1 / 45

Magnetic resonance imaging of spinal cord trauma: a pictorial essay

Magnetic resonance imaging of spinal cord trauma: a pictorial essay. Neuroradiology (2006) 48: 223 – 232 Int. 阮威勝. Introduction. Fractures and joint dislocations can be detected accurately by plain radiology or CT Imaging the spinal cord is more difficult

mdavison
Download Presentation

Magnetic resonance imaging of spinal cord trauma: a pictorial essay

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Magnetic resonance imaging of spinal cord trauma: a pictorial essay Neuroradiology (2006) 48: 223–232 Int.阮威勝

  2. Introduction • Fractures and joint dislocations can be detected accurately by plain radiology or CT • Imaging the spinal cord is more difficult • spinal cord injury can occur in the absence of bone changes • The focus of this review is the role of magnetic resonance imaging (MRI) in the assessment of spinal cord injury following trauma, in both the acute and the chronic stages

  3. Acute Spinal Cord Injury

  4. true cord injury or compression with secondary cord damage • minor injury or more severe trauma five criteria for a minor injury : “five no’s” • no focal neurological signs • no midline spinal tenderness • no intoxication • no painful injury • no depression of consciousness • complete or incomplete lesions A complete lesion involves loss of both functions in the lower sacral segments.

  5. Central cord syndrome • Trauma to the mid cervical and lower cervical spinal cord • Degenerative bone changes are often present • Greater motor impairment in the upper rather than the lower extremities • bladder dysfunction and varying degrees of sensory loss below the level of the lesion

  6. Anterior cord syndrome • Secondary to a disruption of the anterior spinal artery • Typically affects the upper thoracic cord • Predominant motor loss with absent or insignificant sensory deficit

  7. Brown-Séquard syndrome • Hemisection of the spinal cord • Ipsilateral weakness and loss of proprioceptive and vibratory sensation, due to disruption of the corticospinal tracts and dorsal columns • Pain and temperature sensation are lost on the contralateral side because of the affected spinothalamic tract.

  8. Cauda equina syndrome • Trauma at the level of the cauda equina • Difficulty in walking due to weakness of the legs • Sensory disturbance, characteristically found in the perineal region

  9. Spinal cord injury without radiographic abnormality (SCIWORA) • Paediatric population • Relatively large head size and skeletal mobility of the neck of younger children • Can also occur in adults

  10. Clinical evaluation can be difficult and that imaging is of particular importance in evaluating these patients • MRI is the modality of choice for the evaluation of patients with neurological signs or symptoms • Even in the absence of a traumatic lesion on either of these examinations, emergency MRI is indicated and should be obtained as soon as possible and certainly within thefirst hours after injury to prevent irreversible damage to the spinal cord.

  11. In the acute setting, MR images can show transection, haemorrhage, contusion or oedema of the spinal cord • Oedema or contusion is seen after secondary temporary or permanent cord compression • Intramedullary haemorrhage is usually associated with a clinically complete and irreversible spinal cord injury

  12. Spinal cord oedema Crushed vertebra Sagittal TSE T2WI

  13. Traumatic pseudomeningocele STIR Sagittal TSE T2WI Axial GE T2WI

  14. Spinal cord haematoma Axial GE T2WI Sagittal GE T2WI

  15. Axial SE T1WI Sagittal TSE T2WI Axial GE T2WI

  16. MRI can demonstrate ligamentous injuries, muscular lesions, facet joint dislocations and bone marrow oedema • MRI is sensitive and has a high negative predictive value in the assessment of ruptured ligaments

  17. In injury to the upper cervical level, the tectorial membrane can be disrupted • The tectorial membrane lies close to the dens and clivus as an extension of the posterior longitudinal ligament • The integrity plays a crucial role in the stability of the upper cervical region.

