Magnetic resonance imaging (MRI) has been playing an increasingly important role in the spinal trauma patients due to high sensitivity for detection of acute soft tissue and cord injuries. More and more patients are undergoing MRI for spinal trauma in the emergency settings, thus necessitating the interpreting physicians to be familiar with MRI findings in spinal trauma. In this pictorial review, we will first describe the normal anatomy of various ligamentous structures. Indications of MRI in spinal trauma as well as the role of MRI in diagnosing spinal cord and soft tissue injuries will then be discussed. Illustrated cases are mainly of cervical spine trauma, but thoracolumbar spine injuries are also included where appropriate in our review.
Imaging plays a critical role in diagnosis of acute spinal trauma and helps in initiating prompt and accurate treatment in these patients. Conventional radiographs and computed tomography (CT) are the initial imaging modalities used in the diagnosis of most cases of spinal injuries. While stability of the spine may be adequately assessed with CT for surgical decision making by spine surgeons , due to its increased availability in the emergency settings and its inherently superior contrast resolution, MRI has been playing an increasingly important role in the management of spinal trauma patients. Notably, MRI is the modality of choice for evaluation of ligamentous and other soft tissue structures, disc, spinal cord and occult osseous injuries . In this pictorial review, we will first describe the normal anatomy of various ligamentous structures including the craniocervical junction. Then, indications of MRI in spinal trauma as well as the role of MRI in diagnosing spinal cord, soft tissue injuries and occult osseous injuries will be discussed (Table 1). Illustrated cases are mainly of cervical spine trauma, but thoracolumbar spine injuries are also included where appropriate. Various limitations and pitfalls of MRI in spinal trauma imaging will also be discussed.
The typical MRI protocol for spinal injury includes sagittal T1 weighted (T1W) and T2 weighted (T2W) spin echo sequences, and T2* weighted (T2*W) gradient recalled echo (GRE) sequence, and sagittal short tau inversion recovery (STIR) sequences, as well as axial T2W and T2*W GRE sequences. T1W images are mainly used for depiction of anatomy and osseous fractures. STIR images are very sensitive for detection of edema and is helpful in diagnosing the soft tissue and ligamentous injuries, particularly of the interspinous or supraspinous ligaments. Although fat-suppressed T2W images can also be used for detection of edema, STIR images provide more uniform fat suppression. T2W images are very good in detecting the cord edema, and T2*W GRE images are used to detect the hemorrhage in and around the cord . Recently, diffusion tensor imaging (DTI) has been used to detect trauma related changes in the spinal cord which are not seen on conventional MRI technique [7, 8]. Ideally MRI should be performed within 72 hours of injury as the T2 hyperintensity produced by edema improves the conspicuity of the ligaments which are seen as low signal intensity in normal state . Later on, resolution of the edema and hemorrhage reduces sensitivity of MRI to detect ligamentous injuries.
Traumatic disc herniations are most commonly associated with vertebral fracture dislocations and hyperextension injuries of the spine, and are caused by injuries to annulus fibrosus with nucleus pulposus herniation. On MRI, these can appear similar to non-traumatic disc herniations (Fig. 4a, b), and may cause compression of spinal cord leading to central cord syndrome in some cases . MRI is better than CT in evaluating the traumatic disc herniations due to excellent contrast between disc, vertebral body and cerebrospinal fluid on appropriate pulse sequences. Additionally, multiplanar MRI is very helpful in evaluating large disc extrusions and sequestrated disc fragments before closed reduction of spinal dislocations . Undetected disc herniations can cause new or worsening cord injury with progressive neurological deficits. Disc injuries without herniations are characterized by asymmetric widening or narrowing of the disc with abnormal signal related to edema. Histologically, these changes may be related to rupture of annulus fibrosus with hematoma .
Sagittal T2 weighted image (a) and axial gradient recalled echo (GRE) image (b) show the presence of hemorrhagic contusion (arrow, a) in the spinal cord characterized by susceptibility artifact on GRE image (arrow, b)
In conclusion, MRI is more sensitive than other imaging modalities in the diagnosis of soft tissue and spinal cord injuries. While CT is considered adequate for determination of stable vs unstable spinal injuries, MRI can offer additional help due to its ability to better diagnose ligamentous injuries when compared with CT. MRI is also helpful in predicting the prognosis by demonstrating the hemorrhagic and non hemorrhagic cord injuries.
