The examination

There is diversity of opinion regarding the initial imaging of a patient suspected of having a cervical spine injury. It is generally accepted that patients with suspected acute cervical spine injury are initially evaluated using plain film radiography. The minimum should include at least three projections: an anteroposterior (AP) view, a lateral view and an open mouth odontoid view [2]. Depending on the clinical scenario and physical condition of the patient, other useful plain film projections include oblique views which might add visualisation of the neuroforamina, facet joints and in a trauma situation they might be extremely helpful in visualising the posterolateral aspects of the lower cervical and upper thoracic vertebrae. Secondly, a swimmer's view in a trauma situation might also be helpful. This is usually obtained with one arm extended above the head and one by the side and helps to visualise the C7/T1 junction. Thirdly, flexion-extension views might be helpful, where atlanto-axial subluxation is a possibility or ligamentous damage is suspected and is usually done in trauma situations when the patient is in severe pain but the initial radiographs appear normal. This must be done under close medical supervision. The patient must control the movement himself or herself as muscle guarding will help prevent an injury.

In most trauma cases, the cervical spine may be cleared by excellent complete lateral visualisation of the cervical spine, open mouth odontoid view and AP views at the risk of missing significant fractures in fewer than 164 1% of cervical spinal injuries [3].

Depending on the clinical scenario, cervical computed tomography may be used as a screening examination (patients with neurological deficit, severe head injury, high-risk mechanism, unconscious, multi-injured patient), or as a complementary technique to radiography. Usually, magnetic resonance imaging (MRI) is indicated in all patients with partial or progressive neurological deficit after cervical spinal injury and in patients with potential mechanical instability caused by ligamentous injury or associated disc space injury.

In trauma situations, the examination of the cervical spine must cover the area from the base of the skull through the seventh cervical segment. If the cervicothoracic junction is not completely visualised by plain film radiograph, then this needs to be cleared by computed tomography (Figs 4.1 and 4.2).

The quality of the radiographic examination is extremely important. It must be of optimum technical quality to demonstrate both soft tissue and bony anatomy.

Fig. 4.2 Normal cervical spine. Sagittal CT reformats. Endotracheal tube (solid white arrow) and normal atlantodens interval (dotted arrows) with normal vertebral body alignment. Normal facets demonstrated (long white solid arrows).

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