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Imaging of acute spinal trauma: An evolving multi-modality approach
CLINICAL
IMAGING
1990:14:11-16
11
IMAGING OF ACUTE SPINAL TRAUMA: AN EVOLVING MULTI-MODALITY APPROACH ANDREW L. GOLDBERG, MD, RICHARD H. DAFFNER, AND ROLF L. SCHAPIRO, MD
Morbidity from acute spinal trauma is a major problem in every metropolitan community. High-velocity injuries from motor vehicle accidents account for the majority of injuries; patients are also commonly involved in falls and other accidents. The concept of concentrating sophisticated resources for trauma management in designated trauma centers has been increasingly accepted. Nevertheless, the accurate diagnosis of acute spinal injury remains of fundamental importance in smaller hospitals, and even in the ambulatory care setting. Allegheny General Hospital is a Level I Trauma Center serving a tristate region of western Pennsylvania, eastern Ohio, and northern West Virginia. We have been fortunate that, in addition to conventional radiography and computerized tomography (CT], magnetic resonance imaging (MRI) has been in operation since late 1983, and has been used extensively in the evaluation of acute spinal trauma. This article will present an approach to imaging acute spinal injuries with an emphasis on the evolving role of MRI.
PLAIN RADIOGRAPHY
Whereas the practice of plain radiography has reached a mature stage of development, reemphasis of certain technical and interpretive points is appropriate. Injury to the lower cervical spine is the most
From the Department of Diagnostic Radiology, Allegheny General Hospital and The Medical College of Pennsylvania, Allegheny Campus, Pittsburgh, Pennsylvania. Send reprint requests to: Andrew L. Goldberg, MD, Department of Diagnostic Radiology, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-9986. Received May 30, 1989. 0 1990 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899/7071/90/$3.50
New York, NY 10010
MD,
common cause of neurologic deficit. The lateral radiograph of the cervical spine is therefore the most crucial single projection. While two-thirds of significant pathology can be detected on this view, a complete series should also include frontal projections of both the lower cervical spine and of the atlas-axis, as well as “trauma” oblique projections obtained with the patient supine and with 30” of tube angulation (1). With availability of cross-sectional imaging, any views that require manipulation of the neck can no longer be justified. When dealing with the severely traumatized patient, cognizance of the incidence of multiple noncontiguous spinal injuries is important (2). Such injuries may be revealed by frontal and lateral projections of the thoracic and lumbar spine, in addition to the standard cervical views. For this reason, these views are routinely included on all trauma patients at our medical center. A detailed analysis of the principles underlying interpretation of plain spinal radiographs is not the primary focus of this article. However, in this age of sophisticated computer-assisted imaging, plain radiographs remain the single most important screening examination. They complement the physical examination and serve as a road map to direct the application of subsequent CT or MRI investigations. Furthermore, it is worth noting that certain injuries may escape detection by more sophisticated modalities. For example, careful scrutiny of the lateral radiograph was imperative to recognize this atlantooccipital distraction injury in the 6-year-old child shown in Figure 1. The reader is referred to recent efforts to refine an approach to vertebral trauma based on mechanisms of injury (3). COMPUTERIZED
TOMOGRAPHY
In the past decade, CT has assumed an important adjunctive role in the evaluation of vertebral trauma.
12
CLINICAL
GOLDBERG ET AL.
CONVENTIONAL
IMAGlNG
VOL. 14. NO. 1
TOMOGRAPHY
This technique has been relegated to a subsidiary role as CT has equal or superior efficacy with lesser radiation dose. Exceptions may include fractures parallel to the axial plane, particularly involving the odontoid process and adjacent craniocervical structures; congenital anomalies can also be clarified. In most cases, however, careful scrutiny of the CT examination reveals at least a portion of the fracture. Moreover, the sagittal imaging capability of MRI, when available, further reduces the need for linear or complex motion tomography.
