SCI Etiology Introduction Prof. Pia C Sundgren MD, … › files › 61879-Spinal cord trauma...Spinal cord trauma Prof. Pia C Sundgren MD, PhD Head of the Department of Diagnostic

2019-10-12

1

Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019

Spinal cord trauma

Prof. Pia C Sundgren MD, PhD

Head of the Department of Diagnostic Radiology, Clinical Sciences

Co-Director for Lund University BioImaging Center (LBIC)

Lund University, Lund, Sweden


injury to the spinal column and spinal cord is a

major cause of disability affecting predominately

young healthy individuals

costs of life time care and rehabilitation are

extremely high, often over $1,000,000 per

individual

Introduction


SCI Etiology

MVA

35%

Others

7%

Sports

8%

Falls

20%

Violence

30%

despite increased public awareness and safety programs – a problem

incidence: 11,000 per year

prevalence: 200,000 - 250,000

mean age: 31.2 years.

– 56% occur in 16 - 30 yrs.

– second peak in 60-70 range

82% males

peaks in summer and weekends

Spinal trauma and spinal cord injury


Spinal cord injury incidence (per year) 2,3–

83/100,000

Spinal cord injury prevalence (per year) 236–1800/

1000,000

M/F ratio (spinal cord injury) 4:1

Age group (spinal cord injury) 26–55

Based on WHO and Spinal Injury Association

annual reports

Epidemiologic data spinal cord trauma in Europe

Boban J et al Clinical Neuroradiology 2019 (e-book)


type of trauma

unstable factures

fracture fragments into the spinal canal

ligamentous injury

penetrating injuries

Increase the risk for spinal cord injury


AC PCMC

AC

PC

MC

Modified from M. Philips, MD, Vienna,Austria

The anterior, middle and posterior columns

AC: anterior vertebral body, anterior annulus fibrosus, ant. long.lig

MC: posterior vertebral body, post long. lig, post annulus fibrosus

PC: posterior bony elements, lig flava, posterior ligaments

2019-10-12

2


TLICS - Thoracolumbar Injury Classification and Severity Score

A practical scheme based on three injury characteristics

1 morphology of injury determined by radiographic appearance

2 integrity of the posterior ligamentous complex

3 neurologic status of the patient

SLIC - Sub-axial Injury Classification and Severity Scale

Scoring system for cervical injuries and surgical intervention

1. injury morphology

2. disco-ligamentous complex

3. neurologic status of the patient

Vaccaro AR et al A new classification of thoracolumbar injuries.. Spine 2005;15;30:2325-33

Vaccaro AR et al. The subaxial cervical spine injury…. Spine 2007 ;32(21):2365-74

Classification and Severity Score


Conventional MR parameters - protocol

• sagittal T2 STIR, T2-w, T1-w

• axial T1SE, T2 fast SE,

• axial fat sat T2-w (soft tissue injury)

• axial and sagittal T2* GRE (hemorrhage)

• 3D – 3D TSE T2w SPACE (Siemens)

3D TSE T2w DRIVE (GE)

3D TSE T2w VISTA (Philips)


American spine injury association (ASIA) classification

Grade A complete lack of motor and sensory function below the level of

injury (including the anal area)

Grade B some sensation below the level of the injury (including anal

sensation)

Grade C some muscle movement is spared below the level of injury, but 50

% of the muscles below the level of injury cannot move against gravity

Grade D most (> 50 %) of the muscles that are spared below the level of

injury are strong enough to move against gravity

Grade E all neurologic function has returned

• to define and describe the extent patient’s spinal cord injury

• completed within 72 hours after the initial injury.

• grade is based on how much sensation patient can feel at multiple points

on the body and tests of motor function

help determine future rehabilitation and recovery needs


• the length of the lesion is directly proportional to

the neurologic deficit

• the location of the lesion, specifically the upper

boundary of hemorrhage or lesion epicenter

correlates with the neurologic level of injury

• frank hemorrhage within the spinal cord is

predictive of a severe neurologic injury and a poor

prognosis for regaining any useful motor or sensory

function

Correlates of spinal cord injury on MRI and

the neurologic deficit


Lesion DTI DTI metrics

Mapping human spinal cord injury with diffusion tensor

imaging

AnatomyLund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019

Mohamed FB et al Diffusion Tensor Imaging of …… AJNR 2011:32:339-45

Diffusion tensor imaging of spinal cord injury

2019-10-12

3


0 2 4 6 8 10 12 14 16 18 20 22 24

0.00

0.06

0.12

0.18

0.24

0.30

0.36

0.42

0.48

0.54

0.60

0.66

0.72

SCI1

SCI2

SCI3

SCI4

SCI5

AVG 5 CONTROLS

Fra

ctio

na

l A

nis

otr

op

y

SLICE

average FA values for controls compared with FA values for

each individual subject with SCI as a function of slice number



0 2 4 6 8 10 12 14 16 18 20 22 24

0.0000

0.0003

0.0006

0.0009

0.0012

0.0015

0.0018

0.0021

0.0024

0.0027 SCI1

SCI2

SCI3

SCI4

SCI5

AVG 5 CONTROLS

Ra

dia

l D

iffu

siv

ity (

mm

2/s

ec)

