632 Exam 2- Lumbar, Cervical, Thorax, Hip, Pelvis

What structures run through the transverse foramen?

vertebral artery, veins, and spinal nerves

What structures run through the intervertebral foramen?

spinal cord and nerves

Which ligament extends upward and outward from the dens, to the occiput, and prevents excessive rotation of the upper cervical spine?

Alar ligament

Which ligament runs horizontally across the dens and helps with stability of the dens, attaches to lateral masses on either side of C1, and maintains articulation between C1/C2?

Transverse ligament

Are alar and transverse ligaments seen on plain radiograph?

No

How can upper cervical ligamentous instability be seen on plain radiograph?

Spacing issues where there shouldn't be

What is the routine examination of the cervical spine?

AP, lateral

What other cervical view is sometimes included in the routine examination of the cervical spine?

AP, lateral, open mouth

The open mouth view of the cervical spine is also called -

odontoid view

Which view of the cervical spine is required to see upper cervical instability or fracture?

Open mouth AP

Which structure on C2 is best visualized with the AP open mouth view?

Dens

Which cervical spine view is used to visualize the lower cervical spine and CT junction?

Swimmer's lateral

Which cervical spine view is used in ERs for suspected cervical fracture after trauma?

Cross-table lateral

Which cervical spine view is used to assess neural foramina?

bilateral oblique

Which cervical spine view is considered a "Stress view" and is used for suspected instability?

Flexion-extension lateral view

Which cervical spine view is used for suspected facet fracture?

Articular pillar view

True or False:

The articular pillar view is not commonly used, so when there is a suspected facet fracture, the patient will usually have a CT scan

true

IV disks and uncinate processes begin at the ______ level to provide stability to the disks

C2-C3

Which structure on C1 acts as its spinous process?

Posterior arch/tubercle

In the AP view of the cervical spine, the _____ is seen as a black, air filled tube

trachea

The first rib articulates with which spinal level?

T1

In the _____ view of the cervical spine, superimposition of the mandible and skull obscure the upper cervical spine

AP

Intervertebral foramen can only be well visualized in which view of the cervical spine?

Oblique

To gauge if cervical vertebrae are inappropriately rotated, which 2 distances should be assessed on the xray?

pedicle to pedicle and pedicles to spinous process

Which view of the cervical spine is the BEST view for visualizing joint margins and spaces?

Lateral

Where is the central ray i n a cervical AP view?

Below the thyroid cartilage

Where is the central ray in a cervical lateral view?

C4/C5

In a cervical lateral view, the _______ appears as a darker area between the spinous process and articular pillar

lamina

Where is the central ray in a cervical AP open mouth view?

C1/C2 joint space

Which 3 lines should be assessed in a cervical lateral view to determine if instability or a spondy is present?

Anterior vertebral body, lamina, posterior vertebral body

Discontinuities in an anterior vertebral body line suggests

instability or spondy

Which view of the cervical spine best visualizes the intervertebral foramina, uncovertebral joints, facet joints, and pedicles?

Bilateral oblique

Where is the central ray in a cervical bilateral oblique view?

Through C4

_____ scans are able to catch occult and subtle fractures of the cervical spine better than plain radiographs

CT

Your are examining a right posterior oblique view of your patient's cervical spine. From C2-C4, neural foramina are equal in size and shape. At C5, there is a massive decline in IVF size. Your patient's radiculopathy symptoms have not improved after 6 weeks of high quality PT. What are next steps for this patient?

Surgical consult

What is included in the standard 2 view series for the cervical spine?

AP and lateral

When is a standard 2 view series of the cervical spine indicated?

non-radicular C3-C7 pain

What is included in the 3-view series of the cervical spine?

AP, lateral, open mouth

When is a 3-view series of the cervical spine indicated?

Non radicular pain with concern for C1-C2 instability or fracture

What is included in the 5 view series of the cervical spine?

AP, lateral, open mouth, bilateral obliques

When is a 5-view series of the cervical spine indicated?

Radicular pain, very commonly ordered

When would adding on a flexion/extension view of the cervical spine be indicated?

-after spondylolisthesis or upper cervical instability found on previous series

-use for surgical planning

When would adding on a Swimmer's view of the cervical spine be indicated?

If C6-T1 is indicated on a lateral view

What are hallmark findings of DDD on a cervical lateral view?

osteophyte formation, loss of disk height, obliterated and sclerotic facet joints

What are hallmark findings of DDD on a cervical oblique view?

decreased IVF opening correlated with radicular pain

Osteophyte formation on a cervical oblique view is usually a sign of what pathology?

Foraminal encroachment

Which cervical spine criteria has a high sensitivity (99.6%) but very low specificity (12.9%) for identifying significant cervical spine injury?

NEXUS criteria

What 5 things are included in the NEXUS crtieria?

-focal neurological deficit

-midline spinal tenderness

-altered consciousness

-intoxication

-distracting injury

According to the NEXUS criteria for c-spine imaging, does the following patient need imaging:

Pt was in a hit-and-run car accident in the parking lot of Walmart. Pt has midline tenderness at the back of the occiput and a slight headache but otherwise appears unscathed.

Yes- midline spinal tenderness

According to the NEXUS criteria for c-spine imaging, does the following patient need imaging:

Patient was tackled in his high school football game and knocked unconscious for 30 seconds. The AT on field palpated midline spinal tenderness and also found a broken ankle.

Yes- midline spinal tenderness and distracting injury

Which cervical spine imaging rules have a high sensitivity (100%) and decent specificity (43%)?

