Spine Radiology

Cervical spine Thoracolumbar spine X-RAY CT MRI

CERVICAL SPINE
Standard views Lateral view Anterior-Posterior (AP) view Odontoid Peg view (or Open Mouth view)

In trauma case these images are all difficult to acquire because the patient may be in pain, confused, unconscious, or unable to cooperate due to the immobilisation devices. Additional views - 'Swimmer's view' If the lateral view does not show the vertebrae down to T1 then a repeat view with the arms lowered or a 'Swimmer's view' may be required.

Systematic approach to interpret cervical spine xray

Coverage - Adequate? Alignment Anterior/Posterior/Spinolaminar Bones - Cortical outline/Vertebral body height Spacing - Discs/Spinous processes Soft tissues - Prevertebral Edge of image

AP View
Coverage - The AP view should cover the whole C-spine and the upper thoracic spine Alignment - The lateral edges of the C-spine are aligned (red lines ) Bone - Fractures are more clearly visible on lateral view Spacing - The spinous processes (orange) are in a straight line and spaced approximately evenly Soft tissues - Check for surgical emphysema Edges of image - Check for injury to the upper ribs and the lung apices for pneumothorax

 Coverage - All vertebrae are visible from the skull base to the top of T1/T2 (If T1 is not visible repeat image with the patient's the most informative image shoulders lowered or a 'swimmer's' view may be necessary

Lateral view

Alignment - Check the Anterior line GREEN (the line of the anterior longitudinal ligament), the Posterior line ORANGE(the line of the posterior longitudinal ligament), and the Spinolaminar line RED(the line formed by the anterior edge of the spinous processes extends from inner edge of skull). Bone - Trace the cortical outline of all the bones to check for fractures

Lateral
Bone - The cortical outline is not always well defined but forcing your eye around the edge of all the bones will help identify fractures C2 Bone Ring - At C2 (Axis) the lateral masses viewed side on form a ring of corticated bone (red ring ) This ring is not complete in all subjects and may appear as a double ring A fracture is sometimes seen as a step in the ring outline

Lateral view

Disc spaces - The vertebral bodies are spaced apart by the intervertebral discs These spaces should be approximately equal in height Prevertebral soft tissue - Some fractures cause widening of the prevertebral soft tissue due to prevertebral haematoma - Normal prevertebral soft tissue (asterisks) - narrow down to C4 and wider below - Above C4 1/3rd vertebral body width - Below C4 100% vertebral body width Note: Not all C-spine fractures are accompanied by prevertebral haematoma - lack of prevertebral soft tissue thickening should NOT be taken as reassuring Edge of image - Check other visible structures

Odontoid peg /Open mouth view

Its primary purpose is to view lateral mass alignment. If a fracture of the odontoid peg (dens) is present often not visible with this view. If a peg fracture is not visible, but is suspected clinically by a senior clinician, then further imaging with CT should be considered.

Open Mouth viewcont.

This view is considered adequate if it shows the alignment of the lateral processes of C1 and C2(red circles) The distance between the peg and the lateral masses of C1 (asterisks) should be equal on each side Note: In this image the odontoid peg is fully visible which is not often achievable in the context of trauma due to difficulty in patient positioning

Swimmers view
If the lateral view does not show the vertebrae down to T1 then a repeat view with the arms lowered or a 'Swimmer's view' may be required.

This is an oblique view which projects the humeral heads away from the C-spine. A swimmer's view may be useful in assessing alignment at the cervico-thoracic junction if C7/T1 has not been adequately viewed on the lateral image, or on a repeated lateral image with the shoulders lowered. The view is difficult to achieve, and often difficult to interpret. If plain X-ray imaging of the cervicothoracic junction is limited then CT may be required.

Swimmers view- cont.

Oblique image with the humeral heads projected away from the C-spine The cervico-thoracic junction can be seen Check alignment by carefully matching the corners of each adjacent vertebral body anteriorly and posteriorly

Thoracolumbar spine
Standard views - AP - Lateral Systematic approach - Coverage - Adequate? - Alignment - Anterior/Posterior/Lateral - Bones - Cortical outline/Vertebral body height - Spacing - Discs/Spinous processes/Pedicles - Soft tissues - Paravertebral - Edge of image

Thoracic s Lateral and AP

Coverage - The whole spine is visible on both views (T1 till T12) Alignment - Follow the corners of the vertebral bodies from one level to the next

Bones - The vertebral bodies should gradually increase in size from top to bottom Spacing - Disc spaces gradually increase from superior to inferior
Soft tissues - Check the paravertebral line (in AP image) Edge of image - Check the other structures visible

