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How to interpret
spinal radiographs
S
pinal radiography is an important
tool, which can be utilised in
general practice to diagnose many
osseous, and some soft tissue,
lesions of the spine. However, it is
important to:
Understand the limitations of
radiography
Understand how to optimise acquisition
of the radiographs
Optimise your interpretation of the
radiographs to achieve the maximal
use of the technique
Be familiar with common abnormalities
identified on spinal radiographs
Appreciate when there are superior
techniques available.
Limitations of radiography
It is important to have performed a full
clinical and neurological examination
before performing any diagnostic tests,
especially those that require sedation or
general anaesthesia to ensure that you
have correctly localised the lesion. Any
lesions seen on radiographs should be
correlated to your neurological localisation
to help assess their significance.
In general, radiography can provide
useful information about osseous lesions
that lead to potential neurological signs for
the patient, for example vertebral fractures,
vertebral luxation, congenital vertebral
abnormalities and vertebral neoplasia.
Radiographs may also provide information
about lesions that extend into the vertebrae
from surrounding tissues (e.g.
discospondylitis or soft tissue neoplasia),
or may be suggestive of a lesion (e.g.
intervertebral disc extrusion).
It is important to remember that not
all lesions identified on spinal
radiographs may be significant, for
example some congenital vertebral
abnormalities, calcification of the
nucleus pulposus, ventral spondylosis or
diffuse idiopathic skeletal hyperostosis
(DISH) are rarely significant.
Radiographic change can also
substantially lag behind the clinical
picture. Patients with discospondylitis
may have a normal radiograph of the
affected disc space(s) for 24 weeks
despite the patient having clinical signs.
For bone lysis to be seen on radiographs
(e.g. secondary to a vertebral tumour) up
to 50% of the cancellous bone has to be
lost. The sensitivity of radiography for
common problems is relatively poor. For
intervertebral disc extrusions the
sensitivity for diagnosing the correct site
is only 6070%, which is far from
adequate when decompressive spinal
surgery is to be performed.
Due to divergence of the X-ray beam,
the vertebrae and the width of the
intervertebral disc spaces can be distorted
unless they are at the centre of the beam.
This may lead to artefactual narrowing of
the intervertebral disc spaces. There may
be soft tissue disease processes occurring
within the same region as the osseous
abnormality, which may or may not be
related (e.g. syringomyelia, subarachnoid
diverticula, inflammatory disease,
neoplasia or intervertebral disc disease).
How to optimise acquisition of
spinal radiographs
In order to maximise the diagnostic
information that can be obtained from
spinal radiographs, the patient must be
properly positioned. To facilitate this the
patient should be heavily sedated or
anaesthetised as long as there are no other
contraindications. Rotation of the vertebrae
should be minimised by the use of foam
wedges, ties and troughs (Figure 1). If
rotation is identified then the patient should
be repositioned and the radiograph
retaken as many times as is necessary.
On the lateral view
The transverse processes in the
cervical and lumbar spine should be
superimposed
The rib heads within the thoracic spine
should be superimposed
The wings of the ileum should be
superimposed
On the ventrodorsal view
The dorsal spinous processes should
be central on the vertebrae
The spine should also be straight
It is important to have orthogonal views
(i.e. a lateral and ventrodorsal) as
significant lesions (even vertebral luxations)
can readily be missed on a single
radiograph. Some lesions may not be
obvious on one lateral view but become
more obvious on the opposite lateral view,
so ideally both left and right lateral views
should be taken. For patients with a
suspected vertebral instability the tube
head can be rotated horizontally to obtain
Victoria Doyle, European and RCVS
Specialist in Veterinary Neurology, works
us through these challenging images
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the ventrodorsal view while minimising
movement of the patient.
Stressed views of the spine, e.g. for
atlantoaxial subluxation or caudal cervical
spondylomyelopathy (Wobbler syndrome),
can cause marked neurological
deterioration. Ideally, these should be
avoided or done with extreme caution for a
minimal amount of time.
It is important to centre the beam on
the region of interest to minimise distortion
from divergence of the X-ray beam.
