RTE 1032 - Unit 4 (Spine)

Spine

AP Open Mouth: Eval Criteria

• Entire odontoid process, atlantoaxial joint, and lateral masses of C1 demoed

• Upper incisors and base of skull are superimposed

• Atlantoaxial joint is symmetrical

AP Open Mouth: Is this Image Good?

No.

• Base of skull superimposed over dens and lateral masses

• Atlantoaxial joint is not clearly demoed

• Extensive extension of skull

  • Reposition by slight flexion of the neck or angle the CR slightly caudal

How do you take an AP Open Mouth with a C-collar on?

Have the patient open their mouth, then match your CR angle to the biting plane of their upper teeth

• Usually about 3-5 degree caudal angle

• Do not take off the C-collar

AP Open Mouth: Is this Image Good?

No.

• Front incisors are superimposed over C1-C2

• Atlantoaxial joint is not demoed

• Excessive flexion of skull and neck

  • Reposition with slight extension of the neck or angle the CR slightly cephalic

AP Axial C-Spine: Eval Criteria

• Angle CR 15 to 20 degree cephalad neck extended slightly

• C3 to T2 demoed

• Space between pedicles and intervertebral disk spaces clearly seen

• Mandible and base of the skull should superimpose C1-2

AP Axial C-Spine: Is this Image Good?

No.

• Vertebral body of C3 is partially superimposed by base of skull

• Incorrect CR angle (caudal) produced foreshortening of vertebral bodies and closure of intervertebral joint spaces

• Excessive extension superimposed base of skull over upper C-Spine

  • Correct the angle and adjust head so that a line from lower margin of upper incisors to the base of the skull is perp. to IR

Lateral C-Spine: Eval Criteria

• Cervical vertebral bodies, intervertebral joint spaces, articular pillars, spinous processes, and zygapophyseal joints demoed

• C1 through C7-T1 intervertebral joint spaces are clearly seen

• R and L articular pillars and zygapophyseal joints should be superimposed for each vertebra

• Bodies free of superimposition of the articular pillars

• Spinous process seen in profile

Lateral C-Spine: Is this Image Good?

No

• C7 is obscured

• C1 anatomy is clipped and spine is not centered

  • Need to center higher and more anterior

• Tilt leads to poor superimposition of zygapophyseal joints

• Used AEC but it wasn’t centered to bone (underexposed)

Swimmers: Eval Criteria

• CR to T1

• Vertebral bodies and intervertebral disk spaces of C5 to T3 are shown

• Humeral head and arm farthest from the IR are magnified and appear inferior to T4 or T5

• Minimal vertebral rotation indicated by superimposition of cervical zygapophyseal joints and articular pillars, and posterior ribs

• Humeral heads should be separated vertically

Swimmers: Is this Image Good?

No

• CR is too low

  • Move up to T1

• Foggy, noisy, low contrast (underexposure)

  • Increase kVp

Lateral T-Spine: Eval Criteria

• Thoracic vertebral bodies, intervertebral joint spaces, and intervertebral foramina

• T1 to T3 will not be well demoed

• Intervertebral disk spaces should be seen

• Excessive rotation indicated by > 1/2” of space between separated posterior ribs

Lateral T-Spine: Is this Image Good?

No

• Missing part of T1

• Blurry - we want ribs blurred not the vertebrae

  • Ask pt to stay still while taking breaths

• Separated posterior ribs indicate rotation at the superior aspect of spine

• Overexposed

  • Decrease mAs

How does rotation manifest on an AP Open Mouth odontoid?

Asymmetrical lateral masses and off-center alignment of spinous process of C2

How does rotation manifest on an AP Axial C-Spine?

Spinous processes will be off-centered

How does rotation manifest on a Lateral C-Spine?

Poor superimposition of the zygapophyseal joints and articular pillars

How does rotation manifest on a Swimmer's?

Poor superimposition of zygapophyseal joints, articular pillars, and posterior ribs

How does rotation manifest on a Lateral T-Spine?

Poor superimposition of posterior aspects of vertebral bodies and >0.5" of separation between posterior ribs

To accomplish proper flexion or extension of the head and neck for an AP Open Mouth Odontoid, the ___ and ___ should be superimposed.

Upper incisors and base of skull

For AP Open Mouth Odontoid imaging, the base of the skull and/or the upper incisors will be projected about 1" for every ____ angulation.

5 degrees caudal

Poor superimposition of the zygapophyseal joints on a lateral c-spine indicates ____.

Tilt

Excessive rotation of a lateral T-spine is indicated by ____ space between the posterior ribs.

>1/2 inch

Exposure Factors for Spine Imaging

No changes in exposure factors for anything but patient size

What are symptoms of spinal injuries?

Pain, sensory loss, weakness, paralysis, and/or death

Compression

Partial collapse

Distraction

Horizontal fx and separation of posterior elements

Subluxation

Partial dislocation

Once baseline AP/Lat x-rays have been taken, ____ is usually indicated for spinal injuries.

