumerate host and vector factors that affect each phase of cervical spine injury (CSI) among the elderly, and to attribute specific pathoanatomic characteristics of CSI to host and/or vector factors. Methods: Structured review of English literature references selected from MEDLINE keyword search using PUBMED and OVID search engines. Only articles addressing the role of “aging” or being “elderly” (using a variety of definitions) in CSI were included. The following information was abstracted: journal; year of publication; authors' specialty or departmental affiliation; study design; inclusion and exclusion criteria; year(s) of data collection; number of CSI vs. controls; summary findings, including rate estimates, obvious study weaknesses. Results: Seven of 13 articles were medical-record-based case series, most derived from institutional trauma registries. Four were population-based surveys. One was an assessment of Medicare claims data for all-cause trauma and one a review paper. Blunt-force CSI was most commonly related to domestic falls, then to vehicular-pedestrian collisions and finally to vehicular crashes. More than two-thirds of fractures involved CO-C3, especially in individuals with cervical spondylosis and/or osteoporosis. In 15 to 40 % of CO-C3 fractures there is a delay in diagnosis. An adult forme fruste of SCIWORA (spinal cord injury without radiographic abnormality) was a relatively common cause of central and anterior cord syndromes in the absence of observable fractures or dislocations. Conclusions: The epidemiology of CSI in elderly patients should inform triage and imaging decisions. Since most CSI diagnostic errors involve the upper cervical spine, additional attention to the radiographic anatomy of the craniocervical junction and diligent search for abnormalities in this region are warranted.     

Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal?

PURPOSE: To retrospectively determine what information, if any, magnetic resonance (MR) imaging of the cervical spine in obtunded and/or "unreliable" patients with blunt trauma adds to multi-detector row computed tomography (CT) of the entire cervical spine (including routine multiplanar sagittal and coronal reformations) when the CT findings are normal. MATERIALS AND METHODS: The study was HIPAA compliant and institutional review board approved. Informed consent was not required. From April 2001 to November 2003, 1400 trauma patients underwent MR imaging of the cervical spine to evaluate potential cervical spine injuries. Multi-detector row CT of the cervical spine was performed with a four- or 16-detector row scanner. MR imaging of the cervical spine was performed with transverse gradient-echo, sagittal intermediate-weighted, sagittal short inversion time inversion-recovery, and sagittal T1- and T2-weighted fast spin-echo sequences. Many MR examinations were performed to exclude soft-tissue injuries in the cervical spine of obtunded patients with blunt trauma in whom cervical spine injury could not be excluded with physical examination. Complete cervical spine MR studies were obtained to evaluate soft-tissue injuries in 366 obtunded patients with blunt trauma (281 male and 85 female patients; age range, 13-92 years; mean age, 42.1 years). The patients had previously undergone total cervical spine multi-detector row CT with normal findings. The results obtained with these two modalities were compared. RESULTS: MR images were negative for acute injury in 354 of the 366 patients and negative for cervical spine ligamentous injury in 362. Seven of the 366 patients had cervical cord contusions, four patients had ligamentous injuries, three patients had intervertebral disk edema, and one patient had a cord contusion, a ligamentous injury, and an intervertebral disk injury. Four patients had ligamentous injuries; however, all of these patients had ligament injuries limited to only one of the three columns of cervical spine ligament support. Multi-detector row CT had negative predictive values of 98.9% (362 of 366 patients) for ligament injury and 100% (366 of 366 patients) for unstable cervical spine injury. CONCLUSION: A normal multi-detector row CT scan of the total cervical spine in obtunded and/or "unreliable" patients with blunt trauma enabled the authors to exclude unstable injuries on the basis of findings at follow-up cervical spine MR imaging.     

Dynamic motion study of the cervical spine using ultra-fast gradient echo with RF-spoiled GRASS--evaluation of cervical instability]

In order to assess the instability of the cervical spine, ten patients with cervical spondylosis were studied by dynamic MRI using Ultra-Fast RF-Spoiled GRASS which is capable of subsecond imaging. Dynamic MRI has proved to be useful in the evaluation of cervical instability, especially in detecting the transient abnormal mobility of cervical spines which cannot be identified on conventional radiography.     

Destructive spondyloarthropathy of the cervical spine in long-term hemodialyzed patients: a five-year clinical radiological prospective study

