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Traumatic Injuries to the
Cervical Spine
JENNIFER MINIGH, PH.D.
Nowhere in radiography
are the standards for imaging more important than in
dealing with traumatic spine
injury. This article provides
an overview of cervical spine
trauma and specifically
addresses various injuries
and how to image them.
This article is a Directed
Reading. See the quiz at the
conclusion.
After completing this article, readers will be able to:
■ Describe the basic anatomy of the cervical spine.
■ List and describe various forces involved in spinal injury.
■ Discuss various cervical spine injuries.
■ Present recommendations, limitations and diagnostic challenges of imaging cervical spine trauma.
■ Address other patient considerations including safety and care.
I
n May 1995, Hollywood met heartache. Christopher Reeve,
America’s favorite superhero,
broke his neck when he was
thrown from his horse during an
equestrian competition. His resulting
paralysis was not enough to hold down
this hero, though. Mr. Reeve was willing
to share his disability struggles and to
speak out, campaigning tirelessly for spinal cord injury and research.
Approximately 10 000 cervical spine
fractures occur annually, comprising
2.6% of all trauma victims. These cervical spine injuries cause an estimated
6000 deaths and 5000 new cases of quadriplegia each year.1 Motor vehicle accidents and falls account for 50% and 20%
of these injuries, respectively. In fact,
approximately 5% to 10% of unconscious
patients who present to the emergency
department as the result of a motor vehicle accident or fall have a major injury to
the cervical spine. Sports-related activities account for another 15% of cervical
spine injuries. Participants in sporting
events such as diving, equestrian activities, football and gymnastics are considered to be at a high risk for spinal trauma. Of the new cervical spine fractures
each year, as many as 47% of patients
suffer neurologic complications resulting
RADIOLOGIC TECHNOLOGY September/October 2005, Vol. 77/No. 1
in devastating psychological, physical
and financial losses. The mortality rate
among trauma patients with cervical
fractures who required intubation was
37%, with most deaths related to associated injuries, particularly head injury.2
Perhaps the most concerning statistic
is that 10% of all spinal-cord injured
patients arrived at the emergency department neurologically intact.3
Normal Cervical
Spine Anatomy
The purpose of the cervical spine is to
protect the spinal cord and to support the
skull while enabling diverse head movements. This is a big job considering that
cervical vertebrae are smaller than the
other spinal vertebrae.
The normal anatomy of the cervical
spine consists of 7 vertebrae separated
by intervertebral disks. (See Fig. 1.). The
basic parts of a vertebra are an anterior
body and a posterior arch which consists
of the pedicles and laminae. One distinguishing feature of the cervical vertebrae
is the presence of a transverse foramen in
the transverse process.
The vertebrae are joined by a complex
network of ligaments. These ligaments
keep individual bony elements behaving
as a single unit. In 1983, Denis4 proposed
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TRAUMATIC SPINE INJURIES
Fig 1. Typical cervical vertebrae. Axial CT image (above right)
showing the parts of a typical cervical vertebra (C3-C6). A 3-D
reconstruction from an axial CT examination (above left). (Image
courtesy of Nicholas Joseph Jr. Reprinted with permission from:
www.radiographicceu.com/article5.html.)
Fig. 3. Atlas (C1) and axis (C2).
Fig. 2. Three-column model. (Image courtesy of Nicholas Joseph
Jr. Reprinted with permission from: www.radiographicceu.com/
article5.html.)
a 3-column model of the spine. One can view the cervical spine as 3 distinct columns: anterior, middle and
posterior. (See Fig. 2.) The anterior column consists
of the anterior longitudinal ligament and the anterior
two thirds of the vertebral body. The middle column is
formed by the posterior longitudinal ligament and the
posterior one third of the vertebral body. The posterior
column is made up of the remaining ligamentous and
vertebral structures. The anterior and posterior longitudinal ligaments maintain the structural integrity of the
anterior and middle columns. The posterior column is
held in alignment by a more complex ligament system.
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Upper Cervical Region:
The Atlas (C1) and the Axis (C2)
The atlas and the axis are atypical vertebrae. (See
Fig. 3.) The atlas (C1) is ring like and somewhat kidney
shaped when viewed from above or below. It has no
spinous process or body and consists of 2 lateral masses
connected by anterior and posterior arches. The atlas
carries the cranium and rotates on C2’s large, flat superior articular facets.
The axis (C2) vertebra is the strongest cervical vertebra. Its distinguishing feature is an odontoid process
that is a tooth-like structure projecting from the vertebra. This odontoid process is often referred to as the
dens. The dens is held tightly to C1 by the transverse
ligament, thus stabilizing the atlantoaxial joint, which is
a pivot joint that allows rotational movements like shaking the head when saying “no.” (See Fig. 4.) These ligaments provide further stabilization by permitting spinal
column rotation and preventing posterior displacement
of the dens in relation to the atlas.
The C2-C3 Interface
Rotation of the axis on C3 is limited by a blocking
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Table 1
Motor Deficits and Mobility Consequences for
Corresponding Cervical Fractures
Level of
Injury
Fig. 4. Linear tomogram through C1-C2. The left image is
labeled, whereas the right is not labeled to demonstrate a clear view
of the atlantoaxial joints and odontoid process. (Image courtesy of
Nicholas Joseph, Jr. Reprinted with permission from: www.radiographicceu.com/article5.html.)
mechanism that protects the vertebral artery from excessive torsion. This blocking mechanism is also found in
the subjacent cervical vertebrae.
Lower Cervical Region
The lower cervical vertebrae are typical in structure
with some exceptions. In this region, the laminae are
slender and overlap to create a shingling pattern that
increases with age. The seventh cervical vertebra is considered an atypical cervical vertebra because of its long
spinous process that can be seen and felt in the back of
the neck.