  18. Detachment of the tectorial membrane Sagittal TSE T2WI

  19. MRI as Prognostic role • Poor prognosis • complete cord syndrome and abnormal MRI finding • cord contusion (cyst formation) • pre-existing degenerative changes • presence and extent of spinal cord haematoma

  20. Good prognosis • partial cord syndrome and normal MRI findings • absence of spinal cord oedema • The ratio of the maximal anteroposterior diameter of an epidural haematoma to the spinal canal diameter may have prognostic value • Ratios of less than 60% are associated with a full recovery

  21. Pre-existing cervical spondylosisand spinal stenosis Sagittal TSE T2WI Sagittal TSE T2WI Turbo STIR

  22. Epidural haematoma Axialal TSE T2WI Sagittal TSE T2WI Sagittal SE T1WI

  23. SCIWORA Sagittal SE T1WI Turbo STIR

  24. Chronic Spinal Cord Injury

  25. A number of victims of spinal cord trauma may develop new symptoms several weeks or years later • MRI is unequivocally the modality of choice in the diagnostic work-up of these patients

  26. Posttraumatic syringomyelia • 3–4%. • 8 weeks ~ several years • Caused by cystic degeneration of the injured spinal cord at or near the site of the trauma • Clinical presentation is non-specific Ascending sensory signs and motor deficit • Treatment：shunting

  27. Non-communicating syringomyelia • often associated with a Chiari malformation, spinal stenosis or basilar impression • Communicating syringomyelia • mainly seen in children and always associated with hydrocephalus.

  28. Syringomyelia must be differentiated from the “benign” widening of the central canal • typically seen at the junction of the anterior one-third and the posterior two-thirds of the spinal cord and is generally not wider than 2–3 mm • A benign widening of the central canal occurs in approximately 1.5 %

  29. High-pressure and low-pressure syringomyelia • No non-invasive method of distinguishing the two states, but MRI appears to display a flow void within the cavity of a high-pressure syrinx on T2-weighted images. • High-pressure syrinx may correspond to an acute expanding syrinx that, following prompt treatment, is more likely to improve than the low-pressure syrinx

  30. Posttraumatic syringomyelia Sagittal SE T1WI Sagittal TSE T2WI Sagittal TSE T2WI Axial SE T1WI

  31. Sagittal TSE T2WI Sagittal SE T1WI Sagittal TSE T2WI Sagittal SE T1WI

  32. Enlargement of the central canal Axial GE T2WI Axial SET2WI Sagittal TSE T2WI

  33. Progressive posttraumatic myelomalacic myelopathy (PPMM) • 0.3–3.2% • 2 months ~ 30 years • PPMM is a possible precursor of syringomyelia. • Clinically, PPMM and posttraumatic syringomyelia are neurologically indistinguishable; however, MRI can be used to differentiate the two entities. • PPMM is less well defined than cystic myelopathy and has been reported to return high signal on proton density-weighted images

  34. Pathology shows reactive gliosis, microcysts and thickening of the meninges. • It is important to diagnose PPMM since it is potentially treatable. • Local adhesions with cord tethering seem to cause PPMM and surgical untethering with expansive duraplasty leads to clinical improvement in the majority of patients • Intraoperative ultrasound can be helpful in differentiating between myelomalacia and intramedullary cyst formation in this situation

  35. PPMM Sagittal TSE T2WI Sagittal SE T1WI

  36. Sagittal TSE T2WI Sagittal SE T1WI

  37. Spinal cord atrophy • 15–20% • Aeduction in the anteroposterior dimensions of the spinal cord from the normal 6 mm at the cervical level to 7 mm at the thoracic level • Usually observed many years after the traumatic event

  38. Difficult to differentiate atrophy from a subarachnoid cyst with cord compression • Sometimes, both entities may coexist • The most frequent location of intradural arachnoid cysts is the thoracic thecal sac. • It has been suggested that adhesions secondary to bleeding may impair CSF flow with dilatation of the subarachnoid space and the development of a cyst

  39. Spinal cord atrophy Axialal GE T2WI Normal size of spinal cord

  40. Posttraumaticsubarachnoid cyst Sagittal TSE T2WI Axial GE T2WI

  41. patients who have had spinal surgery for stabilization of vertebral fractures can still be examined by MRI when chronic spinal cord injury is suspected. • Operative implanted materials are now usually MR-compatible and do not significantly interfere with the interpretation of images of the spinal cord

  42. operative materials Sagittal TSE T2WI Axial GE T2WI

  43. Conclusion • Patients with focal neurological signs, evidence of cord or disc injury or whose surgery requires cord assessment should be imaged by MRI. • Moreover, the demonstration of lesions on MRI can be predictive and help to provide a functional prognosis. • In the chronic stage of a spinal cord trauma, MRI is the investigation of choice for evaluating complications and late sequelae in patients who develop new neurological symptoms. • Since some of these lesions are treatable, detecting them is extremely important.

More Related