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

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

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

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

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

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

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

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

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

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

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

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