Radiographic and Computed Tomography Evaluation of the Cervical Spine


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  • Chapter Synopsis

  • Conventional radiographs and computed tomography (CT) imaging are integral parts of the evaluation of a patient with suspected cervical spine abnormalities. The treating clinician must have a thorough understanding of the role of the imaging studies available, the radiographic views that should be obtained, and the ability to differentiate normal from abnormal findings. This chapter discusses the conventional radiographic views most commonly used in the cervical spine and their key roles in evaluating for cervical spine disease. It also reviews the benefits of obtaining multiplanar CT imaging and describes when this imaging technique should be used to evaluate patients with known or suspected spinal disorders.

  • Important Points

  • Conventional radiographs and CT images play major roles in the evaluation of patients with known or suspected cervical spine abnormalities.

  • The lateral view of the cervical spine provides most of the information the clinician obtains from conventional radiographic images.

  • A systematic approach to the interpretation of radiographic studies is important to ensuring that adequate views are obtained and all structures are appropriately visualized.

  • The cervical spine is often divided into separate regions: the occipitocervical junction, the atlantoaxial region, and the subaxial region. The unique anatomy of the individual regions leads to characteristic radiographic findings and appearances. The anteroposterior, oblique, dynamic, odontoid, and swimmer’s views all offer specific advantages to complete a thorough evaluation of particular cervical spinal abnormalities.

  • CT allows for multiplanar image reconstruction, which improves overall visualization and detail in imaging of the cervical spine.

  • Although both conventional radiographs and CT images allow for evaluation of the cervical spine, clinicians should know when magnetic resonance imaging is the optimal modality for a particular diagnosis or clinical situation.

The evaluation of a patient with a suspected spinal abnormality always begins with a thorough history and physical examination. The next most important tool in the spine surgeon’s armamentarium is the ability to evaluate imaging studies accurately. Imaging begins with conventional radiographs and often progresses to advanced planar imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) (see Chapter 10 ). In the context of correlating clinical findings, the ability to order and interpret radiographic studies appropriately leads to more accurate diagnosis and treatment. This chapter focuses on the individual radiographic views that aid the clinician in the evaluation of the cervical spine. A discussion of the indications for CT-based evaluation of the cervical spine is also included.

Conventional Radiographic Evaluation

Conventional radiographs are commonly obtained to (1) diagnose (e.g., fracture from trauma), (2) localize the level or levels of abnormality, (3) observe and follow the progression of disease (e.g., tumor, infection, or degenerative or inflammatory conditions such as rheumatoid arthritis or diffuse idiopathic skeletal hyperostosis), (4) observe and follow the progression of deformity (e.g., kyphosis, scoliosis), (5) plan the levels and extent of surgery preoperatively, and (6) follow-up operative procedures.

An understanding of the information that can be obtained from individual radiographic views is necessary to ensure that appropriate studies are initially ordered. Next, the clinician must develop a systematic approach to radiographic studies. This approach should begin by ensuring that the image is of the correct patient and that it adequately visualizes the anatomic structures to be evaluated and allows for assessment of spinal alignment.

Lateral View

The lateral cervical spine radiograph provides most of the information for the evaluation of patients with cervical spine disorders or suspected cervical spine abnormalities.

For a cervical spine lateral radiograph to be considered adequate, the clinician must be able to visualize the area from the occiput to the superior end plate of T1 ( Fig. 9-1 ). The overall spinal alignment should be noted in terms of lordosis, straightening, or kyphosis. Normal vertebral bodies are symmetric and rectangular. The margins of the vertebral body should be visually traced to rule out fracture or an osteolytic process, such as tumor. Disk space height should also be evaluated; a loss of disk space height may indicate degenerative disk disease or chronic infectious conditions. A loss of disk space height with nonbridging, nonmarginal osteophytes or syndesmophytes is a classic finding in patients with degenerative spinal disease.

FIGURE 9-1, Lateral radiograph of the cervical spine. The entire cervical spine, including the occipitocervical junction and the cervicothoracic junction, are well visualized, and the five spinal lines (anterior vertebral body line, posterior vertebral body line, spinolaminar line, spinous process line, and soft tissue shadow line) are well maintained.

