IMAGING IN SPINAL TRAUMA 13.6.23 FINAL.pptx

spinal trauma

1. IMAGING Evaluation IN SPINal TRAUMA 13.6.23 SYED MAQSOOD

2. introduction The spine is composed of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, a sacrum of 5 fused segments, and a coccyx of 4 fused segments. Fractures of the spinal column are found most commonly at C1-C2, C5-C7, and T12-L1. Results mostly from automobile accidents and sports activities. Flexion is the most common line of force in spinal injuries. Spinal cord injuries occur in 10-14% of spinal fractures and dislocations. Fractures of cervical spine produces neurological damage in approx. 40% of cases.

3. CeRvical spine

4. Structurally, the first and second cervical vertebrae possess anatomic features distinct from those of the remaining five cervical vertebrae The first cervical vertebra, C1 or Atlas, is an osseous ring consisting of anterior and posterior arches connected by two lateral masses . The atlas has no body; its main structures are the lateral masses, also called articular pillars. The second vertebra, C2 or Axis, is a more complex structure whose distinguishing feature is the odontoid process, also known as the dens (tooth), projecting cephalad from the anterior surface of the body. ANATOMY

5. radiographs 3 Standard Views Lateral view Anteroposterior (AP) view AP odontoid peg view/Open Mouth veiw

6. Lateral view. (A) For the erect lateral view of the cervical spine, the patient is standing or seated, with the head straight in the neutral position. The central beam (red broken line) is directed horizontally to the center of the C4 vertebra (at the level of the chin). (B) For the cross-table lateral view, the patient is supine on the radiographic table. The radiographic cassette (a grid cassette to obtain a clearer image) is adjusted to the side of the neck, and the central beam is directed horizontally to a point (red dot) approximately 2.5 to 3 cm caudal to the mastoid tip. LATERAL VIEW

7. Alignment: 5 contour lines Anterior vertebral line Posterior vertebral line Spinolaminar line Posterior spinous line Clivusodontoid line, drawn from the dorsum sellae along the clivus to the anterior margin of the foramen magnum should point to the tip of the odontoid process at the junction of the anterior and middle thirds.

8. Height and density of vertebral body should be assessed Disc space - should be uniform Assess spaces between the spinous process

9. Predental space: Distance between the posterior aspect of anterior arch of Atlas (C1) and the anterior aspect of odontoid process. Should be <3mm in adults and <5mm in children.

10. The lateral view of the cervical spine, including the lower part of the skull, is extremely important to evaluate the vertical subluxation involving the atlantoaxial articulation and the migration of the odontoid process into the foramen magnum. Several measurements are helpful to determine atlantoaxial impaction or cranial settling resulting in superior migration of the odontoid process.

11. The Chamberlain line - This line is drawn from the posterior margin of the foramen magnum ( opisthion) to the dorsal (posterior) margin of the hard palate . The odontoid process should not project above this line more than 3 mm ; a projection of 6.6 mm (±2 standard deviation [SD]) above this line strongly indicates cranial settling.

12. The McRae line This line defines the opening of the foramen magnum and connects the anterior margin ( basion ) with posterior margin (opisthion ) of the foramen magnum. The odontoid process should be just below this line or the line may intersect only at the tip of the odontoid process. In addition, a perpendicular line drawn from the apex of the odontoid to this line should intersect it in its ventral quarter.

13. The McGregor line This line connects the posterosuperior margin of the hard palate to the most caudal part of the occipital curve of the skull. The tip of the odontoid normally does not extend more than 4.5 mm above the line.

14. Soft tissue Nasopharyngeal space (C1) – 7mm Retro-pharyngeal space (C2-C4) – 5-7mm Retro-tracheal space (C5-C7) – 22mm (adults) and 14mm (children)

15. Anteroposterior view. (A) For the anteroposterior view of the cervical spine, the patient is either erect or supine. The central beam is directed toward the C4 vertebra (at the point of the Adam's apple) at an angle of 15 to 20 degrees cephalad . (B) The radiograph in this projection demonstrates the C3-7 vertebral bodies and the intervertebral disk spaces. The spinous processes are seen superimposed on the bodies, resembling teardrops. The C1 and C2 vertebrae are not adequately seen.

