Lateral cervical spine xray is the most important trauma screening study . However, clearance of the cervical spine is not possible on basis of single lateral plane study. Moreover, the typical lateral cervical spine xray is centered in the midneck region and interpretation of the occipitocervical junction can be impaired.
To be able to rule out injury following bony structures need to be seen on xray
- Basion
- Opisthion -On the occipital bone, the mid-point on the posterior margin of the foramen magnum
- Occipital condyles
- Mastoid processes
- Tip of the dens
- Outline of atlas and axis
These structures should be visualized in a trauma situation and looked for fracture, rotation, and displacement.
The occipitocervical and atlantoaxial joints should be assessed for congruence.
In adults, widening of the prevertebral soft tissue mass in the upper neck is an important warning sign of major underlying trauma.
Various Reference lines can help in identifying alteration in normal upper cervical spine outline.
Anteroposterior visualization of the upper cervical spine requires either an open-mouth odontoid view. Normally symmetrical articulating occipital condyles, C-1 lateral masses, and C-2 superior articular processes can be visualized. The odontoid is well centered between the lateral masses of C-1.
In this view, there should be no overhang, translation, or distraction between the lateral masses of C-1 and C-2. The articular surfaces of occipital condyles to the C-1 superior facets and those of the atlantoaxial articular surfaces should be equidistant to one another.
Other xrays that can be done to evaluate upper cervical spine are oblique views, one lower cervical spine anteroposterior x-ray, which usually exposes C4 to T4, and a swimmer’s lateral view.
Dynamic Radiographs
Dynamic radiographs of cervical spine are used to find any ligamentous injury to the region.
Any odontoid asymmetry relative to the lateral masses of the atlas or any diastasis of the upper cervical spine articulations to one another is cause for concern about a ligamentous injury to this region.
Dynamic sudies should not be done in patients with with suspected occipitocervical dissociation because of their potential to inflict neurologic compromise. Also, flexion-extension radiographs are contraindicated for patients with known acute cervical spine fractures and dislocations.
Computed Tomography
Computed tomography is a crucial investigation tool in assessment of patients with known or suspected cervical spine fractures.
CT scans allows for high-resolution imaging and makes diagnosis easier. By digital reconstruction of the fracture fragments, articular incongruities, complex fracture patterns and visualizing axial plane fractures can be understood.
A head CT scan incorporating the craniovertebral junction, can be helpful in detecting subarachnoid craniovertebral junction hematoma, which is frequently associated with atlanto-occipital dissociation, and occipital condyle fractures, which are commonly missed on conventional radiography.
Magnetic Resonance Imaging
Magnetic resonance imaging of the craniovertebral junction is indicated for patients with spinal cord injury, and it can be helpful in assessing upper cervical spine ligament trauma. Subarachnoid and prevertebral hemorrhage can be readily demonstrated on MRI scans.
Nuclear Imaging
Radioisotope-based imaging tests, like technetium-99 bone scan, are rarely required in trauma but can be useful in assessing occult fractures, osteoarthritis affecting the upper cervical spine and in pediatric patients for detection of a nondisplaced growth plate injury.
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