Post-traumatic spinal hematoma in diffuse idiopathic skeletal hyperostosis (DISH).

OBJECTIVES: To determine the incidence of spinal hematoma and its relation to neurological deficit after trauma in patients with spinal ankylosis from diffuse idiopathic skeletal hyperostosis (DISH). MATERIALS AND METHODS: A retrospective review of 2256 urgent or emergency MRI referrals over a period of 8 years and nine months revealed 70 DISH patients who underwent CT and MRI scans of the spine. Spinal hematoma was the primary outcome. Additional variables were spinal cord impingement, spinal cord injury (SCI), trauma mechanism, fracture type, spinal canal narrowing, treatment type, and Frankel grades during injury, before and after treatment. Two trauma radiologists reviewed MRI scans blinded to initial reports. RESULTS: Of 70 post-traumatic patients (54 men, median age 73, IQR 66-81) with ankylosis of the spine from DISH, 34 (49%) had spinal epidural hematoma (SEH) and 3 (4%) had spinal subdural hematoma, 47 (67%) had spinal cord impingement, and 43 (61%) had SCI. Ground-level fall (69%) was the most common trauma mechanism. A transverse, AO classification type B spine fracture (39%) through the vertebral body was the most common injury type. Spinal canal narrowing (p < .001) correlated and spinal cord impingement (p = .004) associated with Frankel grade before treatment. Of 34 patients with SEH, one, treated conservatively, developed SCI. CONCLUSIONS: SEH is a common complication after low-energy trauma in patients with spinal ankylosis from DISH. SEH causing spinal cord impingement may progress to SCI if not treated by decompression. CLINICAL RELEVANCE STATEMENT: Low-energy trauma may cause unstable spinal fractures in patients with spinal ankylosis caused by DISH. The diagnosis of spinal cord impingement or injury requires MRI, especially for the exclusion of spinal hematoma requiring surgical evacuation. KEY POINTS: • Spinal epidural hematoma is a common complication in post-traumatic patients with spinal ankylosis from DISH. • Most fractures and associated spinal hematomas in patients with spinal ankylosis from DISH result from low-energy trauma. • Spinal hematoma can cause spinal cord impingement, which may lead to SCI if not treated by decompression.

Costal cartilage fractures in blunt polytrauma patients - a prospective clinical and radiological follow-up study.

PURPOSE: To assess the healing of costal cartilage fractures (CCFX) in patients with blunt polytrauma with follow-up imaging and clinical examination. Effect on physical performance and quality of life (QoL) was also evaluated. METHODS: The study group comprised twenty-one patients with diagnosed CCFX in trauma CT. All the patients underwent MRI, ultrasound, ultra-low-dose CT examinations, and clinical status control. The patients completed QoL questionnaires. Two radiologists evaluated the images regarding fracture union, dislocation, calcifications, and persistent edema at fracture site. An attending trauma surgeon clinically examined the patients, with emphasis on focal tenderness and ribcage mobility. Trauma registry data were accessed to evaluate injury severity and outcome. RESULTS: The patients were imaged at an average of 34.1 months (median 36, range 15.8-57.7) after the initial trauma. In 15 patients (71.4%), CCFX were considered stable on imaging. Cartilage calcifications were seen on healed fracture sites in all the patients. The fracture dislocation had increased in 5 patients (23.8%), and 1 patient (4.8%) showed signs of a non-stable union. Four patients (19.0%) reported persistent symptoms from CCFX. CONCLUSION: Non-union in CCFX is uncommon but may lead to decreased stability and discomfort. Both clinical and radiological examinations play an important part in the post-traumatic evaluation of CCFX. CT and MRI visualize the healing process, while dynamic ultrasound may reveal instability. No significant difference in QoL was detected between patients with radiologically healed and non-healed CCFX. Post-traumatic disability was mostly due to other non-thoracic injuries.