Cervical Spine Injuries and
Neurologic Deficits
The technologist must appreciate the fact that injury
to a vertebra does not directly correlate with injury to
the spinal cord. Likewise, injury to the spinal cord does
not require a vertebral fracture. In other words, a person may “break his neck” yet not sustain a spinal cord
injury (SCI) when only the vertebrae are damaged but
the spinal cord is not affected. In these situations, the
individual may not experience paralysis after the bones
are stabilized; however, as many as 39% of cervical fractures have some degree of associated neurologic deficit.
The effects of SCI depend on 2 factors: the type of
injury and the level of injury. Furthermore, SCI can be
divided into 2 types of injury — complete and incomplete. A complete injury means that there is no function
below the level of the injury; there is no sensation and
no voluntary movement, with both sides of the body
equally affected. An incomplete injury means that there
RADIOLOGIC TECHNOLOGY September/October 2005, Vol. 77/No. 1
Motor Deficits
Mobility
Consequence
C1, C2,
C3, C4
Paralysis of all 4
limbs
Power wheelchair (chin
drive or sip-n-puff)
C5
Shoulder and biceps
control without control of wrist or hand
Power wheelchair
(arm drive)
C6
Wrist control without
hand function
Manual and/or power
chair-sliding board
transfers
C7, T1
Dexterity problems
with the hand and
fingers
Manual chair transfers
w/o sliding board
is some functioning, whether it is movement or sensation, below the primary level of injury.
The level of SCI is very helpful in predicting what
parts of the body might be affected. In general, the
higher up the spinal column the injury occurs, the
more dysfunction a person will experience. Injuries
to the cervical spinal cord result in paralysis of all
4 limbs, which is termed tetraplegia or, more often,
quadriplegia. Injuries below the cervical spine result
in paraplegia, a paralysis of the legs and portions
of the trunk. Quadriplegia is slightly more common
than paraplegia. Table 1 summarizes various motor
deficits and mobility consequences for corresponding
cervical fractures.
Beside a loss of sensation or motor function, individuals with SCI also experience other changes. Very high
injuries (C1, C2) can result in a loss of many involuntary
functions including the ability to breathe. SCIs may
cause sexual dysfunction or dysfunction of the bowel
and bladder. Other effects of SCI may include chronic
pain, in addition to altered regulation of blood pressure,
body temperature and the ability to sweat below the
level of injury.
When an SCI occurs, there usually is swelling of the
spinal cord that may incur further injury and loss of
function. With time, the swelling will begin to dissipate
and the individual may regain some functioning. In the
event of an incomplete injury, the individual may recover some functioning as late as 18 months following the
injury. However, only a very small fraction of individuals
sustaining SCIs completely recover.
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TRAUMATIC SPINE INJURIES
!
"
#
Fig. 6. Dens fracture. A. Type I. B. Type II. C. Type III
Fig. 5. Jefferson burst fracture. A. Open-mouth odontoid projection. Note bilateral displacement of lateral masses (LM) and widened lateral atlantodental interval (*). B. Lateral projection. Note
bilateral posterior arch C1 fractures (arrow) and widened anterior
atlantodental interval (*). (Image courtesy of Thea Trötscher,
R.N., and John H. Harris, M.D. Reprinted with permission from:
Harris & Harris Emergency Radiology Primer at www.uth.tmc.
edu/radiology/test/er_primer/index.html.)
Cervical Fractures
Most cervical spine fractures occur at 2 levels. One
third of fractures occur at the level of C2, while one half
of injuries occur at the C6 or C7 levels. As reported in
accident statistics, the most vulnerable segments to injury are the axis and C5-C6. According to the National
Spinal Cord Injury Statistical Center’s 2004 annual statistical report,1 of the patients discharged with a cervical
spine injury, 39% had injuries that occurred at C4-C6.
According to the report, the atlas was the least involved
of all cervical vertebrae.
Mechanisms of Injury
Nonangular stresses and rotational/angular
forces are the 2 main mechanisms for spinal injury.
Nonangular forces include compression and shear force.
Rotational/angular forces include hyperextension,
hyperflexion and hyperrotary forces.
Compression Forces. This mechanism is best
explained as a force produced when a heavy object is
placed on top of the head. Excessive compression forces
on the neck commonly lead to facet jamming and fixa-
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tion. In addition, these forces can cause fractures of the
atlas or lower cervical bodies. The fractures may be vertical, oblique or bursting in nature.
Shear Forces. Undue shearing forces can disrupt ligaments and produce anterior or posterior subluxation.
Also, these forces can create anterior or posterior fractures of the dens or cause anterior compressive fractures
of the atlas or vertebral body.
Hyperextension Forces. This mechanism is best
described as the force produced when a person strains
to look up by bending the head back. The effects of
forceful posterior bending include ligament sprain,
wedging of a vertebral body, posterior subluxation and
fractures of the atlas or vertebral body.
Hyperflexion Forces. An example of this mechanism
is the force produced when a person strains to look
down by bending the head forward. Excessive anterior
bending may produce much the same effects as hyperextension forces.
Lateral Hyperflexion Forces. This is best explained
as the force produced when a person attempts to place
his or her ear on a shoulder. The effects of excessive
lateral bending include dislocation and fractures of
processes, including the odontoid process. In addition,
lateral wedging of vertebral bodies may occur.
Hyperrotary Forces. This force is produced when a
person strains to look over his or her shoulder. Extreme
rotation of the longitudinal axis may produce ligament
torsion, rotary subluxation, spiral loosening and atlasaxis dislocation.