In the cervical spine, the beam should
be centred on C34 and C67
An additional view centred on the
atlantoaxial region should be taken
if atlantoaxial subluxation is
suspected
In the thoracic spine, the beam should
be centred at T67 and at the
thoracolumbar junction
In the lumbar spine, the beam should
be centred at L34
The beam should be centred on the
lumbosacral region if a lesion in this
region is suspected
If a lesion is identified then further
images centred on the lesion can
provide additional information
The exposure should also be checked
to ensure the radiograph is not over- or
under-exposed or important diagnostic
information could be missed.
How to optimise interpretation
of spinal radiographs
It is very useful to have a system for
evaluating radiographs to ensure that no
area is overlooked and to prevent
focusingon an obvious lesion and
overlooking one that is more subtle.
Theorder is not important and can be
tailored to personal preference as long
asall areas are evaluated.
Assess the paraspinal structures
Count the vertebrae
In dogs and cats there should be:
7 cervical vertebrae
13 thoracic vertebrae
7 lumbar vertebrae
3 fused sacral vertebrae
It is possible to have greater or
fewer vertebrae especially within the
lumbar spine without it necessarily
causing neurological signs
Assess the vertebrae for alignment to
one another in both planes (lateral and
ventrodorsal)
Assess the anatomy of the vertebrae
(e.g. congenital vertebral abnormalities,
presence of growth plates (Figure 2),
fracture lines/fragments)
Figure 1: The correct positioning to obtain spinal
radiographs. The white lines indicate the level at which
the beam should be centred. (A-C) The correct
positioning for cervical radiography; foam pads are
placed under the nose and the neck to ensure a true
lateral view. (D-E) The correct positioning for
thoracolumbar radiography; foam pads have been
placed between the legs to ensure a lateral view of
the spine
A C
E D
B
Figure 2: Lateral view of the atlantoaxial
junction in a normal 6-week-old Boston Terrier.
The apparent separation of bone (arrowed)
ventral to the atlas is part of the developing
body of the vertebra
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How to interpret spinal radiographs
Assess the vertebral canal diameter
within the vertebrae and over the
intervertebral disc spaces
Assess the dorsal spinous processes
individually
Assess the articular processes
(articular facets) individually
Assess the intervertebral foraminae
(e.g. size, shape, uniformity,
opacification)
Assess the intervertebral disc spaces
individually (e.g. width compared to
those immediately adjacent to it,
opacity)
Assess the vertebral endplates
individually (e.g. for signs of sclerosis
or lysis)
Try to familiarise yourself with the
normal vertebral anatomy by using
textbooks or a spinal model. Also try to
familiarise yourself with the lesions that are
unlikely to be clinical significant so that
their presence is not overinterpreted.
Abnormalities that can be
identified on spinal radiographs
It can be helpful to view these conditions
under categories using the DAMNITV
mnemonic:
Degenerative
Anomalous
Metabolic
Nutritional/Neoplastic
Idiopathic, Inflammatory/infectious
Traumatic, Toxic
Vascular
Degenerative
Intervertebral disc disease
Classical radiographic changes
suggestive of intervertebral disc
disease include:
Narrowing of the intervertebral disc
space (Figure 3)
When compared to adjacent
intervertebral discs only
The narrowing may not be
uniform across the disc space
and can make the space
appear wedge-shaped
Extruded mineralised material may
be evident within the vertebralcanal
Opacification of the intervertebral
foraminae at the affected site(s)
Alteration in the normal shape of
the intervertebral formaminae at the
affected site(s)
Narrowing of the articular process
joint
Vacuum phenomenon
Accumulation of gas within the
intervertebral disc
It is important to bear in mind that
the accuracy of detecting the correct
site of an intervertebral disc extrusion is
only 6070%.
