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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 2  |  Page : 192-196

Role of magnetic resonance imaging in the evaluation of spinal trauma


Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(Meghe), Wardha, Maharashtra, India

Date of Submission21-Jan-2020
Date of Decision30-Jan-2020
Date of Acceptance25-Feb-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Ayush Gupta
Flat No. 6A, Shanti Vihar Apartments, Pawan Puri, Bikaner, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_15_20

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  Abstract 


Background: Diagnostic imaging, particularly magnetic resonance imaging (MRI), plays a crucial role in evaluating and detecting spinal trauma. Subtle bone marrow, soft-tissue, and spinal cord abnormalities, which may not be apparent on other imaging modalities, can be readily detected on MRI. Early detection often leads to prompt and accurate diagnosis, expeditious management, and avoidance of unnecessary procedures. Material and Methods: The depiction of parenchymal spinal cord injury (SCI) on MRI not only correlated well with the degree of the neurologic deficit but also bears significant implications in regard to prognosis and potential for neurologic recovery. This prospective observational study was conducted over a period of 18 months from June 2017 to December 2018 on 65 patients with spinal trauma who underwent MRI of the spine. Prior written informed consent was obtained. In our study, it can be concluded that MRI plays a major role in the diagnosis of spinal trauma, directing early and prompt management and predicting prognosis of neurological recovery. Cord edema and normal cord were associated with favorable neurological outcome. Results: Vertebral body fractures, especially in association with cord edema, showed poor neurological recovery, as compared to cord edema and normal cord. Cord transection and cord hemorrhage were associated with complete SCI and with poor neurological recovery. Conclusion: MRI findings in acute SCI correlate well with the initial neurological deficits on admission and at the time of discharge according to the American Spinal Injury Association impairment scale.

Keywords: American Spinal Injury Association impairment score, cord edema, cord hemorrhage, magnetic resonance imaging, spinal trauma


How to cite this article:
Gupta A, Dhande R. Role of magnetic resonance imaging in the evaluation of spinal trauma. J Datta Meghe Inst Med Sci Univ 2020;15:192-6

How to cite this URL:
Gupta A, Dhande R. Role of magnetic resonance imaging in the evaluation of spinal trauma. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 23];15:192-6. Available from: http://www.journaldmims.com/text.asp?2020/15/2/192/304243




  Introduction Top


Diagnostic imaging, particularly magnetic resonance imaging (MRI), plays a crucial role in evaluating and detecting spinal trauma. Subtle bone marrow, soft-tissue, and spinal cord abnormalities, which may not be apparent on other imaging modalities, can be readily detected on MRI. Early detection often leads to prompt and accurate diagnosis, expeditious management, and avoidance of unnecessary procedures.

Many advantages of MRI such as higher contrast resolution, absence of bony artifacts, multiplanar capability, and choice of various pulse sequences make possible to diagnose spinal trauma more accurately. Adequate information about neural and extraneural injuries requiring surgical interventions, for example, significant disc herniations and epidural hematomas, can be obtained in case of spinal cord edema, contusion, hemorrhagic, and ischemia; MRI findings may serve as prognostic indicators.

Most of the diagnostic information in spinal trauma is derived from the sagittal images. Axial images serve as a supplement. Sagittal T1-weighted images offer an excellent anatomic overview. Disc herniations, epidural fluid collections, subluxation, vertebral body fractures, cord swelling, and cord compression are also visualized. Sagittal T2-weighted images depict most of the soft-tissue abnormalities including spinal cord edema and hemorrhage, ligamentous injury, disc herniations, and epidural fluid collections. Axial and sagittal GE images aid in the identification of the acute spinal cord hemorrhage, disc herniations, and fractures.

The depiction of parenchymal spinal cord injury (SCI) on MRI not only correlated well with the degree of the neurologic deficit but also bears significant implications in regard to prognosis and potential for neurologic recovery.

As MRI is an excellent diagnostic modality for the evaluation of spinal trauma, it is possible to suggest that the MRI findings correlated directly with the degree of deficit according to the American Spinal Injury Association (ASIA) impairment scale. The purpose of this study is to evaluate this correlation.

Aim

The aim was to evaluate the role of MRI in spinal trauma, its correlation with clinical profile, and neurological outcome using the ASIA impairment scale.

