Introduction

Any injury that may be caused to the spinal cord by trauma instead of disease is known as spinal cord injury. The numbers of people suffering from this injury range between 250000 and 500, 000 every year (Disabilities and rehabilitation, 2014). Injury in spinal cord results in premature deaths of the people.  Trauma is the most common cause of spinal injury which can be either complete or incomplete. In the last five years there has been an increase in the number of spinal cord injuries (Morishita and et.al., 2008). These injuries have proved to be more fatal for the senior population as compared to the younger group. The most important factors in successful achievement of recovery from spinal cord injury are immobilization and treatment (Parashari and et.al., 2011). Having costly consequences for both the individual and the family, spinal injury needs adequate medical and rehabilitation response. Being a diagnostic procedure, Magnetic Resonance Imaging (MRI) uses a combination of radiofrequencies, a large magnet and a computer. Detailed images of organs and structures within the body are produced. As its performance in identifying the difference between different soft tissues and between normal and abnormal soft tissues is better than other techniques, it is often used in situations that deal with the study of vascular malformations (Khandelwal and et.al.,  2004.). As such, abnormalities in the spinal cord can be recognized in the best possible manner.

MRI finds its use in examining the spinal cord for injuries. If damage is caused to the spinal cord through crushing or bruising, messages cannot be sent and received from the brain. After the injury, the millions of nerve fibers of which the spinal cord is made up are not able to regenerate (What is a spinal cord injury?, 2014). The injury may be complete or incomplete depending on the degree of damage to the nerve fibers. It is a difficult task to diagnose an unstable spinal injury and subsequently manage it. If missed, the injury can have devastating long term consequences (Stekelenburg and et.al., 2007). Hence, it is required for the evaluation procedure of unstable spine to be robust, highly sensitive and easy to implement.

Aims

The present study focuses on identifying the role that MRI plays in spinal injuries. This work has been done with the aim of carrying out a systematic review of the evidences from research studies for the purpose of answering the following research question: what is the role of MRI in spinal injuries? Subsequently, an evidence based recommendation will be made by this research project for the use of MRI in spinal injuries. MRI finds its use in examining the spinal cord for injuries. If damage is caused to the spinal cord through crushing or bruising, messages cannot be sent and received from the brain. After the injury, the millions of nerve fibers of which the spinal cord is made up are not able to regenerate (What is a spinal cord injury?, 2014). The injury may be complete or incomplete depending on the degree of damage to the nerve fibers. It is a difficult task to diagnose an unstable spinal injury and subsequently manage it. If missed, the injury can have devastating long term consequences (Stekelenburg and et.al., 2007). Hence, it is required for the evaluation procedure of unstable spine to be robust, highly sensitive and easy to implement.

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METHODOLOGY

Systematic review is a literature review that is done with the aim of focusing on a research question that helps in the identification, appraisal, selection and synthesis of research evidence of high quality (Cooper, Hedges and Valentine, 2009.). This is done with the relevance to the research question. An exhaustive summary of the current literature that is pertinent to the research question is provided by the review. As the first step of the systematic review, a thorough search of the literature is done for relevant papers. The methodology section of the review provides a list of the databases and citation indexes that were searched. The next steps deals with the checking of the titles and abstracts of the identified articles against the predetermined criteria for eligibility and relevance. The studies that are included in the review are assigned an objective assessment of methodological quality (DeRenzo and Moss, 2005). For combining the results of eligible studies, statistical techniques are used. An outline will be provided by this section related to the use of electronic databases, key search terms and inclusion and exclusion criteria.

Search strategy

For confirming the use of appropriate approach that the researcher will take for the construction of appropriate search strategy, existing research texts were used. Systematic approach has been used for reviewing the literature (Henggeler and et.al., 2006.). An electronic search was conducted of various bibliographic databases such as MEDLINE, CINAHL, EMBASE, Science Direct and Pubmed Central. With this, potentially relevant citations were identified. An internet search was performed for finding the web pages where citations might be available. 

