Utility of a Fast Screening MRI in patients with Cervical Spine Trauma and a Negative CT eP-207 Acharya J Namini A Rajamohan A Metting S Gibbs W

None Disclosure 2

If the CT is negative, but the patient has high risk factors, such as age 65 or greater, dangerous mechanism of injury, paresthesias in the extremities, or obtundation, magnetic resonance imaging (MRI) should be performed. In some cases, the physicians will order the MRI in the absence of these features, for patients that may have cervical spinal pain or tenderness on examination. Introduction 3

The purpose of this study is to demonstrate that for patients with negative CT cervical spine and absence of high risk clinical factors, an abbreviated MRI protocol consisting of only sagittal STIR and axial T2 sequences can identify all significant traumatic findings. Objective 4

Retrospective review of the 49 trauma patients, with CT cervical spine read as negative by a board certified Radiologist, who subsequently went on to have an MRI cervical spine and met the inclusion/exclusion criteria were selected. Inclusion criteria: No evidence of acute traumatic injury on the CT of the Cervical Spine, as per the final signed Radiologist report Patient must have no neurologic deficit No high risk factors: high speed MVA, direct head blow, fall>3 feet Age < 65 years old at the time of the CT examination MRI must be performed within 72 hours of the original CT examination No parasthesias in the extremities No obtundation No focal neurologic deficits Methods and Materials 5

Two blinded, board certified radiologists with CAQ in Neuroradiology, evaluated the MRI cervical spine: sag STIR and axial T2 images, recording all findings. Subsequent review of the same MRI studies were reviewed utilizing all sequences (Sagittal T2, Sagittal STIR, Sagittal T1, Axial T2, Axial T1), recording all findings. Patient treatment information was obtained from the medical record. Methods and Materials 6

We stratified the findings into the following categories: Ligamentous Injury (ALL, PLL, LF) Ligamentous Injury (CCJ) Ligamentous Injury: (Nuchal/supraspinous/interspinous) Soft tissue musculature (paraspinal muscles) Spinal Cord Signal Abnormality Spinal Cord Compression Osseous Edema Epidural/Subdural hematoma Prevertebral edema/hematoma Intervertebral disk injury Methods and Materials 7

We subtyped these findings based on the critical nature of each category: Methods and Materials 8 Low risk: Nuchal/supraspinous/interspinous injury Soft tissue injury Prevertebral/Retropharyngeal Edema Intermediate risk Ligamentous Injury (ALL, PLL, LF) Intervertebral disk injury Osseous Edema High Risk Ligamentous Injury (CCJ) Epidural/Subdural hematoma Spinal Cord Signal Abnormality Spinal Cord Compression

We also subtyped these findings based on the treatment Methods and Materials 9 No Treatment Conservative Treatment (C-collar)Surgical Treatment

Reader 1: Nuchal/supraspinous/interspi nous injury: 11/49 cases Zero additional findings made with the complete study Soft tissue injury: 11/49 Traumatic prevertebral/Retropharygeal Edema: 1/49 Results: Low Risk Injuries 10 Reader 2: Nuchal/supraspinous/intersp inous injury: 11/49 cases Zero additional findings made with the complete study Soft tissue injury: 16/49 Traumatic prevertebral/Retropharygeal Edema: 1/49

Interspinous (yellow) and nuchal (red) ligament injury on Sagittal T2/STIR 11

Reader 1: Ligamentous Injury (ALL, PLL, LF): 2/49: 1 focal ALL injury, 1 questionable ligamentum flavum injury LF injury remained questionable upon review of the entire study. Intervertebral disk injury: 1/49 with focal ALL injury Osseous Edema 3/49 2 with osseous contusion without vertebral body height loss 1 with degenerative facet disease. Intermediate Risk Injuries 12 Reader 2: Ligamentous Injury (ALL, PLL, LF): 1/49: Focal ALL injury Intervertebral disk injury 1/49: With focal ALL injury Osseous Edema 3/49 2 with osseous contusion without vertebral body height loss 1 with inflammatory degenerative endplate edema.

