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Magnetic resonance imaging of spinal cord injury without radiologic abnormality
Surg Neurol 1990;33:281-3
281
Magnetic Resonance Imaging of Spinal Cord Injury Without Radiologic Abnormality Akira Matsumura, Yoichi Kikuchi,
M.D., M.D.,
Kotoo
Meguro,
Mitsuyoshi
Wada,
M.D.,
F.R.C.S. (C.), Hideo
M.D.,
and Yoshitaka
Tsurushima,
Nakata,
M.D.,
M.D.
Departments of Neurosurgery and Radiology, Tsukuba Medical Center, lbaraki, .Japan
Matsumura A, Meguro K, Tsurushima 1I, Kikuchi Y, Wada M, Nakata Y. Magnetic resonance imaging of spinal cord injury without radiologic abnormality. Surg Neurol 1990;33:281-3.
A 3-year-old girl with spinal cord injury without radiologic abnormality (SCIWORA) is reported. Magnetic r e s o n a n c e imaging (MRI) showed an abnormal intensity of the spinal cord at the level of C7 t o T h l in the acute stage and severe atrophic change in the chronic stage. This is the first report of SCIWORA with positive diagnostic imaging. The mechanism of SCIWORA is discussed based on the positive MRI findings.
dent with the diagnosis of C I / 2 subluxation. Lateral cervical spine radiograph rew:aled the atlantoaxial distance to be 6 m m in flexion and 4 m m in the neutral position (Figure 1). Magnetic resonance imaging on the day of admission (Toshiba M R T - 5 0 A , 0.5 Tesla) showed high-intensity changes on T2-weighted images [Field Gradient Echo method (FE) 300/22/Flip angle 15 ° ]
KEY WORDS: Spinal cord injury; Children; Magnetic resonance imaging
Introduction Spinal cord injury without radiologic abnormality is seen in 4 % - 6 6 . 7 ~ of all pediatric spinal cord injuries [2,6,9,10]. Despite severe symptoms and poor neurologic recovery in many cases, the pathology of SCIWO R A is not sufficiently understood. We report a case of S C I W O R A in which a positive MRI was obtained. The level o f neurologic deficits correlated with the level seen on MRI. We discuss the pathomechanism o f S C I W O R A based on the serial MRI findings.
Case
Report
A 3-year-old girl was involved in a m o t o r vehicle accident and became paraplegic (below the level o f T1) immediately after this event. A frontal bruise was seen. She was referred to our hospital 10 days after the acci-
AddreJs reprint reque.*ts to." Akira Matsumura, M.D., Department of Neurosurgery, Tsukuba Medical Center, l-~ Amakubo, Tsukuba Science City, Ibaraki 305, Japan. Received August 29, 1989; accepted December 15, 1989. ~<.' 1990 by Elsevier SLience Publishing Co.. lnc
Figure 1. Lateral ,erv#al radiograph in flexion. Allantoamal (AA) di.)tame Lt 0 ram. u'hi(h (an he indt¢altv< o/'AA .,ub[axation. I)09(Lq)19/90"$3.50
282
Surg Neurol 1990;33:281-3
T2Figure 2. Sagittal MRI taken on the da~ of admt)~ion. ( R ~ weighted image demonstrates high-intensity change of the cora at the level of C7. (~_Q]~)Tl-weighted image shows no definite intensity changes.
within the spinal cord at the level of C7 to T I but did not reveal spinal cord swelling (Figure 2). The patient was immobilized in a Hal() vest for 8 weeks. The second MRI at this time showed a severely atrophic change of the spinal cord in both T l - w e i g h t e d and T2-weighted images (Figure 3). N o neurologic recovery was achieved and she remained paraplegic.
