Multidetector computed tomography of cervical spine fractures in ankylosing spondylitis

PURPOSE: To analyze multidetector computed tomography (MDCT) cervical spine findings in trauma patients with advanced ankylosing spondylitis (AS). MATERIAL AND METHODS: Using PACS, 2282 cervical spine MDCT examinations requested by emergency room physicians were found during a period of 3 years. Of these patients, 18 (16 M, aged 41-87, mean 57 years) had advanced AS. Primary imaging included radiography in 12 and MRI in 11 patients. RESULTS: MDCT detected one facet joint subluxation and 31 fractures in 17 patients: 14 transverse fractures, 8 spinous process fractures, 2 Jefferson's fractures, 1 type I and 2 type II odontoid process fractures, and 1 each: atlanto-occipital joint fracture and C2 laminar fracture plus isolated transverse process and facet joint fractures. Radiographs detected 48% and MRI 60% of the fractures. MRI detected all transverse and odontoid fractures, demonstrating spinal cord abnormalities in 72%. CONCLUSION: MDCT is superior to plain radiographs or MRI, showing significantly more injuries and yielding more information on fracture morphology. MRI is valuable, however, in evaluating the spinal cord and soft-tissue injuries. Fractures in advanced AS often show an abnormal orientation and are frequently associated with spinal cord injuries. In these patients, for any suspected cervical spine injuries, MDCT is therefore the imaging modality of choice.     

Evaluation of spinal trauma by multi detector computed tomography and magnetic resonance imaging

Aim of work

The aim of this work is to assess the role of multi-detector computed tomography (MDCT) and magnetic resonance imaging (MRI) in evaluation of spinal trauma.

Patients and methods

Between January 2013 and April 2014, 98 patients (78 males and 20 females) with spinal injuries were investigated by MDCT and MRI. Assessment of the radiological findings of spinal injury was performed and the following were investigated: vertebral compression fractures, bursts and dislocations, posterior element fractures, C1 and C2 lesions, vertebral listhesis, bone marrow edema, spinal canal compression, disk herniation, extradural hematoma, spinal cord contusions, spinal cord swelling and posterior ligamentous complex injuries.

Result

A total of 271 lesions were diagnosed as follows: 217 lesions were diagnosed using MRI alone, 1 54 lesions were diagnosed using MDCT alone and 100 lesions were diagnosed using MRI and MDCT conjointly. By using MRI 117 more lesions were detected than using MDCT. MRI was significantly superior to MDCT in the diagnosis of bone marrow edema, posterior ligamentous complex injuries, disk herniations, spinal canal compressions, and spinal cord contusions and edema. In cervical spine injuries, MRI was useful for the evaluation of the supporting ligaments and the spinal cord after the patient has been stabilized. The average times required to perform CT and MRI were 1.38 ± 19.83 and 2.00 ± 19.58 days, respectively; this difference was significant (p?0.05) according to the Mann–Whitney test.

Conclusion

MRI was significantly superior to MDCT in the diagnosis of bone marrow edema, posterior ligamentous complex injuries, disk herniations, spinal canal compressions, and spinal cord contusions and edema. In cervical spine injuries, MRI was useful for the evaluation of the supporting ligaments and the spinal cord after the patient has been stabilized.MDCT and MRI are complementary to each other in evaluation of spine injuries.     

Cervical spine fractures in ankylosing spondylitis: MR findings

Purpose: The purpose of this study is to evaluate the MR findings in patients with long-term ankylosing spondylitis (AS) and acute cervical spine fractures. Materials and methods: The magnetic resonance imaging (MRI) studies of five patients with AS and acute cervical spine fractures were retrospectively reviewed for the presence of cervical spine instability, spinal cord compression, and epidural hematoma. Results: Spinal fractures were unstable in all five patients. Three patients had neurological symptoms and abnormal signal within the spinal cord. All patients with neurological deficits had epidural hematomas posterior to the dural sac. Conclusion: MRI is useful for assessment of the integrity of intervertebral disks and spinal ligaments and, therefore, of the instability of the spinal fracture. MRI is mandatory in patients with neurological symptoms, especially in those with a symptom-free interval and those with neurological deterioration after established spinal cord injury, when suspicion for epidural hematoma is high. Electronic Publication     

Non-Contiguous Spinal Injury in Cervical Spinal Trauma: Evaluation with Cervical Spine MRI

Objective

We wished to evaluate the incidence of non-contiguous spinal injury in the cervicothoracic junction (CTJ) or the upper thoracic spines on cervical spinal MR images in the patients with cervical spinal injuries.

