Advances in imaging of vertebral and spinal cord injury

Abstract

Background/objectives: Imaging technology is an important part of the diagnosis and management of spinal trauma. Indications and findings in post-traumatic imaging of the vertebral column and spinal cord are reviewed.

Methods: An extensive literature review was performed on the imaging of vertebral and spinal cord injury. Relevant images from a Level I trauma center were included as examples.

Results: Imaging plays an important role in the evaluation of acute and chronic spinal injury. Spinal cord and soft-tissue injuries are best evaluated by magnetic resonance imaging (MRI), whereas spinal fractures are better characterized by computed tomography (CT). Vascular injuries can be evaluated using CT or MR angiography.

Conclusions: Imaging using CT and MRI is essential in the management of spinal cord injuries, both in the acute and in the chronic settings. MRI shows the status of ligamentous integrity and visualizes internal derangement of the spinal cord. Vascular compromise can be diagnosed by MR and CT angiography. Plain radiography now has a more limited, adjunctive role, and the need for higher risk myelography has been minimized.

Figure 1

Normal anatomy. (a) Sagittal T1-weighted image of the cervical spine. (b) Sagittal T2-weighted image of the cervical spine. (c) Sagittal T2-weighted image of the lumbar spine. Notice the normal termination of the spinal cord at the thoracolumbar junction (arrow). (d) Axial T2-weighted image of the cervical spine.

Figure 2

Causes of spinal stenosis and cord compression. Axial T2-weighted image demonstrating a small epidural hematoma (arrow).

Figure 3

Causes of spinal stenosis and cord compression. Sagittal T2-weighted image demonstrates a disk bulge at C5–C6 (arrow).

Figure 4

Causes of spinal stenosis and cord compression. Axial T2-weighted image showing a burst fracture with retropulsion of fragments into the canal (arrow).

Figure 5

Bony detail with CT. (a) Axial CT demonstrates fractures of the posterior elements of C5 (arrows). (b) Axial STIR sequence at the same level does not show the fractures as clearly, although soft-tissue and intraosseous edema is present (arrows).

Figure 6

Spondylosis and cord injury. Sagittal T2-weighted image with increased signal within the spinal cord at the C6 level consistent with contusion (arrow). No fracture or ligamentous injury was identified.

Figure 7

Cord contusion. T2-weighted image demonstrates a compression fracture of C5 causing cord edema and swelling (arrow).

Figure 8

Cord contusion and hemorrhage. (a) Axial T2-weighted image in a different patient showing increased signal consistent with cord contusion (arrow). (b) Additional T2-weighted image images more inferiorly show signal dropout consistent with areas of cord hemorrhage (arrow).

Figure 9

PPMM. (a) Sagittal CT demonstrates a gunshot wound through the spinal canal at the T8–T9 level (arrow). (b) Sagittal T2-weighted image a few months later demonstrates abnormal signal (arrow) much higher in the cord compared with the primary injury. (c) On the sagittal T1-weighted image, the lesion is slightly hypointense to the cord (arrow). Note that the signal intensity of the lesion is more consistent with edema than cyst formation. (d) The sagittal STIR demonstrates cord signal abnormality at the level of the injury extending cranially (arrows).

Figure 10

Syrinx. Sagittal T2-weighted image shows a small syrinx at the C6 and C7 levels following minor trauma (arrow).

Figure 11

Syrinx. Sagittal T2-weighted image in a different patient shows extensive syrinx formation throughout the entire cervical cord (asterisks). The abnormality was also isointense to cerebrospinal fluid on T1-weighted image (not shown).

Figure 12

Sagittal CT demonstrates markedly displaced fracture in a patient with preexisting diffuse idiopathic skeletal hyperostosis.

Figure 13

Burst fracture. (a) Sagittal CT demonstrates a burst fracture of the L2 vertebral body (arrow) with retropulsion of fracture fragments into the spinal canal. (b) Axial CT at the level of the burst fracture.

Figure 14

Jefferson fracture. (a) Axial CT showing bilateral fractures of the anterior arches of C1 (arrows). (b) Axial CT showing bilateral fractures of the posterior arches of C1 (arrows).

Figure 15

Hyperflexion injury. (a) Sagittal CT demonstrates anterolisthesis of C6–C7 (arrow). (b) Sagittal CT demonstrates a jumped facet (arrow). The tip of the inferior articular process of C6 is fractured.

Figure 16

Flexion-teardrop fracture. (a) Sagittal CT shows mild compression deformity and a small fracture of the anterior-inferior C6 vertebral body (arrow). (b) Sagittal T2-weighted image shows the fracture and an associated anterior longitudinal ligament injury (arrow).

Figure 17

Chance-type fracture. (a) Sagittal CT demonstrates compression deformity of the L1 vertebral body with distraction of the posterior elements (arrow). (b) Sagittal T2-weighted image demonstrates the compression deformity of the L1 vertebral body, as well as edema within the posterior elements (arrow). Note that the retropulsed fragments compress the conus medullaris with mild associated edema.

Figure 18

Spondylolysis. (a) Sagittal CT showing an L5 pars defect (arrow). (b) Sagittal CT showing minimal anterolisthesis of L5 on S1. (c) Axial CT showing bilateral L5 pars defects (arrows).

Figure 19

Hyperextension injury. (a) Sagittal CT demonstrates widening of the anterior T6–T7 disk space (arrow). (b) Sagittal T2-weighted image demonstrates widening of the disk space and edema within the intervertebral disk (arrow).

Figure 20

Hyperextension injury. Sagittal T2-weighted image in a different patient shows marked widening and distraction of C2–C3 disk space with cord compression and edema/hemorrhage (arrows).

Figure 21

Atlanto-occipital distraction injury. (a) Coronal CT show marked widening of the atlanto-occipital space in a child (arrow). (b) Sagittal CT shows the widened atlanto-occipital interval (arrow). (c) Parasagittal CT shows the widened atlanto-occipital interval (arrow).

Figure 22

Ligamentous injury. Sagittal T2-weighted image showing injury to the anterior longitudinal ligament (black arrow) and posterior longitudinal ligament (white arrow) with subluxation and cord compression.

Figure 23

Ligamentous injury. Sagittal STIR sequence in a different patient demonstrates interspinous ligament injury (arrow).

Figure 24

Vertebral artery injury. (a) Axial T2-weighted image demonstrates loss of the normal flow void within the right vertebral artery consistent with dissection (arrow). Note the normal dark flow void in the left vertebral artery. (b) This was confirmed on a coronal maximum intensity projection view with MR angiography (arrow).

Figure 25

Vertebral artery injury. (a) Axial T2-weighted image shows loss of the normal flow void within the right vertebral artery (arrow). (b) Lack of right vertebral opacification is also seen on the axial CT angiogram in the same patient (arrow).