Upper Cervical Fractures
C1 Atlas. Isolated fractures of the atlas are rare and
divided into types I, II and III.5 Jefferson first described
the type II fracture pattern as a “burst” pattern.6 This
fracture can occur from a severe axial force causing
compression. (See Fig. 5.) If the force is great enough,
such as that which occurs in diving injuries, the vertebral arch or body of the adjacent vertebra literally
bursts. Another fracture, the pillar fracture, is an iso-
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Fig. 7. Hangman’s fracture,
lateral view. Note the fracture
(arrows) and the C2-C3 disk
space (*). (Image courtesy of
Thea Trötscher, R.N., and John
H. Harris, M.D. Reprinted
with permission from:
Harris & Harris Emergency
Radiology Primer at www.
uth.tmc.edu/radiology/test/
er_primer/index.html.)
lated fracture of the lateral mass of C1. Regardless of
fracture type, stability is defined as an intact transverse
longitudinal ligament. The “Rule of Spence” is used
to assess the integrity of this ligament and its stability.
The rule states that on an open-mouth odontoid projection, the displacement of the lateral masses to a certain
degree implies a ruptured ligament. All stable patients
with a C1 fracture should have a magnetic resonance
(MR) image taken to assess the integrity of the ligament. If the ligament is ruptured, this is considered the
most unstable of all cervical spine fractures.7
C2 Axis. Fractures of the axis also are divided into
3 types: dens, hangman’s and other.8 The dens fracture
is the most common form and has 4 subtypes that are
classified according to the fracture location, whether
it be at the tip, base, body or some combination of the
dens and vertebra. (See Fig. 6.) The hangman’s fracture,
originally named to describe the effects of hanging a
person from a gallows, now refers to bilateral fracture
of the pedicles of the axis caused by hyperextension or
sudden deceleration. (See Fig. 7.) In present times, this
type of fracture most commonly results from a car accident in which the victim strikes the windshield with his
forehead. A hangman’s fracture often causes death by
suffocation, which nearly occurred during Reeve’s tragic
equestrian accident.
Axis with Atlas Fractures. In the largest case series
examining combined fractures, 43% of axis fractures
and 16% of atlas fractures occur in unison.9 There are
4 main fracture combinations. The most common is the
C1-type II odontoid fracture, while the least common
fracture pattern is the C1-hangman. Combination fractures of C1 and C2 should be evaluated by computed
tomography (CT), with reconstruction whenever an isolated C1 or C2 fracture is seen.10
Lower Cervical Fractures
Lower cervical spine fractures are classified into 4
RADIOLOGIC TECHNOLOGY September/October 2005, Vol. 77/No. 1
Fig. 8. Flexion tear
drop fracture, lateral
view. Arrow points to
“tear drop” fragment.
(Image courtesy of Thea
Trötscher, R.N., and
John H. Harris, M.D.
Reprinted with permission
from: Harris & Harris
Emergency Radiology
Primer at www.uth.tmc.
edu/radiology/test/er_
primer/index.html.)
major subtypes according to the forces involved in the
mechanism of injury: hyperflexion, hyperextension,
compression and lateral flexion/shearing.11,12
Fractures Caused by Hyperflexion. The flexion tear
drop fracture is a fracture of the inferior-anterior portion of a vertebral body, typically occurring at C2. (See
Fig. 8.) It is often the result of diving into shallow water.
This fracture is the most severe and unstable injury of
the cervical spine.
Subluxation is defined as a partial dislocation of a
bone in its joint. In terms of the spine, it is displacement
of a vertebra. Anterior subluxation in the cervical spine
occurs when posterior ligament complexes rupture.
(See Fig. 9.) The anterior longitudinal ligament remains
intact and no associated bony injury is seen. Because
the anterior columns remain intact, this fracture is considered mechanically stable. However, most authorities
approach this injury as if it were potentially unstable
because of the significant displacement that can occur.
A few very rare cases have reported neurologic deficit.
Subluxation between 25% and 50% of the vertebral
body is generally consistent with a unilateral facet dislocation (sometimes referred to as the “locked” vertebra),
whereas subluxation of more than half of the vertebral
body indicates a bilateral facet dislocation. (See Fig. 10.)
This is an extremely unstable condition and is associated
with a high prevalence of SCI. In addition, a significant
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TRAUMATIC SPINE INJURIES
Fig. 9. Anterior subluxation, lateral view. Crossed
lines indicate the abnormal
curvature (arrow) typical
of anterior subluxation.
(Image courtesy of Thea
Trötscher, R.N., and John
H. Harris, M.D. Reprinted
with permission from:
Harris & Harris Emergency
Radiology Primer at www.
uth.tmc.edu/radiology/test/
er_primer/index.html).
number of bilateral facet dislocations are accompanied
by disk herniation.
A clay shoveler’s fracture is a forcible detachment of
a spinous process caused by a sudden load on a flexed
spine. (See Fig. 11.) This fracture occurs most often
at C6, C7 or T1 and is the most stable of the cervical
spine fractures.
Fractures Caused by Hyperextension. An extension
tear drop fracture is radiographically similar to the flexion tear drop fracture, involving the anterior-inferior
portion of a vertebral body. However, this fracture is
more stable than the flexion fracture.
A fracture of the neural arch of C1 occurs when the
head is hyperextended and the posterior neural arch of
C1 is compressed to the point of fracture. Because the
transverse ligament and the anterior arch of C1 are not
involved, this fracture is stable.
Fractures Caused by Compression. A burst fracture
occurs when a downward compressive force is transmitted to lower levels in the cervical spine, causing the body
of the cervical vertebra to shatter outward in a bursting
pattern. (See Fig. 12.) The Jefferson burst fracture of C1
has been discussed previously as an upper cervical fracture. Burst fractures involve disruption of the anterior
and middle columns. In addition, these fractures are
much more severe than simple compression fractures
because the bones spread out in all directions and may
damage the spinal cord.