Ankylosis of the cervical spine increases the incidence of blunt cerebrovascular injury (BCVI) in CTA screening after blunt trauma.

PURPOSE: To examine the incidence, location, and grade of blunt cerebrovascular injury (BCVI), as well as associated strokes in patients with ankylosis of the cervical spine, imaged with CT angiography (CTA) after blunt trauma. The related etiologies of ankylosis had an additional focus. MATERIALS AND METHODS: Altogether of 5867 CTAs of the craniocervical arteries imaged after blunt trauma between October 2011 and March 2020 were manually reviewed for a threshold value of ankylosis of at least three consecutive cervical vertebrae. BCVI was the primary outcome and associated stroke as the secondary outcome. Variables were craniofacial and cervical spine fractures, etiology and levels of ankylosis, traumatic brain injury, spinal hematoma, spinal cord injury, and spinal cord impingement, for which correlations with BCVI were examined. RESULTS: Of the 153 patients with ankylosis and blunt trauma of the cervical spine, 29 had a total of 36 BCVIs, of whom two had anterior and 4 posterior circulation strokes. Most of the BCVIs (n = 32) were in the vertebral arteries. Injuries were graded according to the Biffl scale: 17 grade II, 4 grade III, 14 grade IV, and 1 grade V. A ground-level fall was the most common trauma mechanism. Cervical spine fracture was the only statistically significant predictor for BCVI (OR 7.44). Degenerative spondylosis was the most prevalent etiology for ankylosis. CONCLUSION: Ankylosis of the cervical spine increases the incidence of BCVI up to sevenfold compared to general blunt trauma populations, affecting especially the vertebral arteries.

Post-traumatic spinal hematoma in ankylosing spondylitis.

PURPOSE: The purpose of this study is to examine the incidence, location, and magnetic resonance imaging (MRI) features of spinal epidural hematoma (SEH) and spinal subdural hematoma (SSH) in post-traumatic ankylosing spondylitis (AS) patients. METHODS: A total of 2256 consecutive referrals for urgent and emergency MRI scans of the spine over a period of eight years and nine months were manually reviewed for any mentions indicating axial ankylosis and post-traumatic spinal hematoma. We found 164 patients with ankylosed spines complicated by spinal fracture, of whom 32 had AS. Of the 132 excluded patients, 80 had diffuse idiopathic skeletal hyperostosis (DISH). The primary outcome was the presence of spinal hematoma, and the secondary outcome was spinal canal narrowing and spinal cord impingement. Two musculoskeletal radiologists and one fellow in musculoskeletal radiology reviewed the images for the presence of spinal hematoma and related signal characteristics, blinded to one another and initial reports. RESULTS: Of 28 post-traumatic AS patients, 19 had SEHs and five had spinal SSHs. There was a statistically significant difference between Frankel grades before and after surgery in respect of neurological improvement (p = 0.008). Patients who had radiologically proven spinal cord impingement showed more severe neurological deficits (p = 0.012). Hematomas with T1 heterogeneity showed a significantly increased delay (p = 0.047) between injury and imaging, while other signal characteristics were only approximate. CONCLUSIONS: Both SEH and SSH are common complications in post-traumatic AS patients. Patients benefit from surgery, but the relevance of spinal hematoma as a separate factor causing neurological deficit remains unclear.

MGMT Promoter Methylation and Parathyroid Carcinoma.

