1. C-Spine X-ray Interpretation
Karl Stobbe MD Beamsville, ON
Peter Hutten-Czapski MD New Liskeard, ON
Neil Leslie MD Revelstoke, BC
Trina Larsen Soles MD Golden, BC

2. C-spine x-ray interpretation
When to x-ray
Accuracy of x-ray
What’s normal
Cases

3. Abnormal x-rays are uncommon
4% of patients have c-spine fracture without neurological deficit
1% have spinal cord injury

4. How accurate are x-rays?
Mower et al Ann Emerg Med 2001
n=34,069
3 views missed 0.1% of fractures
Only missed 0.008% of unstable injuries
30% of missed injuries due to inadequate films

7. Patients excluded: Under 16 years old Unstable Acute paralysis
Known vertebral disease: RA, spinal stenosis, etc.
Injuries over 48 hrs old
Minor injuries

8. Pediatrics Epiphyses Fusion lines Pseudosubluxation Anterior wedging
Predental space widening
SCIWORA is more common
Make interpretation difficult
Canadian C-spine rules don’t apply

9. What views to order Routine trauma series:
Lat c-spine first – proceed if normal
A-P
Odontoid view
No data on obliques – but some docs like them!
Obliques can be helpful in seeing C7-T1
Flexion-extension views rarely or never show fracture when other views are normal
In 30% of trauma cases, flex-ext is inadequate for diagnosis
However, it is recommended ahead of MRI; can show ligamentous injury

11. What Is
Normal?

12. (4)
(3) A
(1)
(2) B
The cross table lateral is usually done first at 48” or 72”
Swimmers view done if C7-T1 junction not visualized with cassette next to raised arm
Interpretation Technique (Mneumonic: ABCDS)
Adequate film and Alignment
Bony landmarks
Cartilaginous space
Discs
Soft tissue spaces
Adequate film criteria
Visualize all seven vertebrae (including C7-T1)
Maneuvers to enhance view of lower C-Spine C7-T1
Pull down on arms during cross-table lateral
Swimmer's View
Cervical Spine CT
Alignment
Assessment criteria
Landmarks should line up with <3mm discrepancy
Landmarks
Anterior vertebrae
Posterior vertebrae
Facets
Spinous process (Spinolaminar line)
Middle of anterior spinous process lines up C1-C3
Normal variants: Pseudosubluxation of C2 and C3
Normal in children
Seen in 20% of children under age 8 years
Abnormal findings
Subluxation of >=3 mm is abnormal
Angulation >11 degrees is unstable
Trace unbroken outline of each vertebrae
Trace odontoid outline from C2 vertebrae
Predental space
Distance from dens to C1 body
Normal values
Adult: 3mm
Child: 5mm
Assess symmetry of disc spaces
Soft Tissue spaces
Soft Tissue stripe
Normal C2 stripe: 5 mm
Normal C5 stripe: 20 mm
Normal Fat tissue stripe <3 mm C T1

13. Atlantodens interval
Figure 5-1. A and B, Atlantodens interval (ADI). Normal ADI is less than 4 mm. An ADI above 7 mm suggests gross instability.

14. Cross-table lateral – Soft tissue thickness

15. A-P view
The AP is the next film to be done shooting at an angle 20 deg to cephaled

16. Unilateral facet dislocation
Figure 5-4. Unilateral facet dislocation. Lateral radiograph shows small, unreducible translation at level of injury and "bowtie" sign; facets below the injury are seen in an oblique view because of rotation. An anteroposterior radiograph would reveal a shift in the spinous processes at the level of injury.

