关于脊髓损伤的最详细的sci文章

ORIGINAL ARTICLE

Clinical applicability of magnetic resonance imaging in acute spinal cord trauma

Dionei Freitas Morais ?Joa

?o Sima ?o de Melo Neto ?Lucas Crociati Meguins ?Sara Eleodoro Mussi ?

Jose

′Roberto Lopes Ferraz Filho ?Waldir Anto ?nio Tognola Received:2March 2013/Revised:25September 2013/Accepted:25September 2013óSpringer-Verlag Berlin Heidelberg 2013

Abstract

Purpose To assess the clinical application of magnetic resonance imaging (MRI)in patients with acute spinal cord trauma (SCT)according to the type,extension,and severity of injury and the clinical–radiological correlation.

Methods Diagnostic imaging [computed tomography (CT)and MRI]tests of 98patients with acute SCT were analyzed to assess their clinical diagnostic value.The fol-lowing radiological ?ndings of SCT were investigated:vertebral compression fractures,bursts and dislocations,posterior element fractures,C1and C2lesions,vertebral

listhesis,bone swelling,spinal canal compression,disk herniation,extradural hematoma,spinal cord contusions,spinal cord swelling,and posterior ligamentous complex (PLC)injuries.

Results The radiological ?ndings were better visualized using MRI,except for the posterior elements (p =0.001),which were better identi?ed with CT.A total of 271lesions were diagnosed as follows:217using MRI,154using CT,and 100(36.9%)using both MRI and CT.MRI detected 117more lesions than CT.

Conclusion MRI was signi?cantly superior to CT in the diagnosis of bone swelling,PLC injury,disk herniation,spinal canal compression,spinal cord contusion and swelling present in SCT.MRI detected a larger number of lesions than CT and is highly useful for the diagnosis of soft tissue and intrathecal injuries.

Keywords Spine trauma áMagnetic resonance imaging áComputed tomography áHealth evaluation

Introduction

Spinal cord trauma (SCT)is a pathological condition associated with spinal cord injury that results in permanent and irreversible damage to motor,sensory,and autonomic functions [1,2].

The accurate diagnosis of traumatic spine injuries is crucial to therapeutic success.Details omitted in the ?rst assessment can lead to diagnostic errors with serious con-sequences for patients [3].Reports of traumatic injuries that are undiagnosed in the ?rst assessment most frequently involve the cervical spine (5–25%of cases)[4],whereas the thoracic and lumbar spine are involved in only 5%of such undiagnosed cases.Diagnostic ?aws occur at all

D.F.Morais

Department of Health Sciences,Medical School of Sa

?o Jose ′do Rio Preto (FAMERP),Sa

?o Jose ′do Rio Preto,SP,Brazil D.F.Morais (&)

The Neurosurgery Service of the Base Hospital,Street Jose

′Munia,4850,Jardim do Sul,Sa

?o Jose ′do Rio Preto,SP 15090-500,Brazil

e-mail:dionei.fm@https://www.wendangku.net/doc/b216004227.html,.br;dionei@https://www.wendangku.net/doc/b216004227.html,.br J.S.de Melo Neto

Health and Aging,Medical School of Mar?

′lia (FAMEMA),Mar?

′lia,SP,Brazil L.C.Meguins

Base Hospital,FAMERP,Sa

?o Jose ′do Rio Preto,SP,Brazil S.E.Mussi

Medical School of Catanduva (FAMECA),Catanduva,SP,Brazil

J.R.L.F.Filho

Department of Radiology,FAMERP,Sa

?o Jose ′do Rio Preto,SP,Brazil

W.A.Tognola

Department of Neurological Science,FAMERP,Sa

?o Jose ′do Rio Preto,SP,Brazil

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DOI 10.1007/s00586-013-3047-3

levels and stages of patient care,including at tertiary referral centers[3].

Neuroimaging plays a crucial role in the diagnosis and treatment of patients with SCT.Understanding the phys-iopathological mechanisms and the manner in which they are manifested via imaging are important to therapeutic decision-making[5,6].Various diagnostic imaging modalities complement the initial assessment of patients. Simple radiography(X-rays),computed tomography(CT), and magnetic resonance imaging(MRI)are among the most widely used imaging techniques in this regard[7–9].

