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C-spine x-ray interpretation

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The ABCs of the cervical spine provide a helpful mnemonic to guide the systematic assessment of these x-rays. Remember, you need all three views (lateral, AP and odontoid/open mouth view) for an adequate study.

A: Adequacy

The C7/T1 junction must be visible

A: Alignment

Ensure all four lines are contiguous/uninterrupted

1. Anterior longitudinal line

2. Posterior longitudinal line

3. Spinolaminal line

4. Spinous process line

B: Bones

Each vertebra must be examined for fracture/collapse/avulsion.

Parallel facet joints.

C: Cartilage (aka disc spaces)

Examine for symmetry/normality of the intervertebral discs between each vertebrae

S: Soft tissue

Prevertebral swelling of <2/3 of adjacent vertebral width

<7 mm anterior to C2

<2 cm anterior to C7

S: Spaces and lines

from Slack SE, Clancy MJ Clearing the cervical spine of paediatric trauma patients Emergency Medicine Journal 2004;21:189-193.

Pre-dental space

rom Emergency Radiology: Case Studies via accessemergencymedicine.com

Normal <3 mm

>3 mm (XR) or 2 mm (CT) ?damage to transverse ligament

>5 mm implies rupture of transverse ligament

Basion-dental interval

A marker of occipito-atlantial dissociation

from Chris Partyka

<12 mm on x-ray or

≤8.5 mm on CT

Line of Swischuk

Helps differentiate pathological anterior displacement of the cervical spine (typically C2/3) from physiological displacement, termed pseudosubluxation.

A line is drawn between the anterior aspect of C1 and C3 spinous processes.

Dr Jeremy Jones, Radiopaedia.org, rID: 43445.

The anterior aspect of C2 spinous process should be within 2 mm of this line.

Deviation >2 mm: indicative of true subluxation.

Deviated <2 mm: consistent with pseudosubluxation

from Slack SE, Clancy MJ Clearing the cervical spine of paediatric trauma patients Emergency Medicine Journal 2004;21:189-193.

A: No subluxation. Therefore, posterior cervical line (PCL) cannot be applied. Anterior aspect of spinous process of C2 commonly misses PCL by 2 mm.

B: Subluxation is present. The anterior aspect of spinous process of C2 misses the PCL >2 mm. Finding is suggestive of a hangman’s fracture of the neural arches of C2.

C: Pseudosubluxation is present. The anterior aspect of spinous process of C2 touches or lies within 2 mm of PCL.

About the authors

  • Chris Partyka is an Emergency Physician and Prehospital & Retrieval Specialist working in Sydney, NSW. He has a keen interest in medical education, ultrasound & coffee. He is the father of two young boys & tries to out-smart his paediatric patient's with an expanding knowledge of cartoons

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14 thoughts on “C-spine x-ray interpretation”

  1. hi great presentation Chris, But I was wondering what you referred to as a “one of the rare ED docs with an Australian accent!” about your self?

  2. Nice images! However a further magnifying option would be useful for some of the images even when they are at full size..

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