Radiology of the spine

Dr.Khaled A. Alqfail
Assistant professor of Radiology
Najran university
 CERVICAL SPINE ANATOMY
• Two anatomically distinct regions:
Cervicocranium (C1 and C2)
Lower cervical spine (C3 to C7)
C1-C7
 Cervical Spine
• Clinical considerations are particularly important because:
• – normal C-spine X-rays cannot exclude significant injury
– a missed C-spine fracture can lead to death
– life long neurological deficit may develop after injury..
• Clinico-radiological assessment of spinal injuries should
be managed by experienced clinicians .
• Imaging should not delay resuscitation.
 NEXUS (National Emergency X-
Radiography Utilisation Study)
• 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
• Mneumonic :- NSAID
• 1. Neuro deficit
• 2.Spinal midline tenderness in C-spine
• 3. Alertness
• 4. Intoxication
• 5. Distracting injury
 Cervical Spine Radiography
• CT or MRI is often appropriate in the context of a – high
risk injury:
– neurological deficit,
– limited clinical examination, or
– where there are unclear X-ray findings.
 Cervical Spine Radiograph
• Standard View:
– Anteroposterior view
– Lateral View
– Odontoid (Open Mouth View)
Extended View
– Swimmers View: when lateral radiograph fails to show
vertebrae down to T1
Radiological anatomy – AP view
Radiological anatomy – Lateral view
Radiological anatomy –Open mouth view
 ENHANCEMENT OF C7-T1 VIEW
• Traction on arms if no arm injury is present.
• Swimmer's view (taken with one arm extended over the
head.)
 APPROACH TO C-SPINE X-RAY
• AABCDS
• A = Adequacy
• A = Alignment
• B = Bone
• C = Cartilage
• D = Disc
• S = Soft tissue
 ADEQUATE (LATERAL VIEW)
• 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 pillars.
• Height of the cervical vertebral bodies
should be approximately equal.
• Height of each joint space should be
roughly equal at all levels.
• Spinous process should be in midline
and in good alignment.
 ALIGNMENT (Lateral VIEW)
• Evaluate 5 parallel lines for discontinuity
• Pre-vertebral soft tissues
– C2: < 7 mm from vertebral body
– C6: < 22 mm from vertebral body
– Normal contour of soft tissues.
• Anterior vertebral line
• Posterior vertebral line
• Spinolaminar line
• Spinous process line
 Thoracolumbar spine
• In the context of trauma similar principles apply to
imaging both the Thoracic spine (T- spine) and the
Lumbar spine (L-spine)
 lumbar spine
• Use a systematic approach
• Correlate radiological findings with the clinical
features
• If 'instability' is suspected then further imaging with
CT should be considered
• If you see one fracture - check for another
Radiological anatomy – AP view
Radiological anatomy –lateral view
 Lumbar spine
– Adequate - The whole L-spine should be visible on both views
– Alignment - Follow the corners of the vertebral bodies from one
level to the next.
– Bones - Follow the cortical outline of each bone •
– Discs - Disc spaces gradually increase in height from superior
to inferior

- Note: The L5/S1 space is normally slightly narrower than L4/L5

 Three column model
• The Clinico-radiological assessment of thoracolumbar
spine stability is usually performed by spinal surgeons
with the help of radiologists.
• A simple model commonly used for assessment of spinal
stability is the 'three column' model. This states that if any 2
columns are injured then the injury is 'unstable'.
 Three column model
• This theory is an oversimplification if applied to plain X-rays
alone. It is important to be aware that some injuries are not
visible on X-ray and that 2 and 3 column injuries may be
underestimated as 1 or 2 column injuries respectively.
• If spinal instability is suspected on the basis of clinical or
radiological grounds, then further imaging with CT should be
considered.
Three column model
 Three column model - Fracture simulation

-Injuries 1 and 2 affect one column only and are considered 'stable’
1 - Spinous process injury
2 - Anterior compression injury
- Injuries 3 and 4 affect two or more columns and are considered 'unstable’
3 - 'Burst' fracture
4 - Flexion-distraction fracture - 'Chance' type injury
Jefferson Fracture
• Unstable C1 ring compression fracture
with split lateral masses plus transverse
ligament tear
– Secondary to axial load (E.g. diving
headfirst into shallow water)

• Features on “AP Open Mouth”:

– Displacement of C1 lateral masses
beyond margins of C2 vertebral body
– Lateral displacement >2 mm or unilateral
displacement
Jefferson Fracture
 Clay Shoveler’s fracture
• Stable spinous process fracture

