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- 1. Foto Polos Cervical Pembimbing: Dr. dr. M. Saekhu, Sp.BS(K) dr. Irfani Ryan Ardiansyah
- 2. Standard views 3 view standar adalah : • Lateral, Anterior-Posterior (AP) dan Odontoid (atau tampilan Open Mouth), saat situasi trauma, view ini mungkin sulit diperoleh karena pasien mungkin kesakitan, bingung, tidak sadar, atau tidak dapat bekerja sama karena alat imobilisasi. View tambahan • Jika view lateral tidak dapat terlihat hingga T1 maka foto diulang dengan lengan diturunkan atau biasa disebut ‘Swimmers view’.
- 4. Small vertebral bodies -> less weight to carry Extensive joint surfaces ->greater ROM
- 5. Adekuat • The standard 3 view plain film series is the lateral, antero-posterior, and open-mouth view • The lateral cervical spine film must include the base of the occiput and the top of the first thoracic vertebra • The lateral view alone is inadequate and will miss up to 15% of cervical spine injuries. • If the lower cervical spine is not visible, a CT scan of the region is then indicated
- 6. Alignment • There are multiple lines you need to assess across each of the three radiograph views which should run uninterrupted in healthy individuals.
- 7. Alignment: • Anterior spinal line • Posterior spinal line • Spinolaminal line • Spinous process tips
- 8. Lateral View The anterior longitudinal line runs along the anterior surface of the vertebral bodies. The posterior longitudinal line runs along the posterior surface of the vertebral bodies. The spinolaminar line runs along the anterior edge of the spinous processes (at the junction of the spinous process and the laminae).
- 9. • Anterior subluxation of one vertebra on another indicates facet dislocation • Less than 50% of the width of a vertebral body implies unifacet dislocation • Greater than 50% implies bilateral facet dislocation • This is usually accompanied by widening of the interspinous and interlaminar spaces
- 11. AP View The two lateral lines of the AP view run down either side of the vertebral bodies (represented by the yellow lines in the image below). The spinous process line runs down through each spinous process from C1 to C7 (represented by the blue line in the image below).
- 12. Odontoid View The odontoid/open-mouth view has several intersecting lines which are sometimes referred to as a “meeting of corners”. Irregularities in the areas where these lines intersect may indicate misalignment of the lateral masses of C1 and C2 (e.g. fracture, dislocation). You can also use this view to assess the odontoid peg to make sure it is aligned with the lateral masses of C1. To do this, inspect and compare the space between the peg and the lateral mass of C1 on each side. Asymmetry of the space between the peg and the lateral mass of C1 may indicate fracture or dislocation of the odontoid peg.
- 13. • The open mouth view should visualise the lateral masses of C1 and the entire odontoid peg • Bite blocks may improve viewing • In the unconscious, intubated patient the open mouth view is inadequate and occiput to C2 CT scan is recommended
- 14. • This is usually the second standard view obtained in the emergency department. The main goal is to picture the odontoid process of the C2 and the C1. It can be done with the mouth either open or closed. Two things are assessed when inspecting the odontoid x- ray: the distance between the odontoid process and the lateral masses of the C1 should be equal. If not, the inequality may be due to a slight rotation of the head. Secondly, and considering the previous point, the margins of C1 and C2 should remain aligned (Figure 10).
- 15. Predental space • Figure 6: Predental space, the distance between the anterior surface of the odontoid process and posterior aspect of the anterior ring of C1, in adult, it should not exceed 3 mm, or 5 mm in children.
- 16. Swimmer 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.
- 17. B. Bones • In all three of the previously discussed views, you should carefully inspect the cortex (outer white edge) of each bone in turn, making sure you are systematic (e.g. top to bottom) in your approach. A common pitfall is to stop searching once you have found one abnormality. If an abnormality is identified, you should note it and then continue to follow your systematic approach until all relevant bones have been assessed.
- 18. • Vertebral body and intervertebral disc examination reveal compression and burst type injuries • Bodies normally regular cuboids similar in size and shape to the vertebrae immediately above and below (not C1/C2) • Anterior wedging of vertebral body or teardrop fractures of antero- inferior portion of body implies compression fracture
- 19. • Loss of height of an intervertebral disc space may indicate disc herniation • Analysis of prevertebral soft tissues may allow the diagnosis of cervical injuries • Soft tissue shadow is created by pharyngeal and prevertebral tissues
- 20. • Bone: Watch for a normal bony outline of the vertebras and bone density. Subtle changes in bone density should be noted, as it may indicate a compression fracture. Areas with decreased bone density which may be found in patients with rheumatoid arthritis, osteoporosis or metastatic osteolytic lesions, are more prone to breaking under stress. Acute compression fractures of the above- mentioned changes show as areas of increased bone density (Figure 7).
