Assessment of cervical spinal trauma
In the context of diagnostic imaging of spinal cord injuries at the cervical level, magnetic resonance imaging plays a special role. An MR myelogram sequence (MR Myelogram Sequence) on coronal T2-weighted images allows for detailed visualization of soft-tissue injuries:
- Brachial plexus root avulsion (brachial plexus avulsion) — for example, at the C8 and Th1 segments.
- Traumatic meningoceles — cerebrospinal fluid collections that appear as hyperintense (bright) areas in the injured zone on T2-weighted images.
To systematize subaxial cervical spine injuries, a specialized AOSpine classification system is used. Additionally, postoperative MRI is critically important for predicting the likelihood of neurological deficit recovery. When nonaccidental injury / child abuse (nonaccidental injury / child abuse) is suspected, cervical MRI is used to search for specific injuries in conjunction with neuroimaging of the brain.
Postoperative imaging follow-up
Imaging of the spine after surgical interventions (arthrodesis, bone grafting) requires the specialist to understand what materials and structures were used. The following patterns can be observed on postoperative images of the cervical and other spinal regions:
- Post-corpectomy status: In the treatment of tumors (e.g., chordoma) and vertebral body resection (corpectomy at the C4–C6 levels), a massive autologous iliac crest bone graft is placed for structural support. Fixation is achieved through a combination of an anterior cervical plate and posterior pedicle screws with rods.
- Anterior cervical discectomy and fusion (ACDF): A cortical autologous graft fixed with a plate may be placed in the intervertebral space.
- Use of synthetic cages: If a radiolucent (radiolucent) interbody cage is used, it is not visualized on radiographs itself. Its position is monitored exclusively via metallic radiopaque markers in the form of dots or pins.
Similar evaluation principles are applied in the diagnostic imaging of other spinal regions: for example, on axial CT of the lumbar spine with pedicle screw fixation, screw cross-sections and morselised bone chips (morselised bone chips), which serve as grafting material, are clearly defined.
Calcification and ossification of the ligamentum flavum
Calcification of the ligamentum flavum (ligamentum flavum), as well as the posterior longitudinal ligament, is often a cause of radiculopathy and compressive myelopathy. Periarticular calcifications are degenerative in nature and closely associated with rheumatological pathologies (Ankylosing spondylitis, Forestier disease) and metabolic disorders (hyperparathyroidism, hypercalcemia, renal failure, pseudogout, hemochromatosis).
Ossification of the ligamentum flavum is the process of tissue replacement with mature lamellar bone (lamellar bone) via endochondral ossification. The disease most frequently affects the lower third of the thoracic spine in men under 50 ("Japanese disease") and leads to spastic paraparesis, but very rarely can also involve the cervical level. Computed tomography is the modalities of choice for its diagnosis.
Pathognomonic CT signs of ossification:
- Presence of intense radiopaque (high-density) lines along the contours of the vertebral arches.
- Predominantly bilateral nature of the changes.
- Vector of ossificate development from the medial surface of the pedicle to the midline.
- Formation of a characteristic V-shaped structure in the epidural space with concavity facing anteriorly.
Comprehensive imaging and polytrauma
During diagnostic imaging of back injuries, comprehensive imaging is often required, covering not only isolated cervical injuries but also associated injuries of the spine and thoracic cage (thoracic cage). To assess thoracolumbar junction injuries, a dedicated AOSpine system is used, taking into account fracture morphology and clinical modifiers, along with the TLICS severity score to determine treatment tactics.
In pediatric practice, when nonaccidental trauma is suspected, cervical imaging is necessarily supplemented with central nervous system examination for bridging vein (bridging veins) tears and evaluation of the chronological radiological signs of fracture healing to determine the exact age of the injuries.
To remember the CT appearance of ligamentum flavum ossification, imagine the Latin letter V, pointing backward toward the spinous process (with concavity facing anteriorly) and "growing" from the pedicles toward the center of the epidural space.
Class and exam questions
How to find a radiolucent interbody cage on radiographs or CT after ACDF surgery?
The synthetic radiolucent cage itself is not visible on images. Its precise localization is determined by special radiopaque markers—metallic dots or pins within the intervertebral space.
How do traumatic cervical meningoceles appear on MRI?
On coronal T2-weighted images, they are visualized as hyperintense (bright) areas of cerebrospinal fluid accumulation in the injury zone, which frequently accompanies brachial plexus root avulsion.
What imaging modality is preferred for diagnosing ligamentum flavum ossification?
The imaging modality of choice is computed tomography (CT). It allows for clear visualization of intense radiopaque lines and the V-shape of ossificates growing via endochondral ossification.
What metabolic diseases are associated with ligamentum flavum calcification?
The process is frequently associated with hypercalcemia, renal failure, hyperparathyroidism, hemochromatosis, and pseudogout.
What else to study on this topic
- Detailed analysis of AOSpine classifications for the subaxial and thoracolumbar regions
- Criteria for neurological status assessment and the TLICS injury severity score
- Imaging appearance of transforaminal and posterior lumbar interbody fusion (TLIF and PLIF)
- Chronology of radiological signs of fracture healing in young children
- Vital imaging of bridging vein tears in abusive head trauma
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