Cervical spondylomyelopathy
(Wobbler syndrome)
A common neurological condition in
large (e.g. Dobermann) and giant
breed dogs (e.g. Great Dane)
It can be seen in smaller breeds
(e.g.Chihuahua and Yorkshire Terrier)
Changes associated with this disease
include:
Congenital stenosis of the vertebral
canal
Hansen type II disc disease
(annulus fibrosus protrusion) and
tipping of the vertebrae (especially
seen in Dobermann)
Ligamentous hypertrophy
(ligamentum flavum and dorsal
longitudinal ligaments)
Synovial cysts arising from the
articular facets (possible)
Articular facet degenerative joint
disease (especially seen in giant
breeds)
Spinal radiographs can identify
stenosis and degenerative joint
disease affecting the articular
facets but cannot identify the soft
tissue changes, which also occur
with this condition
Two recent studies have shown that
radiographs cannot accurately identify
the site of compression and so should
not be used in isolation to guide
surgical planning (Figure 4)
Stressed views are not recommended
as spinal cord compression can be
acutely exacerbated leading to marked
neurological deterioration
Degenerative lumbosacral stenosis
Common in middle-aged to older large
breed dogs (e.g. German Shepherd
Dog.) See Figure 5.
Radiographic changes which can be
identified with this condition include:
Sacral osteochondrosis
Transitional vertebrae
Ventral spondylosis
Subluxation of L7S1
Endplate sclerosis of L7S1
Degenerative joint disease of the
articular processes
Figure 3: Lateral views of the (A) cervical and
(B) lumbar spine in two dogs with acute
intervertebral disc herniations. (A) There is
narrowing of the C3C4 disc space.
(B) Mineralised disc material is present in the
L2L3 disc space, projecting into the vertebral
canal and causing opacification of the
intervertebral foramen (arrowed)
A
C3
C4
B
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Accuracy is not 100% and therefore
radiography can lead to diagnosing
false positives and false negatives.
Additional imaging using advanced
techniques (e.g. CT and MRI) as well
as electrodiagnostics are needed to
improve the accuracy of diagnosis.
Articular process degenerative joint
disease/hyperostosis
These changes may not be
significant unless there is
impingement of the vertebral canal
or the nerve root
The changes can form secondarily
toinstability
Ossification of the dura
Bone plaques form on the dura mater
Cervical and lumbar regions are most
commonly affected
This is generally clinically insignificant
Mineralisation of the nucleus pulposus
Many chondrodystrophic dogs will
have mineralisation of the nucleus
pulposus
As long as the mineralised material
remains within the nucleus pulposus
and does not extrude, it is unlikely to
be significant (Figure 6)
Ventral spondylosis deformans
New bone formation ventral to the
vertebrae, which can form ventral
bridges of bone across the
intervertebral disc (Figure 7)
The edges of the new bone formation is
generally smooth
Its a non-inflammatory process
Associated with degeneration of the
annulus fibrosus
Typically forms on the thoracic and
lumbar vertebrae in older dogs
Unlikely to be significant in isolation as
the bone formation does not enter the
vertebral canal
However, it can be seen in association
with more significant lesions (e.g.
intervertebral disc protrusions and
degenerative lumbosacral stenosis)
Sacral osteochondrosis
A condition associated with
degenerative lumobosacral disease in
German Shepherd Dogs and is
therefore likely to be significant
Calcinosis circumscripta
Mineralisation of the ligamentous
structures dorsal to the atlantoaxial
region or dorsal to the mid thoracic
spine (Figure 8)
A
B
Figure 4: (A) Lateral cervical radiograph and
(B) myelogram from an 8-year-old
Dobermann with cervical stenotic
myelopathy. Note the tipping of C6 and the
severe compression of the spinal cord at
C5C6 and C6C7. There is a significant
compression at C67 seen on the myelogram
which is not apparent on the plain radiograph
Figure 5: (A) Neutral and (B) extended lateral
radiographs of a 7-year-old German Shepherd
Dog with degenerative lumbosacral stenosis.
Note the ventral spondylosis, proliferation of
the articular processes and the tunnelling of the
dorsal lamina, which is accentuated on
extension of the pelvis
A
B
Figure 6: Lateral radiography of the
thoracolumbar spine showing opacity of the
T11T12, T12T13 and L1L2 intervertebral disc
spaces. Note the narrowed intervertebral
foramen and opacity in the spinal canal at the
L1L2 disc space (arrowed), which should raise
suspicion for intervertebral disc herniation. The
opacification seen at T1112 and T1213 is still
within the nucleus pulposus and so is unlikely to
be significant at this stage.