- 22. Cartilage Intervertebral discs should be roughly similar in height throughout the cervical spine, with no obvious loss of height at any point in the disc. However, if you suspect disc pathology (e.g disc herniation) from the history/examination (cervical radiculopathy with sensory/motor disturbance at a certain spinal level), this often wouldn’t be clearly seen on a cervical spine X-ray and would be better investigated with an MRI scan.
- 23. Cartilage space assessment • Inspection of a good quality lateral view x-ray in a healthy person should show uniform intervertebral spaces. (Figure 8).
- 24. D -Diskus
- 25. Extra axial soft tissue
- 26. • Pre-vertebral (i.e the area directly anterior to the vertebral bodies) soft tissue is best assessed using a lateral view. Soft tissue appears as a light grey opacity on cervical spine X-rays, located between the vertebral bodies and the darker-grey area that represents the trachea. Any widening of this space may represent a pre-vertebral haematoma and should significantly raise suspicion of a cervical fracture. It should be noted that this area naturally gets wider around the level of C4 so two different acceptable widths are used:
- 27. • above C4 the pre-vertebral soft tissue should be no larger than one- third of the adjacent vertebral body in width. • from C4 onwards the pre-vertebral soft tissue should be no larger than the width of one whole vertebral body. • If a lateral cervical spine X-ray has been requested for another indication (e.g. suspected foreign body in the trachea) you should make sure you include these other structures in your assessment of the radiograph.
- 29. Soft tissue • The prevertebral soft tissues can be used as an indicator of an acute swelling or hemorrhage resulting from an injury, and may sometimes be the only indicator of an acute injury on an x-ray. The normal width of the prevertebral tissue decreases down from C1 to C4 and increases from C4 downwards. Normal measurements from C1 to C4 are less than 7 mm (less than half of the vertebral body at this level), and less than 22 mm below the C5 (less than the vertebral body at this level) see Figure 9. Air within soft tissue could suggest rupture of the esophagus or trachea.
- 30. Kesimpulan
- 31. Latihan 1
- 34. Latihan 2
- 35. Latihan 3
- 36. Latihan 4
Editor's Notes
- 3 tampilan standar adalah - Tampilan lateral - Tampilan Anterior-Posterior (AP) - dan tampilan Pasak Odontoid (atau tampilan Mulut Terbuka). Dalam konteks trauma, gambaran-gambaran ini sulit diperoleh karena pasien mungkin kesakitan, bingung, tidak sadar, atau tidak dapat bekerja sama karena perangkat imobilisasi. Tampilan tambahan Jika pandangan lateral tidak menunjukkan tulang belakang ke T1 maka pandangan berulang dengan lengan diturunkan atau 'pandangan Perenang' mungkin diperlukan. Tampilan samping Tampilan lateral sering kali merupakan gambar yang paling informatif. Penilaian membutuhkan pendekatan yang sistematis.
- Thevertebraeshouldalwaysbecountedslowly,andthebodiesshould be looked at as one proceeds from top to bottom. One should count a second time when looking at posterior elements from top to bottom on lateral film.It should be checked that the alignment is in order.To do this, one should draw an imaginary line joining the anterior aspects of the vertebral bodies (anterior body line), the posterior aspects of the bodies (posterior body line), and the line joining the short interfaces where the spinous processes join the laminae posteriorly (spinolaminar line). All these lines should curve gently and gradually in a slight lordotic config- uration. The upper spinolaminar line (posterior spinal line) is extended from C1 to C3, and the anterior aspect of the spinous process of C2 should not be displaced (by more than 2 mm, with a straight line nor- mally formed joining the anterior aspects of the spinous processes of C1, C2, and C3. An apparent slight subluxation may occur in pre-teenage years, with a grade I shift (less than one quarter of vertebral body shift) occurring as a normal variant (pseudosubluxation; anterior shift of C2 on C3).
- The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation A step of >3.5mm is significant anywhere
- On the AP radiograph, alignment of the spinous processes should be checked. Malalignment with, for example, the top four aligned to the left of the midline and the remainder in a straight line in the midline indi- cates a locked facet situation at that level. (Sometimes only one half of a bifid spinous process may be visible and thus a locked facet may be sim- ulated, though alignment above and below will be unaffected). The un- dulated outline of the lateral masses of the mid and lower cervical spine should be uninterrupted by a fracture or displacement on the AP view.