MRI is the best method for assessing spinal canal con-tent and enables the determination of the severity and extent of spinal cord,vascular,and disk injuries,as well as epidural hematomas.Thus,MRI imaging may provide crucial information related to SCT[8,10].In addition, coronal and sagittal images allow for better identi?cation of soft tissue and ligament injuries compared to CT.MRI is recommended in cases of incomplete neurological injuries, a lack of correlation between the levels of bone injury and neurological impairment,persistent pain with no radio-graphic?ndings,the presence of disks before reduction of dislocation,spinal cord injuries without radiologic abnor-malities(SCIWORA),differentiation of pathological frac-tures,neoplasm in?ltration,infection,and in the prognostic assessment of spinal cord injury[8].

Given its multiplanar capacity,lack of ionizing radia-tion,the low cost of equipment and exams,rapid image acquisition,ability to assess soft tissues and ligaments,and importance in the diagnosis of bone lesions,the clinical use of MRI in patients with acute SCT should improve the diagnostic precision,particularly with regard to the extension,localization,and severity of lesions diagnosed (or not)by CT.

The aim of the present study is to assess the clinical use of MRI in patients with acute SCT according to the type, extension,and severity of injury and the clinical–radio-logical correlation.

Methods

Prospective,descriptive,and cross-sectional studies were conducted at the Base Hospital of Sa?o Jose′do Rio Preto, which is a tertiary referral hospital for the Northwestern area of the state of Sa?o Paulo,from January2008to June 2012.

A total of321patients with acute SCT were investi-gated.Of the total sample,98(30.5%)patients were subjected to clinical assessments and management according to the guidelines in Advanced Trauma Life Support(ATLSò)[2],followed by neurological assess-ments and initial CT imaging that suggested SCT.

The inclusion criteria for the initial clinical and radio-logical assessment were an antecedent of signi?cant trauma,a reduced level of consciousness(due to brain trauma or drugs/alcohol),multiple injuries,chest trauma, mild trauma in older adults,backache(neck or dorsal pain, crepitus,muscle contracture),spinal cord complaints (numbness,formication,limb motor or sensitive de?cit), complaints of instability(aggravated by mechanical stress in the upright position),autonomic dysfunction(bowel or bladder incontinence,priapism),and the results of neuro-logical examinations(altered sensitive,motor,or re?ex activity).

Patients who exhibited normal amplitudes of motion, normal levels of consciousness,a lack of pain,intoxication with alcohol or drugs,or no neurological de?cits were excluded from the study.

The following conditions were considered to be indi-cations for performing spinal CT and MRI:any suspicious image on the X-rays,inappropriate radiographic exams, backaches,and persistent sensory,motor,and autonomic de?cits.MRI was not performed in patients who were gunshot victims;needed immediate neurosurgery;exhib-ited cardiovascular,respiratory,and neurological instabil-ities;or used devices such as pacemakers,intraocular prostheses,and/or surgical clamps.

The CT and MRI reports were written by radiologists and revised by neuroradiologists from the Radiology Ser-vice of Base Hospital of Sa?o Jose′do Rio Preto,SP.

Spinal CT exams were performed using a Philips To-moscan SR4000(Philips Medical Systems,Best,Nether-lands)with the patients in dorsal decubitus on a table.The protocol included multidetector-row helical CT of the affected segments in2-mm sections and reconstruction in the axial,coronal,and sagittal planes.

MRI was performed using a1.5Tesla Philips Gyroscan Intera T15(Philips Medical Systems,Best,Netherlands) with the patients in dorsal decubitus on a table.The pro-tocol included image acquisitions in the following sequences:axial T2and multiplanar gradient recalled (MPGR)T2*;sagittal T1,T2,T2selective partial inversion recovery(SPIR)/FAT;and coronal proton density(PD).

Patients who were agitated or in a coma were sedated (midazolam or propofol)or subjected to anesthetic induc-tion(nitrous oxide,oxygen,sevo?urane,or iso?urane)for the purpose of image acquisition.

