RADIOLOGY CERVICAL, DORSAL, LUMBAR AND SACRAL SPINE XRAY

1. DR. HARSHIL A. KALARIA
RESIDENT,.
DEPARTMENT OF RADIOLOGY

4. Anterior-posterior full-length view of the spine and
Lateral full-length view of the spine

5. Cervical vertebrae
 2 TYPES
 Atypical
 Axis
 Atlas
 C 7
 Typical
 C 3-6

6. 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

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

9. Cervical Spine Radiograph
Standard View:
 Anteroposterior view
 Lateral View
 Odontoid (Open Mouth View)
Extended View
 Swimmers View: when lateral radiograph fails to show
vertebrae down to T1

12. 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.

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

14. 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
(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 4th 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.

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

22. Cervical Spine Systemic Approach
 Coverage - Adequate?
 Alignment - Anterior/Posterior/Spinolaminar
 Bones - Cortical outline/Vertebral body height
 Spacing - Discs/Spinous processes
 Soft tissues - Prevertebral
 Edge of image

23.  Coverage - All vertebrae are visible from the skull base to
the top of T1 (T1 is considered adequate)
 If T1 is not visible 'swimmer's' view
 Alignment - Check the Anterior line (the line of the
anterior longitudinal ligament), the Posterior line (the
line of the posterior longitudinal ligament), and the
Spinolaminar line (the line formed by the anterior
edge of the spinous processes - extends from inner
edge of skull).
 Bone - Trace the cortical outline
 Note: The spinal cord (not visible) lies between the
posterior and spinolaminar lines

24. Cervical Spine Systemic Approach

25. Cervical Spine Systemic Approach
 Disc spaces - The vertebral bodies are spaced apart by the
intervertebral discs - not directly visible with X-rays. These
spaces should be approximately equal in height
 Prevertebral soft tissue - Some fractures cause widening of the
prevertebral soft tissue due to prevertebral hematoma.
 - Normal prevertebral soft tissue - 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
hematoma - lack of prevertebral soft tissue thickening should NOT be
taken as reassuring
 Edge of image - Check other visible structures

27.  Bone - The cortical outline is not always well defined
but forcing your eye around the edge of all the bones
will help you 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

28. Cervical Spine Systemic Approach

29. C-spine systematic approach - Normal AP
 Coverage - The AP view should cover the whole C-spine
and the upper thoracic spine
 Alignment - The lateral edges of the C-spine should be
 aligned
 Bone - Fractures are often less clearly visible on this view
than on the lateral
 Spacing - The spinous processes 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

30. C-spine systematic approach - Normal AP

32. 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.

33. HYPERFLEXION HYPEREXTENSION

34. C-spine - Open mouth view
 This view is considered adequate if it shows the
alignment of the lateral processes of C1 and C2
 The distance between the peg and the lateral
masses of C1 should be equal on each side
 Note: In this image the odontoid peg is fully
visible which is not often achievable in the context
of trauma due to difficulty in patient positioning

35. 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!!!!!!!!!!

37.  The distance between the peg and the lateral processes is
not equal - compare A (right) with B (left)
 This is because when the image was acquired the patient's
head was rotated to one side
 Alignment of the lateral processes can still be assessed and
is seen to be normal

38. Swimmer's' view
 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 cervico-thoracic
junction is limited then CT may be required.

40. Swimmers View

41. 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.

44. 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

45. 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.

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

47.  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.

48. 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)

49. 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.

50. 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

51. 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

52. 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

53. 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.

