ABSTRACT
Study Design
A retrospective study
Objectives
To correlate the MRI findings with the outcome of patient treatment in patients with spinal cord injury. This study tried to study the recovery of patients who have been diagnosed of spinal cord injuries by MRI examination and compared it with the prognosis made by the MRI findings.
Material and methods
45 patients’ data was conveniently selected from the Lagos university teaching hospital Idi-Araba Lagos Nigeria. 32 were male; 13 female. Data were retrieved from the MRI results and patients treatment folder form the hospital record archives under strict confidentiality. Patients included were those who had spinal cord injuries between 2006 to 2012. They underwent MRI examination using appropriate protocols and were neurologically examined and classified according to the ASIA impairment scale. The treatment and recovery patterns were also assessed and formed the basis for comparing the prognosis pre-treatment and outcome post-treatment. The useful qualitative parameters of the MRI findings were limited only to cord oedema and intramedullary haemorrhage for clarity purposes.
Results
At the end of the study, it was discovered that cervical spine was the most prevalent spinal cord injury with 51.12%. Road traffic accident was the major cause of spinal cord injury with 60%. A total number of 13 patients (28.89%) had haemorrhage only; 15 (33.33%) had edema only; 15% had oedema and haemorrhage and 2 patients (4.45%) did not show any abnormality of MRI. 16 patients (35.56%) of the patients had complete recovery. 7 patients (15.56%) had incomplete recovery and 22 patients (48.88%) had no recovery.
A total of 28 patients had presence of haemorrhage. Out of this, 22 patients (78.57%) had no recovery, 5 patients (17.86%) had incomplete recovery and only 1 patient (3.57%) had complete recovery. A total of 15 patients showed presence of only oedema out of which 13 (86.67%) recovered completely and 2 patients (13.33%) had incomplete recovery.
LIST OF CHARTS
Chart 1: pie chart showing sex distribution
Chart 2: Bar chart showing the distribution of heamorrhage and oedema in the different ASIA classifications.
LIST OF FIGURES
Figure 1: showing the internal structure of a spinal cord
Figure 2: showing the meninges of the spinal cord
Figure 3: showing the spinal nerves
Figure 4: showing the dermatomes of the body
Figure 5 showing the blood supply of the spinal cord
LIST OF TABLES
Table 1: Age distribution:
Table 2: frequency distribution of the spinal segment
Table 3: causes of spinal cord injuries
Table 4: Total occurrence of heamorrhage and oedema based on MRI findings
Table 5: ASIA classification pre-treatment
Table 6: MRI findings of the different ASIA classifications
Table 7: Recovery of patients based on MRI findings according to ASIA
Table 8: Total outcome of treatment
Table 9: ASIA classification post-treatment.
TABLE OF CONTENTS
Pages
Approval---------------------------------------------------------------------------------------------i
Certification-----------------------------------------------------------------------------------------ii
Dedication-------------------------------------------------------------------------------------------iii
Acknowledgement----------------------------------------------------------------------------------iv
List of charts-----------------------------------------------------------------------------------------v
List of figures----------------------------------------------------------------------------------------vi
List of tables-----------------------------------------------------------------------------------------vii
Table of content------------------------------------------------------------------------------------vix
Abstract-----------------------------------------------------------------------------------------------ix
CHAPTER ONE: INTRODUCTION
1.1 Background of Study------------------------------------------------------------------------2
1.2 Statement of Problems----------------------------------------------------------------------3
1.3 Objectives of Study--------------------------------------------------------------------------3
1.3.1 General Objective of Study-----------------------------------------------------------------3
1.3.2 Specific Objectives--------------------------------------------------------------------------4
1.4 Significance of Study------------------------------------------------------------------------4
1.5 Scope of Study-------------------------------------------------------------------------------4
1.6 Literature Review----------------------------------------------------------------------------5
CHAPTER TWO: THEORITICAL BACKGROUND
2.1 Anatomy of the Spinal Cord--------------------------------------------------------------12
2.1.1 General Features----------------------------------------------------------------------------12
2.1.2 Segmental and Longitudinal Organization----------------------------------------------13
2.1.3 Structure of the spinal cord----------------------------------------------------------------14
2.1.4 The Spinal Meninges-----------------------------------------------------------------------15
2.1.5 Spinal Nerves-------------------------------------------------------------------------------17
2.1.6 Dermatomes and Myotomes--------------------------------------------------------------19
2.1.7 Blood supply of the spinal cord-----------------------------------------------------------22
2.1.7.1 Arterial blood supply--------------------------------------------------------------22
2.1.7.2 Venous drainage of the spinal cord----------------------------------------------22
2.2 Spinal Cord Injury--------------------------------------------------------------------------23
2.2.1 Mechanism / causes of spinal cord injury-----------------------------------------------23
2.2.2 Symptoms of spinal cord injury----------------------------------------------------------24
2.2.3 Classification of spinal cord injury-------------------------------------------------------25
2.2.3.1 Complete Spinal Cord Injury----------------------------------------------------25
2.2.3.2 Incomplete Spinal Cord Injury---------------------------------------------------25
