Patient examination: radiological evaluation (XR, CT, MRI)

Radiological evaluation of an injured spine includes plain radiographs, Computerized tomography (CT) and Magnetic Resonance Imaging (MRI) scans. The purpose of radiological evaluation is to:

• identify the location and extent of injury
• determine features of vertebral instability
• assess the severity of neurological compression and injury
• classify injury patterns
• identify multilevel injuries

Good quality plain radiographs in two planes (antero-posterior and lateral) must be performed in all patients with suspected spinal trauma.

The appropriate radiograph is performed based on local tenderness or deformity and the presence of neurology (in case of neurological injury).

For the upper cervical spine one can use a C2 targeted x-ray examination.

The AP view is recorded through the open mouth.

Lateral includes occiput to C3.

If the radiographs are not satisfactory or are inconclusive, a CT scan must be performed.

Anatomical landmarks seen in the AP view:

• Odontoid
• C2 body
• C1–C2 facet joint
• C1 lateral mass
• Occ–C1 joint
• Occiput
• Bifid spinal process

What is seen in this image:

• Lateral dislocation of the lateral mass of C1 (Positive Spence sign if dislocation exceeds 7mm)

What this indicates:

• C1 fracture

What is seen in this image:

• Fracture line of the odontoid
• Fracture lines of the odontoid are not usually easily seen in the AP view

What this indicates:

• Type II or III fracture

Anatomical landmarks seen in the lateral view:

• Occiput
• Anterior and posterior arch of C1
• Odontoid
• C2 body
• Isthmus and lamina of C2

What is seen in this image:

• Large atlanto-occipital distance

What this indicates:

• Axial atlanto-occipital dislocation

What is seen in this image:

• Increased atlanto-axial distance

What this indicates:

• Atlanto-axial instabillity

What is seen in this image:

• Fracture of the posterior arch of C1

What this indicates:

• Fracture of C1

What is seen in this image:

• Lefthand image shows fracture of the neck of the odontoid with extension
• Righthand image shows fracture of the neck of the odontoid with posterior dislocation

What this indicates:

• C2 odontoid fracture

What is seen in this image:

• Fracture of the pars interarticularis of C2 and slight anterior slippage of C2 body

What this indicates:

• Traumatic spondylolisthesis of C2

What is seen in this image

• Anterior slippage of the C2 body

What it indicates

• Unstable traumatic spondylolisthesis

CT can reveal associated injuries as well as rule out suspected fractures which are not present.

What is seen:

• Precise fracture morphology
• Associated injuries
• Extent of vertebral body comminution and displacement

Which view:

• Sagittal, axial, and coronal

What is seen in this image:

• Fracture of the pars and angulation C2–C3

Which view:

• Lateral

What this indicates:

• Fracture of the pars

What is seen in this image:

• Occipital condyle fracture

Which view:

• Lateral, coronal

What this indicates:

• Fracture of occipital condyle

What is seen in this image:

• C1 atlas fracture

Which view:

• Coronal, axial

What this indicates:

• Fracture of the C1 ring

What is seen in this image:

• Odontoid fracture

Which view:

• Sagittal, axial

What this indicates:

• Fracture of the dens axis (odontoid)

What is seen in this image:

• Traumatic spondylolisthesis of C2

Which view:

• Sagittal, axial

What this indicates:

• Fracture of C2

What is seen in this image:

• Prevertebral hematoma and effusion in the C1–C2 joint
• Sagittal reconstruction

What this indicates:

• Occipital condyle dislocation

What is seen in this image:

• Hyperintense signal changes in cord

What this indicates:

• Cord injury