Discussion Spinal cord injury without radiologic abnormality is tiefined as a pediatric spinal cord injury with no abnormality on plain film, tomography, or myelography at the time of admission [9J. It accounts for 4(~,,: [6] to 66.7':+: [9} of all pediatric spinal cord injuries. Myelographic findings in S C I W O R A have- been described as follows: free flow ,,f contrast medium is seen, and sometimes cords look slightly swollen with irregular contour [9]. These findings are compatible with our MRI findings, since MRI showed only localized cord intensity changes. Ab-
Matsumura et al
sence of the spinal cord swelling is thought to be a specific tinding fi)r S ( ' I W O R A , since the swelling of the spinal cord is usually seen by MRI in complete spinal cord injuries [1,3,5]. Appearance of the spinal cord in the chronic stage on magnetic resonance imaging in our case was similar to that of cord avulsion. However, MRI in the acute stage did not show the findings of cord avulsion, so that this finding could not be interpreted as primary avulsion or traumatic division [4,7]. The lack of spinal cord swelling in the acute stage may be explained by partial disruption of the cord associated with small hemorrhage and edematous changes, which presented as normal thickness ant| only abnormal intensity of the spinal cord on MRI. T h e finding of a severely atrophic cord m the chronic stage may be the result of absorption of edema and hemorrhage. ]-towever, this hypothesis should be further investigated to be proved. Choi et al [2] postulated some cord injury cases to be an ischemic result, particularly in cases with delayed neurologic detc'rioration. In their series, the injuries primarily inw~lved the chest or retroperitoneum, and the level of the injury was lower thoracic in most cases, where the cord has the poorest blood supply [2]. In our
MRI of Spinal Cord Injury
Surg Neurol 1990;33:281-3
283
frequently seen in pediatric spinal injuries. In the series of Ruge et al [10], the most c o m m o n level of bone involvement was C I-2 in the children under 3 years o f age. They did not describe whether the neurologic level correlated with this high cervical injury, but there was no description of respiratory problems in their series. Therefore, it may be assumed that in some cases the injury to the spinal cord was remote from the bone involvement, as seen in our case. Magnetic resonance imaging is superior to c o m p u t e d tomography in diagnosing the intraparenchymal lesion in cases of spinal cord injury [1,3,5,7] and, with the proper cardiorespiratory monitoring and support, MRI can be p e r f o r m e d even in unstable patients [8]. Because of the lack o f bony lesion, MRI is thought to be the most promising diagnostic tool in S C I W O R A to evaluate the precise level of spinal cord damage. References Figure 3. Sagittal MRI taken 2 month.~ after the injury. On the T I u'eighted image, the cord ts .~evere/~'atrophic, and on the T2-u'elghted image. cerebroJpinal fluid intensity' is seen at the C7 levd.
case, the patient was found to be paraplegic immediately after the injury, with no abdominal or chest injuries. From such clinical history, it is unlikely that the cord injury was caused by ischemic insult. In our case, MR1 showed no evidence of hemorrhage, disruption, or fracture in the perispinal components. From our own observation and other reports, complete spinal cord injury in the adult is associated with some abnormal findings in the perispinal structures, even if there are no findings in the spinal cord itself [unpublished data, 1,5]. These findings support the consideration that S C I W O R A is caused by the transient deformity of the ligaments, joints that are more elastic in children than adults [9]. Plain radiograph of the cervical spine in our case was diagnosed as C1/2 subluxation in the previous hospital. Without having MRI, we would have also attributed the neurologic deficit to the C1/2 subluxation, which is
1. Beers GJ, Raque GH, Wagner GG, Shields CB, Nichols GR, Johnson JR 11, Meyer JE. MR imaging in acute cervical spine trauma. J Comput Assist Tomogr 1988;12:755-61. 2. Choi UJ, Hoffman HJ, Hendrick EB, Humphreys RP, Keith WS. Traumatic infarction of the spinal cord in children. J Neurosurg 1986:65:608-10. 3. Duthoy MJ, Lund G. MR imaging of the spine in children. EurJ Radiol 1988;8: 188-95. 4. Fasano FJ, Stauffer EH. Traumatic division of the spinal cord demonstrated by magnetic resonance imaging. Clin Orthop 1988;No.233:168-70. 5. 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 Radiol 1988; 17:89-95. 6. Hill SA, Miller CA, Kosnik EJ, Hunt WE. Pediatric neck injuries. A clinical study. J Neurosurg 1984;60:700-6. 7. Mathis JM, Wilson JT, Barnard JW, Zelenik ME. MR imaging of spinal cord avulsion. AJNR 1988;9:1232-3. 8. Matsumura A, Meguro K, Mizutani T, Tsurushima H, Satoh N, Tsunoda T, Matsumaru Y, Nakata Y, Wada M, Kikuchi Y, Ebashi T, Nose T. Cardiorespiratory monitoring and support during MRl examination in critically ill patients. Jpn J Magn Reson Med 1989;8:268-74. 9. Pang D, Wilberger JE. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982;57:114-29. 10. Ruge JR, Sinson GP, McLone DG, Cerulo LJ. Pediatric spinal injury: the very young. J Neurosurg 1988;68:25-30.
