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Acute Cervical Spine Injuries: Prospective MR Imaging Assessment at a Level 1 Trauma Center¹

¹ From the Department of Radiology, University of California-Davis Medical Center, 4701 X St, Sacramento, CA 95817 (R.W.K., P.F.B., M.I., C.S.B., W.R.N., R.A.M., F.K.O., D.M.B., V.C.P., B.W.C.) and the Department of Biostatistics, University of California at Davis (C.M.D., R.A.L.). Received October 15, 1998; revision requested November 11; revision received December 28; accepted April 30, 1999. Supported in part by Hitachi, Tokyo, Japan. Address reprint requests to R.W.K.

View larger version (18K): [in a new window]   Figure 1. Histogram shows the number of patients examined for suspected cervical spine injury during the study period of May 1994 to February 1995 at our level 1 trauma center.

View larger version (31K): [in a new window]   Figure 2. A-F, Schematic shows six sets of hypothetical combinations. The reference standard, or left column of eight squares (which represents C1-T1) is positive for vertebral injury and is compared with the reader's possible interpretations, the right column of eight squares. Positive findings are depicted as black squares, which represent the vertebrae. In A, for example, the reference standard is positive for injury at C1 and C2, and the readers detected injury at C1 and C2, which represents complete agreement. In B, the readers determined that injury occurred at C3 and C4, whereas the reference standard determined that injury occurred at C1 and C2. Thus, though the patient was determined to have injury, there was complete disagreement with use of the vertebral level as the unit of observation. We took all possibilities into consideration in our statistical model. We assessed the data by using both the patient and the vertebral level as the units of observation.

View larger version (125K): [in a new window]   Figure 3a. Conventional radiographs of the cervical spine obtained in a 78-year-old man with possible cervical spine injury from a motor vehicle accident. (a) Lateral conventional, (b) lateral swimmer's digital, (c) anteroposterior conventional, and (d) oblique conventional radiographs obtained at the time of presentation depict the cervical spine poorly, with only the upper C5 vertebral level seen clearly. Severe degenerative changes are noted with large anterior osteophytes (arrows in a and b) noted at the C2-3 interspace. d shows osteophytic encroachment (arrow) on the C4-5 neural foramen and disk space narrowing (arrowheads).

View larger version (174K): [in a new window]   Figure 3b. Conventional radiographs of the cervical spine obtained in a 78-year-old man with possible cervical spine injury from a motor vehicle accident. (a) Lateral conventional, (b) lateral swimmer's digital, (c) anteroposterior conventional, and (d) oblique conventional radiographs obtained at the time of presentation depict the cervical spine poorly, with only the upper C5 vertebral level seen clearly. Severe degenerative changes are noted with large anterior osteophytes (arrows in a and b) noted at the C2-3 interspace. d shows osteophytic encroachment (arrow) on the C4-5 neural foramen and disk space narrowing (arrowheads).

View larger version (160K): [in a new window]   Figure 3c. Conventional radiographs of the cervical spine obtained in a 78-year-old man with possible cervical spine injury from a motor vehicle accident. (a) Lateral conventional, (b) lateral swimmer's digital, (c) anteroposterior conventional, and (d) oblique conventional radiographs obtained at the time of presentation depict the cervical spine poorly, with only the upper C5 vertebral level seen clearly. Severe degenerative changes are noted with large anterior osteophytes (arrows in a and b) noted at the C2-3 interspace. d shows osteophytic encroachment (arrow) on the C4-5 neural foramen and disk space narrowing (arrowheads).

View larger version (123K): [in a new window]   Figure 3d. Conventional radiographs of the cervical spine obtained in a 78-year-old man with possible cervical spine injury from a motor vehicle accident. (a) Lateral conventional, (b) lateral swimmer's digital, (c) anteroposterior conventional, and (d) oblique conventional radiographs obtained at the time of presentation depict the cervical spine poorly, with only the upper C5 vertebral level seen clearly. Severe degenerative changes are noted with large anterior osteophytes (arrows in a and b) noted at the C2-3 interspace. d shows osteophytic encroachment (arrow) on the C4-5 neural foramen and disk space narrowing (arrowheads).

