Test your skill in reading these 16 pediatric cervical 
spine radiographs.  Many of these have subtle findings.  
Follow the principles outlined in Case 2 of this volume, 
Cervical Spine Radiographs, and see how accurate 
you can be at interpreting these radiographs.


View Case A





Interpretation of Case A
     Lateral and AP views are shown here. The top  of 
the lateral view was cut off, thus visualizing only part of 
C1.  There is an obvious compression fracture of C5.  
C4 and C7 are also compressed.  There is an avulsion 
of the anterior superior lip of C7.
     The AP view shows a vertical fracture through C5.
     Impression:  Compression fractures of C4, C5, C7.



View Case B





Interpretation of Case B
     Two lateral views are shown here.  Both radiographs 
show that C4 is displaced anteriorly with respect to C5.  
The anterior vertebral body line, the posterior vertebral 
body (anterior spinal canal) line, and the spinolaminal 
(posterior spinal canal) line are out of alignment. 
     Impression:  C4-C5 subluxation.



View Case C
     Radiographs contributed by Martin I. Herman, MD






Interpretation of Case C
     This lateral view shows C4 slightly displaced 
anteriorly with respect to C5.  Someone has placed a 
strip of tape over the arch of C5 to show that the 
posterior border of the C5 vertebral body does not line 
up with the other vertebral bodies.  The borders of the 
tape introduce some artifact.  The lucency that appears 
over the arch of C6 is from the tape (not a fracture).  
The anterior vertebral body line, the posterior vertebral 
body (anterior spinal canal) line, and the spinolaminal 
(posterior spinal canal) line are out of alignment. 
     Impression:  C4-C5 subluxation.



View Case D
     Radiographs contributed by Martin I. Herman, MD





Interpretation of Case D
     This lateral view shows C2 tilted anteriorly over C3.  
While one might consider the possibility that this is a 
C2-C3 pseudosubluxation, this degree of angulation is 
excessive.  Additionally, the C2-C3 facet joints are 
disrupted.  
     Radiographic features consistent with a C2-C3 
pseudosubluxation are:
     1) Neck position should be neutral or in flexion.  
However, in the case of this radiograph, the lower 
portion of the neck (C3 to C7) is in extension (lordosis).  
The only flexion in the neck is at the C2-C3 region, 
which is abnormal.  Since this criterion is not met, this is 
not consistent with a pseudosubluxation.
     2) The Swischuk line should be in good alignment.  
This is a line drawn from the anterior aspect of the 
posterior arch of C1 to the anterior aspect of the 
posterior arch of C3.  The anterior aspect of the 
posterior arch of C2 should be within 1.5 mm of this line 
(refer to  Case 3 of this volume and Case 5 of Volume 
1).  In the case of this radiograph, the Swischuk line 
alignment is satisfactory.
     3) Other factors favoring a pseudosubluxation 
include a benign mechanism of injury, low clinical risk, 
and resolution of the pseudosubluxation upon repeating 
the radiograph following repositioning the neck in 
extension (lordosis) (This often cannot be done if a true 
subluxation is suspected).
     Thus, a satisfactory alignment of the Swischuk line 
alone is not sufficient to rule out a true subluxation.
     The anterior vertebral body line, the posterior 
vertebral body (anterior spinal canal) line, and the 
spinolaminal (posterior spinal canal) line are out of 
alignment. 
     Impression:  C2-C3 subluxation.



View Case E





Interpretation of Case E
     This lateral view shows C2 slightly displaced 
anteriorly with respect to C3.  The anterior vertebral 
body line, the posterior vertebral body (anterior spinal 
canal) line, and the spinolaminal (posterior spinal canal) 
line, are out of alignment.  This radiograph shows poor 
positioning.  It is not a true lateral, rather it is oblique.  
Note the prominence of the intervertebral foramina 
which are most prominent on an oblique view.
     Unlike case D, this radiograph shows the entire 
cervical spine to be in flexion.  The Swischuk line is at 
the limits of tolerance in this case since the anterior 
aspect of the posterior arch of C2 is about 1.5 mm from 
the Swischuk line; however it is not a true lateral view.
     Clinically, this patient's mechanism of injury is low 
risk and her degree of discomfort is felt to be most 
consistent with a pseudosubluxation.  Repeat films of 
her neck in better positioning are normal.
     Impression:  Probable C2-C3 pseudosubluxation.
The anterior vertebral body line, the posterior vertebral 
body (anterior spinal canal) line, and the spinolaminal 
(posterior spinal canal) line, are out of alignment 
probably due to poor positioning.



