In this section
With all radiographs, check you have the correct: Name Date Orientation.
This chapter discusses interpretation of c-spine X-rays (see cervical spine assessment clinical practice guidelines)
Spinal cord injury without radiographic abnormality is defined as injury with objective signs of myelopathy as a result of trauma, but with no evidence of fracture or ligamentous instability on plain x-rays or tomography.
SCIWORA is most frequently seen in younger children (especially under about 8 years of age), and in injuries of the cervical spine. Postulated causes include:
The incidence reported in children ranges from 1% to 10% of all spinal cord injuries.
Younger trauma patients tend to have more profound neurological injury, and hence less long-term improvement.
A number of children will present with minor neurological injury and progress to complete or partial spinal cord injury.
The incidence of this delayed onset of the serious symptoms is reported to be between 5 and 50%. Delays to onset of full symptoms have been as long as 4 days.
Because of these presentations, all children with histories of neurologic symptoms or any neurologic deficit should be treated as having potential spinal cord injury.
Clinical and radiological data must be interpreted together. The c-spine x-ray in the trauma series is the Lateral:
this should identify 80% -90% of fractures.
A full radiological examination of the c-spine requires two further x-rays:
These should be performed when further imaging is required in order to assess the c-spine.
A number of normal radiological findings in children are significantly different from those in adults.
The common findings that cause concern are:
Other normal findings that can be misinterpreted include:
All of these normal findings can be mistaken for acute traumatic injuries in children following trauma.1.
Children more than 8 years old have radiographic appearances similar to adults.
1. Check adequacy
If unable to visualise, use Swimmer's view as described in c-spine
(see cervical spine assessment clinical practice guidelines)
2. Check alignment
Normal lateral c-spine film 1:
Draw 4 smooth curved lines running from top to bottom vertical lines:
Spinal column lies between 2 and 4 Lines: Smooth No steps
No angulation Line 2 should line up with the clivus; Line 4 should line up with the Back of the foramen magnum.
The distances between C3-C7 spinous processes should show no significant widening (fanning).
The distance between the spinous process of C1 and C2 is large.
Normal lateral c-spine film Od odontoid peg - DENS SP spinous process Laminar F Facet Joint A Preodontoid space:
3. Next assess SWISCHUK lines
To assess for Pseudosubluxation.
Normal laxity of spine can be misinterpreted as subluxation.
Here there appears to be subluxation of C2 C3
Draw SWISCHUK lines
SWISCHUK linesThis is within normal limits:
Pseudosubluxation is exaggerated when the neck is in flexion, not in neutral.
Any measurement above 2 mm is abnormal.
4. Assessment of bone / vertebral bodies
Review the outline of each vertebral body Below C2 they should be same height and uniformity
X-ray shows compression # C4 C5:
X-Ray shows # C2 - Hangman's Fracture C7 spinous process:
5. C1 C2 atlanto-axial
Joint between odontoid peg and the anterior arch of the atlas should be less than 4 mm in a child.
90% of children, between 1-4 mm.
6. Joint spaces
Assess spaces between:
Gaps between spinous process: C1-C2 large gap C2-C8 similar size gaps
7. Soft tissues
Review soft tissues
The widening of the prevertebral tissue suggests
Also widened on:
Size of soft tissue space Above the larynx C2: less than one third of the vertebral body width Below the larynx C3-C7: not more than one vertebral body width Progressively narrows towards C7
Any soft tissue swelling which is larger than this is abnormal, unless as above.
X-rays of the same infant:
On the left there is a widened prevertebral space however the neck is in flexion and the infant is crying and the larynx is high
On the right shows normal prevertebral space with the neck in extension and the larynx at C3
Widened soft tissue spaces:
8. Disc spaces
Review the disc spaces they should be of similar height Note large space C6/C7
Note large gap between C1/C2 spinous process
Further imaging of the c-spine
Note normal variant for C3-C6 to have bifid tips to the spinous process.
Normal AP view:
Radiology of Odontoid peg if > 5years
C1 ATLAS is a ring with articular processes the "lateral masses" It articulates:
C2 AXIS anteriorly has the odontoid peg
To check for rotation of the film the line from the middle of the incisors should transect the dens equally
Examples of odontoid fractures:
i. Odontoid peg visible equidistant from each lateral margin unable to see extreme of edges
ii. Abnormal odontoid alignment
Lateral margins overhang (see below)
iii. Normal alignment of lateral margins
The lateral margins are overhanging and not aligned
Odontoid peg fracture
The X-Ray is a portable supine AP.
Inspiration: 6 anterior rib visible on the X-Ray above the diaphragm:
Check position of all internal tubes - Endotracheal tube, Nasogastric tube, etc.
Check all bones present on the X-Ray i.e. spine, ribs, scapula, clavicle and, proximal humerus.
Check acromioclavicular joint and the shoulder joint.
6. Borders /Mediastinum
Check it is clearly defined and normally situated.
Check: -The trachea is central; -The lungs are fully inflated; check for lung markings throughout;
- The lung fields are symmetrical;
- Horizontal fissure in correct position ;
Remember the X-Ray is taken supine
so pneumothorax and haemothorax will differ from an erect
Check: -The size is normal. This is difficult to interpret in an AP film but it is generally 2/3 of the lateral diameter.
- Position - is there any deviation?
Examples of chest x-rays
Right lower lung contusions Left-sided pneumothorax:
Pulmanary contusions Subcutaneous emphysema Pneumomediastinum Bilateral chest drains Intubated - Nasogastric tube:
The radiograph is an AP pelvic view.
Sacrum tip and spine in alignment with symphysis pubis.
Assessed easily by drawing a series of rings and lines. Series of rings:
These should all be smooth with no steps.
Remember to review:
If there are any concerns about
pelvic fractures, seek expert Orthopaedic opinion on further
imaging and treatment
Examples of pelvic fractures
Acetabular fracture Pelvic fractureDislocated right hip:
Dislocated right hip multiple pelvic ring fractures pubic diastasis:
Further imaging should only take place after discussion
with specialist consultant orthopaedic/neurosurgical consultant.
The patient's transfer to a definitive centre of care should not be
delayed to await imaging.