The Art of Interpreting Cervical Spine Radiographs

HomeRadioGraphicsVol. 39, No. 3 PreviousNext Neurologic/Head and Neck ImagingFree AccessRadioGraphics Fundamentals | Online PresentationThe Art of Interpreting Cervical Spine RadiographsMatthew R. Skalski , George R. Matcuk , Jr, Wende N. GibbsMatthew R. Skalski , George R. Matcuk , Jr, Wende N. GibbsAuthor AffiliationsFrom the Department of Radiology, Palmer College of Chiropractic, West Campus, 90 E Tasman Dr, San Jose, CA 95134 (M.R.S.); and Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif (G.R.M., W.N.G.).Address correspondence to M.R.S. (e-mail: [email protected]).Matthew R. Skalski George R. Matcuk , JrWende N. GibbsPublished Online:May 6 2019https://doi.org/10.1148/rg.2019180148MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractThe full digital presentation is available online.Interpreting cervical spine radiographs is routine work for most radiologists. Despite their seemingly simple nature, cervical spine radiographs can be difficult to interpret owing to abundant information, complex anatomy, and projectional variation. In this online presentation, we discuss the art of interpreting these studies, which combines an understanding of normal cervical anatomy, common anatomic variants, projectional pseudopathologic conditions, and true pathologic changes.Developmental anomalies in the cervical spine, such as occipitalization or other segmentation anomalies, are common incidental findings but also may be symptomatic and associated with clinically important anatomic changes such as atlantoaxial instability and basilar invagination. Occipitalization and basilar invagination can also be misdiagnosed owing to the simulation of this appearance when the head is in the lateral flexion position at imaging. Superimposition of overlying anatomy in the upper cervical spine may also mimic pathologic conditions, such as Mach effect mimicking a dens fracture, or may obscure pathologic conditions, as when the head is too extended or flexed on an open-mouth view.Degenerative disease in the cervical spine, although nearly ubiquitous with age, is commonly symptomatic owing to the neuroforamina being bordered by the uncovertebral joints anteriorly and facets posteriorly, both of which are well appreciated radiographically (Figure). In addition, posterior disk-osteophyte complexes that narrow the canal are frequently identifiable at radiography. In the setting of cervical spine trauma, CT has all but supplanted traditional radiographic assessment (sensitivity is about 98% for CT versus about 50% for radiography), yet it remains common to obtain radiographs in less emergent cases and for the dynamic assessment of stability with flexion and extension radiographs.Figure a. Anteroposterior radiograph (a) and oblique illustration (b) of the lower cervical spine show degenerative hypertrophy of the facets (black arrow) and uncovertebral joint (white arrow), leading to neuroforaminal stenosis.Figure a.Download as PowerPointOpen in Image Viewer Figure b. Anteroposterior radiograph (a) and oblique illustration (b) of the lower cervical spine show degenerative hypertrophy of the facets (black arrow) and uncovertebral joint (white arrow), leading to neuroforaminal stenosis.Figure b.Download as PowerPointOpen in Image Viewer This dynamic assessment is also important to assess potential instability associated with inflammatory arthritis. Instability is typically considered when there is a measurement greater than 2.5–3.5 mm of combined intersegmental translation motion of the lower cervical vertebrae between flexion and extension. However, angular instability is less well defined and understood, but a measurement of 11 degrees or greater of intersegmental angular difference when compared to that of the adjacent levels is concerning and may be associated with facet subluxation or dislocation.Neoplasms are frequent in the cervical spine, and the cervical spine is the most common spinal location for osteochondroma and chordoma. Metastatic disease is also frequently encountered, and Pancoast tumors may be detected incidentally on cervical spine radiographs. In