17. Open-mouth Odontoid view
Open mouth view of Odontoid
Adequate film criteria
Entire odontoid and lateral borders of C1-C2 seen
Alignment
Lateral borders of c1 and c2 vertebrae should line up
Vertebral landmarks shifted in on one side
Should be shifted out on other side
Bony Margins
Odontoid should have uninterupted cortex to C2
Odontoid view C1 and C2 should line up

18. The standard C-spine trauma series

19. Obliques are done at 45 deg with the film flat on the table

20. Patient 1
45 year old woman in a motor vehicle accident. She lost control of her car, slid into a ditch and rolled. Was brought to the hospital by ambulance with full c-spine immobilization.
Vital signs stable, patient is alert but has no recall of the accident. She has facial lacerations, bruising on her shoulder and lower abdomen from the seat-belt, and abrasions on both her knees. She complains of neck pain. Chest exam shows good air entry bilaterally. Brief neurological exam is normal.

21. n
A-1-1

22. n
A1-2

23. n
A-1-3

24. n
A-1-4

25. After the x-ray
No abnormality noted by ER physician. Facial lacerations were sutured, she was monitored overnight. X-ray reported as normal the next day by the radiologist.
Patient sent home.

26. 17 year old male, injured when a hay baler fell on his neck
Patient 2a
17 year old male, injured when a hay baler fell on his neck

27. A-2a-1

28. A-2a-2 Flexion – Rotation UID (?VID) C6-C7. Fanning.
Narrow interspace C6-C7.
A-2a-2

29. A-P abnormal – double line as in rotatory facet dislocation
A-2a-3

30. C6 is subluxated anteriorly by 4mm with respect tp C7
C6 is subluxated anteriorly by 4mm with respect tp C7. One small bone fragment measureing 1.2cm in length and 2mm in width is noted at the posterior aspect of the neural canal adjacent to the spinous process of C6 – on the lateral view. This would suggest a fracture from a superior articular process of C7 but could also represent a fracture from an inferior articular facet of C6.
On Oblique vies there is asymmetry of the C6-7 intervertebral foramen on the right side and one small bone fragment is seen just above this which likely represents the previous described fragment.
No other abnormality.
A-2a-4

31. The radiologist’s report:
C6 is subluxated anteriorly by 4mm with respect to C7. One small bone fragment measuring 1.2cm in length and 2mm in width is noted at the posterior aspect of the neural canal adjacent to the spinous process of C6 on the lateral view. This would suggest a fracture from a superior articular process of C7 but could also represent a fracture from an inferior articular facet of C6.
On Oblique views there is asymmetry of the C6-7 intervertebral foramen on the right side and one small bone fragment is seen just above this which likely represents the previous described fragment.
No other abnormality.

32. Patient 3
24 year old female passenger on a motorcycle. Was wearing a helmet. Was thrown from the vehicle, landing on her head.

33. A-3-1 Flexion injury Teardrop # C5 and C6 Post. Extrusion C5 and C6
Fanning C5-C6
Vert # C5 and C6
A-3-1

34. A-3-2 Flexion injury Teardrop # C5 and C6 Post. Extrusion C5 and C6
Fanning C5-C6
Vert # C5 and C6
A-3-2

35. A-3-3 Flexion injury Teardrop # C5 and C6 Post. Extrusion C5 and C6
Fanning C5-C6
Vert # C5 and C6
A-3-3

36. After the x-ray:
Patient died in ER

37. Patient 4a
21 year old male, jumped from moving vehicle. Injured his head, briefly lost consciousness. Complaining of neck pain.

38. Flexion # C4
Post Extrusion
Ant Wedging
Narrow C3-C4 Interspace
A-4a

39. Radiologist’s report:
A complete study could not be done on this patient. Only A/P, odontoid view and a single crosstable projection showing the cervical spine to the level of C5 are available.
There is seen to be a compression fracture of the body C4. This has resulted in anterior wedging of the body with loss of approximately 50 percent of its vertical body height. There appears to be at least one fracture line visible in the coronal plane. Other fracture sites cannot be excluded. There is a posterior extrusion of a portion of the body by approximately 3mm. The C3-4 interspace shows marked narrowing. The appearance of this suggests a hyperflexion injury. There does not appear to be any significant prevertebral edema. The cervical spine below C5 cannot be assessed on these films.

