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One of the basic principles in the primary survey of a trauma patient is immobilisation of the cervical spine till cleared of any injury. Lateral cervical spine radiograph is one of the important initial radiographic assessments. More than often additional radiographs like the Swimmer's view are necessary for adequate visualisation of the cervical...
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Objective
To evaluate the frequency and types of upper cervical spine injuries in asymptomatic elderly patients undergoing computed tomography (CT) for the investigation of minor head trauma.
Materials and Methods
This was a prospective study of 2613 asymptomatic elderly patients with minor head trauma seen between January 2015 and December 2016....
Objectives
To assess whether different cervical spine immobilisation strategies (full immobilisation, movement minimisation or no immobilisation), impact neurological and/or other outcomes for patients with suspected cervical spinal injury in the pre-hospital and emergency department setting.
Design
Systematic review following Preferred Reporting...
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Citations
... Although computed tomography (CT) and magnetic resonance imaging (MRI) have been able to advance the imaging of the cervical spine (C-spine), plain radiography still plays a vital role in the initial assessment of any type of cervical spine injury due to its abundant availability and cost-effectiveness [1,2]. The lateral view of the C-spine is an important examination in radiographic assessment as it can demonstrate all seven cervical vertebrae with their alignments and the cervico-thoracic (C7-T1) junction where 9-18% of injuries to the cervical region are found [3][4][5]. However, due to the overlap of the shoulder girdle and other anatomical structures such as the rib cage (Figure 1), it is challenging to demonstrate the lower cervical vertebrae with the C7-T1 junction on lateral radiographs of the C-spine [3,6,7] Therefore, different positioning techniques are proposed and adapted by researchers and radiographers to overcome this challenge [3,8,9] However, there is inadequacy in guidelines and directives for the use of different positioning techniques in the erect lateral C-spine radiography. ...
... However, each strategy has its own strengths and weaknesses. Certain studies have observed the effects of the swimmer's view [3,5,20], supine oblique view [20], and arm traction technique []6, 21-23 on improving the visibility of lateral C spine radiography. However, with the availability of many such strategies, it was revealed that the radiographers in this study have primarily used only the two positioning techniques of weight-bearing and non-weight-bearing for the erect lateral C-spine radiography. ...
Background: The visualization of the lower cervical spine (C-spine), including the C7-T1 junction on lateral radiograph is a challenge due to the overlapping of the shoulder girdle. Therefore, the radiographers have adapted different positioning strategies to overcome this challenge. This study explores the current practice and perception of radiographers on positioning techniques of erect lateral cervical spine radiography in non-trauma adult patients. Methods: This prospective study was conducted with a self-administered, structured questionnaire distributed among 50 radiographers working in four selected hospitals in Sri Lanka. Results: The radiographers used weight-bearing and non-weight-bearing positioning techniques for the erect lateral C-spine radiography. Most of them employed the standing breath-holding technique for image acquisition with or without exertion. While 54% of the radiographers utilized two water-filled cans during the weight-bearing technique, 82% used holding arms back with the shoulders down and pulling as low as possible in the non-weight-bearing technique. In addition, 88% of the radiographers believed that the weight-bearing position could increase the visibility of the C-spine. Almost all the radiographers (100%) stated that correct positioning instruction could improve the visibility of the C-spine. Conclusion: Radiographers have mainly used two positioning techniques of weight-bearing and non-weight-bearing for erect lateral C-spine radiography for non-trauma adult patients. In addition, most radiographers had a positive attitude toward the weight-bearing technique in the evaluation of lateral C-spine. These results highlight the importance of conducting studies to evaluate the effectiveness of the weight-bearing technique in erect lateral C-spine radiography.
... Although advanced imaging technologies are widely available, the lateral cervical spine radiograph remains the initial standard radiographic assessment for any type of cervical spinal injuries (1)(2)(3). It is a readily available, simple, and cost-effective radiographic examination (2). ...
... It is a readily available, simple, and cost-effective radiographic examination (2). An adequate lateral C-spine radiograph must demonstrate all seven cervical vertebrae (C1-C7), including the cervicothoracic junction (C7-T1), where 9-18% of cervical injuries occur (1,4,5). Demonstration of lower cervical vertebrae is extremely important to avoid misdiagnosis of cervical spinal injuries (1,4). ...
