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Iwate Medical University School of Medicine Morioka 020-8505, Japan
I read with interest the article entitled "Cervical Spine Injuries in Patients 65 Years Old and Older" in the March issue of the American Journal of Roentgenology [1]. The authors included only the cases with evident fractures on conventional radiography and CT, and I believe they correctly pointed out a high frequency of the injury in the atlantoaxial complex. However, if cervical spine injuries without fractures had been included, the results may have turned out differently.
In our experience and also in reports in the literature, cervical spine injuries without fractures are common [2, 3]. Patients commonly fall, hit their heads, and sustain hyperextension injuries. The mechanism of injury is pinching of the spinal cord in the narrow spinal canal, resulting in central spinal cord syndrome [4]. The common location of such injuries is the mid and lower cervical spine, and involvement of multiple levels is common, as the authors pointed out. Although degenerative changes are often noted on radiography, the abnormal findings related to trauma (e.g., cord edema and, occasionally, prevertebral hematoma) may be seen only on MR imaging [3, 5]. Because MR imaging is helpful in determining the prognosis, it is a modality of choice in the evaluation of cervical spine injury when no evident traumatic changes are found on radiography.
Although some hyperextension injuries may be associated with subtle radiographic and CT abnormalities [6], such injuries are not well evaluated without MR imaging. I am interested in how Lomoschitz et al. [1] dealt with neurologically abnormal patients who had no evident fractures.
References
Harborview Medical Center Seattle, WA 98104-2499
We appreciate Dr. Ehara's interest in and comments on our article on cervical spine injuries in the elderly population [1]. We concur that elderly patients may sustain spinal cord injury without radiographic evidence of fracture; typically this injury is caused by hyperextension in patients with degenerative changes of the senescent spine [2, 3].
The objectives of our study [1] were to describe patterns and associated clinical and radiologic findings of cervical spine fractures in the elderly population and to identify any association in fracture pattern between causative trauma mechanism and patient age. Thus, only elderly patients who had sustained cervical spine fractures constituted our study population.
We definitely support the use of MR imaging in patients with neurologic deficits who have sustained a cervical spine injury, independent of radiographic proof of a fracture [4]. In our opinion, multiplanar imaging (CT and MR imaging) of elderly patients with persistent posttraumatic neck symptoms—even after seemingly minor trauma, like falls from standing height—has great utility.
References
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