Acute cervical cord injury without fracture or dislocation of the spinal column

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Object. It is known that the spinal cord can sustain traumatic injury without associated injury of the spinal column in some conditions, such as a flexible spinal column or preexisting narrowed spinal canal. The purpose of this study was to characterize the clinical features and to understand the mechanisms in cases of acute cervical cord injury in which fracture or dislocation of the cervical spine has not occurred.

Methods. Eighty-nine patients who sustained an acute cervical cord injury were treated in our hospitals between 1990 and 1998. In 42 patients (47%) no bone injuries of the cervical spine were demonstrated, and this group was retrospectively analyzed. There were 35 men and seven women, aged 19 to 81 years (mean 58.9 years). The initial neurological examination indicated complete injury in five patients, whereas incomplete injury was demonstrated in 37.

In the majority of the patients (90%) the authors found degenerative changes of the cervical spine such as spondylosis (22 cases) or ossification of the posterior longitudinal ligament (16 cases). The mean sagittal diameter of the cervical spinal canal, as measured on computerized tomography scans, was significantly narrower than that obtained in the control patients. Magnetic resonance (MR) imaging revealed spinal cord compression in 93% and paravertebral soft-tissue injuries in 58% of the patients.

Conclusions. Degenerative changes of the cervical spine and developmental narrowing of the spinal canal are important preexisting factors. In the acute stage MR imaging is useful to understand the level and mechanisms of spinal cord injury. The fact that a significant number of the patients were found to have spinal cord compression despite the absence of bone injuries of the spinal column indicates that future investigations into surgical treatment of this type of injury are necessary.

Article Information

Address reprint requests to: Izumi Koyanagi, M.D., Hokkaido Neurosurgical Memorial Hospital, North 22, West 15, Chuo-ku, Sapporo, 060–0022, Japan. email: k-izumi@jd5.so-net.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Bar graph showing the distribution of the vertebral level of injury in 42 patients with acute SCI. The level is expressed as the intervertebral disc level. The patients in whom SCI at the vertebral body level was caused by OPLL are included in the caudal intervertebral disc level. For example, SCI at the C-3 vertebral body level is included in the C3–4 group. In eight patients SCI occurred at two levels; the uppermost level was used for analysis in these eight patients. The graph indicates that cervical spine injury without fracture or dislocation of the spinal column occurred predominantly at the C3–4 and C4–5 levels.

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    Bone window CT scan obtained in cases of OPLL to measure the sagittal diameter (S) of the spinal canal at the injured level.

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    Magnetic resonance images of the cervical spine obtained in a 53-year-old man who presented with mild tetraparesis (severe pain of the bilateral hands) after falling to the ground. Plain radiography and CT scanning of the cervical spine demonstrated no abnormal findings, except for spondylotic changes visualized at C5–6 and C6–7 and small OPLL at C-7. Left: The sagittal T1-weighted image obtained approximately 5 hours after injury revealing a protruded disc that compresses the spinal cord at C5–6 (arrow). Center: A T2-weighted image revealing a hyperintense area that indicates hematoma or damaged soft tissues over the prevertebral region (arrow) and intramedullary hyperintensity at C5–6. Right: Postoperative T1-weighted image obtained after we performed anterior discectomy and fusion at the C5–6 level and placement of an autologous iliac bone graft and anterior cervical plate 2 days postinjury. The pain and motor weakness of his hands markedly improved after surgery, and his function improved from Frankel Grade D to E.

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    Imaging studies of the cervical spine obtained in a 57-year-old man who became tetraplegic after falling to the ground in a drunken state. Upper Left: Plain lateral x-ray film demonstrating a continuous type OPLL at C4–6 with ossification of the anterior longitudinal ligament. Upper Right: A CT scan obtained at C-4, demonstrating OPLL that narrows the spinal canal. Lower Left: A T2-weighted image revealing hyperintensity at the prevertebral region and spinal cord compression from the C3–4 to C-5 levels. The intramedullary hyperintensity is also visualized at the C-4 level. Lower Right: A CT scan obtained at C-4 after surgery. The patient underwent a C2–7 double-door laminoplasty approximately 20 hours after injury. He gradually recovered (Frankel Grade B–C) from complete paralysis of the upper and lower limbs, but useful motor function was not obtained.

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