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EP - 154
Evaluation for Soft Tissue Injuries on CT
in Acute Cervical Spine Trauma
with MR Imaging Correlation
Naoko Saito 1, Margaret N Chapman 2,3, Akira Uchino 1
Fumikazu Sakai 1,Osamu Sakai 3
1 Radiology,
Saitama International Medical Center, Saitama Medical University
2 Radiology, Boston VA Healthcare System
3 Radiology, Boston Medical Center, Boston University School of Medicine
Introduction
Methods
Results
Discussion
Conclusion
☑ The authors have no conflict of
interest to disclose with respect
to this presentation.
Introduction
Methods
Results
Discussion
Conclusion
• Soft tissue injuries, including ligamentous injury,
muscular injury, and prevertebral
edema/hematoma, are common imaging findings
of cervical spine trauma.
• These injuries are believed to correlate with the
severity of the spinal cord injury. (Song KJ, et al. Martínez-Perez
R et al. Goradia D et al.)
• Although MR can clearly demonstrate these
injuries, the utility of CT in their detection is often
underappreciated.
Introduction
Methods
Results
Discussion
Conclusion
Purpose
• To assess whether CT with soft tissue
window can help identify soft tissue injuries
• To compare CT with MR imaging findings in
patients with acute cervical spine trauma
Introduction
Methods
Results
Discussion
Conclusion
Subjects
• Retrospective imaging review
• From January 2010 to November 2014
• Patients who underwent both CT and MR imaging
of cervical spine for acute traumatic spinal injury
were identified
• Medical records were reviewed for demographics
and admitting diagnosis
• The indication for MRI at our institution
•
•
•
•
Neck pain, midline cervical pain
Neurological deficits on examination
Subjective neurological complaints
Altered mental status
Introduction
Methods
Results
Discussion
Conclusion
Imaging techniques
 CT imaging
• 64-slice MDCT (LightSpeed VCT, GE Healthcare)
• Reviewed in bone (WL/WW: 350/1500) and soft tissue
(WL/WW: 55/450) windows
 MR imaging
• 1.5 MRI (MAGNETOM Avanto, SIEMENS)
• Reviewed in T1, T2-weighted, and STIR images
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•
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Sagittal T1 weighted image: TR/TE 550/10
Sagittal T2 weighted image: TR/TE 3500/85
Sagittal STIR： TR/TE 5000/60, TI 170
Axial gradient-recalled image: TR/TE 500/24, FA 30°
Introduction
Methods
Results
Discussion
Conclusion
Image analysis
• Images were reviewed by a single observer with
special attention directed toward soft tissue changes
 CT
 MRI
• Fracture
•
• Dislocation
•
• Soft tissue abnormality
•
 Interspinous soft tissue
 Supraspinous soft tissue
 Prevertebral soft tissue
 Posterior cervical
musculature
•
Fracture
Dislocation
Soft tissue abnormality
 Interspinous soft tissue
 Supraspinous soft tissue
 Prevertebral soft tissue
 Posterior cervical
musculature
Spinal cord abnormality
Introduction
Methods
Results
Discussion
Conclusion
Evaluation for soft tissue injury: sagittal
CT
STIR
soft
tissue
window
A 74-year-old man with interspinous (arrows) and supraspinous (arrows)
soft tissue injuries and prevertebral edema (arrowheads).
Introduction
Methods
Results
Discussion
Conclusion
Evaluation for soft tissue injury: axial
CT soft tissue window
T2*
A 74-year-old man with interspinous (arrows) and supraspinous (arrows)
soft tissue injuries and prevertebral edema (arrowheads).
Introduction
Methods
Results
Discussion
Conclusion
Patient characteristics
• 157 patients with acute cervical spine trauma were
identified during the 5-year period
• Age:
14 - 92 (avg. 59.5) years old
• Gender:
34 women, 123 men
• Mechanism: Fall 108, MVC/MCA 45, others 4
•
MVC = motor vehicle collision, MCA = motorcycle accident
• Days between CT and MR: 0-26 (avg. 1.2) days
Introduction
Methods
Results
Discussion
Conclusion
Patient characteristics
• 157 patients with acute cervical spine trauma were
identified during the 5-year period
• Fracture
52 patients
• MR imaging abnormality
• Spinal cord injury
83 patients
• Paraspinal soft tissue injury 92 patients
Introduction
Methods
Results
Discussion
Conclusion
Soft tissue abnormalities
• Out of 157 patients,
– 59 patients (37.6%) showed abnormalities in
the paraspinal soft tissues on CT
– 92 patients (58.6%) showed abnormalities in
the paraspinal soft tissues on MR imaging
• Of 92 patients with paraspinal soft tissue injuries
by MR,
– CT identified the abnormalities in 57 patients
(62.0%)
Introduction
Methods
Results
Discussion
Conclusion
Soft tissue abnormalities
• Of 59 patients with paraspinal soft tissue
abnormalities on CT,
– 38 patients (64.4%) demonstrated the
abnormalities adjacent to the fractures
– 18 patients (15.3%) showed prevertebral edema
• Of 18 patients with prevertebral edema on CT,
– 12 patients (66.7%) had cervical spine fractures
Introduction
Methods
Results
Discussion
Conclusion
Soft tissue injury with spinal cord injury
• Of 59 patients with paraspinal soft tissue
abnormalities on CT,
– 37 patients (62.7%) had spinal cord signal
abnormalities on MR imaging
– 11 patients (18.6%) did not have fracture or
dislocation but had spinal cord abnormalities on
MR imaging
• Of 18 patients with prevertebral edema on CT,
– 13 patients (72.2%) had spinal cord injury on
MR imaging
Introduction
Methods
Results
Discussion
Conclusion
Soft tissue injury with spinal cord injury
Paraspinal soft
tissue injury
Prevertebral edema
+ CT findings
59
18
Cord signal
abnormality on
MRI
37
13
Odds Ratio
1.9 (95% CI 0.9 to 3.7) 2.6 (95% CI 0.9 to 7.6)
Introduction
Methods
Results
Discussion
Conclusion
Representative case 1
 Soft tissue injury with fracture and spinal cord injury. A 75-yearold man after a fall from 16 stairs presented with lost of consciousness.
