Trauma X-ray - Axial skeleton
Cervical spine - Abnormal

Key points

  • Normal C-spine X-rays do not exclude significant injury
  • Clinical considerations are of particular importance when assessing appearances of C-spine X-rays
  • Look at all views available in a systematic manner

C-spine - Systematic approach

  • Coverage - Adequate?
  • Alignment - Anterior/Posterior/Spinolaminar
  • Bones - Cortical outline/Vertebral body height
  • Spacing - Discs/Spinous processes
  • Soft tissues - Pre-vertebral
  • Edge of image

C-spine fractures

Cervical spine injuries often have characteristics which depend on the mechanism of injury. This page describes typical appearances of some common C-spine fractures.

C1 fracture

Injury to C1(atlas) results in loss of integrity of its ring structure. The ring expands and loses alignment with the adjacent occipital bone above, and C2 below. This is most readily appreciated on the open mouth view which shows that the lateral masses of C1 no longer align with the lateral masses of C2, and that the spaces between the peg and the C1 lateral masses are widened.

C1'Jefferson' fracture - Open mouth view

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C1 'Jefferson' fracture - Open mouth view

  • The space between the odontoid peg of C2 and the lateral masses of C1 is widened on both sides (arrows)
  • The lateral masses of C1 are both laterally displaced and no longer align with the lateral masses of C2 (red rings)

C2 fractures

Fractures of C2 (axis) may involve the odontoid peg, vertebral body, or the posterior elements.

C2 odontoid peg fracture - Lateral view

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C2 odontoid peg fracture - Lateral view

  • The C2 bone 'ring' is incomplete due to a fracture
  • The odontoid peg is displaced posteriorly

C2 odontoid peg fracture - Open mouth view

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C2 odontoid peg fracture - Open mouth view

  • Displaced fracture of the odontoid peg
  • It is uncommon to see such an obvious fracture on the open mouth view - many fractures of the odontoid peg are more readily seen on the lateral view

C2 'hangman' fracture

The so called 'hangman' fracture results from a high force hyperextension injury. The fracture involves the pedicles of C2 and often results in anterior displacement of the body and peg of C2.

C2 'hangman' fracture - Lateral view

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C2 'hangman' fracture - Lateral view

  • Loss of alignment at C2/C3 with anterior displacement of C2 (large arrow)
  • Following the cortical outline of C2 (white line) reveals discontinuity due to a fracture

'Extension teardrop' fracture - Lateral view

Hyperextension may result in avulsion of the anterior corner of a vertebral body - most commonly C2. The anterior longitudinal ligament remains attached to the bone fragment which is separated from the vertebral body.

'Extension teardrop' fracture - Lateral view

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'Extension teardrop' fracture - Lateral view

  • A fracture fragment is seen at the anterior/inferior corner of C2 resembling a 'teardrop'

C-spine 'flexion teardrop' fracture

This fracture may occur at any level between C3 and C7. It is a highly unstable injury with a high incidence of associated spinal cord injury.

'Flexion teardrop' fracture - Lateral view

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'Flexion teardrop' fracture - Lateral view

  • Following the outline of the vertebral bodies shows an anterior - inferior C6 vertebral corner 'teardrop' fracture fragment
  • The facet joint of C6/C7 is widened - compare with level above

C-spine dislocation injury

It is possible to sustain severe C-spine or spinal cord injury without evidence of a fracture. Dislocations may be transient with spontaneous relocation of the joints at the time of injury. Occasionally there may be locking or 'perching' of the facet joints preventing the bones from returning to their normal positions. This may be unilateral or bilateral.

Bilateral perched facets - Lateral view

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Bilateral perched facets - Lateral view

  • (Same patient as image below)
  • Loss of alignment of all three lines at C5/C6 with 'perching' of the C5 facet on the C6 facet (ring)
  • No fracture is visible
  • The pre-vertebral soft tissue is widened due to a haematoma

Note

  • The spinal canal lies between the posterior (Orange) and spinolaminar (Red) lines
  • Derangement of the spinal canal due to this injury results in a high incidence of spinal cord injury

Bilateral perched facets - AP view

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Bilateral perched facets - AP view

  • (Same patient as image above)
  • There is widening of space between the C5 and C6 spinous processes (SP) with loss of normal alignment
  • Again no fracture is demonstrated

Pre-vertebral soft tissue

Thickening of the pre-vertebral soft tissues is occasionally the only X-ray sign of a C-spine fracture.

Pre-vertebral soft tissue

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Pre-vertebral soft tissue

  • At the level of C3 the pre-vertebral soft tissue is thickened - ( >1/3rd the width of the vertebral body)
  • This soft tissue swelling is the only visible sign of injury
  • CT showed a fracture at C4 not visible on the plain X-ray

Note

  • Not all C-spine fractures are accompanied by pre-vertebral haematoma
  • Lack of pre-vertebral soft tissue thickening should NOT be taken as reassuring

Spinous process 'clay-shoveller's' fracture

Isolated fractures of the spinous processes are often difficult to identify, especially at the cervico-thoracic junction where they may be obscured by overlying soft tissues. A specific check is necessary of the cortical outline of each spinous process.

These avulsion injuries are traditionally known as 'clay-shoveller's' fractures due to the mechanism of repeated forceful flexion associated with shovelling.

Spinous process fracture

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Spinous process fracture

  • A large bone fragment is widely displaced from the C7 spinous process