Cervical Spine Radiographs

LATERAL VIEW The lateral view radiograph detects 70 to 80 percent of traumatic cervical spine injuries. 14 The lateral view should include the cervothoracic junction, as 10 percent of cervical spine fractures will occur at this level. 15 Gentle traction on the upper extremities may move the shoulders out of the way and increase the yield of the interval view. Another radiographic technique for defining the bony anatomy of the cervicothoracic junction is the "swimmer's" view. This can be difficult to perform because of the positioning of the patient and film and difficult to interpret owing to overlying bone shadows and obliteration of the posterior spine. If plain radiographs do not define the cervicothoracic junction in a patient with suspected cervical spine injury, the patient should remain in cervical immobilization and alternate methods such as computed tomography (CT) should be employed.16

The lateral view should be inspected methodically to detect abnormalities ( Table.ii„264z2). Alignment should be evaluated by following anatomic lines ( Fig 2.64.-2).

There should be no stepoffs or breaks in the lines. The anterior longitudinal ligament line follows along the anterior surface of the vertebral bodies. This line should follow the normal lordotic curve of the spine. The line of the posterior longitudinal ligament runs along the posterior bodies of the vertebrae and is immediately anterior to the spinal cord. A change of 11° or more in the angle of this line at an interspace should be considered evidence of ligamentous injury ( Fig n264.::3). The spinolaminal line is formed by the junction of the lamina with the spinous process at each vertebra. Fractures of the odontoid or C2 pedicles can be detected by examining the spinolaminal line. The spinolaminal line connecting C1 with C3 should pass within 1 mm of the spinolaminal junction of C2. Displacement of more than

1 mm suggests anterior or posterior displacement of the odontoid or a hangman's fracture5 (Fig 264-4). The last line is the line connecting the tips of the spinous processes.

TABLE 264-2 Criteria for Clearing the Cervical Spine Cross-Table Lateral View

FIG. 264-2. Alignment of the lateral cervical spine. (From ..., with permission.)

Examination of the soft tissues of the neck may be helpful in defining injury. The upper limits of normal dimensions of the prevertebral tissue are 6 mm at C2 and 22

mm at C6.17 Injury to the cervical spine can cause hematomas and edema that increase the size of the prevertebral space as seen on the lateral view radiograph. Abnormal width of the prevertebral tissues occurs in 33 to 60 percent of cervical spine injuries.17

ANTEROPOSTERIOR (AP) VIEW The AP view is ineffective in evaluating the upper cervical spine because the structures of the face and mandible obscure the bony anatomy. The lateral cortex of the articular masses can show evidence of fracture or dislocation if they are angled as compared with superior or inferior neighbors. The spinous processes can be seen on end, and abnormal widening may indicate a hyperflexion sprain or interfacetal dislocation.

ODONTOID VIEW The odontoid or open-mouth view shows the odontoid and its relationship to the lateral masses of C1. The dens should be centered between the lateral masses, and the lateral masses of C1 should be directly over the lateral portions of C2. Rotation of the head may cause some displacement of the lateral masses and asymmetry of the relationship of the dens and C1. Rotation can be detected by using the space between the central incisors, which should be in the midline in an unrotated view. Displacement of the lateral masses due to rotation will cause one side to be displaced medially and the opposite side displaced laterally.5

FLEXION-EXTENSION VIEWS An injury to the ligamentous structures of the spine may occur without a bone fracture. If the initial radiographs show no evidence of fracture but are suggestive of subluxation or if suspicion of a ligamentous injury exists, flexion and extension views may be performed. Anterior subluxation injuries are exacerbated in flexion and reduced in extension. This should only be performed in awake, cooperative patients. The flexion and extension should be halted at the point where they cause the patient pain.16

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