Occult Disco-Ligamentous Lesions of the Subaxial c-Spine—A Comparison of Preoperative Imaging Findings and Intraoperative Site Inspection

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.

Clinical algorithm for preventing missed diagnoses of occult cervical spine instability after acute trauma: A case report

“…For patients with cervical spine tenderness and/or neurological deficit, static lateral X-ray is the first-line imaging modality for assessing obvious fractures or dislocation of the cervical spine. CT is the gold standard for detecting occult cervical spine fractures but is unable to detect instability in the cervical spine caused by injury to the intervertebral disc, ligament, or other soft tissue[ 6 , 7 ]. MRI provides detailed soft-tissue imaging but has a sensitivity of only 75% in detecting ligamentous injury[ 7 , 8 ].…”

“…CT is the gold standard for detecting occult cervical spine fractures but is unable to detect instability in the cervical spine caused by injury to the intervertebral disc, ligament, or other soft tissue[ 6 , 7 ]. MRI provides detailed soft-tissue imaging but has a sensitivity of only 75% in detecting ligamentous injury[ 7 , 8 ]. Therefore, a more accurate and efficient protocol needs to be developed in order to prevent missed diagnoses of occult cervical spine instability.…”

Editorial on Special Issue “Spine Imaging: Novel Image Acquisition Techniques and Analysis Tools”

“…In a study by Janssen et al, a comparison of preoperative imaging findings from CT and MRI to intraoperative site inspection was performed for patients with suspected disco-ligamentous lesions of the subaxial cervical spine, with the objective of identifying radiological features for under- or over-estimating disco-ligamentous lesions [ 24 ]. Out of the included 83 patients, the majority underwent anterior cervical discectomy and fusion (ACDF; 79 patients), while the remaining patients underwent anterior cervical corpectomy and fusion (4 patients) [ 24 ]. A discrepancy between preoperative imaging and intraoperative surgical findings was revealed in 14 patients, with a specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of 100%/77.4% [ 24 ].…”

“…Out of the included 83 patients, the majority underwent anterior cervical discectomy and fusion (ACDF; 79 patients), while the remaining patients underwent anterior cervical corpectomy and fusion (4 patients) [ 24 ]. A discrepancy between preoperative imaging and intraoperative surgical findings was revealed in 14 patients, with a specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of 100%/77.4% [ 24 ]. When adding the presence of VFs and/or prevertebral hematoma to the model, an increased sensitivity of 95.2% was achieved [ 24 ].…”

“…A discrepancy between preoperative imaging and intraoperative surgical findings was revealed in 14 patients, with a specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of 100%/77.4% [ 24 ]. When adding the presence of VFs and/or prevertebral hematoma to the model, an increased sensitivity of 95.2% was achieved [ 24 ]. Yet, the presence of marked degenerative changes at the cervical spine seems to represent a major risk factor for missing a traumatic disco-ligamentous injury during radiological image reading, and prevertebral hematoma and/or VFs are important image-based hints for co-existing disco-ligamentous injuries.…”