View larger version (128K): [in a new window]   Figure 4a. MR images obtained at 0.3 T in the same 78-year-old patient as in Figure 3. Sagittal (a) T2-weighted (1,500/117) and (b) gradient-echo (250/15, 70° flip angle) images show marked fluid or hemorrhage (white solid arrows in a) in the prevertebral space, disk space edema or hemorrhage (open arrows in a), and cord edema (curved arrows in a and b). Fractures of the C4 and C5 vertebrae (white arrows in b) are noted. The anterior and posterior longitudinal ligaments are intact. None of these injuries were suspected on the radiographs in Figure 3.

View larger version (125K): [in a new window]   Figure 4b. MR images obtained at 0.3 T in the same 78-year-old patient as in Figure 3. Sagittal (a) T2-weighted (1,500/117) and (b) gradient-echo (250/15, 70° flip angle) images show marked fluid or hemorrhage (white solid arrows in a) in the prevertebral space, disk space edema or hemorrhage (open arrows in a), and cord edema (curved arrows in a and b). Fractures of the C4 and C5 vertebrae (white arrows in b) are noted. The anterior and posterior longitudinal ligaments are intact. None of these injuries were suspected on the radiographs in Figure 3.

View larger version (91K): [in a new window]   Figure 5a. (a) Conventional lateral radiograph and (b-d) MR images obtained in a 76-year-old man who sustained a hyperflexion injury to the cervical spine and presented to the emergency room with quadriparesis. a shows evidence of moderate to severe degenerative disk disease of the upper cervical spine but no evidence of fracture or dislocation. The lateral swimmer's, anteroposterior, oblique, and odontoid projections (not shown) were negative for traumatic abnormality. (b) Sagittal T1-weighted (510/35) MR image obtained at 0.3 T shows a large posterior disk extrusion (arrows) that compresses the cord. (c) The resultant cord contusion (arrows) is seen on the sagittal gradient-echo (500/35, 20° flip angle) image. (d) The axial T1-weighted (760/25) MR image further characterizes the posterior central to right paracentral disk extrusion (arrows).

View larger version (109K): [in a new window]   Figure 5b. (a) Conventional lateral radiograph and (b-d) MR images obtained in a 76-year-old man who sustained a hyperflexion injury to the cervical spine and presented to the emergency room with quadriparesis. a shows evidence of moderate to severe degenerative disk disease of the upper cervical spine but no evidence of fracture or dislocation. The lateral swimmer's, anteroposterior, oblique, and odontoid projections (not shown) were negative for traumatic abnormality. (b) Sagittal T1-weighted (510/35) MR image obtained at 0.3 T shows a large posterior disk extrusion (arrows) that compresses the cord. (c) The resultant cord contusion (arrows) is seen on the sagittal gradient-echo (500/35, 20° flip angle) image. (d) The axial T1-weighted (760/25) MR image further characterizes the posterior central to right paracentral disk extrusion (arrows).

View larger version (120K): [in a new window]   Figure 5c. (a) Conventional lateral radiograph and (b-d) MR images obtained in a 76-year-old man who sustained a hyperflexion injury to the cervical spine and presented to the emergency room with quadriparesis. a shows evidence of moderate to severe degenerative disk disease of the upper cervical spine but no evidence of fracture or dislocation. The lateral swimmer's, anteroposterior, oblique, and odontoid projections (not shown) were negative for traumatic abnormality. (b) Sagittal T1-weighted (510/35) MR image obtained at 0.3 T shows a large posterior disk extrusion (arrows) that compresses the cord. (c) The resultant cord contusion (arrows) is seen on the sagittal gradient-echo (500/35, 20° flip angle) image. (d) The axial T1-weighted (760/25) MR image further characterizes the posterior central to right paracentral disk extrusion (arrows).

