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2019-10-12
1
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Spinal cord trauma
Prof. Pia C Sundgren MD, PhD
Head of the Department of Diagnostic Radiology, Clinical Sciences
Co-Director for Lund University BioImaging Center (LBIC)
Lund University, Lund, Sweden
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
injury to the spinal column and spinal cord is a
major cause of disability affecting predominately
young healthy individuals
costs of life time care and rehabilitation are
extremely high, often over $1,000,000 per
individual
Introduction
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
SCI Etiology
MVA
35%
Others
7%
Sports
8%
Falls
20%
Violence
30%
despite increased public awareness and safety programs – a problem
incidence: 11,000 per year
prevalence: 200,000 - 250,000
mean age: 31.2 years.
– 56% occur in 16 - 30 yrs.
– second peak in 60-70 range
82% males
peaks in summer and weekends
Spinal trauma and spinal cord injury
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Spinal cord injury incidence (per year) 2,3–
83/100,000
Spinal cord injury prevalence (per year) 236–1800/
1000,000
M/F ratio (spinal cord injury) 4:1
Age group (spinal cord injury) 26–55
Based on WHO and Spinal Injury Association
annual reports
Epidemiologic data spinal cord trauma in Europe
Boban J et al Clinical Neuroradiology 2019 (e-book)
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
type of trauma
unstable factures
fracture fragments into the spinal canal
ligamentous injury
penetrating injuries
Increase the risk for spinal cord injury
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
AC PCMC
AC
PC
MC
Modified from M. Philips, MD, Vienna,Austria
The anterior, middle and posterior columns
AC: anterior vertebral body, anterior annulus fibrosus, ant. long.lig
MC: posterior vertebral body, post long. lig, post annulus fibrosus
PC: posterior bony elements, lig flava, posterior ligaments
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
TLICS - Thoracolumbar Injury Classification and Severity Score
A practical scheme based on three injury characteristics
1 morphology of injury determined by radiographic appearance
2 integrity of the posterior ligamentous complex
3 neurologic status of the patient
SLIC - Sub-axial Injury Classification and Severity Scale
Scoring system for cervical injuries and surgical intervention
1. injury morphology
2. disco-ligamentous complex
3. neurologic status of the patient
Vaccaro AR et al A new classification of thoracolumbar injuries.. Spine 2005;15;30:2325-33
Vaccaro AR et al. The subaxial cervical spine injury…. Spine 2007 ;32(21):2365-74
Classification and Severity Score
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Conventional MR parameters - protocol
• sagittal T2 STIR, T2-w, T1-w
• axial T1SE, T2 fast SE,
• axial fat sat T2-w (soft tissue injury)
• axial and sagittal T2* GRE (hemorrhage)
• 3D – 3D TSE T2w SPACE (Siemens)
3D TSE T2w DRIVE (GE)
3D TSE T2w VISTA (Philips)
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
American spine injury association (ASIA) classification
Grade A complete lack of motor and sensory function below the level of
injury (including the anal area)
Grade B some sensation below the level of the injury (including anal
sensation)
Grade C some muscle movement is spared below the level of injury, but 50
% of the muscles below the level of injury cannot move against gravity
Grade D most (> 50 %) of the muscles that are spared below the level of
injury are strong enough to move against gravity
Grade E all neurologic function has returned
• to define and describe the extent patient’s spinal cord injury
• completed within 72 hours after the initial injury.
