X ray c-spine

x ray cervical spine

1. X-ray cervical spine Dr Raja Resident Dept. of radiodiagnosis

2. Topics to be discussed Anatomy Projection techniques Lines and angles of spine Normal variants of spine Common fractures

3. Anatomy of cervical spine

4. Cervical vertebrae 2 TYPES Atypical Axis Atlas C 7 Typical C 3-6

5. Atlas 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. Attachment Anterior tubercle & lower border of the anterior arch give attachment to ant. Longitudinal ligament. Upper border of anterior arch gives attachment to ant. Atlanto-occipital membrane. Upper surface of posterior arch has a groove- occupied by vertebral artery & first cervical nerve. Behind the groove the upper border of posterior arch give attachment to post. Atlanto-occipital membrane Lower border of posterior arch –highest pair of ligamenta flava. Posterior tubercle provide attachment to ligamentum nuchae Tubercle on medial side of the lateral mass –give attachment to transverse lig.of atlas.

7. 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

8. 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.

9. Ligamentous Anatomy Anterior longitudinal ligament Reinforces anterior discs, limits extension Posterior longitudinal ligament Reinforces posterior discs, limits flexion Ligamentum nuchae = supraspinous ligament Thicker than in thoracic/lumbar regions Limits flexion Interspinous/intertransverse ligaments Limit flexion and rotation/limits lateral flexion Ligamentum flavum Attach lamina of one vertebrae to another, reinforces articular facets Limits flexion and rotation

10. Ossification centres of atlas C1-3 primary ossification centre. One for anterior arch &two for neural arch. Anterior ossification centre appear 20% at birth & visible by 1 year. Neural arch appear at 7 th fetal week & fuse with anterior arch at 7 th year Neural arch fuse posteriorly by 3th year of life.

11. Ossification centres of axis C2-4 ossification centre. One for each neural arch, body & odontoid process each one. Odontoid process forms in utero from 2 separate ossification centre & fuse in mid line by 7 th fetal month. Secondary ossification centre appear at apex of odontoid process between 3 to 6 yrs & fuse by 12-13 yrs. Body fuse with odontoid process by 3-6yrs. Neural arch fuse with body of odontoid between 3-6 yrs & fuse posteriorly 2-3yrs.

12. 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 . Each process consists of an anterior and a posterior tubercle. These two parts are joined, outside the foramen.

13. Cervical Vertebra (C7)   . Its 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 On the left side it occasionally gives passage to the vertebral artery; more frequently the vertebral vein transverses it on both sides; but the usual arrangement is for both artery and vein to pass in front of the transverse process, and not through the foramen. Sometimes the anterior root of the transverse process attains a large size and exists as a separate bone, which is known as a cervical rib. 

14. Ossification of c3-c7 3 ossification centre-one for body & 2 neural arch. Body fuse with neural arch by 3-6yrs. Neural arch fuse posteriorly by 2-3yrs. Secondary ossification centre may be seen at the tip of transverse process/spinous process and persist until early 3th decade of life & stimulate fracture.

15. Spinal Nerves C1-c8 Cervical Plexus C1-C4 C4 -Phrenic Nerve - Breathing Brachial Plexus C5-T1 C3

16. Dermatomes Myotomes C5 – Abduction C6 – Elbow Flexion/Wrist Extension C7 – Elbow Extension/Wrist Flexion C8 – Finger Flexion C1-2 – Neck Flexion C3 – Lateral Neck Flexion C4 – Shoulder Elevation C1 – top of head C2 – Temporal C3 – Side of jaw/neck C4 – top of shoulders

17. Brachial Plexus

18. Projection & imaging technique

19. Cervical spine view

20. 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.

21. 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.

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

23. 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.

24. LATERAL PROJECTION (grandy method) 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.

25. Lateral view.  1) Anterior arch of atlas  2) Posterior arch of atlas 3) Dens  4)Laminae C2  5) Spinous Process C6  6) C7-T1 Intervertebral Foramina  7) Retropharyngeal Space (Normal < 7mm)  8) Retrotracheal Space ( Normal <2cm).

26. Interpretation of Lateral View

27. Disc spaces should be equal and symmetric

28. AD interval Atlas-dens space – should be 3mm or less(Adult) 1-5mm (children)

29. Prevertebral soft tissue C1 –nasopharyngeal space-<10mm C2-c4 retropharyngeal space-<5-7mm C5-c7- retrotracheal space-<14mm(children), <22mm(adults).

30. 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.

31. HYPERFLEXION HYPEREXTENSION

32. 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!!!!!!!!!!

33. 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.

34. 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 angulation.

35. job list NAME,AGE, SEX IP NO, INDICATION CONTOUR ALIGNMENT DENSITY IVDS LINES BONES JOINTS PRE AND PARAVERTEBRAL SOFT TISSUE

36. Lines & angle

37. Lines in cervical spine

38. Chamberlain line Posterior margin of hard palate to posterior margin of foramen magnum(opisthion) The odontoid process should not project above this line more than 3mm.

39. Mc Gregor line Line is drawn from posterosuperior margin of the hard plate to most caudal part of the occipital curve of the skull. Tip of odontoid normally don’t extend more than 4.5mm above this line.

40. Mc Rae line Line connects the basion with opisthion of foramen magnum. Odontoid process should be just below this line or the line may intersect only at the tip of odontoid process.

41. Ranawat method Coronal axis of c1 is determined by connecting centre of the anterior arch of c1 vertebra with its posterior ring. Centre of sclerotic ring in c2,represent pedicle, is marked. Line drawn along the axis of odontoid process to first line. Normal distance between c1-c2 men-17mm women-15mm(+/-2SD) Decrease in distance indicate cephalad migration of c2.