Fractures Caused by Lateral Flexion/shearing.
Between 4% and 6% of cervical spine injuries occur
from this mechanism. Occupants of a vehicle that has
been broadsided will likely suffer this injury. The impact
propels the victim’s body in 1 direction while the head
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Fig. 10. Bilateral facet dislocation, lateral view. Note that the
body of C4 (a) has an anterior translation equivalent to 50%
of the diameter of the vertebral body. The arrow denotes anterior
dislocation of each articular mass of C4. (Image courtesy of Thea
Trötscher, R.N., and John H. Harris, M.D. Reprinted with permission from: Harris & Harris Emergency Radiology Primer at www.
uth.tmc.edu/radiology/test/er_primer/index.html.)
and neck go in the opposite direction. Examples of fractures include uncinate fracture, isolated pillar fracture
(see Fig. 13), transverse process fracture and lateral vertebral compression.
Cervical Spine Stability
The stability of C3-C7 fractures is based on a 3column theory described by Denis.4,13 As previously
described, the 3 spinal columns (anterior, middle and
posterior) work in conjunction to provide stability to
the spine. (See Fig. 2.) Column disruption can lead to
mechanical instability of the cervical spine. If 1 column
is disrupted, other columns may provide sufficient stability to prevent SCI. If 2 columns are disrupted, the
spine may move as 2 separate units, thus increasing the
likelihood of SCI. Fractures are considered unstable if
more than 1 column is disrupted. The degree of instability depends on several factors, including degenerative
changes related to aging, arthritic conditions, spinal stenosis and spina bifida, as well as the specific mechanism
and location of the injury. Trafton7 has ranked specific
cervical injuries based on their degree of mechanical
instability. The following list ranks cervical spine injuries
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A.
Fig. 12. Burst fracture of lower cervical spine. Axial CT scan
showing a sagittal fracture of the body (a), retropulsed body fragments (arrows) and laminar fracture (c). (Image courtesy of Thea
Trötscher, R.N., and John H. Harris, M.D. Reprinted with permission from: Harris & Harris Emergency Radiology Primer at www.
uth.tmc.edu/radiology/test/er_primer/index.html.)
B.
Fig. 11. Clay-shoveler’s fracture. A. Anteroposterior view. B.
Lateral view. Arrow indicates spinous process fracture line and displacement of superior fragment. (Image courtesy of Thea Trötscher,
R.N., and John H. Harris, M.D. Reprinted with permission from:
Harris & Harris Emergency Radiology Primer at www.uth.tmc.
edu/radiology/test/er_primer/index.html.)
in order of instability (most stable to least stable): (See
Table 2.)
■ Rupture of the transverse ligament of the atlas.
■ Fracture of the dens.
■ Flexion teardrop fracture.
■ Bilateral facet dislocation.
■ Hangman fracture.
■ Extension teardrop fracture.
■ Jefferson fracture.
■ Unilateral facet dislocation.
■ Anterior subluxation.
■ Simple wedge compression fracture.
■ Fracture of the posterior arch of C1.
■ Clay shoveler’s fracture.
Imaging the Cervical Spine
The first step in imaging the cervical spine is to
determine if the patient actually needs imaging and,
if so, which projections are appropriate. The criteria
for imaging apply only to adults with no mental status
changes, including drug or alcohol intoxication. The
presence of the following should be noted:
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Fig. 13. C4 pillar
fracture. Arrows
indicate the “doubleoutline” sign. (Image
courtesy of Thea
Trötscher, R.N., and
John H. Harris,
M.D. Reprinted with
permission from:
Harris & Harris
Emergency Radiology
Primer at www.uth.
tmc.edu/radiology/
test/er_primer/index.
html.)
■ Neurologic deficits consistent with a cord lesion,
such as sensory and motor deficits.
■ Altered sense of reality due to head injury or
intoxication.
■ Complaints of neck pain or tenderness.
■ Significant other injuries that may preclude any
complaints about neck pain or tenderness.
Although some research suggests that these criteria
also may be used in the management of verbal children,14-16 caution is in order because the studies were
small, and the ability of children to complain about pain
or sensory changes can vary.
ACR Imaging Guidelines
The American College of Radiology (ACR)
Committee on Appropriateness Criteria has developed
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TRAUMATIC SPINE INJURIES
Table 2
Common Injuries of the Cervical Spine
Spinal
Level
C1
Injury
[Figure #]
Stability
Cause
Jefferson fracture [5]
Moderately
unstable
Severe axial force
causing compression
Odontoid projection: displaced lateral
masses of C1
Atlantoaxial
subluxation
Highly
unstable
Unknown but often
occurs in patients with
bone degeneration
Odontoid projection: asymmetric lateral
Hangman’s fracture [7]
Unstable
Hyperextension or
sudden deceleration
Lateral projection: bilateral pedicle fracture
of C2
Odontoid fracture [6]
Highly
unstable
Unknown
May be difficult to see on plain-film
radiographs; may require CT scanning
C6, C7, T1 Clay shoveler’s
fracture [11]
Stable
Sudden load on a
flexed spine
Forcible detachment of spinous process;
frequently an incidental finding
Any
Flexion teardrop [8]
Highly
unstable
Sudden and forceful
flexion
Large wedge off the anterior aspect of the
vertebra; alignment abnormalities
Bilateral facet
dislocations [10]
Highly
unstable
Flexion, or a combination with rotation
Anterior displacement of more than half of
the diameter of the vertebral body in the
lateral view
Unilateral facet
dislocations
Unstable
Flexion or a combination with rotation
Anterior dislocation of 25% of a cervical
vertebra on lateral views
C2
guidelines17,18 for determining appropriate imaging
examinations to diagnose specified medical conditions, namely spinal injury. These criteria are intended
to guide professionals in making decisions regarding
radiologic imaging and treatment. The ACR cautions,
however, that using the guidelines blindly in a “protocoldriven” manner may result in many unnecessary studies.
