X-rays are commonly used to image the spine. The cervical spine can be imaged using anteroposterior, lateral, open mouth, flexion/extension, and oblique views. Key anatomical structures like the vertebrae and discs can be evaluated. Common fractures include teardrop fractures and hangman's fractures. The thoracolumbar spine is also imaged with AP and lateral views. Unstable injuries like burst fractures involve vertebral body collapse while stable injuries include wedge fractures. Spondylolysis is a stress fracture of the pars interarticularis seen best on oblique views.

1. X-RAY SPINE
Dr.R.G.Unnikrishnan MD(Ay)
Associate Professor & HOD,
V.P.S.V.Ayurveda College Kottakkal
1

2. W.C. Roentgen discovered X-rays in 1895
•Nobel Prize in physics in 1901 2

3. • Nature of the rays was uncertain:– X-strahlung
•`Skiagraph'(from Greek for a shadow)
• Later `Radiograph'
• Now `X-ray' or`Radiograph'
WHY X-RAY ?
3

4. Conventional angiography
Nuclear medicine
Ultrasonography (USG)
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Interventional radiology
Positron emission tomography (PET)
4

5. 5
X-Ray
Most appropriate screening technique if a fracture is
suspected and in low risk patients.
ADVANTAGES
•Can quickly identify if a fracture or other suspected
bony pathology is present or not.
DISADVANTAGES
• A fracture might not be evident on one view and
often several different projections are necessary.
• A fracture may be occult.

6. 6
Computed Tomography (CT)
To further evaluate numerous musculoskeletal
disorders including neoplasms and simple or complex
fracture.
ADVANTAGES
• Fast and efficient technique
• Good for bony and articular details
• Both intravenous peripheral contrast and intra-
articular contrast may be given.
DISADVANTAGES
• More radiation than an x-ray.
• Metal implants cause significant metal artifact.

7. 7
X-Ray CT

8. 8
Magnetic Resonance Imaging (MRI)
•To evaluate ligament or tendon injury
•To evaluate soft tissue masses
•To evaluate stress fractures and osteomyelitis
ADVANTAGES
 Improved ability than CT to visualize the spinal cord
and other contents of the spinal canal.
Excellent for looking at soft tissue, marrow,
ligaments, and marrow edema.
 Both intra-articular and IV contrast may be used to
better delineate anatomy/pathology.

9. 9
Herniated cervical disc
MRI

10. 10
DISADVANTAGES
• Many contraindications including cardiac
pacemakers, metallic foreign bodies, cerebral
aneurysm clips, electronic devices.
• Metallic implants cause artifacts that limit image
quality.
• Some patients may be claustrophobic.
• Sedation may be required.

11. 2 Branches
•Diagnostic radiology
•Radiation oncology (therapy)
11

12. Plastic sheet coated with a thin emulsion (silver
bromide and a small amount of silver iodide)
Film is exposed to ionizing radiation
Chemical changes resulting in the deposition of
metallic silver, which is black
Amount of blackening on the film is proportional
to the amount of x-ray exposure
X-ray Film
12

13. 13
Five basic densities
• Arranged from least to most dense.
AIR < FAT < SOFTTISSUE/FLUID < CALCIUM < METAL
(Black to White)

14. 14
PRINCIPLE
• Denser an object is, the more x-rays it
absorbs, and the whiter it appears on X-rays.
• Less dense an object is, the fewer x-rays it
absorbs, and the blacker it will appear on X-
rays.

15. 15
1. Air - Appears the blackest.
2. Fat - Lighter shade of grey than air.
3. Soft tissue or Fluid – Less black than Fat.
4. Calcium - Usually contained within bones.
5. Metal – Whitest.
(Objects of metal density are not normally present in the body.)

