A slide presentation on the radiographic examination of the Cervical and ThoracoLumbar spine

1. X ray spine

2. SPINE TRAUMA
CERVICAL SPINE
INJURY
THORACO-LUMBAR
SPINE INJURY

3. CERVICAL SPINE INJURY

4. COMMON MECHANISMS OF INJURY
HYPERFLEXION- MVA, CAR COMES TO SUDDEN STOP
HYPEREXTENSION- MVA, CAR STRUCK FROM BEHIND
COMPRESSION- HEAD FIRST DIVE IN SHALLOW WATER

5. HIGH RISK FACTORS FOR SPINE INJURY
HIGH-VELOCITY BLUNT TRAUMA
MULTIPLE, SEVERE LONG BONE FRACTURES
DIRECT CERVICAL REGION INJURY
ALTERED MENTAL STATUS
FALL FROM GREATER THAN 10 FEET
DROWNING / HEAD FIRST DIVING ACCIDENT
SIGNIFICANT HEAD OR FACIAL INJURY
NECK PAIN, TENDERNESS, OR DEFORMITY
ABNORMAL NEUROLOGICAL EXAMINATION
THORACIC OR LUMBAR VERTEBRAL FRACTURE
HXISTORY OF PRE-EXISTING VERTEBRAL DISEASE

6. CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY
PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD
“ABCDEF” ER PROTOCOL FOLLOWED (AIRWAY, BREATHING, CIRCULATION, DISABILITY/DRUGS,
EXPOSURE, FOLEY CATHETER)
HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)
DECIDE IF IMAGING IS NECESSARY

7. CERVICAL VERTEBRAL ANATOMY:

8. ANT LONGITUDINAL LIG
POST LONGITUDINAL LIG
LIGAMENTA FLAVA
SUPRASPINOUS LIG

9. MENU OF IMAGING OPTIONS
CERVICAL SPINE PLAIN FILMS
ANTERO- POSTERIOR
AND
LATERAL VIEW
STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL
INJURY
SWIMMER’S VIEW

10. Anteroposterior (A-P) View
• Spinous process
deviation
• Lateral Translation
• Coronal deformity

11. Open Mouth View
• Mostly C1-C2 lateral mass
• Occipital Condyles/CO-C1
• Odontoid Process

12. Swimmer’s View
• Cervico-thoracic junction
– obliques sometimes helpful
CASETTE
X-ray BEAM

13. NORMAL C-SPINE VIEWS
LATERAL
AP
ODONTOID

14. C-SPINE FILM INTERPRETATION 7 STEP PROCESS
1. COUNT VERTEBRAE
-C1 THROUGH C7
-IF T1 NOT SEEN 􀃆SWIMMER’S VIEW
2. ASSESS CURVATURE
3. ASSESS VERTEBRAL ALIGNMENT (4 LINES)
-ANT VERTEBRAL LINE
-POST VERTEBRAL LINE
-SPINOLAMINAL LINE
-POST SPINAL LINE
4. ASSESS BONY INTEGRITY
5. ASSESS INTERVERTEBRAL DISK SPACES
6. ASSESS OAA JOINT
7. SOFT TISSUES

15. THE 4 CONTOUR LINES
1-ANT VERTEBRAL LINE
2-POST VERTEBRAL LINE
3-SPINOLAMINAL LINE
4-POST SPINAL LINE

16. Lower Cervical Detection
• Spinous process
gapping
• Facet joint
Apposition
• Inter-vertebral
Gapping
• Angulation
• Translation

17. Lower Cervical Detection
• Spinous process
gapping
• Facet joint
Apposition
• Inter-vertebral
Gapping
• Angulation
• Translation

18. Lower Cervical Detection
• Spinous process
gapping
• Facet joint
Apposition
• Inter-vertebral
Gapping
• Angulation
• Translation

19. Lower Cervical Detection
• Spinous process
gapping
• Facet joint
Apposition
• Inter-vertebral
Gapping
• Angulation
• Translation

20. Lower Cervical Detection
• Spinous process
gapping
• Facet joint
Apposition
• Inter-vertebral
Gapping
• Angulation
• Translation

21. Lower Cervical Detection
• Spinous process
gapping
• Facet joint
Apposition
• Inter-vertebral
Gapping
• Angulation
• Translation

22. JEFFERSON FRACTURE

23. HANGMAN’S FRACTURE

24. DENS FRACTURE
FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2
ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENS
CAN OCCUR AT VARIOUS LEVELS ON THE DENS
VIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECK
UNSTABLE IF DISPLACEMENT OCCURS