SLICE

average radial D values for controls compared with radial D

values for each individual subject with SCI as a function of

slice number



C6

C7

C4

C6

21 year old male in MVA, complaining of neck pain

and stiffness


22 year old male in diving accident complaining of neck

pain and stiffness, paraplegia of the legs


16 yrs. old male injury diving feet first into

a pool. Patient recalls feeling a "break" in

his neck upon entering the poolCourtesy A Flanders, MD


I Acute spinal cord injury

II Subacute spinal cord injury

III Chronic spinal cord injury

Spinal cord injury

2019-10-12

4


Acute spinal cord injury

• spinal cord edema / swelling

• spinal contusion: non-hemorrhagic

• spinal cord contusion: hemorrhagic

• spinal cord transection

• low velocity / compressive SCI


damage of the blood vesselsdisrupted axons

traction and compression forces

microhemorrhages – within minutes

swelling of the cord

secondary ischemia

secondary injury cascade

Primary injury

Modified from M Thurnher, MD


damaged cells / axons / blood vessels

toxic chemicals

attack neighboring cells

normal axons swollen axons

wave of suicide APOPTOSIS

Secondary injury

Modified from M Thurnher, MD Vienna, Austria


focal accumulation of intracellular

and interstitial fluid

• good prognosis

• max after 72 hours

Histo-pathologically all cases have

punctate hemorrhage !

= spinal cord edema

Non-hemorrhagic contusion


11/7/03 12:30pm 1:40pm

C4

15 lbs 25 lbs

2:10pm

C4

12/7/03 post-op


Unilateral facet dislocation C4-5 with non-hemorrhagic SCICourtesy A Flanders, MD

2019-10-12

5


Hemorrhagic contusion

focus of hemorrhage within spinal cord

• true hematomyelia is rare (<1%)

• bad prognosis

• irreversible changes

• iron diffusion into cord parenchyma

cascade of neuronal destruction


28 year old male that jumped from 4th

floor in suicide attempt, complains of

pain and is paraplegic


T1-w T2-w STIR

T1-w

FU 1 year later


Spinal cord transection

Tear of the SC due to significant traumatic injury

involve motor and sensory neurology corresponding

to the level of cord injury:

- lower motor neuron paralysis at the level of injury

- upper motor neuron (or spastic) paralysis below

the level of injury

complete or partial (hemi-transection)

severity depends on location


56 years old male fall 3 meters from roof

presents with mild tingling in his in dig 1 and 2 of both hands


T1-w T2-w STIR PD

2019-10-12

6


Th1 Th1


Central cord syndrome elderly;

flexion/extension injury

of the degenerative

spine

motor weakness of the

upper (more than lower)

extremities with sacral

root sparing

Brown-Séquard

syndrome

cord hemisection

(gunshot or stab)

ipsilateral loss of motor

function and

proprioception

Contralateral loss of

pain and temperature

sense

Anterior cord syndrome Direct or ischemic injury

to ventral 2/3

lLoss of motor function,

pain, and temperature

sensation;

proprioception and light

touch preserved

Spinal cord syndromes



Conus medullaris

syndrome

Injury to sacral cord

(e.g., L1 fracture)

bowel, bladder, and

sexual dysfunction

with normal motor

function

Cauda equina

syndrome

Injury to lumbar and

sacral roots (below

L2 level)

flaccid paralysis of

the legs, without

bowel/bladder

dysfunction

Spinal cord syndromes



Acute Traumatic Central Cord Syndrome (ATCCS)

Acute compressive cord injury (ACI)

greater loss of motor function in upper than lower

extremities

sensory loss below the level of injury


narrowed spinal canal

hypertrophy of ligamentum flavum

low velocity hyperextension trauma

high signal on T2WI + swollen cord

Acute Traumatic Central Cord Syndrome

non-hemorrhagic injury

compressive demyelination of the

LATERAL COLUMNS


Hyperextension

mechanism at C5-6 with

superimposed

spondylosis/stenosis and

spinal cord injury

2019-10-12

7


Body surfer – with CCN symptoms lasting for days

Courtesy A Flanders, MD


T1-w T2-w FLAIR

Violent injuries - penetrating injuries

Gunshot, knifes, tools,….

