Assessing Alignment of the Lateral Cervical Spine (neck) X-Ray
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Assessing Alignment of the Lateral Cervical Spine (neck) X-Ray : Dr. Mahadevan of Stanford Medical School shows Sal what misalignment in the neck could look like in an X-ray
- this is sal here again and i'm still here with my good friend Dr maja Devon from Stanford University.
- In the last video we had looked at adequacy of x-rays for the neck, is the x-ray good enough?
- But now, lets assume that we have good x-rays, now what do we look at?
- Dr Devon: The next step is to look at the alignment, so we talk about the A, B, C's
- The A, B, C's of reading a cerebral-spinal film. A starts with Adequacy, that we went over, and the
- second part of A is Alignment.
- Sal: Ok, so we're still in A, I was expecting something with a B...
- Alright, Alignment. Alright, so this looks like this is about alignment.
- This is about Alignment, and there's four lines that we look at. the first is the anterior vertebral
- body line. Ok, AVBL right over there.
- Exactly, and basically what you're doing is trying to draw a smooth line that connects the anterior aspect,
- the front of, all the vertebral bodies, it should be nice and smooth, it's usually curved, and all the
- points should sort of fit on that line; nothing should be off of that line. That would suggest that
- there was a problem there.
- I see, and anterior as you just said means front.
- Exactly. The next line is going to the back of the vertebral body is the Posterior Vertebral body.
- OK, so not the back of the entire vertabrae, the vertebral body, which is this boxy part right in front.
- Exactly. So, same thing, connecting a line up and down, should be nice and smooth as you've drawn it,
- and nothing should fall off that line, no piece of the vertebral body should fall off of that line as
- you've drawn it.
- Alright, sounds good. And then?
- The next is we connect all the spinal laminar junctions. So this is the spinal laminar line, and it's
- where, sort of the lamina connects to the spinous process.
- Spinous process, sounds like we could make a whole video about that...
- Spinous process, if you look at the back of somebody's neck are those little bumps that you can see...
- Oh, ok, so these triangular things right here...
- Oh, ok, so you are just connecting that line, kind of the front of these triangles, the base of these
- triangles, so to speak.
- OK, then the last one?
- The last line is the spinous process tips. And again, we're just connecting the top, the tip,
- of all the spinous processes, the little bony projections you can see if you look at the back of
- somebody's neck.
- Right, right.
- And these, too, should generally fall in a nice smooth curve.
- Right, and so the general rule is that if any of these aren't aligned the way that we've drawn here,
- it's a problem.
- Exactly, we call it subluxation, or malalignment, or misalignment...
- And these all suggest that there is a problem there.
- Which is a big deal, because your spinal cord is going through there
- Absolutely! If you look between the green and the blue line, that's where your actual spinal cord runs.
- Right, right, right down there.
- I see, so you don't want that to get messed up.
- Alright, so let's look at a few of these x-rays and see if we can, or if anything's wrong, if we can
- spot it.
- Actually, Sal, now that you know how to read cerebrospinal x-rays, I'm going to have you look at the
- first x-ray.
- (Laughing) OK, let's see, so now I'm going to get sued for malpractice! Ok, let's see, alright...
- This one over here, so let me just do the first one. Let me just go over what you told me to do.
- So I'm going to do the anterior side of this vertebral body...
- I'm learning the words, too, talking like a doctor...OK, so I'm going to draw a line here.
- OK, that looks pretty good.
- That looks decent, this still looks decent, and I don't know, that doesn't look great, would this count?
- I mean, this looks like it got shifted over a little bit
- I mean, it's not like like a huge shifting, but it's enough to, that it's not easy to draw a line, so,
- so I was right?
- You're absolutely right, and in fact sometimes it's very subtle. You picked up a very subtle abnormality,
- but again, even though it's subtle on the x-ray it can be serious for the patient, so you potentially
- saved their spinal cord and their lives by picking up an injury like this.
- OK, very good. So it's literally something as subtle as that is what you're looking for.
- Exactly. Again, it should be a nice smooth line or nice smooth curve, and as you can see,
- at that junction, it's no longer smooth.
- You don't even have to look at the other lines, you just, any one of these, that don't go on a line,
- that's enough, you say, hey, do something else.
- Exactly, and that's a great important teaching point, which is if you see any abnormality
- on a plain film, or on an x-ray like this, you stop, and you protect their cervical spine,
- and then you get a more important study or better quality study like a CT scan.
- Fascinating. Although if I do look here, it does look like we could have done the PVBL
- and it looks like that also is a little off, too.
- Well, let's look at a few more.
- I don't want to focus too much on my first victory...
- Alright, so it's clear that this person is facing this way, I can see their teeth.
- So let's see what we can do here. Can I give it a shot again?
- Please, please-
- So, AVBL looks pretty good. This is, well, that looks close, it looks close...
- I agree, and potentially again, you've got a very keen eye and you might have picked it up,
- but most people might have overlooked that.
- Ok, so let's try the other lines here. So this one is more obvious, this one is more obvious, there
- is kind of a disconnection right over there.
- Exactly, and this is the PVBL, or the posterior verterbral body line, and you can see clearly that line is not smooth, it doesn't connect,
- and so there is a problem right there at that junction.
- Ok, ok, Alright, so we have this last one right over here. Let's see what I can do, I don't want to
- lose my streak...
- Alright, so anterior side, this actually looks pretty perfect, actually.
- And in fact, it is perfect.
- OK, let me try the next lines here.
- This is the Posterior Vertebral body line
- Let me do that in a color that's easier to see, magenta, alright. It looks ok, ok, it looks ok, I mean
- nothing obvious on that line.
- I would say again that you've got the keen eye, but in this particular case, I'd say it's fine.
- Its within the normal range, as we say.
- Ok, and so let me do the base of those triangles. Let me do, so this is a triangle right over here...
- Again, you want to be a nice smooth curve, everything should fall on that curve...
- So this, I would have to be a little bit generous with my curve to make it go to these guys down here.
- Exactly, exactly. And this is the spinal laminar line, this is the third line of alignment, as you can