Cervical Spine Magnetic Resonance Imaging in Alert, Neurologically Intact Trauma Patients With Persistent Midline Tenderness and Negative Computed Tomography Results

doi:10.1016/j.annemergmed.2011.06.008

Annals of Emergency Medicine

Volume 58, Issue 6, December 2011, Pages 521-530

Presented as preliminary findings at the Asian Oceanic Congress of Radiology, March 2010, Taipei, Taiwan; the Spine Society of Australia Annual Scientific Meeting, April 2010, Christchurch, New Zealand; the 13th International Conference on Emergency Medicine, June 2010, Singapore; and the Annual Scientific Meeting of the Spine Society of Europe (Eurospine 2010), September 2010, Vienna, Austria.

https://doi.org/10.1016/j.annemergmed.2011.06.008 Get rights and content

Study objective

We aim to determine the prevalence and factors associated with cervical discoligamentous injuries detected on magnetic resonance imaging (MRI) in acute, alert, neurologically intact trauma patients with computed tomography (CT) imaging negative for acute injury and persistent midline cervical spine tenderness. We present the cross-sectional analysis of baseline information collected as a component of a prospective observational study.

Methods

Alert, neurologically intact trauma patients presenting to a Level I trauma center with CT negative for acute injury, who underwent MRI for investigation of persistent midline cervical tenderness, were prospectively recruited. Deidentified images were assessed, and injuries were identified and graded. Outcome measures included the presence and extent of MRI-detected injury of the cervical ligaments, intervertebral discs, spinal cord and associated soft tissues.

Results

There were 178 patients recruited during a 2-year period to January 2009. Of these, 78 patients (44%) had acute cervical injury detected on MRI. There were 48 single-column injuries, 15 two-column injuries, and 5 three-column injuries. Of the remaining 10 patients, 6 had isolated posterior muscle edema, 2 had alar ligamentous edema, 1 had epidural hematoma, and 1 had atlanto-occipital edema. The injuries to 38 patients (21%) were managed clinically; 33 patients were treated in cervical collars for 2 to 12 weeks, and 5 patients (2.8%) underwent operative management, 1 of whom had delayed instability. Ordinal logistic regression revealed that factors associated with a higher number of spinal columns injured included advanced CT-detected cervical spondylosis (odds ratio [OR] 11.6; 95% confidence interval [CI] 3.9 to 34.3), minor isolated thoracolumbar fractures (OR 5.4; 95% CI 1.5 to 19.7), and multidirectional cervical spine forces (OR 2.5; 95% CI 1.2 to 5.2).

Conclusion

In patients with cervical midline tenderness and negative acute CT findings, we found that a subset of patients had MRI-detected cervical discoligamentous injuries and that advanced cervical spine degeneration evident on CT, minor thoracolumbar fracture, and multidirectional cervical spine forces were associated with increased injury extent. However, a larger study is required to validate which variables may reliably predict clinically important injury in such patients, thereby indicating the need for further radiographic assessment.

Introduction

In many cases, midline cervical tenderness after trauma is absent or resolves quickly, allowing clearance of the cervical spine in the absence of intoxication, altered conscious state, painful distracting injury, persistent focal neurologic deficit,1, 2, 3, 4 and acutely abnormal cervical computed tomography (CT) findings. However, persistence of midline cervical tenderness on palpation in alert, neurologically intact patients presents a clinical dilemma because it is unclear which patients require further investigation. The presence of fractures alerts clinicians to the possibility of injury to other cervical structures, but the absence of acute, positive CT findings is often erroneously equated with lack of injury. The level of efficiency in identifying occult cervical disc or ligamentous injury in the absence of fracture is uncertain under many cervical spine clearance protocols. Detection of occult cervical spine injuries and the determination of their clinical significance are imperative in the avoidance of missed injuries, the assignment of appropriate management, and the mitigation of long-term morbidity.

In recent years, magnetic resonance imaging (MRI) has emerged as a definitive and highly sensitive tool in the detection of acute cervical discoligamentous injury.⁵ However, in the setting of cervical CT findings that are negative for acute injury, MRI is generally indicated in patients with trauma-related neurologic symptoms and signs.

Our objective was to determine the presence of MRI-detected injury, if any, and the characteristics associated with injury extent in alert, neurologically intact trauma patients with CT findings negative for acute injury. Our scope was not limited to the detection of instability but focused more broadly on the characterization of injury that may also result either in delayed neurologic deficit or long-term pain or disability.