View Case F
     Radiographs contributed by Collin S. Goto, MD




Interpretation of Case F
     This is an 18-month old male riding unrestrained in 
the front passenger seat of a car involved in a motor 
vehicle collision.  He was ejected from the vehicle,  
sustaining multiple trauma.
     Lateral and AP views are shown here.  The lateral 
view shows separation of the skull from the cervical 
spine (atlanto-occipital dislocation).
     NOTE:  There is a visible lucency at the base of the 
odontoid.  This is the subdental synchondrosis, a 
normal finding in young children.  This synchondrosis 
generally fuses by age 3 to 6 years.
     Impression:  Atlanto-occipital dislocation.



View Case G
     Radiographs contributed by Collin S. Goto, MD




Interpretation of Case G
     This is a 5-year old female who fell off a trampoline 
onto her head with her neck flexed.  She presented to 
the E.D. with neck pain and tingling in her feet.
     Two lateral views are shown here.   The anterior 
vertebral body line, the posterior vertebral body 
(anterior spinal canal) line, and the spinolaminal 
(posterior spinal canal) line, are out of alignment.  C3 is 
displaced anteriorly with respect to C4.  The facet joints 
of C3/C4 are out of alignment.  There is possible facet 
joint subluxation at C2/C3.
     Impression:  C3-C4 subluxation.



View Case H




Interpretation of Case H
     A lateral view is shown here.  The pre-vertebral soft 
tissue space is widened suggesting the possibility of 
hemorrhage into this area from a fracture.  An NG tube 
is in place.  An NG tube in the esophagus could widen 
the pre-vertebral soft tissue space as well.  In this 
instance, it is not certain if the widening of the 
pre-vertebral soft tissue space is pathologic. 
     The anterior vertebral body line, the spinolaminal 
(posterior spinal canal) line, and the spinous processes 
tips line are all in satisfactory alignment.  The posterior 
vertebral body line is slightly disrupted at the C6-C7 
junction where C6 appears to be displaced slightly 
anterior with respect to C7 (difficult to see).  The 
anterior vertebral body line may also be slightly 
disrupted at C6-C7, however, this is so slight that it is 
difficult to be certain.  There is a possible irregularity of 
the posterior inferior corner of the C6 vertebral body.  
This is possibly a small avulsion fracture.  The facets of 
C6 are displaced slightly anteriorly with respect to the 
facets of C7.
     Impression:  Possible small avulsion fracture of the 
posterior inferior corner of the C6 vertebral body.  
Possible anterior displacement of the C6 with respect to 
C7.  These abnormalities are not definite.  The study is 
possibly normal.



View Case I





Interpretation of Case I
     Two lateral views and a single AP view are shown 
here.  The lateral view on the right shows an obvious 
fracture of the odontoid.  However, note that on the 
other lateral view of the same patient, the odontoid 
fracture is not as easy to appreciate.  In the lateral view 
on the left, the odontoid fracture can be identified by the 
angulation of the odontoid.  The other bony elements 
are normal.  Alignment is satisfactory otherwise.
     NOTE:  The fracture at the base of the odontoid 
could possibly be confused with the normal lucency at 
the base of the odontoid in young children (the 
subdental synchondrosis).  However, while it may be 
normal for the odontoid to tilt backward (posteriorly), it 
should NOT be tilting forward (anteriorly).  Anterior 
tilting of the odontoid with a widening of the lucency at 
the base of the odontoid are highly indicative of a 
fracture and not a normal synchondrosis.
     Impression:  Odontoid fracture.



View Case J





Interpretation of Case J
     Lateral, AP, and odontoid views are shown here.  
C7 is not visualized well on the lateral view, making this 
study inadequate.  On the lateral view, C2 may be 
slightly displaced anteriorly with respect to C3.  The 
anterior vertebral body line identifies this displacement 
best.  The posterior vertebral body (anterior spinal 
canal) line, and the spinolaminal (posterior spinal canal) 
line, are within satisfactory alignment.  The lateral view 
also shows an irregularity of the anterior inferior corner 
of the C2 vertebral body.  This can only be seen on the 
enlarged view.  It resembles a small drop dripping from 
the vertebral body (difficult to see).  This is a small 
avulsion fracture.  The pre-vertebral soft tissue space is 
within normal limits.
     The AP view shows good alignment of the spinous 
processes and equal spacing.  The odontoid view 
shows the lateral masses of C1 well-positioned with 
respect to C2.
     Impression:  Small avulsion fracture of the anterior 
inferior corner of the C2 vertebral body.  Slight anterior 
displacement of C2 with respect to C3.