16. X-RAY FILM QUALITY
Based on :
• Contrast of image
• Sharpness of image
16

17. Underexposed film
Too white lacking contrast
17

18. Over exposed film
Too black with poor contrast
18

19. 19
Spine

20. CERVICAL SPINE
20

21. C1 – C7
21

22. CERVICAL SPINE ANATOMY
22
Two anatomically distinct regions
 Cervicocranium (C1 and C2)
 Lower cervical spine (C3 to C7)

23. C1 VERTEBRA - ATLAS
23
• Named after the Greek
mythological Atlas who supported
the world on his shoulders.

24. 24
•Ring of bone with anterior and posterior arches
and large lateral masses.
•Lacks a body & spinous process.
•Superior articular facets articulate with the occipital
condyles (Atlanto-occipital joint) (“yes” movement).
•Inferior articular facets articulate with C2 vertebra
(Axis).
(Sup.) (Inf.)

25. C2 VERTEBRA - AXIS
25
•Has a body.
•Peg like process called the dens or odontoid process
projects superiorly through the anterior portion of the
vertebral foramen of the atlas (“no” movement).
•Articulation between the anterior arch of the atlas and
dens of the axis, and between their articular facets, is
called the atlanto-axial joint.

26. C3 - C6
26
•Structural pattern of the typical cervical vertebra.
•Spinous processes of C2 through C6 are often bifid.

27. C7 VERTEBRA
• Vertebra prominens, has single large spinous
process (seen and felt at the base of the neck).
27

28. 28
LIGAMENTS OF SPINE
Transverse
ligament
of dens

29. 29

30. 30
CERVICAL SPINE X-RAY
VIEWS & RADIOLOGICAL ANATOMY

31. 1. National Emergency X-Radiography
Utilization Study (NEXUS) Low-Risk Criteria
• C-spine imaging is recommended for
patients with trauma unless they meet all of
the following criteria:-
• No midline cervical tenderness
• No focal neuro deficits
• Normal alertness
• No intoxication
• No painful distracting injury
31
2. Canadian Cervical-Spine Rule

32. Mneumonic :- NSAID
1. Neuro deficit
2.Spinal midline tenderness in C-spine
3. Alertness
4. Intoxication
5. Distracting injury
32

33. • Views
CERVICAL SPINE X-RAY
• Antero Posterior view
• Lateral view
• Open mouth (odontoid) view
• Oblique view
33

34. ANTERO POSTERIOR VIEW
34

35. 35
RADIOLOGICAL ANATOMY – AP VIEW

36. LATERAL VIEW
• Important radiographic examination of the acutely
injured cervical spine.
36

37. 37
RADIOLOGICAL ANATOMY – LATERAL VIEW

38. Visualize
• All 7 cervical vertebrae
• C7-T1 junction
(Cervicothoracic junction is a
common place for traumatic
injury)
38

39. LIMITATION OF C7-T1 VIEW
•By the amount of soft tissue -
in the shoulder region.
(shoulder soft tissue shadow)
39

40. ENHANCEMENT OF C7-T1 VIEW
• Traction on arms if no arm injury is present.
• Swimmer's view (taken with one arm
extended over the head.)
40

41. Swimmer’s
view
41

42. Flexion view
FLEXION & EXTENSION VIEWS
42

43. Extension view
43

44. FLEXION & EXTENSION VIEWS
CONDITIONS
• If no fracture is seen on initial films and pain is
present.
• If a pure soft tissue injury is suspected
• To demonstrate ligament instability and subsequent
vertebral mobility.
44

45. CONDITIONS
• Patient should perform the flexion and extension
voluntarily.
• Absolutely contraindicated in documented
unstable injuries.
45

46. OPEN MOUTH (ODONTOID) VIEW
46

47. 47
RADIOLOGICAL
ANATOMY
OPEN MOUTH VIEW
Body of C2, Atlantoaxial
joints, Odontoid process,
Lateral spaces between
the odontoid process and
the articular pillars of C1.