Materials and Methods

Seventy-five cervical spine MR imagings for acute cervical spinal injury were retrospectively reviewed (58 men and 17 women, mean age: 35.3, range: 18-81 years). They were divided into three groups based on the mechanism of injury; axial compression, hyperflexion or hyperextension injury, according to the findings on the MR and CT images. On cervical spine MR images, we evaluated the presence of non-contiguous spinal injury in the CTJ or upper thoracic spine with regard to the presence of marrow contusion or fracture, ligament injury, traumatic disc herniation and spinal cord injury.

Results

Twenty-one cases (28%) showed CTJ or upper thoracic spinal injuries (C7-T5) on cervical spinal MR images that were separated from the cervical spinal injuries. Seven of 21 cases revealed overt fractures in the CTJs or upper thoracic spines. Ligament injury in these regions was found in three cases. Traumatic disc herniation and spinal cord injury in these regions were shown in one and two cases, respectively. The incidence of the non-contiguous spinal injuries in CTJ or upper thoracic spines was higher in the axial compression injury group (35.3%) than in the hyperflexion injury group (26.9%) or the hyperextension (25%) injury group. However, there was no statistical significance (p > 0.05).

Conclusion

Cervical spinal MR revealed non-contiguous CTJ or upper thoracic spinal injuries in 28% of the patients with cervical spinal injury. The mechanism of cervical spinal injury did not significantly affect the incidence of the non-contiguous CTJ or upper thoracic spinal injury.     

Imaging manifestations of spinal fractures in ankylosing spondylitis

BACKGROUND AND PURPOSE: Spinal fractures in ankylosing spondylitis (AS) were difficult to diagnose before CT and MR imaging were available. The purpose of our investigation was to characterize spinal fractures and determine the value of different imaging modalities in AS. METHODS: Twelve successive cases of spinal fractures were identified in MR imaging files of AS patients. Conventional radiographs were available for 12, CT scans for 7, and 3D-CT scans for 4. We carefully reviewed clinical histories and imaging presentations. RESULTS: Fractures were found in the cervical spine in 3 patients and in the thoracolumbar spine in 9. The 3 columns of the spine were involved in 11 patients. A routine 4-mm axial CT was not enough to demonstrate all fractures and ligament tears. The sensitivities of 3D-CT scans for demonstration of the following problems were similar to that of MR imaging and were better than that of conventional radiographs: tearing of the posterior longitudinal ligament, the thoracic spinous process fracture, and the facet fracture. MR imaging depicted these following findings that usually were not shown on conventional radiographs or 3D-CT scans: cord deformity, soft tissue disruption, and ligament tears in the posterior column. MR imaging also showed avascular necrosis and occult fractures better than conventional radiographs or CT scans. CONCLUSIONS: MR imaging shows abnormalities in AS that may not be clear or even detectable by using other imaging methods. With the capability to show lesions in the posterior column, MR imaging can serve to evaluate AS patients with spinal fracture for the possibility of 3-column involvement.     

Thoracic spine trauma

Thoracic spine fractures are most commonly flexion injuries resulting from vehicular accidents or falls. The initial evaluation of any multiple trauma victim should include AP and cross-table lateral radiographs of the thoracic spine. Conventional and computed axial tomography can add additional information regarding posterior element integrity and spinal canal encroachment. MRI can also be useful in that it directly images the effects of fractures on the spinal cord.     

