MD: Evaluation of the Spine

Alignment and Anatomy of CT

-Coronal reformats (like AP radiographs) and sagittal reformats (like lateral radiographs) are best for assessing alignment or deviations

Bone density of CT

-Cortical bone is most dense, and cancellous bone is less dense -Assess for destruction or breaks

disk integrity on MRI

-Evaluate disc height and hydration -Accuracy of diagnosis of intervertebral disc herniation has been limited by a lack of agreement on terminology

vertebral ring apophyses

At approximately age 6, ___________ appear on the anterolateral superior and inferior surfaces of the middle and lower thoracic and upper lumbar vertebrae. these apophyses appear as thin rims of bone slightly separated from the vertebral body. complete at 18yo. radiographic indicator of skeletal age.

CT myelogram

Combination of myelography and CT imaging. Water-soluble contrast media injected into posterior subarachnoid space. Provides ability to see any abnormalities affecting spinal cord, spinal canal, nerve roots, and blood vessels. Invasive and caries risks.

AP open-mouth Swimmer's lateral Oblique views Lateral views in flexion and extension

Common optional projections for the C-spine

Reasons for MRI Imaging in Thoracic Spine

Direct visualization of the spinal cord, nerve roots, and discs.

Value of MRI in visualizing the Cervical Spine

Direct visualization of the spinal cord, nerve roots, and discs.

rib foramen

Formation of an opening within the shaft of the rib. AP or PA film: Note radiolucent oval within the shaft of the rib.

compression fracture to the anterior column

A frequent type of thoracic spine injury involving only one column is a ____________. When greater force is imposed, this one-column injury can become a two-column injury as the posterior column ligaments become damaged. the most common spinal injury detectable on radiographs in all age groups

bone signal on MRI

Assess for irregular signal intensities signifying disease or infection that may be localized or an extension from adjacent tissues

CT scan

If a C-spine fracture is highly suspected, _________is required (ACR 2009) because gives better detail of upper C-Spine. _________ give much better detail of the upper C-spine

false

In flexion, the spinal lines in a lateral radiograph will no longer lie parallel to each other. True False

AP projection view

Looking at the general alignment of columns, vertebral bodies and the zygapophyseal joints: Normal spatial relationship on _______ is: a. Spinous processes midline b. Equidistant between midline spinous process and pedicles on either side

cauda equina syndrome

Loss of rectal tone, urinary retention, saddle anesthesia, and loss of bulbocavernosus reflex with sacral sparing - Surgical emergency!!!!!! complication of lumbar stenosis.

National Emergency X-Radiography Utilization Study (NEXUS)

Low risk rule was designed to help identify those with that sustain an injury and do NOT need diagnostic imaging for the cervical spine. There are 5 criteria that you ask about the individual's clinical presentation, and if all 5 are met, no imaging is required. If all 5 criteria are met, the test has high sensitivity (99.6%) and high predictive value

why is posterior oblique for the sternum the best?

To assess the sternum without superimposition of the heart. To assess the SC joint without superimposition of the other bony and soft tissue structures at this region.

T1- weighted MRI

___________highlight fat, which is what the marrow of the vertebral bodies consists of. Therefore, when looking for compression fractures, MRI is a much more sensitive test compared with radiographs. MRI is also best for detecting other disease processes which may lead to fractures

Articular pillar

_________views can be obtained if a c-spine facet fracture is suspected.

anterior spinal line

anterior margin of the vertebral bodies. red.

Posterior longitudinal ligament

attaching to the posterior margins of the vertebral bodies and intervertebral disks and decreasing in width as it descends from the axis to the sacrum

structural scoliosis

characterized by an inflexible curvature that remains unchanged during lateral flexion to the con vex side. More than 50 pathological conditions are associated with _________. However, approximately 80% of __________cases are termed idiopathic scoliosis because the etiology remains unknown

signs of osteoporosis

classic radiologic hallmarks of increased radiolucency, cortical thinning, and trabecular changes.

AP projection Lateral Projection

common projections for the C-spine

Barge's angle:

coned lateral lumbar xray. WBing lateral view. Line is drawn along sacral base, and a second is drawn parallel to the vertical edge of the image. The inferior intersecting angle averages 53°, with a standard deviation of 4°.

MRI is highly sensitive at detecting:

disc height loss loss of disc signal (dessication of the disc) = disc will appear as darker signal intensity on T2 weighted image annular fissures osteophytes disc herniations synovial joints erosion changes of bone (with RA)

3.5 mm

greater than ________ translation or anterior displacement of the vertebral body suggests a significant problem with cervical stability.

false negatives

if the person is unable to perform greater than 60 degrees of cervical ROM in the sagittal plane for a flexion-extension radiograph, you may get a ____________. You may see MRI and Flex-Ext Radiographs both used to identify the instability, especially for cases of persistent concerns for instability.

cervical retraction exercises

in RA patients and those with unstable Anterior Atlanto-Dens interval you want to stay away from _____________

knees straight or flexed

in lumbar xrays, need to determine if the pts _____________. straight causes distortion and excess lordosis.

discs

intermediate intensity on T1 high intensity on T2

spinal cord and muscle

intermediate intensity on both T1 and T2

Intertransverse ligaments

joining adjacent transverse processes

Ligamenta flava

joins adjacent lamina

Cervical Rib

visualize a cervical rib on radiograph. Having an extra rib is considered to be a risk factor with thoracic outlet compression syndrome. However, only about 10% of those born with this cervical rib have been shown to develop the syndrome.

back pain

with __________, no imaging be acquired within the first month of onset in the absence of certain red flags at initial examination.

transitional vertebra

you may have a patient that tells you, "My doctor says I have an extra bone in my back." This is known as lumbarization of S1. It occurs in < 12% of the population and there is no evidence to support a link with LBP.

Three types of idiopathic scoliosis

Infantile Juvenile Adolescent

Discography

__________ may be appropriate for surgical candidates. Radiopaque dye is injected into the nucleus and dispersed through any fissures in the annulus; Value: pain provocative test through distention of the annulus.

Vertebral compression fractures

___________ are commonly associated with chronic back pain, limited spine mobility, and social isolation. Existence of one previous vertebral fracture increases the risk fivefold for subsequent _________ at multiple levels and threefold for hip fractures Identified on radiograph by the wedge deformity. Most are stable fractures, meaning neurologic status is not threatened by the fracture. MRI or CT scan should be used.

Odontoid fractures

___________ are especially common in the geriatric population (often will present with neck pain and no neurologic deficit).