CT

Paralysis

Loss of motor and sensory function below the spinal cord injury

• Upper c-spine injuries can cause tetraplegia (quadriplegia)

Life expectancy for ventilated tetraplegic patients is ____.

• Risks of tetraplegia include:

• 1-2 yrs

• Blood clots and sepsis due to pneumonia, urinary infections, renal failure, and pressure sores

True or false: It is possible to reverse complete spinal cord damage and paralysis.

False; only patients with partial paralysis may regain functionality

Lordosis is exaggerated/abnormal ___ curvature of the ___ spine.

• Concave

• Lumbar

Kyphosis is exaggerated/abnormal ____ curvature of the ____ spine.

• Convex

• Thoracic

Clay Shoveler’s Fx

Avulsion fx of the spinous processes of C6-T1 due to excessive strain on the neck when lifting heavy objects above head

Clay shoveler's fractures are best demonstrated on a ___.

Lateral C-Spine

Clay shoveler's fractures are considered stable fractures, meaning that the bone is ____ but still in alignment with ____.

• Cleanly broken

• Ligaments and tissues intact

Facets - Unilateral Subluxation

C-spine injury involving flexion, distraction, and rotation resulting in only 1 zygapophyseal joint out of alignment

• Spine is not stable, surgery required

A unilateral subluxation of the facet will result in the vertebral body being ____, creating a ____ artifact on the lateral C-spine image.

• Rotated

• Bowtie

Facet subluxation will require post-op ____.

Halo immobilization

Halo Vest

Brace used to immobilize and protect the c-spine after surgery or trauma; usually worn for 6-12 weeks

• Create OID on XR

Halo vests are attached via ____ into the skull. The sites of these attachments must be frequently monitored for ____.

• Pins

• Infection

Facets - Bilateral Locks

Extreme flexion and distraction, with both right and left zygapophyseal joints on the same level disrupted created bilateral locked facets

In bilateral facet locks, the affected vertebral body ____ the body immediately inferior.

Jumps over

___ is required for bilateral facet locks due to distress of the spinal cord.

Surgery

• Halo post-op

Hangman’s Fx

Extreme hyperextension, resulting in fx that extends through the pedicles of C2, with or without anterior displacement of C2 on C3

• Immb. or surgery

A patient with a hangman's fracture is not stable because the intact ____ is pressed posteriorly against the ____.

• Odontoid

• Brain stem

Hangman's fracture is best demonstrated on ____.

Lateral C-Spine

Jefferson Fx

Comminuted atlas fx as a result of axial loading, e.g. landing on one’s head or abruptly on one’s feet

• Ant. and post. arches of C1 are fx

• Post-op halo

Jefferson fractures are indicated by asymmetry in the odontoid view with displacement of the _____ away from the dens.

Lateral masses

Odontoid Fx

Fx of dens and can extend into the lateral masses or arches of C1

Odontoid fractures may result from _____ or a _____ injury.

• Hyperflexion/extension

• Compression

If an odontoid fracture causes further fracture dislocation/injury to the upper spinal cord, it may lead to _____ or _____.

Tetraplegia or respiratory arrest

Odontoid fractures are best demonstrated on ____.

AP Open Mouth

Teardrop Burst Fx

Comminuted fx to the lower cervical vertebral bodies caused by compression with hyperflexion

Teardrop burst fractures indicate extensive underlying ______ injury and spinal _____.

• Ligamentous

• Instability

It is highly probable that a teardrop burst fracture will cause ____.

Neurologic Damage/Quadriplegia

In a teardrop burst fracture, triangular fragments avulsed from the ____ border of the vertebral body and fragments from the ____ border are displaced into the spinal canal.

• Anteroinferior

• Posterior

Kyphosis

Abnormal or exaggerated convex curvature of the T-spine that results in stooped posture and reduced height

Kyphosis is often caused by compression fractures of the ____ edges of vertebral bodies.

Anterior

Risk factors for kyphosis include:

• Osteoporosis

• Poor Posture

• Rickets

Scoliosis

Abnormal or exaggerated lateral curvature of the spine

• Most common in 10-14 y/o, more in females

Severe scoliosis cases may complicate ____ function and require surgery.

Cardiac and respiratory

Treatment for scoliosis includes ____ which can be adjusted as the child grows.

Expandable, permanent correction rods

Spondylitis

Inflammation of the vertebrae

Spondylosis

Neck stiffness due to age-related degeneration of intervertebral disks.

• Can contribute to arthritic changes

Spondylolisthesis

Forward movement of one vertebra in relation to another.

Spondylolisthesis commonly occurs due to a developmental defect in the ____, spondylolysis, or severe osteoarthritis.

Pars Interarticularis

Spondylolysis

Stress fx through the pars interarticularis of the lumbar vertebrae

C-Spine Odontoid: Which options are true?

1. A repeat with more flexion of the head/neck is needed

2. A repeat with more extension of the head/neck is needed

3. The R/L marker is incorrect

4. This is a well-positioned radiograph; no repeat required.

2 and 3

• Repeat with more extension of the head/neck is needed

• R/L marker is incorrect

Which of the following statements are correct regarding the Odontoid radiograph below?