MAGNETIC RESONANCE IMAGING
FIGURE 1. Case 1. This 6-year-old boy was hypotensive in the emergency room following a motor vehicle accident. Lateral radiograph demonstrates a prevertebral hematoma and a subtle but definite atlanto-occipital distraction injury. The patient survived, and underwent cervico-occipital fusion.
Initial plain radiographic inspection may miss as many as 25% of fractures, which are subsequently diagnosed by other means. CT can be particularly useful in clarifying nondisplaced fractures which may be confused with linear artifacts seen on plain radiographs (4-6). Attention to technical aspects, including the use of thin sections and a high-resolution algorithm for bone detail, is also important. In the thoracolumbar spine, CT has been used to develop an approach to assess potential instability based on the integrity of a three-column structure (7). Complex fracture patterns can be more readily elucidated than on plain films (8) as illustrated by Figure 2. Furthermore, although sometimes compromised by artifact, sagittal reconstructions can be helpful in evaluating the retropulsed fragment (9).
Introduced to clinical practice earlier in this decade, MRI has had a profound impact on spinal imaging. The technique has been more easily applied to ambulatory patients than to acute injury victims, and due to siting considerations, remains inaccessible for this purpose even among some large institutions. In those hospitals where scanning within the first 36 hours after admission has been feasible, MRI has become an increasingly vital tool, particularly as a window on the injured spinal cord (9, 10). The technical aspects merit particular emphasis, as adequate images must be obtained without jeopardizing the spinal cord. When necessary, manual in-line traction can be maintained; scanning is also possible if an MRI-compatible halo-vest has been applied (11). Our initial experience with a prototype 0.5T imager was successful in many cases; image quality has been further improved by a 1.5T unit. Surface coils were used whenever possible to maximize spatial resolution. A Tl-weighted sagittal spin echo sequence is obtained in all cases, usually in conjunction with a transaxial sequence using the same parameters. T2weighted sequences provide a myelographic effect and are more sensitive to intrinsic cord hemorrhage and/or edema, but are more easily degraded by motion artifact. Information of equivalent clinical value can probably be obtained by a low flip angle gradient echo sequence, particularly for the detection of hemorrhage (12). Visualization of the injured spinal cord by MRI is superior to all other methods. The full spectrum of cord trauma, from contusion to complete transection, can be depicted. Preliminary results from imaging at 1.5T suggest prognostic importance related to the presence of acute hemorrhage within the cord. Patients such as those in Figures 3 and 4 have generally
B FIGURE 2. Case 2. This 27-year-old man was in a motor vehicle accident and awakened the next morning with neck pain. (A) Lateral radiograph shows a traumatic spondylolisthesis of CZ-3. (B) CT reveals a comminuted fracture of C-2 with canal encroachment on the right (arrow). (C,D) The fracture lines are seen in the axial plane by MRI (SE; 550/15), although not resolved as precisely as with CT. MRI is advantageous, however, in demonstrating the vertical extent of the fracture (D, arrows), and in confirming an intact spinal cord. The patient was treated conservatively with a halo vest.
14
GOLDBERG ET AL.
CLINICAL
IMAGING
VOL. 14,
NO. 1
B FIGURE
3. Case 3. This 36-year-old man incurred both anoxic brain injury and cervical fracture from a diving accident. (A) Sagittal MRI (SE;300/17) shows a compression fracture of C-6 with slight canal encroachment. Swelling of sethe midcervical cord is noted. (B) The T2-weighted quence (SE;2.1/90) reveals cord injury disproportionate to the degree of bony deformity. Specifically, punctate hypointensity consistent with hemorrhage is seen in the central portion of the cord (arrow), surrounded by hyperintense edema.
FIGURE 4. Case 4. This 39-year-old
man presented with central cord syndrome following a diving accident. (A) There is a burst fracture of the C-5 vertebral body with associated neural arch fractures bilaterally (arrows]. (B) The transaxial gradient echo sequence (GE;200110) illustrates the sensitivity of this technique to the magnetic susceptibility effect of acute hemorrhage (see text). Focal hypointensity consistent with acute hemorrhage can be appreciated within the central gray matter on the left (arrow).