To determine the clinical relevance of diagnostic imaging exams(CT and MRI)in the diagnosis of patients with acute SCT,the following variables were considered: age,gender,etiology,level of neurological impairment as assessed using the American Spinal Injury Association (ASIA)scale[1],and type of diagnostic imaging(CT and MRI).The following SCT radiological?ndings were investigated:vertebral compression fractures,bursts and

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dislocations,C1and C2lesions,posterior element fractures (pedicle,articular facets,lamina,spinous and transverse processes and lateral mass,arch,and joint capsules),ver-tebral listhesis,bone swelling,spinal canal compressions,disk herniations,extradural hematomas,spinal cord con-tusions,spinal cord swelling,and posterior ligamentous complex (PLC,comprising the supraspinous and interspi-nous ligaments,ligamentum ?avum,and facet joint cap-sules)injuries.

The data were analyzed by descriptive and inferential statistics.The results were expressed as the means and standard deviations and as the absolute and relative fre-quencies.The lesions detected via CT and MRI were compared using McNemar’s test.Analyses of the severity of the radiological ?ndings,assessed using the ASIA scale,were performed using Pearson’s Chi-square dependency analysis [11].The Mann–Whitney test was used to analyze the average time before CT and MRI were performed.The numbers of lesions identi?ed by each method were com-pared using Fisher’s exact test.The level of signi?cance was established as p B 0.05.The data were analyzed using Minitab Statistical Software 14.13(Minitab Inc.,State College,Pennsylvania,USA)[12].

The study was approved by the Research Ethics Com-mittee of the Faculty of Medicine of Rio Preto (FAMERP),protocol 4823/2009.

Results

Of the 98total patients with acute SCT,78(79.6%)were male,20(20.4%)were female,and the average age was 41.16±18.13years.Gender vs.age analysis showed that most SCT victims were male and aged 21–30years (Table 1).

The main etiologic agents of acute SCT were motor vehicle accidents (41.8%),falls (28.6%),motorcycle accidents (19.4%),sports (6.1%),and others (4.1%).The

most frequent neurological impairment level on admission was ASIA-E;the results are depicted in Fig.1.

The investigated lesions and the frequencies of identi-?cation by CT and MRI are described in Table 2.According to McNemar’s test,radiological ?ndings were better visualized using MRI,except for the posterior ele-ments,which were better identi?ed using CT (p =0.001).A total of 271lesions were diagnosed:117were iden-ti?ed only by MRI,54only by CT,and 100(36.9%)by

Table 1Distribution of patients with spinal cord trauma according to age and gender Age (years)Male Female Total 0–207(9)2(10)9(9.2)21–3020(25.6)4(20)24(24.5)31–4015(19.2)5(25)20(20.4)41–5017(21.8)2(10)19(19.4)51–609(11.5)1(5)10(10.2)1–706(7.8)3(15)9(9.2)C 714(5.1)3(15)7(7.1)Total

78(100)

20(100)

98(100)

The numbers in parentheses represent

percentages

Fig.1Distribution of neurological impairment levels determined at admission using the ASIA scale

Table 2Frequencies and percentages of patients whose lesions were diagnosed by each test (CT or MRI)independently and conjointly,as well as p values determined using McNemar’s test Lesion

CT,

N =148(100%)MRI,N =218(100%)CT and MRI,N =98(100%)p

Compressive fract.21(14.2)26(11.9)17(17.3)0.27Burst fract.29(19.6)25(11.5)23(23.5)0.29Fract.

dislocation 17(11.5)22(10.1)12(12.2)0.30C1 5.0(3.4) 1.0(0.5) 1.0(1.0)0.13C2 5.0(3.4)7.0(3.2) 4.0(4.1)0.62PLC 2.0(1.35)16(7.3) 1.0(1.0)0.001*SC

compression 14(9.5)28(12.8)12(12.2)0.002*SC contusion 1.0(0.7)22(10.1) 1.0(1.0)0.001*SC swelling 0.0(0) 6.0(2.7)0.0(0.0)0.001*Bone swelling 2.0(1.35)19(8.7) 1.0(1.0)0.001*PE 36(24.3)15(6.9)12(12.2)0.001*EH 0.0(0) 3.0(1.4)0.0(0.0)0.25DH 1.0(0.7)8.0(3.7) 1.0(1.0)0.023*Listhesis