48. 48
OBLIQUE VIEW

49. OBLIQUE VIEW
49
Important in patients with
pain and/or altered
sensation in their upper
limbs.
Caused by nerve
compression at the
intervertebral foramina,
which can be viewed in
oblique view.
 CT is better

50. AABCDS
• A = Adequacy
• A = Alignment
• B = Bone
• C = Cartilage
• D = Disc
• S = Soft tissue
APPROACH TO C-SPINE X-RAY
50

51. ADEQUATE
(LATERAL VIEW)
• Film should include -
all 7 vertebrae.
• C7-T1 junction.
• Have correct density
• Show the soft tissue - and
bony structures well.
C1
C2
C3
C4
C5
C6
C7
T1
51

52. ALIGNMENT (AP VIEW)
• Evaluated using the
edges of the vertebral
bodies and articular
pillars.
• Height of the cervical
vertebral bodies should be
approximately equal.
52

53. • Height of each joint
space should be
roughly equal at all
levels.
• Spinous process should
be in midline and in
good alignment.
53

54. • Pre-vertebral soft tissues
• C2: < 7 mm from
vertebral body
• C6: < 22 mm from
vertebral body
• Normal contour of soft
tissues.
• Anterior vertebral line
• Posterior vertebral line
• Spinolaminar line
• Spinous process line
54
Evaluate 5 parallel lines for discontinuity

55. 55
Evaluate the orientation of the epiglottis, hyoid
bone, tracheal shadow and check for any
foreign bodies.

56. 56
Check the Atlantodens interval or Predental
space is < 3 mm in adults or < 5 mm in children.

57. CERVICAL SPINE X-RAYS
DISLOCATIONS & FRACTURES
57

58. Dislocations
58

59. • Dislocation at the junction
between the Atlas
vertebra and the skull.
• May result in death.
• Anterior dislocation is
much more frequent and
much easier to see on
X-ray.
• Mechanism: Hyperflexion
or hyperextension.
1. Atlanto occipital dislocation (unstable)
59

60. 60
•Anterior displacement
of one vertebral body on another.
•Best seen on the lateral view as a step deformity.
•Step deformity of >3mm is always abnormal & the
spine is unstable.
•Occurs secondarily to hyperflexion of the C.spine.
2. Facet joint dislocations (unstable)

61. •3 types of bilateral facet dislocations, all are
unstable.
•In order of increasing severity
• Subluxed facets
• Perched facets
• Locked facets
61

62. a) Subluxed facet joint
•Mildest form, in which the ligamentous injury
leads to partial uncovering of facet joint.
• Results in mild anterior displacement of one
vertebral body on another .
62

63. b) Perched facet joint
• Inferior articular process appears
to sit 'perched' on the ipsilateral
superior articular process of the
vertebra below.
• Any further anterior subluxation
will result in dislocation.
• Unilateral perched facet results
from flexion-rotation force
• Complications
 Spinal cord or Vertebral artery
injury.
63

64. Spinal cord injury
64

65. c) Locked facet joint
• Results from jumping of the inferior articular
process over the superior articular process of
the vertebra below and becomes locked in the
position.
65

66. Fractures
66

67. 67
1. Unstable
a.Flexion Teardrop fracture
• Secondary to a flexion injury.
• Results in disruption of all ligaments as well as
the intervertebral disc at the level of injury.
• A small fragment of the anteroinferior portion is
broken off of a vertebral body with posterior
displacement of the vertebral body itself.
• Results in anterior spinal cord compression.
• Most severe C-spine injury.
• Presents as quadriplegia,
loss of anterior column
senses etc.

68. 68

69. b) Hangman's fracture
• Secondary to an extension injury, which
commonly occurs in motor vehicle accidents or in
hangings.
69

70. • Bilateral C2 pars fracture, with anterior
displacement of C2 vertebral body.
70

71. c) Hyperextension Fracture-dislocation
• Secondary to a severe circular hyper extending
force (e.g. impact on forehead).
• Results in a slight anterior vertebral subluxation,
with a complex fracture near the articular
surfaces.
71

72. d) Burst fracture
• Results from an axial injury.
• Compression of the vertebral body and results in
loss of both anterior and posterior vertebral body
height.
• Bony fragments may push on the spinal cord.
• Occur most commonly in the mid-cervical spine.
72

73. 73

74. e. Jefferson's fracture
•Secondary to an axial injury. (heavy object fall on
one's head or diving into an empty pool).
74

75. •Consists of unilateral or bilateral fractures of both
the anterior and posterior arches of C1.
75

76. f. Odontoid fracture
• Secondary to a multidirectional injury.
76
Type I: fracture in the upper part of the odontoid.
Type II: fracture at base of the odontoid
Type III: fracture through base of odontoid into body of axis.