MAK(:H
IMA(:IN(;
111110
OF A(:CJTE: SI’IKAI,
TKAlJMA
15
had poor neurologic recovery compared with those whose signal intensity pattern indicates edema only
patients with hemodynamic instability who require more than electrocardiographic monitoring.
(13). MRI can also facilitate surgical management by detecting extradural compressive lesions such as epi-
MYELOGRAPHY
dural hematoma, herniated disc, or bone fragment, without resort to myelography. While CT is still superior in the definition of complex fracture patterns, with use of a surface coil on a high field strength system, MRI can rival CT, as seen in Figure 2 (14). Assessment of ligamentous disruption has proven to be another advantage of MRI. We have found this application particularly useful in diagnosing acute hyperextension injuries of the cervical spine (15). As seen in Figure 5, disruption of the anterior longitudinal ligament is noted, which was difficult to appreciate on plain films due to severe ankylosing spondylitis. MRI is somewhat limited in the evaluation of critically ill patients requiring significant life support equipment. However, mechanical ventilation is not an absolute contraindication, as bag ventilation can be performed by a respiratory therapist using a short segment of extension tubing (9). We will not scan
Before MRI, myelography (film/screen only or combined with CT) was the only means by which spinal cord compression could be excluded following trauma (16).To avoid potential cord compromise, the procedure frequently had to be performed by supine Cl-2 puncture, which added to its difficulty. The need for myelography in the setting of acute trauma has now decreased considerably. It can now be reserved for cases of neurologic injury where MRI is technically impossible or unsuccessful. It is also still the most definitive way to diagnose a dural tear as seen in Figure 6. CONCLUSION
As elaborated above, cross-sectional imaging has assumed an increasingly significant role in the evaluation of acute spinal trauma. Myelography and complex motion tomography has declined in importance, FIGURE 5. Case 5. This 85-year-old woman suffered a fall, and then complained of total body numbness. (A) Clinical findings of ankylosing spondylitis are noted on this lateral radiograph of the thoracic spine obtained following acute trauma. The thoracolumbar junction, however, was poorly ligavisualized. (B) Disruption of the anterior longitudinal ment is noted on the sagittal MR image (arrow), resulting in widening of the anterior disc space. B
16
CLINICAL IMAGING VOL. 14.NO. 1
GOLDBERG ET AL.
If canal compromise or cord injury is detected, CT can then be obtained over a more narrowly defined region of interest to better assess associated fractures. Although redundancy will occur in some cases, CT and MRI will likely prove to be complementary in the evaluation of acute spinal trauma. REFERENCES 1.
Gehweiler JA, Osborne RL, Becker RF. The Radiology of Vertebral Trauma. Philadelphia: WB Saunders, 1980.
2. Rogers LF, Thayer C, Weinberg PE, Kim KS. Acute injuries of the upper thoracic spine associated with paraplegia. AJR 1980;134:67. 3. Daffner RH, Deeb ZL, Rothfus WE. “Fingerprints” of vertebral trauma-a unifying concept based on mechanisms. Skeletal Radio1 1986;15:518. 4. Brant-Zawadski M, Miller EM, Federle MP. CT in the evaluation of spine trauma. AJR 1981;136:369. 5. Handel SF, Lee YY. Computed tomography Radio1 Clin North Am 1981;19:69.
of spinal fractures.
6. Post MJD, Green BA. The use of computed tomography spinal trauma. Radio1 Clin’North Am 1983;21:327.
in
7. McAfee, PC, Hansen AY, Frederickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. J Bone Joint Surg 1983;65-A:461. 8. Brant-Zawadski M, Jeffrey RB, Managi H, Pitts LH. High resolution CT of thoracolumbar fractures. AJNR 1982;3:69. 9. Kalfas I, Wilberger JE, Goldberg AL, Prostko ER. Magnetic resonance imaging in acute spinal cord trauma. Neurosurgery 1988;23:295.
FIGURE 6. Case 6. A shearing fracture of L-2 occurred in this young woman following a motor vehicle accident. Gross dural laceration with extravasion of contrast is noted on this frontal myelogram. A shearing fracture of L-2 is also present. The dura was surgically repaired and spinal instrumentation was applied for stability.