42.           - identifies anterior subluxation & is described as ratio of BC/OA           - BC is the distance from the basion to the midvertical portion of posterior laminar line of the atlas;            - OA is distance from opisthion to midvertical portion of posterior surface of anterior ring of  Atlas ;            - if this ratio is greater than 1 , anterior subluxation exists;  POWERS RATIO

43. Plain film and CT demonstration of measuring the Powers ratio. If the Power's Rule (BC)/(AO) is greater than 1 then anterior occipitoatlantal dislocation has likely occurred

44. HARRIS LINES Have also been referred to as the BDI/BAI or the Rule of Twelve. The basion-posterior axial line interval (BAI) is drawn along the posterior aspect of the dens (the posterior axial line) and a measurement between this line and the tip of the basion is performed.  The basion-dental interval (BDI) is the distance measured between the tip of the basion and the tip of the dens.  When the the BDI and BAI to be greater than 12 mm then occipitoatlantal dissociations has occurred.  It is believed to be the useful, sensitive, radiographic parameters for detecting and characterizing occipitocervical dissociation .

45. Sagittal CT images: Left measures the basion-posterior axial line interval which is denoted by the small horizontal red line. The right image demonstrates measurement of the basion-dental interval which is denoted by the vertical red line. If either of these distances are greater than 12 mm then the diagnosis of occipitocervical dislocation is fairly certain.

46. Wachenheim clivus line A line drawn along posterior aspect of clivus towards odontoid process. Abnormality is suspected when this line does not intersect or is tangential to odontoid process.

47. Normal variant

48. OSSICULUM TERMINALE PERSISTENUM

49. ALSO CALLED UNUNITED SUMMIT EPIPHYSIS, BERGMANN OSSICLE SECONDARY OSSIFICATION CENTRE APPEARS AT 2yrs & FUSION OCCURS BY 12-13 yrs C/F: ASYMPOMATIC , BRAIN STEM FEATURES OCCURS WHEN TRANSVERSE LIGAMENTT DISLOCATES INTO THE CLEFT INCREASED INCIDENCE IN DOWN SYNDROME V SHAPED CRESENT 3-5 mm , OVOID , DIAMOND SHAPE

50. OS ODONTOIDEUM

51. ALSO CALLED UN UNITED ODONTOID PROCESS IT’S A NON-UNION OF DENS WITH AXIS BODY 3-6yrs NORMAL OSSIFICATION ASSOCIATED WITH DOWN SYNDROME, ATLAS HYPOPLASIA, KLIPPEL-FIEL SYNDROME, SKELETAL DYSPLASIA AUDIBLE CREPITUS, SUBOCCIPITAL PAIN R/F: ALTERED SHAPE OF ANTERIOR ARCH OF ATLAS (HYPERTROPHY) , ADI IS NORMAL,

52. ATLANTO OCCIPITAL DISLOCATION

53. Description : Disruption of the atlanto-occipital junction involving the atlanto-occipital articulations.  Mechanism : Hyperflexion or hyperextension. Radiographic features :   1. Malposition of occipital condyles in relation to the superior articulating facets of the atlas. 2. Cervicocranial prevertebral soft tissue swelling.  Stability : unstable

54. Atlanto-axial dislocation AD interval –distance between anterior surface of dens & posterior surface of anterior arch of c1. Atlanto axial instability is define as increase AD interval of >3mm (adult) &>5mm(children). Symptoms presents when the atlas moves forward on the axis to narrow the spinal canal & impinge on the spinal cord. Almost all atlanto-axial dislocation involve forward movement of c1 on c2;posterior dislocation is rare.

55. Traumatic –motor vehicle accident. Non-traumatic cause-down’s syndrome,grisel syndrome,morquio syndrome,rheumatoid arthritis,osteogenesis imperfecta

56. Common fractures

57. 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

58. Jefferson fracture   A  Jefferson fracture  is a  bone fracture  occurring at the  first vertebrae . It is classically described as a four-part break that fractures the  anterior  and  posterior arches  of the vertebra, though it may also appear as a three or two part fracture.

59. 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.

60. 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

61. Type 1-fracture through the pedicle of c2. Type 2-type1+concomitant disruption of intervertebral disc c2-c3. Type 3-type2+c2-c3 facet dislocation.

62. 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

63. Anterior Subluxation Description: disruption of the posterior ligamentous complex. Difficult to diagnose. Subluxation may be stable initially, but it associates with 20-50% delayed instability . Mechanism: hyperflexion Radiographic feature: best seen on flex/ext anterior sublux of more than 4mm fanning of interspinous ligaments loss of normal lordosis

64. 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)

65. Oblique fracture of lower cervical spinous process

66. Burst Fracture Description: fracture of C3-C7 that results from axial compression. Injury to the spinal cord, secondary to displacement of posterior fragments, is common. CT is required to define extent of injury. Mechanism: axial compression Radiographic features: best seen on CT

67. Unilateral Facet Dislocation Description: facet joint dislocation and rupture of the hypophyseal joint ligaments. Mechanism: simultaneous flexion and rotation Radiographic features: best seen on lateral and oblique Anterior dislocation of affected vertebral body by less than half of the vertebral body AP diamete widening of the disc space

68. Bilateral Facet Dislocation Description: complete anterior dislocation of the vertebral body. It is associated with a very high risk of cord damage. Mechanism: extreme flexion of head and neck without axial compression Radiographic feature: best seen on lateral complete anterior dislocation of affected body by half or more of the vertebral body AP diameter. “Bow tie” or “Bat wing” appearance of the locked/jumped facets.

69. Thank u