Section snippets

Study Design and Setting

We report here the cross-sectional analysis of baseline information collected as part of a prospective cohort study conducted at a Level I adult trauma center. The institution is a referral center for metropolitan and regional major trauma patients and has 15,000 trauma presentations per year, of whom 1,500 patients are categorized as having major trauma. Institutional ethics committee approval was obtained and participating patients' informed consent was obtained in writing.

Selection of Participants

Consecutive, adult,

Characteristics of Study Subjects

There were 9,152 trauma patients who underwent admission cervical spine CT during the 2-year study period to January 2009. Of those patients, 741 had CT findings negative for acute injury and persistent midline cervical tenderness. From this group, 178 eligible patients were recruited to the study. The inclusion/exclusion information is presented in Figure 1 and patient characteristics are presented in Table 1.

For the study cohort, cervical spine MRI was conducted at a median of 37.5 hours

Limitations

The main limitation of our study was the potential for measurement (observer) bias, given that the study personnel were not blinded to the hypothesis of the study. A single, experienced researcher recruited the study participants and was responsible for data collection. However, a standard data collection tool was used, the demographic data were collected before MRI, and the data were consistently complete. In addition, the reporting radiologists were cognizant that participants had all

Discussion

In 1963, Holdsworth¹⁴ defined spinal instability as rupture of the posterior ligamentous complex, after the development of his two-column thoracolumbar theory, in which the anterior column comprised the anterior longitudinal ligament, intervertebral disc, and posterior longitudinal ligament and the posterior column involved all components that were posterior to the posterior longitudinal ligament. Subsequent biomechanical studies, however, found that instability in flexion, for example, also

References (53)

J.R. Hoffman et al.
Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)
Ann Emerg Med
(1998)
E.A. Panacek et al.
Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury
Ann Emerg Med
(2001)
H.M. Ackland et al.
Unilateral internal jugular venous thrombosis in a young trauma patient
Injury Extra
(2009)
J.R. Dusseldorp et al.
Unrecognized ligamentous instability due to high-energy, low-velocity mechanism of injury
J Clin Neurosci
(2010)
J.F. Cusick et al.
Biomechanics of the cervical spine 4: major injuries
Clin Biomech
(2002)
G. Borchgrevink et al.
MRI of cerebrum and cervical columna within two days after whiplash neck sprain injury
Injury
(1997)
N. Yoganandan et al.
Biomechanics of the cervical spine part 2Cervical spine soft tissue responses and biomechanical modeling
Clin Biomech (Bristol, Avon)
(2001)
S. Kumaresan et al.
Contribution of disc degeneration to osteophyte formation in the cervical spine: a biomechanical investigation
J Orthop Res
(2001)
J.M. Hsu et al.
Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging
Injury
(2003)
G.W. Hendey et al.
Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma
J Trauma
(2002)

J.R. Hoffman et al.

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt traumaNational Emergency X-Radiography Utilization Study Group

N Engl J Med

(2000)

H.M. Ackland et al.

Magnetic resonance imaging for clearing the cervical spine in unconscious intensive care trauma patients

J Trauma

(2006)

C. Peterson et al.

A cross-sectional study correlating degeneration of the cervical spine with disability and pain in United Kingdom patients

Spine

(2003)

C.K. Peterson et al.

A cross-sectional study correlating lumbar spine degeneration with disability and pain

Spine

(2000)

R.S. Rosen et al.

Increased 18F-FDG uptake in degenerative disease of the spine: characterization with 18F-FDG PET/CT

J Nucl Med

(2006)

S.W. Yu et al.

Progressive and regressive changes in the nucleus pulposusPart II. The adult

Radiology

(1988)

D. Altman

Practical Statistics for Medical Research

(1991)

F. Denis

Spinal instability as defined by the three-column spine concept in acute spinal trauma

Clin Orthop Relat Res

(1984)

F. Denis

The three column spine and its significance in the classification of acute thoracolumbar spinal injuries

Spine

(1983)

F.W. Holdsworth

Fractures, dislocations and fracture-dislocations of the spine

J Bone Joint Surg Br

(1963)

M.M. Panjabi et al.

A biomechanical study of the ligamentous stability of the thoracic spine in man

Acta Orthop Scand

(1981)

M.M. Panjabi et al.

Basic biomechanics of the spine

Neurosurgery

(1980)

M.M. Panjabi et al.

Validity of the three-column theory of thoracolumbar fractures

Spine

(1995)

R. Louis

Spinal stability as defined by the three-column spine concept

Anat Clin

(1985)

H. Bozkus et al.

Biomechanical analysis of rigid stabilization techniques for three-column injury in the lower cervical spine

Spine

(2005)

G.R. Cybulski et al.