View Case K





Interpretation of Case K
     There is a fracture of the spinous process of C7.  
The anterior and posterior vertebral body lines are 
satisfactory.  The spinolaminal line is satisfactory.  The 
tips of the spinous processes are difficult to see with the 
exception of C7, which is fractured.
     This radiograph demonstrates a modest degree of 
"fanning".  Normally, the spinous processes are evenly 
spaced and they converge toward a point because of 
their attachment by the posterior longitudinal ligament 
and the interspinous ligament.  However, this 
radiograph shows that the spinous process of C7 is not 
converging toward the same point as the other spinous 
processes.  This spreading of the spinous processes, 
known as fanning, is consistent with a fracture of the 
spinous process or a tear of the posterior longitudinal 
ligament.
     This has the appearance of a typical "clay 
shoveller's" fracture, which generally occurs when the 
neck is forced forward (flexed) while it is held in 
extension (lordosis).  In this case, this teenager was 
swimming when someone diving from the rocks above, 
fell onto his back.
     Impression:  C7 spinous process fracture.




View Case L





Interpretation of Case L
     Several views are shown here.  The upper left image 
is a lateral view which only shows C1 to the upper 
portion of C5.  Two oblique views are shown in the 
upper right.  The lower left image is an AP view.  The 
right lower image shows two swimmer's views.
     The lateral view show no pre-vertebral soft tissue 
widening.  C1 to the top of C5 are in satisfactory 
alignment.  The swimmer's views show poor images of 
C5 and C6.  C7 is still not well visualized.  The anterior 
portion of the C6 vertebral body is slightly shorter than 
the posterior portion, indicating the possible presence of 
a compression fracture.  While the height of C6 seen on 
the AP and oblique views may seem slightly short, it is 
probably within normal limits.
     Impression:  Possible compression fracture of the 
anterior portion of the C6 vertebral body.  C7 is not 
visualized well.



View Case M





Interpretation of Case M
      Multiple views are shown here.  The upper left 
image is the lateral view.  The upper right image is an 
odontoid view with the AP view beneath it.  The lower 
left images are oblique views.  The lower right image is 
a swimmer's view.
     The lateral view shows C1 to the upper portion of 
C6.  C7 is not visualized.  C4 and C5 show 
compression fractures of the anterior portions of the C4 
and C5 vertebral bodies.  C3 appears to be slightly 
displaced anteriorly with respect to C4 on both the 
lateral view and the swimmer's view.
     C2 appears to be slightly displaced anteriorly with 
respect to C3.  This is due to kyphosis secondary to the 
fractures.
     The odontoid view shows the odontoid well centered 
within C1.  However the lateral margins of the lateral 
masses cannot be determined from this odontoid view.  
Thus, this particular odontoid view is not of satisfactory 
quality.
     There are no identifiable abnormalities on the 
oblique views.  The swimmer's view  shows C6 better, 
but C7 is still not visualized, making this study 
suboptimal.
     Impression:  Compression fractures of C4 and C5.  
Unable to visualize C7.



View Case N





Interpretation of Case N
     A lateral view is shown here with the neck in a flexed 
position.  C2 is out of alignment anteriorly with respect 
to C3. There is a lucency through the base of the 
odontoid.   There is widening of the pre-vertebral soft 
tissue.  The Swischuk line is in satisfactory alignment.  
All of these findings are consistent with a 
pseudosubluxation due to the positioning of the neck in 
flexion.  This film was repeated with a better lordotic 
extension of the neck.  Both the C2-C3 
pseudosubluxation and the pre-vertebral soft tissue 
widening resolved.
     Impression:  Pseudosubluxation.  Normal subdental 
synchondrosis.



View Case O





Interpretation of Case O
     There is fusion of several vertebral units.  Alignment 
appears to be satisfactory, but normal anatomic 
landmarks are not present.
     Impression:  Congenital fusion of adjacent vertebral 
bodies.



View Case P





Interpretation of Case P
     C4 and C5 are out of alignment, displaced 
posteriorly with respect to the rest of the C-spine.  The 
anterior aspects of the C4 and C5 vertebral bodies are 
shorter than the posterior aspects due to wedge type 
compression fractures.  The vertebral body of C6 is 
shortened due to a compression fracture.
     Impression:  Wedge type compression fractures of 
C4 and C5.  Compression fracture of C6.  Posterior 
subluxation of C5 on C6.