This document discusses the role of radiography in the initial evaluation of cervical spine (c-spine) trauma, emphasizing the importance of understanding normal anatomy, standardized imaging approaches, and common injury types. It presents clinical criteria (Nexus) for ruling out c-spine injuries in blunt trauma cases and reviews the limitations and effectiveness of radiographic evaluations compared to advanced imaging techniques like CT and MRI. The findings aim to enhance diagnosis accuracy while reducing unnecessary radiographic exposure in appropriate patient populations.

1. Project: Ghana Emergency Medicine Collaborative
Document Title: The Role of Radiography in the Initial Evaluation of C-Spine Trauma
Author(s): Stephen Hartsell (University of Utah), MD, FACEP 2012
License: Unless otherwise noted, this material is made available under the
terms of the Creative Commons Attribution Share Alike-3.0 License:
http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your
ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly
shareable version. The citation key on the following slide provides information about how you may share and
adapt this material.
Copyright holders of content included in this material should contact open.michigan@umich.edu with any
questions, corrections, or clarification regarding the use of content.
For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use.
Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis
or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please
speak to your physician if you have questions about your medical condition.
Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
1

2. Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy
Use + Share + Adapt
Make Your Own Assessment
Creative Commons – Attribution License
Creative Commons – Attribution Share Alike License
Creative Commons – Attribution Noncommercial License
Creative Commons – Attribution Noncommercial Share Alike License
GNU – Free Documentation License
Creative Commons – Zero Waiver
Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in
your jurisdiction may differ
Public Domain – Expired: Works that are no longer protected due to an expired copyright term.
Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105)
Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain.
Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your
jurisdiction may differ
Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that
your use of the content is Fair.
To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
{ Content the copyright holder, author, or law permits you to use, share and adapt. }
{ Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. }
{ Content Open.Michigan has used under a Fair Use determination. }
2

3. “The role of radiography in the
initial evaluation of C-Spine
Trauma”
Stephen Hartsell MD, FACEP
Director of Education
Division of Emergency Medicine
University of Utah
3

4. OBJECTIVES
§ Better understand normal radiographic anatomy
§ Standardized approach to reading c-spine
radiographs
§ Review of common cervical spine injuries seen in
the blunt trauma patient and their significance
§ Discuss using NEXUS as a framework; who to x-
ray, which studies needed to adequately screen
for CSI and appropriate use of advanced imaging
4

5. Normal Radiographic
Anatomy
5

6. Normal Lower Cervical Vertebra
6
Source Undetermined

7. ABCs of the C-Spine
§ Alignment, Adequacy
§ Bony Element
§ Cartilage Space, Connective Tissue
§ Soft Tissue
7

8. Cross Table Lateral View
Alignment/Adequacy
§ C7 –T1 thru post. F. Magnum
§ ALL & PLL
§ Spinolaminar Line
§ Tips of Spinous Processes
§ Predental Space <=3mm
§ Basion Dental interval (BDI)
§ Basion Axial Interval (BAI)
8
Source Undetermined

9. CTLV – Alignment
BDI, BAI <= 12mm
9
Source Undetermined

10. Pseudosubluxation C2
10
Source Undetermined

11. CTLV – Bony elements
Density & Symmetry
§ Ant. & post. Cortices body
§ Sup. & Inf. Endplates
§ Ring of C2
§ Transverse processes
§ Pedicles
§ Articular Masses
§ Sup. & Inf. Facets
§ Laminae
§ Spinous processes
§ C1-2 and C5-7
11
Source Undetermined

12. Cartilage space and connective tissue
§ Intervertebral disc
§ Interfacetal joints
§ Interlaminal space
§ Interspinous space
12
Source Undetermined

13. Soft Tissue
§ Retropharyngeal space
<= 6mm
§ Retrotracheal space
<= 22mm
§ Cervical esophagus at
C4-5
§ Absolute measurement not
reliable, sensitivity~5%
lower C-spine
13
Source Undetermined

14. Is This An
Adequate
CTLV ?
14
Source Undetermined

15. 15
Source Undetermined

16. Anatomy of the cervicocranium
16
Source Undetermined

17. Odontoid view (open mouth)
Alignment
§ Odontoid process located between lat. masses of axis
§ Lateral margins of atlanto-axial facet joints
§ Bifid spinous process midline
§ w/o tilt or rotation
17
Source Undetermined

18. Odontoid view w/ rotation
18
Source Undetermined

19. Odontoid view
Bony elements
§ Odontoid and artifacts
§ C1 lateral masses
§ C2 vertebral body
19
Source Undetermined

20. Odontoid view
Cartilage space
§ Interfacetal joints
20
Source Undetermined

21. A-P View
Alignment
§ Spinous processes midline
§ Tracheal air shadow
21
Source Undetermined

22. A-P View
Bony elements
§ Vertebral bodies
§ Sup. & Inf. Endplates
§ Uncinate processes
§ Articular masses
Lateral columns
22
Source Undetermined