10. Goldberg AL, Rothfus WE, Deeb ZL, Daffner RH, Lupetin AR, Wilberger JE, Prostko ER. The impact of magnetic resonance on the diagnostic evaluation of acute cervicothoracic spinal trauma. Skeletal Radio1 1988;17:89. 11. McArdle CB, Wright JW, Prevost WJ, Dornfest DJ, Amparo EG. MR imaging of the acutely injured patient with cervical traction. Radiology 1986;159:273. 12. Kulkarni MV, McArdle CB, Kopanicky D, Miner M, Cutler HB, Lee KF, Harris JH. Acute spinal cord injury. MR imaging at 1.5T. Radiology 1987;164:837. 13. Kulkarni MV, Bondurant FJ, Rose SL, Narayana PA. 1.5 Tesla magnetic resonance imaging of acute spinal trauma. Radiographics 1988;8:1059.
but an optimal plain radiographic examination remains the fundamental screening procedure. A qualitative comparison of CT and MRI remains problematic. CT is faster, particularly as examinations of both the spine and brain can be performed concurrently. However, particularly in cases where trauma to the brain is not an issue, MRI may be the initial procedure of choice after plain films, offering the advantage of a long segment survey of the spine.
14. Goldberg AL, Larkins MV, Rothfus WE, Deeb ZL, Daffner RH, Wilberger JE. Acute thoracolumbar fractures: MR/CT correlation. Presented at the 27th Annual Meeting, American Society of Neuroradiology, Orlando, Florida, 1989. 15. Goldberg AL, Rothfus WE, Deeb ZL, Frankel D, Daffner RH, Wilberger JE. Hyperextension injuries of the cervical spine: magnetic resonance findings. Skeletal Radio1 1989; 18:283-288. 16. Cooper PR, Cohen W. Evaluation of cervical spinal cord injuries with metrizamide myelography-CT scanning. J Neurosurg 1984;61:281.
IMAGING
1990:14:11-16
11
IMAGING OF ACUTE SPINAL TRAUMA: AN EVOLVING MULTI-MODALITY APPROACH ANDREW L. GOLDBERG, MD, RICHARD H. DAFFNER, AND ROLF L. SCHAPIRO, MD
Morbidity from acute spinal trauma is a major problem in every metropolitan community. High-velocity injuries from motor vehicle accidents account for the majority of injuries; patients are also commonly involved in falls and other accidents. The concept of concentrating sophisticated resources for trauma management in designated trauma centers has been increasingly accepted. Nevertheless, the accurate diagnosis of acute spinal injury remains of fundamental importance in smaller hospitals, and even in the ambulatory care setting. Allegheny General Hospital is a Level I Trauma Center serving a tristate region of western Pennsylvania, eastern Ohio, and northern West Virginia. We have been fortunate that, in addition to conventional radiography and computerized tomography (CT], magnetic resonance imaging (MRI) has been in operation since late 1983, and has been used extensively in the evaluation of acute spinal trauma. This article will present an approach to imaging acute spinal injuries with an emphasis on the evolving role of MRI.