Databases searched Description
   
The Cochrane Library This consists of databases that provide information on medicine and helath care through scholar articles. (The Cochrane Library, 2013).
   
The National Center for Biotechnology Information (NCBI) With a collection of the databases in the field of medicine and biotechnology, NCBI consists of a pool of information regarding genetics (National Center for Biotechnology Information. 2014).
   
BioMed Central(BMC) A publisher having peer reviewed journal articles BioMed Central is based in UK. It provides information on the subjects of science and technology and biomedicine.
   
PsychINFO

Devoted to over 3 million records in mental health and behavioral sciences, PsychINFO consists of articles that provide information on medicine, nursing and social work (PsycINFO, 2013).
   
Science Direct This is a leading full text database that has pool of information on subjects that are scientific in nature (Science Direct, 2013).

Identification of key search terms

Search terms are the key variables that define a research and provide assistance to proceed with the literature review. The key search terms are the words that are synonyms or acronyms to the particular study (Katrak and et.al., 2004). The researcher can make use of the search terms for identification of the suitable research papers that could be included in the systematic review. As reading all the research papers is a lengthy process. As such, key search terms were identified and made use of for defining the search for conducting the systematic literature review on the role of MRI in spine injuries (Park and et.al., 2005). The citations were retrieved by using the following search terms:

TERM 1 MRI, Magnetic Resonance Imaging
TERM 2 Injury, lesion, damage
TERM 3 Spinal, spinal column, vertebral column

Inclusion and exclusion criteria

After identifying all the potentially relevant citations, examination of the abstract and necessary full text was done for making decision regarding the final inclusion and exclusion. The aim of the research helped in deriving the criteria that were used in the review. The inclusion and exclusion criteria helped in identifying and making decisions regarding the use of research papers for completing the review (Page, 2008). The papers that met the criteria were selected. The inclusion and exclusion criteria for the present systematic review are the following:

INCLUSION CRITERIA EXCLUSION CRITERIA
Articles published from year 2007 to present Papers published prior to 2007
Research papers that have been written in English language  
Research papers written in languages other than English
Studies that focus on the role of MRI  Studies that focus on the role of any other diagnosis test
Researches done on the role of MRI in spinal injuries Researches focusing on the role of MRI in any other injury

Data extraction

Data extraction is the process that helps in taking out relevant information from the research papers selected to be included in the systematic review (Patton, 2002). With the help of this area, detailed information about the research papers is provided in terms of quality, relevance and trustworthiness. In this manner, detailed information is provided for each study that is to be included in the systematic review (Shea and et.al., 2001). For extraction, a tool is used by the researcher for identifying the type of information that is required for the systematic review. For conducting the present literature review, that following question types have been selected for investigating the role of MRI in spinal injuries:

  •    Who is the author of the article?
  •    What is the name of paper and journal that has been selected for the literature review?
  •    With what aim and purpose has the study been conducted?
  •    What are the main themes?
  •    How and what methods have been chosen for collecting the data?
  •    What are the key findings of the study included?

For extracting the most relevant data from the various research papers that have been selected for examining the role of MRI in spinal injuries, information about the setting of the study, sample size and the participants has been obtained in detail (Bhattacharyya, 2009). Data about the methodological approaches that have been adopted in each of the studies has also been collected. Research design and tools for data analysis that have been applied in the studies have also been used for collecting relevant information (Cooper, Hedges and Valentine, 2009). Lastly, useful information that is provided by the findings of each research paper has also been gathered.       

CRITICAL APPRAISAL

One of the most important aspects of systematic review is critical appraisal of all they include studies. For this, various tools and frameworks are applied for assessing the strengths as well as the weaknesses of the selected research papers (Shea and et.al., 2007). In order to critically appraise the included research papers in the present study on identifying the role of Magnetic Resonance Imaging, there has been use of critical appraisal tool of CASP (Critical Appraisal Skills Program). For different types of studies, the tool is different. Some relevant questions have been answered for assessing the reliability, validity and applicability of the research papers that have been included for the present systematic review.