40. Patient 5
17 year old male, was wrestling. Fell on the back of his head – hyperflexion. Slept 4 hours – woke with pain and stiffness in his neck.
Was brought to hospital by his family. Examination was negative.

41. A-5-1 C3-C4 Sublux Fanning Slight overriding facets
Slight widening IV joints
A-5-1

42. A-5-2 C3-C4 Sublux Fanning Slight overriding facets
Slight widening IV joints
A-5-2

43. n
A-5-3

44. Radiologist’s report:
There is a flexion deformity of the cervical spine with loss of alignment at the C3 C4 level. The angulation at this point measures 15 degrees.
This strongly suggests ligamentous injury, probably involving the posterior longitudinal ligament.

45. Patient 6 A 20 year-old female from a motorcycle accident.
Complaining of neck pain.

46. A-6-1 Hyper Flexion B.I.D. – C4-C5 Complete with interlocking facets
Marked prevertebral haematoma
?Jefferson - > 2mm bilat C2 Lat offset bilat.
A-6-1

47. ?Jefferson - >2mm bilat C2 Lat offset.

48. Transferred for surgery. Quadriplegic, but survived.
After the x-ray
Transferred for surgery. Quadriplegic, but survived.

49. Patient 8
22 year-old male
Hyperextension injury: stopped on highway, hit from behind by transport.
Car demolished.

50. A-8 Hyperextension. No pre-vert. edema.
Rupture Ant L. L. and Post L. L.
A-8

51. Radiologist’s report:
There is a fracture-dislocation at the C2, C3 level with approximately 2 mm anterior displacement of C2 on C3.

52. Patient 9
28 year old male complains of a sore neck the day after a fight in a bar.

53. Clay shovelers. Careful look for serious injury – neg.

54. Clay shovelers. Careful look for serious injury – neg.

55. Clay shovelers. Careful look for serious injury – neg.

56. Radiologist’s report:
There is a fracture through the spinous process of C7 with approximately 5mm posterior and caudad displacement of the fragment. Some mild degenerative arthritic changes can be seen at the intervertebral joints at C7-T1. The cervical spine appears otherwise unremarkable.
Comment: Clay shovelers fracture spinous process C7.

57. C1-C2 anatomy
Figure 5-1. A and B, Atlantodens interval (ADI). Normal ADI is less than 4 mm. An ADI above 7 mm suggests gross instability.

58. Patient 10
87 year old male. MVA – hit another vehicle pulling onto the road. Multiple injuries. Required IV fluids, intubation. C-spine lateral was ordered along with chest and pelvic x-rays prior to detailed examination.

59. # Odontoid – Type II with Post displacement.
B-11

60. After the x-ray
Odontoid fracture– Type II with posterior displacement. Transferred for surgery which was successful.
Long and stormy post-op course, eventual death from sepsis.

61. Odontoid fracture, type II
Figure 1-2. Lateral radiograph shows a Type II odontoid fracture (arrow).

62. Odontoid fracture, type II
Figure 1-3. Trispiral tomograms in anteroposterior (A) and lateral (B) projections show a Type II odontoid fracture.

63. Patient 11
52 year old male; fall from a height. Bystanders thought his head bent forward. Patient has no recall of the fall. Complains of headache and neck pain. No neurological findings. Pain with neck movement.

64. # odontoid
# sp proc C5
* post Lam. Line
B-12-1

65. # odontoid
# sp proc C5
* post Lam. Line
B-12-2

66. # odontoid
# sp proc C5
* post Lam. Line
B-12-3

67. After the x-ray
Patient complained of pain and tingling in his hands when flexion x-rays were done.
Immobilized and transferred to referral centre. Surgical stabilization with good outcome.
Rural MD was criticized for ordering too many x-rays when the abnormality was visible on the first 2 films.