CONTEXT: Parathyroid carcinoma (PC) is extremely rare. Prognosis is poor, with no known evidence-based systemic therapies. We previously reported complete remission in a patient with metastasized parathyroid carcinoma and high tumor MGMT promoter methylation status who was treated with temozolomide. OBJECTIVE: To study MGMT promoter methylation status in an additional set of aggressive parathyroid tumors. DESIGN/SETTING: The study included 12 patients: 7 with sporadic and 5 with familial primary hyperparathyroidism (two of the latter carried a CDC73 gross deletion). Patient 9 is the previously described patient with PC and high MGMT methylation status. Her daughter (patient 12) had surgery for severe primary hyperparathyroidism due to atypical parathyroid adenoma during pregnancy. Eleven patients thus had PC and one had atypical parathyroid adenoma. MGMT promoter methylation status was determined from DNA extracted from primary (n = 10) or metastatic (n = 2) tumors. A mean methylation level >20% was considered high. Patient 11 had metastatic PC and received temozolomide cycles. RESULTS: Only the previously published patient (patient 9) had high tumor MGMT promoter methylation status. This was not a characteristic of the atypical parathyroid adenoma of the daughter (patient 12). Patient 11 (CDC73 intragenic deletion) has disseminated PC, low MGMT promoter methylation, and stable disease on follow-up after temozolomide treatment. CONCLUSION: High MGMT promoter methylation status seems rare in PC. However, as demonstrated in other neuroendocrine tumors, some patients with disseminated PC might benefit from temozolomide. Demonstration of high methylation status could be a predictor of positive response to temozolomide treatment.

Recurrent Metastasized Parathyroid Carcinoma-Long-Term Remission After Combined Treatments With Surgery, Radiotherapy, Cinacalcet, Zoledronic Acid, and Temozolomide.

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism with rather poor prognosis. Apart from surgery, no evidence-based treatments exist. A 48-year-old woman presented with weight loss, nausea, constipation, hypercalcemic crisis, and a recurrent neck tumor 5 years after primary surgery of a parathyroid tumor that primarily was classified as an adenoma. Histopathological reevaluation of the original tumor revealed the correct diagnosis to be parathyroid carcinoma (PC). The patient underwent surgery of the recurrent tumor, which was locally invasive with metastatic spread to the mediastinum and neck lymph nodes. Computed tomography demonstrated large lytic bone lesions in both iliac bones including, on the right, a soft tissue mass compatible with bone metastasis. The patient was treated with cinacalcet, repeated zoledronic acid infusions, and temozolomide cycles for 1 year. She underwent two additional neck surgeries for PC and sternotomy for resection of mediastinal metastases. Massive osteolytic lesions in both femoral necks caused imminent fracture risk and therefore both femurs were prophylactically stabilized by intramedullary nail. Serum calcium normalized after the third neck surgery, cinacalcet was discontinued, and parathyroid hormone gradually normalized during continued treatments with temozolomide, adjuvant radiotherapy, and zoledronic acid, with no signs of active disease on imaging and normal biochemistry. The patient remains in remission 17 years after successful combined treatments for recurrent, metastasized PC. The parathyroid tumor tissue demonstrated high O6-methylguanine DNA methyltransferase (MGMT) promoter methylation status, a known predictor of positive temozolomide treatment response in other tumors. In addition, synergistic effects of multiple treatments may have accounted for the favorable response. © 2018 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke.

PURPOSE: BCVI may lead to ischemic stroke, disability, and death, while being often initially clinically silent. Screening criteria for BCVI based on clinical findings and trauma mechanism have improved detection, with Denver criteria being most common. Up to 30% of patients do not meet BCVI screening criteria. The aim of this study was to analyze the effect of augmented Denver criteria on detection, and to determine the relative risk for ischemic stroke. METHODS: Denver screening criteria were augmented by any high-energy trauma of the cervical spine, thorax, abdomen, or pelvis. All acute blunt trauma WBCT including CT angiography (CTA) over a period of 38 months were reviewed retrospectively by two Fellowship-trained radiologists, as well as any cerebral imaging after the initial trauma. RESULTS: 1544 WBCT studies included 374 CTA (m/f = 271/103; mean age 41.5 years). Most common mechanisms of injury were MVA (51.5%) and fall from a height (22.3%). We found 72 BCVI in 56 patients (15.0%), with 13 (23.2%) multiple lesions. The ICA was affected in 49 (68.1%) and the vertebral artery in 23 (31.9%) of cases. The most common injury level was C2, with Biffl grades I and II most common in ICA, and II and IV in VA. Interobserver agreement was substantial (Kappa = 0.674). Of 215 patients imaged, 16.1% with BCVI and 1.9% of the remaining cases had cerebral ischemic stroke (p < .0001; OR = 9.77; 95% CI 3.3-28.7). Eleven percent of patients with BCVI would not have met standard screening criteria. CONCLUSIONS: The increase in detection rate for BCVI justifies more liberal screening protocols.