... An adequate lateral C-spine radiograph must demonstrate all seven cervical vertebrae (C1-C7), including the cervicothoracic junction (C7-T1), where 9-18% of cervical injuries occur (1,4,5). Demonstration of lower cervical vertebrae is extremely important to avoid misdiagnosis of cervical spinal injuries (1,4). According to the literature, 37-72% of cervical spine radiographs do not adequately visualize the lower cervical region (2,4,6). ...
Introduction: Various positioning techniques are utilized to enhance the visualization of lower cervical vertebrae on lateral radiographs. However, the effectiveness of these techniques still remains unclear. This study was conducted to determine the effect of the weight-bearing (WB) technique in visualizing lower cervical vertebrae and cervicothoracic junction (C7-T1) on standing lateral cervical radiographs of adult non-trauma patients. The study was conducted using both computed radiography (CR) and digital radiography (DR) systems.
Methods: Forty-four CR (29 WB and 15 non-WB – NWB) and 61 DR (26 WB and 35 NWB) lateral C-spine radiographs were prospectively evaluated to assess the visible number of cervical vertebral bodies and C7-T1 junction. The instructions given by the radiographer to the patient for the imaging procedure were also assessed on the Likert scale (very good, good, fair, poor, very poor).
Results: There was no significant difference (p > 0.05) in the visualization of the number of vertebral bodies between the two techniques of WB and NWB for CR or DR. Further, no significant relationship (p > 0.05) was observed between the WB technique and the visualization of C7-T1 junction in DR systems. However, a significant difference was identified for CR (p = 0.012). The instruction given to the patient significantly correlated with the visibility of the lower C-spine region within each group of WB and NWB in both imaging systems.
Conclusions: The visibility of the number of vertebral bodies in the lower C-spine region in either CR or DR systems did not demonstrate any enhancement with the WB technique. Regardless of the imaging system or techniques used, adequate instructions given to the patient before and during the imaging procedure of C-spine lateral radiography demonstrated a significant improvement in visualizing the lower C-spine region. In this preliminary study, the application of erect WB radiography technique in evaluating the lower cervical region of adult non-trauma patients gives limited advantage.
... Accordingly, this modified technique can be a useful technique to apply, especially for trauma patients with a suspected cervical spine fracture. Moreover, poor exposure technique, unclear soft tissue shadow visualization, and overlapping bones further marred the image quality of the Swimmer's view radiographs [10]. ...
Introduction: In the Swimmer’s view, the C6 and C7 can be visualized as superimposed on the shoulders. This study aimed to explore the technique to demonstrate C1 to C7 in the lateral spine and improve the diagnostic value in that region.
Material and Methods: An experimental study was carried out using a RANDO phantom to obtain images of the lateral cervical spine. Twelve radiographs were taken using different kVps at different centering points. The image quality of the radiographs was evaluated by two radiographers using the modified image quality criteria score sheet adapted from the Commission of European Communities on image quality. A dose area product meter was utilized to estimate the entrance surface dose (ESD); however, CALDose_X5 Monte Carlo software was used to estimate the effective dose.
Results: The findings indicated that a higher centering point at 2 inches above the pinna of the ear can clearly visualize the lower cervical spine (C6/C7) and cervicothoracic junction (C7/T1). The results of the Kruskal-Wallis test revealed significant differences (p<0.05) in the image quality at different centering points. However, no significant differences were observed (p>0.05) in the ESD between different utilized centering points. The effective dose of the modified technique was reported to be lower, compared to that for the Swimmer’s view.
Conclusion: The modified lateral technique can be used to replace the Swimmer’s view to adequately demonstrate the lower cervical spine and cervicothoracic junction with a lower radiation dose while not harming the patient due to movement during positioning.
... [4][5][6] However, it is often difficult to assess T1 slope with standard upright cervical spine radiographs secondary to poor or no visualization of the upper-end plate of T1 in up to 30% of patients. 7,8 Although T1 slope can be easily measured on computed tomography (CT) and magnetic resonance imaging (MRI), these are supine scans and provide little information on dynamic changes that occur when patients are upright. 9,10 Although there are technologies (i.e., kinematic MRI and EOS imaging) that are better at identifying T1 slope, the cost associated with them remains prohibitive for routine use and is not widely available. ...