77. • Secondary to a powerful
hyperflexion injury.
• Avulsion of a piece of the
spinous process and most
frequently occurs in the lower
C-spine.
77
2. Stable
a) Clay-Shoveler's fracture

78. b) Wedge fracture
• Due to flexion injury.
• Compression of the anterior part of the vertebral
body.
78

79. c) Extension Teardrop
• Due to hyperextension injury.
• Avulsion of a piece of the anteroinferior portion C2.
79

80. THORACIC & LUMBOSACRAL SPINE
80

81. 81

82. •Body
•2 transverse processes
•Pedicles
•Pars interarticularis
•Laminae
•One spinous process
•Vertebral foramen
TYPICAL
VERTEBRA
82

83. THORACIC SPINE
83

84. LUMBAR
SPINE
84

85. SACRUM
85

86. RADIOLOGICAL ANATOMY OF
THORACOLUMBAR SPINE
-AP VIEW-
86

87. 87
RADIOLOGICAL ANATOMY OF
THORACOLUMBAR SPINE
-LATERAL VIEW-

88. Thoracic and Lumbar Fractures
• Thoracic spine is an unusual site for fractures.
• Most fractures occur at thoracolumbar junction
(90% at T11-L4).
• All patients should have CT except for patients
with:-
 Stable compression fractures
 Isolated spinous or transverse process
fractures
 Spondylolysis
88

89. 1. Unstable injury
a) Chance fractures (lap seatbelt fracture,
usually at L2 or L3)
• Distraction from anterior hyperflexion across a
restraining lap seatbelt.
• Horizontal splitting of vertebra
• Rupture of ligaments
89

90. 90

91. b) Burst fracture
•Results in collapse of an entire vertebral body.
•Mechanism of injury is fall from a height.
•On a lateral view, the height of the vertebral body is
reduced.
•Fragments extending into the spinal canal.
•On AP view, the interpedicular distance is increased.
91

92. Burst fracture
92

93. 2. Stable injury
a. Wedge fracture
• Due to hyperflexion
injury.
• Results in the collapse
of the anterior vertebral
body.
• On the lateral view, there
is decreased height of
the anterior wall of the
vertebral body.
• Posterior wall of the
vertebral body is intact.
• Spinal canal is not
involved. 93

94. b. Spinous process fracture
• Fracture line in the spinous process.
• Spinal canal and the stability of the spine are
unaffected.
94

95. c. Transverse process fracture
X-ray
95

96. d) Spondylolysis
96
AP view Oblique view
Appearance of
a Scottie dog

97. 97

98. • A defect in the pars interarticularis.
• Best seen on oblique view where it appears as a
collar on a Scottie dog.
• Chronic stress fracture with nonunion.
• Typically in adolescents involved in sports.
• Most often seen at the L4 or L5 level.
98

99. e) Spondylolisthesis
• 95% of spondylolistheses occur
at L4-L5 and L5-S1.
• Occurs when there are bilateral
pars interarticularis defects
(bilateral spondylolysis).
• Vertebral body of the affected
level is only held against the rest
of the vertebra by ligaments and
intervertebral disc.
• Later superior vertebral body
slips forward on the inferior one.
99

100. 100

101. • Subluxation is classified into four grades,
which indicates the percentage of
displacement.
101

102. 102

103. Infections of the Spine
103

104. Pyogenic spinal infection
• Destruction of the vertebral
endplates and disc space
narrowing (C3/C4 level).
• Usually Bacterial infections
from genitourinary tract.
• Spreading of the infection
causes increasing
destruction of the vertebral
bodies and
development of a
paravertebral soft tissue
mass (e.g. psoas abscess)
104

105. Tuberculous spondylitis (Pott disease)
105
3 patterns of vertebral involvement.
a. Discovertebral destruction
• Similar to pyogenic infection
• Large paravertebral abscess with later calcification.
• Later develop a severe angular spinal deformity (kyphotic
gibbus), as the vertebrae collapse.

