General statements plain film radiography

The lateral radiograph (Fig. 4.3) is the single most important component in the radiographic assessment of the acutely injured cervical spine. Proper patient positioning is essential in obtaining a true lateral radiograph. The degree of laterallarity is assessed usually by the superimposition of the paired articular masses (Fig. 4.4). Usually, the degree of rotation of the head is indicated by

1. lack of superimposition of the angles of the mandible,

2. the articular masses and facet joints becoming superimposed upon the vertebral bodies, and lack of superimposition of the facet joints resulting in a 'bat-wing' or 'bow-tie' appearance.

If the entire body is rotated, there is usually a uniform distance between the posterior cortical margins of the articular masses at each level. If the head is rotated, there is usually a greater distance between the posterior margins of the articular masses and a concomitant decrease in the lamina space. This can be differentiated from a unilateral interfacet dislocation in which there is usually a component of both flexion and rotation [2]. Thus, on top of the rotation, there is usually anterior translation of one vertebral segment relative to another by more than 4 mm indicating the flexion component of the injury.

AP radiograph of the cervical spine (Fig. 4.5) usually visualises the cervical spine from C3 to the upper thoracic segments. It provides valuable evidence of flexion injuries such as anterosubluxation, lateral interfacet 166 dislocation, clay shoveler's fracture (see Question 13) and burst fractures of

Fig. 4.3 Normal lateral radiograph. This demonstrates all seven cervical vertebrae, down to the cervicothoracic junction. There is normal alignment of vertebral bodies, spinolaminar line and interspinous distances. In particular, the prevertebral soft tissue thickness in the retropharyngeal (anterior to C2) and retrotracheal (anterior to C6) regions is normal. Facet joints are demonstrated with long solid white arrows. Solid short arrows point to normal anterior vertebral line, posterior vertebral line, spinolaminar line, and posterior spinous process line to be intact. Projecting over the C2 body is the sclerotic ring known as the Harris ring (dotted arrow), and this is intact. If disrupted, this is suggestive of a type 3 odontoid fracture.

Fig. 4.3 Normal lateral radiograph. This demonstrates all seven cervical vertebrae, down to the cervicothoracic junction. There is normal alignment of vertebral bodies, spinolaminar line and interspinous distances. In particular, the prevertebral soft tissue thickness in the retropharyngeal (anterior to C2) and retrotracheal (anterior to C6) regions is normal. Facet joints are demonstrated with long solid white arrows. Solid short arrows point to normal anterior vertebral line, posterior vertebral line, spinolaminar line, and posterior spinous process line to be intact. Projecting over the C2 body is the sclerotic ring known as the Harris ring (dotted arrow), and this is intact. If disrupted, this is suggestive of a type 3 odontoid fracture.

the lower cervical spine. Frontal projection is the only plain film study in which the uncovertebral body process fracture can be identified [4].

The open mouth projection (Fig. 4.6) is designed to demonstrate the atlanto-axial relationship in the AP projection. It is valuable in recognising fractures of the lateral mass of C1, a Jefferson burst fracture (see Question 7), high- and low-dens fractures, atlanto-axial rotary subluxation/dislocation.

Occasionally, oblique views are helpful in demonstrating not only the intervertebral foramen and facet joint alignment, but also provides additional views of the cervicothroacic junction for alignment [2] (Fig. 4.7).

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