1. Imaging in spinal trauma
Tips and special features
Presenter‘s name Arial 24 pt
Meeting Arial 24 pt
Presenter‘s title Arial 20 pt
City, Month, Year Arial 20 pt

2. Learning outcomes
Describe the imaging modalities that are indicated for the assessment of spinal trauma
Interpret abnormalities evident on x-rays, dynamic films, CT, MRI, etc used to assess spinal trauma
Identify radiographic features of instability and spinal cord injury

3. Plain x-rays “AABCS”: Adequacy of image
Alignment of anterior and posterior elements
Bones—presence of fracture/compression
Cartilage—joint space
Soft tissue—anterior to vertebra and interspinous space
Don’t underestimate the value of a plain x-ray in the assessment of spinal trauma.

4. Ensure visualization of occiput to C7–T1
If not, further imaging is needed
Swimmer’s view or CT to clear the cervical spine

5. Swimmer’s view
Where the C7-T1 disk is not evident on a plain lateral x-ray, a swimmer’s view will usually identify the anterior vertebral alignment and enable assessment of an injury at the cervicothoracic junction.
If not adequately visualized, you will need a CT or MRI to assess this region.

6. Alignment
Four longitudinal lines should be considered in assessing spinal alignment at all levels of the spine.
Disruption or angulation of these lines indicate the presence of disruption of normal spinal alignment.

7. Thoracic and lumbar spine
In the thoracic region the ribs and rib heads may obscure parts of these lines but it should still be possible to assess overall alignment of this region of the spine.
These images indicate normal anatomical components of the lumbar spine.

8. Bones
Pedicle fracture
(Hangman’s)
Facet fracture
Body fracture

9. Bones
Burst fracture
Chance fracture
Fracture/dislocation

10. Bones Cervical prevertebral soft tissue shadow
Nasopharyngeal space (C1) < 10 mm (adult)
Retropharyngeal space (C2–4) < 6 mm
Retrotracheal space (C5–7)
14 mm (children)
22 mm (adults)
No more than width of body

11. CT scans Good bony detail Assessment: Alignment
Fracture extent and location
Canal compromise
Placement of instrumentation and canal decompression
Fusion success
Don’t underestimate the value of a plain x-ray in the assessment of spinal trauma.

12. CT scans—alignment
What is unclear from the plain images is clear on CT.

13. CT scans—extent and location
Demonstrates morphology of the fracture.

14. CT scans—extent and location
Enables assessment of spinal canal compromise.

15. CT scans—instrumentation and decompression
Also demonstrates the placement of fixation and the extent of canal decompression post-surgery.

16. CT scans—fusion
This 19-year-old man presented 3 years after sustaining an L4 burst fracture and underwent anterior canal decompression and fusion with ongoing low back pain.
The CT scan demonstrated a nonunion.

17. CT scans—fusion
12 months after revision anterior/posterior surgery, CT demonstrates a solid fusion.

18. MRI scans Good soft tissue detail Primary role in assessing:
Spinal canal, cord, and neural compromise
Integrity of stabilizing ligamentous structures
Don’t underestimate the value of a plain x-ray in the assessment of spinal trauma.

19. MRI scans—spinal cord compromise
This T2 image of a compression flexion injury of the mid-cervical spine demonstrates the presence of spinal cord compression with extensive signal change and an anterior hematoma.

20. MRI scans—posterior ligamentous complex
Image shows an anterior burst fracture of L3 with complete posterior ligamentous complex disruption.

21. Angiography
Standard angiography or MR angiography is useful in the assessment of cervical and thoracic injuries predominantly
May also be indicated for Chance type injuries of the lumbar spine where there is an incidence of mesenteric vessel, splenic, and other visceral injuries
Don’t underestimate the value of a plain x-ray in the assessment of spinal trauma.

22. Take-home messages
A variety of imaging modalities are available to assess the extent and morphology of spinal injuries
Do not underestimate the value of plain x-rays
CT scans are best for assessing fracture morphology and extent
MRI is best for assessing neural structures and soft tissues but also to assess alignment and subtle fractures
MR angiography and standard angiography are used where vessel injury suspected
Don’t underestimate the value of a plain x-ray in the assessment of spinal trauma.

23. Excellence in Spine