15(10.1)

20(9.2)

13(13.3)

0.18

NC McNemar’s test,Fract.fracture,PLC posterior ligamentous complex,SC spinal cord,EH extradural hematoma,DH disk hernia-tion,PE posterior elements *Signi?cant difference

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both methods simultaneously.According to Fisher’s exact test,MRI was signi?cantly more sensitive in detecting lesions than CT (p \0.05).

The severity of the lesions was assessed using the ASIA scale subdivided into three categories (A,BCD,and E).This assessment showed that fracture dislocation and spinal cord contusion were the lesions associated with the greatest neurological impairment.Spinal cord contusions exhibited statistical signi?cance (p =0.0001)only for the MRI results,whereas the fracture dislocation showed statistical signi?cance for both CT (p =0.013)and MRI (p =0.001)results.With regard to MRI,compression fractures were the lesions associated with the least neurological severity (p =0.032).The remainder of the variables did not exhibit statistical signi?cance (Fig.2).

The average times required to perform CT and MRI were 1.38±19.83and 2.00±19.58days,respectively;this difference was signi?cant (p \0.05)according to the Mann–Whitney test.

Discussion

Regarding gender,males were most frequently affected by spinal cord trauma,which is in agreement with the pub-lished literature [13–16].The predominance of young adults (21–30years)and males is related to their lack of

compliance with traf?c regulations,lack of attention while driving,and higher risks of accidents [17].It is noteworthy that individuals within that age range are economically active,exhibit social integration,and are under heavy social,economic,family,and psychological pressures [16].According to Stein et al.[18],the most frequent causes of SCT in the United States are motor vehicle accidents and falls,which is in agreement with the results of the present study.Stiell et al.[19]reported the same ?ndings in Can-ada,indicating that those factors are causes of concern in several countries.However,other authors have found that falls are the most frequent cause of SCT [20,21].These divergences in the literature have resulted in housing and cultural changes [22].

The most frequent levels of neurological impairment found on admission were ASIA-E (51%)and A (20%),namely,the ones with the best and worst prognoses,respectively.Wilson et al.[23]and Cheran et al.[24]concluded that MRI shows the site,correlates with ASIA scores,and contributes to determining the type of moni-toring and management required by patients.Thus,the relationship between these parameters is crucial at the initial assessment,which aims to improve the prognoses of patients.

Blackmore et al.[25]insist that CT must be used in the initial assessments of high-risk patients to prevent com-plications and reduce costs because the low sensitivity

of

Fig.2Lesions exhibiting statistical correlations between the lesion severity and ASIA scale levels (A,BCD,and E)according to the Chi-square test (p B 0.05);factors 1and 2indicate whether there is a correlation between the

variables (Y yes,N no).Fracture dislocations (DISL.)diagnosed by both CT (a )(p =0.013)and MRI (b )(p =0.001)exhibited greater severity (A)when a lesion was found (DISL.Y).When diagnosed by MRI (c )(p =0.032),vertebral

compression fractures (ACHT)exhibited less lesion severities (E)when lesions were present (ACHT.Y).When diagnosed by MRI (d ),spinal cord contusions (CNT.)exhibited greater lesion severities (A,BCD)when lesions were present (CNT.Y)(p =0.0001)

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X-rays increases secondary expenses related to the treat-ment of motor and sensorial alterations,including longer hospitalization,low productivity,medical malpractice lawsuits,and rehabilitation.However,compared to X-rays, CT increases radiation by50%and may,therefore, increase the potential risk of cancer,a particularly impor-tant consideration for children younger than5years and who have a long life expectancy[4].Moreover,radio-graphic exams exhibit low quality and are performed in an incomplete and inappropriate manner,making their inter-pretation dif?cult;thus,even in specialized centers,some lesions may not be detected during the?rst assessment.