Radiologic Signs of Cervical Spine Trauma

___________ includes examination of the soft tissues, vertebra alignment, and joint characteristics

sagittal MRI

___________ is best for assessing normal alignment or deviations that signal fracture, dislocations, or bone destruction

Coronal reformats and sagittal reformats

________________ are best for assessing spinal alignment or deviations in the thoracic spine

anterior longitudinal ligament

The thoracic spine is supported anteriorly by the __________ attaching to the anterior margins of the vertebral bodies and intervertebral disks, increasing in width as it extends downward from the atlas to the sacrum

The goals of thoracic spine radiographic examination are to:

(1) Identify or exclude anatomical abnormalities or disease processes of the spine(2) Examine sternum for fracture, inflammatory processes or other pathology.

standard projections for lumbar spine

AP view Lateral view

Rudimentary 12th rib

Arrested development of the 12th pair of ribs. AP film: Small, irregularly shaped stubs of bone are present instead of wellformed ribs.

torn posterior ligament complex

An increase in space at one interval level may indicate a ______________

Axial Sequence

Best for viewing: IV disc contour Nerve roots Intervertebral foramina Spinal Canal Facet joints Ligamentum flavum

burst fracture

Characterized by multiple pieces of bone; often occurs at bone ends or in vertebrae

Ankylosing Spondylitis

Chronic, progressive, inflammatory arthritis Characterized by joint sclerosis and ligamentous ossification First manifested as stiffness in the SIJ, progressing eventually to the lumbar and thoracic spine. Men affected 7x more often than women Onset usually in the 20s Diagnosis confirmed by C-reactive protein, erythrocyte sedimentation rate, plasma viscosity, and HLA-B27 First appears on conventional radiographs as abnormal narrowing of the upper half of the SIJ Fusion of joint spaces eventually occurs Anterior borders of the vertebral bodies "square off" in early stages of the disease In later stages, bridging of the vertebral bodies occurs, as well as fusion of the facet joints and intervertebral joints. "Bamboo spine"

Value of CT Scan in visualizing the Cervical Spine

Detailed depiction of bone

Radiographic Examination of Scoliosis are used to:

Determine or rule-out etiology of the scoliosis Evaluate the curvature size, location and flexibility (determine structural v non-structural) Determine skeletal maturity (bone age) [see p 250 for further explanation] Monitor progression OR regression of the curvature

Congenital synostosis

Developmental fusion of adjacent ribs. AP or PA film: Note fusion of adjacent ribs.

Spondylolysis

Defect at the pars interarticularis May be congenital (rare), traumatic, or as a result of a stress fracture from chronic strain Mechanism of Injury: Traumatic or stress fractures are highly associated with repetitive mechanical loading, particularly with extension Most common at L4-5 and L5-S1 Can be Unilateral or Bilateral Common sports: Weight-loading sports (weight lifting), repetitive trunk rotation sports (tennis, baseball, golf), and hyperextension sports (diving, gymnastics, swimming, volleyball, linemen in football) Greater risk if the patient has more coronally oriented facets or have asymmetries due to facet tropism Clinical Presentation: Non radiating, unilateral low back pain Pain exacerbated with loading at the site (trunk extension/rotation, upright single leg standing)

Spondylolisthesis

Forward displacement of one vertebra upon the stationary vertebra beneath it. Can also be called anterolisthesis Retrolisthesis refers to posterior displacement of a vertebra, L4-5 and L5-S1 are most often affected. Can be associated with spondylolysis, congenital or developmental aberrations, pathological processes, or degenerative changes. Clinical Presentation: Complaints of pain following athletic activities or physical labor Lumbar flexion reduces or eliminates pain. Why? Palpation of the spinous processes reveals either a rotation or a deep depression. Rotation is an asymmetrical slip, resulting in a unilateral spondylolisthesis. Palpable depression or step-off is the "spinous process sign."

spinous process sign

Fracture spondylolisthesis is differentiated from degenerative spondylolisthesis through the "_________." If there is a fracture, then the forward slippage of the anterior portion of the vertebra creates a palpable step-off of the spinous processes at the interspace above the level of the slip. If degenerative, the intact vertebra slips forward as a unit, creating the step-off below the level of the slip.

Cervical Stenosis

MRI is usually the preferred method of choice since it isn't invasive and has no ionizing radiation (ACR 2009) A T2-weighted image sequence is used to visualize the CSF signal and signal changes within the spinal cord. If signal changes are seen within the cord, this can be suggestive of some type of cord damage or scarring within the cord. If MRI is contraindicated, then a CT myelogram (injection of contrast to assess both bone and neural tissues) would be done.

C1-2 and C6-C7

Majority of C-spine fractures were missed radiographically were at __________ on CT and MRI images. these Structures are superimposed, calling for additional views, such as the open-mouth and swimmers view, OR more advanced imaging techniques.

Posterior Oblique view of the sternum Normally, we should see:

Manubrium Body of sternum Sternoclavicular Joint Sternal angle Xiphoid process Costoclavicular Joints

in a lateral sternal view, normally you should see:

Manubrium Body of the sternum Xiphoid process You do not see the sternoclavicular joints or sternocostal joints. These structures should lie tangent to the central beam.

"Head and neck CT"

Neuroradiology subspecialty. IV contrast used to evaluate clinical conditions of seizures, infection, and cancer.

Lateral View of the Cervical Spine

Normal things to see: Arches of C1 Dens Vertebral bodies of C2-C7 Articular pillars and lamina Intervertebral disk spaces from C2-3 through C6-7 Spinous processes Transverse processes Facet joint surfaces Make sure that: You appreciate the spinal lines The vertebral bodies are box-shaped with distinct, smooth, curved osseous margins The intervertebral disk spaces are well preserved at each level The articular pillars and facet joints are superimposed as a pair at each level The atlantodental interval is preserved The transverse processes are superimposed over the vertebral bodies Best view for visualizing joint margins and joint spaces

bulging disc

Not a herniation Involves 50-100% of circumference Symmetrical Asymmetrical

rheumatoid arthritis

One area of the spine that we need to be particularly concerned about is the upper C-spine (C1-C2), especially for our patients with _________. Often PTs treat patients after joint replacements secondary to __________, and may be working on postural training exercises for improving gait/balance. We need to be mindful that these individuals may also have ____________ involvement of the cervical spine. __________ can involve the Dens, which can lead to possible C1-C2 subluxation.

herniation

Protrusion - Broad-based (25-50%, 90-180o). Focal ≤25% (<90o) Extrusion- Narrower neck. Sequestered or free fragment Location of _______ defined in 2 planes: Axial plane-zones Sagittal plane-levels

C1-C2 subluxation

Someone with a ___________ may be predisposed to fatal injury with relatively minor trauma. They may present with normal cervical ROM. Can be readily seen on CT scan MRI best at visualizing the neurologic changes

T

T/F: Back pain often resolves without a definitive diagnosis, thus the utilization of radiographs in acute cases has been questioned.