Remember the Vessels! Craniofacial Fracture Predicts Risk for Blunt Cerebrovascular Injury.

PURPOSE: The risk factors for blunt cerebrovascular injuries (BCVIs) are currently under intensive research, yet it is still controversial who should be screened. This study aimed to determine whether craniofacial fractures are associated with BCVI. PATIENTS AND METHODS: This retrospective cohort study focused on patients with suspected polytrauma after whole-body computed tomographic angiography of the cervical arteries. Patients were reviewed for BCVI and craniofacial fractures. Exclusion criteria were hanging injury, gunshot injury or other penetrating injury to the neck, and a cervical fracture on any level. The outcome variable was BCVI, and the main predictor variable was a craniofacial fracture. A secondary predictor variable was a type of craniofacial fracture classified as a facial fracture, skull fracture, or a combination of facial and skull fracture. Other predictor variables were gender, age, and mechanism of injury. In addition, specific craniofacial fractures were analyzed in more detail. The relevance of associations between BCVI and the predictors underwent χ2 testing. Significance was set at .01. RESULTS: Four hundred twenty-eight patients 13 to 90 years old during a 12-month period were included in the analysis. Craniofacial fractures occurred in 75 (17.5%). BCVI occurred significantly more frequently in those with than in those without a craniofacial fracture (18.6 vs 7.4%; P = .002). Patients with craniofacial fracture had a 4-fold increased risk for BCVI, whereas those 31 to 50 years old had 3.4-fold increased risk. Type of craniofacial fracture, gender, and mechanism of injury were not associated with BCVI. CONCLUSION: Craniofacial fractures are a serious risk factor for BCVI. This research suggests that in patients with any craniofacial fracture and suspected polytrauma, rigorous imaging of cervical arteries in search of BCVI is essential.

Incidence and Imaging Findings of Costal Cartilage Fractures in Patients with Blunt Chest Trauma: A Retrospective Review of 1461 Consecutive Whole-Body CT Examinations for Trauma.

Purpose To assess the incidence of costal cartilage (CC) fractures in whole-body computed tomographic (CT) examinations for blunt trauma and to evaluate distribution of CC fractures, concomitant injuries, mechanism of injury, accuracy of reporting, and the effect on 30-day mortality. Materials and Methods Institutional review board approval was obtained for this retrospective study. All whole-body CT examinations for blunt trauma over 36 months were reviewed retrospectively and chest trauma CT studies were evaluated by a second reader. Of 1461 patients who underwent a whole-body CT examination, 39% (574 of 1461) had signs of thoracic injuries (men, 74.0% [425 of 574]; mean age, 46.6 years; women, 26.0% [149 of 574]; mean age, 48.9 years). χ2 and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was calculated by using Cohen kappa values. Results A total of 114 patients (men, 86.8% [99 of 114]; mean age, 48.6 years; women, 13.2% [15 of 114]; mean age, 45.1 years) had 221 CC fractures. The incidence was 7.8% (114 of 1461) in all whole-body CT examinations and 19.9% (114 of 574) in patients with thoracic trauma. Cartilage of rib 7 (21.3%, 47 of 221) was most commonly injured. Bilateral multiple consecutive rib fractures occurred in 36% (41 of 114) versus 14% (64 of 460) in other patients with chest trauma (OR, 3.48; 95% CI: 2.18, 5.53; P < .0001). Hepatic injuries were more common in patients with chest trauma with CC fractures (13%, 15 of 114) versus patients with chest trauma without CC fractures (4%, 18 of 460) (OR, 3.72; 95% CI: 1.81, 7.64; P = .0001), as well as aortic injuries (n = 4 vs n = 0; P = .0015; OR, unavailable). Kappa value for interobserver agreement in detecting CC fractures was 0.65 (substantial agreement). CC fractures were documented in 39.5% (45 of 114) of primary reports. The 30-day mortality of patients with CC fractures was 7.02% (eight of 114) versus 4.78% (22 of 460) of other patients with chest trauma (OR, 1.50; 95% CI: 0.65, 3.47; P = .3371). Conclusion CC fractures are common in high-energy blunt chest trauma and often occur with multiple consecutive rib fractures. Aortic and hepatic injuries were more common in patients with CC fractures than in patients without CC fractures. © RSNA, 2017.

