Beyond broken spines-what the radiologist needs to know about late complications of spinal cord injury

Abstract

Objective: To describe expected imaging findings to assist the emergency room radiologist with recognising complications and pathology unique to the spinal cord injury (SCI) patient population to ensure rapid and accurate diagnosis.

Methods: Pictorial review.

Results: We review several imaging findings common to persons with chronic SCI, emphasising imaging in the emergency setting and on CT.

Conclusion: SCI patients present a unique diagnostic challenge, as they may present with symptoms that are difficult to localise because of abnormal sensation and autonomic instability. Imaging plays an important role in the emergent setting, rapidly differentiating the most commonly encountered complications from less common, unanticipated complications. Radiologists need to be attuned to both the expected findings and potential complications, which may be unique to SCI patients, to ensure accurate diagnosis and treatment in the emergency setting.

Main messages: • Medical complications after spinal cord injury are common and associated with significant morbidity. • Radiologists should be aware of complications unique to the SCI population to aid diagnosis. • Due to abnormal sensation, SCI patients often present with symptoms that are difficult to localise. • In the ED, imaging helps to rapidly differentiate common complications from less anticipated ones.

Fig. 1

Neurogenic bladder with bladder stone formation. SCI patient with indwelling urinary catheter (black arrowhead). Non-contrast CT image shows circumferential urinary bladder wall thickening (white arrow) and a calcified bladder stone layering dependently (black arrow). Note catheter tubing within the bladder lumen (black arrowhead) causing gas in the urinary bladder (white arrowheads)

Fig. 2

Renal calculi: multiple right renal calculi with mild cortical thinning and parenchymal loss in this patient with remote spinal cord injury. Routine urologic follow-up is an essential component in the care of spinal cord injury patients to prevent the consequences of acute obstructive processes and to preserve renal function

Fig. 3

Pyelonephritis: a 26-year-old paraplegic female who presented with diffuse abdominal pain. Axial image from contrast-enhanced CT shows striated enhancement of the kidneys bilaterally, with white arrows indicating linear regions of decreased enhancement

Fig. 4

Pyelitis. Axial image from contrast-enhanced CT shows air within the left renal collecting system (white arrow). There is uroepithelial thickening and enhancement (black arrow)

Fig. 5

Epididymitis: a paraplegic male who presented to the ED with a painful, high-riding testicle. Image from scrotal ultrasound reveals the enlarged, heterogeneous body of the epididymis (black arrow). There is a small associated hydrocele (white arrowhead). Color Doppler image of the epididymis confirms hyperaemia

Fig. 6

Renal atrophy in an SCI patient secondary to chronic vesicoureteral reflux. The right kidney is small with cortical thinning. Note also the thick-walled urinary bladder containing a large, calcified bladder stone

Fig. 7

Suprapubic catheter and renal scarring. An SCI patient with an indwelling suprapubic catheter for 15 years. a Small bladder volume with wall thickening (white arrowheads) and a suprapubic indwelling catheter (white arrow). Note the faecal impaction in the rectum (black arrowheads). b Focal renal cortical scarring of the right kidney (white arrow)

Fig. 8

Faecal impaction: scout radiograph of the abdomen demonstrates a large volume of stool throughout the colon and rectum. Coronal CT image confirms large rectal stool ball with mild associated rectal wall thickening, compatible with faecal impaction

Fig. 9

a Abdominal radiograph of a 20-year-old female with SCI and abdominal pain shows a dilated ascending and transverse colon (white line) with loss of colonic haustrations (white arrowheads) and pseudo-poly formation of the colonic mucosa (black arrow), concerning for toxic mega colon. b The corresponding coronal CT images confirm radiographic findings of bowel dilatation (white line), bowel wall thickening and oedema (white arrow) and mucosal pseudo-polyps (black arrow) typically associated with toxic megacolon

Fig. 10

SMA syndrome. Axial and coronal CT images show the distended, fluid-filled stomach (black arrows) and mild dilation of the proximal duodenum (white arrows). The duodenum is narrowed as it crosses the spine under the superior mesenteric artery and the remaining small bowel is small in caliber (not shown). Note the substantial streak artifact from the spinal fusion hardware

Fig. 11

a Anteroposterior radiograph of a 29-year-old male with C2 tetraplegia from a diving accident shows elevation of the left hemidiaphragm (black arrow) in relation to the right (white arrow), concerning for diaphragmatic paralysis. b Fluoroscopic spot image from the subsequently obtained “sniff” test confirms the diagnosis