• grade is based on how much sensation patient can feel at multiple points
on the body and tests of motor function
help determine future rehabilitation and recovery needs
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
• the length of the lesion is directly proportional to
the neurologic deficit
• the location of the lesion, specifically the upper
boundary of hemorrhage or lesion epicenter
correlates with the neurologic level of injury
• frank hemorrhage within the spinal cord is
predictive of a severe neurologic injury and a poor
prognosis for regaining any useful motor or sensory
function
Correlates of spinal cord injury on MRI and
the neurologic deficit
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Lesion DTI DTI metrics
Mapping human spinal cord injury with diffusion tensor
imaging
AnatomyLund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Mohamed FB et al Diffusion Tensor Imaging of …… AJNR 2011:32:339-45
Diffusion tensor imaging of spinal cord injury
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
0 2 4 6 8 10 12 14 16 18 20 22 24
0.00
0.06
0.12
0.18
0.24
0.30
0.36
0.42
0.48
0.54
0.60
0.66
0.72
SCI1
SCI2
SCI3
SCI4
SCI5
AVG 5 CONTROLS
Fra
ctio
na
l A
nis
otr
op
y
SLICE
average FA values for controls compared with FA values for
each individual subject with SCI as a function of slice number
Diffusion tensor imaging of spinal cord injury
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
0 2 4 6 8 10 12 14 16 18 20 22 24
0.0000
0.0003
0.0006
0.0009
0.0012
0.0015
0.0018
0.0021
0.0024
0.0027 SCI1
SCI2
SCI3
SCI4
SCI5
AVG 5 CONTROLS
Ra
dia
l D
iffu
siv
ity (
mm
2/s
ec)
SLICE
average radial D values for controls compared with radial D
values for each individual subject with SCI as a function of
slice number
Diffusion tensor imaging of spinal cord injury
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
C6
C7
C4
C6
21 year old male in MVA, complaining of neck pain
and stiffness
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
22 year old male in diving accident complaining of neck
pain and stiffness, paraplegia of the legs
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
16 yrs. old male injury diving feet first into
a pool. Patient recalls feeling a "break" in
his neck upon entering the poolCourtesy A Flanders, MD
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
I Acute spinal cord injury
II Subacute spinal cord injury
III Chronic spinal cord injury
Spinal cord injury
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Acute spinal cord injury
• spinal cord edema / swelling
• spinal contusion: non-hemorrhagic
• spinal cord contusion: hemorrhagic
• spinal cord transection
• low velocity / compressive SCI
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
damage of the blood vesselsdisrupted axons
traction and compression forces
microhemorrhages – within minutes
swelling of the cord
secondary ischemia
secondary injury cascade
Primary injury
Modified from M Thurnher, MD
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
damaged cells / axons / blood vessels
toxic chemicals
attack neighboring cells
normal axons swollen axons
wave of suicide APOPTOSIS
Secondary injury
Modified from M Thurnher, MD Vienna, Austria
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
focal accumulation of intracellular
and interstitial fluid
• good prognosis
• max after 72 hours
Histo-pathologically all cases have
punctate hemorrhage !
= spinal cord edema
Non-hemorrhagic contusion
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
11/7/03 12:30pm 1:40pm
C4
15 lbs 25 lbs
2:10pm
C4
12/7/03 post-op
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Unilateral facet dislocation C4-5 with non-hemorrhagic SCICourtesy A Flanders, MD
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Hemorrhagic contusion
focus of hemorrhage within spinal cord
• true hematomyelia is rare (<1%)
• bad prognosis
• irreversible changes
• iron diffusion into cord parenchyma
cascade of neuronal destruction
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
28 year old male that jumped from 4th
floor in suicide attempt, complains of
pain and is paraplegic
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
T1-w T2-w STIR
T1-w
FU 1 year later
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Spinal cord transection
Tear of the SC due to significant traumatic injury
involve motor and sensory neurology corresponding
to the level of cord injury:
- lower motor neuron paralysis at the level of injury
- upper motor neuron (or spastic) paralysis below
the level of injury
complete or partial (hemi-transection)
severity depends on location
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
56 years old male fall 3 meters from roof
presents with mild tingling in his in dig 1 and 2 of both hands
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
T1-w T2-w STIR PD
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Th1 Th1
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Central cord syndrome elderly;
flexion/extension injury
of the degenerative
spine
motor weakness of the
upper (more than lower)
extremities with sacral
root sparing
Brown-Séquard
syndrome
cord hemisection
(gunshot or stab)
ipsilateral loss of motor
function and
proprioception
Contralateral loss of
pain and temperature
sense
Anterior cord syndrome Direct or ischemic injury
to ventral 2/3
lLoss of motor function,
pain, and temperature
sensation;
proprioception and light
touch preserved
Spinal cord syndromes
Boban J et al Clinical Neuroradiology 2019 (e-book)
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Conus medullaris
syndrome
Injury to sacral cord
(e.g., L1 fracture)
bowel, bladder, and
sexual dysfunction
with normal motor
function
Cauda equina
syndrome
Injury to lumbar and
sacral roots (below
L2 level)
flaccid paralysis of
the legs, without
bowel/bladder
dysfunction
Spinal cord syndromes
Boban J et al Clinical Neuroradiology 2019 (e-book)
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Acute Traumatic Central Cord Syndrome (ATCCS)
Acute compressive cord injury (ACI)
greater loss of motor function in upper than lower
extremities
sensory loss below the level of injury
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
narrowed spinal canal
hypertrophy of ligamentum flavum
low velocity hyperextension trauma
high signal on T2WI + swollen cord
Acute Traumatic Central Cord Syndrome
non-hemorrhagic injury
compressive demyelination of the
LATERAL COLUMNS
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Hyperextension
mechanism at C5-6 with
superimposed
spondylosis/stenosis and
spinal cord injury
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Body surfer – with CCN symptoms lasting for days
Courtesy A Flanders, MD
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
T1-w T2-w FLAIR
Violent injuries - penetrating injuries
Gunshot, knifes, tools,….