Left C7-T1 facet joint (red) and left T1 transverse process (yellow) edema on Sagittal T2/STIR and Axial T2 13

Both readers identified one case with intervertebral disc injury and anterior longitudinal ligament injury; all of these findings were identified by both readers on the Fast MRI consisting of only the Sag STIR and Ax T2. Retrospective review of the CT study demonstrated abnormal findings, which were missed on the initial Radiologist interpretation. 14

Reader 1: Ligamentous Injury (CCJ): 0/49 Epidural/Subdural hematoma: 0/49 Spinal Cord Signal Abnormality: 1/49 1 with atraumatic cord abnormality (a review of the patient history indicated the patient had Multiple Sclerosis.) Traumatic Spinal Cord Compression 0/49 High Risk Injuries 15 Reader 2: Ligamentous Injury (CCJ): 0/49 Epidural/Subdural hematoma: 0/49 Spinal Cord Signal Abnormality: 4/49 2 chronic degenerative myelopathic change in the spinal cord 1 with mild prominence of the lower cervical spinal cord central canal 1 with atraumatic cord abnormality (a review of the patient history indicated the patient had Multiple Sclerosis.) Traumatic Spinal Cord Compression 0/49

Well defined T2 hyperintense focus in the dorsal C3 cord (yellow) on Sagittal T2/STIR and Axial T2. Note the extensive interspinous ligamentous injury from C4-C7 (red). Review of the chart indicated a history of Multiple Sclerosis. Both Radiologists indicated that the cord finding was NOT POSTTRAUMATIC 16

We also characterized the patients based on their treatment Findings 17 No Treatment Conservative Treatment (C-collar)Surgical Treatment 45/49 4/49 3 with 6 week C-collar placement 1 with 4 week C-collar placement 0/49

Reader 2: Ligamentous Injury (ALL, PLL, LF): 1/49 (1 ALL) Ligamentous Injury (CCJ): 1/49 Ligamentous Injury: (Nuchal/supraspinous/interspinous): 11/49 Soft tissue musculature (paraspinal muscles): 16/49 Spinal Cord Signal Abnormality: 4/49 Traumatic Spinal Cord Compression: 0/49 Osseous Edema: 3/49 Epidural/Subdural hematoma: 0/49 Prevertebral edema/hematoma: 1/49 Intervertebral disk injury: 1/49 Summary 18 Reader 1: Ligamentous Injury (ALL, PLL, LF): 2/49 (1 ALL, 1 LF) Ligamentous Injury (CCJ): 0/50 Ligamentous Injury: (Nuchal/supraspinous/interspinous): 12/50 Soft tissue musculature (paraspinal muscles): 12/50 Spinal Cord Signal Abnormality 4/49 Traumatic Spinal Cord Compression: 0/49 Osseous Edema: 3/49 Epidural/Subdural hematoma: 0/49 Prevertebral edema/hematoma: 1/49 Intervertebral disk injury: 1/49

Both readers found NO ADDITIONAL TRAUMATIC FINDINGS on the abbreviated 2 sequence study compared to the complete 5 sequence study. Reader 2 found that the full sequence was helpful for diagnosis of non traumatic findings, specifically fat containing lesions both in the bone as well as the subcutaneous tissues Reader 1 reported possible injury to the ligamentum flavum on one case. Upon review of the entire study, the suspicion for injury persisted. Reader 1 found no additional utility with the complete 5 sequence study to help in the diagnosis of traumatic findings. Both readers identified one case with intervertebral disc injury, anterior longitudinal ligament injury, prevertebral edema, and interspinous ligament injury; all of these findings were identified by both readers on the Fast MRI consisting of only the Sag STIR and Ax T2. Retrospective review of the CT study demonstrated abnormal findings, which were missed on the initial Radiologist interpretation. Results 19

An abbreviated Fast MR cervical spine examination, consisting of only a sagittal STIR and an axial T2, is sufficient to characterize all significant injuries in trauma patients with negative CT of the cervical spine and absence of high risk features. Eliminating unnecessary sequences significantly decreases imaging acquisition time, improving through- put. Scanner time is precious, and with fast screening protocols, this time saved can be used for patients with significant pathology who require a full MRI evaluation. Conclusion 20

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