16. A variant of the anteroposterior projection known as the open-mouth view may also be obtained as part of the standard examination. This view provides effective visualization of the structures of the first two cervical vertebrae. The body of C2 is clearly imaged, as are the atlantoaxial joints, the odontoid process, and the lateral spaces between the odontoid process and the articular pillars of C1.

17. Open-mouth view . - For the open-mouth view, the patient is positioned in the same manner as for the supine anteroposterior projection; the head is straight, in the neutral position. With the patient's mouth open as widely as possible, the central beam is directed perpendicular to the midpoint of the open mouth . During the exposure, the patient should softly phonate “ah” to affix the tongue to the floor of the mouth so that its shadow is not projected over C1 and C2

18. Swimmer's view (A) For the swimmer's view of the cervical spine, the patient is placed prone on the table with the left arm abducted 180 degrees and the right arm by the side, as if swimming the crawl. The central beam is directed horizontally toward the left axilla . The radiographic cassette is against the right side of the neck, as for the standard cross-table lateral view. (B) The radiograph obtained in this projection provides adequate visualization of the C7, T1, and T2 vertebrae , which would otherwise be obscured by the shoulders.

19. CT MDCT is the preferred initial imaging modality in blunt spinal trauma patients. Should include from cranio-cervical junction to the level of third thoracic vertebral body. Has been shown to detect almost 100% of fractures. Malalignment and soft tissue swelling , in the absence of bony injury indicates ligament disruption.

20. MRI Modality of choice in assessing soft tissue injuries, spinal cord injury, and intervertebral discs and ligaments. Whole spine should be imaged in sagittal plane. Axial sections are targeted at areas of abnormality. Sagittal sequences – T1 and T2 weighted fat-saturated sequences. STIR sequence can be used as an alternative .

21. MECHANISM OF CERVICAL SPINE INJURY

22. Daffner et al stressed, vertebral fractures occur in predictable and reproducible patterns that are related to the type of force applied to the vertebral column. The same force applied to the cervical, thoracic, or lumbar spine will result in injuries that appear quite similar, producing a pattern of recognizable signs that span the spectrum from mild soft-tissue damage to severe skeletal and ligamentous disruption Daffner termed these patterns fingerprints of spinal injury . They depend on the mechanism of injury, which may be an excessive movement in any direction: flexion, extension, rotation, vertical compression, shearing, distraction—or a combination of these.

23. F lexion: most common mechanism anterior  atlantoaxial subluxation anterior subluxation  (hyperflexion sprain) anterior  wedge fracture clay-shoveler fracture flexion teardrop fracture bilateral facet dislocation hyperflexion fracture-dislocation lateral flexion unilateral  occipital condyle fracture lateral mass C1 fracture flexion-rotation unilateral facet dislocation rotatory  atlantoaxial dislocation Extension hangman fracture extension teardrop fracture posterior arch C1 fracture posterior atlantoaxial subluxation extension-rotation articular pillar fracture  floating pillar Axial loading/compression burst fracture (with axial loading) Jefferson fracture Complex injuries atlantooccipital dislocations (shearing) occipital condyle fracture odontoid process fracture

24. Of the greatest initial importance in suspected cervical injuries, however, is the question of stability of a fracture or dislocation. Stability of the vertebral column depends on the integrity of the major skeletal components, the intervertebral disks, the apophyseal joints, and the ligamentous structures. One of the most important factors is the integrity of the ligaments of the spine: the supraspinous and interspinous ligaments, the posterior longitudinal ligament, and the ligamenta flava, which together with the capsule of the apophyseal joints constitute the so-called posterior ligament complex of Holdsworth .

25. FLEXION INJURIES Hyperflexion sprain Wedge compression fracture Unilateral interfacetal dislocation Bilateral interfacetal dislocation Hyperflexion teardrop fracture-dislocation Spinous process fracture

26. Hyperflexion Sprain Injuries to the soft tissues of the spine without fracture. Radiograph shows angulation of anterior spinal line with widening of gap between two spinous processes.

27. Hyperflexion Sprain - mri Edema in the posterior soft tissues indicating a hyperflexion injury Edema in the vertebrae of the lower C-spine and upper T-spine indicating bone bruise as a result of axial loading.