- The open-mouth view is the best projection for excluding a possible odontoid peg fracture, but sometimes CT may be required for confirma- tion. The occipito-atlantal and atlantoaxial articulations should also be assessed, and the two sides should be symmetrical. The lateral aspects of C1 and C2 should be perfectly aligned. This relationship will be dis- turbed when the patient is rotated (but still within normal limits), but is definitely abnormal when compression and splaying of the body of C1 occurs (Jefferson’s fracture), with the lateral masses of C1 lateral to the lateral masses of C2 on the open-mouth view.
- Theindividualelementsshouldbeexaminedcarefully:bodies,pedicles, facet joints, laminae, spinous processes, and disc spaces. (Note that un- covertebral joints overlying disc spaces, and transverse processes superimposed on posterior parts of vertebral bodies may simulate bony injuries). The disc spaces should be carefully examined for narrowing (usually due to pre-existing degenerative disease) or widening which may be part of a serious hyperextension injury, may be subtle, but will be associated with local precervical soft tissue swelling. The localized narrowing of a disc space anteriorly or posteriorly should also be re- garded with suspicion and other signs should be sought.
- Figure 7: Watch for a non-disrupted bony outline. Disruption, as in the above examples means fracture of the bone structure. Also search for any hypo- or hyper-dense areas in the bone, as it may be the only indication of the compression fracture. In (A) slight widening of the soft tissue is visible just in front of the fracture, under the white arrow, which may indicate that this is an acute injury
- Figure 8: Uniform intervertebral cartilage spaces, also facet joints must be inspected, for any unusual alignment or increased space. An emergency physician may diagnose subluxations and dislocations of the facet joints through the assessment of cartilage space between corpora of vertebrae, facet joints, and space between spinous processes. Increased interspinous distance by more than 50% suggests a ligamentous injury and the protective muscle spasm may make the interpretation difficult.
- Aprecervicalsofttissueswelling,whichmaybelocalizedorgeneralized, should be excluded. In the upper cervical spine, the precervical soft tis- sue thickness should not exceed 7 mm at the anteroinferior aspect of C2 and should not exceed an AP vertebral body width or 21 mm at lower cervical-spine level. (As elsewhere in radiology, measurements do have their limitations and a soft tissue thickness of more than 7 mm may be seen at the C2 level in large or obese patients. In a small patient a meas- urement of 7 mm may even be abnormal and injury may still be present).
- Afterthebonypartsofthecervicalspinehavebeenexaminedonthe various projections, certain other areas should be reviewed, and these include the following: Parts of the mandible may be visible, and mandibular fractures may be associated with cervical-spine injuries. The pituitary fossa, which may be included on the lateral radiograph, should always be looked at. An air fluid level in the sphenoid sinus would suggest a base of skull fracture and CT would be indicated for further evaluation; air fluid lev- els in the maxillary antra would suggest facial bone injury (note that concomitant sinusitis, a common and often incidental condition, may also cause air fluid levels). Foreign material in soft tissues should be excluded. The endotracheal tube and nasogastric tube may be visible and mal- position and/or complications should be noted. Soft tissue haematoma with tracheal deviation may be noted. Surgical emphysema along fascial planes may be due to local trauma or associated with pneumomediastinum. Signs of concomitant chest trauma (such as signs of aortic rupture or pneumothorax) may be noted on the AP cervical-spine radiograph.
- C-spine systematic approach - Normal Lateral 1 Coverage - All vertebrae are visible from the skull base to the top of T2 (T1 is considered adequate) - If T1 is not visible then a repeat image with the patient's shoulders lowered or a 'swimmer's' view may be necessary 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) - GREEN = Anterior line - ORANGE = Posterior line - RED = Spinolaminar line Bone - Trace the cortical outline of all the bones to check for fractures Note: The spinal cord (not visible) lies between the posterior and spinolaminar lines
- C-spine systematic approach - Normal Lateral 2 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 Pre-vertebral soft tissue - Some fractures cause widening of the pre-vertebral soft tissue due to pre-vertebral haematoma - Normal pre-vertebral soft tissue (asterisks) - 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 pre-vertebral haematoma - lack of pre-vertebral soft tissue thickening should NOT be taken as reassuring Edge of image - Check other visible structures
- C-spine normal anatomy - Lateral (detail) 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
- 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 are aligned (red lines ) Bone - Fractures are often less clearly visible on this view than on the lateral Spacing - The spinous processes (orange) 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
- C-spine normal anatomy - Open mouth view This view is considered adequate if it shows the alignment of the lateral processes of C1 and C2 (red circles) The distance between the peg and the lateral masses of C1 (asterisks) 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
- C-spine normal anatomy - ' Swimmer's' view Oblique image with the humeral heads projected away from the C-spine The cervico-thoracic junction can be seen Check alignment by carefully matching the corners of each adjacent vertebral body - anteriorly and posteriorly