... Despite its importance, however, T1 slope is not visualized in up to 30%e40% of patients secondary to body habitus and shoulder obstruction. 7,8 ...
Background:
T1 slope has emerged as an important radiographic parameter in the evaluation and surgical management of adult cervical spinal deformity. Given the high rates of nonvisualization of T1 slope on upright cervical radiographs, however, this study examined the evaluation of C7 slope as a potential surrogate marker.
Methods:
This is a retrospective review in adult patients with and without cervical deformity to examine the correlation of C7 and T1 slopes on routine upright cervical radiographs. In secondary analysis, correlations of C7 and T1 slopes were made amongst various demographic variables, different surgical groups, and various measures of cervical alignment. Cervical deformity was defined as sagittal vertical axis >40 mm, coronal Cobb angle >10°, and sagittal Cobb >10° in kyphosis.
Results:
C7 slope was visualized in 93% of patients as opposed to T1 slope in 68% of patients, leading to a final study population of 129 patients. Mean values of C7 and T1 slopes were 26.5° and 28.1°, respectively. Significant correlation was found in patients with and without cervical deformity (r = 0.9, P < 0.01). This correlation remained significant amongst demographics, surgical groups, and measures of cervical alignment.
Conclusions:
Results demonstrated that C7 and T1 were in direct correlation in a variety of different cohorts regardless of deformity status or prior fusion. This study indicates that C7 slope may be reliably used a surrogate marker especially when visualization of T1 slope is not possible.
... Swimmer's and oblique radiographs have been described for this purpose but generally provide suboptimal visualization. 4,5 Computed tomography and magnetic resonance imaging are capable of generating high-quality images of the cervicothoracic junction, but are generally performed supine without physiologic loading and such imaging is subject to motion artifact. ...
... Swimmer's view has been shown to be inadequate in as many as 45% of radiographs. 5 Both the swimmer's and weighted arm views confound an accurate assessment of alignment as they are not performed in a natural standing position. Oblique views may visualize the cervicothoracic junction, but distort the evaluation of spinal segments as they are not true lateral images. ...
Study Design
Single-center retrospective review.
Objectives
The cervicothoracic junction (CTJ) is typically difficult to visualize using traditional radiographs. Whole-body stereoradiography (EOS) allows for imaging of the entire axial skeleton in a weightbearing position without parallax error and with lower radiation doses. In this study we sought to compare the visibility of the vertebra of the CTJ on lateral EOS images to that of conventional cervical lateral radiographs.
Methods
Two fellowship-trained spine surgeons evaluated the images of 50 patients who had both lateral cervical radiographs and EOS images acquired within a 12-month period. The number of visible cortices of the vertebral bodies of C6-T2 were scored 0-4. Patient body mass index and the presence of spondylolisthesis >2 mm at each level was recorded. The incidence of insufficient visibility to detect spondylolisthesis at each level was also calculated for both modalities.
Results
On average, there were more visible cortices with EOS versus XR at T1 and T2, whereas visible cortices were equal at C6 and C7. Patient body mass index was inversely correlated with cortical visibility on XR at T2 and on EOS at T1 and T2. There was a significant difference in the incidence of insufficient visibility to detect spondylolisthesis on EOS versus XR at C7-T1 and T1-2, but not at C6-7.
Conclusions
EOS imaging is superior at imaging the vertebra of the CTJ. EOS imaging deserves further consideration as a diagnostic tool in the evaluation of patients with cervical deformity given its ability to produce high-quality images of the CTJ with less radiation exposure.
... die konventionelle Röntgendiagnostik übersieht in etwa 1 1 ⁄3 3 der Fälle relevante HWS-Frakturen (▶ Abb. 1 und 2). Hinzu kommt, dass die röntgenologische Darstellung oftmals nicht die gesamte HWS suffizient und diagnostisch verwertbar abzubilden vermag; das gilt vor allem für den zervikothorakalen Übergang [4]. Daffner und Harris haben die sog. ...