68. Patient 12
84 year old woman injured in MVA at 50 kph. She was the front seat passenger, wearing seat belt.
She has no recall of the accident, appears slightly confused but in no distress, though complains of neck pain.

69. X-ray tech: “very difficult patient to do. Did my best.”

70. No interpretation possible

71. Fracture line visible base of odontoid with sl gap posteriorly.

72. No interpretation possible

73. No interpretation possible

74. No interpretation possible

75. Looks normal but lousy film.

76. Partial visualization of foramina – look fine.
B-13-7

77. After the x-rays
Frustrated with the poor quality films, the rural ER doc has a last look. On one lateral film, he wonders about the odontoid. Decides to immobilize the patient’s c-spine and talk to the nearest surgical centre. With much reluctance the patient is accepted in transfer.

78. Radiologist’s report:
The cervical spine is very difficult to image in this patient due to her inability to co-operate and fairly marked cervical kyphosis. There is seen to be a moderately severe degree of osteoporosis throughout the cervical spine. Moderately advanced degenerative arthritic change is present with interspaces at C5-6 and C6-7 slightly narrowed suggesting degenerative disc disease.
On one lateral projection there is seen to be a deformity of the odontoid process of C2. This appears to be angulated ventrally by approximately 15 degrees and a step deformity can be seen in both its anterior and posterior margins measuring approximately 3mm. The overall appearance is strongly suggestive of a fracture of the odontoid process (type III).

79. Patient 13
A young man was involved in a MVA. He arrives by ambulance in full spinal immobilization to Revelstoke hospital. He has neck pain spasm and tenderness. Neurological examination is normal. A cross table Xray was taken at 62” 80KV and 3 msec

80. IX-1 Fracture Odontoid with posterior displacement.
Also note incidental fracture C7-T1. Clayshoveler’s Fracture.
IX-1

81. Radiology Report Fracture Odontoid with posterior displacement.
Also note incidental fracture C7-T1. Clayshoveler’s Fracture.

82. Atlantodens interval
Figure 5-1. A and B, Atlantodens interval (ADI). Normal ADI is less than 4 mm. An ADI above 7 mm suggests gross instability.

83. Atlantodens interval
Figure 5-1. A and B, Atlantodens interval (ADI). Normal ADI is less than 4 mm. An ADI above 7 mm suggests gross instability.

84. Patient 14
A 7-year-old male was diving off a ledge when he landed head first in shallow water. He was pulled semiconscious from the water by lifeguards. While maintaining his airway, the lifeguards placed the patient in full C-spine immobilization. When the patient became more alert, he complained of pain to his upper neck region. Paramedics transported the patient to the ED.
Upon arrival, the patient is awake, alert, cooperative, and in C-spine immobilization. His vital signs are normal, and the neurologic exam is nonfocal. He continues to complain of upper neck pain. A cross table lateral neck radiograph is obtained.

85. The lateral neck radiograph is suggestive of mild prevertebral soft tissue widening.
II-1

86. Not so unusual Quality II-2
The ideal open mouth odontoid view should have the odontoid centered in the mouth with the lateral masses of C1 clearly visible. However, even in large cities physicians are commonly presented with such poorly positioned radiographs because it is often very difficult to properly position a patient, with neck pain. It is often impossible to obtain a satisfactory open mouth view in very young children who are not cooperative. In such patients, a CT scan may be necessary. Avoid the pitfall of misinterpreting a poorly positioned odontoid view. In this radiograph, only the lower lateral corners of the lateral masses of C1 are visible. However, this should be sufficient to make the diagnosis of a Jefferson fracture.
II-2

87. But it is enough
The lateral margins of the lateral masses (inferior articular facets of C1) should align with the lateral margins of the structures below it (superior articular facets of C2). The space between these two facets is the atlanto-axial joint. In this radiograph, the lateral masses of C1 are displaced outward, indicating a "bursting" of the ring of C1 (the Jefferson Fracture).
II-3