PLAIN RADIOGRAPHY
Whereas the practice of plain radiography has reached a mature stage of development, reemphasis of certain technical and interpretive points is appropriate. Injury to the lower cervical spine is the most
From the Department of Diagnostic Radiology, Allegheny General Hospital and The Medical College of Pennsylvania, Allegheny Campus, Pittsburgh, Pennsylvania. Send reprint requests to: Andrew L. Goldberg, MD, Department of Diagnostic Radiology, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-9986. Received May 30, 1989. 0 1990 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899/7071/90/$3.50
New York, NY 10010
MD,
common cause of neurologic deficit. The lateral radiograph of the cervical spine is therefore the most crucial single projection. While two-thirds of significant pathology can be detected on this view, a complete series should also include frontal projections of both the lower cervical spine and of the atlas-axis, as well as “trauma” oblique projections obtained with the patient supine and with 30” of tube angulation (1). With availability of cross-sectional imaging, any views that require manipulation of the neck can no longer be justified. When dealing with the severely traumatized patient, cognizance of the incidence of multiple noncontiguous spinal injuries is important (2). Such injuries may be revealed by frontal and lateral projections of the thoracic and lumbar spine, in addition to the standard cervical views. For this reason, these views are routinely included on all trauma patients at our medical center. A detailed analysis of the principles underlying interpretation of plain spinal radiographs is not the primary focus of this article. However, in this age of sophisticated computer-assisted imaging, plain radiographs remain the single most important screening examination. They complement the physical examination and serve as a road map to direct the application of subsequent CT or MRI investigations. Furthermore, it is worth noting that certain injuries may escape detection by more sophisticated modalities. For example, careful scrutiny of the lateral radiograph was imperative to recognize this atlantooccipital distraction injury in the 6-year-old child shown in Figure 1. The reader is referred to recent efforts to refine an approach to vertebral trauma based on mechanisms of injury (3). COMPUTERIZED
TOMOGRAPHY
In the past decade, CT has assumed an important adjunctive role in the evaluation of vertebral trauma.
12
CLINICAL
GOLDBERG ET AL.
CONVENTIONAL
IMAGlNG
VOL. 14. NO. 1
TOMOGRAPHY
This technique has been relegated to a subsidiary role as CT has equal or superior efficacy with lesser radiation dose. Exceptions may include fractures parallel to the axial plane, particularly involving the odontoid process and adjacent craniocervical structures; congenital anomalies can also be clarified. In most cases, however, careful scrutiny of the CT examination reveals at least a portion of the fracture. Moreover, the sagittal imaging capability of MRI, when available, further reduces the need for linear or complex motion tomography.
MAGNETIC RESONANCE IMAGING
FIGURE 1. Case 1. This 6-year-old boy was hypotensive in the emergency room following a motor vehicle accident. Lateral radiograph demonstrates a prevertebral hematoma and a subtle but definite atlanto-occipital distraction injury. The patient survived, and underwent cervico-occipital fusion.
Initial plain radiographic inspection may miss as many as 25% of fractures, which are subsequently diagnosed by other means. CT can be particularly useful in clarifying nondisplaced fractures which may be confused with linear artifacts seen on plain radiographs (4-6). Attention to technical aspects, including the use of thin sections and a high-resolution algorithm for bone detail, is also important. In the thoracolumbar spine, CT has been used to develop an approach to assess potential instability based on the integrity of a three-column structure (7). Complex fracture patterns can be more readily elucidated than on plain films (8) as illustrated by Figure 2. Furthermore, although sometimes compromised by artifact, sagittal reconstructions can be helpful in evaluating the retropulsed fragment (9).
Introduced to clinical practice earlier in this decade, MRI has had a profound impact on spinal imaging. The technique has been more easily applied to ambulatory patients than to acute injury victims, and due to siting considerations, remains inaccessible for this purpose even among some large institutions. In those hospitals where scanning within the first 36 hours after admission has been feasible, MRI has become an increasingly vital tool, particularly as a window on the injured spinal cord (9, 10). The technical aspects merit particular emphasis, as adequate images must be obtained without jeopardizing the spinal cord. When necessary, manual in-line traction can be maintained; scanning is also possible if an MRI-compatible halo-vest has been applied (11). Our initial experience with a prototype 0.5T imager was successful in many cases; image quality has been further improved by a 1.5T unit. Surface coils were used whenever possible to maximize spatial resolution. A Tl-weighted sagittal spin echo sequence is obtained in all cases, usually in conjunction with a transaxial sequence using the same parameters. T2weighted sequences provide a myelographic effect and are more sensitive to intrinsic cord hemorrhage and/or edema, but are more easily degraded by motion artifact. Information of equivalent clinical value can probably be obtained by a low flip angle gradient echo sequence, particularly for the detection of hemorrhage (12). Visualization of the injured spinal cord by MRI is superior to all other methods. The full spectrum of cord trauma, from contusion to complete transection, can be depicted. Preliminary results from imaging at 1.5T suggest prognostic importance related to the presence of acute hemorrhage within the cord. Patients such as those in Figures 3 and 4 have generally
B FIGURE 2. Case 2. This 27-year-old man was in a motor vehicle accident and awakened the next morning with neck pain. (A) Lateral radiograph shows a traumatic spondylolisthesis of CZ-3. (B) CT reveals a comminuted fracture of C-2 with canal encroachment on the right (arrow). (C,D) The fracture lines are seen in the axial plane by MRI (SE; 550/15), although not resolved as precisely as with CT. MRI is advantageous, however, in demonstrating the vertical extent of the fracture (D, arrows), and in confirming an intact spinal cord. The patient was treated conservatively with a halo vest.
