Spine x-ray interpretation

Dr. Mohamed Swailem

Specialist Radiologist
Al-Nahdha Hospital

Master Degree (M.Sc)

Fellowship of the Egyptian Board (FEBR)
Certified Arab Board
Objectives

1. Review the standard x-ray views to cervical, thoracolumbar and

sacrococcygeal spine.

2. Review radiological anatomy of the spine.

3. Review a systematic approach to spine x-ray interpretation.

4. Determine common trauma-related spine abnormalities.

Spine x-ray interpretation

1. Cervical spine.
2. Thoracolumbar spine.
3. Sacrococcygeal spine.
Whole Spine Anatomy (AP view)

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Whole Spine Anatomy (AP view)

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Spine x-ray interpretation

1. Cervical spine.
2. Thoracolumbar spine.
3. Sacrococcygeal spine.
Standard x-ray views

• Lateral view

• Anterior-Posterior (AP) view

• Open mouth (odontoid) view

Cervical vertebrae (lateral view)

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C-spine normal anatomy (lateral)

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C-spine systematic approach

Coverage: All vertebrae are visible from the skull base to the top
of T2 (T1 is considered adequate). If T1 is not visible then a repeat
image with the patient's shoulders lowered or a 'swimmer's' view
may be necessary

Alignment: Check the

- Anterior line (the line of the anterior longitudinal ligament)
- Posterior line (the line of the posterior longitudinal ligament),
- Spinolaminar line (the line formed by the anterior edge of the
spinous processes - extends from inner edge of skull)

Bone: Trace the cortical outline of all the bones to check for
fractures
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C-spine systematic approach

Disc spaces: The vertebral bodies are spaced apart by the

intervertebral discs, not directly visible with X-rays. These
spaces should be approximately equal in height

Pre-vertebral soft tissue: Some fractures cause widening of

the pre-vertebral soft tissue due to pre-vertebral
hematoma
- Normal pre-vertebral soft tissue (asterisks) narrow down to
C4 and wider below
- Above C4 ≤ 1/3rd vertebral body width
- Below C4 ≤ 100% vertebral body width

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Edge of image: Check other visible structures
Cervical vertebrae (AP view)

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C-spine normal anatomy (AP)

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C-spine systematic approach

Coverage: The AP view should cover the whole C-spine and the
upper thoracic spine

Alignment: The lateral edges of the C-spine are aligned (red lines )

Bone: Fractures are often less clearly visible on this view than on the
lateral

Spacing: The spinous processes (orange) are in a straight line and

spaced approximately evenly

Soft tissues: Check for surgical emphysema

Edges of image: Check for injury to the upper ribs and the lung
apices for pneumothorax
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Additional views

If the lateral view does not show the vertebrae down to

T1 then a repeat view with the arms lowered or a
'Swimmer's view' may be required.
Cervical injuries
Jefferson fracture (C1)

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Do you see the fracture?
C2 odontoid peg fracture

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Do you see the fracture?
C2 “hangman” fracture

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What is the difference?

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Extension tear drop fracture Flexion tear drop fracture
- Most commonly C2 - May occur at any level between C3 and C7.
- It is a highly unstable injury with a high
incidence of associated spinal cord injury.

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Bilateral perched facets

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Do you see the fracture?
Spinous process “Clay Choveller’s” fracture

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What is abnormal?

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Retropharyngeal abscess

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Spine x-ray interpretation

1. Cervical spine.
2. Thoracolumbar spine.
3. Sacrococcygeal spine.
Standard thoracic spine views
(AP and lateral)

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T-spine normal anatomy (lateral)

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T-spine normal anatomy (AP)

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Thoracic spine systematic approach

Coverage: The whole spine is visible on both

views

Alignment: Follow the corners of the vertebral

bodies from one level to the next

Bones: The vertebral bodies should gradually

increase in size from top to bottom

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Thoracic spine systematic approach

Spacing: Disc spaces gradually increase from superior

to inferior
Note: Due to magnification and spine curvature the
vertebral bodies and discs at the edges of the image
can appear larger than those in the center of the image

Soft tissues: Check the paravertebral

Edge of image: Check the other structures visible

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Standard lumbar spine views
(AP and lateral)

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Lumbar spine normal anatomy (lateral)

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Lumbar spine normal anatomy (AP)

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L- spine systematic approach

Coverage: The whole L-spine is visible on

both views

Alignment: Follow the corners of the vertebral

bodies from one level to the next (dotted lines)

Bones: Follow the cortical outline of each bone

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L- spine systematic approach

Spacing: Disc spaces gradually increase in

height from superior to inferior
Note: The L5/S1 space is normally slightly
narrower than L4/L5

Soft tissues: Check the paravertebral

Edge of image: Check the other structures visible

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L- spine systematic approach

Alignment: The vertebral bodies and spinous

processes are aligned

Bones : The vertebral bodies and pedicles are intact

Spacing: Gradually increasing disc height from

superior to inferior. The pedicles gradually become
wider apart from superior to inferior.
Note: The lower discs are angled away from the
viewer and so are less easily assessed on this view
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Lumbar vertebrae (oblique view)

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Three column model
for injury
classification

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Three column
model
Fracture
simulation

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Injury classification
• The 'three column model' can be used to form a basic classification of thoracolumbar
spinal injuries.

• Spinal injuries which are seen to disrupt structures of 2 or more columns are
considered 'unstable’.

• If the middle column is seen to be injured it is usually taken that another column
must be injured even if no anterior or posterior column fracture is visible.

• If an injury is seen which disrupts 1 column then a second fracture is also present in
approximately 15% of cases. If a 2 column injury is seen then likelihood of a second
fracture increases to 40%. RULE: If you see one fracture - check for another

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1 Column - Anterior compression injury
1 Column - Anterior compression injury

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1 Column - Anterior compression injury

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2 Column – “Burst” fracture
2 Column – “Burst” fracture

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Is this fracture stable?
3 Column- Flexion distraction “Chance”
fracture

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Osteoporotic “insufficiency” injuries

Thoracic spine - 'Wedge' compression fracture Lumbar spine - Biconcave fracture

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Do you see the fracture?
Spinous process fracture

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Do you see the fracture?
Do you see the fracture?

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Spine x-ray interpretation

1. Cervical spine.
2. Thoracolumbar spine.
3. Sacrococcygeal spine.
Sacrum (AP view)

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Sacrum (lateral view)

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Sacroiliac Joint (oblique view)

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Sacral and coccyx fractures

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Take home points

Systematic approach for spine x-ray interpretation:

1. Coverage
2. Alignment
3. Bone
4. Disc spaces
5. Pre/para-vertebral soft tissue shadow.
6. Soft tissue
7. Edge of the film
Recourses
• www.radiologymasterclass.co.uk

• www.radiopaedia.org

• www.imaios.com/en/e-anatomy

• www.radiologykey.com

• www.ce4rt.com/positioning
Thank you