281
Magnetic Resonance Imaging of Spinal Cord Injury Without Radiologic Abnormality Akira Matsumura, Yoichi Kikuchi,
M.D., M.D.,
Kotoo
Meguro,
Mitsuyoshi
Wada,
M.D.,
F.R.C.S. (C.), Hideo
M.D.,
and Yoshitaka
Tsurushima,
Nakata,
M.D.,
M.D.
Departments of Neurosurgery and Radiology, Tsukuba Medical Center, lbaraki, .Japan
Matsumura A, Meguro K, Tsurushima 1I, Kikuchi Y, Wada M, Nakata Y. Magnetic resonance imaging of spinal cord injury without radiologic abnormality. Surg Neurol 1990;33:281-3.
A 3-year-old girl with spinal cord injury without radiologic abnormality (SCIWORA) is reported. Magnetic r e s o n a n c e imaging (MRI) showed an abnormal intensity of the spinal cord at the level of C7 t o T h l in the acute stage and severe atrophic change in the chronic stage. This is the first report of SCIWORA with positive diagnostic imaging. The mechanism of SCIWORA is discussed based on the positive MRI findings.
dent with the diagnosis of C I / 2 subluxation. Lateral cervical spine radiograph rew:aled the atlantoaxial distance to be 6 m m in flexion and 4 m m in the neutral position (Figure 1). Magnetic resonance imaging on the day of admission (Toshiba M R T - 5 0 A , 0.5 Tesla) showed high-intensity changes on T2-weighted images [Field Gradient Echo method (FE) 300/22/Flip angle 15 ° ]
KEY WORDS: Spinal cord injury; Children; Magnetic resonance imaging
Introduction Spinal cord injury without radiologic abnormality is seen in 4 % - 6 6 . 7 ~ of all pediatric spinal cord injuries [2,6,9,10]. Despite severe symptoms and poor neurologic recovery in many cases, the pathology of SCIWO R A is not sufficiently understood. We report a case of S C I W O R A in which a positive MRI was obtained. The level o f neurologic deficits correlated with the level seen on MRI. We discuss the pathomechanism o f S C I W O R A based on the serial MRI findings.
Case
Report
A 3-year-old girl was involved in a m o t o r vehicle accident and became paraplegic (below the level o f T1) immediately after this event. A frontal bruise was seen. She was referred to our hospital 10 days after the acci-
AddreJs reprint reque.*ts to." Akira Matsumura, M.D., Department of Neurosurgery, Tsukuba Medical Center, l-~ Amakubo, Tsukuba Science City, Ibaraki 305, Japan. Received August 29, 1989; accepted December 15, 1989. ~<.' 1990 by Elsevier SLience Publishing Co.. lnc
Figure 1. Lateral ,erv#al radiograph in flexion. Allantoamal (AA) di.)tame Lt 0 ram. u'hi(h (an he indt¢altv< o/'AA .,ub[axation. I)09(Lq)19/90"$3.50
282
Surg Neurol 1990;33:281-3
T2Figure 2. Sagittal MRI taken on the da~ of admt)~ion. ( R ~ weighted image demonstrates high-intensity change of the cora at the level of C7. (~_Q]~)Tl-weighted image shows no definite intensity changes.
within the spinal cord at the level of C7 to T I but did not reveal spinal cord swelling (Figure 2). The patient was immobilized in a Hal() vest for 8 weeks. The second MRI at this time showed a severely atrophic change of the spinal cord in both T l - w e i g h t e d and T2-weighted images (Figure 3). N o neurologic recovery was achieved and she remained paraplegic.
