Spine MRI in Trauma Patients

4th Musculoskeletal MRI meeting 2017: Spine MRI

6th May, 2017

Ospedale Regionale di Lugano, Civico, Aula MagnaGustav Andreisek, MD, MBA

Professor of Radiology, University of Zurich and Head of Radiology Spital Thurgau,Cantonal Hospital Münsterlingen,Switzerland

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Disclosures

Gustav Andreisek

was co-worker of a study which resulted in US patent (USPTO Number 12/947,256); received grants from Swiss National Science Foundation (SNCF), Holcim, and Siemens; is currently Co-PI or Sub-PI in several third party funded clinical trials at the University of Zurich (Sponsors include: Millennium Pharmaceuticals, Eli Lilly, GlaxoSmithKline, Cytheris SA, Roche, BioChemics, Novartis, Bristol-Meyers Squibb, TopoTarget, and Merck Sharp & Dohme) and where money is paid to the department Gustav Andreisek works for. The department also receives grants from Bayer and Guerbet and has ongoing research collaborations with Siemens and Philips.

has given workshops and talks at a congress which was sponsored by MephaPharma AG, Switzerland, and received a speaker fee. He also gives talks at Lunch symposia and CME courses, which are organized and sponsored by Guerbet, and receives speakers fees. Gustav Andreisek served as a consultant for Otsuka Pharmaceutical Europe Ltd at a one-day meeting in London, and received a consultant fee and reimbursement of travel costs. Gustav Andreisek was invited by GE, Philips and Siemens for official company receptions at international radiological congresses (RSNA).

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53 ys old lady after minor trauma

Initially seen by familiy doctor, referred to external hospital

CC: fall on soft ground day before, now back pain

PMH: n/a

Two weeks later, persistent pain

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Content

Challenges

Guidelines and Reporting Strategy

Future Directions

MRI

CT

15 - 20 min

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Challenges

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Availablity 24 / 7 / 365

Imaging modalities

Radiographs

CT

MR

Radiologist on-call

Experienced technicians and radiologists on-call for emergency MRI

Human resources, costs, reimbursement, outsourcing

Guidelines must cover national and (best) international situations and infra-structure

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Full service or fast track imaging

Image acquisition

Plain films

CT • Axials, sagittals, coronals• 3D volume rendering• Angio / perfusion• Surgical planning simulations

MRI• Angio (cervical spine)• Diffusion-weighted imaging for spinal

cord

Source USZ

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Full service or fast track imaging

Image interpretation

Full image evaluation (incl. all degenerative changes)

Fast track image evaluation (only focussed on trauma)

step-wise approach with preliminary image reading andsubsequent full report (within 24hrs)

(Semi-) quantitative analysis

Data transfer

PACS

Reporting in-house vs externally

Source USZ

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Plain Film

Widely available, cheap, fast

Mainstay of bone and joint imaging, particularly in trauma

Disadvantages

uses ionising radiation (x rays)

limited information regarding soft tissues

Spine ??Source USZ

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Computed Tomography (CT)

Cross sectional imaging capability

Reformatting in other planes and 3D

Best for bony cortex and calcification

Good at evaluation of comminuted fractures to complex structuresPelvisCalcaneusWristSpine

Source USZSource USZ

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Quelle: 20min.ch

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Magnetic Resonance (MR) Imaging

Source USZ

Multiplanar imaging

Excellent soft tissue contrast

Ideally for radiographically occult fractures

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Added value of MRIA 37-year-old woman after a bicycle accident.

AO A1.2 vs AO B1.2

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Change of therapy due to MRI

AO A3.1 vs B1.2

53-year-old man after a car accident

Thoraco-Lumbar Injury Classification and Severity (TLICS) injury severity score (ISS)

1 vs 7

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24 ys old male with cervical spine traumaNeck pain, no neurological deficits

Cervical Spine = CTSource USZ

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Nuclear Medicine

Source UHN, Toronto

entire skeleton at once

bone scan is an indicator of bone turn over

very sensitive, not specific

fracture

tumour

arthritis

infection

metabolic bone disease

multiple metastases

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‘Non-specific uptake xiphoid process region of the sternum. Correlation with clinical examination suggested.’

‘Unless there has been trauma to these sites I cannot exclude metastatic disease and further radiologic correlation is recommended.’

‘This likely represents a normal variant, however, correlation with x-ray is recommended to rule out loosening or other pathology.’

‘Clinical correlation and further investigation with a left shoulder radiograph is recommended.’

‘Suspected degenerative change midcervical spine, radiograph would be confirmatory.’

‘Possible traumatic injury to the sternoclavicular joints bilaterally. Radiographic correlation is recommended.’