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Critical Appraisal Skills Programme (CASP): Systematic review

The review addressed a clearly focused question of systematic review of role of MRI imaging in managing acute spinal cord injury.

Yes the authors searched for the right type of papers as they were able to answer the questions relevant to this review. The recommended protocol for MRI in spinal cord injury could be identified. They were also able to find out the effect of MRI on initial management. The papers helped in detecting the ability of MRI to predict the long term neurological outcome of a patient.     

Yes, important and relevant studies were included. Systematic review of literature was done on MRI between 1988 and 2009. Multiple databases such as PubMed, EMBASE and Ovid Medline were used for conducting an initial systematic research. For determining the eligibility for inclusion, both the title of the citation as well as the abstracts of all the references was reviewed. The search was kept limited to human subjects and those articles that were published in English. It can be said that relevant studies were included as the authors excluded those studies form the review that were based on the use of magnetic strength of less than 1.5 Tesla. Also, those studies were excluded that were on chronic stages of spinal cord injury.     

Yes the authors of the review assessed the quality of the collected studies with the use of Downs and Black scoring system based on 27 questions. Scoring was done for each study twice. The studies were rated differently between the two investigators were reviewed till a consensus score was reached.

Yes the results of the review have been combined. It was reasonable to do so as the aim of the paper was to find out if MRI could be recommended for prognostication of acute spinal; cord injury. 

The overall results of the review were obtained by dividing the articles into seven topics. These were spinal cord injury without radiological abnormality, vertebral artery injury, spinal clearance, and soft tissue injury, other specific topics and descriptive MRI findings. As per the results, there was always presence of hemorrhage concurrently with edema. MRI demonstrates it in the form of hyper intensity normally associated with edema. The values of MRI as part of standard clearance protocol were in a questionable position due to small number of significant findings and lack of resulting changes in surgical management.

No information has been provided in the review on the precision of the results. 

Yes the results can be applied to the local population who is suffering from injuries of spinal cord.

Yes all the important outcomes were considered as the study contains much relevant information. The outcomes were related to various aspects such as MRI sequences, soft tissue injury, bone injury, disk, vertebral artery injuries etc.

Yes, the benefits of the study are worth the harms and the costs as the review helped in providing useful information on the role of MRI in spinal injury. The study provided insights into the possibility of developing new MRI techniques so that better spinal cord lesions could be visualized. Also, the study provided several benefits in the form of visualization of eventual repairs with the help of MRI, tracking of transplanted cells and recognition of adverse effects of this therapy.

 Critical Appraisal Skills Programme (CASP): Meta analytic review

Yes the review addressed a clearly focused question related to the use of MRI in cervical spine injuries following trauma.  

Yes, right types of papers were looked by the authors. These were on the topics that were relevant for this review. Sensitivity of MRI was measured by some papers. Research papers on MRI as a safe and reliable method for evaluation of the injuries of cervical spine were referred to.  Studies on the use of MRI helped the authors in answering various questions. These were related to the clearance of cervical spine in case no ligamentous injury was shown by MRI. The papers also helped in knowing the superiority of MRI in the detection of injury of cervical spine. As such, the role that MRI plays in spinal injuries could be assessed by the authors.   

Yes, the authors included relevant studies for conducting the review. National Library of Medicine was searched for obtaining the studies. Also, National Institutes of Health MEDLINE database was also used for searching the studies. From the search, those articles were retrieved that were in English language and were based on identification of cervical spine injury from 1988 to 2007. The authors excluded editorials, letters to the editor, review articles and other forms of general commentary from the search.   

Yes, the quality of the included studies was assessed by the authors. This was done by classifying the articles as Class I, II or III.  

No, the results of the review were not combined. This is because it was not reasonable to do so as the studies were done on different aspects that are related to MRI and spinal injury and demonstrated different results.  