Canadian C spine rules

What are the 3 high risk factors in the canadian C spine rules?

age over 65, dangerous mechanism, paresthesias in the extremities

Your 69 y.o. female pt recently fell down her front steps (5 stairs) and fractured her occiput. She was hospitalized and received sutures in the base of her skull and is currently hemodynamically stable. Should your pt receive radiography based on her presentation?

Yes- high risk factors present

A 75 year old patient was in a a bicycle crash at the park. She has paresthesias in BUEs but is telling you she's fine. What are your next steps?

Refer for CT d/t presence of high risk factors

What are the low risk factors in the Canadian C spine rules?

-simple rear end MVC

-sitting in ED

-ambulatory at any time

-delayed onset neck pain

-absence of midline cspine tenderness

If there are NO LOW RISK FACTORS present AND no high risk factors present in a patient with cervical injury, what are your next steps?

Refer for CT scan

Your 29 y.o. pt was recently in a simple rear-end MVC. He is having focal headaches and dizziness. He reports no paresthesias in extremities. What should you do to determine if he should receive radiography?

Assess AROM cervical rotation to left and right sides

Your 29 y.o. pt was recently in a simple rear-end MVC. He is having focal headaches and dizziness. He reports no paresthesias in extremities. He cannot rotate his neck 45 degrees left or right.

Does he need radiography?

Yes, CT scan

Your 29 y.o. pt was recently in a simple rear-end MVC. He is having focal headaches and dizziness. He reports no paresthesias in extremities. He CAN rotate his neck 45 degrees left or right.

Does he need radiography?

No

What initial imaging should be ordered for an individual with new or increasing nontraumatic cervical or neck pain with no "red flags"?

Conservative treatment should be tried first

What initial imaging should be conducted for an individual with new or increasing nontraumatic cervical or neck pain with no "red flags"?

The patients symptoms have worsened after 6 weeks of high quality PT.

Plain radiography

What initial imaging should be conducted for an individual with new or increasing nontraumatic cervical or neck pain with multiple red flags?

Plain radiography

What initial imaging should be conducted for an individual with new or increasing nontraumatic cervical radiculopathy with no "red flags"?

Initial conservative therapy may be reasonable

What initial imaging should be conducted for an individual with new or increasing nontraumatic cervical radiculopathy with no "red flags"?

The patient's pain has not improved in the last 6 weeks of PT.

MRI w/o contrast

What initial imaging should be ordered for suspected spinal cord compression?

Urgent MRI

What initial imaging should be ordered for possible spinal canal stenosis?

MRI

What initial imaging should be ordered for possible spinal canal stenosis who CANNOT have an MRI?

CT or CT myelography

What initial imaging should be ordered for a patient with a suspected infection or abscess of the spine?

Emergent MRI

All of the following are red flags for sinister pathology of which region?

-constitutional s/s

-immunosuppression

-IV drug use

-history of malignancy or unexplained weight loss of insidious onset

-age >50 yrs

-prolonged use of corticosteroids or osteoporosis

-rheumatological condition

-neurological s/s

Cervical Spine

A patient with cervical pain has been taking immunosuppression drugs s/p lung transplant. What is this red flag a concern for?

Spine infection

A patient reports to OP PT for neck pain. They report a history of breast cancer 10 years ago and also mention recent unexpected weight loss. What is this red flag a concern for?

Cancer metastases

A patient reports to OP PT for severe neck pain. They mention that they were diagnosed with RA 2 years ago. What is this red flag a concern for?

Upper cervical instability

What initial imaging should be ordered for an adult patient with headache with one or more red flags present?

CT

________ vertebrae have large bodies, short pedicles, and short broad lamina that form blunt and large spinous processes

lumbar

All lumbar facet joints are in the _________ plane, except for L5

sagittal

L5 facet joints are in the ______ plane

coronal

What are the standard projections for the lumbar spine?

AP, lateral

What are possible additional views of the lumbar spine?

Cone down (L5-S1), obliques, flexion/extension

Where is the central ray in an AP view of the lumbar spine?

L4/L5

Which lumbar projection can best visualize spondylolisthesis?

Lateral

In a lateral view of the lumbar spine, _____ are superimposed as a pair at each level

pedicles

In a lateral view of the lumbar spine, IV foramina appear as -

radiolucent ovals

Which view of the lumbar spine shows the facet joints, pars interarticularis, and pedicles and shows spondylolysis the best?

Oblique

Spondylosis is -

degenerative changes in the vertebral column

Spondylolysis is -

fracture of pars interarticularis

Spondylolisthesis is -

anterior slippage of a vertebrae

Which view of the lumbar spine is a cones view of the lumbosacral junction and removes superimposition of the ilium over L5/S1?

Lateral coned view (L5-S1)

Which vertebrae articulates with the 12th rib?

T12

Which distances should be assessed in a lumbar spine AP view to see if any vertebrae are rotated?

Interpedicular and between each spinous process

Normal interpedicular distance in an AP view of the lumbar spine is ______ mm

25-30

The anterior vertebral body line runs along which ligament?

anterior longitudinal

The posterior vertebral body line runs along which ligament?

posterior longitudinal

The spinolaminar line runs along which landmark?

Junction of the spinous process and lamina

True or False:

With lumbar flexion and extension, the anterior vertebral body line, posterior vertebral body line, and spinolaminar lines should all remain parallel and evenly spaced

True

True or False:

Cone down L5-S1 view is not commonly used because it requires a high radiation dose to prevent distortion of L5-S1 over the ilium

True

A _____ posterior oblique projection of the lumbar spine images right sided structures

right

A _____ posterior oblique projection of the lumbar spine images left sided structures

left

A posterior oblique lumbar view shows _______ facet joints closest to the image receptor

downside

An anterior oblique lumbar view shows ______ facet joints further from the image receptor

upside

A ______ image shows "downside" left facet joints

left posterior oblique