Conventional Radiography
The ACR states that if the above criteria are met,
plain-film radiographs are the mainstay of the initial
imaging evaluation. The exam should include 3 projections: a true lateral projection, an anteroposterior projection; and an open-mouth odontoid projection. (See
Fig. 14.) A lateral projection using the Twining method,
commonly called the “swimmer’s lateral,” for T1 is frequently needed, especially in men. The importance of
obtaining all these projections, described in more detail
below, and demonstrating all of the vertebrae cannot be
overemphasized. Although some missed cervical fractures are the result of image misinterpretation, the most
frequent cause of overlooked injury is an inadequate
film series.19,20 (See Table 3.)
60
Radiologic Findings
Lateral projection. Approximately 85% to 90% of
cervical spine injuries are evident in a lateral projection, making it the most useful image from a clinical
standpoint. (See Fig. 14a.) However, some experts
believe the single portable cross-table lateral radiograph, often obtained in the trauma room, should be
abandoned. This projection is insufficient to exclude a
cervical spine fracture and frequently must be repeated
in the radiology department.21,22
For complete imaging, the lateral projection must
include all 7 cervical vertebrae as well as the C7-T1 junction. If no arm injury is present, traction of the arms may
help to demonstrate all 7 vertebrae on the lateral film. If
all 7 vertebrae and the C7-T1 junction are still not visible,
a swimmer’s lateral, taken with 1 arm extended over the
head, may remedy the problem. (See Fig. 15.) Because
there is less scatter, a coned-down swimmer’s lateral gives
better detail than does the full cervical spine swimmer’s
projection, especially when using digital imaging.
Anteroposterior projection. This projection is used
to reveal the spinous processes of C2 to T1; however, it is
the least useful projection from a clinical standpoint.23
(See Fig. 14b.)
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A
Fig. 15. Swimmer’s lateral projection. (Image courtesy of Nicholas
C
Joseph, Jr. Reprinted with permission from: www.radiographicceu.
com/article5.html.)
B
Fig. 14. The standard radiographic image series to evaluate
trauma of cervical spine. A. Lateral projection. B. Anteroposterior
projection. C. Open-mouth odontoid projection. (Image courtesy of
Thea Trötscher, R.N., and John H. Harris, M.D. Reprinted with
permission from: Harris & Harris Emergency Radiology Primer at
www.uth.tmc.edu/radiology/test/er_primer/index.html.)
Odontoid projection. The open-mouth odontoid projection is used to evaluate an area that is difficult to demonstrate on a cross-table lateral image because of shadow
superimposition. (See Fig. 14c.) It is used to assess trauma
to C2. Occasionally, the tip of the odontoid process is not
adequately visualized, and the technologist may use the
Fuchs method, which is a modified projection to demonstrate the superior third of the odontoid tip. However,
this projection is unreliable when the patient is in a cervical collar and the neck cannot be extended.
Oblique and flexion/extension radiographs. Plainfilm imaging beyond lateral and anteroposterior projections may be useful in selected cases. Supine oblique
studies aid in examining lateral masses, whereas flexion
and extension projections are commonly used for patients
with severe pain and tenderness but who have normal lateral and anteroposterior films.24 These additional studies
are not generally used for routine protocols.
Oblique projections are most valuable in adding 2
more images of the C7-T1 junction. This is considered a
laminar projection because the image can reveal disruptions in the normal shingling appearance of the verte-
RADIOLOGIC TECHNOLOGY September/October 2005, Vol. 77/No. 1
bral laminae. Because both of these functions can now
be accomplished through the use of CT, the ACR states
that the use of supine oblique projections is no longer
necessary for patients who are undergoing cervical
CT examination.
According to the Eastern Association for the Surgery
of Trauma (EAST), a panel created to evaluate and
develop evidence-based guidelines for controversial topics in trauma, a patient with significant midline pain
requires flexion/extension projections to evaluate for
ligamentous injury, which commonly arises from hyperrotational injuries.25 (See Fig. 16) These radiographs
should only be obtained in conscious patients who are
able to cooperate. The patient should be able to limit the
motion of his or her neck based on the occurrence of
pain. Under no circumstances should cervical spine flexion and extension be forced, as this may result in SCI.
Although the literature still recommends flexion/
extension radiographs, the ACR states that these projections are not very helpful except to ensure that minor
degrees of vertebral slippage in patients with cervical
spondylosis (spinal osteoarthritis) are fixed deformities.26,27 Furthermore, muscle spasms are common in
injured patients and preclude an adequate examination
in the acute setting. According to the ACR, flexion/
extension radiography is best reserved for follow-up
of symptomatic patients, usually in 7 to 10 days after
muscle spasms have subsided. Although the use of flexion/extension radiography can provide information
concerning ligament instability, MR is the procedure of
choice for demonstrating this anatomy.