The overall results of the review pointed towards the use of MRI in case of patients who complain of neck pain. MRI can be used as a treatment option before removing the collar. It should be done ideally before 72 hours from the injury. MRI finds its use in the patients with persistent cervical spine pain after trauma. However, the risk/benefit ratio of obtaining MRI in addition to CT could not be clearly obtained. It was also found out that MRI is expensive and obtaining it may put an obtunded ICU patient at significant risk. MRI does not play a significant role if CT of cervical spine is negative for injury in the obtunded patient. However, cervical spine immobilization could only be discontinued on obtaining a normal MRI Cervical spine. Being more sensitive to the identification of soft tissue injuries, Magnetic Resonance Imaging is considered as the reference standard in identification of injuries to spinal cord. But, clinical significance of all the injuries obtained by MRI is not clear.     

No information is available on the precision of results.

Yes the results can be applied to the local population. It is applicable for those people who have undergone CT of cervical spine but are still suffering from persistent pain. The results also pertain to those people who have to undergo discontinuation of immobilization of cervical spine.  

Yes, all the important outcomes were considered by the review. It not only identified the relevance of MRI but also compared it with CT.  

As relevant information was gained according to the topic, the benefits of the study are worth the costs.

 Critical Appraisal Skills Programme (CASP) :  Diagnostic test study

Yes a clearly focused question was discussed by the study. This was focused in terms of the people who suffered spinal injuries. People with posterior ligamentous complex injury have been included in the study. Spine trauma population has been assessed. The study aims to address the issue related to the pathologic correlation of posterior ligamentous injury with MRI. The study tried to investigate the pathologic correlation of MRI of ligamentous spinal injuries. The study made an attempt to detect the wide acceptance of MRI in spine trauma. The question included information regarding the population which was patients with spinal injury. It also provided information about the diagnostic test MRI. The outcome of the question was focused on investigating the role of MRI in ligamentous spinal injury.

Yes there was comparison with an appropriate reference standard. This was the computed tomography. This was considered as accurate and best method for detecting the spinal cord injuries. However, the reference test that was computed tomography scan was not the best available indicator in the circumstances.

No, all the patients did not get the diagnostic test and the reference standard. There were two patient cases that were described by the authors in this study. Patient in case one get the diagnostic test as well as the reference standard. Patient in case two got only the diagnostic test performed. Tre reference standard was not applied to the patient in the second case.  

No the results of the test have not been influenced by the results of the reference standard. The tests were performed independently.   

Yes the disease status of the tested population was clearly described. Precise definition of the cases has been provided. The first case, a 21 year old woman reported of significant pain in the thoracic spine. The patient did not report loss of consciousness, skin abrasions, cerpitus or palpable step offs.However, tenderness to palpation in the mid thoracic area was reported. Differential diagnosis was performed in this case. Computed tomography images of the cervical, lumbar and thoracic spine were obtained. Compression of T5 and T6 vertebrae was identified. Given the suspicion of ligamentous injury, a thoracic spine MRI was obtained. The second case was of a 54 year old woman who was hit by her own car, reported lower back pain. Reduced sensation in the left L2 and L3 dermatome was also reported. The authors have also described the case by providing information such as feeling of weakness of the left hip flexors and the left ankle dorsiflexion in the second case. Due to suspicion regarding the compression injury, lumbar MRI was performed. Inferior end plate and superior endplate fracture of the L2 w2as reported by the MRI. However, sufficient number of cases was not selected by the authors. The study described only two cases. 

No, sufficient detail has not been provided about the methods for performing the test. No protocol was followed in this regard.