Complications in three-column cervical spine injuries requiring anterior-posterior stabilization

Spine

(1992)

Cited by (34)

Injury patterns of the spine following blunt trauma: A per-segment analysis of spinal structures and their detection rates in CT and MRI
2023, Heliyon
To provide a detailed analysis of injury patterns of the spine following blunt trauma and establish the role of supplementary MRI by evaluating discrepancies in the detection rates of damaged structures in CT and MRI.
216 patients with blunt trauma to the spine who underwent CT followed by supplementary MRI were included in this study. Two board-certified radiologists blinded to clinical symptoms and injury mechanisms independently interpreted all acquired CT and MRI images. The interpretation was performed using a dedicated catalogue of typical findings associated with spinal trauma and assessed for spinal stability using the AO classification systems.
Lesions to structures associated with spinal instability were present in 31.0% in the cervical spine, 12.3% in the thoracic spine, and 29.9% in the lumbar spine. In all spinal segments, MRI provided additional information regarding potentially unstable injuries. Novel information derived from supplementary MRI changed clinical management in 3.6% of patients with injury to the cervical spine. No change in clinical management resulted from novel information on the thoracolumbar spine. Patients with injuries to the vertebral body, intervertebral disc, or spinous process were significantly more likely to benefit from supplementary MRI.
In patients that sustained blunt spinal trauma, supplementary MRI of the cervical spine should routinely be performed to detect injuries that require surgical treatment, whereas CT is the superior imaging modality for the detection of unstable injuries in the thoracolumbar spine.
Unilateral Alar Ligament Injury: Diagnostic, Clinical, and Biomechanical Features
2019, World Neurosurgery
Citation Excerpt :
It can thus be suggested that investigation should continue with an MRI in the presence of significant clinical findings. MRI is the examination of choice for demonstrating ligamentous injuries in occult cervical injuries.20 Some studies showed that alar ligament hyperintensity can be seen on MRIs of normal patients.21,22
Isolated unilateral alar ligament injury (ALI) is a very rarely diagnosed condition, with only 9 cases reported in the literature. The purpose of this study is to determine clinical, diagnostic, and biomechanical features of unilateral ALI.
A total of 6 patients diagnosed with ALI were included in this series. The hospital records and radiologic imaging of admission and follow-ups were investigated retrospectively.
Rotation of the neck and/or hyperflexion was always present as a mechanism of injury. The patients were neurologically intact. All patients presented with mild neck pain aggravated by head rotation. On computed tomography (CT) scans, the dens was observed to be displaced to the opposite side. Magnetic resonance imaging (MRI) showed a widened lateral dens-atlas space with high signal intensity. All patients underwent lateral flexion–extension CTs for the confirmation of craniovertebral junction (CVJ) stability. The patients were treated with hard collars. The follow-up MRI of 3 patients obtained at the third month showed normal lateral dens–atlas interval and recovered ligaments. All patients were pain free after 6 months.
Unilateral ALI appears to be more common but misdiagnosed than previously thought. Trauma mechanism consists of hyperflexion and contralateral rotation. Neck pain aggravated with rotation is the most significant clinical finding. Dens lateralization is the most important finding in CT scans. An MRI focusing on the CVJ is essential for the diagnosis. The stability of CVJ must be checked with a flexion–extension CT scan. Unilateral ALI is a stable condition and responds to conservative treatment.
Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma
2018, Annals of Emergency Medicine
Citation Excerpt :
The NEXUS low-risk criteria and the Canadian C-Spine Rule study have previously demonstrated that imaging is unnecessary in awake and alert patients who are neurologically intact and without distracting injury.34-36 However, the use of these criteria is inconsistent, especially in patients with persistent cervical tenderness.37,38 Although CT has been accepted as the standard first-line diagnostic modality in patients with blunt trauma, the adequacy of a normal CT result alone has been questioned.
Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population.
A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies.
The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed.
MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result.
Unstable cervical spine fracture with normal computed tomography imaging
2015, American Journal of Emergency Medicine
Computed tomography for clearance of cervical spine injury in the unevaluable patient
2013, World Neurosurgery
Citation Excerpt :
First, although CT scanning has high sensitivity to detect osseous injury, it is a poor diagnostic study to detect soft-tissue injuries such as ligamentous injury. Of note, even when MRI is used in a separate population of neurologically intact patients with midline cervical tenderness but CT negative studies, up to 44% display evidence of acute cervical injury in a recent prospective trial of 178 patients (1). Second, CT scan is a nonweight-bearing study.
To review computed tomography (CT) as a stand-alone test for the clearance of cervical spine injury in the unevaluable patient population.
A PubMed database search was performed using a combination of search terms and Medical Subject Headings. Studies that met inclusion criteria were those with unevaluable patient populations suffering blunt trauma who underwent both CT and magnetic resonance imaging (MRI) of the cervical spine.
Our analysis of 13 articles revealed that a total of 1322 unevaluable patients with a negative CT C-spine who also underwent MRI; 137 of these patients (10%) had positive findings on MRI. Among nine studies with patient management data, a total of 115 patients had positive MRI findings in the setting of a negative CT. Of those 115 patients, 52%, or 60 patients, had changes to their management based on MRI findings. Surgical stabilization was required in three patients, representing 2.5% of the 115 patients with positive MRI findings. The total number of patients in these nine studies who had a negative CT was 855. Therefore, the negative predictive value of a negative CT in this patient population was 92.9% for clinically significant cervical spine injury and 99.6% for cervical spine injury requiring operative intervention.
The evidence supporting CT for the stand-alone evaluation of the cervical spine in the unevaluable patient is insufficient. We contend that a CT of the cervical spine must be supplemented by an additional examination addressing ligamentous instability in this patient population.
Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes
2022, EMA - Emergency Medicine Australasia

