The influence of initial spinal cord haematoma and cord compression on neurological grade improvement in acute traumatic spinal cord injury: A prospective observational study

Published:October 10, 2022DOI:


      • Prospective multi-centre study, traumatic spinal cord injury including cervical and thoracic, n = 120.
      • Magnetic resonance imaging of all patients.
      • Various MRI parameters were evaluated for prediction of neurological improvement pre-discharge, including haematoma.
      • Thoracic injury, haematoma, and MSCC >25% gave ∼ 90% probability of AIS grade A at discharge – no change from admission.


      Study design

      Prospective observational cohort study linked with administrative data.


      Magnetic Resonance Imaging (MRI) is routinely performed after traumatic spinal cord injury (TSCI), facilitating early, accurate diagnosis to optimize clinical management. Prognosis from early MRI post-injury remains unclear, yet if available could guide early intervention. The aim of this study was to determine the association of spinal cord intramedullary haematoma and/or extent of cord compression evident on initial spine MRI with neurological grade change after TSCI.


      Individuals with acute TSCI ≥16 years of age; MRI review. Neurological gradings (American Spinal Injury Association Impairment Scale (AIS)) were compared with initial MRI findings. Various MRI parameters were evaluated for prediction of neurological improvement pre-discharge.


      120 subjects; 79% male, mean (SD) age 51.0 (17.7) years. Motor vehicle crashes (42.5%) and falls (40.0%) were the most common injury mechanisms. Intramedullary spinal cord haematoma was identified by MRI in 40.0% of patients and was associated with more severe neurologic injury (58.3% initially AIS A). Generalised linear regression showed higher maximum spinal cord compression (MSCC) was associated with lower likelihood of neurological improvement from initial assessment to follow up prior to rehabilitation discharge. Combined thoracic level injury, intramedullary haematoma, and MSCC > 25% resulted in almost 90% probability of pre-discharge AIS (grade A) remaining unchanged from admission assessment.


      MRI is a vital tool for evaluating the severity and extent of TSCI, assisting in appropriate management decision-making early in TSCI patient care. This study adds to the body of knowledge assisting clinicians in prognostication.