T

T/F: T12 compression fracture commonly associated with calcaneal fracture due to compressive forces of landing

false

The AP view of the lower cervical spine is the best projection to show the intervertebral disc space. True False

False

The Spinolaminar Line in the thoracic spine should angulate posteriorly in an extended position in a stress view. The Lateral Projection of the thoracic spine is the best view to capture the vertebral body of T2. True False

Lateral Projection View

There are 3 basic lines of reference at which to look at the ________ images: 1. Anterior Spinal Line 2. Posterior Spinal Line 3. Spinolaminar Line Normal vertebral alignment assessed on _________ via intact parallel relationship of these three lines of reference in any degree of flexion or extension.

Canadian C-Spine Rules NEXUS low risk rule

These Two Clinical Decision Rules (CDRs) provide clinicians with guidelines to assist decision-making following a suspected trauma to the cervical spine. These two guidelines are meant to identify individuals at risk of significant cervical injuries such as fracture, dislocation or ligamentous instability requiring diagnostic imaging. These CDRs help clinicians determine (1) whether the patient presents with potential for significant cervical injury, and (2) whether radiographic examination is or is not needed.

What would be different about the posterior oblique image to assess the SC joint instead of the sternum?

The central ray would be moved superiorly on the pt to the level of the SC joint.

See page 171 in the text.

The retrotracheal space is the distance from the posterior wall of the trachea to the anteroinferior aspect of __________ , which should be _________ mm in adults and __________in children.

Right Anterior Oblique (RAO)

The right anterior side of the pt's neck is closest to the image receptor. This position will open the right intervertebral foramen, so it is one of the positions that can be used to image the RIGHT intervertebral foramen.

Right Posterior Oblique (RPO)

The right posterior side of the pt's neck is closest to the image receptor. This position will image the LEFT intervertebral foramen.

rib stress fracture

Usually misdiagnosed as intercostal muscle strain May require CT or cone scan to diagnose Ultrasonography is far superior to radiographs, but is very time-consuming and hard to perform if under the clavicle or under the scapula

lateral view thoracic spine normally you should see:

Vertebral bodies Pedicles, laminae, and spinous processes Intervertebral foramina Facet joints that are visible Axillary portion of the ribs Diaphragm

Sagittal Plane MRI is Best for viewing:

Vertebral bodies (bodies have higher signal than disc in T1, but lower in T2) Disc signal, disc height, posterior contour (if you see a horizontal band through the disc that has a lower signal, this is fibrous tissue that is a sign of normal maturation) Epidural space Spinal canal, spinal cord Anterior and posterior longitudinal ligaments Interspinous and supraspinous ligaments Pathology at L5-S1

See page 170.

When examining the lines of the cervical spine, the spinal canal should lie in between Lines _________ and __________

c

You are reviewing radiographs of a 26 year old patient with neck pain. The Atlanodental Interval measures 3mm. How should you proceed? a. Continue with treatment as needed. This value is normal. b. Continue with treatment, but recommend to the patient that he may want to follow up with the primary care physician when it is convenient. c. Calmly call an ambulance or recommend that the pt's family member drive the patient to the emergency room.

Oblique views

a ________ c-spine projection gives: Assessment of neural foramina. Can be a right or a left. Setting up "________" involves turning the patient's body and head 45° from the lateral position. There are 4 Oblique images that can be obtained: Right Anterior Oblique (RAO) Right Posterior Oblique (RPO) Left Anterior Oblique (LAO) Left Posterior Oblique (LPO) Normal things to see: Vertebral bodies Pedicle, lamina, and spinous process at each level Inferior and superior articulating processes of the facet joints Intervertebral foramina Contralateral pedicle Angle of the mandible Thoracic ribs

posterior spinal line

posterior margin of the vertebral bodies. brown.

Articular capsules

supports the facet joints

sternal body

the 3rd-6th ribs attach to the __________.

sternal manubrium

the first fib attaches to the _______.

spinolaminar line

the junction of lamina and spinous processes. green

Scheuermann's Disease

common condition of adolescent boys and girls in which backache and thoracic kyphosis are manifestations of osteochondrosis of secondary centers of ossification in the spine. affects the lower thoracic an upper lumbar spines, resulting in a thoracic kyphosis as well as a 50% occurrence of scoliosis. It is one of two conditions believed to mimic vertebral fractures in the thoracic spine

IntrAvertebral disc herniations:

Commonly due to weakening of the vertebral endplate (Osteoporosis of Scheuermann's disease), but can be due to acute trauma. The nuclear material protrudes into the vertebral body, which produces Schmorl's notes (small osseous cavities in the vertebral body). The nuclear material that protrudes at the anterior edge of the vertebral body can cause a triangular fragment of bone that can become departed from the body (limbus vertebra). usually asymptomatic IF they occur in isolation and without associated trauma.

Tuberculous Osteomyelitis (Pott's Disease)

secondary to a tuberculous lesion elsewhere in the body. Back pain is the earliest and most common symptom, with nerve root or spinal cord compression occurring in 50% of cases. Pain is usually localized and most common in the thoracic spine. A focal kyphosis is seen at the level of vertebral collapse. Standing and ambulating increase pain. Systemic manifestations such as weight loss, fever, and fatigue are usually present. As the infection progresses, a paravertebral abscess spans several vertebrae, with infection spreading up and down the spine under the anterior and posterior longitudinal ligaments. Lower thoracic vertebrae are the usual sites

right/left oblique xray of sacrum, normal to see:

Ilium Wing of the sacrum Sacroiliac joint Potentially some gas bubbles

CC junction - CT junction

Radiologic examination of the cervical spine includes the entire cervical spine from the _________ to the superior endplate of the first thoracic vertebra (_________)

Left Anterior Oblique (LAO)

The left anterior side of the pt's neck is closest to the image receptor. This position will open the left intervertebral foramen, so it is one of the positions that can be used to image the LEFT intervertebral foramen.

Left Posterior Oblique (LPO)

The left posterior side of the pt's neck is closest to the image receptor. This position will image the RIGHT intervertebral foramen.

spinal fractures

The literature supports the superiority of CT over radiographs in the detection of ___________. Some factors that account for this are that noncontiguous spinal injuries are often multiple (as many as 25%); thus identification of a spina fracture at one level may imply a need to survey the remainder of the spine.

thoracic kyphosis

The normal ___________ increases with postural maturity, from approximately 20 degrees in childhood to approximately 30 to 40 degrees in adulthood.

6

The normal value of the retropharyngeal space is ________mm or less.