Follow-up
Gang member in fight with a kife
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
gunshot
resulting in a complete
cord transection
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
In Amsterdam the gang members are
using a stingray tail…
Courtesy dr E Veldhuizen
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Courtesy of Dr. J. van Goethem
Carpenter was playing with his pneumatic nail tool
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Brown-Séquard syndrome
is caused by damage to one half of the spinal cord
paralysis and loss of proprioception on the ipsilateral
(same side) as the injury or lesion
loss of pain and temperature sensation on the
contralateral side as the lesion
seen in association with penetrating injuries, gunshot,
knives etc
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Atlanto-Occipital Dislocation (AOD)
uncommon injury characterized by complete disruption of all ligamentous relationships between occiput and atlas
death usually occurs from stretching of the brainstem
reported to occur in 31% of fatal MVAs
more common in children due to larger cranial ratio
up to 50% of AOD’s are overlooked initially
increasing number of survivors of this injury
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Courtesy A Flanders, MD
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019 Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Case K – Set 3
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Spinal cord injury without radiographic abnormality
- SCIWORA -
specific to children and extremely rare in adults
incidence: 19-34% of all spinal cord injuries in children
more common in younger children < 8 years of age
can have delayed onset of clinical symptoms and
signs up to 4 days after initial injury
recurrent SCIWORA several days to weeks after
initial event (17%)
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
• immature and elastic pediatric spine
• vulnerable to external forces
• allows for significant inter-segmental movement
• transient disc protrusion
compression and stretching of the spinal cord
cord injury
Spinal cord injury without radiographic abnormality
- SCIWORA -
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
The elasticity of neonatal bony spine is eight
times that of the cord
Biomechanics in children
5
cm
6/7
mm
Leventhal H. J. Pediatr 56:447 1969
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
3 year old in MVA
SCIWORA
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
T2-wSTIRT1-w
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Clinical and neurological deterioration after SCI
Acute neurological deterioration
• 5-10% of SCI
• occurs within the first several hours or days after SCI
• 1-2 vertebral levels
• usually temporary
- increased length of T2/FLAIR signal in the spinal
cord – spinal cord edema
MRI should be performed at least 72 hours after
injury for prognosis
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Clinical and neurological deterioration after SCI
subacute progressive ascending myelopathy – SPAM
deterioration ascending ⩾4 vertebral levels above the initial injured site
• occur within the first few weeks after SCI
• unrelated to mechanical instability or syrinx formation
• rare 0.42-1%
• most common in young and middle aged males
• mortality rate 10%
• risk factors: complete injury, low blood pressure, early post-op mobilization, nonsurgical treatment
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Subacute progressive ascending myelopathy
SPAMC5 level ascending to C3 – day 10
C6 C6 C6
30 days post MPSCourtesy A Flanders, MD
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Late deterioration
post-traumatic progressive myelopathy – PTPM
present as deterioration in neurological status after a period of neurological stability
> 2 months
morphologic changes associated with PTPM:
• syringomyelia
• myelomalacia
• cord tethering
• atrophy
Clinical and neurological deterioration after SCI
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
post traumatic syrinx myelomalacia and atrophy
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Spinal nerve root injuries
caused by traction
• damage to the spinal grey matter columns
• complete root avulsion
• often associated with brachial plexus injury
exclude prior to exploration of the plexus
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
damage to the spinal grey
matter columsT2-w
Coronal STIR
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
T2 - medicT2-flash 6 mm > > > > > >
damage to the spinal grey matter colums
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
32328313
CT-myelogram complete nerve root avulsion
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
32328313
C4 C5
C6 C7
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
transverse lig.
Ligamentous injury
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
unstable fracture with ligamentous injury
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019 Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Unstable
2019-10-12
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Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019 Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Treatment and prognosis
• surgical decompressionearly (< 24 hrs), late (> 24 hrs)
acute traumatic cord syndrome
adult acute SCI patients regardless of level of injury
• use of Methylprednisolone Sodium Succinate (MPSS)
24-hour infusion of high-dose MPSS be offered to
adult patients within 8 hours of acute SCI as a
treatment option
• anticoagulant thromboprophylaxis
be offered routinely to reduce the risk of
thromboembolic events in the acute period after SCI
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Treatment and prognosis
• MR imaging
perform in adult and paediatric patients with
acute SCI prior to surgical intervention to
facilitate improved clinical decision-making
perform in adult and paediatric patients in
the acute period after SCI, to improve
prediction of neurologic outcome
Michael G. Fehlings et al. Global Spine Journal 2017, Vol. 7(3S) 84S-94S
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Take home messages
MRI is a most for evaluation of the spinal cord
evaluate for spinal cord edema vs hemorrhagic
contusions – for final outcome and prognosis
possibility of
• multiple levels of injury
• combined injuries (facets, disc herniation's,
vascular…)
active search for signs of ligamentous injury
and instability
Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019
Thank you