‘Mild focal activity within the left acetabulum anteriorly which is non-specific and could be related to either degenerative changes or a metastatic deposit.’

Typical Report of Bone Scan

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‘Non-specific uptake xiphoid process region of the sternum. Correlation with clinical examination suggested.’

‘Unless there has been trauma to these sites I cannot exclude metastatic disease and further radiologic correlation is recommended.’

‘This likely represents a normal variant, however, correlation with x-ray is recommended to rule out loosening or other pathology.’

‘Clinical correlation and further investigation with a left shoulder radiograph is recommended.’

‘Suspected degenerative change midcervical spine, radiograph would be confirmatory.’

‘Possible traumatic injury to the sternoclavicular joints bilaterally. Radiographic correlation is recommended.’

‘Mild focal activity within the left acetabulum anteriorly which is non-specific and could be related to either degenerative changes or a metastatic deposit.’

Typical Report of Bone Scan

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Impact on Therapy

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Cost, Radiation, Reliability

Lack of cost-efficacy studies with regard to CT and/or MR in acute spinal trauma

Huge variability in radiation exposure even within a small, well developed country

No prospective controlled study on the reliability of different imaging techniques in different clinical scenarios.

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Content

Challenges

Guidelines and Reporting Strategy

Future Directions

MRI

CT

15 - 20 min

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Evidence-based guidelines

increasing role in patient care and reimbursement decisions

federal and state agencies and third-party payers look to evidence-based recommendations to improve quality of care and halt the increase in health care costs

Joshi GP. How Important Is Evidence-Based Medicine in Epidural Injection for Low Back Pain? Practical pain management. First published on: March 1, 2014

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ACR Appropriatness Criteria

https://acsearch.acr.org/list

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Clinical Scenarios Variant 1-8 = cervical spine

Variant 9, 10 = adults, thoraco-lumbar

Variant 11-14, age <14 yrs

> age14

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Clinical Scenarios > age14

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Severity of thoraco-lumbar trauma

Compression Type

Flexion – Extension Distraction Type

Multidirectional Rotation -

TranslationType

20% of spinal fractures are multiple 95% of spinal fractures are at continuous levels Most thoracolumbar spinal fractures occur in the Th10-L2 region

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Magerl AO Classification (1994)

This Swiss system classifies thoracolumbar fractures into 3 groups,based on the mechanism of injury:

A. Compression or Burst A1: Wedge A2: Split or coronal A3: Burst

B. Flexion - Distraction B1: Distraction of the posterior soft tissues (subluxation) B2: Distraction of the posterior arch (Chance fracture) B3: Distraction of the anterior disc (extension spondylolysis)

C. Multi-directional with translation C1: Anterior-posterior (dislocation) C2: Lateral (lateral shear) C3: Rotational (rotational burst)

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Type A Fractures (65%)

Injury to spinal cord (due to displacement of posterior

fragments) is common

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Type B Fractures (15%)

Chance Fracture

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Flexion - Distraction Fracture

Seat belt fracture; Chance fracture;

Anterior wedging of low thoracic or upper lumbar vertebrae

Focal kyphosis, facet and vertebra subluxation

Stabilizing ligaments (anterior, posterior longitudinal, capsular, ligamenta flavum) are torn with this mechanism

Up to 65% have intra-abdominal injury, especially bowel

Neurological damage in 30%

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Flexion - Distraction Fracture

Typically located at thoracolumbar junction or upper lumbar spine Must obtain CT once plain film findings suggest fracture, or show

focal kyphosis; look for intra-abdominal injury MR to evaluate cord injury, compression > 15 degrees of kyphosis ⇒ indicates instability

STIRT2T1

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Type C Fractures (20%)

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Content

Challenges

Guidelines and Reporting Strategy

Future Directions Emergency MRI

Dual-energy MDCT

MRI

CT

15 - 20 min

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Emergency MR Imaging

Recent literature shows a significant added value of complimentary emergency MRI especially with regard to patient management which is frequently changed after MRI.

Fracture classification

Associated findings

Occult fractures / Bone bruise

Myelopathy and false positive CT

Winklhofer et al. Magnetic resonance imaging frequently changes classification of acute traumatic thoracolumbar spine injuries. Skeletal Radiol 2012Pizones et al. Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment. Eur Spine J. 2011;20 Suppl. 3:390–6.Crosby et al. Diagnostic abilities of magnetic resonance imaging in traumatic injury to the posterior ligamentous complex: the effect of years in training. The Spine Journal 2011

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Dual-energy MDCT

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Conclusion

CT is the mainstay in spinal trauma imaging.

Emergency MRI provides complementary information and is indicated in all patients

with neurologic deficits.

It should also used in patients without neurologic deficits.

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