Objective: To describe the radiographic features and progression of cervical spine destructive spondyloarthropathy (DSA) in hemodialyzed patients, and to evaluate the relationship between this disease and patient characteristics, biochemical values, and hemodialysis duration. Design and patients: Standard radiographs, and lateral flexion and extension views of the cervical spine, were performed annually for 5 years in 31 hemodialyzed patients who were divided into three groups at the commencement of the study: those showing (I) DSA, (II) vertebral rim erosions (VRE) without DSA, and (III) absence of DSA and VRE. Magnetic resonance (MR) imaging and computed tomography (CT) were performed in seven and two patients respectively. The imaging features were evaluated for the presence and progression of spondyloarthropathy and correlated with clinical and biochemical variables. Statistical analysis was performed using one-way analysis of variance. Results: The duration of hemodialysis appeared to be the main predictive factor (P=0.0003) for DSA, which was found in six patients (19%). DSA was found to correlate with higher levels of beta2-microglobulin (P<0.00001), parathyroid hormone (P<0.05), and alkaline phosphatase (P<0.05). Clinical symptoms were minimal. In two patients, MR imaging revealed changes mimicking spondylodiscitis. In another patient, CT of the craniocervical junction showed bone resorption due to a pseudotumor, and basilar invagination. Conclusions: DSA of the cervical spine is often clinically silent. Pathogenesis of DSA may be multifactorial but its progression is most influenced by the duration of hemodialysis. On MR imaging, DSA may mimic spondylodiscitis. Received: 23 January 2001 Revision requested: 27 February 2001 Revision received: 15 March 2001 Accepted: 18 April 2001     

Tunneling Schmorl’s nodes in an elderly woman treated for acute lymphoblastic leukemia

We present a 70-year-old woman with pre-B acute lymphoblastic leukemia in whom serial imaging studies showed the development of multiple vertebral collapse, and communicating superior and inferior Schmorl’s nodes creating a longitudinal channel (”tunneling” Schmorl’s nodes) through the anterior aspect of T12 to L3 vertebral bodies of her osteoporotic thoracolumbar spine. This was observed after achieving complete remission of the disease and during maintenance therapy. The finding is felt to be secondary to iatrogenic exacerbation of osteoporosis. Received: 26 May 2000 Revision requested: 23 June 2000 Revision received: 10 July 2000 Accepted: 13 July 2000     

Cervical spine fractures in patients 65 years and older: a clinical prediction rule for blunt trauma

PURPOSE: To determine clinical predictors of cervical spine fracture in the elderly and to develop a clinical prediction rule to guide appropriate imaging in high-risk patients. MATERIALS AND METHODS: Institutional review board approval was received with waiver of informed consent. A retrospective case-control study was performed on blunt trauma patients 65 years and older with cervical spine fractures and on randomly selected control subjects without fracture. Potential predictors of fracture were evaluated through simple and multivariate logistic regression. Simple predictors were grouped into clinically similar composite variables and were analyzed with multivariate logistic regression and recursive partitioning. A clinical prediction rule was generated. The receiver operating characteristic curve was calculated and adjusted through bootstrap validation. Absolute cervical spine fracture probabilities were calculated by using Bayes theorem for all elderly patients and for patients who underwent computed tomography. Results were compared with a previous prediction rule for all adults. RESULTS: Composite predictors of fracture in the elderly included focal neurologic deficit (adjusted odds ratio, 17.7; 95% confidence interval [CI]: 3.8, 83.4), severe head injury (odds ratio, 3.2; 95% CI: 1.5, 7.1), high-energy mechanism (odds ratio 6.7; 95% CI: 3.1, 14.8), and moderate-energy mechanism (odds ratio 3.3; 95% CI: 1.3, 8.3). The prediction rule stratified patients into risk groups with fracture probabilities ranging from 0.4% (95% CI: 0.1%, 1.3%) to 24.2% (95% CI: 5.7%, 100%). CONCLUSION: Clinical factors can be used to stratify patients 65 years and older into risk groups with a wide range of probabilities of cervical spine fracture. Knowledge of cervical fracture risk can help guide appropriate imaging in high-risk patients.     

Screening for catastrophic neck injuries in sports

The cervical spine is prone to injury due to the structure of the articulating vertebrae at the level of C4-C6, where the spinal cord occupies more of the spinal canal. Cervical spine injuries can occur in all sports and all ages. Participation in contact sports certainly increases the possibility of cervical spine injuries. In screening for catastrophic neck injuries it is vital to examine incidence and injury surveillance statistics in sports. These data can help determine sport-specific preponderance of catastrophic injury. Screening methods for predisposition to catastrophic cervical spine injuries include a concise history, physical examination, and radiographic methods. There is currently no universal classification system utilizing imaging of the cervical spine that has been validated as a screening method for catastrophic neck injuries.     

颈椎病患者后纵韧带的磁共振影像及临床意义

目的：探讨颈椎病后纵韧带的磁共振影像特点及其临床意义。方法：对2000年4月。2002年4月的42例颈椎病的磁共振影像和临床资料进行回顾性分析。结果：磁共振检查提示后纵韧带骨化9例，后纵韧带肥厚17例，颈椎问盘脱出16例。16例行颈椎后路手术，26例行颈椎前路手术切除后纵韧带。平均改善率为61．8％，优11例，占31．4％；良14例，占40％；一般8例，占22．9％；差2例，占5．7％。结论：MRI对后纵韧带骨化、后纵韧带肥厚和颈椎问盘脱出的诊断有重要价值，对手术方案的选择有重要意义。