Uni ver si t y of Br i t i sh Col umbi a

Under gr aduat e Radi ol ogy

Cur r i c ul um

Brain and Behaviour Block

2. Imaging of the Spine


Dr. Savvas Nicolaou, MD

Danial Hou

December 2007
Table of Contents


Incidence............................................................................................................................. 3
Spine Imaging Modalities................................................................................................... 4
Plain Radiography........................................................................................................... 5
Computed Tomography.................................................................................................. 8
Magnetic Resonance Imaging....................................................................................... 10
Myelography................................................................................................................. 12
Normal Radiographic Anatomy........................................................................................ 13
C-Spine Interpretation................................................................................................... 16
Lateral View Interpretation....................................................................................... 16
A-P View Interpretation............................................................................................ 18
Odontoid Peg View Interpretation............................................................................ 19
Trauma.............................................................................................................................. 20
Common Findings:........................................................................................................ 20
Unstable Injury.............................................................................................................. 21
Flexion Injuries............................................................................................................. 21
Simple Wedge Fracture............................................................................................. 21
Flexion Teardrop Fracture........................................................................................ 21
Clay Shovelers Fracture........................................................................................... 23
Odontoid Fractures.................................................................................................... 23
Extension Injuries......................................................................................................... 23
Extension Teardrop Fracture..................................................................................... 23
Hangmans Fracture.................................................................................................. 24
Axial Injuries................................................................................................................ 24
J effersons fracture.................................................................................................... 24
Burst Fracture............................................................................................................ 26
Take Home Messages................................................................................................... 27
Thoracolumbar Spine........................................................................................................ 28
Anatomy........................................................................................................................ 28
Imaging......................................................................................................................... 28
Evaluating the Thoracolumbar Spine........................................................................ 28
On the lateral view:................................................................................................... 28
On the AP view:........................................................................................................ 29
On the Oblique view:................................................................................................ 29
Injury............................................................................................................................. 31
Chance Fracture........................................................................................................ 31
Burst Fracture............................................................................................................ 31
Wedge Fracture......................................................................................................... 31
Spondylolysis............................................................................................................ 31
Spondylolisthesis...................................................................................................... 32




Incidence

The diagnosis of an unstable spinal injury and its subsequent management can be difficult,
and a missed spine injury can have devastating long-term consequences. Spinal column
injury must therefore be presumed until it is excluded.

Almost half of cervical spine injuries are associated with spinal cord injury. Spinal cord
injury most often occurs in teenagers and young adults. The mean age at injury is 30.7
years, but injury most frequently occurs at age 19. Overall about 82% of all patients are
males. The three most common causes of spinal fractures are motor vehicle accident
(50%), falls (25%), and sports injuries (10%).

There is a wide range of severe sequelae associated with neck injuries, ranging from neck
pain to quadriplegia, and even death. It is crucial to assess for spinal cord injuries prior
to patient mobilization.


Figure 13-D Dual Energy CT Reconstruction of a trauma patient whose C-Spine fracture
was not visualized on X-Ray. The patient was taken to the operating room and when
moving the patient to the operating table, the patients skull dislocated from the C1
Vertebrae resulting in the death of the patient.
Spine Imaging Modalities


When to image? Here is a suggested diagnostic algorithm

Table 1. Selection of Imaging Modality

Plain Radiography

There are 3 standard views for evaluating the cervical spine: a) Lateral, b) AP, and c)
Odontoid Peg views.

Any film series that does not include all seven cervical vertebra and the C7-T1 junction
on the Lateral and A-P views is inadequate. Thus, a fourth view is acquired if there is
difficulty in visualizing the C7-T1 junction. Options are either a Swimmers view, with
one arm extended over the head, or a Lateral View with downward traction on both arms.
For each of the views, the cervical collar is to remain on the patient. It is of note that
these views do not require the patient to move his/her neck.

Figure 2 Lateral View

Figure 3. AP View



Figure 4. Odontoid Peg View

Table 2. Summary of Plain Radiographic Techniques:
Technique Likely Findings
Lateral Patient supine and immobilized
Cross-table projection
Gentle traction on shoulders
Most fractures and
dislocations are seen
AP Patient supine
Head and neck straight
Vertebral body and
uncinate process
fractures
Lateral mass fractures
Spinous process fractures
Open Mouth
view (Peg view)
Patient supine
Head and neck straight
J efferson burst fracture
of C1.
Dens fracture
Avulsion of lateral
masses of C1
Swimmers view Patient supine
One arm fully abducted above the
head
Caudal traction on opposite arm
Vertebral body fractures
Malalignment at the
cervicothoracic junction
Oblique views Patient upright or supine and
rotated 45 degrees to film cassette
Trauma obliques performed with
patient supine and X-Ray beam
angled
Laminar and pedicle
fractures
Unilateral interfacetal
dislocation
Flexion-
extension views
Patient upright
Patient performs active flexion and
extension
Movement stopped if significant
pain or neurologic deficit develops
Flexion: Posterior
ligament tears
Extension: Anterior
ligament injury.
Fracture displacement
Computed Tomography