The results indicated that magnetic resonance imaging is a powerful tool that can be used by the clinician for obtaining information related to the posterior ligamentous complex.  It has various useful sequences that help in the diagnoses of spinal trauma. These include sagittal and axial T1 weighted image, T2 weighted FSE and STIR sequences that assist in highlighting bone edema.  Ligamentous injuries in the spine can be best identified with T2 weighted images with fat saturation. This is because ligaments are thin and a fat binds them on either side. These appear as hyper intense on both T1 and T2 images. However, in isolation, T1 images prove to be inadequate for identification of ligamentous injuries. In case of clinical suspicion of posterior ligamentous injury, necessary information can be provided by MRI. Yes the sensitivity and likelihood ratios have been presented. Also, the results have been presented in such a way that they can be worked out. The study reported the diagnostic accuracy of MRI for both supraspinous ligament and interspinous ligament injury with a sensitivity of 89.4 per cent and 98.5 per cent respectively. The specificity of diagnostic accuracy of MRI for supraspinous ligament injury in the spine was found out to be 92.3 per cent. This was reported to be 87.2 per cent in case of interspinous ligament injury.  

As there are no confidence limits, the researcher cannot be sure of the results.

Yes, the results can be applied to the patients or the population of interest. The population of interest consists of the people with spinal injury. The patients in the study are of younger as well as middle age. Hence, the results can be applied to the population of interest. The results indicate the efficiency of MRI in detecting ligamentous injuries of spine.

Yes, the test can be applied to the population of interest for detection of spinal injuries with the help of its various sequences. However, the resources need to be there for application of the test. MRI machine is required for testing for the presence of ligamentous injury in the spine. Also, for the interpretation of the test, high level of expertise is required. Considering the current practice and availability of services, MRI can be applied to test for ligamentous injuries in the people with spinal trauma.

Yes all the outcomes were important to the population considered. This is because, with the knowledge of MRI, patient well being will be improved. The people who suffer from spinal injury will benefit by MRI. This is because its sequences are helpful in detecting ligamentous injuries in the spine. With this, better and timely steps can be taken for treatment. Knowledge of the result of the test will lead to a change in patient management. It will improve the delivery of service. Accurate and specific treatment can be provided with the precise detection of the injury by using MRI and its various sequences.          

Use of this test will have a positive impact on the population of interest. Better treatment can be provided to the patients who suffer from spinal injury. MRI accurately detects the injury of ligaments in the spine region. Hence, by using its sequences, timely detection of the spinal trauma can be done. 

 Critical Appraisal Skills Programme (CASP) : Control case study

Yes the study addressed clearly focused issue of plasticity of injured human spinal cord. There is little evidence regarding the change of spinal cord after injury. Traumatic injury of the spine leads to acute disruption of somatosensory signals. There is also seen an inability to process motor, autonomic and reflex arcs within the region of the spinal cord that gets damaged.

Yes the authors used appropriate method to answer the question. They compared healthy control subjects to chronic spinal cord injury patients. Chronic spinal cord injury patients were grouped according to the degree of sensory loss. As the question was focused on finding the information regarding the plasticity of the spinal cord, the patients need to be compared with healthy individuals. Also, it was necessary to assess the degree of sensory loss. Hence, use of case control study was appropriate as helped in answering the study question. 

Yes the cases were recruited in an acceptable way. Precise definition of the cases has been provided. The chronic spinal cord injury patients were selected after 1 year of injury. These were grouped according to the degree of sensory injury. Subjects who had complete injury and there was no preserved sensation below the level of injury were placed in Grade A. those subjects who suffered incomplete injury and there was some preserved sensation below the level of injury belonged to grade B, C and D. in grade C the subjects with complete motor and sensory recovery after spinal cord injury were placed. This was used as the reliable system for selecting the cases. 38 cases were selected for the study which was a sufficient number.  

Yes the controls were selected in an acceptable way. They were representative of population that suffered spinal injury before one year. With an average age of 37 years, they control subjects were representative of an age range of 23 to 62 years. These were categorized according to the level of injury. The number of controls selected for the study was 20 which were sufficient.  

Yes the exposure was clearly defined and accurately measured. There was application of thermal stimulation in an identical pattern to both the healthy control and spinal cord injury participants in control subject, C5 and C8 dermatomes were heated on both the sides of the body. 3T General Electric System was used to collect spinal fMRI data. This was done by using previously established methods based on SEEP or signal enhancements by extracellular protons. This is a contrast mechanism that can detect changes in tissue water content related to neural activity. The measurement methods were similar in cases and controls. As the plasticity of the spinal cord and its networks was to be measured, the measures adopted such as thermal stimulation truly reflected what they are supposed to measure.    