88. Repeat View
A Jefferson fracture is a compression and/or bursting fracture of C1. This unstable fracture is the result of a direct blow to the vertex of the head (axial compression load), either from a fall or from an object striking the vertex of the head. Neurologic injury is rare but can occur if there is involvement of C2. The axial load to the head (skull and occipital condyles) focuses the stress on the C1 lateral masses, causing them to be compressed against the superior articular facets of C2. In the most classic cases, the damage to C1 usually occurs in four places, with fractures in two sites anteriorly and two sites posteriorly. The transverse diameter of the spinal canal is increased as a result of the displacement of the lateral masses. When C1 is fractured in less than four places, transverse ligament tears are common and can lead to more instability. If the transverse ligament remains intact, there will be no neurologic deficits, and the lateral cervical spine X-ray may appear normal. If the transverse ligament is ruptured, C1 will move forward on C2, and the spinal cord will be compressed. Radiographic findings can show bilateral displacement of the C1 lateral masses when compared to the C2 articular pillars. There can be unilateral lateral displacement of the C1 lateral mass if there is no movement of the opposite lateral mass. Routine radiographs sometimes may not show evidence of a fracture. The open mouth odontoid view will best show the lateral displacement of the C1 lateral masses. Neck rotation can cause false positive radiographs.
II-4

89. CT of our patient
This CT image of our patient shows the unilateral fracture of the "ring" of C1. The odontoid process is visible. The spinal cord is faintly visible posterior to the odointoid within the neural arch.
II-5

90. X-ray Report
The lateral neck radiograph is suggestive of mild prevertebral soft tissue widening.
Jefferson fracture (C1 ring) is demonstrated

91. Jefferson fracture
Figure 2-5. A Jefferson fracture is identified on this open-mouth anteroposterior radiograph by lateral displacement of lateral masses of C1 vertebra.

92. Jefferson fracture
Figure 1-1. A, Open-mouth anteroposterior radiograph of the cervical spine shows malalignment of the lateral masses of the atlas (arrows). B, Lateral radiograph demonstrates fracture lines of the posterior arch of C1 (arrowheads). These findings are diagnostic of Jefferson fracture.

93. Jefferson fracture
C-17

94. Atlantoaxial spondylolisthesis, type I
Figure A-C, Atlantoaxial spondylolisthesis. Type I injuries are minimally displaced and well treated in a brace or halo. Type II injuries require traction to restore alignment, but heal well in a halo once alignment is regained. Type III injuries cannot often be reduced closed. Open reduction of the dislocated facet is required, followed by wire fixation of the facets.

95. Atlantoaxial spondylolisthesis, type II
Figure A-C, Atlantoaxial spondylolisthesis. Type I injuries are minimally displaced and well treated in a brace or halo. Type II injuries require traction to restore alignment, but heal well in a halo once alignment is regained. Type III injuries cannot often be reduced closed. Open reduction of the dislocated facet is required, followed by wire fixation of the facets.

96. Patient 15
A young male was involved in a MVA. He was dragged semi conscious up an embankment by his friend. A cross table Xray was done on arrival at the Revelstoke hospital. He has a lot of neck pain spasm and tenderness. Neurological examination is normal.

97. Radiologist’s first comment is “Why are you taking post mortem Films”?
C2 Fracture/dislocation. Hangman type
Neurosurgeon unable to reduce the dislocation so fused as is.
VII-1

98. After the X-ray
Radiologist’s first comment is “Why are you taking post mortem Films”?
C2 Fracture/dislocation. Hangman type
Neurosurgeon unable to reduce the dislocation so fused as is.

99. Hangman's fracture
A, Anteroposterior radiograph of a "hangman's" fracture. The fracture of the bilateral pars can be best visualized on the CT scans. B, CT scans of the normal relationship between C1 and C2. C, CT scans of the body of C2 and the fracture lines through the pars. D, CT scans of sagittal reconstruction show the anterior subluxation of C2 on C3.