The spinal cord functions primarily in the transmission of nerve signals from the motor cortex to the body, and from the afferent fibers of the sensory neurons to the sensory cortex. It is also a center for coordinating many reflexes and contains reflex arcs that can independently control reflexes. It is also the location of groups of spinal interneurons that make up the neural circuits known as central pattern generators. These circuits are responsible for controlling motor instructions for rhythmic movements such as walking.
The spinal cord is the main pathway for information connecting the brain and peripheral nervous system. Much shorter than its protecting spinal column, the human spinal cord originates in the brainstem, passes through the foramen magnum, and continues through to the conus medullaris near the second lumbar vertebra before terminating in a fibrous extension known as the filum terminale.
The spinal cord is continuous with the caudal portion of the medulla, running from the base of the skull to the body of the first lumbar vertebra. It does not run the full length of the vertebral column in adults. It is made of 31 segments from which branch one pair of sensory nerve roots and one pair of motor nerve roots. The nerve roots then merge into bilaterally symmetrical pairs of spinal nerves. The peripheral nervous system is made up of these spinal roots, nerves, and ganglia.
The dorsal roots are afferent fascicles, receiving sensory information from the skin, muscles, and visceral organs to be relayed to the brain. The roots terminate in dorsal root ganglia, which are composed of the cell bodies of the corresponding neurons. Ventral roots consist of efferent fibers that arise from motor neurons whose cell bodies are found in the ventral (or anterior) gray horns of the spinal cord.
The spinal cord (and brain) are protected by three layers of tissue or membranes called meninges, that surround the canal. The dura mater is the outermost layer, and it forms a tough protective coating. Between the dura mater and the surrounding bone of the vertebrae is a space called the epidural space. The epidural space is filled with adipose tissue, and it contains a network of blood vessels. The arachnoid mater, the middle protective layer, is named for its open, spiderweb-like appearance. The space between the arachnoid and the underlying pia mater is called the subarachnoid space. The subarachnoid space contains cerebrospinal fluid (CSF), which can be sampled with a lumbar puncture, or "spinal tap" procedure. The delicate pia mater, the innermost protective layer, is tightly associated with the surface of the spinal cord. The cord is stabilized within the dura mater by the connecting denticulate ligaments, which extend from the enveloping pia mater laterally between the dorsal and ventral roots. The dural sac ends at the vertebral level of the second sacral vertebra.
In cross-section, the peripheral region of the cord contains neuronal white matter tracts containing sensory and motor axons. Internal to this peripheral region is the grey matter, which contains the nerve cell bodies arranged in the three grey columns that give the region its butterfly-shape. This central region surrounds the central canal, which is an extension of the fourth ventricle and contains cerebrospinal fluid.
The spinal cord is elliptical in cross section, being compressed dorsolaterally. Two prominent grooves, or sulci, run along its length. The posterior median sulcus is the groove in the dorsal side, and the anterior median fissure is the groove in the ventral side.
The human spinal cord is divided into segments where pairs of spinal nerves (mixed; sensory and motor) form. Six to eight motor nerve rootlets branch out of right and left ventralateral sulci in a very orderly manner. Nerve rootlets combine to form nerve roots. Likewise, sensory nerve rootlets form off right and left dorsal lateral sulci and form sensory nerve roots. The ventral (motor) and dorsal (sensory) roots combine to form spinal nerves (mixed; motor and sensory), one on each side of the spinal cord. Spinal nerves, with the exception of C1 and C2, form inside the intervertebral foramen (IVF). These rootlets form the demarcation between the central and peripheral nervous systems.
Generally, the spinal cord segments do not correspond to bony vertebra levels. As the spinal cord terminates at the L1-L2 level, other segments of the spinal cord would be positioned superior to their corresponding bony vertebral body. For example, the T11 spinal segment is located higher than the T11 bony vertebra, and the sacral spinal cord segment is higher than the L1 vertebral body.
The grey column, (as three regions of grey columns) in the center of the cord, is shaped like a butterfly and consists of cell bodies of interneurons, motor neurons, neuroglia cells and unmyelinated axons. The anterior and posterior grey column present as projections of the grey matter and are also known as the horns of the spinal cord. Together, the grey columns and the gray commissure form the "grey H." 2b1af7f3a8