Inconsistent correlation between anatomic abnormalities and symptomatology

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Spinal Imaging D70 ()

Spinal Imaging

Last updated: September 5, 2017

Inconsistent correlation between anatomic abnormalities and symptomatology:

    • 25% of asymptomatic people have small lumbar disc protrusions visible on MRI;

    • some patients with disabling clinical symptoms have minimal abnormalities on MRI.

MRI is imaging modality of first choice; other investigations are considered only when MRI is either contraindicated or impossible.

Imaging is ordered by specifying vertebral levels, while neurologic disability is defined by spinal cord level!

Plain X-ray

- still commonest method of imaging.

  • most indications are no longer justified.

  • specific indications – fractures / dislocations, degenerative conditions, evaluation of instability.

Most episodes of back pain are self-limited and do not require imaging!

American College of Radiology recommendation – do not obtain lumbar spine radiographs for acute low-back pain unless fracture, malignancy, or infection are suspected.

Radiograph Evaluation


  1. Alignment (anterior and posterior vertebral body, posterior spinal canal, spinous processes)

alignment of cervical spine – see below

  1. Bony changes:

  1. vertebral body height

  2. bone contour – trace around each vertebra individually – look for fractures, osteophytes.

  3. bony density:

  1. decreased density (rheumatoid arthritis, osteoporosis, osteomalacia, metastatic osteolytic lesions) - weak points that are apt to succumb under stress.

  2. increased density (acute compression fractures of vertebral bodies, metastatic osteoblastic lesions).

  1. Cartilages – are intervertebral disc space margins parallel?; slight anterior or posterior widening of intervertebral space (or interspinous spaces) may be only clue to unstable dislocation.

  2. Soft tissues (mainly in lateral cervical view – see below)

Signs of instability

  1. subluxation of vertebra

  2. disruption of posterior vertebral body line

  3. widening of apophyseal joints / increased interpedicular distance

Cervical spine

AP projection

(least useful from clinical standpoint)

  • supine or seated, with baseline extended 20°.

  • centering:

      1. through mouth (which is held open) - for upper vertebrae.

      2. at sternal notch, perpendicular to film - for lower cervical vertebrae.

  • jaw may be moved gently during exposure, to produce autotomogram.

  • to show posterior intervertebral joints and lateral masses, use 30° caudal tube angulation.

  • tracheal and laryngeal air shadows should be within midline.

  • straight line should connect points bisecting spinous processes (if not, suspect rotary injuries).

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