脊髓亚急性联合变性的MRI诊断要点分析

目的分析脊髓亚急性联合变性(SCD)的MRI诊断要点。资料与方法回顾性分析15例临床确诊SCD的病人临床及MRI资料,分析其脊髓MRI表现特点,统计分析SCD病人受累脊髓节段数与血清VB12水平、发病时间的相关性。结果 15例SCD病人均于横断面影像上显示颈胸段脊髓对称性等或长T1、长T2信号,13例病变主要位于颈胸段水平脊髓后索,2例同时累及后索、侧索及前索。但于横断面T2WI上颈段与胸段脊髓异常信号形态各具特点。颈段脊髓受累时于横断面T2WI上呈脊髓内"倒V"形或"反兔耳"形的对称性高信号。胸段脊髓受累时于横断面T2WI上呈脊髓内"哑铃"形的对称性高信号。统计学分析显示15例SCD病人脊髓受累节段数与血清VB12水平呈负相关,而与病程长短无相关性。结论脊髓MR成像对于SCD脊髓疾病的诊断有重要价值。     

Clinical role of radiography for thoracic spine fractures in daily practice in the MDCT era: a retrospective review of 255 trauma patients

Purpose

To retrospectively assess the diagnostic efficacy of radiography in detecting vertebral body fractures of the thoracic spine compared with MDCT, to assess the confounding factors reducing the diagnostic efficacy, and to investigate the outcomes of radiographically overlooked patients.

Materials and methods

Two hundred fifty-five patients suspected of thoracic spine fractures were enrolled. We assessed the diagnostic efficacy of radiography for the patients sub-grouped based on five confounding factors: chest abnormalities, head injuries, cervical spine fractures, upper extremity injuries, and age of 65?years or older. We investigated the outcomes of radiographically overlooked patients.

Results

Three hundred fifty-one vertebral body fractures were detected. The per-fracture sensitivities and specificities were 55?% and 94?% for vertebral body fractures and 41 and 99?% for unstable fractures. In patients with upper extremity injuries or aged 65?years or older, radiography was less sensitive in detecting the unstable fractures (P?<?0.05). Nineteen patients were overlooked by radiography; two had neurological deficits and needed surgical fixation; 15 with no neurological deficit were conservatively treated with uneventful outcomes.

Conclusion

Radiography had low sensitivity but high specificity. In daily practice, primary use of MDCT is beneficial for patients with neurological deficit or upper extremity injuries or elderly patients.     

轻中型颅脑损伤合并无脊髓损伤的上颈椎骨折脱位的诊治

目的总结轻中型颅脑损伤合并无脊髓损伤的上颈椎骨折脱位的诊治经验,以提高对其的认识和疗效。方法回顾性分析2012年1月—2017年12月海军军医大学附属公利医院骨科收治的25例轻中型颅脑损伤合并无脊髓损伤的上颈椎骨折脱位患者临床资料,男性14例,女性11例;年龄20~71岁,平均48.2岁。颅脑损伤9例行手术治疗,16例行非手术治疗;颈椎骨折10例行非手术治疗,13例单独行颈椎手术,2例一期颅颈联合手术。出院时进行格拉斯哥预后评分(GOS评分),术后门诊随访X线片或CT片评价颈椎骨折愈合情况。结果出院时GOS V级20例,IV级4例,I级1例。随访12~48个月,平均24.5个月,复查颈椎X线片或CT示骨折愈合良好。结论颅脑损伤患者常规颈椎CT扫描有助于上颈椎损伤的早期诊断。上颈椎不稳定骨折在病情允许下尽早手术,可减少并发症的发生。     

老年上颈椎损伤的临床特点与治疗

目的 探讨老年上颈椎损伤的临床特点与治疗方法.方法 回顾性分析我科2003年1月-2007年12月间收治的>60岁上颈椎骨折脱位患者28例的临床资料,其中男20例,女8例;年龄60～86岁,平均68.1岁.致伤原因:跌伤16例,交通伤8例,高处坠落伤4例.寰椎骨折5例;枢椎骨折15例,其中齿状突骨折8例,C2椎弓骨折6例,C2椎体骨折1例;寰枢椎损伤伴下颈椎损伤5例;寰枢椎同时损伤2例,其中齿状突骨折伴寰椎侧块骨折1例,齿状突骨折伴寰椎前弓骨折1例;寰枢关节脱位1例.并发脊髓损伤4例.保守治疗8例,开放手术治疗8例,微创经皮手术治疗12例.结果 平均住院时间比较,保守组与传统手术组间差异无统计学意义(P>0.05),而微创经皮组短于保守组与传统手术组(P<0.05).保守治疗组2例死亡,开放手术组1例死亡,其余25例均获得随访,随访时间9～56个月,平均16.8个月.保守治疗组患者满意率为50%,开放手术组为72%,微创手术组为75%.保守治疗组中4例发生并发症,传统手术组3例,微创手术组2例.结论 老年上颈椎损伤发生率较高,其损伤特点以低能量暴力为主,损伤类型以齿状突骨折最常见,具有脊髓损伤发生率低、漏诊率高等特点.在排除手术禁忌证的情况下,手术治疗特别是微创手术可取得较好的临床疗效.     