MDCT findings in sports and recreational accidents.

BACKGROUND: Sports and recreational accidents involving critical areas of the body occur commonly in the general population. Reports on their demographics and recommendations for screening procedures are, however, few. PURPOSE: To assess injuries of the craniofacial area, spine, and torso resulting from sports and recreational accidents with multidetector computed tomography (MDCT) as primary imaging method in a Level I trauma center. MATERIAL AND METHODS: All emergency room CT requests over a time span of 105 months were reviewed retrospectively for trauma mechanism and injury. Patients were identified using an electronic picture archiving and communications system (PACS), and MDCT studies interpreted by two radiologists independently. RESULTS: Of a total of 5898 patients, 492 patients (301 boys/men, 191 girls/women, age range 2-76 years, mean 33.5 years, median 29.5 years) with sports or recreational accidents emerged. A total of 102 traumatic findings were diagnosed, thereof 72 (71%) serious. The three most commonly encountered serious injuries were intracranial injury, fractures of facial bones, and vertebral injuries. The three most common injury mechanisms were bicycling, horseback riding, and team ball sports. Patients from recreational activities were on average significantly younger (29.2 years) than those from sports accidents (36.9 years; P < 0.001). Only age groups <21 years and 41-50 years differed in injury severity from the other age groups (P = 0.004 and P = 0.063, respectively). Of all trauma mechanisms, only bicycling had a significantly increased risk of injury (P < 0.001). CONCLUSION: Injuries in sports and recreational accidents presented with an overall incidence of 21%, of which 71% are serious. The most common mechanisms of injury were bicycling, horseback riding, and team ball sports. The largest incidence of serious injury involved bicycling. Because of the high probability of a serious injury and the high energies that are often involved in these accidents, we recommend ruling out of internal injury by MDCT as the primary imaging modality.

Measurement of spinal canal narrowing, interpedicular widening, and vertebral compression in spinal burst fractures: plain radiographs versus multidetector computed tomography.

OBJECTIVE: To assess the reliability of measurements of spinal canal narrowing, vertebral body compression, and interpedicular widening in burst fractures in radiography compared with multidetector computed tomography (MDCT). MATERIALS AND METHODS: Patients who had confirmed acute vertebral burst fractures over an interval of 34 months underwent both MDCT and radiography. Measurements of spinal canal narrowing, vertebral body compression, and interpedicular widening from MDCT and radiography were compared. RESULTS: The 108 patients (30 female, 78 male, aged 16-79 years, mean 39 years) had 121 burst fractures. Eleven patients had multiple fractures, of which seven were not contiguous. Measurements showed a strong positive correlation between radiography and MDCT (Spearman's rank sum test: spinal canal narrowing k = 0.50-0.82, vertebral compression k = 0.55-0.72, and interpedicular widening k = 0.81-0.91, all P < 0.05), except for the cervical spine (k = -0.50 to 0.61, with all P > 0.25) and for interpedicular widening in the thoracic spine (k = 0.35, P = 0.115). The average difference in measurements between the modalities was 3 mm or fewer. CONCLUSION: Radiography demonstrates interpedicular widening, spinal canal narrowing and vertebral compression with acceptable precision, with the exception of those of the cervical spine.