Abnormal or questionable findings on X-Ray should be evaluated with CT. It is estimated
that up to 20% of fractures are missed on X-Ray. CT scans have improved diagnostic
accuracy for subtle osseous abnormalities and for evaluating the vertebral canal. Patients
who present with neurological symptoms should have a CT performed, as it allows for
visualization of bony fragments in the canal. Some disadvantages of CT scans are:
relatively high cost, increased radiation exposure, and inability to show ligamentous
injuries.

Figure 5. Axial CT view


Figure 6. Coronal CT view


Figure 7. Sagittal CT sectional view
Magnetic Resonance Imaging

MRI is typically not used in the acute trauma situation due to the lengthy duration of the
exam, high cost, and lack of bony details. However, there are situations where MRI is
indicated over other imaging modalities. MRI is advantageous in that it allows for soft
tissue contrast, thus allowing for increased diagnostic sensitivity in evaluating the spinal
cord, ligamentous injuries, and intervertebral discs. As well, there is no radiation
exposure with MRI scans. Therefore, patients with neurological symptoms or suspected
ligamentous injury should be evaluated with a MRI.



Figure 8. Coronal MRI view

Figure 9. Sagittal MRI view


Figure 10. Axial MRI view





Myelography


Myelograms are typically a two step process for obtaining the images. Myelograms are
most often performed in patients who have contraindications to MRI or nondiagnostic
MR studies. Noninonic contrast material is injected under fluoroscopy by the
interventional radiologist into the subarachnoid space of the spinal canal via lumbar
puncture. Images are obtained initially conventional film and then with a CT scanner.
Indications: disc herniations and traumatic nerve root avulsion.


Figure 11. L4-5 disc
herniation deforming


Figure 12. Post-myelogram CT showing C6-7 osteophytes
and right C7 root sleeve amputation























Normal Radiographic Anatomy


Dens
Occiput
Ant. Arch C1
C2 Body
Post. Arch
C1
Intervertebral
Disc Space
Sup.
Articular
Facet
Facet J oint
Spinous
Processes
Inf.
Articular
Facet
T1
C7
C6
Vertebral
Bodies
C5
C4
C3
Figure 13. Lateral Radiograph

Figure 14. Anterior Radiograph
Spinous Processes
Trachea
Dens
C2
C1 Lateral Mass

Figure 15. Odontoid Anterior View

Figures 13 to 15. Normal lateral C-spine. This demonstrates all seven cervical
vertebrae, down to the cervicothoracic junction. There is normal alignment of vertebral
bodies, spinolaminar line and interspinous distances. In particular, the prevertebral soft
tissue thickness in the retropharyngeal (anterior to C2) and retrotracheal (anterior to C6
regions is normal. Facet joints are demonstrated with long solid white arrows. Solid
short arrows point to normal anterior vertebral line, p
)
osterior vertebral line, spinolaminar
arrow),
and this is intact. If disrupted, this is suggestive of a Type 3 odontoid fracture.
line, and posterior spinous process line to be intact.
Projecting over the C2 body is the sclerotic ring known as the Harris ring (dotted
C-Spine Interpretation

When interpreting radiographs, it is best to interpret each view at a time using a
systematic approach to avoid missing important features. It is customary to begin with
the lateral view.


Lateral View Interpretation

When reviewing lateral spine films, use the ABCS mnemonic.

A Adequacy and Alignment

B Bones

C Cartilaginous Disc Spaces

S Soft Tissue

A Adequacy: The lateral C-spine film must include all 7 vertebrae and include the C7-T1
junction.

Alignment



Draw 4 parallel lines and assess for
discontiuity or step-off.

Lines:
1) Anterior Vertebral Line
2) Posterior Vertebral Line
3) Spinolaminar Line
4) Posterior Spinous Line

These lines should follow a slightly
lordotic curve, smooth and without
step-offs. Any malalignment
should be considered evidence of
ligamentous injury or occult
fracture, and cervical spine
immobilization should be
maintained until a definitive
diagnosis is made.
B Bones

Assess the vertebral bodies. Each should be uniformly square/rectangular. The anterior
and posterior heights should be approximately equal.

As well, inspect closely for a fracture through the odontoid peg.


