X-ray spine

X-ray spine

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  X-RAY SPINE Dr.R.G.Unnikrishnan MD(Ay) AssociateProfessor & HOD, V.P.S.V.Ayurveda College Kottakkal 1
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  W.C. Roentgen discoveredX-rays in 1895 •Nobel Prize in physics in 1901 2
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  • Nature ofthe rays was uncertain:– X-strahlung •`Skiagraph'(from Greek for a shadow) • Later `Radiograph' • Now `X-ray' or`Radiograph' WHY X-RAY ? 3
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  Conventional angiography Nuclear medicine Ultrasonography(USG) Computed tomography (CT) Magnetic resonance imaging (MRI) Interventional radiology Positron emission tomography (PET) 4
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  5 X-Ray Most appropriate screeningtechnique if a fracture is suspected and in low risk patients. ADVANTAGES •Can quickly identify if a fracture or other suspected bony pathology is present or not. DISADVANTAGES • A fracture might not be evident on one view and often several different projections are necessary. • A fracture may be occult.
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  6 Computed Tomography (CT) Tofurther evaluate numerous musculoskeletal disorders including neoplasms and simple or complex fracture. ADVANTAGES • Fast and efficient technique • Good for bony and articular details • Both intravenous peripheral contrast and intra- articular contrast may be given. DISADVANTAGES • More radiation than an x-ray. • Metal implants cause significant metal artifact.
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  7 X-Ray CT
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  8 Magnetic Resonance Imaging(MRI) •To evaluate ligament or tendon injury •To evaluate soft tissue masses •To evaluate stress fractures and osteomyelitis ADVANTAGES  Improved ability than CT to visualize the spinal cord and other contents of the spinal canal. Excellent for looking at soft tissue, marrow, ligaments, and marrow edema.  Both intra-articular and IV contrast may be used to better delineate anatomy/pathology.
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  9 Herniated cervical disc MRI
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  10 DISADVANTAGES • Many contraindicationsincluding cardiac pacemakers, metallic foreign bodies, cerebral aneurysm clips, electronic devices. • Metallic implants cause artifacts that limit image quality. • Some patients may be claustrophobic. • Sedation may be required.
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  2 Branches •Diagnostic radiology •Radiationoncology (therapy) 11
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  Plastic sheet coatedwith a thin emulsion (silver bromide and a small amount of silver iodide) Film is exposed to ionizing radiation Chemical changes resulting in the deposition of metallic silver, which is black Amount of blackening on the film is proportional to the amount of x-ray exposure X-ray Film 12
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  13 Five basic densities •Arranged from least to most dense. AIR < FAT < SOFTTISSUE/FLUID < CALCIUM < METAL (Black to White)
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  14 PRINCIPLE • Denser anobject is, the more x-rays it absorbs, and the whiter it appears on X-rays. • Less dense an object is, the fewer x-rays it absorbs, and the blacker it will appear on X- rays.
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  15 1. Air -Appears the blackest. 2. Fat - Lighter shade of grey than air. 3. Soft tissue or Fluid – Less black than Fat. 4. Calcium - Usually contained within bones. 5. Metal – Whitest. (Objects of metal density are not normally present in the body.)
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  X-RAY FILM QUALITY Basedon : • Contrast of image • Sharpness of image 16
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  Underexposed film Too whitelacking contrast 17
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  Over exposed film Tooblack with poor contrast 18
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  19 Spine
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  CERVICAL SPINE 20
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  C1 – C7 21
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  CERVICAL SPINE ANATOMY 22 Twoanatomically distinct regions  Cervicocranium (C1 and C2)  Lower cervical spine (C3 to C7)
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  C1 VERTEBRA -ATLAS 23 • Named after the Greek mythological Atlas who supported the world on his shoulders.
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  24 •Ring of bonewith anterior and posterior arches and large lateral masses. •Lacks a body & spinous process. •Superior articular facets articulate with the occipital condyles (Atlanto-occipital joint) (“yes” movement). •Inferior articular facets articulate with C2 vertebra (Axis). (Sup.) (Inf.)
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  C2 VERTEBRA -AXIS 25 •Has a body. •Peg like process called the dens or odontoid process projects superiorly through the anterior portion of the vertebral foramen of the atlas (“no” movement). •Articulation between the anterior arch of the atlas and dens of the axis, and between their articular facets, is called the atlanto-axial joint.
