Abstract
Despite the general acceptance of magnetic resonance imaging (MRI) as the gold standard for diagnostics of traumatic disco-ligamentous injuries in the subaxial cervical spine, clinical experience shows cases where no lesion is detected in MRI exams but obtained during surgery. The aim of this study was to compare intraoperative site inspection to preoperative imaging findings and to identify radiological features of patients having a risk for under- or over-estimating disco-ligamentous lesions. We performed a retrospective analysis of our clinical database, considering all patients who underwent surgical treatment of the cervical spine via an anterior approach after trauma between June 2008 and April 2018. Only patients with availability of immediate preoperative computed tomography (CT), 3-Tesla MRI scans, and information about intraoperative findings were considered. Results of preoperative imaging were set in context to intraoperative findings, and receiver operator characteristics (ROC) were calculated. Out of 144 patients receiving anterior cervical surgery after trauma, 83 patients (mean age: 59.4 ± 20.5 years, age range: 12–94 years, 63.9% males) were included in this study. Included patients underwent surgical treatment via anterior cervical discectomy and fusion (ACDF; 79 patients) or anterior cervical corpectomy and fusion (4 patients) with ventral plating. Comparing preoperative imaging findings to intraoperative site inspection, a discrepancy between imaging and surgical findings was revealed in 14 patients, leading to an overall specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of the cervical spine of 100%/77.4%. Yet, adding the existence of prevertebral hematoma and/or vertebral fractures according to preoperative imaging improved the sensitivity to 95.2%. Lack of sensitivity was most likely related to severe cervical spondylosis, rendering correct radiological reporting difficult. Thus, the risk of missing a traumatic disco-ligamentous injury of the cervical spine in imaging seems to be a particular threat in patients with preexisting degenerative cervical spondylosis. In conclusion, incorporating the existence of prevertebral hematoma and/or vertebral fractures can significantly improve diagnostic yield.
Highlights
Cervical spine injury is common, either isolated or as a concomitant injury in polytrauma, and can lead to devastating morbidity and mortality [1,2]
magnetic resonance imaging (MRI) performed with a 3-Tesla system using dedicated multi-sequence protocols for suspected cervical trauma, (3) a field of view (FOV) covering at least the entire cervical spine, and (4) availability of detailed information about intraoperative findings were included
Our findings show that presence of a prevertebral hematoma and/or vertebral fractures on the level of disco-ligamentous injury are highly suggestive for a disco-ligamentous injury in cases where ligamentous discontinuity or evident disc trauma is not explicitly visible in MRI, suggesting that rigorous interpretation of instability only when such pathology is captured by MRI should be made with high caution
Summary
Cervical spine injury is common, either isolated or as a concomitant injury in polytrauma, and can lead to devastating morbidity and mortality [1,2]. In the emergency setting of blunt trauma, computed tomography (CT) of the cervical spine is the first-line imaging modality of choice for initial evaluation and potential clearance [5,6]. This is due to the wide disposability and speed of examination of CT, with radiographs being required if CT is yet unavailable [5,6,7]. The detection of spinal cord injury, other soft tissue damage, occult osseous lesions, or small hematoma is possible [11]. Prompt initial imaging-based diagnostics can be key for correct clinical decision-making, to detect and treat possibly life-threatening complications early, and to plan the surgical procedure [12,13,14,15,16]
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