C Cartilaginous Disc Spaces: Check each intervertebral disc space. Each disc space
should be roughly equal anteriorly and posteriorly. A widening suggests vertebral
compression.

S Soft Tissues

Assessing the prevertebral soft tissues can be an important indicator of an occult fracture.
Soft tissue swelling in the setting of trauma can signify hematoma formation; however, it
is of note that swelling is extremely variable and nonspecific.

Maximum allowable prevertebral soft tissue spaces are as follows:

Vertebra Level Maximum Allowable Size Approx. % of Vertebral Body Width
C1-C4 7mm 30%
C5-C7 22mm 100%

If there is prevertebral soft tissue swelling in the absence of a visible fracture, the patient
is to be referred for further radiographic workup.





Figure 16. This lateral C-spine radiograph
shows marked widening of the lower
prevertebral soft tissues (arrow) anterior to the
C5 level with bony destruction of the C4
vertebral body. This was due to prevertebral
abscess in association with cervical
osteomyelitis. Gas can sometimes migrate into
this potential space from aerodigestive tract
injuries.




AP View Interpretation

The AP view usually only demonstrates C3 to C7. The uncovertebral joints and spinous
processes can be evaulated.

First begin with the alignment once again. Use the lateral edges of the vertebral bodies
to ensure that the line is smooth without step-offs.

Second, assess the spinous processes.
They should be in a straight line and
the distance between processes should
be roughly equal at all levels. No
space between the processes should be
greater than 50% wider than the one
above or below. If a spinous process is
displaced, suspect a facet dislocation.

Third, assess the height of each
vertebral body. They should be
approximately equal at all vertebral
levels.

Finally, check the intervertebral disc
spaces. Once again, they should be
roughly equal at all vertebral levels.












Figure 17
Odontoid Peg View Interpretation

The odontoid view is the best view to assess for a fracture through the odontoid process.

Begin by inspecting for a fracture through the odontoid peg.

Next, check that the distance between the odontoid and lateral mass of C2 is equal on
both sides.

Check the lateral margins of C1 and C2 to ensure that they align. Any asymmetry
suggests either a fracture or a rotational abnormalitiy.





Figure 18. Normal odontoid process view or Open mouth peg view.
This view best evaluates the alignment of the lateral masses of C1 (arrows) on the articular
pillars of C2(dotted arrows), the space on either side of the dens with respect to the C1
lateral masses (lateral atlantodens interval), and the odontoid process (AKA Dens).


Trauma

Common Findings:
The majority of C-spine injuries are due to motor vehicle or sporting accidents. Arthritis
and degenerative changes increase ones susceptibility to acquire these injuries. These
injuries are classified based on the mechanisms of trauma, which can be described
according to the physical forces applied to the vertebral column. The four major
mechanisms of trauma are as follows:

Flexion: Forward bending of the head and neck in the mid-sagittal plane
Extension: Bending of the head and neck posteriorly in the mid-sagittal plane
Lateral bending: Movement of head in the coronal plane
Rotation: Turning or pivoting of the head and spinal segments on the vertical
axis extending through the torso, head and neck.
Compression (axial load): Force exerted down the vertical axis through the
head and spine

As described above whenever plain radiographs of the spine are obtained the three
column principle should be applied. That is, the three contour lines seen on a lateral film
should be assessed carefully. They should be smooth, and unbroken. Instability is present
if any two of the three columns are disrupted or more than 3mm or 11 degrees of
angulation is observed. The following table summarized some common spinal injuries
that may be seen in a trauma setting.

Table 3. Common Spinal Injuries

Flexion Injuries Simple Wedge Fracture
Flexion Teardrop Fracture
Clay Shovelers Fracture
Odontoid Fracture
Rotational Injuries Unilateral Facet Dislocation
Extension Injuries Teardrop Fracture
Hangmans Fracture
Axial Injuries J effersons Fracture
Burst Fracture














Unstable Injury
Radiographic indications of an unstable injury may include

Anterior subluxation of >4mm
>11 of angulation
Associated compression fracture of >25% of vertebral body
Changes in normal disc space
Fanning or widening of the interspinus distance

Radiographic indications of an unstable injury may include

Anterior subluxation of >4mm
>11 of angulation
Associated compression fracture of >25% of vertebral body
Changes in normal disc space
Fanning or widening of the interspinus distance


Flexion Injuries

Simple Wedge Fracture

A wedge fracture is a compression fracture of the anterior vertebral body. They are
typically caused by anterior or lateral flexion. Compression fractures are typically stable
and not associated with neurological injury. They are best seen on the lateral view with
decreased height of the anterior wall of the vertebral body compared to the adjacent
normal vertebra. The posterior wall of the vertebral body has preserved height.

