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Most appropriate screening technique if a fracture is
suspected and in low risk patients.
•Can quickly identify if a fracture or other suspected
bony pathology is present or not.
• A fracture might not be evident on one view and
often several different projections are necessary.
• A fracture may be occult.
Computed Tomography (CT)
To further evaluate numerous musculoskeletal
disorders including neoplasms and simple or complex
• Fast and efficient technique
• Good for bony and articular details
• Both intravenous peripheral contrast and intra-
articular contrast may be given.
• More radiation than an x-ray.
• Metal implants cause significant metal artifact.
Magnetic Resonance Imaging (MRI)
•To evaluate ligament or tendon injury
•To evaluate soft tissue masses
•To evaluate stress fractures and osteomyelitis
Improved ability than CT to visualize the spinal cord
and other contents of the spinal canal.
Excellent for looking at soft tissue, marrow,
ligaments, and marrow edema.
Both intra-articular and IV contrast may be used to
better delineate anatomy/pathology.
• Many contraindications including cardiac
pacemakers, metallic foreign bodies, cerebral
aneurysm clips, electronic devices.
• Metallic implants cause artifacts that limit image
• Some patients may be claustrophobic.
• Sedation may be required.
Plastic sheet coated with a thin emulsion (silver
bromide and a small amount of silver iodide)
Film is exposed to ionizing radiation
Chemical changes resulting in the deposition of
metallic silver, which is black
Amount of blackening on the film is proportional
to the amount of x-ray exposure
Five basic densities
• Arranged from least to most dense.
AIR < FAT < SOFTTISSUE/FLUID < CALCIUM < METAL
(Black to White)
• Denser an object is, the more x-rays it
absorbs, and the whiter it appears on X-rays.
• Less dense an object is, the fewer x-rays it
absorbs, and the blacker it will appear on X-
1. Air - Appears the blackest.
2. Fat - Lighter shade of grey than air.
3. Soft tissue or Fluid – Less black than Fat.
4. Calcium - Usually contained within bones.
5. Metal – Whitest.
(Objects of metal density are not normally present in the body.)
X-RAY FILM QUALITY
Based on :
• Contrast of image
• Sharpness of image
Too white lacking contrast
Over exposed film
Too black with poor contrast
CERVICAL SPINE ANATOMY
Two anatomically distinct regions
Cervicocranium (C1 and C2)
Lower cervical spine (C3 to C7)
C1 VERTEBRA - ATLAS
• Named after the Greek
mythological Atlas who supported
the world on his shoulders.
•Ring of bone with anterior and posterior arches
and large lateral masses.
•Lacks a body & spinous process.
•Superior articular facets articulate with the occipital
condyles (Atlanto-occipital joint) (“yes” movement).
•Inferior articular facets articulate with C2 vertebra
C2 VERTEBRA - AXIS
•Has a body.
•Peg like process called the dens or odontoid process
projects superiorly through the anterior portion of the
vertebral foramen of the atlas (“no” movement).
•Articulation between the anterior arch of the atlas and
dens of the axis, and between their articular facets, is
called the atlanto-axial joint.
C3 - C6
•Structural pattern of the typical cervical vertebra.
•Spinous processes of C2 through C6 are often bifid.
• Vertebra prominens, has single large spinous
process (seen and felt at the base of the neck).
LIGAMENTS OF SPINE
1. National Emergency X-Radiography
Utilization Study (NEXUS) Low-Risk Criteria
• C-spine imaging is recommended for
patients with trauma unless they meet all of
the following criteria:-
• No midline cervical tenderness
• No focal neuro deficits
• Normal alertness
• No intoxication
• No painful distracting injury
2. Canadian Cervical-Spine Rule
FLEXION & EXTENSION VIEWS
• If no fracture is seen on initial films and pain is
• If a pure soft tissue injury is suspected
• To demonstrate ligament instability and subsequent
• Patient should perform the flexion and extension
• Absolutely contraindicated in documented
Important in patients with
pain and/or altered
sensation in their upper
Caused by nerve
compression at the
which can be viewed in
CT is better
• A = Adequacy
• A = Alignment
• B = Bone
• C = Cartilage
• D = Disc
• S = Soft tissue
APPROACH TO C-SPINE X-RAY
• Film should include -
all 7 vertebrae.
