Imaging in Spinal Emergency Syndromes

Arvinda HRAssociate professor,

Dept of NI & IR,NIMHANS, Bangalore.

Background

• True spinal emergencies are rare.• Early diagnosis is the key.• The recognition of red flags, followed by a

thorough neurologic exam and appropriate imaging.

• Clinicians must be aware of the presenting symptoms and accurately interpret imaging results in order to promptly diagnose and treat these conditions.

• Any new deficit developing as a result of involvement of spinal cord.

• It can be compressive / non-compressive myelopathy.

Non compressive Myelopathy

• Transverse Myelitis.• Inflammatory and autoimmune.• Infections.• Vascular.• Metabolic, Radiation, and Metastatic.

Compressive Myelopathy

• Epidural Hematoma.• Epidural Abscess.• Cord Compression due to trauma.• Miscellaneous.

Transverse Myelitis

NMO

Multiple sclerosis

Vascular Causes

Arterio-Venous Shunts• Spinal Dural AV Fistula.• Perimedullary fistula.• Spinal AVM.• Juvenile AVM.

Cause symptoms due to • Haemorrhage.• Venous hypertension.• Direct mass effect.

Arterio-Venous Malformation

• In 20% to 40% of cases, there is an associated arterial or venous aneurysm.

• Younger age, usually in young adults aged 20 to 30 years.

• Haemorhage / acute neurologic symptoms.

Juvenile Metameric Vascular Malformation

• Are large, high-flow lesions with involvement of the para-spinal tissues.

• Usually paediatric population.• Neurologic deficits occur from compression,

hemorrhage, or vascular steal phenomenon.

Perimedullary AV fistula

• Usually located in the midline and ventrally in the subarachnoid space.

• The lesion consists of an abnormal connection between the anterior spinal artery and an enlarged venous network.

• Young adult / paediatric population.• Venous hypertension / haemorrhage.

Dural AV fistula

• Located at the exiting nerve root sleeve.• Progressive neurologic symptoms.• Haemorrhage is rare.• Venous hypertension – reduction in arterio-

venous pressure gradient.• Emergency due to acute worsening of the

motor and bladder and bowel functions.• Gold standard is DSA. CTA / MRA.

Spinal Dural AV Fistula

Cavernoma

• Represent around 5.0% of all intramedullary lesions found in adults.

• Peak presentation is during the fourth decade, Females are more commonly affected than males.

• Discrete episodes of neurological deterioration with varying degrees of recovery between episodes.

• Acute onset of symptoms with rapid decline.

Spinal cord Infarct

• Rare. Comprising only 1% of all strokes.• Experience pain followed by acute neurologic

deficits.• 2 potential pathophysiological mechanisms for

spinal cord infarction: • Hypoperfusion from arterial insufficiency and

Hypotension.• Occlusion of a specific arterial branch (anterior

spinal artery or, sometimes, posterior spinal artery)

• Atherosclerosis / Dissection of Aorta.• 4% of Dissection can lead to paraplegia /

paraparesis due to SCI.• Aortic surgery – from 1.0% to 10%.• Equal frequency in cervical and thoraco-

lumbar spine levels, extremely rare at upper thoracic spine level.

• Different patterns.

Epidural Abscess

• Rare entity.• Diabetes, IV Drug abuse, superficial infections

of the back, immunocompromised.• Staphylococcus aureus, TB.• Fever, back pain and neurologic deficits.• Thoracic and lumbosacral region more than

cervical.

• Concomitant osteomyelitis – 80%.• CT myelography.

Pyogenic

Tubercular

Arachnoiditis

Post spinal anaesthesia weakness

Spinal Cord Abscess

• Intramedullary cord abscess is extremely rare.• Hart reported the earliest documented spinal

cord abscess in 1830.• MRI is the modality to diagnose the condition.• 70% will have residual deficit even after

treatment.

Epidural hematoma

• Following spine surgery, 0.1 – 0.2% neurologic deficits. But present in 30-80% of cases.

• Coagulopathy, Instrumentation.• Spontaneous – extremely rare. Elder age group.

Male.• Usually venous bleed. No cause is known• Chiropractic manipulation, epidural anesthesia,

and steroid injection. • Sudden onset of severe back pain.

• Either thoracic / cervical.

Spine Trauma

• Represent 3% to 6% of all skeletal injuries. • 55% of all spinal injuries (including all types

of spinal injuries) involve the cervical spine, 15% the thoracic spine, 15% the lumbar spine, and 15% the lumbosacral spine.

• The risk of damage to the spinal cord is greater in cervical spine injuries than in the thoracic and lumbar regions

• The overall incidence of cervical spine fracture without spinal cord injury is 3%.

No imaging required

• No midline cervical spine tenderness.• No focal neurologic deficit.• Normal level of alertness.• No intoxication.• No painful distracting injury.

• Imaging : X-ray, CT scan and MRI.• Flexion and Extension views.

Stability Versus Instability

• The 3-column theory of Denis divides the spinal column into anterior, middle, and posterior columns.

• The anterior column consists of the anterior vertebral body, the anterior longitudinal ligament, and the anterior annulus fibrosis.

• The middle column consists of the posterior vertebral body, the posterior longitudinal ligament, and the posterior annulus.

• The posterior column consists of the posterior bony elements including the pedicles, the lamina, the facets, and the spinous processes, the ligaments including the ligamentum flavum, the interspinous, and supraspinous ligaments, and the facet joint capsule.

Conclusions

• Prompt recognition of the spinal emergencies are extremely important.

• Timely intervention in required to prevent permanent cord injury.

• Imaging does help in the diagnosis and management of a particular condition.

Thank you