addition, a variety of rare primary osseous neoplasms may manifest in the cervical spine, such as aneurysmal bone cyst, osteoblastoma, osteoid osteoma, and brown tumor.The cervical spine is host to a variety of normal and pathologic soft-tissue calcifications that may be discovered at routine radiography. Normal and variant calcifications include thyroid and tracheal cartilages, nuchal sesamoids, and the stylohyoid ligaments. Pathologic calcifications are diverse and include atherosclerotic calcifications, lymph node calcifications, salivary stones, glandular parenchymal calcifications, and calcified thyroid and parathyroid lesions.Finally, infection involving the cervical region, with extension to the spine and subsequent spondylodiscitis, manifests with disk height loss and eventual destruction of the vertebral endplates.The online presentation reviews these entities and more, with numerous case examples and detailed medical illustrations to clarify concepts. Differential considerations and potential pitfalls are also discussed.Presented as an education exhibit at the 2017 RSNA Annual Meeting.All authors have disclosed no relevant relationships.Suggested Readings Choi BW, Song KJ, Chang H . Ossification of the posterior longitudinal ligament: a review of literature . Asian Spine J 2011 ; 5 ( 4 ): 267 – 276 . Crossref, Medline, Google Scholar Dreizin D, Letzing M, Sliker CW, et al. Multidetector CT of blunt cervical spine trauma in adults . RadioGraphics 2014 ; 34 ( 7 ): 1842 – 1865 . Link, Google Scholar Jain N, Verma R, Garga UC, Baruah BP, Jain SK, Bhaskar SN . CT and MR imaging of odontoid abnormalities: a pictorial review . Indian J Radiol Imaging 2016 ; 26 ( 1 ): 108 – 119 . Crossref, Medline, Google Scholar Jurik AG . Imaging the spine in arthritis: a pictorial review . Insights Imaging 2011 ; 2 ( 2 ): 177 – 191 . Crossref, Medline, Google Scholar Kim YJ, Park JY, Choi KY, Moon BJ, Lee JK . Case reports about an overlooked cause of neck pain: calcific tendinitis of the longus colli—case reports . Medicine (Baltimore) 2017 ; 96 ( 46 ): e8343 . Crossref, Medline, Google Scholar Resnick D, Kransdorf M . Bone and joint imaging . 3rd ed. Philadelphia, Pa : Elsevier Saunders , 2005 . Google ScholarArticle HistoryReceived: Apr 20 2018Revision requested: May 30 2018Revision received: June 26 2018Accepted: July 13 2018Published online: May 06 2019Published in print: May 2019 FiguresReferencesRelatedDetailsCited ByClinical Atlas of Bone SPECT/CTTimVan den Wyngaert2023Imaging of pediatric cervical spine traumaMindy X.Wang, Nicholas M.Beckmann2021 | Emergency Radiology, Vol. 28, No. 1Missed cervical spine subluxation leading to bilateral facet dislocation with severe deformity requiring 360 fixationSayed SamedTalibi, Jonathan KyawThant, DavorDasic, AmjadShad2021 | Radiology Case Reports, Vol. 16, No. 10Radiopaedia.orgAndrewMurphy2018Accompanying This ArticleThe Art of Interpreting Cervical Spine RadiographsMay 6 2019Default Digital Object SeriesRecommended Articles Differential Diagnosis of Facet Joint DisordersRadioGraphics2021Volume: 41Issue: 2pp. 543-558Foreign Bodies on Lateral Neck Radiographs in Adults: Imaging Findings and Common PitfallsRadioGraphics2017Volume: 37Issue: 1pp. 323-345Injuries to the Rigid Spine: What the Spine Surgeon Wants to KnowRadioGraphics2019Volume: 39Issue: 2pp. 449-466Multidetector CT of Laryngeal Injuries: Principles of Injury RecognitionRadioGraphics2019Volume: 39Issue: 3pp. 879-892Spinal Neuroarthropathy: Pathophysiology, Clinical and Imaging Features, and Differential DiagnosisRadioGraphics2016Volume: 36Issue: 3pp. 783-799See More RSNA Education Exhibits Cranio Vertebral Junction Abnormalities: Radiological Assessment and Image Based ReviewDigital Posters2018C2 Fractures: What the Spine Surgeon Wants to KnowDigital Posters2020DISH, Ankylosing Spondylitis, and Spondyloarthrosis: What's the Difference?Digital Posters2019 RSNA Case Collection Pediatric Idiopathic Intervertebral Disc CalcificationRSNA Case Collection2020 Cervical spine goutRSNA Case Collection2022Klippel Feil Syndrome RSNA Case Collection2022 Vol. 39, No. 3 Slide PresentationMetrics Altmetric Score PDF download