Cervical Spine Radiography Interpretation Lab

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Cervical Spine Radiography Interpretation Lab

• Annie T. Sadosty, M.D.
• Department of Emergency Medicine
• Mayo Clinic, Rochester

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Who Needs a C-Spine X-ray?

• Patients w/ Neck Trauma who
• have mid-line cervical tenderness
• have distracting injuries
• have focal neurologic deficits
• have mental status depression
• are intoxicated

Hoffman et al, NEXUS Trial, NEJM 200034394-9.
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The NEXUS Trial
Validity of a set of clinical criteria to rule
out injury to the cervical spine in patients with
blunt trauma

• In 34,069 patients, clinical criteria
• Sensitivity 99.0 (98.0-99.6)
• NPV 99.8 (99.6-100)
• LR (-) 0.076

Hoffman et al, NEXUS Trial, NEJM 200034394-9.
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Radiographic C-Spine Evaluation

• Lateral
• AP
• Odontoid

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Normal Lateral C-Spine
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Normal AP C-Spine
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Odontoid View
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Approach to C-Spine X-ray Interpretation

• Adequacy of film
• Four lines
• Soft tissue
• ASL
• PSL
• SLL
• A/O joint

• Odontoid
• Predental space
• Harris ring
• Vertebral bodies
• Facets
• Spinous processes

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4 Lines
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C1-C2 Relationship
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Lower C-spine Imaging (C7-T1)

• Swimmers view
• Arm traction
• CT

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Swimmers View
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Radiographic Unknowns

• Look at the following radiographs systematically
  and attempt to identify the injury.

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Unknown
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Atlanto-Occipital Dissociation

• Distraction type injury.
• Almost uniformly fatal due to respiratory arrest
  in the field.
• Head is disconnected from the neck.

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Unknown
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Jefferson Fracture

• C1 burst fracture involving both anterior and
  posterior arches
• Mechanism axial loading
• Odontoid View --gt Lateral displacement of lateral
  masses of C1

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C1-C2 Relationship
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Unknown
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C1-C2 Subluxation

• Seen in patients with Rheumatoid Arthritis
• Very unstable often atraumatic
• Beware when intubating patients with RA

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Unknown
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Unknown
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Odontoid Fractures
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Odontoid Fractures
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Unknown
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Hangmans Fracture

• Bilateral fracture of the pars interarticularis.
• Mechanism Hyperextension injury (MVC)
• Usually not associated with neurologic deficit.

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Hangmans Fracture Example
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Unknown
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Hyperflexion Strain Example
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Hyperflexion Injury on AP
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Hyperflexion Strain

• Posture of the C-spine is flexed.
• Interspinous distance is increased with fanning
  of the spinous processes.
• Anterior disc space is often narrowed, while
  posterior disc space is often widened.
• See partial uncovering of the facets.

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Unknown
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Flexion Teardrop Fractures

• Devastating injuries.
• Hyperflexion injury.
• Named for the triangle-shaped fragment which
  falls like a tear off the anteroinferior corner
  of the vertebral body.
• Clinically presents with acute anterior cervical
  cord syndrome.

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Unknown
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UID Example
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UID Example, AP
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Unilateral Interfacetal Dislocation

• Mechanism flexion with rotation
• Radiographic findings
• Displacement of dislocated vertebra lt 50 AP
  diameter
• Above level of dislocation, vertebra oblique.
  Below, vertebra in true lateral view.
• Naked facet

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Unknown
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Bilateral Interfacetal Dislocation

• Hyperflexion injury
• High incidence of spinal cord injury.
• X-Ray findings
• Anterior displacement of vertbra gt one half of
  the vertebral body.
• Extensive soft tissue swelling

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Unknown
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Unknown AP
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Clay Shovelers Fracture

• Avulsion fracture of the spinous process of the
  cervical spine.
• Mechanism abrupt flexion of the head and neck
  against the tense set of posterior ligaments.

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Not Sure?
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Summary

• C-Spine injuries are tricky.
• Do not trust the exam of a drunk, demented or
  distracted individual.
• When in doubt, image.
• Keep the patient immobilized until you are
  certain there is not an injury.
• Review the x-rays carefully and use a systematic
  approach to do so.