Incidence of pulmonary embolism after the first 3 months of spinal cord injury.

BACKGROUND: Pulmonary embolism (PE) is a significant cause of morbidity and mortality in patients with spinal cord injury (SCI). Prophylactic anticoagulation is associated with a reduction in mortality rates, but there is limited evidence regarding the incidence rate of PE following cessation of anticoagulation after the first 3 months of injury. STUDY DESIGN: Single-centre retrospective study. OBJECTIVE: To estimate the incidence rate of PE after 90 days of SCI. SETTING: The National Spinal Injuries Centre at Stoke Mandeville Hospital, Aylesbury, UK. METHODS: The study includes 640 new-onset SCI patients. All computer tomography pulmonary angiograms (CTPAs) or ventilation-perfusion lung scans between 2008 and 2013 were identified. Medical notes and scans were reviewed and clinical outcomes and radiological findings were recorded. RESULTS: A total of 91 patients with a new-onset SCI had a CTPA or a perfusion lung scan. PE was detected in a total of 8 patients. The incidence of PE was 1.25%; 95% confidence interval (0.39-2.11) over a 6-year period. The duration of injury at the time of PE was 7 months. CONCLUSION: The incidence rate of PE post 3 months of SCI remains significant, though much lower than immediately post injury.

Posterior circulation infarction in patients with traumatic cervical spinal cord injury and its relationship to vertebral artery injury.

STUDY DESIGN: Prospective study. OBJECTIVE: To ascertain the prevalence of posterior circulation stroke in traumatic chronic spinal cord injured (SCI) patients and associated traumatic vertebral artery injuries (VAI). METHODS: All adult patients with cervical SCI and American Spinal Injury Association Impairment Scale (AIS) grade A or B referred for follow-up magnetic resonance imaging of their spinal cord were invited to take part in the study between January 2010 and December 2012 at the National Spinal Injury Centre. Two additional sequences were added to the existing imaging protocol to evaluate the brain and vertebral arteries. RESULTS: Ninety-eight patients were recruited. All imaging were analysed independently by three consultant radiologists. Posterior circulation infarcts were noted in seven (7%) patients. Significant VAI was noted in 13 patients (13%) with 10 occlusions and 3 with high-grade stenosis. However, only one patient had co-existent posterior circulation infarct and significant VAI. CONCLUSION: There is an increased prevalence of posterior circulation infarction in SCI patients. The relationship with associated traumatic VAI requires further investigation.

Outcomes of whole-body computed tomography in spinal cord-injured patients with sepsis.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To evaluate the efficacy of body computed tomography (CT) in spinal cord injury (SCI) patients with sepsis. SETTING: Specialist acute care and rehabilitation SCI centre in United Kingdom. METHODS: Patients with SCI and suspected or known sepsis, who had CT of the chest, abdomen and pelvis, over a 4-year period, were identified. Only patients who fulfilled the definition of sepsis or severe sepsis were included. Their medical notes and CT scans were reviewed and clinical outcomes and radiological findings recorded. RESULTS: Twenty-two patients with sepsis were identified including seven categorised as having severe sepsis. A specific radiological diagnosis was found in three patients (14%) and non-specific findings were found in 15 patients (68%). CONCLUSION: Although in the majority of cases, the findings were non-specific, a small number of patients had significant pathology identified by CT, which influenced their management significantly.

Out-of-hours MRI provision in the UK and models of service delivery.

AIM: To examine current out-of-hours magnetic resonance imaging (MRI) provision through a snapshot survey of National Health Service (NHS) trusts and to assay how radiographer staffing cover was provided for out-of-hours services. MATERIALS AND METHODS: A snapshot postal survey was mailed to heads of service of all 234 trusts in England and Wales. A literature search on the models of service delivery and correlation with the authors' internal MRI rota, which has provided a full on-call service for 20 years was undertaken. RESULTS: The response rate was 45.7% (107 of 234); 14% of responders provided full access to MRI 24 h a day; 63% provided extended weekday service, typically to 20.00 h; and 81% provided a weekend daytime service. The radiographers running the service were typically from the core MRI team. Approximately one-third (29.9%) of trusts provided training in basic brain and spine MRI to non-core MRI team members, but they typically did not participate in out-of-hours provision. CONCLUSION: There is currently a paucity of information on the provision of out-of-hours MRI in the NHS. However, there is increasing pressure to provide complex imaging out of hours, and in the future, trauma centres may be required to provide MRI to assess spinal injury. The authors describe a system to provide access to MRI at no additional cost to the organization based on 20 years of experience. A minority of surveyed acute NHS trusts have full out-of-hours access to MRI. Demand for MRI provision out of core hours is likely to increase.