No information has been provided regarding the confounding factors.  

No, the authors have not taken account of the potential confounding factors in the design or in their analysis.     

An increased number of active voxels which are relative to controls were shown by the patients with chronic incomplete SCI or spinal cord injury when they were stimulated in a dermatome of normal; sensation. Spinal fMRI can be used for investigation of changes in spinal processing of somatosensory information in the spinal cord of humans. It was used to measure an increase in the average number of active voxels in dermatosomes of normal sensation in chronic SCI patients.     

No information has been provided related to the precision of the results.  

Yes the results are believable as chronic spinal cord injury patients were included in the study.  

Yes the results can be applied to the local population. The subjects covered in the study are similar to the population that is being considered by the researcher.   
No information is provided regarding this.

EVALUATION OF RESEARCH DESIGNS

Paper  Type of study Purpose  Sample Design Data Collections Key findings
Bozzo, A., Marcoux, J. and Goulet, B., 2011. The Role of Magnetic Resonance Imaging in the Management of Acute Spinal Cord Injury. Systematic review To answer three questions:
  1. What is the recommended protocol for MRI in acute spinal injury?
  2. Is the initial management affected by MRI?
  3. Is a patient’s long term neurological outcome predicted by MRI?
113 original papers were included in the study due to their quality and relevance for conducting systematic review. There were no randomized control trials. The evidence of each article was classified according to Strauss and associates. Downs and Black scoring system based on 27 questions was used for assessing the methodological quality of the selected publications. With the maximum possible score of 44, each publication was scored twice. Consensus score was obtained for those studies that were rated differently by two investigators by reviewing them.  Data was collected by conducting an initial systematic search by nursing multiple databases such as Ovid Medline, PubMed, and EMBASE. Determination of the exact time to perform MRI within the acute period cannot be done. Most often, MRI was performed by the authors within the first 72 hours post injury. For prognosticative purposes, sequences other than sagittal were not found to be useful. In the future, other sequences could be considered as useful for prognostication on account of the rapidly improving software and the increasing magnet strength. 
Como, J. J., Diaz, J. J., Dunham, C. M., Chiu, W. C., Duane, T. M., Capella, J. M., Holevar, M. R., Khwaja, K. A., Mayglothling, J. A., Shapiro, M. B. and Winston, E. S. 2009. Cervical Spine Injuries Following Trauma. Meta-analytic review To find out when should MRI be performed and who needs it. 78 articles were identified out of which the guidelines were selected by using 52 articles. The target population for these articles was trauma patients with suspected spine injury.  Meta-analytic review. The quality and strength of the review was assessed by weighing them according to a rating scheme. Various electronic databases were searched for collecting the data. A search was performed of the National Library of Medicine and National Institute of Health MEDLINE database by using PubMed. With the help of this search, articles of English language were retrieved. These were from the years 1998 to 2007 regarding the identification of the cervical spine injury.      The risk benefit ratio of using MRI is not clear. Its use must be individualized. Removal of cervical collar can be done if nothing abnormal is disclosed by the MRI.
Original study: Dekutoski, B. M., Hayes, L. M., Utter, P. A., Szatkowski, P. J., Port, D. J., Wald, T. J., Inwards, Y. C., Vaccaro, R. A., Fehlings, G. M., 2010.N Pathologic Correlation of Posterior Ligamentous Injury With MRI. Diagnostic test study To find out the pathological correlation of posterior ligamentous injury with MRI Two patient cases were described by the authors. The study was based on the research of diagnostic test control. MRI has been established as diagnostic method for spinal injury. By describing the case, information was provided how well MRI can predict the injuries of spine. Data collection was done by studying the cases of two patient who suffered spinal injuries. The symptoms and signs of injury were observed and analyzed. Both the patients got MRI which helped in predicting the spinal injuries. In this manner, the sensitivity and specificity of MRI was obtained. MRI can be used as a helpful diagnostic tool as it has the capability of providing useful information to the clinician regarding the condition of the posterior ligamentous complex.  MRI can provide the necessary information with its proper sequences.
Cadotte, W. D., Bosma, R., Mikulis, D., Nugaeva, N., Smith, K., Pokrupa, R., Islam, O., Stroman, W. P., Fehlings, G. M., 2012. Plasticity of the Injured Human Spinal Cord: Insights Revealed by Spinal Cord Functional MRI. Case control study To demonstrate the use of spinal fMRI in investigation of the changes in spinal processing of somatosensory information in the spinal cord of humans. The sample size consisted of 38 individuals. Case control study. 20 healthy control subjects were compared with 18 spinal cord injury patients.  Chronic spinal cord injury patients were grouped according to the degree of sensory loss.  Spinal fMRI data was collected at 3 Tesla at two institutions from 38 individuals. This was done by making use of standard SEEP functional MR imaging techniques.  An increased number of active voxels that were relative to controls were shown by the patients with chronic incomplete spinal cord injury when they were stimulated in a dermatome normal sensation. fMRI has been useful in investigating the changes in spinal processing. 

