Radiographic anatomy and views of c spine

cervical spine Radiography

1. Radiographic views of Cervical spine Chandan Prasad Rajbhar Tutor College of paramedical sciences TMU, Moradabad

2. Topics Anatomy Projection techniques Common fractures

3. Anatomy of cervical spine

4. Cervical vertebrae 2 TYPES Atypical Axis Atlas C 7 T y p i c a l C 3- C 6

5. A tla s Doesn’t Have body &spinous process Its ring-like, has anterior and a posterior arch and two lateral masses. Each lateral mass has superior articular facet&inferior articular facet. Superior articular facet articulate with occipital condoyle- atlanto - occipital joint. Inferior articular facet articulate with axis superior facet –atlanto - axis joint. Transverse process project laterally from lateral mass which is pierced by foramen transversorium

6. AXIS The second cervical vertebra (C2) of the spine is named the axis The most distinctive characteristic of this bone is the strong odontoid process ("dens") which rises perpendicularly from the upper surface of the body

7. Dens provide attachment at its apex to apical ligament & on each side to alar ligament. Anterior surface of body gives attachment to ant. Longitudinal ligament. Posterior surface of body gives attachment to vertical limb of cruciate ligament , membrana tectoria, post.longitudinal ligament.

8. C3-c6 vertebra The body of these four vertebrae is small, and broader from side to side than from front to back. The pedicles are directed laterally and backward, and are attached to the body midway between its upper and lower borders, so that the superior vertebral notch is as deep as the inferior. The laminae are narrow, and thinner above than below; the vertebral foramen is large, and of a triangular form. The spinous process is short and bifid , the two divisions being often of unequal size. The superior and inferior articular processes of neighbouring vertebrae often fuse on either or both sides to form an articular pillar , a column of bone which projects laterally from the junction of the pedicle and lamina. The transverse processes are each pierced by the foramen transversorium , which, in the upper six vertebrae, gives passage to the vertebral artery and vein , as well as a plexus of sympathetic nerves .

9. Cervical Vertebra (C7) It has a long and prominent spinous process. Its thick, nearly horizontal, not bifurcated. Foramen transversorium may be as large as that in the other cervical vertebrae . T he anterior root of the transverse process attains a large size and exists as a separate bone, which is known as a cervical rib.

10. Projection & imaging technique

11. Cervical spine view

12. Plain Films Plain films provide the quickest way to survey the cervical spine. An Adequate spine series includes three views: a true lateral (which must include all seven cervical vertebrae as well as C7-T1 junction), and AP view, and an open mouth odontoid view. These three views do not require the patient to move the neck, and should be obtained without removal of the cervical collar.

13. POSITIONING AP projection : Patient - either erect or supine Center the mid-sagittal plane of patients body to mid line of table. Adjust the shoulders to lie in the transverse plane Extend the neck enough so that a line from lower edge of chin to the base of the occiput is perpendicular to the film. Central beam is directed towards C4 VERTBRA(thyroid cartilage) Tube tilt- 15 to 20 degrees cephalad.

14. Film size-18*22cm or 24*30cm. Kvp-80 Suspended expiration. Collimation-include the lower margin of mandible to lung apex.

15. AP View The height of the cervical vertebral bodies should be approximately equal. The height of each joint space should be roughly equal at all levels. Progressive loss of disc height uncinate process impact on the reciprocating fossa,producing osteophytes Spinous process should be in midline and in good alignment.

16. LATERAL PROJECTION Patient position: Place the patient in a lateral position either seated or standing. Adjust the height of the cassette so that it is centered at the level of 4 th cervical segment Adjust the body in a true lateral position, with the long axis of cervical vertebrae parallel with plane of film  Elevate the chin slightly to prevent superimposition of mandible. Ask the patient too look steadily at one spot on the wall to aid in maintaining the position of head Respiration is suspended at end of full exhalation to obtain max depression of the shoulder.

17. Lateral view. Anterior arch of atlas Posterior arch of atlas Dens Laminae C2 Spinous Process C6 C7-T1 Intervertebral Foramina Retropharyngeal Space (Normal < 7mm) Retrotracheal Space

18. Interpretation of Lateral View

19. Disc spaces should be equal and symmetric

20. Hyperflexion & hyperextension views Used to Demonstrate normal anterioposterior movement or fracture/subluxation or degenerative disc disease(vacuum phenomenon). Spinous process are elevated and widely separated in hyperflexion. Depressed and closed approximation on the hyperextension position.

21. HYPERFLEXION HYPEREXTENSION

22. ODONTOID VIEW SUPINE OR ERECT POSITION. ARMS BY THE SIDE. OPEN MOUTH AS WIDE AS POSSIBLE. ADJUST HEAD SO THAT LINE FROM LOWER EDGE OF UPPER INCISORS TO THE TIP OF MASTOID PROCESS IS PERPENDICULAR TO THE FILM Ask to PHONATE ah!!!!!!!!!!

23. Transoral/AP dens(peg) view An adequate film should include the entire odontoid and the lateral borders of C1-C2. Occipital condyles should line up with the lateral masses and superior articular facet of C1. The distance from the dens to the lateral masses of C1 should be equal bilaterally. The tips of lateral mass of C1 should line up with the lateral margins of the superior articular facet of C2. The odontoid should have uninterrupted cortical margins blending with the body of C2.

24. OBLIQUE(ANT.&POSTERIOR) Patient may be erect or recumbent. Patient is rotated 45 degree to one side –to left for demonstrating right side neural foramina & to the right to demonstrate left neural foramina. Central beam directed to c6 vertebra(base of neck) . Tilt of 15-20 degree caudal for anterior oblique& posterior oblique 15-20 degree cephalad angulatio

25. FRACTURES AND PATHOLOGIES

26. Jefferson Fracture Description: compression fracture of the bony ring of C1, characterized by lateral masses splitting and transverse ligament tear. Mechanism: axial blow to the vertex of the head (e.g. diving injury) Radiographic features: in open mouth view, the lateral masses of C1 are beyond the body of C2. A lateral displacement of >2mm or unilateral displacement may be indicative of a C1 fracture. CT is required to define extent of fracture. Stability: unstable

27. Odontoid Fractures Three types: Type I - fracture in the superior tip of the odontoid. (rare) Type II - fracture is at the base of the odontoid. It is the most common type of odontoid fracture and is UNSTABLE. Type III fracture through the body of the axis. Has the best prognosis.

28. Hangman’s Fracture Description: fractures through the pedicle of the axis. Mechanism: hyperextension (e.g. hanging, chin hits dashboard in MVA) Radiographic feature: best seen on lateral view prevertebral swelling Anterior dislocation of the C2 vertebral body bilateral C2 pedicle fractures

29. Flexion Teardrop Fracture Description: posterior ligament disruption and anterior compression fracture of the vertebral body. Mechanism: hyperflexion and compression (e.g. diving into shallow water) Radiographic feature: Teardrop fragment from anterior vertebral body, posterior body sublux into spinal canal

30. Clay Shoveler’s Fracture Description: fracture of a spinous process C6-T1. Mechanism: powerful hyperflexion, usually combined with contraction of paraspinal muscles pulling on the spinous process. Radiographic feature: best seen on lateral spinous process fracture ghost sign on AP (i.e.. Double spinous process of C6 or C7 resulting from displaced fractured process)