Figure 7: Lateral radiograph of the lumbar spine
showing spondylosis at the L1L2, L2L3, L3L4
and L4L5 intervertebral disc spaces
L1
L2
L3 L4 L5
L6
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Can cause variable neurological signs
from pain to tetra/paraparesis
depending on location and severity
Anomalous
Osteochondromatosis/multiple
cartilaginous exostosis
See Figure 9
Occurs in young dogs and cats
Bones formed from endochondral
ossification are affected in either the
axial or appendicular skeleton
Abnormal growths capped with
cartilage form on these bones and
undergo endochondral ossification
The growths stop when the other
growth plates close
Malignant transformation of the growths
can occur
Depending upon the site of the growth,
there may be impingement of the
vertebral canal resulting in spinal cord
compression
Atlantoaxial subluxation
This can result from aplasia/hypoplasia
of the dens or abnormal ligamentous
structures
Classically seen in young toy breed
dogs but must not be overlooked in
older large breed patients
A lateral radiograph should be taken
initially. The patients neck should be in
a neutral position or very slightly flexed
as moderate flexion can cause
significant neurological deterioration
A ventrodorsal view can be obtained if
necessary and if the risk of instability is
low, but care should be taken that the
neck is not flexed
An open mouthed view to visualise the
dens is not required
The C1 and C2 vertebrae should have
a linear alignment in the normal patient
(Figure 10)
Transitional vertebrae
Vertebrae at the thoracolumbar or
lumbosacral junctions can be
transitional and show features of the
vertebrae in the adjacent section
T13 may only have one rib (Figure 11)
This is unlikely to be clinically
significant unless it is not taken into
account when planning
decompressive spinal surgery in
this region as the wrong disc space
could be opened
Sacralisation of the L7 vertebrae can
occur with a relatively high frequency
(Figure 12).
In German Shepherd Dogs this has
been shown to predispose them to
degenerative lumbosacral disease
78% of German Shepherd Dogs
with degenerative lumbosacral
stenosis had transitional
lumbosacral vertebrae
The hypothesis is that the instability
caused by the transitional vertebrae
at the lumbosacral junction
predisposes affected dogs to
degenerative lumbosacral disease
Hemivertebrae
Part of the vertebrae (especially the
body) fails to form resulting in a
wedge-shaped vertebra
Butterfly vertebrae occur if the central
part of the vertebral body fails to form
(Figure 13)
How to interpret spinal radiographs
Figure 8: Lateral cervical radiograph of a
4-month-old Hungarian Viszla with calcinosis
circumscripta. Note the focus of mineralisation
dorsal to the atlas (arrowed)
Figure 9: Multiple cartilaginous exostoses in a
4-month-old Golden Retriever. The exostoses
are present on the ribs and, the bodies and the
spinous processes of the thoracic vertebrae
Figure 10:
(A) Lateral and
(B) ventrodorsal
views of the
normal adult
atlantoaxial
junction. The
dens is visible in
(B) (arrowed)
A
B
Figure 11:
Ventrodorsal
view of the
thoracolumbar
junction in a
Cocker Spaniel.
