Arteriovenous malformation of the spinal cord mimicking a tumour

We report an arteriovenous malformation of the spinal cord mimicking a tumour on plain radiographs of the spine.     

Myelographic findings in cervical spines without degenerative changes

Summary One hundred cervical myelographies in patients without degenerative changes on plain radiographs were evaluated. Pathologic changes were seen in 75 patients, most of them with congenital spinal canal stenosis and dural sac stenosis. Normal values for sagittal diameter of the dural sac from C2 to C6 were established. It was found that a quotient <0.9 between the sagittal diameter of the spinal canal and the midsagittal diameter of the vertebral body indicated congenital stenosis. It is concluded that plain radiographs of the cervical spine are unreliable in predicting the diagnostic value of cervical myelography.     

Primary amyloidoma of the cervical spine

Primary solitary amyloidoma of the spine is a disease characterized by localized deposits of amyloid. We describe and illustrate the radiologic appearance of primary solitary amyloidoma of the spine on plain radiographs, CT scans, and MR images. The imaging findings revealed features of a nonspecific soft-tissue mass with calcifications. Epidural extension of the amyloidoma caused spinal cord compression.     

Computed tomography of spine trauma

Nine patients admitted to the hospital for spine trauma were studied with computed tomography. The use of computed tomography minimized patient motion, allowed excellent definition of compromise of the spinal canal by fracture fragments, and better delineated fractures of the neural arches than plain films or tomography. Plain radiographs and computed tomography scans permitted complete evaluation of spine trauma with no additional investigations being necessary.     

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.     

Sports-related injury of the pediatric spine

Acute spinal injuries are fortunately rare in pediatric sports but can be catastrophic. Imaging is integral to the diagnosis and care of spinal trauma. Plain radiographs and CT are critical for detecting vertebral fracture, and MR imaging is an essential adjunct for evaluating muscular, ligamentous, and spinal cord injury. Back pain is a common complaint among athletes of all ages. The growing spine has unique weaknesses that result in a higher rate of detectable radiologic abnormalities. Disk pathology is less common in children, and is often uniquely associated with fracture of the ring apophyses. Spondylolysis is far more prevalent in youth athletes than in their adult counterparts, requiring a different approach to imaging for assessment of adolescent back pain.     

Vertebral morphometry: current methods and recent advances

Vertebral fractures are the hallmark of osteoporosis and are associated with increased morbility and mortality. Because a majority of vertebral fractures often occur in absence of specific trauma and are asymptomatic, their identification is radiographic. The two most widely used methods to determine the severity of vertebral fractures are the visual semiquantitative (SQ) assessment and the morphometric quantitative approach, involving the measurements of vertebral body heights. The measurements may be made on conventional spinal radiographs (MRX: morphometric X-ray radiography) or on images obtained from dual X-ray absorptiometry (DXA) scans (MXA: morphometric X-ray absorptiometry).The availability of a rapid, low-dose method for assessment of vertebral fractures, using advanced fan-beam DXA devices, provides a practical method for integrated assessment of BMD and vertebral fracture status. The visual or morphometric assessment of lateral DXA spine images may have a potential role for use as a prescreening tool, excluding normal subjects prior to performing conventional radiographs.     

X线平片与螺旋CT对先天性脊柱侧弯的应用价值

目的探讨多层螺旋CT(MSCT)和X线平片对于先天性脊柱侧弯的诊断价值。方法对临床诊断为先天性脊柱侧弯的40例患者行脊柱CT扫描,经最大密度投影(MIP)、多平面图像重组(MPR)、表面容积遮盖(SVR)及表现遮盖图像(SSD)后处理,并对照X线平片分析不同的处理后图像的应用价值。结果术前X线平片诊断脊椎形成障碍18例,脊椎分节障碍15例,混合型7例。MSCT诊断脊椎形成障碍13例,脊椎分节障碍12例,混合型15例,伴有脊柱纵裂6例,肋骨畸形8例,椎管内纵行骨嵴4例。SVR图像可较全面地评价先天性脊柱侧弯的所有相关表现。结论MSCT的多种后处理图像较X线平片更具优势,能准确和全面判断脊柱畸形的类型和范围。     

Initial imaging strategies in spinal trauma patients

A review is presented of the radiographs that should be taken of the spine of a severely injured spinal trauma patient within the first 24 h. The patient will probably present to a small local hospital or health care centre; the capacities and skills of such a small radiological unit are discussed. Consideration is then given to the radiological procedures which a specialized trauma centre should undertake after transfer of the patients. The main emphasis of the review is on plain films.     

Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication

Trauma constitutes a significant portion of emergency department practice. Such patients often have suspected cervical spine injury necessitating cervical spine radiographs. The importance of detecting cervical spine injury is obvious because failure to do so can lead to tragic consequences for patient and physician alike. Although most cervical spine radiographs are justified, poorly indicated and unnecessary examinations are unfortunately commonplace. Indiscriminate ordering of cervical spine examinations can easily exceed radiology resources assigned to the emergency department. Rational ordering practices are therefore essential for efficient patient management. A risk-tailored approach to performing these examinations, which can improve efficiency, is presented. Once obtained, cervical spine radiographs are presumed to detect injury with consistently high sensitivity. Prevailing conditions of emergency department practice that may lower the "sensitivity" of cervical spine radiographs are reviewed. Overreliance on the initial radiologic examination may lead to inappropriate haste in the evaluation of suspected cervical region injury as exemplified by the commonly voiced mandate to "clear the cervical spine" of injury. This approach is discouraged in patients with significant trauma in favor of a careful, progressive evaluation of the potentially injured cervical spine. Periodic review of these complex issues and close cooperation between clinical services are emphasized.     

The rheumatoid cervical spine: signs of instability on plain cervical radiographs

The cervical spine is a common focus of destruction from rheumatoid arthritis, second only to the metacarpophalangeal joints. Joint, bone and ligament damage in the cervical spine leads to subluxations which can cause cervical cord compression resulting in paralysis and even sudden death. Because many patients with significant subluxations are asymptomatic, the radiologist plays a key role in recognizing the clinically important clues to instability on plain radiographs of the cervical spine-often difficult in rheumatoid arthritis when the bony landmarks are osteoporotic or eroded. This review focuses on the signs of instability on plain radiographs of the cervical spine, using diagrams and clinical examples to illustrate methods of identifying significant subluxations in rheumatoid arthritis.     

Occult and secondary injuries missed by plain radiography of the cervical spine in blunt trauma patients

Background: Plain radiography does not visualize every cervical spine injury sustained by blunt trauma victims. The purpose of this study was to examine the prevalence and types of injuries missed by plain radiographs of the cervical spine and determine how frequently such radiography fails to detect any cervical spine injury. Methods: Images from all radiographic studies performed on blunt trauma victims presenting to 21 participating institutions were reviewed to compile an exhaustive list of all CSIs sustained by each individual. These injuries were then compared with the injuries detected by plain radiography alone. Patients were classified as having a “sentinel” injury if one or more of their injuries were visible on plain radiographs. Patients were classified as having a radiographically “occult” injury if none of their injuries were visible on plain radiographs. The number and types of injuries missed on plain radiographs were then separately tabulated for the sentinel and occult injury groups. Results: Plain radiographs were completed in 570 of 818 victims of acute cervical spine injury and revealed 702 of 1,056 injuries. Plain films failed to detect 98 occult injuries present in 60 patients (10.5 %), and failed to detect 256 secondary injuries in 510 patients (89.5 %) who had a sentinel injury identified. Plain radiographs failed to reveal 79 of 136 (58.1 %) lateral mass injuries and 67 of 105 (63.8 %) lamina injuries, making these the most frequent sites of missed injury. Conclusions: Plain radiographs frequently fail to reveal injuries to the cervical spine, particularly those involving the lamina and lateral mass. The majority of the missed injuries represent secondary injuries in patients with a sentinel injury identified on these films. However, plain films fail to detect any injury in a minority of injured patients.     

Radiographic manifestations of congenital anomalies of the spine

Although the foregoing review of embryologic development and congenital anomalies of the spine in infants and children is necessarily brief, the most commonly encountered abnormalities have been reviewed, and when possible, an attempt has been made to cite the stage of embryologic development at which the various abnormalities originate. As noted, congenital abnormalities of the spine are relatively uncommon but may be of profound clinical significance. During the past decade, the most significant developments in the diagnosis and treatment of these abnormalities have been ultrasonography, CT scanning, and MR imaging. In the neonate, the spinal cord and neural outflow can be evaluated by ultrasonography until the osseous elements begin to fuse. Thereafter, MR imaging is the procedure of choice because it permits evaluation of the spine and spinal cord in all planes of imaging and provides detailed evaluation of the effect of osseous abnormalities on neural structures. Finally, plain radiographs of the spine for evaluation of neonates who have any of a spectrum of sacral dimples are rarely helpful, and in the presence of significant cutaneous or subcutaneous abnormalities, ultrasonography is the preferred modality for evaluation.     

