Spine MRI in Trauma Patients 4th Musculoskeletal MRI meeting 2017: Spine MRI 6th May, 2017 Gustav Andreisek, MD, MBA Ospedale Regionale di Lugano, Civico, Aula Magna Professor of Radiology, University of Zurich and Head of Radiology Spital Thurgau, Cantonal Hospital Münsterlingen, Switzerland
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 Mepha Pharma 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).
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
Content 15-20 minpersonal use only MRI Challenges CT Guidelines and Reporting Strategy Future Directions
Challenges
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
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
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 and subsequent full report (within 24hrs) (Semi-) quantitative analysis Data transfer PACS Reporting in-house vs externally Source USZ
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
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 structures Pelvis Calcaneus Wrist Spine Source USZ Source USZ
Quelle: 20min.ch
Magnetic Resonance (MR) Imaging Multiplanar imaging Excellent soft tissue contrast Ideally for radiographically occult fractures Source USZ
Added value of MRI A 37-year-old woman after a bicycle accident. Pe rso na lu se AO A1.2 on ly vs AO B1.2
Change of therapy due to MRI Pe 53-year-old man after a car accident rso na A3.1 lu AO vs se B1.2 on ly Thoraco-Lumbar Injury Classification and Severity (TLICS) injury severity score (ISS) 1 vs 7
24 ys old male with cervical spine trauma Pe Neck pain, no neurological deficits rso na lu se on ly Cervical Spine = CT Source USZ
Nuclear Medicine 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 Source UHN, Toronto
Typical Report of Bone Scan 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 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.
Impact on Therapy
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.
Content 15-20 minpersonal use only MRI Challenges CT Guidelines and Reporting Strategy Future Directions
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
ACR Appropriatness Criteria https://acsearch.acr.org/list
Clinical Scenarios > age14 Variant 1-8 = cervical spine Variant 9, 10 = adults, thoraco-lumbar Variant 11-14, age <14 yrs
Clinical Scenarios > age14
Severity of thoraco-lumbar trauma Compression Type Flexion Extension Distraction Type 20% of spinal fractures are multiple 95% of spinal fractures are at continuous levels Most thoracolumbar spinal fractures occur in the Th10-L2 region Multidirectional Rotation - Translation Type
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)
Type A Fractures (65%) Injury to spinal cord (due to displacement of posterior fragments) is common
Type B Fractures (15%) Chance Fracture
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%
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 T2 STIR T1
Type C Fractures (20%)
Content 15-20 minpersonal use only MRI Challenges CT Guidelines and Reporting Strategy Future Directions Emergency MRI Dual-energy MDCT
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 2012 Pizones 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
Dual-energy MDCT
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.