28. Wedge compression fracture Anterior wedging of 3mm or more Increased concavity along with increased density due to bony impaction Usually involves the upper endplate

29. Unilateral interfacetal dislocation Unilateral interfacet dislocation is due to a hyperflexion injury with rotation Superior facet on one side slides over the inferior facet and becomes locked Anterior subluxation of the upper vertebral body of about 25% of the AP diameter of the body

30. Malalignment of the spinous processes - rotatory injury. Spinous processes of C4 and C5 seem shorter on the lateral view AP Lateral

31. CT c onfirms the unilateral dislocation. The contralateral facet joint is only distracted . I nverted hamburger sign

32. Bilateral Perched Facets This type of vertebral subluxation occurs as a result of a flexion injury. There is disruption of the posterior ligamentous complex, and the inferior and superior articular processes of the involved vertebrae are in apposition. This injury is best diagnosed on the lateral and oblique projections of the cervical spine, or CT with sagittal and oblique reformation.

33. Perched facets. A 34-year-old woman injured her neck in a skiing accident. (A) Pillar view of the cervical spine demonstrates bilateral obliteration of the facet joints at the C6-7 level. The joints above appear normal. Displacement of the spinous processes to the right (arrows) is the result of rotation. (B) Lateral radiograph shows perched facets of vertebrae C6 and C7 (arrow).

34. Bilateral Locked Facets Bilateral dislocation of the cervical spine in the facet joints is the result of extreme flexion of the head and neck; it is an unstable condition caused by extensive disruption of the posterior ligament complex. Interlocking of the articular facets is initiated by the forward movement of the inferior articular facet of the upper vertebra over the superior articular facet of the underlying vertebra. This causes the lamina and spinous process of the two adjacent vertebrae to spread apart and the vertebral bodies to sublux .

35. In the later stage of dislocation, the inferior articular facet of the upper vertebra locks in front of the superior articular facet of the lower vertebra, which results in complete anterior dislocation. The configuration of this injury leads to complete disruption of the posterior ligament complex, the posterior longitudinal ligament, the annulus fibrosus, and frequently the anterior longitudinal ligament. It is also associated with a high incidence of cervical spinal cord damage.

36. Soft tissue swelling anteriorly Disruption of the disc Non- hemorrhagic cord injury

37. Flexion tear drop fracture R esult of a combination of  flexion  and  compression. T eardrop fragment comes from the anteroinferior aspect of the vertebral body . P osterior part of the vertebral body is displaced backward into the spinal canal. F acet joints and interspinous distances are widened and the disc space may be narrowed.

38. Teardrop fracture,, is the most serious and unstable of cervical spine injuries. Disruption of the anterior longitudinal ligament may cause avulsion of a teardrop-shaped fragment of the anterior surface of the body of C5. This fracture is also typified by posterior displacement of the involved vertebra and fracture of its posterior elements. Depending on the severity of the injury, varying degrees of spinal cord damage may result.

39. Spinous process fracture Mechanism- Forced flexion action of the head and upper cervical spine, opposed action of the interspinous & supra-spinous ligament Oblique avulsion fracture of the spinous process of the C6, C7 and T1 vertebra ( Clay-shoveler fracture) Stable fracture

40. CLAY SHOVELER'S FRACTURE . A 33-year-old man injured his neck in wrestling competition. Sagittal CT reformatted image of the cervical spine shows a displaced fracture of the spinous process of C7 (arrow).

41. EXTENSION INJURIES Posterior arch fracture Extension teardrop fracture Hangman fracture

42. POSTERIOR ARCH FRACTURE Most common fracture of Atlas Posterior arch of atlas compressed between occiput and large posterior arch of axis during severe hyperextension Occasionally lead to serious vascular injury

43. EXTENSION TEARDROP FRACTURE O ccurs when the anterior longitudinal ligament pulls a bony fragment from the inferior aspect of the vertebra T rue avulsion A ssociated with the central cord syndrome due to buckling of the ligamentum flava into spinal canal

44. HANGMAN FRACTURE Traumatic spondylolisthesis of axis(C2) Bilateral fracture of pars interarticularis or isthmus Most frequent fracture in fatal traffic accidents. Neurological involvement is rare

45. Classification of hangman’S fracture Type I (65%) Hairline fracture C2-C3 disc normal Type II (28%) Displaced C2 Disrupted C2-C3 disc Ligamentous rupture with instability Type III (7%) Displaced C2 C2-C3 bilateral interfacet dislocation Severe instability