Lateral (in detail)

Alignment - Vertebral body alignment is assessed by carefully matching the anterior and posterior corners of the vertebral bodies with the adjacent vertebra Bones - Gradual increase in vertebral body height from superior to inferior Spacing - Disc spaces gradually increase in height from superior to inferior

VB = Vertebral body P = Pedicle SP = Spinous process (ribs overlying) F = Spinal nerve exit foramen

AP (in detail)
Alignment - The vertebral bodies and spinous processes (SP) are aligned Bones - The vertebral bodies and pedicles are intact Other visible bony structures include the transverse processes (TP) -ribs costovertebral and costotransverse joints

Spacing - Each disc space is of equal height when comparing left with right. The pedicles gradually become wider apart from superior to inferior Soft tissue - Note the normal paravertebral soft tissue which forms a straight line on the left - distinct from the aorta

Lumbar s Lateral
Coverage - The whole Lspine should be visible

Alignment - Follow the corners of the vertebral bodies from one level to the next (dotted lines) Bones - Follow the cortical outline of each bone
Spacing - Disc spaces gradually increase in height from superior to inferior Note: The L5/S1 space is normally slightly narrower than L4/L5

Lumbar s Lateral

Lateral (in detail)

Check the cortical outline of each vertebra The facet joints comprise the inferior and superior articular processes of each adjacent level The pars interarticularis literally means 'part between the joints' - P = Pedicle - SP = Spinous process

L-spine - Normal AP
Alignment - The vertebral bodies and spinous processes are aligned Bones - The vertebral bodies and pedicles are intact Spacing - Gradually increasing disc height from superior to inferior. The pedicles gradually become wider apart from superior to inferior - Note: The lower discs are angled away from the viewer and so are less easily assessed on this view

L-spine - Normal AP

L-spine AP (detail)
Check carefully for pedicle integrity and transverse process fractures

Three column model Fracture

Anterior column = Anterior half of the vertebral bodies and soft tissues Middle column = Posterior half of the vertebral bodies and soft tissues

Posterior column = Posterior elements and soft soft tissues

Three column model

Injuries 1 and 2 affect one column only and are considered 'stable'

1 - Spinous process injury 2 - Anterior compression injury

 Injuries 3 and 4 affect two or more columns and are considered 'unstable'

3 - 'Burst' fracture
4 - Flexion-distraction fracture - 'Chance' type injury

CT scan of spine
Up to 20 % of fractures are missed on conventional radiographs. The advantages of CT are: 1. CT is excellent for characterizing fractures and identifying osseous compromise of the vertebral canal because of the absence of superimposition from the transverse view. 2. CT provides patient comfort by being able to reconstruct images in the axial, sagittal, coronal, and oblique planes from one patient positioning. The limitations of CT are: 1. difficult to identify those fractures oriented in axial plane (e.g. dens fractures). 2. unable to show ligamentous injuries. 3. relatively high costs.

CT Cervical Spine Axial

CT Cervical Spine Coronal

CT Cervical Spine Sagittal

CT Thoracic Spine Axial

CT Thoracic-Lumbar Spine Sagittal

CT Lumbar Spine Axial

Zyapophyseal joint= facet joint

MRI
Most sensitive imaging modality in the study of spine disease.

Difference between T1 and T2 image

T1-weighted image Bone marrow Hyperintense/high signal (white)
Hypointense/low signal (black )

T2-weighted image Hypointense/low signal (black )

Hyperintense/high signal (white)

CSF

Neural tissue (eg.spinal cord/nerve roots)

Cortical bone Intervertebral disc

Intermediate signal
Hypointense Intermediate signal

Intermediate signal
Hypointense Hyperintense (because of the water content)

T1-weighted sagittal, cervicothoracic spine

The spinal cord is very easily seen.
The CSF anterior and posterior to the cord is hypointense. The high signal arising from the vertebral body bone marrow (arrows) is due to the fat content. The disk spaces are readily visualized and are of lower signal intensity

T2-weighted sagittal lumbar spine

CSF is now very hyperintense, and the spinal cord appears to have relatively low signal intensity. The disks (arrowheads), because of their water content (when normal), appear higher in signal intensity when compared with the T1weighted image. The bone marrow, on the other hand, is lower in signal intensity .

T1

Lumbar spine &

T2

Axial T2 wtd MRI of cervical spine at C5-C6 level

Axial T1 wtd MRI of thoracic spine

end