54. The Thoracic vertebrae
 2 TYPES
 Atypical
 T1
 T10
 T11
 T12
 Typical
 T2-T9

58. Thoracic spine - Standard views
 AP and Lateral - Assess both views systematically .
 Note: The upper T-spine may not be visible on the
lateral view - if injury is suspected here then a
swimmer's view may be helpful

60. Thoracolumbar spine - 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

61. Thoracolumbar spine - Systematic approach
 Coverage - The whole spine is visible on both views
 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

62. Thoracolumbar spine - Systematic approach
 Spacing - Disc spaces gradually increase from superior
to inferior - Note: Due to magnification and spine
curvature the vertebral bodies and discs at the edges of
the image can appear larger than those in the centre of
the image
 Soft tissues - Check the paravertebral line (see AP
image below)
 Edge of image - Check the other structures visible

63. VB = Vertebral body
P = Pedicle
SP = Spinous process (ribs overlying)
F = Spinal nerve exit foramen

65. Thoracic spine - Systematic approach
 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, and the 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

66. The Lumbar vertebrae

68. Lumbar Spine Radiograph
Standard View:
 Anteroposterior view
 Lateral View
Extended View:
lat hyperflexion
lat hyperextension
oblique
RPO and LAO show right pars interarticularis,
LPO and RAO show left pars interarticularis

75. Lumber Spine –Systemic Approach
 Coverage - The whole L-spine should be visible on
both views
 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

76. Lumber Spine –Systemic Approach
 Check the cortical outline of each vertebra
 The facet joints comprise the inferior and superior
articular processes of each adjacent level
 The pars interarticularis literally means 'part between
the joints'
 P = Pedicle
 SP = Spinous process

77. Lumber Spine –Systemic Approach

79. Lumber Spine –Systemic Approach
 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

80. Lumber Spine –Systemic Approach

81.  Check carefully for pedicle integrity and transverse
process fractures

84. Three column model
 The Clinico-radiological assessment of thoracolumbar
spine stability is usually performed by spinal surgeons
with the help of radiologists.
 A simple model commonly used for assessment of
spinal stability is the 'three column' model. This states
that if any 2 columns are injured then the injury is
'unstable'. This theory is an over simplification if
applied to plain X-rays alone. It is important to be
aware that some injuries are not visible on X-ray and
that 2 and 3 column injuries may be underestimated as
1 or 2 column injuries respectively.
 If spinal instability is suspected on the basis of clinical
or radiological grounds then further imaging with CT
should be considered.

86. Three column model - Anatomy
 Anterior column = Anterior half of the vertebral
bodies and soft tissues
 Middle column = Posterior half of the vertebral
bodies and soft tissues
 Posterior column = Posterior elements and soft soft
tissues

87.  Three column model - Fracture simulation
 Injuries 1 and 2 affect one column only and are considered 'stable'
 1 - Spinous process injury
 2 - Anterior compression injury
 Injuries 3 and 4 affect two or more columns and are considered 'unstable'
 3 - 'Burst' fracture
 4 - Flexion-distraction fracture - 'Chance' type injury
Three column model - Fracture simulation

88. Anterior compression injury
Anterior compression injury is a common fracture
pattern which results from traumatic hyper-flexion
with compression. Although considered 'stable'
the greater the loss of height anteriorly the
greater the risk of middle column involvement. X-
ray may underestimate the extent of injury and so
if there has been high risk injury or other
suspicion of instability then CT should be
considered.

90. 'Burst' fracture
'Burst' fractures result from high force vertical
compression trauma. Posterior displacement of
vertebral body fracture fragments into the spinal
canal leads to a high risk of spinal cord or nerve
root damage.

92. Flexion-distraction fracture
Flexion-distraction injuries are associated with high force
deceleration injuries and are most common at the
thoracolumbar junction. Also known as 'Chance-type'
fractures (after the radiologist who first described them)
these injuries are unstable and carry a high risk of
neurological deficit and abdominal organ injury.
The 'fracture' line may pass through the disc rather than
the vertebral body, and so there may not be visible bone
injury of the anterior column.

96. Osteoporotic 'insufficiency' injuries
Thoracolumbar spine injuries are very common in
patients with osteoporosis. Common fracture
patterns include 'wedge' injuries and 'biconcave'
fractures.

97. Lateral radiograph of an osteoporotic spine, showing
compression fractures in the L1 and L3 vertebral bodies.

101. The Sacralcoccygeal vertebrae


106. THANK YOU