Zusammenfassung
Die HWS ist – aufgrund ihrer hohen Mobilität – sowohl hinsichtlich ihrer knöchernen als auch ihrer diskoligamentären Integrität und Stabilität bei Akzelerations-/Dezelerationstraumen stärker gefährdet als andere Wirbelsäulenabschnitte. Dabei treten die meisten derartigen Verletzungen in der unteren HWS auf. Die konventionelle Projektionsradiografie kann weder diesen Abschnitt durchweg suffizient abbilden noch ist das HWS-Röntgen ausreichend sensitiv genug, zervikale Frakturen sicher zu erkennen. Die moderne Multislice-CT-Technik bietet sich hierzu als eine ausreichend sichere und sensitive Methode an, diesen diagnostischen Nachteil – insbesondere zur Beurteilung knöcherner Läsionen – zu überwinden. Der MRT wiederum kommt ein wachsender Stellenwert bei der Einschätzung diskoligamentärer Verletzungsmuster zu, und sie ist unverzichtbar zur Beurteilung intraspinaler Pathologien, insbesondere von traumatischen Myelonläsionen. Im Weiteren werden die für die HWS exklusiven Verletzungsmuster des kraniozervikalen Überganges einschließlich HWK II gesondert und ausführlich besprochen.
... The swimmer's view is commonly utilized to improve visualization of pathology at the cervicothoracic junction, particularly after trauma (7)(8)(9)(10). In a standard swimmer's view, one arm is abducted overhead, with the contralateral arm drawn caudally towards the patient's feet, thus removing the overlying shoulders from obscuring the lower cervical and upper thoracic spine during lateral x-rays (7-10). ...
Background:
Neural blockade of the cervical medial branches is a validated procedure in the diagnosis and treatment of cervical zygapophyseal joint pain. Fluoroscopic visualization of the lower cervical medial branch target zones (CMBTZs) in lateral view is sometimes challenging or not possible due to the patient's shoulders obscuring the target. Large shoulders and short necks often exacerbate the problem. Clear visualization is critical to accuracy and safety.
Objective:
We aim to describe a method for optimal fluoroscopic visualization of the lower CMBTZs using a modified swimmer's view.
Study design:
A technical report.
Setting:
A private practice.
Methods:
Discussion with accompanying fluoroscopic images of the cervical spine, focusing on the lateral aspects of the lower cervical articular pillars in both the traditional lateral view and modified swimmer's view. Four authors served as volunteers for undergoing fluoroscopic x-rays in both views. Visualization of each lower CMBTZ was attempted and stored. The most caudal, clearly visualized levels were compared in both views for each participant.
Results:
Visualization of the lower CMBTZs can be successfully obtained with the modified swimmer's view and in select patients is superior to a lateral view.
Limitations:
A limitation to this study is the design as a technical report. A future prospective study is warranted.
Conclusions:
Modified swimmer's view can serve as a primary method of visualizing the lower CMBTZs or an alternate view when a lateral view is unable to clearly demonstrate target landmarks. This can improve the ease, accuracy, and safety of performing diagnostic cervical medial branch blocks (CMBBs).
Key words:
Swimmer's view, cervical medial branch block, facet joint, fluoroscopy.
... A swimmer's view can be done if the lateral view fails to demonstrate the C7-T1 junction, but this view is adequate in only 55% of cases. 34 Despite additional views and repeated examinations, a significant number of cervical spine radiography is inadequate. The data from many studies collaborate this fact suggesting that the rate of inadequate cervical radiographs might be as high as 37%-72%. ...
Cervicothoracic junction trauma is an important cause of morbidity and mortality in trauma patients. Imaging has played an important role in identifying injuries and guiding appropriate, timely therapy. Computed tomography is currently a method of choice for diag- nosing cervicothoracic junction trauma, in which the pattern of injuries often suggests possible mechanisms and potential injuries. In this article, the authors describe and illustrate common and uncommon injuries that can occur in the cervicothoracic junction.
... It has been reported that the evaluation of radiographs by experienced clinicians is required to prevent a delayed diagnosis caused by mistakes of clinicians at the time of the initial diagnosis [18]. It is thought that one way to reduce the rate of a delayed diagnosis is to perform computed tomography (CT) for the cases that are difficult to diagnose by simple radiography [19,20]. Although MRI can effectively differentiate injury involving soft tissue or intervertebral disc, nonetheless, as compared with CT, its sensitivity and specificity for fractures are not high [21], and so CT is thought to be more useful for the initial evaluation. ...