23. A-P view
Cartilage space and connective tissue
§ Intervertebral disc space
§ Interspinous space
§ Joints of Luschka
23
Source Undetermined

24. Swimmer’s View
§ For evaluation of C7-T1
interface when CTLV is
inadequate
§ Posterior C7 not well visualized
§ Use only when suspicion of
injury is low
24
Source Undetermined

25. CSI by Mechanism
Hyperflexion
25

26. Hyperflexion Strain
§ Hyperkyphosis at level of injury
§ Ant. displacement Vertebral
Body > 2mm
§ Disruption post. Ligamentous
complex
§ Interspinous & Interlaminal
fanning
§ Disc space widened post. And
narrowed ant.
26
Source Undetermined

27. Hyperflexion Strain (cont)
27
Source Undetermined

28. Hyperflexion Strain (cont)
§ Soft Tissue Swelling may be only
evidence CSI.
§ Loss of cervical esophagus highly
suspicious of CSI
§ Flexion film shows anterolisthesis
C4 on C5 with upward and
forward movement of inferior
facet
§ 30% to 50% incidence delayed
instability
28
Source Undetermined

29. Hyperflexion Strain
MRI
§ Sagittal STIR image
§ Ruptured ALL
§ Ruptured PLL
§ Abnormal signal throughout
interspinous and
supraspinous ligaments
29
Source Undetermined

30. Bilateral Facet Dislocation
§ Dislocation of bilat. facet joints
§ All ligamentous structures
disrupted
§ Ant. Displacement => 50% A-P
diameter subjacent vertebral
body
§ Purely soft tissue injury w/ pre -
vertebral STS
§ Unstable
30
Source Undetermined

31. Bilateral Facet Dislocation (cont)
31
Source Undetermined

32. Bilateral Facet Dislocation
CT
32
Source Undetermined

33. Flexion Teardrop Fracture
Marked prevertebral STS
Retropulsion of fragments
into spinal canal
Anterior Cord Syndrome
Quadriplegia
loss pain, pinprick, temp
preserve post. column
(vib.,pressure, proprio)
33
Source Undetermined

34. Hyperflexion with rotation
Unilateral Facet Dislocation
34

35. Unilateral Facet Dislocation
§ Ant. Subluxation of vertebral
body <= 25% AP diameter
§ Ant. Dislocation of one articular
mass inferior facet
§ Rarely assoc. w/ neuro deficit
of nerve root distribution
§ Mechanically stable
35
Source Undetermined

36. Unilateral Facet Dislocation (cont)
§ Dislocated Articular mass stuck in subjacent intervertebral
Foramina (locked)
§ Obliques to confirm site of dislocation
36
Source Undetermined

37. Unilateral Facet Dislocation (cont)
§ A-P view – spinous process
at level of dislocation
displaced towards
side of dislocation
37
Source Undetermined

38. Vertical Compression
38

39. Jefferson Fracture of C1
§ At least one Fracture through the ant. & post. Arch
§ Lateral expulsion of the lateral masses of C1
§ TAL avulsion or rupture with increased AADI
§ Retropharyngeal swelling
39
Source Undetermined

40. Jefferson Fracture C2 (cont)
§ Lat. displacement of C1 articular masses on odontoid view
§ Coronal CT reformations – disruption of occiputal-C1
articulation, displacement C1 lat. mass
40
Source Undetermined

41. Jefferson Fracture (textbook)
Odontoid view and axial CT
41
Source Undetermined

42. Burst Fracture
Intrusion of NP into
vertebral body
Retropulsion fracture
fragments
Fracture on A-P view
42
Source Undetermined

43. Hyperextension
43

44. Hangman’s Fracture
Traumatic Spondylolisthesis
§ Bilateral Pars Interarticularis Fx
§ Type I – III
§ Ant. Displacement C2 vertebral
body
§ Disruption intervertebral disc
§ Dislocation C2-3 Facet Joints
§ Displaced & angulated posterior
arch
§ STS
§ Mechanically unstable
44
Source Undetermined

45. Hangman’s Fracture
45
Source Undetermined

46. Myelopathy and the
Cervicocranium
A-P diameter > at this level of the
C-spine
Auto decompression
46
Source Undetermined

47. Diverse Mechanisms
47

48. Odontoid Fracture
§ Hi (type II) Fracture
§ Soft Tissue Swelling
§ +/- Odontoid Displacement
§ Fracture at base of Odontoid
§ Most common type
§ Unstable, 26-36% nonunion
48
Source Undetermined

49. Odontoid Fracture
§ Low (Type III)
§ Disruption “ Ring of C2” on
CTLV
§ Fracture upper C2 vertebral
body
§ +/- prevertebral soft tissue
swelling
§ Unstable, better prognosis
than Type II
49
Source Undetermined