14
GOLDBERG ET AL.
CLINICAL
IMAGING
VOL. 14,
NO. 1
B FIGURE
3. Case 3. This 36-year-old man incurred both anoxic brain injury and cervical fracture from a diving accident. (A) Sagittal MRI (SE;300/17) shows a compression fracture of C-6 with slight canal encroachment. Swelling of sethe midcervical cord is noted. (B) The T2-weighted quence (SE;2.1/90) reveals cord injury disproportionate to the degree of bony deformity. Specifically, punctate hypointensity consistent with hemorrhage is seen in the central portion of the cord (arrow), surrounded by hyperintense edema.
FIGURE 4. Case 4. This 39-year-old
man presented with central cord syndrome following a diving accident. (A) There is a burst fracture of the C-5 vertebral body with associated neural arch fractures bilaterally (arrows]. (B) The transaxial gradient echo sequence (GE;200110) illustrates the sensitivity of this technique to the magnetic susceptibility effect of acute hemorrhage (see text). Focal hypointensity consistent with acute hemorrhage can be appreciated within the central gray matter on the left (arrow).
MAK(:H
IMA(:IN(;
111110
OF A(:CJTE: SI’IKAI,
TKAlJMA
15
had poor neurologic recovery compared with those whose signal intensity pattern indicates edema only
patients with hemodynamic instability who require more than electrocardiographic monitoring.
(13). MRI can also facilitate surgical management by detecting extradural compressive lesions such as epi-
MYELOGRAPHY
dural hematoma, herniated disc, or bone fragment, without resort to myelography. While CT is still superior in the definition of complex fracture patterns, with use of a surface coil on a high field strength system, MRI can rival CT, as seen in Figure 2 (14). Assessment of ligamentous disruption has proven to be another advantage of MRI. We have found this application particularly useful in diagnosing acute hyperextension injuries of the cervical spine (15). As seen in Figure 5, disruption of the anterior longitudinal ligament is noted, which was difficult to appreciate on plain films due to severe ankylosing spondylitis. MRI is somewhat limited in the evaluation of critically ill patients requiring significant life support equipment. However, mechanical ventilation is not an absolute contraindication, as bag ventilation can be performed by a respiratory therapist using a short segment of extension tubing (9). We will not scan
Before MRI, myelography (film/screen only or combined with CT) was the only means by which spinal cord compression could be excluded following trauma (16).To avoid potential cord compromise, the procedure frequently had to be performed by supine Cl-2 puncture, which added to its difficulty. The need for myelography in the setting of acute trauma has now decreased considerably. It can now be reserved for cases of neurologic injury where MRI is technically impossible or unsuccessful. It is also still the most definitive way to diagnose a dural tear as seen in Figure 6. CONCLUSION
As elaborated above, cross-sectional imaging has assumed an increasingly significant role in the evaluation of acute spinal trauma. Myelography and complex motion tomography has declined in importance, FIGURE 5. Case 5. This 85-year-old woman suffered a fall, and then complained of total body numbness. (A) Clinical findings of ankylosing spondylitis are noted on this lateral radiograph of the thoracic spine obtained following acute trauma. The thoracolumbar junction, however, was poorly ligavisualized. (B) Disruption of the anterior longitudinal ment is noted on the sagittal MR image (arrow), resulting in widening of the anterior disc space. B
16
CLINICAL IMAGING VOL. 14.NO. 1
GOLDBERG ET AL.