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Table 3
Radiographic Evaluation of Adults
Projection
Cross-table lateral
Assessments/Goals
Visualize all 7 vertebral bodies and the C7-T1 junction
Verify alignment of cervical spine by following 3-column model
Check individual vertebrae thoroughly for obvious fracture or changes in bone density
Evaluate changes in prevertebral spaces
Check for fanning of the spinous processes
Note abrupt changes in angles
Swimmer’s lateral
Visualize all 7 cervical bodies and, more importantly, the C7-T1 junction
Oblique
Verify proper shingling of vertebrae
Note if interlaminar space between 2 continuous laminae is increased
Odontoid
Verify proper alignment of the lateral masses of C1 with respect to the odontoid process
Check for fractures or lateral displacement
Assess symmetry of the interspace between C1 and C2
Anteroposterior
Verify that a straight line connects the spinous processes, thus bisecting the cervical spine
Note vertical splitting of any spinous process
Computed Tomography
There are 3 situations in which CT is necessary: when
a fracture is seen, when a fracture is suspected and when
the spine is poorly visualized on plain films. When a
fracture is seen on the plain films, a CT of the cervical spine that extends 1 level above to 1 level below the
injury is recommended. A significant number of patients
will have additional fractures in the surrounding areas
that are not seen on the plain films.28 When radiography indicates a suspected fracture, patients should
undergo CT. Research has shown that 22% to 42% of
patients whose radiographs are inconclusive actually
have fractures.28,29 In several studies, CT has been shown
to effectively rule out a fracture.28-31
CT is also advantageous for areas of the cervical
spine that are poorly visualized. Between 9% and 26%
of patients have inadequate plain films, generally of
C1-C2 and C6-C7.29,32 Schleehauf showed that 7% of
those with inadequate plain films had positive CT
scans.29 More importantly, in a meta-analysis of more
than 1500 blunt trauma patients over a 3-year period,
CT detected 100% of cervical spine injuries that
were undiagnosed by inadequate plain films.30,29 The
ACR recommends that patients who are not alert or
conscious, are under the influence of a substance, or
who have distracting injuries, cervical tenderness and
62
neurologic findings (eg, sensory and motor deficits)
should have, at a minimum, a 3-projection cervical
radiographic series followed by helical CT scan.20,33,34
The cervical CT examination should be performed
immediately after a cranial CT scan while the patient
is still in the CT suite. This is a time-effective and costeffective approach. 35
Magnetic Resonance
According to EAST, an MR examination should be
conducted within 8 hours for any patient presenting
with a neurologic deficit. MR provides more information about the spinal cord than any other imaging
study.36-38 Such information includes intrinsic compression (from edema or hematoma formation) or extrinsic
compression (from disk herniation or bony fragments).
MR should be reserved for patients who have clear-cut
neurologic findings and for those suspected of ligament
instability.39 The ACR states that MR should be used in
cases of known or suspected soft-tissue injuries such as
disc herniations, ligament tears, epidural hematoma
and spinal cord edema or hematoma.40-42 A recent review
article by Saifuddin43 goes further by recommending
total spinal MR to screen for multiple noncontiguous
injuries, which occur in about 20% of patients.43 MR,
however, is not adequate for evaluation of bony trauma.
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Other Cervical Spine Injuries
Vertebral Artery
This injury is seen in up to 11% of cervical blunt
trauma patients and presents as an expanding cervical
hematoma.48,49 Patients with vertebral subluxation, facet
dislocations or foramen fractures are at increased risk
for vertebral artery injury and probably should undergo
additional imaging studies.50
Fig. 16. Flexion/extension projections. (Image courtesy of Michael
Richardson, M.D., and the University of Washington Web site.
Available at: www.rad.washington.edu/quickcases/cases/Case09/
text.html. Reprinted with permission.)
Myelography with CT should be used in place of MR
only if MR is not available and the patient cannot be
safely transferred to a MR facility. The inherent risks of
patient positioning required for myelography and CT
exams are considerable; thus, supervised transport to an
MR facility may pose less risk to the patient.
Comparison of Techniques
Plain Radiography vs CT
Schenarts and colleagues compared the sensitivity
of CT (at C1-C2) to plain-film radiography (5-projection) in blunt trauma patients.44 CT detected 96% of
upper cervical fractures vs 54% detected by plain-film
radiographs. Interestingly, no fractures were missed with
the combination of radiography and CT. Other studies
have shown similar results.45,46 Another group, Berne
and associates,33 compared CT (at C1-T1) to plain-film
radiography (3-projection) in similar patients over 8
months. Plain films were 61% sensitive in detecting cervical spine injury vs 90% with CT. As before, the combination of imaging techniques was 100% sensitive in
detecting cervical spine injury.
CT vs MR
Velmahos and colleagues compared the sensitivity of
CT and MR in detecting ligament injury in asymptomatic blunt trauma victims. The study revealed that isolated ligament injury without subluxation was detected
in 25% of patients by CT vs 100% with MR.47
RADIOLOGIC TECHNOLOGY September/October 2005, Vol. 77/No. 1
SCIWORA
SCI without radiographic abnormality (SCIWORA) is
defined as the presence of neurologic symptoms in the
absence of radiographic findings. Recent evidence suggests
a higher incidence of adults presenting with SCIWORA
than previously thought.51 The most common level of
injury was C4. SCIWORA classically is seen in children
with symptoms ranging from transient neuropathy to complete cord injury. Often a transient neuropathy will have
a “lucid interval,” only to return hours or days later. The
SCIWORA syndrome occurs when the elastic ligaments of
a child’s neck stretch during trauma. This action causes
the spinal cord to stretch, thus leading to neuronal injury
or, in some cases, complete severing of the cord.52 This situation may account for up to 70% of SCI in children and
is most common in children younger than 8 years.
Ligament Injury
Although the combination of CT and radiography
is adequate to evaluate the bony spine, the issue of
ligament injury needs to be addressed. On plain films
these injuries may be seen on lateral projections as a
misalignment of the cervical vertebrae. Unfortunately,
not all ligament injuries are obvious. Symptoms include
focal neck pain in the absence of radiographic findings.