2.2.4 ASIS classification-------------------------------------------------------------------------27
2.3 Basic physics of MRI----------------------------------------------------------------------28
2.3.1 Pulse Sequences--------------------------------------------------------------------30
2.3.1.1 Partial saturation/ saturation recovery sequence-------------------------------31
2.3.1.2 Inversion Recovery Sequence----------------------------------------------------32
2.3.1.3 Spin Echo sequence----------------------------------------------------------------32
2.3.1.4 Fast imaging or Gradient Echo sequences--------------------------------------32
2.4 MRI Images---------------------------------------------------------------------------------33
2.4.1 T1 weighted images----------------------------------------------------------------33
2.4.2 T2-weighted images----------------------------------------------------------------33
2.4.3 Proton-density weighted images-------------------------------------------------33
2.5 Use of MRI in Diagnosis of Spinal Cord Injury----------------------------------------34
2.6 Protocol for MRI spinal cord-------------------------------------------------------------35
CHAPTER THREE: RESEARCH METHODOLOGY
3.0 Design of Study-----------------------------------------------------------------------------36
3.1 The Area of Study--------------------------------------------------------------------------36
3.2 Data Selection-------------------------------------------------------------------------------36
3.2.1 Target Population------------------------------------------------------------------36
3.2.2 Sample Size/ Sample Method----------------------------------------------------36
3. 2. 3Selection Criteria-------------------------------------------------------------------37
3.2.4 Exclusion Criteria------------------------------------------------------------------37
3.3 Materials Used------------------------------------------------------------------------------37
3.3.1 Source of Data----------------------------------------------------------------------37
3.3.2 Method of Data Collection--------------------------------------------------------38
3.4.1 Data Analysis-------------------------------------------------------------------------------38
CHAPTER FOUR: RESULT
4.1 Presentation OF Results-------------------------------------------------------------------41
CHAPTER FIVE: DISCUSSION, SUMMARY, CONCLUSION, RECOMMENDATION
5.1 Discussion-----------------------------------------------------------------------------------47
5.2 Summary-------------------------------------------------------------------------------------51
5.3 Conclusion-----------------------------------------------------------------------------------51
5.4 Recommendations--------------------------------------------------------------------------52
5.5 Limitations of the study--------------------------------------------------------------------53
REFERENCES--------------------------------------------------------------------------------------54
INTRODUCTION
Spinal cord injury is injury affecting the spinal cord.1 It could be direct or indirect. When direct, there is direct impact of traumatic pressure on the spinal cord resulting from falls, car accidents, gun shots, sport injuries, industrial accidents etc. trauma affecting nerves, blood vessels, lymph nodes, tissues, bones etc of the spinal cord could indirectly result to spinal injury.
Depending on the extent of damage, spinal injuries can also be judged complete or incomplete. Complete when there is total loss of nervous functions and incomplete when loss is only partial.2
In Nigeria, there have been increased cases of spinal cord injuries as evidenced by increase in number of patient needing diagnosis of spinal injury related cases.3 Sequel to this, diagnosis and treatment becomes of paramount importance in management of these patients.
In recent years, MRI has gained widespread acceptance as the method of choice for imaging of spinal diseases and spinal traumas4. It is a non invasive imaging technique that uses the hydrogen properties of tissues in the body to generate images characteristic of normal and abnormal conditions of the tissues and organs.
MRI is preferred over the other imaging modalities as it is able to detect subtle changes in the spinal cord framework which otherwise may not be seen with other modalities. It also has additional advantages such as higher contrast resolution, absence of bony artefacts, multi-planar capability and choice of various pulse sequences. It can identify the level of cord injury and associated tissue injuries.4, 5
With findings made by MRI of spinal cord injury, prognosis of patient condition is made and this forms the basis of treatment given by the physician4, 5. This goes to say that what MRI is able to detect helps the physician in administering care and treatment to the patient. As a result, there is close relationship between MRI findings in patients with spinal cord injury and the outcome of their treatment.
From review of related literatures on research works on same or similar field, it was noted that prognosis in spinal cord injuries investigations is based broadly on the presence or absence of hemorrhage or edema in the spinal cord or a combination of both. Patients who presented with any of the patterns based on this broad classification are expected to have a classified pattern of recovery. The American Spinal Injury Association classified spinal injuries based on the degree of loss of functions into ASIA A, B, C, D and E6. The relationship between the patterns of MRI findings and ASIA classifications are very essential in every research works that studies MRI application in spinal cord injury cases.
This research hopes to harness the possibility of assessing how well MRI findings can correlate with the outcome of treatment given to the patients. It will study how best patients respond to treatment given based on prognosis made from MRI finding. It will be able to follow critical the patients’ pattern of recovery; did the patient recover after treatment? Was there any improvement or did the patients’ conditions worsen? What was the rate of recovery; fast or slow? Was recovery complete or incomplete? And was MRI reports able to predict these outcomes correctly?