Flexion Teardrop Fracture

A flexion teardrop fracture is caused by hyperflexion of the cervical region. Severe
flexion injury such as occurs with neck injuries caused by diving into shallow water.
Usually involves the lower cervical spine at C5 (70%). Completely unstable with
paraplegia in more than 80% of cases. Radiological features include: anterior vertebral
body avulsion fracture (teardrop body), Posterior vertebral body subluxation or
displacement, Fracture of the spinous process, Prevertebral hematoma, and Cord
compression from fracture fragments or vertebral body displacement.







Figure 19. MRI






















Figure 20. Radiography

Figure 21. CT



















Clay Shovelers Fracture

Fracture of a spinous process, most often seen in the lower cervical spine. It is named the
Clay Shovelers fracture because workers shoveling clay sustained these fractures when
they tried to toss a heavy shovelful of clay over their shoulders. The fracture is best seen
on the lateral view.

Odontoid Fractures

Fractures through the odontoid dens are classified based on the location of the fracture.
These are easily missed if close inspection of the Odontoid Peg view is not performed.

Type 1: fracture of the superior odontoid, rare and stable
Type 2: fracture through the base of the odontoid, unstable, nonunion
Type 3: fracture through the base of the odontoid into the body of the axis, usually stable


Extension Injuries

Extension Teardrop Fracture

This fracture is to be distinguished
from a flexion teardrop injury. The
anterior longitudinal ligament avulses
the antero-inferior corner of the
vertebral body. Unlike a flexion
teardrop fracture, the anterior height of
the vertebral body is not reduced.


Figure 22. A lateral radiograph showing an
extension teardrop fracture















Hangmans Fracture

A Hangmans fracture is a bilateral C2 pedicle fracture with anterior displacement
(spondylolisthesis) of the anterior part of C2. This fracture is seen with hanging and in
motor vehicle accidents when the chin strikes the dashboard. The radiographic features
are: bilateral pars interarticularis fractures of C2, anterior dislocation of the C2 vertebral
body, and prevertebral soft tissue swelling.














Figure 23. Fracture of C2 Radiograph

Figure 24. Axial CT at C2


Axial Injuries



Jeffersons fracture

J effersons fracture is a burst fracture of bony ring of C1. It is caused by compression of
the cervical region from an axial force applied to the vertex of the head. This injury can
be seen in diving injuries. On radiographs, there is displacement of lateral masses of C1
beyond the margins of the C2 vertebral body, may be associated with prevertebral soft
tissue swelling.

Figure 26

Figure 25














Figure 28

Figure 27















It is important to note that fractures typically occur in 2 or more places. (Try breaking a
pretzel in only 1 area).


Figure 29


Burst Fracture

A burst fracture is the collapse of an entire vertebral body, usually extending into the
posterior elements. They are typically caused by an axial load to the spine, such as a fall
from a height. There is concern for retropulsion of the fracture fragments into the spinal
canal leading to spinal cord injury. On the lateral view, the heights of the anterior and
posterior vertebral body is decreased as compared to adjacent vertebra. On the A-P view,
there is widening of the interpedicular distance.



Take Home Messages

A Simple compression fracture =compression of the anterovertebral corner and wedging
of the vertebral body is stable since posterior aspects of spine are intact

Remembering that a burst fracture =loss of anterior height of vertebral body, however
also includes fragmentation of its posterior border. Usually posterior fragments are often
displaced in spinal canal with high incidence of associated neurological complications

Diagnostic evaluation acute setting is CT. If suspicion regarding spinal cord injury,
further evaluate with MRI examination




Thoracolumbar Spine

Anatomy

The thoracic spine is composed of 12 vertebrae. The thoracic spine is concave anteriorly
(kyphosis).

The lumbar spine is composed of 5 vertebrae. The lumbar spine is concave posteriorly
(lordosis).


Imaging

The initial imaging study thoracic or lumbar spinal injuries are plain radiographs. Serious
spinal injuries may be clinically obvious and plain radiographs can be used to exclude
severe traumatic injuries. CT is superior to radiographs in evaluation of fractures, and
MRI provides the best visualization of the spinal cord, nerve roots, intervertebral disks,
and ligaments. Therefore if an initial assessment of injuries with radiographs is negative
but clinical symptoms are present, further imaging by CT or MRI may be indicated.


Evaluating the Thoracolumbar Spine

There are three views traditionally used: Lateral, Anterior-Posterior, and Oblique views.

On the lateral view:

For plain radiographs, the three column approach is used for evaluation.

