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Cervical Spine

Cervical Spine


  • Appropriate exposure - from C1 to T1. If T1 is not visible, get radiographer to do other views (swimmer’s view).
  • Views: AP, lateral, peg, left/right oblique.
  • 70% of pathology can be identified on lateral view alone.

A. Alignment: lateral C-spine X-rays

Assess four parallel lines:

  1. Posterior vertebral line (posterior margin of vertebral bodies)
  2. Anterior vertebral line (anterior margin of vertebral bodies)
  3. Spinolaminar line (posterior margin of spinal canal)
  4. Posterior spinous line (tips of the spinous processes)


  • These lines should follow a slightly lordotic curve, smooth and without step-offs.
  • Any malalignment should be considered evidence of fractures or ligmentous injury, and cervical spine immobilization should be maintained until a definitive diagnosis is made.
  • Atlanto-axial distance: < 3mm in adults, < 5mm in children.
  • Harris ring: may be incomplete in peg fractures.

A. Alignment: AP C-spine X-rays

Assess 3 parallel lines:

  1. Spinous process line.
  2. Uncovertebral joint line.
  3. Lateral mass line.

A. Alignment: Open Mouth View

  • Displacement of either C1 lateral masses indicates burst (Jefferson) fracture.
  • Atlanto-odontoid interval: distance between the odontoid peg and C2 lateral mass should be equal on both sides.

B. Bones

  • Look for peg, bony, facet or pars fracturs.
  • Beware the Mach effect: optical illusion resulting from overlapping shadows from superimposed structures.

S. Soft Tissue

  • Prevertebral soft tissue: look for widening, gas.


  • Pseudo-subluxation: common in chiildren with disruption of on eof the lines by < 2mm.
  • Odontoid fractures: types 1-3.


1. Goodman, L. and Felson, B. (2015). Felson's principles of chest roentgenology. 3rd ed. Philadelphia, PA: Elsevier, Saunders.
2. Dähnert W. Radiology Review Manual. LWW. (2011) ISBN:1609139437. Read it at Google Books - Find it at Amazon
3. Elizabeth Puddy, Catherine Hill; Interpretation of the chest radiograph, Continuing Education in Anaesthesia Critical Care & Pain, Volume 7, Issue 3, 1 June 2007, Pages 71–75, https://doi.org/10.1093/bjaceaccp/mkm014

Ⓒ A. Manickam 2018

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