The incidence and distribution of burst fractures.

This study was conducted to assess occurrence and distribution of burst fractures as well as common accident mechanisms and the associated neurologic deficit. Using picture archiving and communications system, all emergency multidetector computed tomography studies over 34 months were retrieved and evaluated for burst fractures by two radiologists by consensus. Initial neurological findings were retrieved from patients' medical records. One hundred fifty-two patients (112 male) with a total of 169 burst fractures were found. In both genders, the incidence of burst fractures peaked at the thoracolumbar junction and between levels T5 and T8. In 10% of cases, more than one burst fracture was seen, thereof 53% on noncontiguous levels. Main accident mechanisms were falls, traffic, and sports. Neurological deficit was highest in patients with burst fractures of the cervical spine, independent of accident mechanism, and lowest in thoracolumbar junction fractures. Burst fractures occur frequently in high energy traumas and are most commonly associated with falling and traffic accidents. Multiple burst fractures occur in 10% of cases, half thereof on noncontiguous levels.

Diagnostic value of pelvic radiography in the initial trauma series in blunt trauma.

The purpose of the study was to evaluate the diagnostic value of pelvic radiography in the initial trauma series when compared to multidetector CT (MDCT) findings in serious blunt trauma. Inclusion criteria were blunt trauma and pelvic radiography in the initial trauma series, followed by a whole-body MDCT. A total of 1386 patients (874 male, 512 female, age 16-91 years, mean 41 years) met the inclusion criteria. Imaging studies were evaluated retrospectively by anatomical region and classified, when possible, using the Tile classification. Based on MDCT, a total of 629 injuries occurred in 226 (16%) of these 1386 patients. Radiography depicted 405 fractures in these 226 patients, giving an overall sensitivity of 55%. In 24 patients (11%) radiography was false-negatively normal. The sensitivity of radiography was mainly good in the anteroinferior parts of the pelvis, fair in the acetabulum and ileum, and poor in the posterior ring. By MDCT 141 (62%) patients were classified using the Tile classification and by radiography 133 patients (59%) were classified. MDCT and radiography showed the same type of pelvic injury in 72 patients (59%) and the subtype in 17 patients (14%). In 48 patients (40%) the pelvis was shown to be stable by radiography but unstable by MDCT. In conclusion, the sensitivity of pelvic radiography is low, and it is not reliable for determining if the pelvic injury is stable or not.

Spine fractures in falling accidents: analysis of multidetector CT findings.

The purpose of the present study was to assess incidence, fracture type, and location of spine fractures due to falls. All emergency room CT requests during a time period of 26 months were reviewed retrospectively. Patients who had fallen or jumped and were initially examined with multidetector CT (MDCT) were included. The MDCT studies were evaluated by two radiologists for trauma location, fracture type, and multiple level involvement. A total of 237 patients (184 males, 53 female, age range 16-86 years, mean age 42 years) met the inclusion criteria. A total of 203 vertebral fractures were seen in 127 patients. Burst fracture (n=78) was the most frequent type of trauma, usually located in the thoracolumbar junction (50%). Also, compression fracture (n=52) was most common in the thoracolumbar junction (39%). Posterior column fracture (n=52) was most frequently detected in the cervical spine (40%). Multiple-level spine fractures were seen in 41 (32%) of the injured patients, of which 12 (29%) had fractures at noncontinuous levels. With increasing height the overall incidence of fractures increased, and burst fractures and multiple level spine fractures became more frequent. Age had no effect on fracture type or location. Spine fractures due to falls are common. Burst fracture is the most common fracture type and most frequently seen in the thoracolumbar junction. Multiple-level fractures were seen in 32% of the cases, of which 29% were seen at noncontinuous levels. Serious spine fractures are seen in all falling height and age groups.