Spinal trauma occurs with an annual incidence of approximately 15 to 40 cases per million. It commonly results from motor vehicle accident, fall from height, community violence and workplace related injury [1]. The incidence in South Asia is around 21 per million [2]. Trauma to the spine and spinal cord is a potentially devastating injury. The incidence of spinal cord injury (SCI) is more common in young male patients, occurring most frequently in persons between 16 and 40 years of age. Imaging studies are essential to confirm the exact location of the injury, to assess the stability of the spine, and to define the repercussion of the trauma on the diameters of the spinal canal and neural foramina. The advent of magnetic resonance imaging (MRI) has made it possible to accurately characterize the underlying SCI even when radiographs and computerized tomography (CT) scan are normal. MRI, with superior tissue characterization, provides the best evaluation of soft tissue pathology and is essentially the only direct evaluation of the spinal cord and nerve roots. Several types of traumatic spinal cord lesions can be found: intramedullary hemorrhage, spinal cord contusion/edema, extrinsic compression by a bone fragment or a traumatic disc herniation, and even complete transection of the cord [3]. MRI helps in predicting neurological recovery. Neurological recovery is usually insignificant in patients with intramedullary hemorrhage or cord transection, whereas patients with cord edema or contusion may significantly recover from neurological dysfunction [4]. Plain radiographs, and even multidetector computed tomography, do not rule out injury to the spinal cord [5]. Quantitative measurements for evaluating spinal trauma like mean canal compromise (MCC), mean spinal cord compression (MSCC), and lesion length of cord are also important in predicting the severity of damage and predicting recovery [6]. The aim of our study was to compare MRI findings with clinical profile and neurological status of the patient and to correlate the MRI findings with neurological recovery of the patients and predict the outcome.

Fifty-seven patients of acute SCI were included in the study from among the patients reporting within 72 hours of the injury for treatment at Department of Radiodiagnosis in Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (Rohtak, India) between the periods of January 2012 to May 2014. Prior written informed consent was obtained from each patient after explaining the procedure, risks and benefits. The included patients were with either injury on radiograph or radiographically normal patients with neurologic deficit. All the patients underwent X-ray, and MRI examinations and 36 patients underwent CT scans as well, within 72 hours of injury. The neurological status of the patients was compared at admission and discharge and correlated with the MRI findings. The mean period of stay in hospital was 14.11±5.74 days. In 27 patients, the long-term follow-up was done at a mean time of 285.9±43.94 days comparing the same parameters.

The male to female ratio of our study was 2.8:1. Singh et al. [11] in their study of epidemiology of spinal trauma patients in the same region as ours had observed the male to female ratio of 2.9:1.

Agarwal et al. [12] also reported the most common age group as 20-39 years. In their study Singh et al. [11] had a mean age of 35.4 years. Katzberg et al. [13] had a mean age of 37.8 years in spinal trauma patients in their study. Chiu et al. [14] reported most common cause of injury in developing world, as fall from height followed by road side accident. In developed countries, the most common cause is road side accident followed by fall from height.

The most common neurological status was ASIA A in about 25 patients (43.9%). Similar results were reported by Parashari et al. [15] who reported 41.93% patients in ASIA A group; Andreoli et al. [16] reported 42% in group ASIA A and Ramon et al. [17] reported 51%.

The distribution of patients in different group as per ASIA impairment scale in our study showed that the most common neurological status as ASIA A (43.9%), followed by ASIA C (19.3%). Least common neurological status was ASIA D (10.5%). Parashari et al. [15] reported most common neurological status as ASIA A (41.9%), followed by ASIA D (27.4%); however, Mahmood et al. [18] and Flanders et al. [19] had ASIA D (42.15%) and ASIA E (30.8%) as the most common group, respectively, in their study.

Pattern described in our study was similar to patterns described by Ramon et al. [17], Mahmood et al. [18], and Bondurant et al. [20]. However, the cord lesion described by Kulkarni et al. [4] comprised of type I: as T2WI showing large area of hypointensity surrounded by thin rim of hyper intensity and T1WI as inhomogeneous signals; type II: as central hyperintensity surrounded by hyper intensity on T2WI and normal intensity on T1WI; type III: as small area of central hypointensity surrounded by thick hyperintensity.

In our study, 13 patients (22.8%) had cord hemorrhage; 13 (22.8%) had cord contusion; 15 (26.3%) had cord edema and 16 (28.1%) had normal cord on MRI. Cord abnormality was seen in 47 patients (75.8%) out of 62 patients by Parashari et al. [15] and in 19 patients (70%) out of total 27 patients by Kulkarni et al. [4].

Miyanji et al. [6] observed that patients with complete SCI (ASIA A) had more MCC (p=0.005), MSCC (p=0.002), and lesion length (p=0.005), as compared to incomplete SCI or neurologically normal status. Although the final outcome of neurological recovery was more strongly correlated to the spinal cord compression than canal compromise. Haar et al. [10] also found a positive correlation between the complete SCI on Frankel grade with the MCC (p=0.009), MSCC (p=0.008), and Lesion Length (p=0.001). Similar results were reported by Furlan et al. [21].

The patients with ASIA A impairment scale showed improvement in 36% of cases only; whereas, all the patients in ASIA B, C, and D grade of injury showed some level of improvement.

Parashari et al. [15] reported that out of total 62 patients in their study; 30.65% of patients showed improvement and 43.5% of patients showed no improvement; furthermore, 23% of the patients with ASIA A grade injury improved in their study. Harrop et al. [22] reported that 7% of ASIA A impairment scale patients had improvement, whereas 94% of cases in ASIA D category had some improvement. Rao et al. [23] reported that none of the patients with ASIA A impairment scale neurological injury showed improvement and all the patients of group ASIA D improved.

We observed that out of 13 patients with cord hemorrhage with edema pattern, only two patients (15.45%) had shown improvement (p<0.001); out of 13 patients with cord contusion, nine patients (69.2%) had shown improvement (p=0.028) and out of 14 patients with cord edema only with neurological deficit at admission, 13 patients (86.2%) had shown improvement over the period of hospital stay (p=0.045).

Ramon et al. [17], Bondurant et al. [20], Mahmood et al. [18], and Tewari et al. [24] had reported that cord hemorrhage was associated with poor neurological outcome, as compared to contusion or edema pattern. Rao et al. [23] in their study also observed that the 84% of patients of edema less than three segments long had improvement, as compared to 16.6% of patients with improvement of edema more than three segments involved.

Haar et al. [10] also concluded that the lesion length (p=0.011) and MSCC (p=0.063) are predictors of poor neurological recovery. Miyanji et al. [6], Fehlings et al. [25] and Rao et al. [23] also studied the quantitative variables and their relationship with neurological status and found a significant correlation between the poor neurological recovery and severity of MSCC and lesion length.

MRI is an excellent available tool for depicting the changes within the injured spine. It allows the radiologist to directly evaluate the soft tissue of spine like ligaments and disc in a case of trauma. It differentiates between spinal cord edema, contusion and hemorrhage, each of which has different prognostic implications for the patients. Cord edema and normal cord in a case of injury is associated with favorable neurological outcome. Cord contusion shows lesser neurological recovery, as compared to cord edema and normal cord. Cord hemorrhage is associated with complete SCI and poor neurological recovery. MRI is also the modality of choice to assess the extent of cord lesion, as well as amount of canal compromise and cord compression. The severity of canal compromise, cord compression, and lesion length have a direct relationship with poor neurological outcome.