46. AXIAL loading - BURST FRACTURE High energy axial loading Loss of vertebral height, more on anterior portion Retropulsion of posterior vertebral body into spinal canal Interpedicular widening

47. JEFFERSON FRACTURE Burst fracture of C1 Splitting of the C1 ring with fracture of both anterior and posterior arch Unilateral or bilateral Radiograph : Spreading apart of lateral masses creating paraodontoid spaces. Total offset >8mm signifies rupture of transverse ligament

48. Odontoid process fracture 11-13% of cervical spine injuries. 75% of cases are children. Anderson and D’Alonzo classification ( I,II,III) Associations: Atlanto -axial dislocations Jefferson fracture Radiographic features may be subtle Should be differentiated from Os odontoideum

49. Anderson and D’Alonzo classification Avulsion of the tip of the dens Type I Type II Type III Through the base of the dens Most common fracture Unstable and poor healing Through the body of the axis and sometimes facets Better prognosis than type II

50. Slic score ( subaxial cervical spine injury classification) Severity score for cervical spine trauma that helps in determining treatment and prognosis SLIC is based on the assessment of three independent predictors of clinical outcome: Morphology of Injury Disco-ligamentous Integrity Neurologic Status

51. The score of each domain is added to give the total SLIC score, which helps determine whether surgery is indicated ≤3: non-surgical management = 4: equivocal ≥ 5: surgical management

52. THORACOLUMBAR SPINE

53. RADIOGRAPHS 2 views Anteroposterior view Lateral view Alignment should be assessed Spinous process should be central with symmetrical appearance of pedicles and vertebral body

54. For the anteroposterior view of the thoracic spine, the patient is supine on the table, with the knees flexed to correct the normal thoracic kyphosis. The central beam is directed vertically about 3 cm above the xiphoid process . On the radiograph in this projection, the vertebral end plates and pedicles and the intervertebral dis c spaces are seen. The height of the vertebrae can be determined, and changes in the paraspinal line can be evaluated.

55. (A) For the anteroposterior projection of the lumbar spine, the patient is supine on the table, with the knees flexed to eliminate the normal physiologic lumbar lordosis. The central beam is directed vertically to the center of the abdomen at the level of the iliac crests . (B) The radiograph in this projection demonstrates the vertebral bodies, the vertebral end plates, and the transverse processes; the intervertebral disk spaces are also well delineated. The spinous processes are seen en face, appearing as teardrops; the pedicles, also visualized en face, project as oval densities on either side of the bodies.

56. Anteroposterior coned-down view of the lumbar spine demonstrates a characteristic configuration of the lower aspects of L3 and L4. This “Cupid's bow” contour is lost in cases of compression fracture.

57. For the lateral view of the thoracic spine, the patient is erect with the arms elevated. To eliminate structures that would obscure the bony elements of the thoracic spine, the patient is instructed to breathe shallowly during the exposure. The central beam is directed horizontally to the level of the T6 vertebra with about 10-degree cephalad angulation. The radiograph in this projection demonstrates a lateral image of the vertebral bodies and intervertebral disk spaces.

58. For the lateral projection of the lumbar spine, the patient is recumbent on the radiographic table on either the left or right side; the knees and hips are flexed to eliminate the lordotic curve. The central beam is directed vertically to the center of the body of L3, at the level of the patient's waist. (B) The lateral radiograph of the lumbar spine allows adequate evaluation of the vertebral bodies, pedicles, and spinous processes as well as the intervertebral foramina and disk spaces.

59. Oblique view of the lumbar spine. (A) For the posteroanterior oblique projection of the lumbar spine, the patient is recumbent on the table, with the right side rotated 45 degrees to demonstrate the rightsided articular facets. (Elevation of the left side allows demonstration of the left-sided articular facets.) The central beam is directed vertically toward the center of L3. (B) The posteroanterior oblique radiograph demonstrates the facet joints, the superior and inferior articular process, the pedicles, and the pars interarticularis.