Note the 13th
vertebra (starred)
only has one rib
*
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They are most commonly seen in the
thoracic spine and the T8 vertebra is
most commonly affected
Screw-tailed breeds are over-
represented but other miniature and toy
breeds can also be affected
These vertebrae can be incidental
findings
However, they can cause stenosis of
the vertebral canal, instability and
abnormal angulation (kyphosis), which
can lead to neurological signs
They may also be associated with other
pathology including intervertebral disc
protrusions, subarachnoid diverticulae
and syringomyelia, which can be
responsible for neurological signs
Block vertebrae
The developing vertebrae fail to
segment and the vertebrae remain
fused (Figure 14)
They can be clinically insignificant
However, they can also affect the
stability of the spine, predisposing the
patient to intervertebral disc disease at
adjacent sites
Spina bifida
Results from the failure of the neural
tube and overlying tissues to fuse
(Figures 13 and 15)
Most commonly occurs in the lumbar
or thoracic regions
The dorsal spinous processes often
appear split/duplicated on the
ventrodorsal view
In some circumstances it can be a
clinically insignificant lesion but in
others it can cause severe neurological
deficits, for example sacrocaudal
dysgenesis in Manx cats
May have overlying lesions within the
skin (e.g. change in direction of the hair
growth, draining tract) or lesions of the
meninges (meningocele) or of the
meninges and spinal cord
(meningomyelocele)
Figure 12: Vetrodorsal radiograph of a
5-year-old German Shepherd Dog with
lumbosacral pain and evidence of sacralisation
of L7. Note the absence of the left transverse
process of L7
Figure 13: A young male Bulldog with a
butterfly vertebrae at L4 (arrowed). The patient
also has spina bifida affecting T12
Figure 14: Lateral (A) and ventrodorsal (B) views
showing a block vertebra at C2C3 and
complete absence of the dens in a 10-year-old
Poodle. The point at which the two vertebrae
are fused is visible (arrowed)
A
B
Figure 15: Vetrodorsal radiograph of the cranial
thoracic spine. There is spina bifida affecting
the first thoracic vertebra. Note the duplication
of the spinous process (arrowed)
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Nutritional
Hypervitaminosis A
Cats fed on large amounts of liver
Leads to excessive new bone formation
on the vertebrae resulting in anyklosing
spondylitis
Usually cervical vertebrae are affected
(can extend to lumbar vertebrae)
Vertebral column becomes rigid and
causes pain
Change of diet may not significantly
alter the bony changes
Neoplastic
Primary or secondary vertebral body
tumours (Figure 16)
Osteosarcomas, fibrosarcomas,
chondrosarcomas,
haemangiosarcomas, plasma cell
tumours, carcinomas, lymphomas
and liposarcomas are all reported
Show aggressive changes to the
bone, especially lysis, loss of
cortical outline and possible bony
proliferation
Pathological fractures are possible
Multiple myeloma (a disseminated
plasma cell tumour) will show
multiple osteolytic lesions in the
bone marrow
Tumours arising within the
surrounding soft tissues can cause
pressure on surrounding bony
structures (e.g. the intervertebral
foraminae and vertebral canal)
leading to bony destruction; for
example, malignant nerve sheath
tumours leading to enlargement of the
intervertebral foramen
Idiopathic
Diffuse idiopathic skeletal hyperostosis
(DISH)
Calcification of the various soft tissues
(Figure 17) occurs including:
The ventral longitudinal ligament
Ventral aspect of the annulus
fibrosus
Paravertebral soft tissues
At least four neigbouring vertebrae
must be affected to fulfill the
terminology
It appears as a more extreme version
of ventral spondylosis deformans
Almost half the Boxer dogs in one
study were affected by DISH
Very rarely causes neurological signs
Inflammatory/infectious
Discospondylitis
Infection of the intervertebral disc and
the endplates of the adjacent vertebrae
(Figure 18)
Infection can also affect the
surrounding soft tissue and enter the
vertebral canal (empyema)
Infection can be bacterial
(Staphylococcus intermedius or
S.aureus most commonly) or fungal
(Aspergillus spp.)
Often affects multiple sites, so it is
important to screen the entire
vertebralcolumn
Common sites include:
Lumbosacral junction
Caudal cervical spine
Mid thoracic spine
Thoracolumbar spine
Radiographic changes can lag
behindthe clinical picture for 24
weeks and include:
Narrowing of the intervertebral
discspace
Lysis and sclerosis of the adjacent
vertebral endplates
Pathological vertebral fractures
Traumatic
Vertebral fractures/luxations
See Figures 19 and 20
Patients with a suspected vertebral
fracture or luxation should not be
heavily sedated or anaesthetised, as
relaxation of the surrounding
musculature may cause movement
through the unstable area leading to
neurological deterioration
These patients should be strapped to a
spinal board to try to prevent further
movement
Lateral radiographs can be obtained of
the entire vertebral column as well as
any other part of the patients body
which may have sustained trauma, for
example the thorax to assess for rib
fractures, pulmonary contusions etc.
