This document provides guidance on radiographic evaluation of the spine. It discusses cervical, thoracic, and lumbar spine radiography, including standard views, systematic evaluation approaches, and normal anatomy. Key points include the importance of clinical assessment in interpreting cervical spine films, and the "three column model" for assessing thoracolumbar spine stability based on which vertebral columns are injured. Detailed systematic approaches are presented to thoroughly evaluate spine radiographs for coverage, alignment, bone integrity, disc spacing, soft tissues and image edges.

1. Spine Radiography
DR MUHAMMAD BIN ZULFIQAR
PGR III FCPS SHL

2. Spine Radiography
• Cervical Spine
• Thoracolumber Spine

3. Cervical Spine Radiography
• Clinical considerations are particularly important
because
– normal C-spine X-rays cannot exclude significant injury
– a missed C-spine fracture can lead to death
– life long neurological deficit.
• Clinico-radiological assessment of spinal injuries
should be managed by experienced clinicians .
• Imaging should not delay resuscitation.

4. Cervical Spine Radiography
• CT or MRI is often appropriate in the context
of a
– high risk injury,
– neurological deficit,
– limited clinical examination, or
– where there are unclear X-ray findings.

5. 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

6. 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

7. • 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

8. Cervical Spine Systemic Approach

9. 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 haematoma
• - Normal prevertebral 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 prevertebral
hematoma - lack of prevertebral soft tissue thickening should NOT be
taken as reassuring
• Edge of image - Check other visible structures

10. Cervical Spine Systemic Approach

11. Cervical Spine Systemic Approach
• 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

12. Cervical Spine Systemic Approach

13. 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

14. C-spine systematic approach - Normal AP

15. 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
• 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

17. • 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

18. 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.

19. Swimmers View

20. Thoracolumber spine
• In the context of trauma similar principles
apply to imaging both the Thoracic spine (T-
spine) and the Lumbar spine (L-spine).

21. Thoracolumber spine
• Use a systematic approach
• Correlate radiological findings with the clinical features
• If 'instability' is suspected then further imaging with CT should
be considered
• If you see one fracture - check for another

22. Thoracic spine - Standard views
• AP and Lateral - Assess both views
systematically .
• Images of the thoracic and lumbar spine are
often large and the bones should be
scrutinized in detail
• 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

23. 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

24. Thoracolumbar spine - Systematic approach
• Lateral and AP
• 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

25. 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

27. Thoracic spine - Systematic approach
• Alignment - Vertebral body alignment is
assessed by carefully matching the anterior
and posterior corners of the vertebral bodies
with the adjacent vertebra
• Bones - Gradual increase in vertebral body
height from superior to inferior
• Spacing - Disc spaces gradually increase in
height from superior to inferior

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

30. 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

31. 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

33. 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

34. Lumber Spine –Systemic Approach

35. 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

36. Lumber Spine –Systemic Approach

37. • Check carefully for pedicle integrity and
transverse process fractures

38. 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.

40. 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

41. • 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

42. THANX