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  C3 - C6 26 •Structuralpattern of the typical cervical vertebra. •Spinous processes of C2 through C6 are often bifid.
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  C7 VERTEBRA • Vertebraprominens, has single large spinous process (seen and felt at the base of the neck). 27
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  28 LIGAMENTS OF SPINE Transverse ligament ofdens
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  30 CERVICAL SPINE X-RAY VIEWS& RADIOLOGICAL ANATOMY
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  1. National EmergencyX-Radiography Utilization Study (NEXUS) Low-Risk Criteria • 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 31 2. Canadian Cervical-Spine Rule
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  Mneumonic :- NSAID 1.Neuro deficit 2.Spinal midline tenderness in C-spine 3. Alertness 4. Intoxication 5. Distracting injury 32
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  • Views CERVICAL SPINEX-RAY • Antero Posterior view • Lateral view • Open mouth (odontoid) view • Oblique view 33
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  ANTERO POSTERIOR VIEW 34
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  35 RADIOLOGICAL ANATOMY –AP VIEW
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  LATERAL VIEW • Importantradiographic examination of the acutely injured cervical spine. 36
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  37 RADIOLOGICAL ANATOMY –LATERAL VIEW
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  Visualize • All 7cervical vertebrae • C7-T1 junction (Cervicothoracic junction is a common place for traumatic injury) 38
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  LIMITATION OF C7-T1VIEW •By the amount of soft tissue - in the shoulder region. (shoulder soft tissue shadow) 39
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  ENHANCEMENT OF C7-T1VIEW • Traction on arms if no arm injury is present. • Swimmer's view (taken with one arm extended over the head.) 40
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  Swimmer’s view 41
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  Flexion view FLEXION &EXTENSION VIEWS 42
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  Extension view 43
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  FLEXION & EXTENSIONVIEWS CONDITIONS • If no fracture is seen on initial films and pain is present. • If a pure soft tissue injury is suspected • To demonstrate ligament instability and subsequent vertebral mobility. 44
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  CONDITIONS • Patient shouldperform the flexion and extension voluntarily. • Absolutely contraindicated in documented unstable injuries. 45
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  OPEN MOUTH (ODONTOID)VIEW 46
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  47 RADIOLOGICAL ANATOMY OPEN MOUTH VIEW Bodyof C2, Atlantoaxial joints, Odontoid process, Lateral spaces between the odontoid process and the articular pillars of C1.
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  48 OBLIQUE VIEW
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  OBLIQUE VIEW 49 Important inpatients with pain and/or altered sensation in their upper limbs. Caused by nerve compression at the intervertebral foramina, which can be viewed in oblique view.  CT is better
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  AABCDS • A =Adequacy • A = Alignment • B = Bone • C = Cartilage • D = Disc • S = Soft tissue APPROACH TO C-SPINE X-RAY 50
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  ADEQUATE (LATERAL VIEW) • Filmshould include - all 7 vertebrae. • C7-T1 junction. • Have correct density • Show the soft tissue - and bony structures well. C1 C2 C3 C4 C5 C6 C7 T1 51
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  ALIGNMENT (AP VIEW) •Evaluated using the edges of the vertebral bodies and articular pillars. • Height of the cervical vertebral bodies should be approximately equal. 52
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  • Height ofeach joint space should be roughly equal at all levels. • Spinous process should be in midline and in good alignment. 53
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  • Pre-vertebral softtissues • 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 54 Evaluate 5 parallel lines for discontinuity
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  55 Evaluate the orientationof the epiglottis, hyoid bone, tracheal shadow and check for any foreign bodies.
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  56 Check the Atlantodensinterval or Predental space is < 3 mm in adults or < 5 mm in children.