Non-displaced rib fracture

Vertical or oblique fracture line with offset of cortical margin. Presence of soft-tissue density may be hematoma associated with nearby fracture. Better seen on follow-up radiographs since callous formation is seen 10-14 days post injury

cervical spine screen questions

Was the onset traumatic or not? Is there neurologic involvement? If so, is it suggestive of peripheral or central in origin? Any suggestion of a serious pathology? History of cancer or other bone disorders? Mechanical integrity/stability?

Schmorl's nodes

Weakening of the cartilaginous endplates that permit herniation of disk material through the plates and into the vertebral body. Associated with developmental weakness of the endplates, trauma, or various pathologic conditions that weaken bone, such as osteoporosis, Paget's disease, DJD, sickle cell anemia, Scheuermann's disease, and malignancies. Common in thoracic and lumbar spines. Lateral film: Protrusions of disk material into the body create cavities that eventually ossify. These cavities then radiograph as distinct squared-off sclerotic nodes. More nodes may be present but not seen on radiograph if the cavities have not ossified yet.

Between the Posterior Spinal Line and the Spinolaminar Line

Where would you find the spinal canal in the lateral view conventional radiograph?

Abnormal Joint Relationships in C-spine

Widened atlantodental interspace Widened interspinous space Widened intervertebral disk space Narrowed intervertebral disk space Facet disarticulation

Abnormal Soft Tissues in C-spine

Widened retropharyngeal space (normally 2-5 mm at C2-C4) Widened retrotracheal space (normally 18-22 mm in adults at C5-C7) Displacement of prevertebral fat pad Tracheal displacement Laryngeal displacement

infantile idiopathic scoliosis

appears before age 3 and may include neurological involvement. Many cases resolve spontaneously, although some progress to severe deformity.

Adolescent idiopathic scoliosis (AIS)

appears between age 10 and skeletal maturity at a 7:1 female:male ratio. The condition may become apparent at puberty or during a growth spurt. Skeletal maturity usually arrests the progressive development of a curve and also halts the effectiveness of treatment. Surgical treatment may be required if nonoperative treatment fails to halt curve progression.

Juvenile idiopathic scoliosis

appears between ages 3 and 10, more often in girls, and presents a high ris for progression

effacement (indention from adjacent structures) has 2 kinds:

- Mechanical narrowing from degenerative changes from posterior vertebral body endplates, discs, arthritic facets, free fragments, or thickened ligaments - Intramedullary disease, such as demyelinating, neopastic, degenerative, inflammatory, and congenital. Can be taken with or without contrast.

Canal space/Central nervous system on MRI

-Assess spinal canal space on both sagittal and axial views. -Contents of thecal sac can be assessed -Look for effacement -Evaluate for intramedullary disease

Canal space of CT

-Assess the canal space on axial views for patency -Look for encroachment through central canal or lateral recesses -Identify floating free fragments

Cervical Radiculopathy

-see a higher contribution of bony origin, especially in the geriatric population -typically MRI is the imaging tool of choice for diagnosing this condition CPR consists of 4 tests, upper limb tension test, ipsilateral rotation < 60 degrees, reduction of symptoms with traction and Spurlings test. If the individual tests positive on all 4 of the tests, there is a 90% probability of having a diagnosis of _____________.

NEXUS criteria

1. No tenderness to palpation of posterior midline C-spine (over spinous processes) 2. Alert and oriented 3. No focal neurological deficit 4. No evidence of intoxication 5. No other clinical evidence that would distract from cervical spine injury

Luschka's bifurcated rib

A split at the anterior end of an upper rib. AP or PA film: Note bifurcation of rib creating radiolucent area.

sacrum

A vertical line through L3 should fall through the anterior 1/3 of the ________. If more than 1-2 cm anterior, there is an anterior weight-bearing, which will increase the shear stress on the lower lumbar discs and facets. This is more valuable if the image is taken in a standing position.

lumbar ribs

Accessory ribs seen most often at L1. These ribs may have all the characteristics of a thoracic pair of ribs or may present only as rudimentary stubs of bone. AP film: Note either well-developed thoracic-like rib pairs present at L1 or small, irregularly shaped stubs of bone that are distinct from the transverse processes.

CT Imaging in the Lumbar Spine indications

Acute trauma in adults Degenerative conditions and osteoarthritis Post-operative evaluation of bone graft or instrumentation fusion Infectious processes of the spine Image guidance for spinal interventions Neoplastic conditions and complications Inflammatory lesions and crystal deposition disease Congenital or developmental spinal abnormalities Spinal cord Syrinxes and other intrathecal masses Contraindicated use of MRI

CT Imaging in Thoracic Spine Indications:

Acute trauma in adults Degenerative conditions and osteoarthritis Post-operative evaluation of bone graft or instrumentation fusion Infectious processes of the spine Image guidance for spinal interventions, such as ESIs Neoplastic conditions and complications Inflammatory lesions and crystal deposition disease Congenital or developmental spinal abnormalities Spinal cord Syrinxes and other intrathecal masses Contraindicated use of MRI

Degenerative Joint Disease (DJD)

Affects zygapophyseal (facet) joints Articular cartilage thinning Subchondral bone sclerosis Eburnation Osteophytosis Decreased facet joint space Sclerosis Osteophytosis at joint margins

CT with sagittal and coronal views or both CT and MRI

After acute trauma, if the patient meets the clinical criteria for the CDR or the NEXUS, then the current ACR Appropriateness Guidelines for suspected spinal trauma recommend a ________________ as complementary studies be used for further assessment of instability or myelopathy

Hyperflexion

Ant. Col: Vertebral body compression fracture Mid. Col: Tear of posterior longitudinal ligament (PLL) Post. Col: Tear of posterior ligament complex (PLC), dislocation of facet joints

Hyperflexion plus rotation

Ant. Col: Vertebral endplate fracture, disk rupture Mid. Col: Tear of PLL Post. Col: Tear of PLC; dislocation or fracture at facet joints

Spondylosis Deformans

Anterior or anterolateral disc herniation resulting in anterior or anterolateral vertebral endplate osteophytosis Claw-like spurs cupping toward intervertebral disc - present at more than 1 level, but distinguished from DISH

exhallation

Better exposure of the lower ribs in an PA or AP view is achieved when the patient ___________. It allows for elevation of diaphragm and viscera, as well as allows for more homogenous soft-tissue density to view the ribs.

foraminal encroachment

CT scans are the best imaging modality for revealing ___________.