• C7-T1 junction.
• Have correct density
• Show the soft tissue - and
bony structures well.
ALIGNMENT (AP VIEW)
• Evaluated using the
edges of the vertebral
bodies and articular
• Height of the cervical
vertebral bodies should be
• Height of each joint
space should be
roughly equal at all
• Spinous process should
be in midline and in
• Pre-vertebral soft tissues
• C2: < 7 mm from
• C6: < 22 mm from
• Normal contour of soft
• Anterior vertebral line
• Posterior vertebral line
• Spinolaminar line
• Spinous process line
Evaluate 5 parallel lines for discontinuity
Evaluate the orientation of the epiglottis, hyoid
bone, tracheal shadow and check for any
Check the Atlantodens interval or Predental
space is < 3 mm in adults or < 5 mm in children.
• Dislocation at the junction
between the Atlas
vertebra and the skull.
• May result in death.
• Anterior dislocation is
much more frequent and
much easier to see on
• Mechanism: Hyperflexion
1. Atlanto occipital dislocation (unstable)
of one vertebral body on another.
•Best seen on the lateral view as a step deformity.
•Step deformity of >3mm is always abnormal & the
spine is unstable.
•Occurs secondarily to hyperflexion of the C.spine.
2. Facet joint dislocations (unstable)
•3 types of bilateral facet dislocations, all are
•In order of increasing severity
• Subluxed facets
• Perched facets
• Locked facets
a) Subluxed facet joint
•Mildest form, in which the ligamentous injury
leads to partial uncovering of facet joint.
• Results in mild anterior displacement of one
vertebral body on another .
b) Perched facet joint
• Inferior articular process appears
to sit 'perched' on the ipsilateral
superior articular process of the
• Any further anterior subluxation
will result in dislocation.
• Unilateral perched facet results
from flexion-rotation force
Spinal cord or Vertebral artery
a.Flexion Teardrop fracture
• Secondary to a flexion injury.
• Results in disruption of all ligaments as well as
the intervertebral disc at the level of injury.
• A small fragment of the anteroinferior portion is
broken off of a vertebral body with posterior
displacement of the vertebral body itself.
• Results in anterior spinal cord compression.
• Most severe C-spine injury.
• Presents as quadriplegia,
loss of anterior column
b) Hangman's fracture
• Secondary to an extension injury, which
commonly occurs in motor vehicle accidents or in
• Bilateral C2 pars fracture, with anterior
displacement of C2 vertebral body.
c) Hyperextension Fracture-dislocation
• Secondary to a severe circular hyper extending
force (e.g. impact on forehead).
• Results in a slight anterior vertebral subluxation,
with a complex fracture near the articular
d) Burst fracture
• Results from an axial injury.
• Compression of the vertebral body and results in
loss of both anterior and posterior vertebral body
• Bony fragments may push on the spinal cord.
• Occur most commonly in the mid-cervical spine.
e. Jefferson's fracture
•Secondary to an axial injury. (heavy object fall on
one's head or diving into an empty pool).
•Consists of unilateral or bilateral fractures of both
the anterior and posterior arches of C1.
f. Odontoid fracture
• Secondary to a multidirectional injury.
Type I: fracture in the upper part of the odontoid.
Type II: fracture at base of the odontoid
Type III: fracture through base of odontoid into body of axis.
• Secondary to a powerful
• Avulsion of a piece of the
spinous process and most
frequently occurs in the lower
a) Clay-Shoveler's fracture
b) Wedge fracture
• Due to flexion injury.
• Compression of the anterior part of the vertebral
c) Extension Teardrop
• Due to hyperextension injury.
• Avulsion of a piece of the anteroinferior portion C2.
RADIOLOGICAL ANATOMY OF
RADIOLOGICAL ANATOMY OF
Thoracic and Lumbar Fractures
• Thoracic spine is an unusual site for fractures.
• Most fractures occur at thoracolumbar junction
(90% at T11-L4).
• All patients should have CT except for patients
Stable compression fractures
Isolated spinous or transverse process
1. Unstable injury
a) Chance fractures (lap seatbelt fracture,
usually at L2 or L3)
• Distraction from anterior hyperflexion across a
restraining lap seatbelt.
