Neck and Shoulder Imaging and Complaints

Question 1

Indications for spine radiography

Answer 1

• Trauma: C1-C2, C6-C7 are most frequently injured levels win the cervical spine
• Shoulder or arm pain (radiculopathy)
• Occipital headache (upper cervical instability)
• Limitation in motion
• Planned or prior surgery
• Malignancy
• Arthritis
• Congential anomalies
• Spinal abnormality
• Suspected instability

Question 2

What and how many views for a routine cervical spine radiologic evaluation

Answer 2

• 3-5 projections
• AP lower cervical spine
• Lateral view
• Sometimes AP open mouth and R/L oblique

Question 3

Describe a AP view of the cervical spine

Answer 3

• Chin is projected over base of skull (chin up)
• Angled x-ray beam is parallel to cervical disc
• Best view for alignment & to observe oblique fractures

Question 4

Describe the lateral view of the cervical spine

Answer 4

• Best initial view to evaluate alignment, spacing, soft tissues, & vertebrae
• “Lines of Life” these lines should demonstrate: slight lordotic curve, smooth & without step-offs; any malalignment in any degree of neck motion should be considered evidence of bony or ligamentous injury

Question 5

Describe oblique view of the cervical spine

Answer 5

• Done only after fracture or dislocation injuries are ruled out
• Can assist with identification of neural foramina narrowing

Question 6

Describe an open mouth view of the cervical spine

Answer 6

• Teeth are projected over the base of skull (mouth is open)
• Axis & atlas projected between upper & lower teeth
• Demonstrates C1-2 alignment

Question 7

Describe dens/Odontoid fractures

Answer 7

• in younger patients they are typically the result of high-energy trauma which occurs as a result of motor vehicle or diving accidents
• in elderly pop. the trauma can occur after lower energy impacts such as falls from a standing position
• Most common MOI is a hyperextension of the cervical spine pushing the head & C1 vertebrae backward (most common C2 fracture)

Question 8

Describe a Jefferson fracture

Answer 8

• Typical MOI is diving head first into shallow water
• Axial loading along the axis of the cervical spine results in the occipital condyles being driven into the lateral masses of C1
• Not normally associated with neurological deficit although spinal cord injury may occur if there is a retropulsed fragment affecting the cervical cord

Question 9

Describe a trauma screen

Answer 9

• Series of radiographs & selected advanced imaging (CT) to screen & prioritize injuries in a trauma vicim
• Cross table lateral view for fx or dislocation of cervical spine
• Indicators: abnormal soft tissues, abnormal vertebral alignment, abnormal joint positions
• Role of MRI is to aid in characterization of soft tissue injury, neural element injury, disk injury, or neurological deficit

Question 10

Radiologic signs of cervical trauma

Answer 10

• Abnormal vertebral alignment, soft tissue, or joint relationship
• Stable injury = intact posterior spinal ligaments
• Unstable injury = displacement
• Lower c-spine =higher frequency of injury in adults
• Upper c-spine = higher frequency of injury in children; SCIWORA = spinal cord injury w/o radiographic abnormalities

Question 11

Signs of abnormal vertebral alignment

Answer 11

• Loss of parallelism (3 lines)
• Loss of lordosis
• Acute kyphotic angulation
• Rotation of vertebral body
• Loss of facet joint articulation indicating dislocation

Question 12

Describe abnormal joint relationship

Answer 12

• Widened atlantodental interface: degeneration, stretching, rupture of the transverse ligament
• Widened interspinous process space (“fanning”)
• Widened or narrowed intervertebral disc space
• Loss of facet articulation

Question 13

Signs of abnormal soft tissue

Answer 13

• Widened retropharyngeal or retrotracheal spaces
• Displacement of the trachea or larynx
• Displacement of the pre vertebral fat pad

Question 14

What are the ABCDs of cervical spine radiograph interpretation

Answer 14

• Alignment and Anatomy
• Bone density
• Canal space: free fragments from disc
• Disc integrity
• Soft tissue: edema

Question 15

NEXUS (National Emergency X-Radiography Utilization Study) meet all low-risk criteria