"Abdominal or Pelvic CT"

CT study of the organs in the abdominal cavity as well as evaluate the lumbosacral spine (due to the proximity) "Gold standard" with contrast for imaging abdominal or pelvic pain or trauma imaging MRI rarely used due to poor image quality secondary to visceral motion

MRI with contrast

Common variation of standard MRI. Paramagnetic contrast allows molecules to align in the magnetic field and can be manipulated. Used for demonstrating suspected infection, spinal cord lesions, or evaluate post-operative spine to differentiate scar tissue from residual disc material

Pectus carinatum

Congenital abnormal prominence of the sternum. Commonly termed "pigeon breast." Severe cases increase the AP diameter of the thorax enough to impair coughing and restrict the volume of ventilation. Surgery may be warranted to place the sternum in a more normal position via resection of the costal cartilages. Lateral film: Note anterior position of sternum.

Pectus excavatum

Congenital condition in which the sternum is abnormally depressed. Commonly termed "funnel chest." Severe cases may compromise functioning of the heart and lungs and require surgical intervention. Lateral film: Note posterior position of sternum.

Ligamentous Injury

Controversial injury patterns because the characteristics of motion are controversial. Conventional radiographic examination of the SIJ cannot evaluate stability or instabilities. Presence of acute inflammation or degenerative changes that may accompany SIJ dysfunction can be evident

Indications for MRIs in the Cervical Spine

Degenerative disc disease Extradural soft tissue and bony neoplasms Intradural masses or leptomeningeal disease Intramedullary tumors Treatment fields for radiation therapy Intrinsic spinal cord pathology Spinal vascular malformations and/or cause of occult subarachnoid hemorrhage Syringohydromyelia Congenital spinal abnormalities/scoliosis Postoperative intraspinal fluid or postoperative soft tissue changes Meningeal abnormalities Spinal infections Preoperative assessment for vertebroplasty/kyphoplasty

hemivertebrae

Failure of one half of the vertebral body to grow. Often associated with other vertebral anomalies. In isolation a hemivertebra will become the apex of a structural scoliosis. Common in lower thoracic and upper lumbar spines. AP film: The involved vertebral body presents a triangular appearance. Adjacent disk spaces are of normal height but adjacent vertebral endplates may be deformed, slightly altering the shape of the bodies.

1, 11, 12

Each rib head forms a costocentral joint with two adjacent vertebral bodies and the interposed intervertebral disk. Each rib tubercle forms a costotransverse joint with a transverse process except for ____________ which only attach to one vertebral body.

lumbar spine

Intervertebral disc heights should be largest in ___________. There is a normal wedge shape of the disc in lower lumbar segments, particularly L5-S1.

Rule of treatment for fracture management

If it acts like a fracture but radiographs are negative, treat it as a fracture (immobilize!) and reevaluate with radiographs in 1 to 2 weeks. If a fracture is present, it will announce itself on the follow-up radiograph by localized density changes at the fracture site. If a fracture is not present, the patient has only suffered minor inconveniences. The good sense of this fracture management principle avoids the detrimental possibilities of an unstabilized fracture and the reality of malpractice actions. Errors on the side of caution rarely have adverse outcomes

do you order imaging for LBP?

If the person is younger than 50 years of age and there is no indications of systemic disease imaging isn't necessary. Imaging won't add value to initiation of care. If the person is over the age of 50 OR there are suggestions of systemic disease routine radiographs and lab tests can almost completely rule out systemic disease. Advanced imaging (CT scan, MRI) is considered reserved for surgical decision-making OR strong suggestion of systemic disease.

CT with contrast

Iodine-based contrast enhances density of blood vessels and vascular tissues. Can evaluate vascularity of a tumor or define an epidural infection. allows molecules to align in the magnetic field and can be manipulated

normal things to see on AP view lumbar xray

Lumbar vertebral bodies Spinous processes Pedicles Transverse processes Superior and inferior articular processes Sacrum Psoas shadow If vascular tissues have been calcified, you can see them on x-ray

nerve roots and SC

MRI is first choice to assess ___________

Os Odontoideum

Many children with Downs Syndrome may be born without a transverse ligament or have a condition known as ___________. The odontoid peg does not fuse with the rest of C2, putting these individuals at risk of having an unstable upper cervical spine.

conventional radiography

Many disorders of the cervical spine are well defined by _______________, and the inappropriate use of expensive advanced imaging is discouraged . However, a complete evaluation may at times require more than one imaging modality.

rib fractures

Most common thoracic injury Usually fractured from direct blows Other examples of Mechanism of Injury: Coughing in frail people Survivors of CPR Overuse stress (rowing, golf, and pitching) Abuse in pediatric populations Classically characterized by history, localized tenderness, and deep pain on inspiration; rarely dislocate Complications: pleural punctures, hemothorax, lung punctures, pneumothorax, lung contusion

Lumbar Stenosis

Narrowing or constriction of the spinal canal secondary to adjacent soft tissue or bony enlargement Can compromise the spinal cord, the thecal sac, and the dural membranes. Often a complication or advanced stage of degenerative processes Structures that may contribute to the constriction: osteophytes at the joint margins; bony hypertrophy of the pedicles, laminae, and zygapophyseal joints; intervertebral disc bulging; displacement of the entire vertebra itself in the case of degenerative spondylolisthesis; thickening of the ligamentum flavum. Most serious complication: cauda equine syndrome.

Line 1: Anterior vertebral body line Line 2: Posterior vertebral body line Line 3: Spinolaminar line (looks like shingles in thoracic spine)

Normal alignment of a lateral thoracic view is verified by identifying the three parallel lines, like in cervical spine.

AP Lower Cervical Spine Projection

Normal things to see: Vertebral bodies C3-T1 (check uncinate processes) Spinous processes C3-T1 Large transverse process of T1 First rib and costotransverse joints Clavicles Presence of air in trachea Make sure that: Vertebral bodies are aligned relatively vertically Spinous processes are aligned in midline Distance from the spinous processes to lateral borders on each side should be equal from each side Superimposition of overlapping facet joints and articular pillars creates an illusion on one smooth column of bone on both sides of vertebral bodies (the "lateral column") Transverse processes are mostly within the image of the lateral column Air-filled trachea overlies the cervical spine at midline

Anterior disc herniation

Occurs as an injury to or weakness of the Sharpey's fibers. These fibers attach the annulus to the vertebral rim. Protrusion of the nucleus may elevate the anterior longitudinal ligament and lead to osteophyte formation at the anterior and lateral vertebral joint margins, known as spondylosis deformans. usually asymptomatic IF they occur in isolation and without associated trauma.