      AIS (American Spinal Injury Association Impairment Scale), MCC (Maximum Canal Compression), MSCC (Maximum Spinal Cord Compression), MRI (Magnetic Resonance Imaging), TSCI (Traumatic Spinal Cord Injury), ISNCSCI (International Standards for Neurological Classification of Spinal Cord Injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ackery A.
        • Tator C.
        • Krassioukov A.
        A global perspective on spinal cord injury epidemiology.
        J. Neurotrauma. 2004; 21: 1355-1370
        • Badhiwala J.H.
        • Wilson J.R.
        • Witiw C.D.
        • Harrop J.S.
        • Vaccaro A.R.
        • Aarabi B.
        • et al.
        The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data.
        Lancet Neurol. 2021; 20: 117-126
        • Yousefifard M.
        • Rahimi-Movaghar V.
        • Baikpour M.
        • Ghelichkhani P.
        • Hosseini M.
        • Jafari A.
        • et al.
        Early versus late spinal decompression surgery in treatment of traumatic spinal cord injuries; a systematic review and meta-analysis.
        Emerg. (Tehran). 2017; 5e37
        • Middleton J.
        • McElduff P.
        • Pearse J.
        • Walsh J.
        • Cameron I.
        • et al.
        Identifying predictors of higher acute care costs for patients with traumatic spinal cord injury and modeling acute care pathway redesign.
        Spine (Phila Pa 1976). 2019; 44 (4 Mar 2019): E974-E983
        • Marino R.
        • Barros T.
        • Biering-Sorensen F.
        • Burns S.
        • Donovan W.
        • Graves D.
        ASIA neurological standards committee 2002.
        J. Spinal Cord Med. 2003; 26 (S50 - S6)
        • Al-Habib A.
        • Attabib N.
        • Ball J.
        • Bajamma L.S.
        • Casha S.
        • Hurlbert R.
        Clinical predictors of recovery after blunt spinal cord trauma: systematic review.
        J. Neurotrauma. 2011; 28: 1431-1443
        • Kurpad S.
        • Martin A.
        • Tetreault L.
        • Fischer D.
        • Skelly A.
        • Mikulis D.
        • et al.
        Impact of baseline magnetic resonance imaging on neurologic, functional, and safety outcomes in patients with acute traumatic spinal cord injury.
        Glob. Spine J. 2017; 7 (151S–74S)
        • Fehlings M.
        • Vaccaro A.
        • Wilson J.
        • Singh A.
        • Cadotte D.
        • Harrop J.
        • et al.
        Early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in acute spinal cord injury study (STASCIS).
        PLoS One. 2012; 7e32037
        • Freund P.
        • Seif M.
        • Weiskopf N.
        • Friston K.
        • Fehlings M.
        • Thompson A.
        MRI in traumatic spinal cord injury: from clinical assessment to neuroimaging biomarkers.
        Lancet Neurol. 2019; 18: 1123-1135
        • Gupta R.
        • Mittal P.
        • Sandhu P.
        • Saggar K.
        • Gupta K.
        Correlation of qualitative and quantitative MRI parameters with neurological status: a prospective study on patients with spinal trauma.
        J. Clin. Diagn. Res. 2014; 8 (Rc13–7)
        • Kulkarni M.V.
        • Bondurant F.J.
        • Rose S.L.
        • Narayana P.A.
        1.5 tesla magnetic resonance imaging of acute spinal trauma.
        . 1988; 8: 1059-1082
        • Bondurant F.J.
        • Cotler H.B.
        • Kulkarni M.V.
        • McArdle C.B.
        • Harris Jr., J.H.
        Acute spinal cord injury. A study using physical examination and magnetic resonance imaging.
        Spine (Phila Pa 1976). 1990; 15: 161-168
        • Ramón S.
        • Domínguez R.
        • Ramírez L.
        • Paraira M.
        • Olona M.
        • Castelló T.
        • et al.
        Clinical and magnetic resonance imaging correlation in acute spinal cord injury.
        Spinal Cord. 1997; 35: 664-673
        • Rutges J.
        • Kwon B.K.
        • Heran M.
        • Ailon T.
        • Street J.T.
        • Dvorak M.F.
        A prospective serial MRI study following acute traumatic cervical spinal cord injury.
        Eur. Spine J. 2017; 26: 2324-2332
        • Miyanji F.
        • Furlan J.
        • Aarabi B.
        • Arnold P.
        • Fehlings M.
        Acute cervical traumatic spinal cord injury: MR imaging findings correlated with neurologic outcome—prospective study with 100 consecutive patients.
        Radiology. 2007; 243: 820-827
        • Tempest-Mitchell J.
        • Hilton B.
        • Davies B.M.
        • Nouri A.
        • Hutchinson P.J.
        • Scoffings D.J.
        • et al.
        A comparison of radiological descriptions of spinal cord compression with quantitative measures, and their role in non-specialist clinical management.
        PLoS One. 2019; 14e0219380
        • Flanders A.E.
        • Spettell C.M.
        • Tartaglino L.M.
        • Friedman D.P.
        • Herbison G.J.
        Forecasting motor recovery after cervical spinal cord injury: value of MR imaging.
        Radiology. 1996; 201: 649-655
        • Furlan J.C.
        • Kailaya-Vasan A.
        • Aarabi B.
        • Fehlings M.G.
        A novel approach to quantitatively assess posttraumatic cervical spinal canal compromise and spinal cord compression: a multicenter responsiveness study.
        Spine (Phila Pa 1976). 2011; 36: 784-793
        • Talbott J.
        • Whetstone W.
        • Readdy W.
        • Ferguson A.
        • Bresnahan J.
        • Saigal R.