60. Thoraco -lumbar spine CT Should be performed as part of polytrauma CT protocol, with IV contrast for assessment of vascular injury CT is very useful in diagnosing / excluding thoracic spine injury Thoracolumbar junction, more prone for pure ligamentous injury without bony fractures MRI – gold standard for assessing purely ligamentous injury

61. Denis three-column concept Any injury that involves two of three columns unstable

62. Tlics ( Thoraco-Lumbar Injury Classification and Severity score)

63. Flexion compression injury Wedge compression fracture with mild kyphosis Horizontal sclerotic band of trabecular impaction Frequently involves superior endplate Posterior cortex of body intact (distinguishes from burst fracture)

64. Burst fracture Axial compressive force through the spine Retropulsion of posterosuperior vertebral body fragment Widening of interpedicular distance Posterior bowing of the vertebral body margin is diagnostic of an axial compression (burst) fracture. 

65. Burst fracture gets 2 points for morphology in the TLICS In the absence of a neurologic deficit, PLC integrity should be confirmed at MR imaging, if conservative management is planned

66. Flexion Distraction injury Rupture of posterior bony and/or ligamentous structures by distraction, with variable degree of compression of anterior column Common at thoracolumbar junction High chance of cord injury classically caused by a deceleration-type motor vehicle accident 

67. Fracture-dislocation. Lateral radiograph of the thoracolumbar spine (A) and sagittal reformatted CT image (B) demonstrate characteristic features of a flexion-distraction type of fracture-dislocation.

68. Translation/rotation injury Includes all fractures that are result of displacement in horizontal plane Often unilateral or bilateral facet dislocation is seen Severe type of injury, always involves the PLC In TLICS 3 points for the morphology ,3 points for the PLC, total of 6 points indicating the need for surgical stabilization.

69. Chance fracture: Pure osseous Fracture occur through one vertebra, passing through pedicles and spinous process at single level Involvement of posterior ligamentous structures without posterior bony injury – soft-tissue Chance injury High association with intra-abdominal injuries

70. Bony Chance Soft tissue Chance

71. The spectrum of seat-belt injuries involving the lumbar spine.

72. (C) Sagittal CT reformation demonstrates the fracture of posterior elements to better advantage. (D) Parasagittal MR image demonstrates disruption of the posterior ligaments and a large soft-tissue hematoma. The findings are typical of a two-level seat-belt injury.

73. Spondylolysis and Spondylolisthesis Spondylolysis, a defect in the pars interarticularis (the junction of the pedicle, articular facets, and lamina) of a vertebra (neck of the “Scotty dog”), may be an acquired abnormality, secondary to an acute fracture, or, as is more commonly the case, it may result from chronic stress (stress fractur e). Spondylolisthesis  denotes the slippage of one vertebra relative to the one below.  It is encountered more commonly in the lower lumbar spine and has a high prevalence among athletes. These abnormalities are seen predominantly in the lumbar spine (90% of cases) and most commonly at the L4-5 and L5-S1 levels.

74. Types of spondylolisthesis. Spondylolisthesis may occur in association with spondylolysis resulting from a defect in the pars interarticularis, or secondary to degenerative disk disease and degeneration and subluxation of the apophyseal joints ( pseudospondylolisthesis ).

75. The spinous-process sign - The spinous-process sign can help differentiate true spondylolisthesis from pseudospondylolisthesis by the appearance of a step-off in the spinous processes above the level of vertebral slip in the former and below that level in the latter (red arrows indicate direction of slip).

76. CT of spondylolysis. (A) Axial and (B) sagittal reformatted CT images show bilateral defect in the pars interarticularis of L5 vertebra (arrow).

77. A severe degree of spondylolisthesis at the L5-S1 level can be identified on the anteroposterior radiograph by the ventrocaudal displacement of L5 over the sacrum. This configuration creates curvilinear densities called as inverted Napoleon's hat sign .

78. Inverted Napoleon's hat sign. (A) Anteroposterior radiograph of the lumbosacral spine in a 21year-old man with severe (grade 4) spondylolisthesis shows curvilinear densities in the sacral area forming an inverted Napoleon's hat.

79. The simple grading of spondylolisthesis proposed by Myerding is based on the amount of forward slipping.

80. Traumatic sacral injuries Isolated sacral fractures are uncommon 2 types: Horizontal Most common type Common at S3-S4 level High horizontal fractures occur from high falls ( suicidal jumper’s fracture ) Vertical Usually indirect trauma to pelvis Visible in frontal radiograph Usually runs nearly the entire length of sacrum  

81. Traumatic Coccydynia Coccydynia has a myriad of causes but is most commonly found in the posttraumatic setting . Patients often have a history of recent or remote trauma to the region and develop chronic mechanical symptoms 

82. Figure 15. Patient positioning and setup for seated lateral radiography of the coccyx. Illustration shows the patient in a seated position on a hard-surface stool with their thighs horizontal, which may require placing their feet on a footrest, depending on the height of the stool. They are then instructed to lean back to the point of maximum tenderness and hold in this position for image acquisition. The arm position may vary depending on patient comfort and how far they recline.