How to interpret spinal radiographs
Figure 16: Lateral radiograph revealing the
vertebral canal and the intervertebral foramen
at L6L7 are expanded and there is new bone
ventral to the body of L6 (arrowed). The cause
was a poorly differentiated sarcoma
Figure 17: Lateral view of the lumbar spine of a
Boxer with disseminated idiopathic skeletal
hyperostosis (DISH). Note the nearly continuous
new bone along the ventral margin of the
visible vertebrae
Figure 18: Lateral radiograph of an 8-year-old
Airedale Terrier with lumbar pain. Gross
irregular lysis and osseous proliferation of the
vertebral endplates of L7 and S1 (arrowed) can
be seen, which are compatible with
discospondylitis
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The X-ray beam can then be rotated
horizontally to obtain the orthogonal
view. In this way, the patient does not
have to be moved into dorsal
recumbency, which could readily cause
worsening of the injury
Appreciate when there are
better techniques available
The accuracy of spinal radiography is
insufficient for diagnosis and treatment
planning for some common neurological
diseases.
Spinal radiography for intervertebral
disc disease will only correctly identify
the site of disc extrusion in 6070% of
cases. Therefore, it is an inadequate
diagnostic test if the patient is going to
have decompressive spinal surgery
If the patient is going to be referred
for surgery then spending time
acquiring radiographs is of very
little benefit to the patient. The
patient will be anaesthetised for
more accurate diagnostic testing
(e.g. magnetic resonance imaging)
when the patient arrives
Chiari malformation is a prevalent
disease within small breed dogs
(especially Cavalier King Charles
Spaniels) resulting in neurological signs
including neck pain, phantom
scratching and cervical myelopathy. In
a recent study, 28% had atlanto-
occipital overlapping concurrently,
which can be responsible for pain and
a cervical myelopathy in its own right.
Unfortunately, neither of these
conditions can be accurately
diagnosed without advanced imaging
(MRI)
Only some of the changes associated
with caudal cervical
spondylomyelopathy can be identified
radiographically, and radiographs
cannot reliably identify the sites of
compression
Spinal radiographs cannot diagnose
intraparenchmal spinal cord lesions (e.g.
fibrocartilaginous embolism), inflammatory
disease (e.g. granulomatous
meningoencephalomyelitis) or
intramedullary neoplasia. In these cases
more advanced imaging (e.g. MRI) is
required for diagnosis.
A
B
Figure 19: (A) Lateral cervical radiograph of a
7-month-old Doberman that fell from a
balcony. The body of C2 is fractured and
displaced dorsally, causing severe compression
of the overlying spinal cord. (B) The fracture
was reduced by traction wires placed around
the heads of two screws situated in the caudal
body of C2. Additional screws were placed in C1
and C3 and the construct was stabilised with
polymethylmethacrylate cement
Figure 20: Radiographic confirmation of a
complete caudal vertebral luxation in a cat with
avulsion of the tail
NEUROLOGY MANUAL
Images for this How To
have been taken from the
BSAVA Manual of Canine
and Feline Neurology, 4th
editon, edited by Simon
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An accompanying DVD-ROM contains over
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Conclusion
Spinal radiography is an important tool in
diagnosing many neurological conditions.
In order for the technique to be most
useful, the positioning of the patient is
crucial. Care should be taken over the
positioning to prevent acute neurological
deterioration in some conditions. Having a
system to ensure that the entirety of the
radiograph is examined can prevent
lesions from being overlooked. The
clinician should be familiar with the
common conditions that can be identified
on radiographs and which are likely to be
insignificant to prevent over interpretation.
The clinician should also bear in mind the
limitations of radiography and understand
when more advance techniques are
required.
References and further reading are available at
www.bsava.com .
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