Long-term effect of MRI on sacral anterior root stimulator: the Stoke Mandeville experience.

STUDY DESIGN: Retrospective review study. OBJECTIVES: To identify whether it is safe to perform a magnetic resonance imaging (MRI) exam on patients who have a sacral anterior root stimulator (SARS). SETTING: Adult patients with spinal cord injury and implanted SARS attending the National Spinal Injuries Centre who have had MRI scans. METHODS: Retrospective review between 1989 and 2010. The effect of the MRI scans on the function of the SARS (Finetech-Brindley, UK) was assessed up to 6 months following MRI at 0.2 and 1.5 T. RESULTS: A total of 18 patients with SARS implants had MRI scans at 0.2 and 1.5 T of the cervical, thoracic and lumbar spine, head, shoulder and pelvis. MRI examinations were abandoned on two occasions in one patient due to radiofrequency interference. One patient's stimulator ceased to function 5 months following MRI; both of these patients showing complications had their MRI examinations at 0.2 T. There were no adverse effects at 1.5 T. In one patient the SARS was removed within 6 months after MRI due to an unrelated medical condition. A total of 17 patients showed no symptoms that required terminating the examination. In all the 11 patients with a complete and functioning implant before MRI at 1.5 T, the SARS was functioning appropriately, and no change in bladder function was reported up to 6 months following MRI. CONCLUSION: It is safe to perform an MRI scan on patients with SARS providing the examination is conducted in a 1.5 T system.

Resolution of SPAM following cordectomy: implications for understanding pathophysiology.

STUDY DESIGN: Case report. OBJECTIVE: To describe the clinical benefit of a spinal cordectomy with the aim of limiting neurological deterioration related to the development of a subacute posttraumatic ascending myelopathy (SPAM) supporting previously described mechanism for SPAM formation. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, UK. METHOD AND RESULTS: A 38-year old patient presented 6 months after spinal cord injury substantial neurological deterioration expanding from the initial T4-injury level through C4. Magnetic resonance imaging revealed intra-medullary haemorrhage at the site of injury and subsequent-ascending cord oedema. A cordectomy was performed leading to neurological stabilisation and complete resolution of SPAM. CONCLUSION: Cordectomy can be an effective intervention in case of rapid progressive neurological deterioration.

Subacute progressive ascending myelopathy following spinal cord injury: MRI appearances and clinical presentation.

STUDY DESIGN: Retrospective Case Review. OBJECTIVES: To describe the clinical presentation and course of patients with magnetic resonance imaging (MRI) features of subacute progressive ascending myelopathy (SPAM). A rare complication of spinal cord injury. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, UK. MATERIALS AND METHODS: A retrospective review of the case notes and MRI studies of 11 cases with typical MRI features of ascending myelopathy presenting to a tertiary Spinal Injuries centre over a 15-year period. RESULTS: Eleven patients were identified with MRI features typical of SPAM, a median of 13 days (mean 24, range 4-86 days) following cord injury. The median number of cord segments involved above the initial insult was 6 (mean 6.2, range 4-11). MRI appearances include extension four or more segments cephalad to the initial cord injured segment, cord expansion and increased intramedullary T2 signal with a rim of cord sparing peripherally. Cord changes and neurological deficits improved over time but did not return to the initial injured level on MRI. One patient died (mortality 9%). CONCLUSION: SPAM is a rare cause of neurological deterioration following spinal cord injury but may remain subclinical. SPAM most commonly presents as neurological deterioration but may present with shoulder pain, respiratory deterioration or remain subclinical. There are characteristic MRI appearances. It can be fatal.

Diffusion weighted magnetic resonance imaging for acute stroke: practical and popular.

AIM: To evaluate the feasibility and impact of diffusion weighted magnetic resonance imaging (DW MRI) as the first line neuroimaging of stroke at a district general hospital. METHODS: Prospective audit of all in-patients admitted with clinically suspected acute stroke and referred for imaging over a consecutive 17 week period. The data collected included scan type, time from cerebral event to imaging request, and time from formal radiological request to neuroimaging. Clinicians' (general physicians, neurologists, and radiologists) perceptions were assessed by a questionnaire. RESULTS: 148 patients had neuroimaging for clinically suspected stroke during this period. Eighty one per cent of patients (120 of 148) had DW MRI as first line. Ninety two per cent of these patients had DW MRI within 24 hours of the formal radiological request. Twenty eight patients did not undergo DW MRI because lack of MRI safety, clinical state, unavailability because of maintenance service or lack of trained staff. Clinicians found the introduction of the DW MRI based service a significant improvement on computed tomography, especially for equivocal cases. CONCLUSION: DW based MRI service is both feasible and sustainable in the setting of a district general hospital and most clinicians feel that this is a significant improvement to stroke services.