25. COMPRESSION FRACTURE
VARIABLE SEVERITY, FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF
VERTEBRAL BODY (BURST)
LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODY
DUE TO LONG AXIS COMPRESSION OR HYPERFLEXION
DIVING INTO SHALLOW POOL
STABLE 􀃆UNSTABLE

26. TEARDROP FRACTURE
AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODY
ANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE, AVULSION)
HYPEREXTENSION INJURY
UNSTABLE INJURY
LAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND
COMPRESS/CONTUSE THE SPINAL CORD

27. CLAY SHOVELER’S FRACTURE
AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENT
USUALLY OCCURRING FROM C6-T2
HYPERFLEXION; DIRECT TRAUMA; DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN
SHOVELING MOTION)
STABLE

28. THORACO-LUMBAR
SPINE INJURY

29. Anatomy

30. MENU OF IMAGING OPTIONS
DORSAL SPINE PLAIN FILMS
ANTERO- POSTERIOR
AND
LATERAL VIEW
LUMBO SACCRAL SPINE
ANTERO- POSTERIOR
AND
LATERAL VIEW

31. Thoracic Spine

32. Lumbar Spine

33. Determinants of Stability
• T & L spines are more stable than C-spine
– Strong ligaments
– Stabilization by ribs
– Bigger intervertebral discs
– Larger facet joints
– Less mobility
• Fractures & dislocations tend to occur where
curvature changes
– T11-12 (thoracolumbar junction)
– L5-S1 (lumbosacral junction)

34. Mechanisms of Injury
• Hyperflexion +/- rotation
– Commonest
– Usually see anterior wedge #’s or Chance #
• Shearing
– Ant or post translation
• Hyperextension
• Axial loading
– Compression or burst #’s

35. 3 Column Model
• Anterior column
– Ant longitudinal lig
– Ant annulus fibrosis
– Ant vertebral body
• Middle column
– Post longitudinal lig
– Post annulus fibrosis
– Post vertebral body
• Posterior column
– Spinous processes
– Transverse processes
– Lamina
– Facet joints
– Pedicles
– Post ligamentous complex
• 2 or more columns disrupted = unstable
• Most disruption of middle columns are
unstable

36. Stable or Unstable?
• Radiographic findings suggestive of instability
– Vertebral body collapse w/ widening of pedicles
– > 33% canal compromise on CT
– > 2.5 mm translation b/w vertebral bodies in any plane
– Bilateral facet dislocation
– Abnormal widening b/w spinous processes or lamina and >
50% anterior collapse of vertebral body

37. Stable or Unstable?
• Checklist for Instability
– Anterior elements disrupted 2 pts
– Posterior elements disrupted 2 pts
– Saggital plane translation > 2.5 mm 2 pts
– Saggital plane rotation > 5o 2 pts
– Spinal cord or cauda equina damage 2 pts
– Disruption of costovertebral articulations 1 pt
– Dangerous loading anticipated 2 pts
– 5 or more pts unstable until healed or surgically stabilized

38. Stable or Unstable?
• Risk of neurologic injury
increases with
– > 35% canal narrowing at
T11-12
– > 45% canal narrowing at
L1
– > 55% canal narrowing at
L2 & below

39. Approach to T & L Spines
• A – adequacy & alignment
– All vertebrae need to be visible
– Ant & post longitudinal lines
– Facet joints should lie on smooth curve
– Normal kyphosis & lordosis
– All spinous processes should lie in straight line
• B – bones
– Trace cortical margins of each vertebrae
– Difference b/w ant & post body ht < 2 mm
– Progressive increase in vertebral body ht moving down
spine
– Wink sign & interpedicular distance
– Don’t forget to look at transverse processes

40. Approach to T & L Spines
• C – cartilage
– Progressive increase in disc space moving down
spine (except L5-S1)
– Facet joint alignment
• S –soft tissue
– Look at paraspinal stripe and prevertebral space

41. Injury Detection
Thoracic and Lumbar Spines
• Same principles
• Landmarks and Lines:
Lateral View
– Posterior VB line
– Anterior VB line
– Inter-spinous Distance
– Translation

42. Injury Detection
Thoracic and Lumbar Spines
• Same principles
• Landmarks and Lines: A-P
View
– Spinous process to Pedicles
– Inter-pedicular Distance
– Translation

43. Thoracic and Lumbar Injuries

44. Height Loss
Adjacent fracture

45. Transverse process fractures
of L2-4
Significance of transverse process
fractures is not the fractures in and
of themselves but rather the high
incidence of associated serious
intraabdominal injury (~20%)

46. Anterolisthesis
Of L4 on L5