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  CERVICAL SPINE X-RAYS DISLOCATIONS& FRACTURES 57
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  Dislocations 58
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  • Dislocation atthe junction between the Atlas vertebra and the skull. • May result in death. • Anterior dislocation is much more frequent and much easier to see on X-ray. • Mechanism: Hyperflexion or hyperextension. 1. Atlanto occipital dislocation (unstable) 59
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  60 •Anterior displacement of onevertebral body on another. •Best seen on the lateral view as a step deformity. •Step deformity of >3mm is always abnormal & the spine is unstable. •Occurs secondarily to hyperflexion of the C.spine. 2. Facet joint dislocations (unstable)
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  •3 types ofbilateral facet dislocations, all are unstable. •In order of increasing severity • Subluxed facets • Perched facets • Locked facets 61
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  a) Subluxed facetjoint •Mildest form, in which the ligamentous injury leads to partial uncovering of facet joint. • Results in mild anterior displacement of one vertebral body on another . 62
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  b) Perched facetjoint • Inferior articular process appears to sit 'perched' on the ipsilateral superior articular process of the vertebra below. • Any further anterior subluxation will result in dislocation. • Unilateral perched facet results from flexion-rotation force • Complications  Spinal cord or Vertebral artery injury. 63
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  Spinal cord injury 64
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  c) Locked facetjoint • Results from jumping of the inferior articular process over the superior articular process of the vertebra below and becomes locked in the position. 65
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  Fractures 66
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  67 1. Unstable a.Flexion Teardropfracture • 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. • Most severe C-spine injury. • Presents as quadriplegia, loss of anterior column senses etc.
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  b) Hangman's fracture •Secondary to an extension injury, which commonly occurs in motor vehicle accidents or in hangings. 69
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  • Bilateral C2pars fracture, with anterior displacement of C2 vertebral body. 70
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  c) Hyperextension Fracture-dislocation •Secondary to a severe circular hyper extending force (e.g. impact on forehead). • Results in a slight anterior vertebral subluxation, with a complex fracture near the articular surfaces. 71
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  d) Burst fracture •Results from an axial injury. • Compression of the vertebral body and results in loss of both anterior and posterior vertebral body height. • Bony fragments may push on the spinal cord. • Occur most commonly in the mid-cervical spine. 72
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  e. Jefferson's fracture •Secondaryto an axial injury. (heavy object fall on one's head or diving into an empty pool). 74
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  •Consists of unilateralor bilateral fractures of both the anterior and posterior arches of C1. 75
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  f. Odontoid fracture •Secondary to a multidirectional injury. 76 Type I: fracture in the upper part of the odontoid. Type II: fracture at base of the odontoid Type III: fracture through base of odontoid into body of axis.
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  • Secondary toa powerful hyperflexion injury. • Avulsion of a piece of the spinous process and most frequently occurs in the lower C-spine. 77 2. Stable a) Clay-Shoveler's fracture
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  b) Wedge fracture •Due to flexion injury. • Compression of the anterior part of the vertebral body. 78
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  c) Extension Teardrop •Due to hyperextension injury. • Avulsion of a piece of the anteroinferior portion C2. 79
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  THORACIC & LUMBOSACRALSPINE 80
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  •Body •2 transverse processes •Pedicles •Parsinterarticularis •Laminae •One spinous process •Vertebral foramen TYPICAL VERTEBRA 82
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  THORACIC SPINE 83
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  LUMBAR SPINE 84
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  SACRUM 85
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  RADIOLOGICAL ANATOMY OF THORACOLUMBARSPINE -AP VIEW- 86
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  87 RADIOLOGICAL ANATOMY OF THORACOLUMBARSPINE -LATERAL VIEW-
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  Thoracic and LumbarFractures • Thoracic spine is an unusual site for fractures. • Most fractures occur at thoracolumbar junction (90% at T11-L4). • All patients should have CT except for patients with:-  Stable compression fractures  Isolated spinous or transverse process fractures  Spondylolysis 88
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  1. Unstable injury a)Chance fractures (lap seatbelt fracture, usually at L2 or L3) • Distraction from anterior hyperflexion across a restraining lap seatbelt. • Horizontal splitting of vertebra • Rupture of ligaments 89
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  b) Burst fracture •Resultsin collapse of an entire vertebral body. •Mechanism of injury is fall from a height. •On a lateral view, the height of the vertebral body is reduced. •Fragments extending into the spinal canal. •On AP view, the interpedicular distance is increased. 91
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  Burst fracture 92
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  2. Stable injury a.Wedge fracture • Due to hyperflexion injury. • Results in the collapse of the anterior vertebral body. • On the lateral view, there is decreased height of the anterior wall of the vertebral body. • Posterior wall of the vertebral body is intact. • Spinal canal is not involved. 93
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  b. Spinous processfracture • Fracture line in the spinous process. • Spinal canal and the stability of the spine are unaffected. 94
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  c. Transverse processfracture X-ray 95
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  d) Spondylolysis 96 AP viewOblique view Appearance of a Scottie dog
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  • A defectin 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. 98
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  e) 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. 99
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