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CERVICAL SPINE
Standard views Lateral view Anterior-Posterior (AP) view Odontoid Peg view (or Open Mouth view)
In trauma case these images are all difficult to acquire because the patient may be in pain, confused, unconscious, or unable to cooperate due to the immobilisation devices. Additional views - 'Swimmer's view' If the lateral view does not show the vertebrae down to T1 then a repeat view with the arms lowered or a 'Swimmer's view' may be required.
AP View
Coverage - The AP view should cover the whole C-spine and the upper thoracic spine Alignment - The lateral edges of the C-spine are aligned (red lines ) Bone - Fractures are more clearly visible on lateral view Spacing - The spinous processes (orange) are in a straight line and spaced approximately evenly Soft tissues - Check for surgical emphysema Edges of image - Check for injury to the upper ribs and the lung apices for pneumothorax
Coverage - All vertebrae are visible from the skull base to the top of T1/T2 (If T1 is not visible repeat image with the patient's the most informative image shoulders lowered or a 'swimmer's' view may be necessary
Lateral view
Alignment - Check the Anterior line GREEN (the line of the anterior longitudinal ligament), the Posterior line ORANGE(the line of the posterior longitudinal ligament), and the Spinolaminar line RED(the line formed by the anterior edge of the spinous processes extends from inner edge of skull). Bone - Trace the cortical outline of all the bones to check for fractures
Lateral
Bone - The cortical outline is not always well defined but forcing your eye around the edge of all the bones will help identify fractures C2 Bone Ring - At C2 (Axis) the lateral masses viewed side on form a ring of corticated bone (red ring ) This ring is not complete in all subjects and may appear as a double ring A fracture is sometimes seen as a step in the ring outline
Lateral view
Disc spaces - The vertebral bodies are spaced apart by the intervertebral discs These spaces should be approximately equal in height Prevertebral soft tissue - Some fractures cause widening of the prevertebral soft tissue due to prevertebral haematoma - Normal prevertebral soft tissue (asterisks) - narrow down to C4 and wider below - Above C4 1/3rd vertebral body width - Below C4 100% vertebral body width Note: Not all C-spine fractures are accompanied by prevertebral haematoma - lack of prevertebral soft tissue thickening should NOT be taken as reassuring Edge of image - Check other visible structures
Swimmers view
If the lateral view does not show the vertebrae down to T1 then a repeat view with the arms lowered or a 'Swimmer's view' may be required.
This is an oblique view which projects the humeral heads away from the C-spine. A swimmer's view may be useful in assessing alignment at the cervico-thoracic junction if C7/T1 has not been adequately viewed on the lateral image, or on a repeated lateral image with the shoulders lowered. The view is difficult to achieve, and often difficult to interpret. If plain X-ray imaging of the cervicothoracic junction is limited then CT may be required.
Thoracolumbar spine
Standard views - AP - Lateral Systematic approach - Coverage - Adequate? - Alignment - Anterior/Posterior/Lateral - Bones - Cortical outline/Vertebral body height - Spacing - Discs/Spinous processes/Pedicles - Soft tissues - Paravertebral - Edge of image
Coverage - The whole spine is visible on both views (T1 till T12) Alignment - Follow the corners of the vertebral bodies from one level to the next
Bones - The vertebral bodies should gradually increase in size from top to bottom Spacing - Disc spaces gradually increase from superior to inferior
Soft tissues - Check the paravertebral line (in AP image) Edge of image - Check the other structures visible
VB = Vertebral body P = Pedicle SP = Spinous process (ribs overlying) F = Spinal nerve exit foramen
AP (in detail)
Alignment - The vertebral bodies and spinous processes (SP) are aligned Bones - The vertebral bodies and pedicles are intact Other visible bony structures include the transverse processes (TP) -ribs costovertebral and costotransverse joints
Spacing - Each disc space is of equal height when comparing left with right. The pedicles gradually become wider apart from superior to inferior Soft tissue - Note the normal paravertebral soft tissue which forms a straight line on the left - distinct from the aorta
Lumbar s Lateral
Coverage - The whole Lspine should be visible
Alignment - Follow the corners of the vertebral bodies from one level to the next (dotted lines) Bones - Follow the cortical outline of each bone
Spacing - Disc spaces gradually increase in height from superior to inferior Note: The L5/S1 space is normally slightly narrower than L4/L5
Lumbar s Lateral
L-spine - Normal AP
Alignment - The vertebral bodies and spinous processes are aligned Bones - The vertebral bodies and pedicles are intact Spacing - Gradually increasing disc height from superior to inferior. The pedicles gradually become wider apart from superior to inferior - Note: The lower discs are angled away from the viewer and so are less easily assessed on this view
L-spine - Normal AP
L-spine AP (detail)
Check carefully for pedicle integrity and transverse process fractures
Injuries 3 and 4 affect two or more columns and are considered 'unstable'
3 - 'Burst' fracture
4 - Flexion-distraction fracture - 'Chance' type injury
CT scan of spine
Up to 20 % of fractures are missed on conventional radiographs. The advantages of CT are: 1. CT is excellent for characterizing fractures and identifying osseous compromise of the vertebral canal because of the absence of superimposition from the transverse view. 2. CT provides patient comfort by being able to reconstruct images in the axial, sagittal, coronal, and oblique planes from one patient positioning. The limitations of CT are: 1. difficult to identify those fractures oriented in axial plane (e.g. dens fractures). 2. unable to show ligamentous injuries. 3. relatively high costs.
MRI
Most sensitive imaging modality in the study of spine disease.
CSF
Intermediate signal
Hypointense Intermediate signal
Intermediate signal
Hypointense Hyperintense (because of the water content)
T1
T2
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