If canal compromise or cord injury is detected, CT can then be obtained over a more narrowly defined region of interest to better assess associated fractures. Although redundancy will occur in some cases, CT and MRI will likely prove to be complementary in the evaluation of acute spinal trauma. REFERENCES 1.
Gehweiler JA, Osborne RL, Becker RF. The Radiology of Vertebral Trauma. Philadelphia: WB Saunders, 1980.
2. Rogers LF, Thayer C, Weinberg PE, Kim KS. Acute injuries of the upper thoracic spine associated with paraplegia. AJR 1980;134:67. 3. Daffner RH, Deeb ZL, Rothfus WE. “Fingerprints” of vertebral trauma-a unifying concept based on mechanisms. Skeletal Radio1 1986;15:518. 4. Brant-Zawadski M, Miller EM, Federle MP. CT in the evaluation of spine trauma. AJR 1981;136:369. 5. Handel SF, Lee YY. Computed tomography Radio1 Clin North Am 1981;19:69.
of spinal fractures.
6. Post MJD, Green BA. The use of computed tomography spinal trauma. Radio1 Clin’North Am 1983;21:327.
in
7. McAfee, PC, Hansen AY, Frederickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. J Bone Joint Surg 1983;65-A:461. 8. Brant-Zawadski M, Jeffrey RB, Managi H, Pitts LH. High resolution CT of thoracolumbar fractures. AJNR 1982;3:69. 9. Kalfas I, Wilberger JE, Goldberg AL, Prostko ER. Magnetic resonance imaging in acute spinal cord trauma. Neurosurgery 1988;23:295.
FIGURE 6. Case 6. A shearing fracture of L-2 occurred in this young woman following a motor vehicle accident. Gross dural laceration with extravasion of contrast is noted on this frontal myelogram. A shearing fracture of L-2 is also present. The dura was surgically repaired and spinal instrumentation was applied for stability.
10. Goldberg AL, Rothfus WE, Deeb ZL, Daffner RH, Lupetin AR, Wilberger JE, Prostko ER. The impact of magnetic resonance on the diagnostic evaluation of acute cervicothoracic spinal trauma. Skeletal Radio1 1988;17:89. 11. McArdle CB, Wright JW, Prevost WJ, Dornfest DJ, Amparo EG. MR imaging of the acutely injured patient with cervical traction. Radiology 1986;159:273. 12. Kulkarni MV, McArdle CB, Kopanicky D, Miner M, Cutler HB, Lee KF, Harris JH. Acute spinal cord injury. MR imaging at 1.5T. Radiology 1987;164:837. 13. Kulkarni MV, Bondurant FJ, Rose SL, Narayana PA. 1.5 Tesla magnetic resonance imaging of acute spinal trauma. Radiographics 1988;8:1059.
but an optimal plain radiographic examination remains the fundamental screening procedure. A qualitative comparison of CT and MRI remains problematic. CT is faster, particularly as examinations of both the spine and brain can be performed concurrently. However, particularly in cases where trauma to the brain is not an issue, MRI may be the initial procedure of choice after plain films, offering the advantage of a long segment survey of the spine.
14. Goldberg AL, Larkins MV, Rothfus WE, Deeb ZL, Daffner RH, Wilberger JE. Acute thoracolumbar fractures: MR/CT correlation. Presented at the 27th Annual Meeting, American Society of Neuroradiology, Orlando, Florida, 1989. 15. Goldberg AL, Rothfus WE, Deeb ZL, Frankel D, Daffner RH, Wilberger JE. Hyperextension injuries of the cervical spine: magnetic resonance findings. Skeletal Radio1 1989; 18:283-288. 16. Cooper PR, Cohen W. Evaluation of cervical spinal cord injuries with metrizamide myelography-CT scanning. J Neurosurg 1984;61:281.