35 to 40

Once a patient is past _______ years of age, osteophyte lipping visible on radiograph, and a little extension of the disc beyond the vertebral body margins visible on MRI is NOT necessarily a pathologic finding if there is NO encroachment on any neural elements

Clinical Decision Rules

Our goal as physical therapists is to see if the ___________ have been appropriately applied or not during the medical screening, OR if we are acting as the primary contact clinician we may need to apply these __________ in making decisions regarding imaging referral prior to treatment. help guide decisions of when to image, not what type of image to perform

indications for lumbar xrays

Pain radiating into the legs Evaluation of scoliosis and kyphosis Ostoporosis and compression fractures Children: hip pain, limping, or refusal to bear weight Trauma involving the spine Limitation in motion Planned or prior surgery Evaluation of primary and secondary malignancies Arthritis Suspected congenital anomalies Syndromes associated with spinal abnormalities Evaluation of spinal abnormality seen on other imaging studies Follow-up of known abnormality Suspected spinal instability

thorax-abdomen-pelvis body (TAP) CT scans

Patients with serious injuries are often assessed with ___________. The data from these scans can be reformatted t evaluate the spine without further cost or radiation exposure and without additional time required to perform separate radiographic studies.

posterior ligament complex

Posteriorly, the thoracic spine is supported by the _____________. The posterior ligament complex consists of the following: Posterior longitudinal ligament, Ligamenta flava Supraspinous and interspinous ligaments, Intertransverse ligaments, Articular capsules

canal diameter

The ___________ of the thoracic spine is narrower in the thoracic spine than that of the cervical and lumbar spine. At T6, the sagittal diameter should be 16 mm, while it is 23 mm in the midcervical and 26 mm at ths midlumbar.

costo-central joints

The ______________, between the ribs and the vertebral bodies, are supported by the following: 1. Articular capsules 2. Intra-articular ligaments, blending with the fibers o the intervertebral disk 3. Radiate or stellate ligaments extending from the rib heads to the vertebral bodies and interposed disks

sternoclavicular joint

The ________________is the synovial articulation between the manubrium of the sternum and the proximal end of the clavicle. A fibrocartilaginous disk, or meniscus, is interpose between the articulating surfaces. This disk facilitates antero-posterior and supero-inferior gliding of the joint, as well as rotation of the clavicle. The principal stabilizing structure is the costoclavicular ligament

See page 168 in your text, right column, under "Radiologic Observations."

The _________are farthest from the film plate, and thus are imaged with the ________ degree of size distortion in comparison to other structures.

scoliosis

a lateral deviation of the spine from the midsagittal plane combined with rotational deformities of the vertebrae and ribs. Pathological changes due to compressive forces on the concave side of a curvature include narrowed disk spaces, wedge-shaped vertebral bodies, shorter and thinner pedicles and laminae, and narrowed intervertebral foraminal and spinal canal spaces. Pathological changes on the convex side of a curvature include widened rib spaces and a posteriorly positioned rib cage, resulting in the deforming "rib hump"

AP or PA views of the ribs normally you should see:

Thoracic vertebrae Costovertebral joints Diaphragm and heart The patient is instructed to breathe in and hold breath. It allows for depression of the diaphragm and better visualization of the ribs.

AP Thoracic Spine Normal things to see:

Thoracic vertebral bodies Spinous processes Pedicles Transverse processes Superior and inferior articular processes Ribs and their vertebral articulations

normal things to see on lateral view lumbar xray

Three lines that reference vertebral alignment Vertebral bodies Intervertebral foramina Pedicles, laminae, and spinous processes

cartilage space

Which element of the ABCS Search Pattern was most helpful for you in identifying the C2-C3 intervertebral disc

alignment

Which element of the ABCS Search Pattern was most helpful for you in identifying the spinous process of C7, transverse process of C6, pedicles of C7

soft tissue

Which element of the ABCS Search Pattern was most helpful for you in identifying the trachea?

See page 168 in your text, left column, first paragraph.

Which of the following structures would appear superimposed relative to the upper cervical vertebrae, making this projection inappropriate for upper cervical spine evaluation? a. Hyoid b. Pituitary gland c. Mandible d. Skull

butterfly vertebrae

The endplates are indented toward the center of the body and filled with continuous disk material from adjacent superior and inferior disk spaces. Usually clinically insignificant. The divided body halves are approximately symmetrical and maintain axial alignment of the vertebrae. Common in both the thoracic and lumbar spines. AP film: The lucency of the invaginating disk material creates the appearance of the vertebral body as a pair of ____________wings.

thoracolumbar vertebrae

The incidence of acute injury is highest in the _____________. The 12th thoracic and 1st lumbar vertebrae are most frequently involved and, less often, the 11th thoracic an 2nd lumbar vertebrae. Compression fractures and fracture- dislocations commonly occur in this region

c

The interpedicular distance between the opposing paired pedicles is typically _____ in the cervical spine. a. 10 mm b. 20 mm c. 30 mm d. 40 mm

Flexion-Extension Radiographs

____________may be used to detect the ligamentous injury and amount of displacement of the vertebral segment.

compressive forces

The smaller the Barge's angle and the larger the Ferguson's angles, the increase in __________at the facet joints or transverse shearing forces at the disc. These are associated with increased axial loading of the disc and facet joints.

31

The spinal cord is divided into __________different segments

right anterior oblique (RAO)

The sternum is almost impossible to see on an anteroposterior projection because of the superimposition of the denser thoracic spine. Therefore, a frontal view of the sternum is obtained by rotating the body just enough to bring the sternum out of the shadow of the spine. A posterior oblique projection, with the patient in a_____________ position, is most commonly used, as this will project the sternum over the homogeneous density of the heart, providing contrast

pedicle method

The__________ gives a value to the axial rotation of the curve.

effacement

_________ May be due to mechanical narrowing from degenerative changes

Epidural hematomas

__________ and intrinsic cord damage/blood are well seen on MRI

Sagittal MRI views

__________ are best for demonstrating alignment

dislocations of C-spine

__________ are described by the direction and amount of translation of the superior vertebral segment movement. greater than 3.5 mm translation or anterior displacement of the vertebral body suggests a significant problem with cervical stability. ___________ can occur with or without fractures.

Cobb method

__________ is a common radiographic measurement of the scoliotic curve in the frontal plane, based on the Anteroposterior projection view. Gives a value to the deviation of the spine from the mid-sagittal plane

Flexion forces

___________ account for approximately 90% of compression fractures; lateral bending forces account for the remaining 10%

cortical bone and ligaments

low intensity on both T1 and T2

Supraspinous and interspinous ligaments

joins adjacent spinous processes

CSF

low intensity on T1 high intensity on T2

right/left lumbar oblique xrays

make sure you can see The "Scottie dog" appearance of the pars on ___________. Preferably, the Scottie dog should not have a radiolucent "collar", which indicates a fracture.

diaphragm

upper ribs, 1 to 9, which can be visualized above the density of the __________, and the lower ribs, 8 to 12, which can be imaged with altered exposure below the level of the __________

T2 weighted MRI

used to assess for "bone bruises" or marrow edema

soft tissues of CT

-Examine the prevertebral soft tissues sagittal for presence of edema from trauma

Disk integrity of CT

-Evaluate posterior and posterolateral margins on axial views for contour and intact borders

soft tissue on MRI

-Examine paravertebral soft tissues for presence of edema due to trauma, primary neoplasms, infection, or extension of masses -Inspect integrity of ligaments and spinal cord

Thoracolumbar or other coned views

A coned view is a close-up view of a designated area. Cone refers to the circular aperture attachment on the x-ray tube, which limits the exposure field

right convex thoracic curve

The most frequently seen curve is the ___________. The major curve ex tends from T4-T6 to T11-L1.