STIR
There is a posterior spinous process fracture of C4 (arrows). CT with soft tissue
window shows fat stranding within the intraspinous soft tissues (arrow) adjacent the
to fracture. STIR image demonstrates intra- and supraspinous soft tissues injuries
(arrows) and spinal cord injury with hemorrhage at the level of C4/5 (arrow).
Introduction
Methods
Results
Discussion
Conclusion
Representative case 2
 Prevertebral edema with spinal cord injury. A 73-year-old woman
after a fall from standing presented with quadriplegia.
STIR
There is no fracture on CT. CT with soft tissue window shows prevertebral edema
(arrowheads) and fat stranding within the intra- and supraspinous (arrows) soft tissues,
correlating with STIR image. Spinal cord injury at the level of C2-5 is seen (arrow).
Introduction
Methods
Results
Discussion
Conclusion
 Evaluation for soft tissue injuries in acute cervical
spine trauma
• Soft tissue injuries are believed to correlate with
the severity of the spinal cord injury
• Could be useful in predicting neurologic outcome
(Song KJ, et al. Martínez-Perez R et al. Goradia D et al.)
 Ligamentous injury: anterior longitudinal
ligaments, posterior longitudinal ligaments, and
ligamentum flavum
• MR imaging has been reported as clearly superior
to CT in detecting soft tissue injuries
• Utility of CT in their detection is often underappreciated
Introduction
Methods
Results
Discussion
Conclusion
 Evaluation for soft tissue injuries on CT
• CT identified approximately 2/3 of the soft tissue
abnormalities observed on MR imaging
• CT findings of soft tissue abnormality:
 Fat stranding within the interspinous and
supraspinous regions
 Posterior cervical musculature swelling
 Prevertebral soft tissue swelling
• These CT findings may be associated with ligamentous
injuries
• Soft tissue abnormalities were often seen adjacent
to the fractures on CT
• Evaluation with soft tissue window could help to detect
subtle fractures
Introduction
Methods
Results
Discussion
Conclusion
 Evaluation for soft tissue injuries on CT
• About 60% of the patients with paraspinal soft
tissue abnormality on CT had spinal cord injury
on MR imaging
• Furthermore, approximately 20% of those
patients did not have fracture or dislocation
• Evaluation of paraspinal soft tissue abnormality on
CT could also be useful in predicting neurologic
outcome
Introduction
Methods
Results
Discussion
Conclusion
 Patients with prevertebral edema on CT were more
likely to have spinal cord injury
• Prevertebral edema is thought to be associated
with more severe cervical spine trauma
• Prevertebral edema/hematoma
 Occurred mainly in hyperextension and whiplash
injuries (Hutter G et al.)
• Disruption of the anterior ligaments
• Fractures of the anterior bony elements
 Occurred in the elderly or anticoagulated patients
(Hutter G et al.)
 Caused by high-energy trauma in younger patients
(Kuhn JE et al.)
Introduction
Methods
Results
Discussion
Conclusion
 Limitations
– Evaluation for soft tissue on CT
• Beam hardening artifacts
– Retrospective nature
• Time difference between CT and MR examinations
• Sampling bias
– A single observer
– Correlation of surgical findings or clinical outcome
• Future study
Introduction
Methods
Results
Discussion
Conclusion
Conclusion
• Although MR imaging is highly sensitive for
detecting ligamentous and paraspinal soft tissue
injuries, CT with soft tissue window can also
demonstrate paraspinal soft tissue abnormalities
in patients with acute cervical spine injury.
• Patients with soft tissue abnormalities, especially
prevertebral edema on CT, are 3 times more
likely to have spinal cord injuries.
Introduction
Methods
Results
Discussion
Conclusion
References
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Martínez-Perez R, Paredes I, Cepeda S, et al. Spinal Cord Injury after Blunt
Cervical Spine Trauma: Correlation of Soft-Tissue Damage and Extension of
Lesion. AJNR Am J Neuroradiol. 2014;35:1029-34.
Hutter G, Benz R, Taub E, et al. Extensive cervical prevertebral hemorrhage with
airway obstruction after low-energy hyperextension injury. Injury Extra
2014;45:53-55.
Tan LA, Kasliwal MK, Traynelis VC. Comparison of CT and MRI findings for
cervical spine clearance in obtunded patients without high impact trauma. Clin
Neurol Neurosurg 2014;120: 23–26.
Song KJ, Kim GH, Lee KB. The efficacy of the modified classification system of
soft tissue injury in extension injury of the lower cervical spine. Spine
2008;33:E488–93.
Goradia D, Linnau KF, Cohen WA, et al. Correlation of MR Imaging Findings with
Intraoperative Findings after Cervical Spine Trauma. AJNR Am J Neuroradiol.
2007;28:209-15.
Kuhn JE, Graziano GP. Airway compromise as a result of retropharyngeal
hematoma following cervical spine injury. J Spinal Disord 1991;4:264-9.
Thank you!