50. NEXUS
National Emergency X-
Radiography Utilization Study
50

51. Validity Of A Set Of Clinical Criteria To
Rule Out Injury To The Cervical Spine In
Patients With Blunt Trauma
§ Hoffman J., et al NEJM 2000;343:94-9
§ Prospective, Observational Multicenter Study
§ 34,069 patients w/ Blunt Trauma who underwent
C-spine imaging
§ Examined the performance of a set of 5 clinical
criteria to identify patients who have a low
probability of cervical spine injury
51

52. Patients considered Low Prob. Injury if :
Stable and met 5 Criteria
§ No Midline Cervical Tenderness
§ No Focal Neurological Deficit
§ Normal Alertness
§ No Intoxication
§ No Painful Distracting Injury
52

53. Performance of Clinical Criteria
§ 818 patients (2.4%) x-ray documented
injury : missed 8
§ 576 patients w/ clinically significant* injury :
missed 2
§ Sensitivity 99.0, NPV 99.8; Specificity 12.9
PPV 2.7
§ Rate of missed CSI : 1 in 4000 patients
§ * spinous, trans. process fx., wedge < 25%,
osteophyte fx., type I odontoid, end-plate fx.
53

54. Conclusions
§ Confirms validity of a decision instrument
based on 5 clinical criteria for identifying
blunt trauma patients who have extremely
low probability of having CSI.
§ Sensitivity ~ 100% for clinically significant
injury
§ Decrease in ordering of radiographs by
12.6%
54

55. Sons of Nexus
§ Reliability of Standard 3- view series
§ Value of F/E views in acute blunt trauma
§ Distribution and Patterns of CSI
55

56. Use of Plain Radiography to Screen for
Cervical Spine Injuries
§ Mower WR, et al. AnnEM. July 2001;38;1-7
§ 34,069 patients; 818 had total of 1,496 CSI (2.4%)
§ Plain radiographs ; 932 CSI in 498 patients (1.4%)
missed 564 CSI in 320 patients (.94%)
§ Majority missed CSI; x-rays interpreted as
abnormal but not dx or inadequate (.80%)
§ 23 patients (.07%) had 35 CSI (3 ? Unstable) not
visualized on adequate plain films
§ 2.81% of all injured patients, 4.13% of 557 w/
adequate 3-view
56

57. Use of Plain Radiography (cont.)
35 missed CSI
§ 3 ( 2 patients ) dx on MRI
§ 8 ( 6 patients ) dx on Flex/Ext
§ 29 ( 18 patients ) dx on CT
§ 1 detected on risk management review
§ Sensitivity adequate 3-view 89%, NPV 99%
§ Lamina & Post. arch most common site
§ C 6-7 (48%) most common level followed by
C 2 (20%)
57

58. Use of Plain Radiography (cont.)
Conclusions
§ Standard 3-view reliable screen in most
blunt trauma patients.
§ On rare occasions will fail to detect unstable
injuries. (.20% of injuries,.008% all patients)
§ Difficult to obtain adequate plain
radiographic imaging in a substantial #
patients. ( 30%)
58

59. Use of Flexion-Extension Radiographs of
the Cervical Spine in Blunt Trauma
§ Pollack CV Jr,et al. AnnEMJuly2001;38:8-11
§ 818 patients w/ CSI, F/E ordered in 86
§ 6 patients w/ CSI not seen on 3-view,none
clinically significant
§ 3 dislocations detected, all seen on 3-view
§ 15 of 16 subluxations detected, 4 missed on
3-view*
59

60. Use of Flex/Ext (cont.)
Conclusions
§ Largest prospective study; adds very little to
3-view supplemented when appropriate w/
CT, MRI.
§ MRI preferable evaluate Lig. Instability
§ CT better to evaluate for occult Fx.
60

61. Distribution and Patterns of Blunt
Traumatic Cervical Spine Injury
§ Goldberg W,et al. Ann EM July
2001;38;17-21
§ 34,069 patients, 818 (2.4%) radiographic
CSI
§ 1,195 Fractures & 231 Subluxations or
dislocations
61

62. Distributions and patterns (cont)
RESULTS
§ C2 most common site of fracture (23.9%)
§ C3 least likely to be injured
§ C5-6 & C6-7 most common level of
dislocation
§ 240 patients (29.3%) clinical insign. CSI
§ 32.3% patients > 50 years, had 45.3% of all
atlantoaxial injuries
62

63. Advanced Imaging
CT Scan
§ CT detects 97-100% of Fractures but
accuracy in detecting purely ligamentous
injury not documented
§ Limited in patients with severe degenerative
disc disease
§ Inability to detect axially oriented fractures,
lig.injury and facet subluxation largely
overcome on current scanners if thin cuts
and multiplanar reformations (MPR).
63

64. Advanced Imaging
MRI
§ MRI highly sensitive in detection of
ligamentous injury but my be too sensitive
§ Much less sensitive than CT in detection of
fractures to the posterior arch and injuries to
the crainiocervical junction.
§ In patients with neurologic deficits, MRI is
the study of choice to define cord injury or
impingement
64