83. Figure 9a. Coccyx fracture in a 72-year-old man with coccygeal pain after falling off a chair. (a) Lateral radiograph shows a fracture (arrows) of the first coccygeal body. (b) Sagittal T1-weighted image demonstrates T1-hypointense and short inversion time inversion-recovery (STIR)– hyperintense (not shown) edematous signal intensity (arrowhead) corresponding to the suspected site of fracture, as well as cortical offset posteriorly , confirming the diagnosis. US-guided pericoccygeal injection was successfully performed for pain management.

84. Figure 9b. Coccyx fracture in a 72-year-old man with coccygeal pain after falling off a chair. (a) Lateral radiograph shows a fracture (arrows) of the first coccygeal body. (b) Sagittal T1-weighted image demonstrates T1-hypointense and short inversion time inversion-recovery (STIR)– hyperintense (not shown) edematous signal intensity (arrowhead) corresponding to the suspected site of fracture, as well as cortical offset posteriorly , confirming the diagnosis. US-guided pericoccygeal injection was successfully performed for pain management.

85. Injury to the Dis c overtebral Junction One of the most frequent conditions affecting the dis c overtebral junction is herniation of an intervertebral disk. Injury to the intervertebral disk and the diskovertebral junction can result from acute trauma or from subtle subclinical, often endogenous injury. Depending on the direction of herniation of disk material, a spectrum of injuries of the intervertebral disk and adjacent vertebrae may be seen .

86. Intravertebral Dis c Herniation Ventrocaudal dis c herniation, as well as ventrocephalad herniation, which is much less commonly seen, produces an abnormality known as limbus vertebra . Herniation of dis c material into a vertebral body at the site of attachment of the annulus fibrosus to the body's rim separates a small, triangular fragment of bone, which is commonly mistaken for an acute fracture or infectious spondylitis. Reactive bone sclerosis adjacent to the defect, however, indicates a chronic process. The adjacent dis c space is invariably narrowed, and a radiolucent cleft known as the vacuum phenomenon may be seen in the dis c space, representing degeneration of the disk .This abnormality, which is invariably asymptomatic, is the product of chronic, endogenous trauma.

87. LIMBUS VERTEBRA Lateral radiograph of the lumbar spine in a 55-year-old woman with breast cancer who underwent radiographic examination to exclude bone metastases shows anterior intravertebral disk herniation into the body of L2 (limbus vertebra). Note the vacuum phenomenon (arrow), indicating disk degeneration.

88. Secondary ossification centers The secondary ossification centers of the vertebral ring apophysis in the growing skeleton, as seen here in a 5-year-old girl, should not be mistaken for limbus vertebrae.

89. Annular Tears Tears or fissures of the annulus fibrosus of lumbar intervertebral dis c s may occur secondary to trauma and may also be caused by degenerative changes of the dis c related to normal aging. T hese tears represent separations between annular fibers, separations of annular fibers from their vertebral insertions, or breaks through these fibers in any orientation, involving one or more layers of the annular lamellae. Annular tears are found in both symptomatic and asymptomatic individuals.

90. Type I is a concentric tear that is characterized by rupture of the transverse fibers connecting adjacent lamellae in the annulus, without disruption of the longitudinal fibers. Type II is a radial tear that represents fissures extending from the periphery of the annulus to the nucleus pulposus associated with disruption of the longitudinal fibers. Type III is a transverse tear caused by the disruption of Sharpey fibers at the periphery of the annulus fibrosus. Type II and III tears can be seen on T2-weighted MRI as hyperintense foci within the annulus. These tears can also be occasionally demonstrated by CT diskography.