• Horizontal splitting of vertebra
• Rupture of ligaments
b) Burst fracture
•Results in collapse of an entire vertebral body.
•Mechanism of injury is fall from a height.
•On a lateral view, the height of the vertebral body is
•Fragments extending into the spinal canal.
•On AP view, the interpedicular distance is increased.
2. Stable injury
a. Wedge fracture
• Due to hyperflexion
• Results in the collapse
of the anterior vertebral
• On the lateral view, there
is decreased height of
the anterior wall of the
• Posterior wall of the
vertebral body is intact.
• Spinal canal is not
b. Spinous process fracture
• Fracture line in the spinous process.
• Spinal canal and the stability of the spine are
• A defect in the pars interarticularis.
• Best seen on oblique view where it appears as a
collar on a Scottie dog.
• Chronic stress fracture with nonunion.
• Typically in adolescents involved in sports.
• Most often seen at the L4 or L5 level.
• 95% of spondylolistheses occur
at L4-L5 and L5-S1.
• Occurs when there are bilateral
pars interarticularis defects
• Vertebral body of the affected
level is only held against the rest
of the vertebra by ligaments and
• Later superior vertebral body
slips forward on the inferior one.
Pyogenic spinal infection
• Destruction of the vertebral
endplates and disc space
narrowing (C3/C4 level).
• Usually Bacterial infections
from genitourinary tract.
• Spreading of the infection
destruction of the vertebral
development of a
paravertebral soft tissue
mass (e.g. psoas abscess)
Tuberculous spondylitis (Pott disease)
3 patterns of vertebral involvement.
a. Discovertebral destruction
• Similar to pyogenic infection
• Large paravertebral abscess with later calcification.
• Later develop a severe angular spinal deformity (kyphotic
gibbus), as the vertebrae collapse.
• Infection begins anteriorly under the periosteum and
spreads under the anterior longitudinal ligament.
• Erosions of the anterior aspects of one or more vertebral
• Infection develops within the vertebral body without
involvement of the disc space.
• Infected vertebra often collapses.
•Refers to infection of the
• Staphylococcal infection,TB
•Vertebral osteomyelitis and disc space infection at L2-L3.
•Bony destruction with partial collapse of L3.
•“Rugger jersey spine” :- striped
appearance from the alternating
areas of osteosclerosis along the disc
plates with central osteoporosis.
•In chronic renal failure, secondary
* Most serious complication of cervical rheumatoid
arthritis is atlantoaxial subluxation.
* Widening of the predental space.
* Malalignment of the spinolaminar lines of C1 and C2
Spina bifida occulta
• Failure of fusion of the laminae
of L5, producing a cleft.
• Normal variant with no
associated neurologic or clinical
Severe spina bifida
• Congenital absence of the
laminae of L3, L4, and L5.
• Usually associated with
Mild cervical spondylosis
•Narrowing of the C5 disc space.
•Posterior spurs impinge on the
Severe cervical spondylosis
• Spurs encroaching the neural
foramina at multiple levels.
“Bamboo spine” appearance of vertebral column
Diffuse idiopathic skeletal hyperostosis (DISH)
•Results in a rigid spine, similar to
•Ossification of the posterior
longitudinal ligament may produce
•Syndesmophytes are coarse and
Appearance after laminectomy
• Absence of the laminae and spinous
processes of L3 and L4.
• Lucency represents the surgical
Osteoarthritis of the
• Disc space narrowing
& Osteophytes at
Osteoarthritis of the lumbar spine
•Narrowing of the intervertebral disc space
between L5 and S1.
• Sclerosis of the facet joints at L4/5 (F) with
•C/o Sudden onset back pain and leg weakness,H/o breast cancer.
•X-Ray:- Reduced height of the T6 vertebral body & loss of
visualization of the left pedicle due to bone destruction.
•MRI:- Destruction and partial collapse of T6 & Neoplastic tissue is
invading the spinal canal and compressing the spinal cord. 125
•MRI is the choice.
•Posterior herniation of the L4/5 disc.
•Transverse image:- Herniation into the right side of the
•Right L5 nerve root is compressed.