This document discusses imaging in spinal emergencies. It outlines various compressive and non-compressive causes of myelopathy including transverse myelitis, infections, vascular issues like arterio-venous malformations, and trauma. Specific conditions discussed in more detail include spinal dural arteriovenous fistulas, cavernomas, spinal cord infarcts, epidural abscesses, and epidural hematomas. The importance of early diagnosis through neurological exam and appropriate imaging like CT, MRI, and angiography is emphasized to promptly diagnose and treat these time-sensitive spinal conditions.

1. Imaging in Spinal
Emergency
Syndromes
Arvinda HR
Associate professor,
Dept of NI & IR,
NIMHANS, Bangalore.

2. Background
• True spinal emergencies are rare.
• Early diagnosis is the key.
• The recognition of red flags, followed by a
thorough neurologic exam and appropriate
imaging.
• Clinicians must be aware of the presenting
symptoms and accurately interpret imaging
results in order to promptly diagnose and treat
these conditions.

3. • Any new deficit developing as a result of
involvement of spinal cord.
• It can be compressive / non-compressive
myelopathy.

4. Non compressive Myelopathy
• Transverse Myelitis.
• Inflammatory and autoimmune.
• Infections.
• Vascular.
• Metabolic, Radiation, and Metastatic.

5. Compressive Myelopathy
• Epidural Hematoma.
• Epidural Abscess.
• Cord Compression due to trauma.
• Miscellaneous.

6. Transverse Myelitis

11. NMO

14. Multiple
sclerosis

18. Vascular Causes

19. Arterio-Venous Shunts
• Spinal Dural AV Fistula.
• Perimedullary fistula.
• Spinal AVM.
• Juvenile AVM.
Cause symptoms due to
• Haemorrhage.
• Venous hypertension.
• Direct mass effect.

20. Arterio-Venous Malformation
• In 20% to 40% of cases, there is an associated
arterial or venous aneurysm.
• Younger age, usually in young adults aged 20
to 30 years.
• Haemorhage / acute neurologic symptoms.

25. Juvenile Metameric Vascular
Malformation
• Are large, high-flow lesions with involvement
of the para-spinal tissues.
• Usually paediatric population.
• Neurologic deficits occur from compression,
hemorrhage, or vascular steal phenomenon.

32. Perimedullary AV fistula
• Usually located in the midline and ventrally in
the subarachnoid space.
• The lesion consists of an abnormal connection
between the anterior spinal artery and an
enlarged venous network.
• Young adult / paediatric population.
• Venous hypertension / haemorrhage.

36. Dural AV fistula
• Located at the exiting nerve root sleeve.
• Progressive neurologic symptoms.
• Haemorrhage is rare.
• Venous hypertension – reduction in arterio-
venous pressure gradient.
• Emergency due to acute worsening of the
motor and bladder and bowel functions.
• Gold standard is DSA. CTA / MRA.

37. Spinal Dural AV
Fistula

41. Cavernoma
• Represent around 5.0% of all intramedullary
lesions found in adults.
• Peak presentation is during the fourth decade,
Females are more commonly affected than males.
• Discrete episodes of neurological deterioration
with varying degrees of recovery between
episodes.
• Acute onset of symptoms with rapid decline.

45. Spinal cord Infarct
• Rare. Comprising only 1% of all strokes.
• Experience pain followed by acute neurologic
deficits.
• 2 potential pathophysiological mechanisms for
spinal cord infarction:
• Hypoperfusion from arterial insufficiency and
Hypotension.
• Occlusion of a specific arterial branch (anterior
spinal artery or, sometimes, posterior spinal
artery)

46. • Atherosclerosis / Dissection of Aorta.
• 4% of Dissection can lead to paraplegia /
paraparesis due to SCI.
• Aortic surgery – from 1.0% to 10%.
• Equal frequency in cervical and thoraco-
lumbar spine levels, extremely rare at upper
thoracic spine level.
• Different patterns.

48. Epidural Abscess
• Rare entity.
• Diabetes, IV Drug abuse, superficial infections
of the back, immunocompromised.
• Staphylococcus aureus, TB.
• Fever, back pain and neurologic deficits.
• Thoracic and lumbosacral region more than
cervical.

49. • Concomitant osteomyelitis – 80%.
• CT myelography.

50. Pyogenic

52. Tubercular

56. Arachnoiditis

58. Post spinal anaesthesia weakness

60. Spinal Cord Abscess
• Intramedullary cord abscess is extremely rare.
• Hart reported the earliest documented spinal
cord abscess in 1830.
• MRI is the modality to diagnose the condition.
• 70% will have residual deficit even after
treatment.

63. Epidural hematoma
• Following spine surgery, 0.1 – 0.2% neurologic
deficits. But present in 30-80% of cases.
• Coagulopathy, Instrumentation.
• Spontaneous – extremely rare. Elder age group.
Male.
• Usually venous bleed. No cause is known
• Chiropractic manipulation, epidural anesthesia,
and steroid injection.
• Sudden onset of severe back pain.

64. • Either thoracic / cervical.

67. Spine Trauma
• Represent 3% to 6% of all skeletal injuries.
• 55% of all spinal injuries (including all types
of spinal injuries) involve the cervical spine,
15% the thoracic spine, 15% the lumbar spine,
and 15% the lumbosacral spine.
• The risk of damage to the spinal cord is greater
in cervical spine injuries than in the thoracic
and lumbar regions

68. • The overall incidence of cervical spine fracture
without spinal cord injury is 3%.

69. No imaging required
• No midline cervical spine tenderness.
• No focal neurologic deficit.
• Normal level of alertness.
• No intoxication.
• No painful distracting injury.
• Imaging : X-ray, CT scan and MRI.
• Flexion and Extension views.

70. Stability Versus Instability
• The 3-column theory of Denis divides the spinal
column into anterior, middle, and posterior
columns.
• The anterior column consists of the anterior
vertebral body, the anterior longitudinal ligament,
and the anterior annulus fibrosis.
• The middle column consists of the posterior
vertebral body, the posterior longitudinal
ligament, and the posterior annulus.

71. • The posterior column consists of the posterior
bony elements including the pedicles, the
lamina, the facets, and the spinous processes,
the ligaments including the ligamentum
flavum, the interspinous, and supraspinous
ligaments, and the facet joint capsule.

77. Conclusions
• Prompt recognition of the spinal emergencies
are extremely important.
• Timely intervention in required to prevent
permanent cord injury.
• Imaging does help in the diagnosis and
management of a particular condition.

78. Thank you