• Hyperflexion plus paraspinous

muscle contraction pulling on
spinous processes

• Radiographic features:
– Lateral: spinous process fracture
– AP View: “Ghost sign” ~ double
spinous process of C6 or C7
resulting from displaced
fractured spinous process
Clay Shoveler’s fracture

“Ghost sign”
 Hangman’s
Fracture
• Unstable fractures through the
axis pars interarticularis from
hyperextension & distraction

• Radiographic features best

seen on lateral view:
– Prevertebral soft tissue swelling
– Avulsion of C2 anterior inferior
corner associated with rupture
of the anterior longitudinal
ligament
– Anterior dislocation of C2
vertebral body
– Bilateral C2 pars interarticularis
fractures
 Flexion Teardrop fracture
• Unstable
• 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.
 Flexion Teardrop fracture
• Most severe C-spine injury.
• Presents as quadriplegia.
• Radiographic features:
• Prevertebral swelling (anterior longitudinal ligament tear)
• Teardrop fragment (anterior vertebral body avulsion fracture)
• Posterior vertebral body subluxate into spinal canal
• Cord compression from vertebral body displacement
• Spinous process fracture
 Wedge fracture
• Due to flexion injury. (stable fracture)
• Compression of the anterior part of the vertebral body.
 Burst Fracture

• Vertebral body fracture

resulting from axial
compression (unstable
fracture).

• May cause injury of the

cord secondary to posterior
fragment displacement

• CT required to evaluate
extent of damage
Burst Fracture
 Chance fractures
• lap seatbelt fracture, usually at L2 or L3. (unstable fracture)
• Distraction from anterior hyperflexion across a restraining
lap seatbelt.
• Horizontal splitting of vertebra.
• Rupture of ligaments.

Empty vertebral body sign

 Spondylolysis
• 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.
Spondylolysis
Spondylolysis
 Spondylolisthesis
• 95% of spondylolistheses occur at L4-L5 and L5-S1.
• Occurs when there are bilateral pars interarticularis
defects (bilateral spondylolysis)
• Vertebral body of the affected level is only held against
the rest of the vertebra by ligaments and intervertebral
disc.
• Later superior vertebral body slips forward on the inferior
one
 Spondylolisthesis
• Subluxation is classified into four grades, which indicates
the percentage of displacement.
Spondylolisthesis
 Tuberculous spondylitis (Pott’s disease)
• 3 patterns of vertebral involvement:
a. Discovertebral destruction
• Destruction of the vertebral
endplates and disc space narrowing.
• Large paravertebral abscess with
later calcification.
• Later develop a severe angular
spinal deformity (kyphotic gibbus),
as the vertebrae collapse.
 Tuberculous spondylitis (Pott’s disease)
2) Subligamentous
• Infection begins anteriorly
under the periosteum and
spreads under the anterior
longitudinal ligament.

• Erosions of the anterior

aspects of one or more
vertebral bodies.
 Tuberculous spondylitis (Pott’s disease)
• 3) Central
• Infection develops within the vertebral
body without involvement of the disc space
• Infected vertebra often collapses..
 Discitis
• Refers to infection of
the intervertebral
disc.
• Staphylococcal
infection,TB
• MRI is the imaging A T1-weighted sagittal image demonstrates marked

modality of choice
hypointensity of the L4-5 disc(arrowhead) and adjacent
vertebral bodies(asterisks) with irregular, poorly defined

due to its very

endplates and a ventral epidural soft tissue process (arrows).
after IV gadolinium administration demonstrate peripheral
high sensitivity
enhancement of the disc (arrowheads) and marked vertebral
enhancement (asterisks). A moderate amount of uniformly
and specificity
enhancing soft tissue is present in the ventral spinal canal
at the L4-5 level (arrows), suggesting epidural inflammatory changes.
 Osteoporosis
• Osteoporosis : low bone mass and loss of
bone tissue.
• Leads to weak and fragile bones
increasing risk for fractured bones,
particularly in the hip, spine, and
wrist.
 Osteoporosis
• The main radiographic features of generalized
osteoporosis are:
1. Reduced bone density and increased radiolucency.
2. Cortical thinning.
3. Spinal radiography show vertebral fractures.
4. Kyphosis of the thoracic spine, obvious to the clinician as
“Dowager's hump."
Osteoporosis
 Disc prolapse

• MRI is the choice.

• Posterior herniation of the L4/5 disc.

• Transverse image show Herniation
into the right side of the spinal canal.
• Right L5 nerve root is compressed.