Evaluation for Soft Tissue Injuries on CT in Acute Cervical Spine Trauma with MR Imaging Correlation...
Transcript of Evaluation for Soft Tissue Injuries on CT in Acute Cervical Spine Trauma with MR Imaging Correlation...
Evaluation for Soft Tissue Injuries on CT in Acute Cervical Spine Trauma
with MR Imaging Correlation Naoko Saito 1, Margaret N Chapman 2,3, Akira Uchino 1
Fumikazu Sakai 1,Osamu Sakai 3
1 Radiology, Saitama International Medical Center, Saitama Medical University2 Radiology, Boston VA Healthcare System
3 Radiology, Boston Medical Center, Boston University School of Medicine
EP - 154
Introduction Methods Results Discussion Conclusion
☑ The authors have no conflict of interest to disclose with respect to this presentation.
Introduction Methods Results Discussion Conclusion
• Soft tissue injuries, including ligamentous injury, muscular injury, and prevertebral edema/hematoma, are common imaging findings of cervical spine trauma.
• These injuries are believed to correlate with the severity of the spinal cord injury. (Song KJ, et al. Martínez-Perez R et al. Goradia D et al.)
• Although MR can clearly demonstrate these injuries, the utility of CT in their detection is often underappreciated.
Introduction Methods Results Discussion Conclusion
Purpose
• To assess whether CT with soft tissue window can help identify soft tissue injuries
• To compare CT with MR imaging findings in patients with acute cervical spine trauma
Introduction Methods Results Discussion Conclusion
• Retrospective imaging review• From January 2010 to November 2014• Patients who underwent both CT and MR imaging
of cervical spine for acute traumatic spinal injury were identified
• Medical records were reviewed for demographics and admitting diagnosis
• The indication for MRI at our institution• Neck pain, midline cervical pain• Neurological deficits on examination• Subjective neurological complaints• Altered mental status
Subjects
Introduction Methods Results Discussion Conclusion
CT imaging• 64-slice MDCT (LightSpeed VCT, GE Healthcare)• Reviewed in bone (WL/WW: 350/1500) and soft tissue
(WL/WW: 55/450) windows
MR imaging• 1.5 MRI (MAGNETOM Avanto, SIEMENS)• Reviewed in T1, T2-weighted, and STIR images
• Sagittal T1 weighted image: TR/TE 550/10• Sagittal T2 weighted image: TR/TE 3500/85• Sagittal STIR : TR/TE 5000/60, TI 170• Axial gradient-recalled image: TR/TE 500/24, FA 30°
Imaging techniques
Introduction Methods Results Discussion Conclusion
Image analysis
CT • Fracture• Dislocation• Soft tissue abnormality
Interspinous soft tissue Supraspinous soft tissue Prevertebral soft tissue Posterior cervical
musculature
MRI • Fracture• Dislocation• Soft tissue abnormality
Interspinous soft tissue Supraspinous soft tissue Prevertebral soft tissue Posterior cervical
musculature• Spinal cord abnormality
• Images were reviewed by a single observer with special attention directed toward soft tissue changes
Introduction Methods Results Discussion Conclusion
STIRCTsoft
tissue window
A 74-year-old man with interspinous (arrows) and supraspinous (arrows) soft tissue injuries and prevertebral edema (arrowheads).
Evaluation for soft tissue injury: sagittal
Introduction Methods Results Discussion Conclusion
T2*
A 74-year-old man with interspinous (arrows) and supraspinous (arrows) soft tissue injuries and prevertebral edema (arrowheads).
Evaluation for soft tissue injury: axial
CT soft tissue window
Introduction Methods Results Discussion Conclusion
Patient characteristics
• 157 patients with acute cervical spine trauma were identified during the 5-year period• Age: 14 - 92 (avg. 59.5) years old • Gender: 34 women, 123 men• Mechanism: Fall 108, MVC/MCA 45,
others 4• MVC = motor vehicle collision, MCA = motorcycle accident
• Days between CT and MR: 0-26 (avg. 1.2) days
Introduction Methods Results Discussion Conclusion
Patient characteristics
• 157 patients with acute cervical spine trauma were identified during the 5-year period• Fracture 52
patients
• MR imaging abnormality• Spinal cord injury 83
patients• Paraspinal soft tissue injury 92
patients
Introduction Methods Results Discussion Conclusion
Soft tissue abnormalities
• Out of 157 patients,– 59 patients (37.6%) showed abnormalities in
the paraspinal soft tissues on CT– 92 patients (58.6%) showed abnormalities in
the paraspinal soft tissues on MR imaging
• Of 92 patients with paraspinal soft tissue injuries by MR,
– CT identified the abnormalities in 57 patients (62.0%)
Introduction Methods Results Discussion Conclusion
Soft tissue abnormalities
• Of 59 patients with paraspinal soft tissue abnormalities on CT,
– 38 patients (64.4%) demonstrated the abnormalities adjacent to the fractures
– 18 patients (15.3%) showed prevertebral edema
• Of 18 patients with prevertebral edema on CT, – 12 patients (66.7%) had cervical spine fractures
Introduction Methods Results Discussion Conclusion
Soft tissue injury with spinal cord injury• Of 59 patients with paraspinal soft tissue
abnormalities on CT,– 37 patients (62.7%) had spinal cord signal
abnormalities on MR imaging– 11 patients (18.6%) did not have fracture or
dislocation but had spinal cord abnormalities on MR imaging
• Of 18 patients with prevertebral edema on CT,– 13 patients (72.2%) had spinal cord injury on
MR imaging
Introduction Methods Results Discussion Conclusion
Soft tissue injury with spinal cord injury
Paraspinal soft tissue injury
Prevertebral edema
+ CT findings 59 18
Cord signal abnormality on
MRI37 13
Odds Ratio 1.9 (95% CI 0.9 to 3.7) 2.6 (95% CI 0.9 to 7.6)
Introduction Methods Results Discussion Conclusion
Representative case 1 Soft tissue injury with fracture and spinal cord injury. A 75-year-old man after a fall from 16 stairs presented with lost of consciousness.
