1. Salzburg December 2001
Sherlock bones
Med Apps
Spinal cord injury
Q: A 55 year old male fell from her horse and is now fully tretraplegic. Your first imaging choice is MRI?
yes no
Franz Kainberger

2. Salzburg December 2001 Incorrect
Imaging workup of complex hyperflexion injury of the spine is necessary
Incorrect
CCT and CT: first imaging choice.
associated fractures or facet joint lesions are common and may influence decision for surgical stabilization
You find significant narrowing of the spinal canal on level C5/C6 due to degenerative disk disease. What additional investigation should be performed before proceeding to next diagnostic steps:
CT angiography to check for injury of vertebral arteries.
back
Franz Kainberger

3. MRI displays edema and hemorrhage
Salzburg December 2001
MRI displays edema and hemorrhage
correct
MRI should be the 2nd choice of imaging. STIR sequences are indispensable for detecting edema.
MRI performed some hours after injury
back
Franz Kainberger

4. Reduced spinal capacity indicates the risk and cause of cord injury
Salzburg December 2001
Reduced spinal capacity indicates the risk and cause of cord injury
Prognostic impact
Q: You tell the patient and her referring physician that in this case
it is hemorrhage with a worse prognosis of her tetraplegia
there is no cord transection, the patient has a good chance to recover completely
with view on the degenerative disk, the bright spots is related to it
it is spinal cord contusion with a generally worse prognosis but recovery may be possible
(1)
(2)
(3)
(4)
decribe lesions and click on image at their anatomic location
Franz Kainberger

5. Spinal capacity indicates the risk and cause of cord injury
Salzburg December 2001
Spinal capacity indicates the risk and cause of cord injury
Disk herniation with retrolisthesis and posterior spondylosis
Slight cord swelling with acute edema, no transection
back
Franz Kainberger

6. Salzburg December 2001 incorrect
Hemorrhage should not be hyperintense on T2 in early stages of cord injury
Franz Kainberger

7. Salzburg December 2001 incorrect
Prognosis does not only depend on complete cord transection.
Indicators of incomplete fiber dissection are
imaging features:
cord swelling,
hemorrhage,
extent of cord lesion
location within cord (anterior, central, or rarely posterior)
patient‘s age
clinical presentation
back
Franz Kainberger

8. Salzburg December 2001 incorrect
Spondylogenic myelopathy is an important DDx with T2-hyperintense lesions due to gliosis. In this case, however, extent of lesions is not confined to the level of disk herniation.
back
Franz Kainberger

9. Cord contusion edema: better prognosis than hemorrhage
Salzburg December 2001
Cord contusion edema: better prognosis than hemorrhage
correct
Low „spinal capacity“
Torg et al., JBJS Am 1986; 1354
acute spinal cord injury – grading
signal intensity
contusion with edema
T1 iso- or hypointense T2 hyperintense
hemorrhage
T1 hyperintense after 3 days
T2 hypointense chronic: hyperintense gliosis or hypointense hemosiderin
cord transection
cord discontinuity
back
Franz Kainberger

10. MRI adds prognostic information
Salzburg December 2001
MRI adds prognostic information
Diagnosis: Cord contusion with edema
In hyperflexion osteophytes act like nails that are hammered into the cord
Prognosis depends on severity of injury: (1) Cord contusion with edema, small area of compression, no cord swelling: good prognosis, (2) Cord hemorrhage (hypointense in acute phase on T1 and T2), large cord compression, and/or swelling: worse prognosis (3) Complete cord transection
Other prognostic factors are - age: > 50 yrs poorer prognosis due to impaired microcirculation with tendency to cord necrosis - clinical presentation
Franz Kainberger

11. Salzburg December 2001
Fortunately, our patient recovered completely after several weeks – and committed during a follow-up visit that he again was riding his horse.
Franz Kainberger

12. Hyperflexion of cervical spine
Salzburg December 2001
Hyperflexion of cervical spine
Summary & Learning Objectives
to understand the relationship between the spinal column and the spinal cord in case of injury
Spinal capacity expresses the width of the spinal canal
Spondylosis is an important risk factor for cord injury
to estimate the prognosis based on imaging findings in the context with clinical presentation
Three degrees of cord injury: contusional edema, hemorrhage, complete transection
References:
Fruewald F, Tscholakoff D, Kainberger F. Orientierungshilfe Radiologie, 2011
Miyanji F et al. Acute cervical traumatic spinal cord injury. Radiology 2007; 243: 820
back
Franz Kainberger