CT of the spine: are plain spine radiographs necessary?

This study was designed to determine whether plain radiographs added any information of clinical significance to the information provided by CT (computed tomography) and its standard digital radiographs in 100 patients presenting for CT of the lumbar spine and 46 patients presenting for cervical spine CT. In only three (3%) of the lumbar studies and two (4.3%) of the cervical studies did the plain radiographs add diagnostic information. The added diagnostic information did not affect patient management in all cases with indications other than trauma. Good quality oblique cervical spine digital radiographs were obtained in 10 cases simply by moving the tube and detectors to the 45 degrees and 135 degrees azimuths. The evidence from this study suggests that when a CT examination of lumbar or cervical spines is planned on a high resolution CT scanner for indications other than trauma, a conventional plain radiographic examination can be omitted in the first instance.     

Evaluation of traumatic spinal canal stenosis in thoracolumbar burst fractures. A comparison of three methods for measuring the percent canal occlusion

OBJECTIVES: Various percent canal occlusion measurement methods have been used to assess the spinal canal stenosis following a thoracolumbar burst fracture. However, there are no studies performed comparing these techniques. The objective of this study was to determine the reliability of three techniques used to measure the spinal canal stenosis in thoracolumbar burst fractures on lateral radiograph and CT scans, and to identify the most reliable and practical method of assessment. METHODS: Fifty preoperative lateral radiographs and axial computed tomography (CT) scans of thoracolumbar burst fractures were analyzed by five observers in two sessions. The three measurement techniques were tested: the ratio of sagittal diameter of spinal canal at the injury level to that at the adjacent level on lateral plain radiographs (Ratio 1) and on axial CT scans (Ratio 2); and the ratio of cross-sectional area of spinal canal at the injury level to that at the adjacent level on axial CT scans (Ratio 3). Interobserver and intraobserver reliability for each measure was assessed. RESULTS: Greater coefficient of variation (CV) of measurement was founded for the Ratio 1 obtained from lateral plain radiographs than the other two ratios (Ratio 2 and 3) from CT scans (P<0.05), while no differences of CV were noted between the Ratio 2 and Ratio 3 with CT scans (P>0.05). There was no significant improvement (P>0.05) of the interobserver agreement after a 3-month interval for all three methods. A high significant positive correlation was observed between Ratio 1 and Ratio 2, Ratio 1 and Ratio 3, and Ratio 2 and Ratio 3 (P<0.05 for all). CONCLUSIONS: CT scans are more reliable than plain radiographs in the evaluation of spinal canal occlusion in thoracolumbar burst fractures although the agreement might be acceptable for the latter. Measurement of sagittal diameter of spinal canal using CT scan might be a more reasonable choice than of cross-sectional area of spinal canal because of its simplicity and comparable measurement reliability.     

High-resolution CT scanning in the evaluation of cervical spine fractures: comparison with plain film examinations

Forty-nine patients with cervical spine fractures were identified among 160 patients who underwent CT of the cervical spine for blunt trauma. Although there was a high index of suspicion on the plain film interpretation, as well as a large percentage of false positives, many fractures were found on CT that were not suggested, even in retrospect, on the plain radiographs. Of the 136 fractures ultimately identified in these patients, CT detected 135 (99%) while only 64 (47%) were seen or suspected on the initial screening radiographs. At first glance, this might appear to discredit the plain films as a screening device. However, most of these "occult" fractures occurred in vertebrae that had been identified as probably fractured in other parts, for example, pedicle fractures found in vertebrae initially suspected of harboring only a vertebral body fracture. Most of the remainder of the uncovered fractures were in vertebrae immediately adjacent to ones that were initially identified as fractured. Indeed, of the 49 patients with fractures, only one had an adequately exposed and positioned plain film that was completely normal. The ability of CT to determine quickly and confidently the presence or absence of cervical fractures and to define the position of fragments in relation to the spinal canal is of considerable value in the medical and nursing management of the seriously traumatized patient. For example, when a fracture is seen or suspected on conventional films, a limited CT examination of the area is recommended. Plain films should be used to guide the CT examination so that an intact vertebra above and below the lesion is included. If an adequately exposed and positioned plain film series of the cervical spine is normal, it is unlikely that CT will reveal a fracture. While conventional radiographs fail to detect a surprising number of fractures, they retain their value as a screening tool and as a guide to selective CT imaging.     