True

The lateral view of the cervical spine is the best projection to evaluate the intervertebral disc space. True False

spinal tumors

The vast majority of _________ are meta static. In persons over the age of 30, most are in the thoracic and lumbar spine. ________ are usually characterized using multiple imaging modalities. Approximately 90% of deaths due to cancer revealed ________. The organ origins of metastases are: Breast, Lung, Thyroid, Kidney and Prostate

Oblique views of the upper thoracic region

These demonstrate facet joints. This view is not included in the routine projections because the thoracic facet joints are rarely involved in pathology

Where should the central ray be positioned to image the sternum in posterior oblique view?

body of the sternum

Ferguson's angle:

coned lateral lumbar xray. WBing lateral view. A line is drawn along the sacral base, and a second line is drawn horizontal to the edge of the image. The inferior intersecting angle averages 41°, with a standard deviation of 2°.

sternal angle

the second rib attaches to the __________.

primary indications for CT of cervical spine

Acute trauma in adults Degenerative conditions and osteoarthritis Postoperative evaluation of bone graft or instrumentation fusion Infection processes of the spine Image guidance for spinal interventions Neoplastic conditions and their complications Inflammatory lesions and crystal deposition disease Congenital or developmental spine abnormalities Spinal cord syringes and other intrathecal masses when MRI is contraindicated Contraindication of use of MRI

Hyperflexion over fixed horizontal restraint; "seatbelt injury"

Ant. Col: Horizontal body fracture Mid. Col: Horizontal body fracture Post. Col: Fissuring of laminae, pedicles, and transverse processes

Hyperextension

Ant. Col: Rupture of anterior longitudinal ligament and intervertebral disk Mid. Col: Compression of posterior disk Post. Col: Compression fracture of vertebral arches or dislocation of facet joints

Hyperflexion plus shear: "traumatic spondylolisthesis"

Ant. Col: Shear fracture through vertebral body or disk Mid. Col: Body fracture and PLL tear Post. Col: Fracture of pedicles and PLC tear

MRI of the Thoracic Spine Indications:

Degenerative disc disease Extradural soft-tissue and bony neoplasms Intradural extramedullary masses Intradural masses or leptomeningeal disease Intramedullary tumors Treatment fields for radiation therapy Intrinsic spinal cord pathology Spinal vascular malformations Occult subarachnoid hemorrhage Syringohydromyelia Congenital spinal abnormalities/scoliosis Post-operative intraspinal fluid or post-operative soft tissue changes Meningeal abnormalities Spinal infections Pre-operative assessment for vertebroplasty or kyphoplasty

MRI of the lumbar Spine Indications:

Degenerative disc disease Extradural soft-tissue and bony neoplasms Intradural extramedullary masses Intradural masses or leptomeningeal disease Intramedullary tumors Treatment fields for radiation therapy Intrinsic spinal cord pathology Spinal vascular malformations Occult subarachnoid hemorrhage Syringohydromyelia Congenital spinal abnormalities/scoliosis Post-operative intraspinal fluid or post-operative soft tissue changes Meningeal abnormalities Spinal infections Pre-operative assessment for vertebroplasty or kyphoplasty

Degenerative Disc Disease (DDD)

Dehydration of the disc Nuclear herniation Annular protrusion Fibrous replacement of the annulus Intravertebral herniation of nuclear material Accumulation of nitrogen gas in fissures of disc Decreased disc space height Osteophytes at vertebral endplates Schmorl's nodes Vacuum phenomenon Remember, healthy discs in T2-weighted MRIs should appear bright white due to their water content.

Reasons for CT Imaging in Thoracic Spine

Detailed depiction of bone

Erb's anomoly

Diminished size or incomplete fusion of one or both first ribs. AP or PA film: Note malformation of first ribs. May see congenital synostosis of the first rib to the second rib

When to image for a disc:

Failure of conservative treatment. Other treatment options need to be explored. Exception: signs/symptoms of cauda equine syndrome

cross-table lateral, AP, and AP open-mouth

In cases of c-spine trauma,___________ views must be obtained on an immobilized patient prior to moving the patient.

b

In order to identify the vertebra that you are examining, at what vertebral level should the ribs begin (i.e. the first rib articulation)? a. C7 b. T1 c. T2

b

In order to identify the vertebral levels you are looking at, at what intervertebral level do the discs begin? a. C1-2 b. C2-3 c. C3-4 d. C4-5

pediatric population

In the __________, AP, lateral and open-mouth projections are often sufficient for most clinical indications. Additional views are less indicated than for adults, but would include the same views discussed above.

right oblique

In the clinic or in the hospital setting, the terms the "_________" would refer to the patient's right IV foramina are visible.

Sacroiliitis

Inflammation of the synovial portions of the SIJ Unilateral or bilateral Etiologies: inflammatory disorders, arthritides, infection, or early degenerative processes Lower half of the joint appears wide due to progressive inflammatory erosions In later subacute stages, the joint spaces will appear narrowed and exhibit other changes typical of DJD

20 mm

Interpedicular distance is normally __________, and represents the transverse diameter of the spinal canal.

radiologist consultation

Prior to initiating treatment, PTs should review the __________ if one exists. Equally as important, do not rely of the results of any imaging study alone. Physical evaluations, particularly ligamentous stability tests, should be performed on every patient who has sustained a cervical spine trauma.

IntERvertebral disc herniations:

Protrusions of the disc material in a posterior or posterolateral direction that have the potential to compromise the spinal canal and its contents. May result from trauma or preexisting degenerative conditions that gradually weaken the elasticity and resilience of the annulus and posterior ligaments. The disc is unable to withstand normal stresses. can cause LBP and radicular pain. Symptoms are typically aggravated with active or repetitive flexion, prolonged sitting, or performing a Valsalva maneuver. Pressure on the nerve root can result in paresthesias, decreased DTRs, and decreased muscle strength. If cauda equina occurs, it is a SURGICAL EMERGENCY!