STIR
There is a posterior spinous process fracture of C4 (arrows). CT with soft tissue window shows fat stranding within the intraspinous soft tissues (arrow) adjacent the to fracture. STIR image demonstrates intra- and supraspinous soft tissues injuries (arrows) and spinal cord injury with hemorrhage at the level of C4/5 (arrow).
Introduction Methods Results Discussion Conclusion
Representative case 2 Prevertebral edema with spinal cord injury. A 73-year-old woman
after a fall from standing presented with quadriplegia.
There is no fracture on CT. CT with soft tissue window shows prevertebral edema (arrowheads) and fat stranding within the intra- and supraspinous (arrows) soft tissues, correlating with STIR image. Spinal cord injury at the level of C2-5 is seen (arrow).
STIR
Evaluation for soft tissue injuries in acute cervical spine trauma
• Soft tissue injuries are believed to correlate with the severity of the spinal cord injury
• Could be useful in predicting neurologic outcome (Song KJ, et al. Martínez-Perez R et al. Goradia D et al.)
Ligamentous injury: anterior longitudinal ligaments, posterior longitudinal ligaments, and ligamentum flavum
• MR imaging has been reported as clearly superior to CT in detecting soft tissue injuries
• Utility of CT in their detection is often underappreciated
Introduction Methods Results Discussion Conclusion
Evaluation for soft tissue injuries on CT
• CT identified approximately 2/3 of the soft tissue abnormalities observed on MR imaging • CT findings of soft tissue abnormality:
Fat stranding within the interspinous and supraspinous regions
Posterior cervical musculature swelling Prevertebral soft tissue swelling
• These CT findings may be associated with ligamentous injuries
• Soft tissue abnormalities were often seen adjacent to the fractures on CT
• Evaluation with soft tissue window could help to detect subtle fractures
Introduction Methods Results Discussion Conclusion
Evaluation for soft tissue injuries on CT
• About 60% of the patients with paraspinal soft tissue abnormality on CT had spinal cord injury on MR imaging
• Furthermore, approximately 20% of those patients did not have fracture or dislocation
• Evaluation of paraspinal soft tissue abnormality on CT could also be useful in predicting neurologic outcome
Introduction Methods Results Discussion Conclusion
Patients with prevertebral edema on CT were more likely to have spinal cord injury
• Prevertebral edema is thought to be associated with more severe cervical spine trauma
• Prevertebral edema/hematoma Occurred mainly in hyperextension and whiplash
injuries (Hutter G et al.)
• Disruption of the anterior ligaments• Fractures of the anterior bony elements
Occurred in the elderly or anticoagulated patients (Hutter G et al.)
Caused by high-energy trauma in younger patients (Kuhn JE et al.)
Introduction Methods Results Discussion Conclusion
Limitations
– Evaluation for soft tissue on CT• Beam hardening artifacts
– Retrospective nature• Time difference between CT and MR examinations• Sampling bias
– A single observer
– Correlation of surgical findings or clinical outcome• Future study
Introduction Methods Results Discussion Conclusion
Introduction Methods Results Discussion Conclusion
• Although MR imaging is highly sensitive for detecting ligamentous and paraspinal soft tissue injuries, CT with soft tissue window can also demonstrate paraspinal soft tissue abnormalities in patients with acute cervical spine injury.
• Patients with soft tissue abnormalities, especially prevertebral edema on CT, are 3 times more likely to have spinal cord injuries.
Conclusion
Introduction Methods Results Discussion Conclusion
• Martínez-Perez R, Paredes I, Cepeda S, et al. Spinal Cord Injury after Blunt Cervical Spine Trauma: Correlation of Soft-Tissue Damage and Extension of Lesion. AJNR Am J Neuroradiol. 2014;35:1029-34.
• Hutter G, Benz R, Taub E, et al. Extensive cervical prevertebral hemorrhage with airway obstruction after low-energy hyperextension injury. Injury Extra 2014;45:53-55.
• Tan LA, Kasliwal MK, Traynelis VC. Comparison of CT and MRI findings for cervical spine clearance in obtunded patients without high impact trauma. Clin Neurol Neurosurg 2014;120: 23–26.
• Song KJ, Kim GH, Lee KB. The efficacy of the modified classification system of soft tissue injury in extension injury of the lower cervical spine. Spine 2008;33:E488–93.
• Goradia D, Linnau KF, Cohen WA, et al. Correlation of MR Imaging Findings with Intraoperative Findings after Cervical Spine Trauma. AJNR Am J Neuroradiol. 2007;28:209-15.
• Kuhn JE, Graziano GP. Airway compromise as a result of retropharyngeal hematoma following cervical spine injury. J Spinal Disord 1991;4:264-9.
References
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