Surface coil MR of spinal trauma: preliminary experience

Nineteen fractured vertebral bodies involving the spine from C1 to L2 in 14 patients were imaged with a 0.6-T magnet using prototypical surface coils. Ten of these patients were studied within the first week of trauma. CT and plain films are superior to MR in detecting fractures and identifying the origin of displaced fragments in cases of extensive comminution. However, all body fractures and most posterior element fractures in the thoracolumbar spine were visible on MR. Fractures involving the cervical neural arch were difficult to detect on transverse section without CT correlation. Our results indicate that MR can probably replace CT in the thoracolumbar region. MR is superior to CT in demonstrating ligamentous injury and trauma to the disk. Unlike CT, MR shows the relation of the thecal sac and spinal cord to retropulsed fragments and epidural hematoma. MR also visualizes cord parenchyma; two cases of cord hemorrhage were not seen on CT. Even at this early stage of development, surface coil MR promises to become important in the evaluation of spinal trauma, not only in assessing the integrity of the spinal canal and cord, but in separating stable from unstable fractures on the basis of disruption of the posterior ligaments and elements. Additionally, the demonstration of rupture of specific ligaments may have an impact on surgical management.     

Thoracic fractures and dislocations in motorcyclists

Motorcyclists who are involved in accidents generally suffer severe multiple injuries, some of which are not readily apparent on initial examination. One such subtle injury is fracture, with or without dislocation, in the upper thoracic spine. The severe spinal cord damage produced by the injury is often overshadowed by cerebral or cervical injury. Proper diagnosis is further hampered by the fact that the upper thoracic region is difficult to examine radiographically on plain films, particularly when using portable equipment. Of a group of 14 motorcyclists having 26 fractures and/or dislocations in the thoracic region, 12 had 24 injuries between T3 and T8. These 24 injuries represented 56% of the fractures and/or dislocations encountered in a larger study of trauma to the thoracic vertebral column. All of these were flexion injuries, suffered when the individual was thrown from the motorcycle and struck a large, solid object. In three cases, the diagnosis was delayed as much as 48 h because proper films were not obtained initially. Because of the serious consequences of delayed treatment, we recommend that all motorcyclists who have sustained severe trauma be examined by overpenetrated film of the upper thoracic region.     

急性颈椎外伤的MRI诊断

目的 分析急性颈椎外伤的MRI征象,评价MRI在急性颈椎外伤诊断中的价值及限度。方法收集急性颈椎外伤150例,均有MRI检查和X线平片,15例有CT片,采用14个参数进行分析记录。结果150例中MRI检出骨折51个,小关节脱位30个,椎体脱位35个;外伤性椎间盘突出40个,硬膜外血肿2例;脊髓损伤69例;脊髓受压迫20例;前、后纵韧带损伤21例;棘间韧带和黄韧带损伤15例;椎前血肿或水肿30例;椎旁和背侧软组织损伤40例;X线平片发现椎体骨折55个,椎体脱位35个;小关节脱位35例,附件骨折25个,椎前软组织肿胀20例。15例CT均发现骨折,小关节脱位,椎管狭窄。结论MRI在显示脊髓、韧带、椎间盘和软组织损伤方面优于CT和X线平片。MRI能全面反映颈椎各种损伤的病理特征,为评估颈椎稳定性提供充分的依据;MRI和X线片的骨折检出率没有明显差异,CT应该用于复杂的颈椎骨折检查。     

