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Plain Film Radiology
The standard 3 view plain film series is the lateral,
antero-posterior and open-mouth view.
The lateral cervical spine film must include the base
of the occiput and the top of the first thoracic vertebra.
The lateral view alone is inadequate and will miss up
to 15% of cervical spine injuries. The lower cervical
spine may be difficult to examine and caudal traction
on the arms should be used to improve visualisation.
Repeated attempts at plain radiography are usually unsuccessful
and waste time. If the lower cervical spine is not visualised
a CT scan of the region is indicated.
How to read the lateral
cervical spine film.
The antero-posterior view must include the spinous
processes of all the cervical vertebrae from C2 to T1.
The open-mouth view should visualise the lateral masses
of C1 and the entire odontoid peg. Bite blocks may improve
the open-mouth view. In the unconscious, intubated patient
the open mouth view is inadequate and should be replaced
by a CT scan from the occiput to C2.
The addition of two oblique views to the standard 3-view
series does not increase the sensitivity of plain film
evaluation. Some centres use two supine or trauma-oblique
views to replace the antero-posterior view. These views
can provide excellent visualisation of the posterior
elements of the cervical spine and provide significantly
more information than the antero-posterior view.
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Lateral
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Antero-Posterior
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Open
Mouth
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CT Scanning
Thin-cut (2mm) axial CT scanning on specific bone
windows, with sagittal and coronal reconstruction should
be used to evaluate abnormal, suspicious or poorly visualised
areas on plain radiology. With technically adequate
studies and experienced interpretation, the combination
of plain radiology and directed CT scanning provides
a false negative rate of less than 0.1%. The scan should
include the entire vertebral body above and below the
region of interest, as these must be undamaged for subsequent
internal fixation.
Assessment of soft tissue injury
in the awake patient
The patient with normal radiological evaluation as
described above who has persistent symptoms requires
an evaluation of soft tissue injury with static flexion
and extension imaging of the neck at the extremes of
the active range of motion.
Pure disc or ligamentous disruption can produced unstable
cervical spine injuries and will usually be detected
by such imaging. The movements are safe provided the
patient performs them actively and halts if there is
an increase in pain or neurological symptoms.
Magnetic Resonance Imaging
All patients with an abnormal neurological examination
should be evaluated in a specialist unit and have an
MRI scan of the spine. Patients who report transient
neurological symptoms (the 'stinger' or 'burner') but
who have a normal exam should also undergo an MRI assessment
of their spinal cord.
References
Plain Film Radiology
Clark CR, Igram CM, el-Khoury GY, et al: Radiographic
evaluation of cervical spine injuries. Spine 13:742-7,
1988
Fischer RP: Cervical radiographic evaluation of
alert patients following blunt trauma. Ann Emerg
Med 13:905-7, 1984
el-Khoury GY, Kathol MH, Daniel WW: Imaging of
acute injuries of the cervical spine: Value of plain
radiography, CT, and MR imaging. AJR Am J Roentgenol
164:43-50, 1995
Hoffman JR, Schriger DL, Mower W, et al: Low-risk
criteria for cervical-spine radiography in blunt trauma:
A prospective study. Ann Emerg Med 21:1454-60, 1992
Jacobs LM, Schwartz R: Prospective analysis of acute
cervical spine injury: A methodology to predict injury.
Ann Emerg Med 15:44-9, 1986
Jergens ME, Morgan MT, McElroy CE: Selective use
of radiography of the skull and cervical spine.
West J Med 127:1-4, 1977
Ross SE, Schwab CW, David ET, et al: Clearing the
cervical spine: Initial radiologic evaluation. J
Trauma 27:1055-60, 1987
Shaffer MA, Doris PE: Limitation of the cross table
lateral view in detecting cervical spine injuries: A
retrospective analysis. Ann Emerg Med 10:508-13,
1981
Streitwieser DR, Knopp R, Wales LR, et al: Accuracy
of standard radiographic views in detecting cervical
spine fractures. Ann Emerg Med 12:538-42, 1983
West OC, Anbari MM, Pilgram TK et al. Acute cervical
spine trauma: diagnostic performance of single-view
versus three-view radiographic screening. Radiology
204:819-23, 1997
Woodring JH, Lee C: Limitations of cervical radiography
in the evaluation of acute cervical trauma. J Trauma
34:32-9, 1993
Obliques vs AP
Holliman CJ, Mayer JS, Cook RT, et al: Is the anteroposterior
cervical spine radiograph necessary in initial trauma
screening? Am J Emerg Med 9:421-5, 1991
Ireland AJ; Britton I; Forrester AW Do supine oblique
views provide better imaging of the cervicothoracic
junction than swimmer's views? J Accid Emerg Med,
1998 May, 15:3, 151-4
Turetsky DB, Vines FS, Clayman DA, Northup HM. Technique
and Use of Supine Oblique Views in Acute Cervical Spine
Trauma. Ann Emerg Med 1993; 22: p. 685-689
How many X-rays?
Doris PE, Wilson RA. The Next Logical Step in the
Emergency Radiographic Evaluation of Cervical Spine
Trauma : The Five-view Trauma Series. J Emerg Med
1985; 3: p. 371-375
Freemyer B, Knopp R, Piche J, et al: Comparison
of five-view and three-view cervical spine series in
the evaluation of patients with cervical trauma.
Ann Emerg Med 18:818-21, 1989
MacDonald RL, Schwartz ML, Mirich D, et al: Diagnosis
of cervical spine injury in motor vehicle crash victims:
How many x-rays are enough? J Trauma 30:392-7, 1990
Flexion-Extension Views
Lewis LM, Docherty M, Ruoff BE, et al: Flexion-extension
views in the evaluation of cervical-spine injuries.
Ann Emerg Med 20:117-21, 1991
Computed Tomography
Acheson MB, Livingston RR, Richardson ML, et al: High-resolution
CT scanning in the evaluation of cervical spine fracture:
comparison with plain film examinations. AJR Am
J Roentgenol 148:1179-85, 1987
Borock EC, Gabram SG, Jacobs LM, et al: A prospective
analysis of a two-year experience using computed tomography
as an adjunct for cervical spine clearance. J Trauma
31:1001-6, 1991
Mace SE: Emergency evaluation of cervical spine
injuries: CT vs plain radiographs. Ann Emerg Med
14:973-5, 1985
Nunez DB, Jr., Zuluaga A, Fuentes-Bernardo DA, Rivas
LA, et al. Cervical spine trauma: how much more do
we learn by routinely using helical CT? Radiographics
16(6): 1307-1318, 1996
Schleehauf K, Ross SE, Civil ID, et al: Computed
tomography in the initial evaluation of the cervical
spine. Ann Emerg Med 18:815-7, 1989
CT of Occiput-C3
Blacksin MF and Lee HJ. Frequency and significance
of fractures of the upper cervical spine detected by
CT in patients with severe neck trauma. AJR Am J
Roentgenol 165(5): 1201-1204, 1995
Kirshenbaum KJ, Nadimpalli SR, Fantus R, et al:
Unsuspected upper cervical spine fractures associated
with significant head trauma: Role of CT. J Emerg
Med 8:183-98, 1990
CT of C7-T1
Ohiorenoya D, Hilton M, Oakland CD et al. Cervical
spine imaging in trauma patients: a simple scheme of
rationalising arm traction using zonal divisions of
the vertebral bodies. J Accid Emerg Med. 13:175-6,
1996
Tehranzadeh J, Bonk RT, Ansari A, et al: Efficacy
of limited CT for nonvisualized lower cervical spine
in patients with blunt trauma. Skeletal Radiol 23:349-52,
1994
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