Discussion Spinal cord injury without radiologic abnormality is tiefined as a pediatric spinal cord injury with no abnormality on plain film, tomography, or myelography at the time of admission [9J. It accounts for 4(~,,: [6] to 66.7':+: [9} of all pediatric spinal cord injuries. Myelographic findings in S C I W O R A have- been described as follows: free flow ,,f contrast medium is seen, and sometimes cords look slightly swollen with irregular contour [9]. These findings are compatible with our MRI findings, since MRI showed only localized cord intensity changes. Ab-
Matsumura et al
sence of the spinal cord swelling is thought to be a specific tinding fi)r S ( ' I W O R A , since the swelling of the spinal cord is usually seen by MRI in complete spinal cord injuries [1,3,5]. Appearance of the spinal cord in the chronic stage on magnetic resonance imaging in our case was similar to that of cord avulsion. However, MRI in the acute stage did not show the findings of cord avulsion, so that this finding could not be interpreted as primary avulsion or traumatic division [4,7]. The lack of spinal cord swelling in the acute stage may be explained by partial disruption of the cord associated with small hemorrhage and edematous changes, which presented as normal thickness ant| only abnormal intensity of the spinal cord on MRI. T h e finding of a severely atrophic cord m the chronic stage may be the result of absorption of edema and hemorrhage. ]-towever, this hypothesis should be further investigated to be proved. Choi et al [2] postulated some cord injury cases to be an ischemic result, particularly in cases with delayed neurologic detc'rioration. In their series, the injuries primarily inw~lved the chest or retroperitoneum, and the level of the injury was lower thoracic in most cases, where the cord has the poorest blood supply [2]. In our
MRI of Spinal Cord Injury
Surg Neurol 1990;33:281-3
283
frequently seen in pediatric spinal injuries. In the series of Ruge et al [10], the most c o m m o n level of bone involvement was C I-2 in the children under 3 years o f age. They did not describe whether the neurologic level correlated with this high cervical injury, but there was no description of respiratory problems in their series. Therefore, it may be assumed that in some cases the injury to the spinal cord was remote from the bone involvement, as seen in our case. Magnetic resonance imaging is superior to c o m p u t e d tomography in diagnosing the intraparenchymal lesion in cases of spinal cord injury [1,3,5,7] and, with the proper cardiorespiratory monitoring and support, MRI can be p e r f o r m e d even in unstable patients [8]. Because of the lack o f bony lesion, MRI is thought to be the most promising diagnostic tool in S C I W O R A to evaluate the precise level of spinal cord damage. References Figure 3. Sagittal MRI taken 2 month.~ after the injury. On the T I u'eighted image, the cord ts .~evere/~'atrophic, and on the T2-u'elghted image. cerebroJpinal fluid intensity' is seen at the C7 levd.
case, the patient was found to be paraplegic immediately after the injury, with no abdominal or chest injuries. From such clinical history, it is unlikely that the cord injury was caused by ischemic insult. In our case, MR1 showed no evidence of hemorrhage, disruption, or fracture in the perispinal components. From our own observation and other reports, complete spinal cord injury in the adult is associated with some abnormal findings in the perispinal structures, even if there are no findings in the spinal cord itself [unpublished data, 1,5]. These findings support the consideration that S C I W O R A is caused by the transient deformity of the ligaments, joints that are more elastic in children than adults [9]. Plain radiograph of the cervical spine in our case was diagnosed as C1/2 subluxation in the previous hospital. Without having MRI, we would have also attributed the neurologic deficit to the C1/2 subluxation, which is
1. Beers GJ, Raque GH, Wagner GG, Shields CB, Nichols GR, Johnson JR 11, Meyer JE. MR imaging in acute cervical spine trauma. J Comput Assist Tomogr 1988;12:755-61. 2. Choi UJ, Hoffman HJ, Hendrick EB, Humphreys RP, Keith WS. Traumatic infarction of the spinal cord in children. J Neurosurg 1986:65:608-10. 3. Duthoy MJ, Lund G. MR imaging of the spine in children. EurJ Radiol 1988;8: 188-95. 4. Fasano FJ, Stauffer EH. Traumatic division of the spinal cord demonstrated by magnetic resonance imaging. Clin Orthop 1988;No.233:168-70. 5. 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 Radiol 1988; 17:89-95. 6. Hill SA, Miller CA, Kosnik EJ, Hunt WE. Pediatric neck injuries. A clinical study. J Neurosurg 1984;60:700-6. 7. Mathis JM, Wilson JT, Barnard JW, Zelenik ME. MR imaging of spinal cord avulsion. AJNR 1988;9:1232-3. 8. Matsumura A, Meguro K, Mizutani T, Tsurushima H, Satoh N, Tsunoda T, Matsumaru Y, Nakata Y, Wada M, Kikuchi Y, Ebashi T, Nose T. Cardiorespiratory monitoring and support during MRl examination in critically ill patients. Jpn J Magn Reson Med 1989;8:268-74. 9. Pang D, Wilberger JE. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982;57:114-29. 10. Ruge JR, Sinson GP, McLone DG, Cerulo LJ. Pediatric spinal injury: the very young. J Neurosurg 1988;68:25-30.