1. The atlantoaxial articulation is well demonstrated

2. The odontoid process is incompletely visualized

3. More flexion is required to move upper incisors inferiorly

4. More extension is required to move base of skull more inferiorly

1, 2, and 3

• The atlantoaxial articulation is well demonstrated

• The odontoid process is incompletely visualized

• More flexion is required to move upper incisors inferiorly

Evaluate the AP Axial C-spine radiograph below and select any of the statements that are true (multiple answers possible):

1. Not all required vertebrae are demonstrated

2. There is excessive extension of the head/neck

3. The R/L marker is incorrect

4. This is a well-positioned radiograph; no repeat required.

1 only

• Not all required vertebrae are demonstrated

Evaluate the Lateral C-spine radiograph below and select any of the statements that are true (multiple answers possible):

1. All required vertebrae are demonstrated

2. A repeat with more flexion of the head/neck is needed

3. The R/L marker is correct

4. This is a well-positioned radiograph; no repeat required.

3 only

• The R/L marker is correct

AP L-Spine: Eval Criteria

• Centered at the crest (or 1.5” above) to include T12 to sacrum

• No rotation

• Open intervertebral joint spaces

How does rotation manifest on an AP L-spine?

• SI joints unequal from spinous processes

• Spinous processes shifted to either side of midline of vertebral column

• Transverse processes of unequal length

AP L-Spine: Is this Image Good?

No.

• Slight right rotation evidenced by spinous processes projected to the left of midline

• T12 is clipped due to low centering at the crest

• Needs collimation

• Needs marker

Lateral L-Spine: Eval Criteria

• Centered at the crest to include T12 to sacrum

• Spinal column aligned parallel to the IR

• No tilt

• No rotation

Lateral L-Spine: Is this Image Good?

No

• Note: There are 6 lumbar vertebrae

• Rotation and tilt begin in L4 and gets progressively worse as you move up the spine

  • Stack the hips and shoulders (fixes rotation) and place a support sponge under the waist (fixes tilt)

• Overexposed; loss of contrast; decrease kVp

• Marker cut-off

Rotation Lateral L-Spine

• Separated posterior vertebral bodies

• Spinous process shifted to the right of midline = slight LPO

Tilt (or ____) Lateral L-Spine

• Sagging

• Indicated by closed intervertebral foramina and joint spaces

To fix rotation on a lateral L-spine, ensure the ____ are stacked. To fix tilt or sagging, place a _____ under the patient's waist.

• Hips and shoulders

• Support sponge

Oblique L-Spine: Eval Criteria

• 45 degree rotation indicated by 5 Scottie dogs stacked on top of each other

• Open zygapophyseal joints and the pedicle between the midline and lateral aspect of the vertebral border

• May be different at L1 and L5 - Evaluate the L3 pedicle

Oblique L-Spine Under-Rotation

• Pedicle is situated away from the vertebral body midline toward lateral border

• More of the lamina is demoed (body of dog)

Oblique L-Spine Over-Rotation

• Pedicles are demoed closer to vertebral body midline, and less of the lamina is demoed

Lordosis

Abnormal or exaggerated concave lumbar curvature

Lordosis may result from:

• Pregnancy

• Obesity

• Poor Posture

• Rickets

Lordosis can cause ____, ____, and ____.

• Muscle pain

• Numbness

• Weakness

_____ will best demonstrate the extent of lordosis. ____ views can also be helpful in indicating more aggressive treatment.

• Lateral L-Spine

• Flex/Ext

Ankylosing Spondylitis

Inflammatory disease that can cause vertebrae to fuse - new bone forms in an attempt to heal inflammation, more common in males

• “Bamboo spine”

Ankylosing spondylitis makes the spine ____, less ____, and can result in ____ posture.

• Flatter

• Flexible

• Hunched

In ankylosing spondylitis, calcification occurs at the ____ ligament.

Anterior longitudinal

Herniated Nucleus Pulposus

aka Slipped Disk. Soft inner part of the intervertebral disk protrudes through the fibrous outer layer, pressing on the spinal cord or nerves

HNP is usually caused by ___.

Improper lifting

HNP most frequently occurs at vertebral level ___, causing ___.

• L4/5

• Sciatica

Which modalities are best in evaluating HNP?

CT/MRI

True or False: some HNPs may heal and resolve over time.

True

Chance Fractures

Result from a hyperflexion force that causes fx through the vertebral body and posterior elements

Posterior aspects of the vertebrae that may be damaged in a chance fracture include:

• Spinous process

• Pedicles

• Facets

• Transverse processes

Transitional Vertebrae

Often an incidental finding that occurs when the vertebra takes on a characteristic of the adjacent region of the spine

• Not directly linked to any problems

• Congenital anomaly 25% of population

Sacralization

L5 assimilates to the sacrum

Lumbarization

S1 acts as a 6th rib-free lumbar vertebra

Transitional vertebrae can also affect L1, which has _____ that present as short ribs.

Elongated transverse processes