Objectives

  1. To enumerate the MRI findings in patients with acute spinal trauma
  2. To assess the neurological deficits of patients with acute spinal trauma on admission and discharge using the ASIA impairment scale
  3. To correlate MRI findings with clinical profile and neurological outcome.


Source of data

Cases of acute spinal trauma who underwent MRI of the spine in the Department of Radiodiagnosis, Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, were included in the study. Detailed neurological examination of the patient was done during the scan. Detailed neurological examination of the patient was also done during his or her discharge from the hospital.

Type of study

This was a hospital-based prospective study.

Study period

The study was conducted from June 2017 to December 2018.

Sample size



Total patients in the last year n = 78

χ2 = Chi-square value for 1 degrees of freedom at some desired probability level = 3.84

P = 50% proportion

C = confidence interval of the one choice

=0.05

n = 3.84 × 78 × 0.5 × 0.5/0.05 × 0.05 × 77 + 3.84 × 0.5 × 0.5

=64.83

Sixty-five patients with spinal trauma irrespective of age and sex referred to the Acharya Vinoba Bhave Rural Hospital, Sawangi, Meghe, were included. After giving informed consent and ethical clearance, patients had MR imaging done [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 1: Saggital T2W(a) image showing compression fracture of superior endplate of body of L1 vertebra with retropulsion of posterior fragment indenting over thecal sac causing narrowing of spinal canal. Decreased D12-L1 space with anterolisthesis of L1 over L2. ASIA impairment score – at admission: B , at discharge:B

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Figure 2: Saggital GRE image showing wedge compression fracture of L2 vertebral body with retropulsion of vertebral body causing cord compression at the same level with epidural collection at the level of L2, L3 vertebral bodies showing blooming on GRE s/o epidural hemorrhage. ASIA score at admission: A , at discharge:A

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Figure 3: Saggital T2W image demonstrate hyperintensity in the spinal cord at the level of C5-C6 s/o cord edema. There is straightening of cervical cord with no e/o fracture. ASIA score – at admission: D, at discharge: E

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Figure 4: Saggital T2W image showing fracture of superior endplate of C5 with decreased body height, anterior wedging of the vertebral body compressing anterior thecal sac and spinal cord. There is hyperintensity in the cord at C4-C6 level on saggital T2W1 and STIR s/o cord edema. ASIA score- at admission: C , at discharge: D

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Figure 5: Axial GRE image at the T10-T11 level confirming the intramedullary low-intensity signal . it is an intramedullary hemorrhage (hematomyelia). ASIA score at- admission: A, discharge:A

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Ethical Approval

Ethical approval for this study (DMIMS(DU)/IEC/2019-20/1972) was provided by the Ethical Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) on 11/02/19.

Equipment

GE MRI 1.5 tesla (Hhes & Medical Services Private Limited, Darjiling, West Bengal, India) with phased array coil was used for the acquisition of images in all patients.

Method of collection of data

MR imaging of the spine was performed in the axial and sagittal planes using a combination of pulse sequences. The study was performed with patient in the supine position with quiet breathing obtaining sagittal T2- and T1-weighted fast spin-echo (FSE) images, short tau inversion recovery (STIR), coronal STIR, and axial T2- and T1-weighted FSE images for proper evaluation of cord hemorrhage.

Sagittal images were 5.0-mm thick with a 0.5-m slice gap. The field of view (FOV) of the area of interest is adequate at 24 cm in the cervical spine and at 32 cm in the lumbosacral spine. In the dorsolumbar spine, a large FOV was needed (34/36 cm) for accurate labeling of the involved levels.

T2-weighted information was obtained using a single FSE acquisition using a split echo train, resulting in intermediate T2-weighted sequences. For the short TE image, an echo train of three with two excitations was used, whereas for the long TE image, an echo train of 15–30 with single excitation was used. For each sequence, 256–448 steps were followed in both the frequency and phase axes. Fat suppression was employed on the long TR sequences to improve visualization of edema in the posterior ligamentous complexes (STIR). Axial images were obtained using FSE or gradient echo pulse sequences. Technical parameters included 16° flip angle, minimum TR/TE, 224 × 320 matrix, and two excitations in T1WI and one excitation in T2WI. The TE used was <15 ms in T1WI and up to 100 ms in T2WI in order to minimize unwanted susceptibility effects that might exaggerate bony stenosis.

