C-Spine X-Ray

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  • Make sure that the C7-T1 junction is adequately visualized
    • Obtain swimmer's view or oblique view if inadequate
  • Peds
    • Most pediatric fractures occur higher than C3
    • Pseudosubluxation of C2-C3 is common in children <8yr
      • To distinguish from true dislocation or fracture:
        • Draw line from cortex of post arch of C1 to cortex of posterior arch of C3
        • This line should pass through or be <1mm ant to posterior arch of C2
  • Most common approach is to evaluate three parallel vertical columns
    • Anterior column: alternating vertebral bodies and intervertebral disks surrouded by anulus fibrosus and anterior longitudinal ligament
    • Middle column: posterior parts of annulus fibrosis and posterior vertebral wall, posterior lognitudinal ligament, spinal cord, paired laminae and pedicles, articulating facets, transverse processes, nerve roots and vertebral arteries/veins
    • Posterior column: spinous process, nuchal ligament, interpsinous and supraspinous ligaments, and ligamentum flavum.
    • Disruption of one column is generally stable. Disruption of two or more is unstable.
Lateral film

Measurements (Normal)

  • Predental space (anterior aspect of odontoid to post aspect of ant ring of C1)
    • Adult <3mm
    • Peds <5mm
    • Widening of space suggests Jefferson burst fracture of C1
  • Anterior soft tissue
    • Distance between ant border of C2 and post pharynx should be <6mm in adults and peds
    • Distance between ant border of C6 and post trachea should be <22 mm in adults
      • Should be <14mm in children <15yr or less than width of vertebral body at each level
  • Bones
    • Vertebral body: Anterior height should be no more than 3mm shorter than posterior height

Lateral View

  • Alignment
    • Disruption in the anterior, posterior, or spinolaminal lines
  • Bones
    • Obvious fracture
    • Disruption of ring of C1
    • Double facet sign indicates fractured articular facet
    • Loss of vertebral height
  • Cartilage
    • Intervertebral disc space height and length should be uniform
      • Narrowing: disc herniation or adjacent vertebral fracture
      • Widening: posterior ligamentous injury
  • Soft tissue
    • Widening of the prevertebral soft tissue suggests fracture

AP View

  • Alignment of spinous processes
  • Distance between spinous processes
  • Uniformity and height of vertebrae

Odontoid View

  • Spacing of dens and lateral masses
  • Lateral alignment of C1 and C2
  • Uniformity of bones

X-ray vs CT

  • Plain radiographs may be appropriate in low-risk patients
  • High risk patients requiring CT:
    • Closed head injury
    • Neurologic deficits
    • High energy trauma
    • Unreliable examination
    • Pain out of proportion to exam
    • Inadequate plain films

See Also