View all citing articles on Scopus

: Supervising editor: Allan B. Wolfson, MD

: Author contributions: HMA and PAC conceived the study and were responsible for recruitment and managed the data. HMA, PAC, DKV, GJF, DJC, RW, GMM, JVR, and ODW provided input into the study design. HMA secured research funding. HMA, PAC, DKV, GJF, DJC, RW, GMM, and JVR supervised the conduct of the trial. HMA was responsible for primary data collection. DKV and GJF were responsible for review of images. GMM, SML, and JVR were responsible for patient review and management decisions. RW provided advice on statistical design. HMA and RW analyzed the data. PAC chaired the steering committee. HMA drafted the article, and all authors contributed substantially to editing and revision. HMA and PAC take responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Funded by the Transport Accident Commission, Victoria, Australia (grant No. NV16).

: Earn CME Credit: Continuing Medical Education is available for this article at www.ACEP-EMedHome.com.

: Publication date: Available online August 5, 2011.

: Please see page 522 for the Editor's Capsule Summary of this article.

: Provide feedback on this article at the journal's Web site, www.annemergmed.com.

: A podcast for this article is available at www.annemergmed.com.

View full text

Trauma/original researchCervical Spine Magnetic Resonance Imaging in Alert, Neurologically Intact Trauma Patients With Persistent Midline Tenderness and Negative Computed Tomography Results

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design and Setting

Selection of Participants

Characteristics of Study Subjects

Limitations

Discussion

Ann Emerg Med

Ann Emerg Med

Injury Extra

J Clin Neurosci

Clin Biomech

Injury

Clin Biomech (Bristol, Avon)

J Orthop Res

Injury

Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma

J Trauma

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt traumaNational Emergency X-Radiography Utilization Study Group

N Engl J Med

Magnetic resonance imaging for clearing the cervical spine in unconscious intensive care trauma patients

J Trauma

A cross-sectional study correlating degeneration of the cervical spine with disability and pain in United Kingdom patients

Spine

A cross-sectional study correlating lumbar spine degeneration with disability and pain

Spine

Increased 18F-FDG uptake in degenerative disease of the spine: characterization with 18F-FDG PET/CT

J Nucl Med

Progressive and regressive changes in the nucleus pulposusPart II. The adult

Radiology

Practical Statistics for Medical Research

Spinal instability as defined by the three-column spine concept in acute spinal trauma

Clin Orthop Relat Res

The three column spine and its significance in the classification of acute thoracolumbar spinal injuries

Spine

Fractures, dislocations and fracture-dislocations of the spine

J Bone Joint Surg Br

A biomechanical study of the ligamentous stability of the thoracic spine in man

Acta Orthop Scand

Basic biomechanics of the spine

Neurosurgery

Validity of the three-column theory of thoracolumbar fractures

Spine

Spinal stability as defined by the three-column spine concept

Anat Clin

Biomechanical analysis of rigid stabilization techniques for three-column injury in the lower cervical spine

Spine

Complications in three-column cervical spine injuries requiring anterior-posterior stabilization

Spine

Trauma/original research
Cervical Spine Magnetic Resonance Imaging in Alert, Neurologically Intact Trauma Patients With Persistent Midline Tenderness and Negative Computed Tomography Results