Nevertheless, it is important to correctly recognize the
injury because missed cervical trauma in a neurologically
intact patient can result in neurologic deterioration.20,53
Whiplash
Mention should be made of whiplash patients, who
have no radiologically demonstrable injuries and yet
have a spinal sensory deficit or motor deficit. The clinical picture in whiplash injury varies greatly, ranging
from simple headaches to neck pain and paresthesia
in the hands. This syndrome was first described by
Schneider,54 who called it a central SCI. It usually results
from hyperextension trauma, such as a face-first fall
down stairs or a motor vehicle accident. Evidence shows
that 50% of patients recover within 6 weeks; however,
recovery may take up to 3 years.55
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Challenges in Evaluating the
Stability of the Cervical Spine
When a lateral film, such as a portable lateral
c-spine image, is solely used to “clear” the cervical spine,
approximately 15% of vertebral injuries are missed. In
addition, plain-film studies have reported false-negative
rates as high as 20% and a false-positive rate of 40%.31
Although some missed cervical fractures, subluxations
and dislocations are the result of film misinterpretation,
the most frequent cause of overlooked injury is an inadequate film series.19,20 Image quality becomes an important factor in a complete radiographic series, as well as
obtaining the necessary projections to demonstrate all
the vertebrae. Occasionally, it is impossible to fully visualize all 7 cervical vertebrae and, more importantly, the
C7-T1 junction in a true lateral image. This may be due
to limitations of patient mobility or, perhaps, shadow
superimposition over questionable areas. A swimmer’s
lateral may adequately expose these areas.
If the original film series is inadequate or there
are still questionable areas, the technologist may have
to perform additional projections. If there is any
question of an abnormality on the plain radiograph
or if the patient has neck pain that seems to be disproportionate to the findings on plain films, a CT
scan of the area in question should be obtained.
Failure to fully demonstrate the spine has resulted in
patient morbidity.
Aside from inadequate film series, there are other
challenges of clearing the cervical spine. For example,
the patient’s neck should remain immobilized until a
full cervical spine series can be obtained. However,
the need for immobility often hinders completion of
the series.
Another imaging challenge is the radiography of
uncommon cervicocranial injuries such as occipitoatlantal dissociation and atlantoaxial rotation. These conditions deserve special consideration because they are difficult to diagnose radiographically. Occipitoatlantal dissociation is the generic term that includes occipitoatlantal dislocation and occipitoatlantal subluxation. While
dislocations are more common and uniformly fatal, the
subluxation is less frequent, and is rarely fatal.
Procedure Limitations
Although they may be considered adequate to rule
out a fracture, cervical spine radiographs have limitations. Reportedly, up to 20% of fractures are missed
on plain radiographs.21,31,45 Many projections have
unique disadvantages. The swimmer’s lateral projection
64
requires patient cooperation for positioning, which may
pose a problem for the radiologic technologist. In addition, the superimposition of the clavicles, upper ribs
and shoulder joints may obscure visualization of some
of the vertebrae.
The open-mouth odontoid projection is considered
unreliable for intubated patients due to its false-negative
rate of approximately 16%. In addition, artifacts caused
by the teeth overlying the dens may give the appearance
of a fracture through the process. If there is any question of a fracture, the projection should be repeated
without the teeth in the field of view. If it is not possible
to exclude a fracture of the dens, CT can be used.
CT and MR imaging have limitations too. For
example, fractures in the axial plane, including base
of odontoid and some subluxations, may not be readily
apparent with CT.56 Also, CT is excellent for identifying fractures, but its ability to show ligament injuries is
limited.56 MR is used as an adjunct to plain-film radiography and CT scanning, especially to demonstrate soft
tissue injury. Although MR approaches 100% sensitivity
for the detection of ligament injury, there are several
problems with this approach. First, there is a high falsepositive rate.57 Second, the clinical implications of many
of these injuries are not yet known. Other problems with
MR involve the physical nature of the procedure. Lack
of availability and the time required for MR scanning
limits its usefulness in the acute setting.37,58 Often, MR
involves the transportation of an unstable patient to a
remote part of the hospital where resuscitation is difficult. Furthermore, resuscitation equipment with metal
parts may not function properly within the magnetic
field generated by the MR scanner. In addition, the
radiologic technologist must be aware if a patient has
any metallic implants or devices, which can be difficult
to determine if the patient is unconscious or unable to
communicate.
Diagnostic Imaging Challenges
The following situations place special demands on
radiologic technologists when they perform a complete
radiography study for patients with cervical spine trauma:
■ Unconscious or uncooperative patients. These
patients may not be able to communicate about
their pain or remain still for various positions.
■ Intubated patients. The odontoid projection may
be compromised in these patients. Similarly, if
airway anesthesia is inadequate, conscious patients
may cough or vomit when the endotracheal tube
is manipulated, causing significant patient move-
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ment. The vast majority of cervical motion is
produced at the occipitoatlantal and atlantoaxial
joints. The subaxial cervical segments are displaced only minimally.59
Cervical collar problems. Not all collars are
radiolucent.
Area of injury. Localizing the area of injury may
become a problem in several circumstances. For
example, there may be multiple areas of injury
that require imaging. Also, other injuries may
mask a SCI and mislead the trauma team.
Degenerative changes. Spondylosis is a degenerative disorder that may cause loss of normal spinal
structure and function. Symptoms may mimic
those of spinal injury.
Pain without obvious finding. “Significant” neck
pain is not defined and is determined by the treating physician. Extreme pain to 1 patient may feel
like a simple itch to another. In addition, pain may
be present in cases of SCIWORA, as discussed previously. Furthermore, neck pain from spondylosis
is common and often mistaken for acute injury.
Congenital changes. Congenital deformities of the
spine are caused by anomalous vertebral development in the embryo. These changes in the spine
shape and size may make it difficult to accurately
assess vertebral damage. The 3 major patterns
of congenital spinal deformity are hyperlordosis
(exaggerated lumbar curve), kyphosis (a progressive spinal disorder that may cause a deformity
described as humpback or hunchback) and scoliosis (abnormal curvature of the spine).