91. SCIWORA ( Spinal Cord Injury Without Radiographic Abnormality) Distraction mechanism – spinal column more flexible than spinal cord Occurs in upper cervical spine in children <8 years MRI – to diagnose spinal cord injury and evaluate posterior soft tissues

92. SPINAL CORD INJURY Injuries are classified as (1) nonedematous cord, (2) edema spanning a single vertebral level, (3) edema spanning multiple levels, and (4) mixed hemorrhage and edema. Patients with diffuse edema will almost invariably have permanent , at least partial, deficits with lower degrees of recovery. Appreciable spinal cord hemorrhage is usually associated with complete motor and sensory loss and will rarely show meaningful improvement . Hemorrhage is rarely seen in the absence of edema . Prognosis from spinal cord hemorrhage appears to be slightly better when less than 50% of the spinal cord cross-sectional area is involved.

93. The length of hemorrhage does not correlate with injury severity , likely because of the uniformly poor outcome in these patients regardless of whether single or multiple levels are involved . Cord expansion is seen with more severe injury resulting from accumulation of both intra- cellular and interstitial fluid above and below the injury. Greater degrees of cord compression and canal compromise, best seen using axial T2 images, may correlate with worse prognosis . Spinal cord compression specifically by extraaxial hematoma may be another independent predictor of poor outcome.

94. On axial SWI there is low signal involving a greater proportion of the cord surface area, but the sequence is limited by motion. The full craniocaudal extent of cord hemorrhage (arrows) is well visualized on sagittal SWI.

95. MRI of soft-tissue injuries of the cervical spine. Sagittal T2-weighted MRI of a 53-year-old patient presenting with acute onset of paraplegia following an accident, shows the hyperintense epidural hematoma at the level of C4 and C5 located posteriorly, with compression of the cord (arrow).

96. This 37-year-old woman presented with central cord syndrome after a fall 2 years prior to this study. On this sagittal STIR image, there is atrophic thinning of the cord (solid arrows) and a focus of syrinx at C4-5 (open arrow). A 56-year-old man with remote craniocervical injury after a motor vehicle collision. The patient developed progressive lower extremity weakness and was found to have a long segment of syringo - hydromyelia spanning C5-T9 , with only a thin residual rim of spinal cord along the periphery

97. A. Sagittal STIR image of a T4-T5 fracture-dislocation in a 64-year-old woman involved in a motor vehicle collision. The cord is transected at this level, and there is an intervening gap (open arrow). B, On sagittal T1-weighted image, dorsal epidural fat outlines the severed and displaced rostral and caudal ends of the spinal cord

98. BRACHIAL PLEXUS INJURY Avulsion of nerve roots from cervical spine Occurs with associated spinal cord injury Due to traction forces applied to shoulder, gets transmitted to cord via brachial plexus Complete nerve root avulsion accompanied by Dural tear, resulting in traumatic pseudomeningocele

99. VASCULAR INJURY Damage to the vertebral arteries seen in up to 40% of patients following cervical subluxation/dislocation Dissection of the vertebral artery is more frequent than carotid artery dissection.

100. Advanced imaging techniques

101. Diffusion tensor imaging A 20-year-old female patient. Neurologically, she was ASIA grade B after a car accident. a Sagittal T2-weighted MR image acquired at 1.5 T shows wedged fracture of L1 vertebra compressing lower end of the spinal cord (white arrow ). b Fiber tractography shows complete interruption in the spinal cord white matter tract (yellow arrow ). c Sagittal color coded ADC map shows an ADC value at the injury level (1.61) lower than values above (2.16) and below (2.23) the injury level. d sagittal color coded FA map shows lower FA value at the injury level (0.232) than values above (0.477) and below (0.439) the injury level valuable tool in assessment of the cord injury in cases of spinal trauma when compared with conventional MRI. FA and ADC values were significantly decreased at the level of injury. FA is more sensitive and accurate in detecting abnormalities mainly at the site of injury.

102. Figure 1: MR spectroscopic voxel localization and representative spectra. A, Placement of the spectroscopic voxel of interest. A representative spectrum (background in gray) in a healthy control subject, a participant with paraplegic spinal cord injury (SCI) , and a participant with tetraplegic SCI. The resulting fits (black) are shown in B . The metabolic components identified in the fit in B are given in red for creatine (Cr) , total N - acetylaspartate ( tNAA ) , total choline-containing compounds ( tCho ) , myo -inositol ( mI ) , and glutamine and glutamate complex ( Glx ) . ppm = Parts per million.  MR spectroscopy shows biochemical changes above the level of spinal cord injury. ■ Lower total  N - acetylaspartate -to- myo -inositol and choline-containing compounds-to- myo -inositol ratios at MR spectroscopy were associated with worse sensory and motor outcomes ( P  < .05). Mr spectroscopy