Ⅰ期前后路联合手术治疗颈髓前后方同时受压

目的 探讨颈髓前后方同时受压Ⅰ期前后路手术的方法。方法 总结1999年6月～2003年11月收治的25例颈髓前后方同时受压的临床资料。男18例，女7例；年龄28～56岁，平均36．4岁。交通伤致颈椎三柱骨折18例，嵌夹型颈椎病5例，椎体和附件、椎板恶性巨细胞瘤2例。结果 25例均行Ⅰ期前后路联合手术减压内固定，创伤患者术后l例死亡，17例有不同程度恢复；颈椎病患者症状和阳性体征基本消失；肿瘤患苫疼痛基本消失，其中1例出现肺转移。结论 对各种原因引起颈髓前后方同时受压的患者，Ⅰ期前后路联合手术是理想方法，可使严重颈椎骨折脱位患者彻底解除颈髓压迫，损伤节段获得早期稳定，方便护理和功能锻炼，有利于脊髓功能恢复。     

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.     

Focal Anterior Displacement of the Thoracic Spinal Cord without Evidence of Spinal Cord Herniation or an Intradural Mass

Objective

We report magnetic resonance imaging (MRI) findings on focal anterior displacement of the thoracic spinal cord in asymptomatic patients without a spinal cord herniation or intradural mass.

Materials and Methods

We identified 12 patients (male:female = 6:6; mean age, 51.7; range, 15-83 years) between 2007 and 2011, with focal anterior displacement of the spinal cord and without evidence of an intradural mass or spinal cord herniation. Two radiologists retrospectively reviewed the MRI findings in consensus.

Results

An asymmetric spinal cord deformity with a focal dented appearance was seen on the posterior surface of the spinal cord in all patients, and it involved a length of 1 or 2 vertebral segments in the upper thoracic spine (thoracic vertebrae 1-6). Moreover, a focal widening of the posterior subarachnoid space was also observed in all cases. None of the patients had myelopathy symptoms, and they showed no focal T2-hyperintensity in the spinal cord with the exception of one patient. In addition, cerebrospinal fluid (CSF) flow artifacts were seen in the posterior subarachnoid space of the affected spinal cord level. Computed tomography myelography revealed preserved CSF flow in the two available patients.

Conclusion

Focal anterior spinal cord indentation can be found in the upper thoracic level of asymptomatic patients without a spinal cord herniation or intradural mass.     

Absent cord sign in acute spinal trauma

Review of magnetic resonance imaging (MRI) findings in 100 patients suffering acute spinal trauma from 1985 to 1987 revealed four patients who had suffered thoracic spine fractures and acute subarachnoid hematomas. The spinal cord was not demonstrated on the T1-weighted sagittal MRI due to the similarities in signal intensity between the spinal cord and acute hemorrhage. Nonvisualization of the thoracic cord should not be presumed to be artifactual until subarachnoid hematoma is excluded.     

颈椎过屈性损伤的MRI诊断

目的分析不同程度颈椎过屈性损伤的影像表现，评价ＭＲＩ表现的意义。方法３１例颈椎过屈性损伤，平均年龄３２岁，外伤史明确。全部病例在伤后不同时间行ＭＲＩ扫描，ＭＲＩ扫描前常规摄颈椎平片，部分行ＣＴ扫描。结果３１例中１７例伤及Ｃ４～６椎体，占５５％，同时累及２个椎体４例，占１３％。影像表现为棘突骨折、椎体前脱位、椎体宽界面压缩骨折、双侧关节突关节脱位、屈曲泪滴样骨折５种类型。ＭＲＩ同时显示２４例后部复合韧带撕裂，３例后纵韧带和５例前纵韧带撕裂，１６例椎间盘受压或碎裂变形，２３例颈髓受压、形态信号异常，其中３例横断。结论ＭＲＩ能反映不同程度不同方向的屈曲外力引起的颈椎和脊髓不同程度的病理变化，ＭＲＩ对脊髓、间盘、韧带等软组织损伤的评价，是判断不同程度颈椎过屈性损伤椎体稳定性及预后的依据。ＭＲＩ可反映颈椎过屈性损伤全部损伤机制及其病理基础     

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.