CERVICAL SPINE RTEC 124 WEEK 6 Rev 2010

Review the anatomy

Direction of cervical zygapophyseal joints seen in OBLIQUE seen in LATERAL position

INTERVERTEBRAL FOREAMEN AP = SIDE UP PA = SIDE DOWN

POSITIONING FOR CERVICAL SPINE ROUTINE “5 views” (arthritis, etc) AP “ODONTOID” AP (axial) BOTH OBLIQUES, LATERAL (UPRIGHT) SWIMMERS – LATERAL (if needed) ROUTINE “2view” AP (axial) , AP “ODONTOID”, TRAUMA CROSS TABLE LATERAL (minimum) “ CLINICAL “ ROUTINE “LATERAL (UPRIGHT) pt is ↑ ┴ C/R PT is ↑ or ↓ AP “ODONTOID” ┴ < C/R (15 – 20 º) ↑ (AP ) AP (axial) BOTH OBLIQUES, SWIMMERS – LATERAL (if needed) pt is ↑ or ↓

Done supine or upright

May be more difficult to do upright - use a sponge on back of head to relax neck muscles May need to use a ┴ or C/R < 5º ↑ To move incisors off dens

Done supine or upright

LATERAL C.SP

Some rotation ((zygo & pillars not s/i) & TILT

C.SP OBLIQUES

With head in true lateral – Look at the mandible position

With head in oblique – Look at the mandible position

“SWIMMERS FOR C.SP TWINNING & PAWLOW METHODS

Name of the position ?

C/R @ C7- T1 PERP OR ANGLED 5 CAUD

Alternate Positioning FLEXION & EXTENSION Purpose? Flexion and extension views should be obtained in awake and cooperative patients to further evaluate for injury. Flexion views will exaggerate the radiographic abnormalities and extension views will reduce them. Anterior subluxation & check for ROM

MML ┴ to IR MML // with CR Alternate Positioning Fuchs vs Judd Demonstrates? MML ┴ to IR MML // with CR

AP oblique atlanto-occipital joint.

BEST SEEN

SPINAL INJURY PT an overview : this will be covered in more detail in the TRAUMA lecture

“TRAUMA SERIES” SHOULD CONSIST OF 2 “views” /projections 90º TO EACH OTHER MOVE C/R AND CASSETTE – NOT THE PATIENT !!! “TAKE IT AS IT LIES” “DO NOT HARM”

                                                                                                                                            When the patient is a true “trauma” care must be taken not to move the patient At a minimum the AP’s & laterals are done with the C.COLLAR in place Then after CLEARED by the MD – you may proceed (?w/o? collar????? ) May be required to repeat AP & Lat again without collar artifact

X-TABLE LATERALS AKA ‘DORSAL DECUBITUS” CERVICAL SPINE Can be done with or without a grid With Comp Rad probably need a grid

X-table Lateral C. SP

Peds pt with comp Dis loc C-2 C-3 Pt died on table

For Odontoid in C collar

X-table lat –”Swimmers” Note: Mrs X-table lat –”Swimmers” Note: Mrs. Charman’s tip : Place forearm on forehead to prevent superimposition of humerus + c.sp

Alternate “Trauma Views” OBLIQUE – TRAUMA C.SP

Pathology Terms Neck pain HANGMANS FX Many causes including Trauma MVA, sports, falls degenerative disease Infections Neoplasms congenital variations, inflammatory arthritis psychic tension Etc……… HANGMANS FX JEFFERSON FX CLAY SHOVELER’S FX SUBLUXATION COMPRESSION FX REVIEW PG # 388 Merrills

more pathology C. SP Whiplash Injuries” Passengers forewarned of an impending rear collision can potentially protect themselves by flexing the neck and tucking the chin against the chest. An extended head potentiates the risk of ligamentous rupture and articular dislocation. Areas of preexisting degenerative disease are most susceptible to injury. radiculopathy- segmental motor or sensory signs associated with a root disorder. (numbness in hands/arms) Tear drop fx from Extreme flexion

Spinal Cord C-1 ring fx

.AVULSION FX c-1 A fracture involving the entire anterior arch is unstable  

A wedge fracture of a vertebra is caused by compression between two other vertebrae Surgical repair After subluxation or Wedge fx

HANGMAN’S FX C.SP The hangman´s fracture is located in the pedicles of C2, with C2 displacing anteriorly on C3

Jefferson’s fx a burst fx of C-1 –atlas = results from compression of the C.SP – may also be associated with fx of C-2 (axis) May or may not involve the transverse ligament

Jefferson fracture lateral displacement of lateral masses of C1 bilaterally (white lines).

Image Critique (Elsevier)

Image Critique (Elsevier) Shoulders are not rotated away from the cervicothoracic region, preventing clear image of the spine. There are two possible reasons: excessive rotation of the upper torso beyond a 45° oblique position or incorrect or inadequate CR angle angle

Excessive flexion excessive extension of neck

excessive flexion of neck excessive extension of neck

Some rotation & Tilt

C 7 not seen Use weights (5-10) lbs if possible Expose on expiration

Not enough rotation to 45º Position? TOO much rotation (look at spinous Process) Looks like “AP”

Upper OK – lower - too much rotation of body (Done PA ) CR < wrong way

LAO Head is lateral Atlas & post arch obscured Cortex of skull on s/I Mandibles not s/I 1st Tsp not shown (head tiled away from IR too much) CR/IR too superior Keep IP line ┴ to IR & move CR ↓

Some studies of spinal trauma have recorded a missed injury rate as high as 33%.

C1 c2 sublux c4 wedge fx

Fracture of the pedicles with dislocation of C5 and C6 Fracture of the pedicles with dislocation of C5 and C6. Note superior portion of C7 shown on this image.

Dislocation of the C3 and C4 articular processes Note that C7 is not well demonstrated