A-B-C-D-E-F
C-Spine Radiology Adequacy (occiput-T1), Alignment (4 lines)
Bones (vertebrae)
Cartilage (discs, epiphyses, ossification
centers)
Dens
Extra-axial soft tissue (pre-vertebral, pre-
dental)
Facet
103.06.10
Adequacy
Skull base
C1-C7
Upper T1
The most common reason for a missed
cervical spine injury is a cervical spine
radiographic series that is technically
inadequate
Swimmers View Adequacy
Three views:
1. true lateral view
2. AP view
3. open-mouth odontoid view
Swimmer's view
Portable cross-table lateral view
should not be obtained (frequently inadequate)
Alignment
Anterior spinal line Anterior spinal line
Posterior spinal line Posterior spinal line
Spinolaminal line Spinolaminal line
Spinous process tips Spinous process tips
Alignment Bones
Anterior vertebral line
Posterior vertebral line
Spinolaminal line
Spinous process tips
Bones Bones
Anterior components
Vertebral body (cortices, endplates)
Transverse process
Posterior components
Articular masses and pedicles
Facet joints
Lamina
Spinous process
Cartilage
Intervertebral discs
Epiphyses (childhood)
Subdental synchondrosis
Ossification centers (childhood)
Tapered anterior vertebrae
Absent C1 anterior ring
Extra-axial Soft Tissue Soft tissue
Parameter Adults Children
Predental space < 3 mm < 5 mm
Prevertebral space - C2 < 7 mm < 1/2 vertebral body
Prevertebral space - C6 < 21 mm < 1 vertebral body
Angulation < 11 degrees < 11 degrees
Cord dimension 10 to 13 mm Adult size by 6 yr
Subluxation
Angulation between two adjoining
vertebrae > 11 degrees
Overriding of vertebra by > 3 mm
C2/3 Subluxation Case: 6-year-old boy
C2/3 Pseudosubluxation
Swischuck line < 2 mm off
C2 posterior spinal line v.s. Swischuk line
Pseudosubluxation (< 8-16Y) :
Displacement < 1.5-2 mm
Hangman fracture :
Displacement > 1.5-2 mm
Odontoid View
Jefferson fracture (C1)
Blowout of the ring
Axial loading
Open-mouth (odontoid) view
1/3 associated with C-2 fracture
Unstable
Usually not associated with cord injury
Lateral offset of C1 lateral masses > 1mm
from C2 vertebral body
Normal
C-1 Rotary Subluxation
Odontoid not equidistant from lateral masses
Children
Torticolis (chin toward uninvolved side)
Immobilize in place
Consult NS
Extension view
Flexion view
Odontoid Subluxation / dislocation Odontoid Fractures
Ruptured transverse ligament Type I : Avulsion of tip
Predental space : Stable
Ad > 3mm Type II : At the base
Pd > 5mm (symptomatic if > 7-10mm) Unstable
Odontoid fractures D/D : Synchondrosis if < 6Y
C1 spinal canal (Steel rule of 3) : Type III : Through vertebral body
Odontoid Free space Cord Unstable
Unstable
type I - involves only the
upper part of the dens
type II (most common) -
occurs where the dens and the
vertebral body join
type III - through the upper
body C2 vertebra
Some odontoid fractures can
be treated with external
support (such as C collar or
halo traction) alone while
others (especially type II)
require surgery
Hangman Fracture
Traumatic spondylolisthesis of C2
Mechanism :
Extension + Distraction
Extension + Axial compression
X-ray : C2/3 subluxation
Unstable
Traction contraindicated Hangman fracture - a hyperextension injury involving
bilateral pars interarticularis fractures of the axis
Clay shoveler fracture
C7>C6>T1
Unilateral Facet
Dislocation
(Bowtie Sign)
Unilateral Facet Dislocation (AP) Oblique view
Bilateral Facet Facet Dislocation
Dislocation
Unilateral (UFD) :
Stable
< 25% translation
Bilateral (BFD) :
Unstable
> 50% translation
Teardrop Fractures
Extension teardrop :
Stable in flexion, unstable in extension
Cortices : Same length
Flexion teardrop :
Extremely unstable
Cortices : Unequal length
Flexion teardrop Extension teardrop
Wedge fracture of C5
Interspinous widening*
Narrowed C5-C6
*
intervertebral disc space
C6
Burst Vertebral Body Atlanto-occipital
dislocation (AOD)* -
longitudinal distraction
Mechanically stable with separation of the
*
occiput from the atlas
Spinal cord injury
can occur (even total Gap between occipital
transection) condyles and atlas > 5 mm
Fracture lines:
# Odontoid type II
# Mandibular ramus
Oblique C-spine
Pedicles
Articular mass
Intervertebral foramen
Transverse process
Laminae - aligned in the fashion of shingles
Oblique views show the pedicle in profile, and also allows
assesment of the intervertebral foramina (and osteophytes
encroaching along their margins)
SCIWORA
Spinal Cord Injury WithOut Radiographic Abnormality
67%-80% of pediatric SCI
Mainly < 8 Y
Plain films / tomograms / CT (-)
May have transient neurologic symptoms and
apparently recover then return 1d later with significant
neurologic abnormalities
Poor prognosis
SCIWORA Spinal EDH
Etiology : Venous bleeds
Vascular injuries Minor traumas
(occlusion, spasm,
infarction) Ascending neurologic symptoms
Ligamentous injury Hours or days
Disc impingement MRI
Incomplete neuronal
destruction
Clear neck collar
SPINAL
Severe pain
Point of tenderness
Injury mechanism
Neurologic deficit
Thank You
Altered level of consciousness
Limitation of motion