Harris and associates described five lines for the evaluation of the cervical spine on the lateral radiograph: (1) the anterior vertebral body line, (2) the posterior vertebral body line, (3) the spinolaminar line, (4) the spinous process line, and (5) the soft tissue line. These lines should be evaluated carefully in every patient. Disruption of one of these lines, even if subtle, should prompt the examiner to scrutinize that area further for abnormality. For example, spondylolisthesis, or displacement of one vertebral body over another, as classified by Wiltse and colleagues and graded by Meyerding, results in disruption of these radiographic lines and indicates abnormality with the potential for instability. These findings should be interpreted according to the clinical situation. For example, after acute trauma to the cervical spine, such a finding may warrant immediate immobilization or surgical stabilization ( Fig. 9-2 ). In contrast, in the setting of chronic degenerative or rheumatologic disease, this finding would prompt further clinical or radiographic evaluation, such as flexion and extension views, as described later.

FIGURE 9-2, Spondylolisthesis. Lateral radiograph of the cervical spine showing disruption of the spinal lines, widening of the spinous processes ( arrow ), and anterolisthesis of C4 on C5. The degree of listhesis can be measured as a percentage of the displacement of the inferior end plate of the superior vertebral body over the superior end plate of the inferior vertebral body (end plates highlighted with lines ).

In addition to osseous structures, soft tissue shadows can be appreciated on lateral radiographs. In particular, the shadow anterior to the vertebral bodies representing the retropharyngeal soft tissues should be evaluated. According to some clinicians, the shadow should be less than 5 mm at the C3 level ( Fig. 9-3 ), and it should be less than 22 mm at the C6 level. However, other clinicians have found this measurement to be unreliable. A larger soft tissue shadow may be the result of edema related to a fracture, an infection in a patient with a retropharyngeal abscess, or a retropharyngeal hematoma in a patient who recently underwent an anterior cervical spinal procedure.

FIGURE 9-3, This 35-year-old man fell from a scaffold, with forcible extension of the neck, and sustained an extension-distraction injury with incomplete spinal cord injury. This lateral conventional radiograph shows substantial edema in the anterior soft tissues ( arrowheads ).

Occipitocervical Junction

The occipitocervical junction can be a particularly challenging region to evaluate on conventional radiographs because of the overlap of anatomic landmarks. Radiographic lines and parameters have been described to aid in evaluating the relationship of the base of the occiput with C1 and C2 for disassociation, basilar invagination, and cranial settling. The Harris “rule of twelves” is one such relationship with which the spine surgeon should be familiar, especially in the setting of major occipitocervical trauma. The dens-basion interval, measured as the distance from the basion to the tip of the odontoid process, should be less than 12 mm. Similarly, the basion-axial interval, the distance from a vertical line drawn along the posterior aspect of the dens (termed the posterior axial line) to the basion, should be less than 12 mm. A distance of more than 12 mm for either interval indicates atlanto-occipital dissociation. Additional radiographic lines and parameters can aid in the evaluation of the occipitocervical junction ( Fig. 9-4 and Table 9-1 ). The reliable use of these lines and parameters largely depends on the ability to visualize their corresponding landmarks. CT and MRI have aided substantially in the accurate evaluation of these parameters in this region and have widely replaced conventional radiographs for definitive evaluation.

FIGURE 9-4, Lines and measurements for the evaluation of basilar invagination.

Table 9-1
Occipitocervical Junction: Anatomic Relationships, and Lines for Use with Magnetic Resonance Imaging, Computed Tomography, and Conventional Radiographs
From Zebala LP, Buchowski JM, Daftary AR, et al: The cervical spine. In Khanna AJ, editor: MRI for orthopaedic surgeons, New York, 2010, Thieme, pp 229–268.
Eponym Parameters Pathologic Features
Wackenheim clivus baseline Tangent drawn along the superior surface of the clivus Dens should be below the line.
Clivus canal angle Angle formed between Wackenheim line and the posterior vertebral body line Normal ranges are 180 degrees in extension to 150 degrees in flexion. An angle of <150 degrees is considered abnormal.
Chamberlain line Between the hard palate and the opisthion Protrusion of the dens >3 mm above this line is considered abnormal.
McRae line Basion to the opisthion Protrusion of the dens above this line is abnormal.
McGregor line From the hard palate to the most caudal point on the midline occipital curve Odontoid process rising >4.5 mm above this line is considered abnormal.
Ranawat criterion Distance between the center of the pedicle of C2 and the transverse axis of C1 Measurement of <15 mm in males and <13 mm in females is abnormal.
Welcher basal angle Tangent to the clivus as it intersects a tangent to the sphenoid bone The normal range is 125 to 143 degrees. Platybasia exists when the basal angle is >143 degrees.

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