View larger version (130K): [in a new window]   Figure 5d. (a) Conventional lateral radiograph and (b-d) MR images obtained in a 76-year-old man who sustained a hyperflexion injury to the cervical spine and presented to the emergency room with quadriparesis. a shows evidence of moderate to severe degenerative disk disease of the upper cervical spine but no evidence of fracture or dislocation. The lateral swimmer's, anteroposterior, oblique, and odontoid projections (not shown) were negative for traumatic abnormality. (b) Sagittal T1-weighted (510/35) MR image obtained at 0.3 T shows a large posterior disk extrusion (arrows) that compresses the cord. (c) The resultant cord contusion (arrows) is seen on the sagittal gradient-echo (500/35, 20° flip angle) image. (d) The axial T1-weighted (760/25) MR image further characterizes the posterior central to right paracentral disk extrusion (arrows).

View larger version (69K): [in a new window]   Figure 6a. Conventional radiographs obtained in the (a) lateral and (b) anteroposterior projections poorly demonstrate a C6 burst fracture in a 28-year-old male steel worker who fell from approximately 30 feet. The patient's shoulders obscure C6 in a, and the compression of C6 is better appreciated on the anteroposterior (arrows in b) and lateral swimmer's (not shown) projections.

View larger version (108K): [in a new window]   Figure 6b. Conventional radiographs obtained in the (a) lateral and (b) anteroposterior projections poorly demonstrate a C6 burst fracture in a 28-year-old male steel worker who fell from approximately 30 feet. The patient's shoulders obscure C6 in a, and the compression of C6 is better appreciated on the anteroposterior (arrows in b) and lateral swimmer's (not shown) projections.

View larger version (91K): [in a new window]   Figure 7a. Axial (a) CT scan and (b) T1-weighted (760/25) MR images obtained in the same patient as in Figure 6. The vertical, parasagittal vertebral fracture (double arrows in a) and the anteriorly displaced laminar fractures (single arrows in a) that create a narrowing of the anteroposterior canal diameter (arrows in b) are depicted. (c) Sagittal gradient-echo (500/35, 20° flip angle) MR image demonstrates anterior wedging and retropulsion of the C6 vertebra (arrowhead), anterior longitudinal ligament stretching, posterior longitudinal ligament stretching, and flaval ligament tears (curved arrows). Cord contusion (straight arrows) spans three vertebral levels.

View larger version (126K): [in a new window]   Figure 7b. Axial (a) CT scan and (b) T1-weighted (760/25) MR images obtained in the same patient as in Figure 6. The vertical, parasagittal vertebral fracture (double arrows in a) and the anteriorly displaced laminar fractures (single arrows in a) that create a narrowing of the anteroposterior canal diameter (arrows in b) are depicted. (c) Sagittal gradient-echo (500/35, 20° flip angle) MR image demonstrates anterior wedging and retropulsion of the C6 vertebra (arrowhead), anterior longitudinal ligament stretching, posterior longitudinal ligament stretching, and flaval ligament tears (curved arrows). Cord contusion (straight arrows) spans three vertebral levels.

View larger version (107K): [in a new window]   Figure 7c. Axial (a) CT scan and (b) T1-weighted (760/25) MR images obtained in the same patient as in Figure 6. The vertical, parasagittal vertebral fracture (double arrows in a) and the anteriorly displaced laminar fractures (single arrows in a) that create a narrowing of the anteroposterior canal diameter (arrows in b) are depicted. (c) Sagittal gradient-echo (500/35, 20° flip angle) MR image demonstrates anterior wedging and retropulsion of the C6 vertebra (arrowhead), anterior longitudinal ligament stretching, posterior longitudinal ligament stretching, and flaval ligament tears (curved arrows). Cord contusion (straight arrows) spans three vertebral levels.