103. Role of interventions :diagnostic CT myelography and vertebral biopsy. (a) Lateral fluoroscopic image shows contrast injected into thecal sac using 22-gauge spinal needle ( black arrow ) at the L1/2 level. (b) CT lateral image post intrathecal contrast injection shows posterior displacement of the conus ( white arrows ) by a discitis related abscess ( black dashed lines ). (c) Biopsy needle was advanced into vertebral body under fluoroscopic guidance, ensuring a diagnostic sample is obtained safely.

104. Image-Guided Botulinum Toxin Injections In patients with paraplegia after SCI, spasticity of the psoas muscle can be a great source of complaint often resulting in functional disability. Computed tomography (CT) guidance is the most accurate procedure for the precise and rapid injection  . Computed tomography (CT) image-guided botulinum injection highlighting a case of a male tetraplegic patient who was experiencing disabling spasms in his upper limb. Axial CT image of the patient lying supine. A 25-gauge needle ( white arrow ) was placed into the subscapularis muscle ( dashed lines ) via an anterior approach. The patient’s spasms subsided for 3 months following the injection.

105. Ct guided steroid injection Back pain is a common problem in people with SCI. If clinical suspicion allied to MRI findings of nerve root compression or facet joint disease suggests these as a source of pain, CT-guided injection is an accurate method of treatment . Usually a combination of long-acting steroids ( eg , triamcinolone acetonate 40 mg) and 1 mL of 0.5% bupivicaine can provide both a diagnostic and therapeutic benefit.

106. vertebroplasty There has been increasing interest in the use of vertebral cement augmentation techniques ( vertebroplasty , kyphoplasty ) in spinal trauma . More recently, several authors have described cement augmentation either alone or in combination with pedicle screw fixation for traumatic thoracolumbar burst injuries.This technique has the potential advantage of providing anterior column support with cement and posterior stabilization without the need for anterior surgical approach  A 60-year-old patient presented with pain and spasm and a cervical spinal injury with pseudarthrosis ( white arrows ) at T12/L1 that was demonstrated on (a) sagittal T2-weighted MRI and (b) CT scan. (c) Sagittal CT post anterior cement augmentation ( black arrowhead ) and posterior screw stabilization ( black arrows ) are shown.

107. summary Mechanical stabilization of the acutely injured spine is a primary concern. One of the key roles of imaging is the detection of spinal lesions that (may) lead to an (possibly) unstable spine . In this respect, MDCT is superior to all other imaging techniques. It is more accurate, faster and needs less patient mobilization compared with plain film . To avoid unnecessary imaging, and in this way reduce costs and patient radiation exposure, a set of clinical/ anamnestic rules allows for accurate patient triage in the trauma setting and as such to determine which patients do not need spinal imaging.

108. Another set of rules determines which patients need to have MDCT and which patients can be imaged by either plain film or MDCT. Another major concern in trauma patients are spinal cord lesions. MR is the preferred technique to visualize these lesions, to diagnose if they are hemorrhagic or not, to detect and determine the cause of spinal cord compression and to monitor the evolution of these lesions after the acute injury . the TLICS is an easy scoring system that depicts the features important in predicting spinal stability, future deformity, and progressive neurologic compromise. TLICS also facilitates appropriate treatment recommendations.

109. SPOTTERS Sign ? Dx ?

110. …….#? …..VIEW ?

111. CLASSIFICATION AND TYPE ? …..#?

112. ……#??

113. SIGN ? SEEN IN ?

114. Tlics score ?

115. The findings are: Morphology: Translation - 3 points PLC: always disrupted in translation - 3 points TLICS: 6 points

116. REFERENCES ORTHOPEDIC IMAGING-A PRACTICAL APPROACH-GREENSPAN CT AND MRI OF WHOLE BODY IMAGING – HAAGA RSNA ARTICLE Alkadeem et al. Egyptian Journal of Radiology and Nuclear Medicine www.ncbi.nlm.nih.gov/pmc/articles/PMC3743971 / journals.lww.com/neurosurgery/ Fulltext /2016/11000/ Imaging_of_Spine_Trauma

117. THANK YOU