Atlantodental Inferface:

Represented by radiolucent line anterior to the articulating facet of the dens. This width should remain constant with any position of neck flexion or extension due to the transverse ligament. An increase of more than 3 mm indicates a C1-2 subluxation.

Abnormal Vertebral Alignment in C-spine

Reversal of lordosis Acute kyphotic angulation Rotation of vertebrae Widened intervertebral space Step-offs in vertical alignment

Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Rheumatological abnormality characterized by proliferation of one at osseous sites of ligamentous and tendinous attachments, notable at the ALL Flowing ossification of at least 4 contiguous vertebrae Preservation of disc height and absence of DDD findings Absence of sacroiliitis or facet DJD

radiodense

The diaphragm may appear as ___________ , which may be superimposed over the lower thoracic vertebrae.

a, b, c

The structures that can be best evaluated in the thoracic spine are: (Select all that apply). [mark all correct answers] a. Intervertebral disc space b. Intervertebral foramina c. Vertebral bodies

transitional vertebrae

The thoracic spine is most commonly injured because of flexion forces. The vertebrae most commonly injured are the _________ of the cervicothoracic and thoracolumbar regions. These regions are predisposed to injury because they are the junctions between the relatively immobile thoracic spine and the more flexible cervical and lumbar spines

costotransverse joints

The____________, between the ribs and the transverse processes, are supported by the following: 1. Articular capsules 2. Middle costotransverse ligaments, attaching the rib necks to the transverse processes 3. Superior costotransverse ligaments, attaching the rib necks to the transverse processes of the vertebrae above 4. Lateral costotransverse ligaments, extending from the tips of the transverse processes to the nonarticular portion of the rib tubercle

Sacral insufficiency fractures.

These fractures are common in the elderly population, especially women. The fractures are often bilateral, and parallel the SI joint lines. Interesting fact: these fractures are often overlooked as a potential cause of LBP and pelvic pain. ** MRI is indicated for these individuals because it is often undetected with radiographs.

Swimmer's lateral view of the upper thoracic region

This is a lateral view with the patient's arm placed overhead, to remove superimposition of the shoulder from obscuring the lower cervical and upper thoracic vertebrae. This view is the best view to visualize C7, T1, T2, and, most of the time, T3.

Lateral Flexion and Extension Stress View:

This is an optional view. the spatial relationship between spinal lines in preserved throughout flexion and extension. Disruption may be due to fracture, dislocation, or severe degenerative changes.

Indications of Thoracic Radiographic Examination

Trauma Pain radiating around the chest wall Evaluation of malignancies Compression fractures Suspected spinal instability Planned or prior surgery Evaluation of kyphosis and scoliosis

20 to 45 degrees

Trunk flexion, extension, and lateral flexion each incur a proximately _________ of motion in the thoracic spine

35 to 50 degrees

Trunk rotation incurs approximately _____________of rotation within the thoracic spine.

block vertebrae

Two adjacent vertebrae fused at birth. Partial or complete fusion of bodies, facets; spinous processes may be present. No motion at fused segment. Excessive compensatory motion at adjacent freely moving joints with resultant accelerated degenerative changes. Common in both the thoracic and lumbar spines. Lateral film: Small AP diameter of bodies with indented "wasp-waist" appearance of the fused intervertebral disk space. Facets fused in half the cases. Spinous processes may be fused or malformed.

osteoporosis

___________ is a major public health threat for half of Americans over age 55. One in two women and one in four men will have an __________ related fracture in their remaining lifetimes. Vertebral compression fractures are among the earliest and most common of these _________ fractures. With early radiographic identification, radiologists can help initiate early treatment intervention and minimize subsequent risk of fracture 65% of vertebral fractures are asymptomatic. 30% reduction in cortical bone mass (not sensitive for detecting early change). DEXA scans more appropriate for early changes

nonstructural scoliosis

___________ is characterized by a curvature that retains flexibility and will reverse or straighten on lateral flexion toward the convex side. ________ can result from postural adaptations, nerve root irritation, inflammation, or leg length inequality

Distracting injuries

____________ are defined as acute injuries requiring immediate attention, such as long bone fractures or visceral injuries requiring surgery. Again, the utility of a CT scan to acquire all data in one exam is unsurpassed.

Atlanto-Dens Interval

____________, which is an indirect measure of the canal size. In adults, anything greater than 3 mm suggests instability. Cervical retraction exercises and isometric extension exercises tend to increase the anterior ___________ - be careful with RA pts.

Swimmer's lateral

a ________ c-spine projection gives: C7 and CT Junction because of the superimposition of the thoracic spine and scapula with a plain lateral view

AP open-mouth

a ________ c-spine projection gives: Position of dens, outline of dens, alignment of atlas ordered To examine the articulation and structures of C1 and C2. If the mouth was closed, the radiodensity of the teeth and mandible would obscure the central beam from reaching the cervical spine. Normal things to see: Base of the occiput Angle of mandible Dens and body of C2 Anterior arch of the atlas Posterior arch of the atlas Lateral atlantoaxial facet joints Transverse processes of the atlas Make sure that: Atlas positioned symmetrically on axis Equal widths of lateral masses Lateral borders of the lateral masses should not be more lateral than superior articular processes of C2 (mild may be normal in children) Dens positioned symmetrically between the lateral masses Joint spaces at lateral atlantoaxial facet articulations are of equal height C2 spinous process positioned in midline Dens superimposed on both the anterior and posterior arches of atlas

Lateral views in flexion and extension

a ________c-spine projection Assesses for instability

Intervertebral Disc Herniation

an extension of the disc material beyond adjacent vertebral margins Incidence: Most common in the 25-45 year-old age group Men more frequently than women Predominance in individuals who are obese, smoke, or are exposed to vehicular vibrations (drive 18 wheelers, school busses, construction equipment, lawn mowers) 90% occur L 4-5, small percentage L3-4, and rarely L1-2 May result from degenerative changes in the vertebral joints because excessive axial, shear, or rotational forces are increased on the disk; leads to degeneration of annulus fibrosus May result from trauma, such as compression fractures or endplate fractures Injuries to the annulus fibrosus are manifested by fissures or tears, which provide a pathway for herniation of the nucleus pulposus Herniations of nuclear material through the confines of the annulus fibrosus may occur:

Canadian C-Spine Rules

the ____________ are specifically designed to identify patients at risk for fractures, dislocations or ligamentous instability. It has been found to be highly sensitive for detecting cervical spine fractures Dangerous mechanism = fall from > 3 ft / 5 stairs, axial load, MVA at > 60 mph, rollover or ejection, motorized recreational vehicle accident, bicycle collision Simple rear-end MVA = this excludes pushed into on-coming traffic, hit by bus or large truck, rollover, hit by high speed vehicle Delayed onset neck pain = no immediate onset after the trauma