The following findings were identified after assessing the MR images and considered for the study:

  1. Cord hemorrhage
  2. Cord edema >3 cm in length
  3. Cord edema <3 cm in length
  4. Fracture of the vertebral body and posterior elements
  5. Normal cord.


Clinical assessment of spinal cord injury

A standardized physical examination as endorsed by the international standards for neurological and functional classification of SCI patients, also commonly called the ASIA guidelines, was performed. A detailed motor and sensory examination of the patient was done and graded according to the ASIA scale which is as follows [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]:
Table 1: Functions

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Table 2: Most common sites

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Table 3: Most common findings

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Table 4: According to the American Spinal Injury Association impairment scale

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Table 5: Outcome in patients with cord edema

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Table 6: Outcome in patients with vertebral body fracture without cord edema

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Table 7: Outcome in patients with vertebral body fracture with cord edema

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Table 8: Outcome in patients with cord hemorrhage

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Table 9: Outcome in patients with no cord findings

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Table 10: Various cord finding and their effect on outcome (multivariate analysis)

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Data analysis

The strength of the association between the extent of SCI and outcome was described using odd's ratio. Chi-square test of significance (P < 0.005) was used to assess the association between MR findings and clinical outcomes.

Inclusion criteria

All the patients of acute spinal trauma undergoing MR imaging formed the study group.

Exclusion criteria

  1. Postoperative patients of spinal trauma undergoing MRI scan of the spine
  2. Uncooperative patients
  3. Patients with metallic implants, patients with pacemaker/cochlear implant in situ, and patients with claustrophobia/any other psychiatric abnormality.


Observation and results

In our prospective study, 65 patients underwent MRI for the evaluation of spinal trauma with majority being males (69%).[1],[2],[3],[4],[5]


  Conclusion Top


It can be concluded after the study that MRI plays a major role in the diagnosis of spinal trauma, directing early and prompt management and predicting prognosis of neurological recovery. Cord edema and normal cord were associated with favorable neurological outcome.

Vertebral body fractures, especially in association with cord edema, showed poor neurological recovery, as compared to cord edema and normal cord. Cord transection and cord hemorrhage were associated with complete SCI and with poor neurological recovery.

MRI findings in acute SCI correlate well with the initial neurological deficits on admission and at the time of discharge according to the ASIA impairment scale.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Samad SA, Phatak SV. An Unusual Case of Abdominoscrotal Swelling in a Young Patient-Hydrocele En Bissac. J Clin Diagn Res 2018;12:3-5. Available from: https://doi.org/10.7860/JCDR/2018/37640.12278. [Last accessed on 2019 Dec 18].  Back to cited text no. 1
    
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Sandhu GS, Nagrale HR. Computed Tomography Evaluation of Brain in Chronic Alcoholics. J Neurosci Rural Pract 2020;11:63-71. Available from: https://doi.org/10.1055/s-0039-1700610. [Last accessed on 2019 Dec 18].  Back to cited text no. 2
    
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Meshram P, Pawaskar A, Kekatpure A. 3D CT Scan-Based Study of Glenoid Morphology in Indian Population: Clinical Relevance in Design of Reverse Total Shoulder Arthroplasty. J Clin Orthop Trauma 2020;11: S604-9. Available from: https://doi.org/10.1016/j.jcot.2020.03.001. [Last accessed on 2019 Dec 18].  Back to cited text no. 3
    
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Sharma S, Singh AD, Sharma SK, Tripathi M, Das CJ, Kumar R. Gallium-68 DOTA-NOC PET/CT as an Alternate Predictor of Disease Activity in Sarcoidosis. Nucl Med Commun 2018;39:768-78. Available from: https://doi.org/10.1097/MNM.0000000000000869. [Last accessed on 2019 Dec 18].  Back to cited text no. 4
    
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Anil PK, Anil P, Iratwar SW, Patil A, Mundhe VM, Rathod CT. Decompressive Craniectomy for Traumatic Acute Extradural Haematoma: Decision Making and Outcomes. J Clin Diagn Res 2020;14:PR1-3. Available from: https://doi.org/10.7860/JCDR/2020/43142.13462. [Last accessed on 2019 Dec 18].  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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