ETHICAL ISSUES IN THE AREA OF STUDY

For conducting the research in an efficient manner, care is to be taken to give due consideration to the ethical implications (Bryman, 2008). It is for this reason that ethical issues have been considered while undertaking the systematic literature review on the role of MRI in spinal injuries. These are the following:

Beneficence-

This segment deals with the reliability and validity aspects of the research. Hence, the researcher has ensured to maintain the validity and reliability in all aspects. The first step towards this has been selecting copyright sources. The data provided in the journal articles has not been skewed. It has been made sure that the most valid methodology has been selected which is suitable in all possible accords (Gardner, 2004). The aspect of transparency has also been given prime importance. For this, accurate extraction of data has been done.

Justice-

Efforts have been made by the researcher to avoid being partial to one area of the study and demonstrate only positive or negative aspects. Care has been taken to be strict regarding the concept of plagiarism.

Conclusion

MRI plays a significant role in the evaluation and detection of spinal trauma. Spinal injuries consist of a wide spectrum including acute sprain/strain, intravertebral disk injury, increased spinal stenosis, nerve root injuries etc. spinal cord abnormalities occurring due to injury which may not be apparent on other imaging techniques can be readily detected with the help of MRI (Giuliano and Knipfing, 2013). Magnetic resonance imaging is a powerful tool that can be used as a non invasive adjunct to examination for injuries in the spine. It plays a crucial role in the clinical assessment of ligamentous, soft tissue and disk injuries. With early detection of injuries, prompt and accurate diagnosis can be performed thus leading to expeditious management. This helps in avoiding unnecessary procedures. With many advantages of MRI such as multiplanar capability, absence of bony artifacts, high contrast resolution and choice of various pulse sequences, spinal trauma can be diagnosed more accurately (Rajasekaran and et.al., 2010). With the analysis of the literature review, it can be concluded that various MRI findings in acute injury of the spinal cord correlate well with the clinical findings. Hence, for initial diagnosis of injury in spinal cord, MRI is a useful tool. In the setting of thoracic trauma, there is continuous evolution of role of MRI owing to the improvement of its diagnostic accuracy. In the case of clinical suspicion of a posterior ligamentous complex injury which will influence the treatment decision of the patient, necessary information can be provided by the proper sequences of MRI (Rihn and et.al., 2009).  