Columns:

Anterior: From the anterior longitudinal ligament to the anterior 2/3 of the vertebral
body

Middle: From the posterior 1/3 of the vertebral body to the posterior longitudinal
ligament

Posterior: From the posterior ligaments to the posterior bone arch


As a general rule, if two of the columns are disrupted, instability is present.


Trace the three column lines described previously and make sure that there are no breaks
or kinks present. The posterior margin of each vertebral body is slightly concave.

Check whether the vertebral bodies are the same height anteriorly and posteriorly. Look
for loss of height or wedging of a vertebral body. This is evidence of a compression
fracture.

Look for fragments of bone detached from the anterior aspect of a vertebral body


On the AP view:

On the AP view, each vertebra in the thoracolumbar spine looks like an owls head. Each
eye represents a pedicle and the beak of the owl represents the spinous process.

In the lumbar region, the distance between the pedicles should become gradually wider
apart. Look for any abnormal widening of the distance between the pedicles. If there is a
missing eye in the owls eye, it represents destruction of the pedicle. If there is increased
space between the owlss eyes, it represents a burst fracture. If there is a crack in the eye,
it represents a chance fracture.


Look for displacement or widening of the thoracic paraspinal lines. This may indicate a
paraspinal hematoma resulting from a fracture. Note that in the lumbar spine there is no
paraspinal line.
Look for abnormal widening of the distance between the pedicles. In the
lumbar region the distance between the pedicles should become gradually
wider when descending from L1 to L5.
Look for any fractures of the transverse processes


On the Oblique view:

The oblique view is used mainly to evaluate a pars interarticularis injury.

On this view, the vertebra are described by the appearance of a Scotty Dog. The Scotty
Dog is the outline formed by the vertebral arches of the lumbar spine. It is such that if
the patient is turned to the right, the left neural foramen is visualized.

Nose: Transverse process
Ear: Superior articular process
Eye: Pedicle
Neck: Pars interarticularis
Front leg: Inferior articular process
Body: Lamina
Tail: Contralateral superior articular process
Rear leg: Contralateral inferior articular process


For evaluation of the oblique view, ensure that the spine looks like a pile of Scottie dogs.
Ensure that none of them has a collar, which implies a pars interarticularis defect.


Fractures and disc-related pathologies are more common in the lower thoracic and lumbar
spine compared to the upper thoracic spine. In fact most fractures occur at the junction
between the immobile thoracic spine and the mobile lumbar spine. In the upper thoracic
region the combination of bony protection, limited motility, and kyphosis minimizes
fractures and disk-related pathology, while in the lower thoracic and lumbar sections the
curvature and mobility of these regions make it susceptible to disk herniation and
vertebral burst fractures.

Injury

Chance Fracture

A chance fracture results in horizontal severing of a vertebra. The mechanism is
typically a hyperflexion injury, typically caused by a lap seatbelt during a motor vehicle
accident. This fracture is characterized by the transverse splitting of the vertebra and
spinous process, often with associated rupture of the intervertebral disc. There is often
associated intra-abdominal pathology. All three columns are involved. This fracture is
best seen on the lateral view.

Burst Fracture

A burst fracture is the collapse of an entire vertebral body, usually extending into the
posterior elements. They are typically caused by an axial load to the spine, such as a fall
from a height. There is concern for retropulsion of the fracture fragments into the spinal
canal leading to spinal cord injury. On the lateral view, the heights of the anterior and
posterior vertebral body is decreased as compared to adjacent vertebra. On the A-P view,
there is widening of the interpedicular distance.

Wedge Fracture

A wedge fracture is a compression fracture of the anterior vertebral body. They are
typically caused by anterior or lateral flexion. Compression fractures are typically stable
and not associated with neurological injury. They are best seen on the lateral view with
decreased height of the anterior wall of the vertebral body compared to the adjacent
normal vertebra. The posterior wall of the vertebral body has preserved height.


Spondylolysis

Spondylolysis is a bony defect in the pars interarticularis. It is best seen on dedicated
oblique views where the bony defect forms a collar on the neck of the Scotty dog.
Spondylolysis is believed to be a chronic stress fracture most commonly seen in
adolescent adults. It is most commonly seen at L4/L5.


Spondylolisthesis

Spondylolisthesis is slipping of a vertebral body relative to its inferior adjacent vertebra.
Spondylolisthesis is caused by bilateral spondylolysis. Approximately 50% of patients
with spondylolysis also have spondylolisthesis.

Spondylisthesis is graded from I-IV, depending on the degree of translation:

I: <25% displacement
II: 25-50% displacement
III: 50-75% displacement
IV: >75% displacement