Answer 15

• No posterior midline cervical spine tenderness
• No evidence of intoxication
• Normal level of alertness
• No focal neurological deficit
• No painful, distracting injuries
• If YES meet all low-risk criteria then no radiograph and if NO then radiograph

Question 16

CT indications for cervical spine

Answer 16

• Acute trauma in adults
• Degenerative conditions
• Infections of the spine
• Image guidance for injections
• Neoplasms
• Congenital abnormalities
• Developmental abnormalities
• Intrathecal masses

Question 17

ABCDs for cervical spine CT

Answer 17

• Alignment & Anatomy: coronal & sagittal view for alignment (fx, dislocation, bone destruction)
• Bone density: cortical bone is dense, cancellous bone is less dense, CT best for fractures & ligamentous considerations
• Canal space: axial view to assess for free space & any fragments
• Disc integrity: posterior & posterior lateral marginal assessment in axial view for herniated disc
• Soft tissue: sagittal view assess for trauma to prevertebral soft tissues

Question 18

Describe Tori and Pavlov’s ratio for CT interpretation

Answer 18

• Width of the spinal canal should equal the width of the corresponding vertebra
• Normal ratio is canal diameter ÷ body diameter = 1
• A ratio of <0.85 indicates spinal stenosis

Question 19

Indications for a cervical spine MRI

Answer 19

• DDD (degenerative disc disease)
• Masses/tumors in the dura
• Treatment fields for radiation therapy
• Intrinsic spinal cord pathology
• Spinal vascular malformation
• Congential anomalies
• Post operative interspinal changes
• Meningeal abnormalities
• Spinal infections
• Pre-operative assessment for verteboplasty

Question 20

ABCDs for cervical spine MRI

Answer 20

• Alignment: sagittal view best for alignment (fx, dislocation, bone destruction)
• Bone signal: assess for any irregular signal intensities
• Canal space/CNS: canal space in sagittal & axial views, look for effacement (indention of theca sac)
• Disk integrity: disk height & hydration of NP; evaluate posterior margins on sagittal & posterolateral margins on axial view
• Soft tissue: evaluate paravertebral structures

Question 21

MR imaging has been proven to be the technique of choice for imaging of

Answer 21

• Intervertebral disk degeneration
• Diffuse posterior disk bulging
• Herniation
• Protrusion/extrusion

Question 22

What cervical spine structures can you see in the axial view of an MRI

Answer 22

• IV disks
• IV foramina
• Spinal canal, epidural space, theca sac
• Facet joints
• Ligamentum flavum
• Nerve roots

Question 23

Cerviical spine structures seen in sagittal view on MRI

Answer 23

• Vertebral bodies/endplates
• Disk signal, height
• Epidural space, nerve roots
• Spinal canal and cord
• Anterior & posterior longitudinal ligaments
• Interspinous & supraspinous ligaments
• Spinous processes

Question 24

Describe DDD (degenerative disc disease)

Answer 24

• Present on radiographie in most persons >60 yrs
• Changes in disc include: dehydration, nuclear herniation, annular protrusion, & fibrous replacement of the annulus
• Decreased disc height

Question 25

Describe diffuse idiopathic skeletal hyperostosis (DISH)

Answer 25

• Characterized by bony proliferation at sites of tendinous & ligamentous insertion of the spine affecting elderly individuals
• On imaging typically characterized by the flowing ossification of the anterior longitudinal ligament

Question 26

Different spinal fractures

Answer 26

• Most commonly occur at C1-C2, C5-C7, T9-L2
• Teardrop fx
• Transverse process fx
• Compression fx: wedge or burst fracture
• Articular pillar
• Hangman fx (posterior C2 fx): hyperextension with axial load
• Clayshoveler’s fx (spinous process fx of C6, C7, T1, T2)

Question 27

Describe cervical spine dislocations

Answer 27

• Most serious & life threatening injuries
• Fx through the base of the dens combined with a ligament rupture will cause a fx & dislocation of the atlantoaxial joint (C1-C2)
• Hangman’s fx of the axis ca be associated with anterior dislocation of C2 on C3
• Lower cervical fx of the posterior vertebral structures + tears of the posterior ligaments may cause a vertebral body to displace anteriorly, transecting or contusing the spinal cord