... Although MRI can effectively differentiate injury involving soft tissue or intervertebral disc, nonetheless, as compared with CT, its sensitivity and specificity for fractures are not high [21], and so CT is thought to be more useful for the initial evaluation. Sekula et al. [22] proposed performing multidimensional CT together with plain lateral radiography for polytrauma patients to rule out injury in the cervical vertebral area, and the usefulness of CT for the evaluation of injury in the cervical vertebral area has been proven by several studies [20,[23][24][25][26]. In our study, making the diagnosis using only simple radiography was difficult, and 1 case in group 1 (10%) and 5 cases in group 2 (33%) were diagnosed by CT. ...
Retrospective study.
To examine the clinical and radiologic characteristics of patients with stage 1 and 2 distractive flexion injury according to Allen's classification and who were not diagnosed immediately after injury, and to analyze the outcomes of surgical treatments.
For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, attention should be paid when performing radiographs as well as when interpreting the radiographs.
The study was conducted on 10 patients (group 1) with stage 1 or 2 distractive flexion injury and who were not diagnosed immediately after injury from January 2003 to January 2009. The control group (group 2), 16 distractive flexion injury patients who were diagnosed immediately were selected. The simple radiographs, the degree of soft tissue swelling and the magnetic resonance imaging findings of the two groups were compared, and the clinical and radiologic results were examined.
The degree of the prevertebral soft tissue swelling of group 1 was lower in group 1, and it was statistically significant (p = 0.046). The fusion was achieved in all cases (100%) in group 1, however, re-displacement as well as the loss of reduction occurred in one case, despite of delayed fusion and good clinical result. In group 2, bone fusion was achieved in 15 cases of 16 cases (94%).
For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, it is desirable to perform computed tomography if diagnosis is not clear. Even if the diagnosis is delayed, stage 1 and 2 distractive flexion injury could be readily reduced by traction, and the treatment outcomes are considered to be comparable to those of the patients diagnosed immediately after injury.
... In addition, image quality issues have been raised in swimmers projections. 16 Oblique projections have been criticised as hard to interpret 17 although others disagree. 5, 18 Jenkins, Curran and Locke 19 undertook a survey into the techniques in use to show C7/T1; they stated that supine obliques give better information about spinal alignment, with less radiation of the patient. ...
... The use of the swimmers projection continues regardless of the recommendations of the BTS 11 guidelines of 2003 that: "If the cervicothoracic junction is not adequately seen, oblique views or a coned penetrated view may be considered, before resorting to a CT scan of this area" (p411). The swimmers projection has been criticised as giving a higher radiation dose than the plain radiographic alternatives, 5,11,13 for being difficult to reproduce adequately; a recent study 16 found only 55% of swimmers radiographs of sufficient diagnostic quality. The movement required can bring further attendant dangers 1,11,14,15 and the possibility of exacerbating an injury is risked. ...
The study objectives were: to investigate current cervical spine radiographic imaging practices in conscious adult patients with suspected neck injury; reasons behind variation and consideration of dose estimates were explored. Comparison with a previous survey19 has been made.Questionnaires were sent to superintendent radiographers responsible for accident and emergency X-ray departments in English trusts with over 8500 emergency admissions per year, with a response rate of 97% (n = 181/186).Departmental cervical spine imaging protocols were reported by 82% of respondents. None use fewer than the three standard projections; if the cervicothoracic junction (C7/T1), is not adequately demonstrated 87% use swimmers projections, 9% supine obliques, 3% CT alone. Following projectional radiography, 97% perform CT. A significant (p = 0.018) increase was found since 199919 in CT use once the swimmers projection fails; fewer now use obliques at this point, continuing with CT instead. No significant difference (p = 0.644) was found in choice of first supplementary radiographs; despite British Trauma Society’s11 recommendation to undertake supine obliques, swimmers remain the most widespread technique.An 85% response rate (n = 103/121) completed a second questionnaire, exploring reasons behind the various practices. Several reported a perceived difficulty in interpreting oblique radiographs, some a concern over high dose of the swimmers.Numerous issues affect the acquisition of cervical spine radiographs. Patient radiation dose should be a major consideration in selection of technique. A potential need for training in interpretation of obliques is highlighted. Specific guidelines for optimum projections should be researched, and protocols issued to ensure best practice.