100. Atlantoaxial spondylolisthesis, type II
Figure A-C, Atlantoaxial spondylolisthesis. Type I injuries are minimally displaced and well treated in a brace or halo. Type II injuries require traction to restore alignment, but heal well in a halo once alignment is regained. Type III injuries cannot often be reduced closed. Open reduction of the dislocated facet is required, followed by wire fixation of the facets.

101. Patient 16
62 year old male.

102. C-18-1

103. C-18-2

104. Radiologist’s comments
Hyper Extension injury
Hangman’s fracture
Seen best with slight flexion
Posterior laminar line
C2-C3 Step deformity

105. Patient 17
Elderly female brought to ER from MVA. Found at the scene. Car badly damaged. She was the driver. Car flipped. Was wearing seat belt.

106. C-19 Hangman’s # C2 1. Prevert. soft tissue swelling
2, Disruption Laminar Line
3. Displ. C2-C3
4. Disc C2/C3 – Post>Ant
C-19

107. Radiologist’s report:
There is a slight step deformity with approximately 3mm anterior displacement of the body of C2 on C3. Films are not of good quality, however, there appears to be a defect through the pedicles of C2 with slight displacement of the anterior and posterior fragments.
There is a marked degree of swelling of the prevertebral soft tissues at this level.
Comment: These findings are suggestive of hyperextension or “Hangman’s” fracture.
Crosstable lateral view only is available which demonstrates the cervical spine only to be to the level of C4. The cervical spine appears, otherwise, unremarkable.

108. Patient 18
A 7-year-old female is brought in by paramedics in full C-spine immobilization after being involved in a motor vehicle accident. According to her parents, the unrestrained child was sitting in her restrained mother's lap on the passenger side when the passenger side of the car was broadsided by another vehicle. The child's head was thrown into the dashboard, and she sustained severe injuries to the face and scalp.
Upon arrival at the hospital, the patient is crying and responsive to all stimuli. There are multiple facial lacerations, a large scalp laceration, and facial edema/ecchymosis.

109. V-1

110. The hangman's fracture is an unstable fracture of the C2 pedicles, with forward displacement of C1 and the body of C2 on C3.
V-2

111. Hangman's fracture
A, Anteroposterior radiograph of a "hangman's" fracture. The fracture of the bilateral pars can be best visualized on the CT scans. B, CT scans of the normal relationship between C1 and C2. C, CT scans of the body of C2 and the fracture lines through the pars. D, CT scans of sagittal reconstruction show the anterior subluxation of C2 on C3.

112. Patient 19
29 year old male, front-seat passenger. High-speed collision with parked vehicle in a residential neighbourhood. Driver has been airlifted to trauma centre.
Patient is a “happy drunk”. Smiling, wandering around ER, uncooperative. Extremity bruises are his only obvious injuries. He has no complaints.
Exam: midline tenderness over c-spine.

113. C-21-1

114. C-21-2

115. C-21-3

116. Patient 19
When told he has an unstable c-spine injury, the patient goes out for a smoke, refuses to believe diagnosis.
Eventually he agrees to be immobilized and transferred.

117. Radiologist’s comments:
Unilateral Facet Dislocation C4-C5
Flexion – rotation injury

118. Patient 20
31 year old tourist from Calgary on snow machine tour. Hits a bump, thrown off snow machine into the air and hits a tree about 15 feet off the ground. Slides down, c/o neck pain. Brought to ER on spine board with full spinal precautions. Some tingling in R hand.

123. Patient 21
79 year old woman. Known history of osteoporosis. Fell in the bathroom and hit face on the sink. C/O neck pain. Drove self to hospital. Arrived in ER with a towel wrapped around her neck

129. A final word of caution “SCIWORA”
Spinal Cord Injury WithOut Radiographic Abnormality
(Treat the patient not the x-ray)