Fig. 12

Syrinx: T2-weighted sagittal image from cervical spine MRI that shows expansion of the spinal cord with central cyst formation extending from the C6 level into the upper thoracic spine (white arrows)

Fig. 13

Neuromuscular scoliosis: upright scoliosis radiograph of a 51-year-old male (T6 SCI from a snowboarding injury 18 months earlier) shows neuromuscular dextroscoliosis. The scoliosis angle is 18° measured between the endplates of T2 and L2 (white lines). Anteroposterior alignment was normal (not shown)

Fig. 14

Charcot spine in a 32-year-old female with SCI due to a motor vehicle crash 2 years prior. a Parasagittal CT image of the left T11 pedicle shows development of an irregular pseudarthrosis with sclerosis and fragmentation (black arrow). b Coronal CT image depicts the pseudarthrosis (white arrow) and disc space narrowing above it. There is associated mild dextroscoliosis

Fig. 15

Marked osteopaenia and spiral tibial shaft (white arrow) and metaphyseal (white arrowhead) fractures in a patient with a remote SCI. These patients are at high risk for limb fractures, often occurring with only minor trauma, such as bed or wheelchair transfers

Fig. 16

Marked muscular atrophy in patient 7 years after SCI. a Non-contrast CT image shows marked atrophy of the gluteal musculature with fatty replacement (white arrow). b The same patient, 7 years earlier, demonstrating baseline muscle mass (white arrowheads)

Fig. 17

Heterotopic ossification: a patient 2 years after SCI, with soft tissue ossification involving both hips. The hip is the most commonly involved joint

Fig. 18

Heterotopic ossification: large soft tissue ossification bridging the knee joint (white arrows). This patient presented with chronic lower extremity swelling and decreased range of motion

Fig. 19

Heterotopic ossification. a Hip radiograph of a 46-year-old male 3 months after T4 SCI shows ill-defined calcifications medial to the lesser trochanter (white arrow). b Blood pool image of the subsequently obtained triple-phase bone scintigraphy shows hyperaemia in the left groin (white arrow). c Delayed bone scintigraphy images confirm avid tracer uptake medial to the left proximal femur (white arrows). Bone scan findings confirm maturing heterotopic ossification

Fig. 20

Decubitus ulcer and chronic osteomyelitis. Large skin and soft tissue defect extending to the left ischium, which is irregular, with osseous remodelling and sclerosis (black arrows). A left hip effusion is present as well

Fig. 21

Septic hip effusion with extensive soft tissue infection and abscess. a Fluid and gas are present in the left hip joint. The joint space is widened and there is osseous destruction and fragmentation along the margins of the acetabulum. Numerous rim-enhancing abscesses are present surrounding the hip and within the soft tissues of the proximal left thigh, (white arrows). b Marked asymmetry of the lower extremities with enlargement of the left leg and a large soft tissue abscess in the medial left thigh (white arrows)

Fig. 22

Fournier’s gangrene. a Coronal non-contrast CT image shows scrotal wall oedema (black arrow), with extensive subcutaneous gas in the scrotum and perineum (white arrows). Also note the presence of a bladder catheter (black arrowheads) and heterotopic ossification around the left hip (small white arrows). b Axial image from the same patient demonstrating the extent of infection and presence of gas throughout the perineum and scrotum (white arrows)

Fig. 23

Benign hip effusions. Large bilateral hip effusions (white arrows) detected incidentally on CT abdomen and pelvis obtained for another indication. These were found to be sterile effusions in this patient without fever or elevated white blood cell count

Fig. 24

Abdominal radiograph of a 33-year-old female with thoracic SCI from a motor vehicle collision 15 years prior shows superior subluxation of the left femoral head (black arrow) due to spasticity. The right femur (white arrow) is normally aligned

Fig. 25

a The lateral scout image from an abdominal CT of a 39-year-old male with C2 SCI from a fall 4 years prior shows an intrathecal baclofen pump in the right lower abdominal quadrant (black arrow). The tubing from the pump extends posteriorly (white arrow) before entering the thecal canal. b Axial CT image of the same patient confirms the intrathecal position of the catheter tip (black arrow)

Fig. 26

Hardware complication: a 24-year-old male presents with back pain 24 months after posterior segmental instrumentation and fusion of L3 to L5 for SCI because of a crush injury. a Antero-posterior radiograph shows disruption and distraction of the left fusion rod (white arrowhead). Failure of the right fusion rod is less conspicuous (white arrow). b The lateral radiograph demonstrates a break in the L5 pedicle screw (black arrow). Follow-up radiographs have to be carefully scrutinised for the presence of hardware failure and comparison with priors is essential