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					Title: Imaging of Spinal Cord Injuries
Authors: Kahi A, Hockberger R.
Journal: Emergency Medicine Clinics of North America (2007)

Key Points
              Radiographs (including flexion/extension views) are used commonly as screening but may be insufficient especially in cases of
               obtunded or unresponsive patients.
              CT scan has been increasingly used as an imaging modality for spine trauma and has high sensitivity and specificity, but the high
               levels of radiation exposure associated with CT is concerning.
              MRI is the most useful imaging modality for evaluation of the spinal cord itself as well as the other soft tissue structures of the spine.

Clinical Conclusions
              Early diagnosis and management of spinal cord injury is critical in minimizing complications and the severity of the injury so maging
               modalities must be carefully selected to allow for early detection of injury without additional risk to the patient.

Section Highlights
              Blunt mechanism trauma (e.g. motor vehicle crashes) account for 46.9% of cases followed by falls, acts of violence, and sports
                         1                                                    2
               injuries. ; penetrating trauma accounts for 10-20% of cases.
              55% of all spine injuries involve the cervical spine with lesser but equal percentage involving the thoracic (15%), thoracolumbar
               (15%), and lumbosacral (15%) regions.
              Spinal cord injury without radiographic abnormality (SCIWORA) is defined as the presence of neurologic deficits in the absence of an
               apparent injury on a complete, technically adequate plain radiographic series and is more commonly seen in the pediatric patient
Routine Radiographs
              Two clinical decision rules have been developed to help promote the judicious use of radiography in evaluating trauma patients.
               Box 1-2
              Flexion-extension (F/E) radiographic series can be useful in detecting ligamentous injury in the setting of negative x-rays or an
               obtunded patient but have high false positive and false negative rates.
CT and MRI
              CT and MRI are playing increasingly important roles in the evaluation of thoracic and lumbar injury but concern remains about the
               high cost of these imaging modalities.
              MRI is widely accepted as the imaging modality of choice for identify the spinal cord and other soft tissue structures of the spine as
               well as to diagnose SCIWORA in which MRI findings include central disc herniation, spinal stenosis, cord edema, and contusion.
               Figure 1
              The disadvantages of CT include higher doses of radiation, decreased efficacy in the presence of severe degenerative disease, and
               limited ability to evaluate soft tissue structures.
              MRI has some additional complications as it may be associated with delays, risk with transport, and equipment (ventilators,
               monitors) must be compatible with the MRI machine.
              Helical CT has also been shown to have superior accuracy (Figures 2A-D) and is not associated with the high levels of radiation that is
               involved when evaluating the cervical spine
Pediatric Spinal Injuries
              Pediatric injuries comprise only 2-5% of all spine injuries with most being from motor vehicle accidents. ,
              Spine injuries are more common in children over the age of 8 years but SCIWORA accounts for 2/3 of severe c-spine injuries in those
                          6, 7
               under 8.
Geriatric Spinal Injuries
              The elderly account for a disproportionate majority of total spine injuries with age over 65 years being shown to have increased
                    8, 9
              Older age is also associated with greater morbidity and decreased self-reported favorable outcomes after spine injury.

                                                                    Key References

1.        NSCISC, Spinal cord injury facts and figures at a glance. 2006, National Spinal Cord Injury Statistical Center: Burmingham AL.
2.        Bagley L.J., Imaging of spinal trauma. Radiol Clin North Am, 2006. 44(1): p. 1-12, vii.
3.        Cooper D.J. and Ackland H.M., Clearing the cervical spine in unconscious head injured patients - the evidence. Crit Care Resusc, 2005. 7(3):
          p. 181-4.
4.        Lowery D.W., Wald M.M., Browne B.J., Tigges S., Hoffman J.R., and Mower W.R., Epidemiology of cervical spine injury victims. Ann Emerg
          Med, 2001. 38(1): p. 12-6.
5.   Brown R.L., Brunn M.A., and Garcia V.F., Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1
     pediatric trauma center. J Pediatr Surg, 2001. 36(8): p. 1107-14.
6.   Pang D. and Wilberger J.E., Jr., Spinal cord injury without radiographic abnormalities in children. J Neurosurg, 1982. 57(1): p. 114-29.
7.   Pang D. and Pollack I.F., Spinal cord injury without radiographic abnormality in children--the SCIWORA syndrome. J Trauma, 1989. 29(5): p.
8.   Hoffman J.R., Mower W.R., Wolfson A.B., Todd K.H., and Zucker M.I., Validity of a set of clinical criteria to rule out injury to the cervical
     spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med, 2000. 343(2): p. 94-9.
9.   Stiell I.G., Wells G.A., Vandemheen K.L., Clement C.M., Lesiuk H., De Maio V.J., Laupacis A., Schull M., McKnight R.D., Verbeek R., Brison
     R., Cass D., Dreyer J., Eisenhauer M.A., Greenberg G.H., MacPhail I., Morrison L., Reardon M., and Worthington J., The Canadian C-spine
     rule for radiography in alert and stable trauma patients. Jama, 2001. 286(15): p. 1841-8.

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