Old injuries. Following a fracture, most vertebrae will “heal” and form a new union of bone.
However, many conditions predispose bones to
nonunion (eg, Down syndrome and rheumatoid
arthritis). Furthermore, new trauma may be superimposed on old injuries. These old injuries may
confound a diagnosis. It is important to get an
accurate medical history of the patient to properly
assess the injury.
Adequate evaluation of the C7-T1 junction. The
C7-T1 junction is a unique area that deserves
much attention. It is a common site of developmental anomalies; it is a major site of arterial,
lymphatic and neurologic traffic; and it is the
juncture of the highly mobile cervical spine and
the very limited thoracic spine. The features of the
C7-T1 junction highlight the area’s importance
and contribute to the difficulty of adequately visu-
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alizing this region. Radiographs of this region are
technically difficult to obtain, and in at least 26%
of all trauma patients, this space is not visualized
on the 3-view series.60
Swimmer’s lateral projection. If a patient’s arms
are in traction, a swimmer’s lateral may have limited value.
Pseudosubluxation. In physiologic misalignment
caused by ligamentous laxity, pseudosubluxation
can be confusing. Pseudosubluxation can occur at
the C2-C3 level and, less commonly, at the C3-C4
level. Pseudosubluxation usually occurs in children, but it also may be seen in adults.
Flexion-extension radiographs. A recent study
noted that up to one third of all flexion/extension
studies are inadequate due to limited range of
motion.61 According to the ACR, flexion/extension radiographs are not very helpful except to
ensure that minor degrees of vertebral slippage in
patients with cervical spondylosis are fixed deformities.26,27 Furthermore, muscle spasms in acutely
injured patients preclude an adequate examination in the acute setting. Additionally, cord injuries
have been reported as a result of this maneuver.62
Evaluation of stability. Stability can be difficult
to assess in an acutely injured patient because the
degree of instability depends on several factors,
including degenerative changes and the specific
mechanism and location of the injury.
Pediatric Considerations
Children and adults have structural differences in
the cervical spine. These differences can alter injury patterns and cause distinct pathology in young children.
Children have more elastic intervertebral ligaments and
more horizontally aligned facet joints. This anatomy
predisposes them to subluxation of the cervical spine
without bony injury. To further compound this problem, immature neck muscles and a proportionally large
head make pediatric cervical spines act like a fulcrum
and thus increase the chance of injury. As the pediatric
cervical spine matures, the fulcrum effect migrates from
the upper cervical levels to the lower ones until it reaches C5. Most injuries occur at the C1-C3 levels in children
younger than 8 years.
Other Patient Safety Considerations
Emergency Procedures
When a cervical spine injury is suspected, the first
step in the protocol is to minimize neck movement and
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further injury. The management of a patient with a
potential SCI begins with the care of paramedics prior
to transport. Ideally, the patient is immobilized in the
neutral position on a full spine board with a cervical
collar and side head supports. In addition, the shoulders
and pelvis are strapped so that the neck is not the center
of the body’s rotation. The patient must be treated as if
the spinal column were fractured, even when there is no
external evidence. If a spinal misalignment or fracture is
identified, the patient should be placed in skeletal traction with tongs as soon as possible, even if no evidence
of neurologic deficit exists. In addition, steroids should
be administered to the patient. The use of steroids for
neurologic injury has become the standard to prevent
secondary causes of SCI such as swelling. According to
3 North American Spinal Cord Injury Study reports,
the recommended management for patients with SCI is
administration of methylprednisolone within 3 hours of
injury.63-68 All in all, the number 1 treatment for spinal
injury is prevention.
Radiation Protection
As with any radiologic study, the major overall goal
is to produce high quality films without exposing the
patient to excessive radiation. Collimation is important
to radiographic detail and is a part of the overall practice of the ALARA (as low as reasonably achievable)
principle. However, care should be taken not to collimate anatomic structures of the neck out of the radiographic image during the trauma survey.
The Role of the Radiologic Technologist
Education is the key to a good radiology department
response to trauma. Often an emergency room physician must make a rapid initial diagnosis. Therefore, it
is imperative that these studies be performed correctly
and completely. Technologists should be aware of the
indications for special projections of the cervical spine,
including how to adequately visualize all vertebrae
(especially C2 and the C7-T1 junction).
Trauma imaging requires the technologist to be aware
of the patient’s history and to know the sequence of diagnostic imaging. For example, a gunshot injury or stabbing
may require the chest to be imaged before neck and
spine imaging. But, as a rule, spine imaging is the priority for motor vehicle accidents and diving injuries. The
technologist must work quickly and decisively to complete
imaging while the patient is treated by the trauma team.
By remaining knowledgeable about current radiographic
imaging standards, the radiologic technologist is armed
66
with the proper knowledge that translates into safe quality patient care. Nowhere in radiography are the standards
for imaging more important than when dealing with traumatic spine injury.
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Acknowledgement
The images from the Harris & Harris Emergency
Radiology Primer, found at www.uth.tmc.edu/radiology/test/
er_primer/index.html, were acquired from work supported by the
John S. Dunn Research Foundation.
Jennifer Minigh, Ph.D., has more than 10 years of research
and teaching experience in the areas of pharmacology, toxicology, molecular genetics, signal transduction and oncology. Dr.
Minigh is the director of Medical Communication Consultants
and serves as secretary and immediate past-president of
the Ohio Valley Chapter of the American Medical Writers
Association.
Reprint requests may be sent to the American Society of
Radiologic Technologists, Communications Department, 15000
Central Ave. SE, Albuquerque, NM 87123-3917.
© 2005 by American Society of Radiologic Technologists.
September/October 2005, Vol. 77/No. 1 RADIOLOGIC TECHNOLOGY