Technological advances in imaging methods such as CT and MRI have enabled better visualization of lesions and more precise diagnoses and have increased our under-standing of the mechanisms underlying injuries.Multide-tector CT,which was used in the present study,exhibits high resolution,allows for reconstruction in several planes, assesses bone injury and spinal deformities precisely and in great detail,and can detect fractures with or without dis-location[26].

MRI provides greater detail relative to soft tissues,such as those present in spinal cords,extradural hematomas, disk herniations,muscles,spinal canal compressions,and ligament injuries[26].The latter include the interspinous and posterior longitudinal ligaments,which are particularly affected in motor vehicle accidents,especially in cases of cervical whiplash syndrome[27].In the present study, diagnostic differences were evident with regard to the frequency of lesions.

According to Munera et al.[28],MRI provides impor-tant information for the prognosis and treatment of patients, particularly in cases involving incomplete or progressive neurological de?cits and intense pain(as the odds that such patients will exhibit soft tissue injuries that are undetect-able by CT are high).The present study con?rms that MRI detects soft tissue injuries,as described above,with high precision,indicating that its use in the acute stage could improve the prognosis of patients by allowing them to receive the recommended interventions in a timely manner (earlier).

The literature[3,29]suggests there are?aws in the diagnosis of bone lesions by MRI.However,the present study demonstrates that,except for the posterior elements, no signi?cant differences were found between diagnoses of vertebral compression fractures,dislocations,bursts and C2 lesions assessed by CT and MRI.

In C1,lesions were detected in5(3.4%)patients via CT and in only one patient(0.5%)via MRI.However,as reported in the literature[30],it is not possible to make de?nitive conclusions based on the signi?cance of this difference(p=0.13)and due to the low frequency of C1 lesions.

Regarding lesion severity,MRI was better at detecting spinal cord contusions,a type of injury that correlated with the worst neurological impairment based on the ASIA scale.In addition,vertebral compression fractures,a type of injury that correlated with less neurological impairment, were better identi?ed by MRI.Thus,MRI exhibited improved clinical–radiological correlation in patients with SCT[31].

In general,the MRI was more sensitive in detecting lesions than CT.According to Chandra et al.[32]during the initial evaluation after the SCT,the majority of patients requires the use of both MRI and CT.However,the use of CT should be reduced,due to the high dose of radiation, besides the quality of the detection of lesion extent by MRI in relatively young population,as demonstrated in this study.

MRI is useful for the diagnosis of hematoma,hemor-rhagic and non-hemorrhagic contusion,edema,degree of spinal cord compression,ischemia and spinal cord tran-section,in acute traumatic SCI.Furthermore,MRI detects associated disk’s lesions,ligaments,bruises and vertebral fractures.It is the best known method to establish good clinical–radiological correlation,is fundamental for plan-ning the approach and improves the clinical outcome of patients with SCT[32],as shown in Fig.3.

There were signi?cant differences in the average times required to perform the imaging tests following admission, with MRI being performed2days later on average.These ?ndings are explained by the use of the Guidelines for Management of Acute Cervical Spinal Injuries[33]and Hadley and Walters[34],which aims to obtain normal results,investigate non-stabilized syndromes,and con?rm more complex soft tissue lesions by recommending that MRI be performed48h after admission.

Conclusion

In the present study,acute SCT occurred more frequently in males and young adults,was mainly caused by motor vehicle accidents,and was associated with a higher frequency of ASIA-E neurological impairment levels.MRI was signi?-cantly superior to CT in the diagnosis of bone swelling, posterior ligamentous complex injuries,disk herniations, spinal canal compressions,and spinal cord contusions and swelling.Except for the posterior elements,there were no signi?cant differences between the two methods in diag-nosing vertebral compression fractures,bursts and disloca-tions,and C1and C2lesions.MRI identi?ed a larger number of lesions than CT and is quite useful for the diagnosis of soft tissue and intrathecal injuries.Detection of spinal cord contusions by MRI correlated with greater SCT severity, whereas vertebral compression fractures correlated with less

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neurological impairment (as assessed by the ASIA scale).Thus,MRI exhibited a superior clinical–radiological cor-relation in patients with acute SCT (Fig.4).

Con?ict of interest

None.

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