Authors of section

Authors

Ronald Lehman, Daniel Riew, Klaus Schnake

General Editor

Luiz Vialle

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Patient examination: Radiological evaluation (XR,CT, MRI)

1. Preliminary Remarks

Radiological evaluation of an injured spine includes plain radiographs, Computerized tomography (CT) and Magnetic Resonance Imaging (MRI) scan. The purpose of radiological evaluation is to:

  • identify the location and extent of injury
  • determine features of vertebral instability
  • assess the severity of neurological compression and injury
  • classify injury patterns

identify multilevel injuries

2. Plain radiographs

I ntroduction

Good quality plain radiograph in two planes (antero-posterior and lateral) must be performed in all patients with suspected spinal trauma.

The appropriate radiograph is performed based on local tenderness or deformity and the presence of neurology (in case of neurological injury).

patient examination radiological evaluation xr ct mri

For the upper cervical spine one can use a C2 targeted X-ray examination.

AP view is recorded thorough the open mouth.

Lateral incudes occiput to C3.

If the radiographs are not satisfactory or inconclusive, CT scan must be performed.

patient examination radiological evaluation xr ct mri

What is seen in the AP radiograph

In the antero-posterior film, the following factors are observed:

Anatomical landmarks in AP view

  • Odontoid
  • C2 body
  • C1-C2 facet joint
  • C1 lateral mass
  • C0-C1 joint
  • Occiput
  • Bifid spinal process
patient examination radiological evaluation xr ct mri

What is seen:

  • Lateral dislocation of the lateral mass of C1 (Positive Spence sign if dislocation exceeds 7mm)

What it indicates:

  • Type 4 ATLAS fracture
patient examination radiological evaluation xr ct mri

What is seen:

  • Fracture line of the odontoid
  • Fracture lines of the odontoid are usually not easily seen in the AP view.

What it indicates:

Anderson D'Alonzo Type II or III fracture

patient examination radiological evaluation xr ct mri

3. What is seen in the lateral x-rays

Anatomical landmarks seen in the lateral view:

  • Occiput
  • Anterior and posterior arch of C1
  • Odontoid
  • C2 body
  • Isthmus and lamina of C2
patient examination radiological evaluation xr ct mri

What is seen:

  • Large atlanto occipital distance

What it indicates:

  • Axial atlanto occipital dislocation
patient examination radiological evaluation xr ct mri

What is seen:

  • Increased atlanto axial distance

What it indicates:

  • Atlanto axial instabillity
patient examination radiological evaluation xr ct mri

What is seen:

  • Fracture of the posterior arch C1

What it indicates:

  • Fracture of C1
patient examination radiological evaluation xr ct mri

What is seen:

  • Left shows fracture of the neck the odontoid with extension
  • Right image shows fracture of the neck the odontoid with posterior dislocation

What it indicates:

  • C2 odontoid fracture
patient examination radiological evaluation xr ct mri

What is seen:

  • Fracture of the pars interarticularis of C2 and slight anterior slippage of C2 body

What it indicates:

  • Traumatic spondylolisthesis of C2
patient examination radiological evaluation xr ct mri

What is seen

  • Anterior slippage of the C2 body

What it indicates

  • Unstable traumatic spondylolisthesis
patient examination radiological evaluation xr ct mri

4. What is seen in CT scans

CT can reveal associated injuries as well as rule out suspected fractures which are not present.

What is seen:

  • Precise fracture morphology
  • Associated injuries
  • Extent of vertebral body comminution and displacement

Which view:

  • Sagittal, axial, and coronal
patient examination radiological evaluation xr ct mri

What is seen:

  • Fracture of the pars and angulation C2-C3

Which view:

  • Lateral

What it indicates:

  • Spondyloschisis type IIa
patient examination radiological evaluation xr ct mri

What is seen

  • Occipito condyle fracture

Which view

  • Lateral, coronal

What it indicates

  • Fracture of C0 (occipital condyle)
patient examination radiological evaluation xr ct mri

What is seen

  • C1 atlas fracture

Which view

  • Coronal, axial

What it indicates

  • Fracture of the C1 ring
patient examination radiological evaluation xr ct mri

What is seen

  • Odontoid fracture

Which view

  • Sagittal, axial

What it indicates:

  • Fracture of the dens axis (odontoid)
patient examination radiological evaluation xr ct mri

What is seen

  • Traumatic spondylolisthesis of C2

Which view

  • Sagittal, axial

What it indicates

  • Fracture of C2
patient examination radiological evaluation xr ct mri

What is seen

  • Prevertebral hematoma and effusion in the C1-C2 joint
  • Sagittal reconstruction

What it indicates

  • Occipito condyle dislocation
patient examination radiological evaluation xr ct mri

What is seen

  • Hyperintense signal changes in cord

What it indicates

  • Cord injury
patient examination radiological evaluation xr ct mri