Sensitivity of plain radiography for pediatric cervical spine injury

Pediatric patients with suspected cervical spine injuries (CSI) often receive a computed tomography (CT) scan as an initial diagnostic imaging test. While sensitive, CT of the cervical spine carries significant radiation and risk of lethal malignant transformation later in life. Plain radiographs carry significantly less radiation and could serve as the preferred screening tool, provided they have a high functional sensitivity in detecting pediatric patients with CSI. We hypothesize that plain cervical spine radiographs can reliably detect pediatric patients with CSI and seek to quantify the functional sensitivity of plain radiography as compared to CT. We analyzed data from the NEXUS cervical spine study to assess the sensitivity of plain radiographs in the evaluation of CSI. We identified all pediatric patients who underwent plain radiographic imaging, and all pediatric patients found to have CSI. We then determined the sensitivity of plain radiographs in detecting pediatric patients with CSI. We identified 44 pediatric patients with CSI in the dataset with age ranging from 2 to 18 years old. Thirty-two of the 44 pediatric patients received cervical spine plain films as a part of their workup. Plain films were able to identify all 32 pediatric patients with CSI to yield a sensitivity of 100 % in detecting injury victims (95 % confidence interval 89.1–100.0 %). Plain radiography was highly sensitive for the identification of CSI in our cohort of pediatric patients and is useful as a screening tool in the evaluation of pediatric CSI.     

Is there need for thoracic spine radiographs following a negative chest CT in trauma patients?

The purpose of this study was to assess the need for conventional radiographs of the thoracic spine for routine clearance of trauma patients in whom chest CT has revealed no spinal trauma. The study was in the form of a retrospective review of trauma patients over the previous five years who underwent conventional radiographs of the thoracic spine following a chest CT that revealed no spinal trauma. Two hundred thirty-five trauma patients were found to have undergone conventional thoracic spine series following a chest CT that showed no spinal trauma. In 234 of the cases, the thoracic spine series was also negative. In one case, the thoracic spine series revealed mild anterior compression of the T7 vertebral body. This injury was stable and required no specific intervention. CT of the chest is an adequate evaluation of the thoracic spine in trauma patients who require routine thoracic spine clearance, making subsequent conventional radiographs of the thoracic spine unnecessary. Electronic Publication     

Transdiaphragmatic jejunal duplication: a report of five cases.

Five infants with intrathoracic transdiaphragmatic duplication cysts are presented. Diagnosis was possible from the combination of several features on plain chest radiographs: (a) right-sided cystic areas lying posteriorly in the chest, (b) lower cervical or upper dorsal spinal dysraphism, and (c) unusual gas collection beneath the right hemidiaphragm. Barium studies, positive-contrast myelography, and computed tomography were helpful in preoperative assessment.     

Clearing the cervical spine in victims of blunt trauma

Cervical spine injuries occur in 2.3% to 6.4% of victims of blunt trauma. The difficulty of identifying the minority of patients with cervical spine injuries continues to challenge those who triage and treat the acutely injured. We retrospectively reviewed our practice for cervical spine clearance, which consists of three-view plain radiographs supplemented by focused further studies, such as computed or plain film tomography and flexion/extension views, as needed. Fifty-four patients with cervical spine injuries were identified during a 39-month period, which represented approximately 1% of the patients evaluated. Eighty cervical spine injuries were found, of which nine were missed. Review of the six patients in whom the nine cervical spine injuries were missed demonstrated error in the interpretation of radiographic studies in five patients, only two of whom were felt to have technically adequate films in hindsight. We conclude that a protocol based on three-view plain film radiographs supplemented by focused additional studies will allow the visualization of virtually all cervical spine injuries and that the main cause of missed injuries is errors of interpretation.