106. b. Subligamentous
• Infection begins anteriorly under the periosteum and
spreads under the anterior longitudinal ligament.
• Erosions of the anterior aspects of one or more vertebral
bodies.
106

107. 107
c. Central
• Infection develops within the vertebral body without
involvement of the disc space.
• Infected vertebra often collapses.

108. Discitis
•Refers to infection of the
intervertebral disc.
• Staphylococcal infection,TB
108

109. 109
•Vertebral osteomyelitis and disc space infection at L2-L3.
•Bony destruction with partial collapse of L3.

110. X-RAYS OF VARIOUS
CONDITIONS
110

111. Osteophyte of degenerative arthritis
111

112. •Loss of cortical bone (picture frame
vertebra)
• Compression fractures and vertebra
plana (Reduced entire height
anteriorly and posteriorly)
Osteoporosis
112

113. LUMBAR SPONDYLOSIS
113

114. •“Rugger jersey spine” :- striped
appearance from the alternating
areas of osteosclerosis along the disc
plates with central osteoporosis.
•In chronic renal failure, secondary
hyperparathyroidism.
114

115. * Most serious complication of cervical rheumatoid
arthritis is atlantoaxial subluxation.
* Widening of the predental space.
* Malalignment of the spinolaminar lines of C1 and C2
115

116. Spina bifida occulta
• Failure of fusion of the laminae
of L5, producing a cleft.
• Normal variant with no
associated neurologic or clinical
findings.
116

117. Severe spina bifida
• Congenital absence of the
laminae of L3, L4, and L5.
• Usually associated with
neurologic abnormalities
including hydrocephalus.
117

118. Mild cervical spondylosis
•Narrowing of the C5 disc space.
•Posterior spurs impinge on the
vertebral canal.
118

119. Severe cervical spondylosis
• Spurs encroaching the neural
foramina at multiple levels.
119

120. Ankylosing spondylitis
“Bamboo spine” appearance of vertebral column
120

121. Diffuse idiopathic skeletal hyperostosis (DISH)
•Results in a rigid spine, similar to
ankylosing spondylitis
•Ossification of the posterior
longitudinal ligament may produce
spinal stenosis.
•Syndesmophytes are coarse and
usually symmetric.
121

122. Appearance after laminectomy
• Absence of the laminae and spinous
processes of L3 and L4.
• Lucency represents the surgical
margins
122

123. Osteoarthritis of the
cervical spine
• Disc space narrowing
& Osteophytes at
multiple levels.
123

124. Osteoarthritis of the lumbar spine
•Narrowing of the intervertebral disc space
between L5 and S1.
• Sclerosis of the facet joints at L4/5 (F) with
degenerative spondylolisthesis.
124

125. Vertebral metastasis
•C/o Sudden onset back pain and leg weakness,H/o breast cancer.
•X-Ray:- Reduced height of the T6 vertebral body & loss of
visualization of the left pedicle due to bone destruction.
•MRI:- Destruction and partial collapse of T6 & Neoplastic tissue is
invading the spinal canal and compressing the spinal cord. 125

126. IVDP
126
•MRI is the choice.
•Posterior herniation of the L4/5 disc.
•Transverse image:- Herniation into the right side of the
spinal canal.
•Right L5 nerve root is compressed.

127. Prevertebral soft tissue swelling
127

128. Type-II Odontoid fracture
128

129. L1 compression fracture
129

130. T8 compression fracture
130

131. Facet fracture of C7
131

132. Scoliosis
132

133. Lordosis
133

134. Kyphosis
134

135. Gibbus
135

136. SACRALIZATION
136

137. 137
Lumbarization of S1
Spina Bifida

138. Vertebral artery calcification
138

139. CERVICAL SPONDYLITIS
139

140. Ankylosing spondylitis
140

141. Prevertebral mass
141

142. CERVICAL RIB
142

143. Thank you
143