        The brain and spinal injury center score: a novel, simple, and reproducible method for assessing the severity of acute cervical spinal cord injury with axial T2-weighted MRI findings.
        J. Neurosurg. Spine. 2015; 23: 495-504
        • Dalkilic T.
        • Fallah N.
        • Noonan V.K.
        • Salimi Elizei S.
        • Dong K.
        • Belanger L.
        • et al.
        Predicting injury severity and neurological recovery after acute cervical spinal cord injury: a comparison of cerebrospinal fluid and magnetic resonance imaging biomarkers.
        J. Neurotrauma. 2018; 35: 435-445
        • Skeers P.
        • Battistuzzo C.R.
        • Clark J.M.
        • Bernard S.
        • Freeman B.J.C.
        • Batchelor P.E.
        Acute thoracolumbar spinal cord injury: relationship of cord compression to neurological outcome.
        J. Bone Joint Surg. Am. 2018; 100: 305-315
        • Middleton J.
        • Sharwood L.
        • Cameron P.
        • Middleton P.
        • Harrison J.
        • McClure R.
        • et al.
        Right care, right time, right place: improving outcomes for people with spinal cord injury through early access to intervention and improved access to specialised care: study protocol.
        BMC Health Serv. Res. 2014; 14
        • Maynard F.
        • Bracken M.
        • Creasey G.
        • Ditunno J.
        • Donovan W.
        • Ducker T.
        • et al.
        International standards for neurological and functional classification of spinal cord injury.
        Spinal Cord. 1997; 35: 266-274
        • Vaikuntam B.P.
        • Middleton J.W.
        • McElduff P.
        • Pearse J.
        • Walsh J.
        • Cameron I.D.
        • et al.
        Assessing the impact of care pathways on potentially preventable complications and costs for spinal trauma patients: a data linkage study.
        BMJ Open. 2018; 8e023785
        • Gedeborg R.
        • Warner M.
        • Chen L.H.
        • Gulliver P.
        • Cryer C.
        • Robitaille Y.
        • et al.
        Internationally comparable diagnosis-specific survival probabilities for calculation of the ICD-10-based injury severity score.
        J. Trauma Acute Care Surg. 2014; 76: 358-365
        • Sundararajan V.
        • Henderson T.
        • Perry C.
        • Muggivan A.
        • Quan H.
        • Ghali W.A.
        New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality.
        J. Clin. Epidemiol. 2004; 57: 1288-1294
        • Australian Consortium for Classification Development
        The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM/ACHI/ACS).
        Tenth ed. Independent Hospital Pricing Authority, Darlinghurst, NSW2017
        • Collins G.S.
        • Reitsma J.B.
        • Altman D.G.
        • Moons K.G.M.
        Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement.
        BMC Med. 2015; 13: 1
        • Roberts T.T.
        • Leonard G.R.
        • Cepela D.J.
        Classifications in brief: American spinal injury association (ASIA) impairment scale.
        Clin. Orthop. Relat. Res. 2017; 475: 1499-1504
        • Burns S.
        • Biering-Sørensen F.
        • Donovan W.
        • Graves D.
        • Jha A.
        • Johansen M.
        • et al.
        International standards for neurological classification of spinal cord injury, revised 2011.
        Top. Spinal Cord Inj. Rehab. 2012; 18: 85-99
        • Fehlings M.
        • Tator C.
        An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies.
        J. Neurosurg. 1999; 91: 1-11
        • STATACorp
        Stata Statistical Software.
        2017 (Version 15.1 IC)
        • R Core Team R
        A Language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2014;URL
        • Flanders A.E.
        • Schaefer D.M.
        • Doan H.T.
        • Mishkin M.M.
        • Gonzalez C.F.
        • Northrup B.E.
        Acute cervical spine trauma: correlation of MR imaging findings with degree of neurologic deficit.
        Radiology. 1990; 177: 25-33
        • Schaefer D.M.
        • Flanders A.E.
        • Osterholm J.L.
        • Northrup B.E.
        Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury.
        J. Neurosurg. 1992; 76: 218-223
        • Bozzo A.
        • Marcoux J.
        • Radhakrishna M.
        • Pelletier J.
        • Goulet B.
        The role of magnetic resonance imaging in the management of acute spinal cord injury.
        J. Neurotrauma. 2011; 28: 1401-1411
        • DeVivo M.J.
        Epidemiology of traumatic spinal cord injury: trends and future implications.
        Spinal Cord. 2012; 50: 365-372
        • Lenehan B.
        • Street J.
        • Kwon B.
        • Noonan V.
        • Zhang H.
        • Fisher C.
        • et al.
        The epidemiology of traumatic spinal cord injury in British Columbia, Canada.
        Spine (Phila Pa). 2012; 37: 321-329
        • Middleton P.
        • Davies S.
        • Anand S.
        • Marial O.
        • Reinten-Reynolds T.
        • Middleton J.
        The prehospital epidemiology and management of spinal cord injuries in NSW: 2004-2008.
        Injury. 2012; 43: 480-485
        • Whiteneck G.
        • Gassaway J.
        • Dijkers M.
        • Backus D.
        • Charlifue S.
        • Chen D.
        • et al.
        Inpatient treatment time across disciplines in spinal cord injury rehabilitation.
        J. Spinal Cord Med. 2011; 34: 133-148