Follow-up

Gang member in fight with a kife


gunshot

resulting in a complete

cord transection


In Amsterdam the gang members are

using a stingray tail…

Courtesy dr E Veldhuizen


Courtesy of Dr. J. van Goethem

Carpenter was playing with his pneumatic nail tool


Brown-Séquard syndrome

is caused by damage to one half of the spinal cord

paralysis and loss of proprioception on the ipsilateral

(same side) as the injury or lesion

loss of pain and temperature sensation on the

contralateral side as the lesion

seen in association with penetrating injuries, gunshot,

knives etc

2019-10-12

8


Atlanto-Occipital Dislocation (AOD)

uncommon injury characterized by complete disruption of all ligamentous relationships between occiput and atlas

death usually occurs from stretching of the brainstem

reported to occur in 31% of fatal MVAs

more common in children due to larger cranial ratio

up to 50% of AOD’s are overlooked initially

increasing number of survivors of this injury


Courtesy A Flanders, MD

Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019 Lund University / Faculty of Medicine / Department of Clinical Sciences/ Radiology / ECNR/2019

Case K – Set 3


Spinal cord injury without radiographic abnormality

- SCIWORA -

specific to children and extremely rare in adults

incidence: 19-34% of all spinal cord injuries in children

more common in younger children < 8 years of age

can have delayed onset of clinical symptoms and

signs up to 4 days after initial injury

recurrent SCIWORA several days to weeks after

initial event (17%)


• immature and elastic pediatric spine

• vulnerable to external forces

• allows for significant inter-segmental movement

• transient disc protrusion

compression and stretching of the spinal cord

cord injury

Spinal cord injury without radiographic abnormality

- SCIWORA -

2019-10-12

9


The elasticity of neonatal bony spine is eight

times that of the cord

Biomechanics in children

5

cm

6/7

mm

Leventhal H. J. Pediatr 56:447 1969


3 year old in MVA

SCIWORA


T2-wSTIRT1-w


Clinical and neurological deterioration after SCI

Acute neurological deterioration

• 5-10% of SCI

• occurs within the first several hours or days after SCI

• 1-2 vertebral levels

• usually temporary

- increased length of T2/FLAIR signal in the spinal

cord – spinal cord edema

MRI should be performed at least 72 hours after

injury for prognosis



subacute progressive ascending myelopathy – SPAM

deterioration ascending ⩾4 vertebral levels above the initial injured site

• occur within the first few weeks after SCI

• unrelated to mechanical instability or syrinx formation

• rare 0.42-1%

• most common in young and middle aged males

• mortality rate 10%

• risk factors: complete injury, low blood pressure, early post-op mobilization, nonsurgical treatment


Subacute progressive ascending myelopathy

SPAMC5 level ascending to C3 – day 10

C6 C6 C6

30 days post MPSCourtesy A Flanders, MD

2019-10-12

10


Late deterioration

post-traumatic progressive myelopathy – PTPM

present as deterioration in neurological status after a period of neurological stability

> 2 months

morphologic changes associated with PTPM:

• syringomyelia

• myelomalacia

• cord tethering

• atrophy



post traumatic syrinx myelomalacia and atrophy


Spinal nerve root injuries

caused by traction

• damage to the spinal grey matter columns

• complete root avulsion

• often associated with brachial plexus injury

exclude prior to exploration of the plexus



damage to the spinal grey

matter columsT2-w

Coronal STIR


T2 - medicT2-flash 6 mm > > > > > >

damage to the spinal grey matter colums

2019-10-12

11


32328313

CT-myelogram complete nerve root avulsion


32328313

C4 C5

C6 C7


transverse lig.

Ligamentous injury


unstable fracture with ligamentous injury


Unstable

2019-10-12

12


Treatment and prognosis

• surgical decompressionearly (< 24 hrs), late (> 24 hrs)

acute traumatic cord syndrome

adult acute SCI patients regardless of level of injury

• use of Methylprednisolone Sodium Succinate (MPSS)

24-hour infusion of high-dose MPSS be offered to

adult patients within 8 hours of acute SCI as a

treatment option

• anticoagulant thromboprophylaxis

be offered routinely to reduce the risk of

thromboembolic events in the acute period after SCI


Treatment and prognosis

• MR imaging

perform in adult and paediatric patients with

acute SCI prior to surgical intervention to

facilitate improved clinical decision-making

perform in adult and paediatric patients in

the acute period after SCI, to improve

prediction of neurologic outcome

Michael G. Fehlings et al. Global Spine Journal 2017, Vol. 7(3S) 84S-94S


Take home messages

MRI is a most for evaluation of the spinal cord

evaluate for spinal cord edema vs hemorrhagic

contusions – for final outcome and prognosis

possibility of

• multiple levels of injury

• combined injuries (facets, disc herniation's,

vascular…)

active search for signs of ligamentous injury

and instability


Thank you

Documents

SCI Etiology Introduction Prof. Pia C Sundgren MD, … › files › 61879-Spinal cord trauma...Spinal cord trauma Prof. Pia C Sundgren MD, PhD Head of the Department of Diagnostic