LIMITATIONS OF THE REVIEW

There were various limitations that were faced by the researcher while conducting the systematic literature review. The first was availability of limited word count. Had the word limit allowed, a more detailed description could have been provided by the researcher regarding the role of MRI in spinal injuries (Golafshani, 2003). Another limitation was the presence of limited time frame. Had the time constraint not been here, a comprehensive systematic review had been completed. As such, more reliable and thorough results would have reaped by the review. As many of the selected studies made use of selective models, the aspect of validity and reliability of studies had to be compromised. Also, there has been constant evolution in the use of use of MRI technique for detection of injuries. Due to the recent advancements made in the screening tools, there has been generation of new information. Considering this aspect, it can be a limitation that the results of the present systematic literature review will be rendered obsolete in few years.

RECOMMENDATIONS

The benefit and crucial role of MRI in spinal injuries has been clearly understood. Hence, there are various implications regarding the implementation of this diagnostic tool on a mass level. In this regard, there needs to be development of new MRI techniques so that spinal cord lesions can be visualized in a better manner (Ellingson and et.al., 2008). There is also a requirement to advance the concerned diagnostic tool for visualization of eventual repair and detection of adverse effects of therapy (Rajasekaran and et.al., 2010). However, it is recommended that MRI should be done in all the patients with acute spinal cord injury to provide direction for its management.   

REFERENCES

  • Bhattacharyya, K. D., 2009. Research Methodology. Excel Books India.  
  • Bozzo, A., Marcoux, J. and Goulet, B., 2011. The Role of Magnetic Resonance Imaging in the Management of Acute Spinal Cord Injury. Journal of Neurotrauma. 28(8). Pp.1401-1411.  
  • Bryman, A., 2008. Of methods and methodology.  Qualitative Research in Organizations and Management: An International Journal. 3(2). pp.159 – 168.
  • Cadotte, W. D., Bosma, R., Mikulis, D., Nugaeva, N., Smith, K., Pokrupa, R., Islam, O., Stroman, W. P., Fehlings, G. M., 2012. Plasticity of the Injured Human Spinal Cord: Insights Revealed by Spinal Cord Functional MRI. PLoS ONE 7(9).   
  • Como, J. J., Diaz, J. J., Dunham, C. M., Chiu, W. C., Duane, T. M., Capella, J. M., Holevar, M. R., Khwaja, K. A., Mayglothling, J. A., Shapiro, M. B. and Winston, E. S. 2009. Cervical Spine Injuries Following Trauma. J Trauma. 67 (3). Pp.651-9.  

APPENDIX

CASP for diagnostic test study

  1. Was there a clear question for the study to address?
  2. Did the authors use an appropriate method to answer their question?
  3. Did all the patients get the diagnostic test and the reference standard?
  4. Could the results of the test have been influenced by the result of the reference standard?
  5. Is the disease status of the tested population clearly described?
  6. Were the methods of performing the test described in sufficient detail?
  7. What are the results?
  8. How sure are we about the results?
  9. Can the results be applied to the patients/the population of interest?  
  10. Can the testy be applied to the patient or population of interest?
  11. Were all outcomes important to the population considered?
  12. What would be the impact of using this test on the population?

CASP for case control study

  1. Did the study address a clearly focused issue?
  2. Did the authors use an appropriate method to answer their question?
  3. Were the cases recruited in an acceptable way?  
  4. Were the controls selected in an acceptable way?
  5. Was the exposure accurately measured to minimize bias?
  6. What confounding factors have the authors accounted for?
  7. Have the authors taken account of the potential confounding factors in the design and/or in their analysis?
  8. What are the results of this study?  
  9. How precise are the results?  
  10. Do you believe the results?  
  11. Can the results be applied to the local population?  
  12. Do the results of this study fit with other available evidence?

CASP for systematic or meta analytic review

  1. Did the review address a clearly focused question?
  2. Did the authors look for the right type of papers?
  3. Do you think the important, relevant studies were included?
  4. Did the review’s authors do enough to assess the quality of the included studies?
  5. If the results of the review have been combined, was it reasonable to do so?
  6. What are the overall results of the review?
  7. How precise are the results?
  8. Can the results be applied to the local population?
  9. Were all important outcomes considered?
  10. Are the benefits worth the harms and costs?
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