Another line (B) is traced along the posterior aspect of the intervening cervical vertebral bodies. In this group, 35% (n = 6) of the patients revealed a lordotic alignment (mean 22.00; SD 6.39°), 60% of the patients (n = 12) revealed a straight C-spine alignment (mean 5.75; SD 5.01°), and one patient (5%) had a kyphotic alignment (+14°). need for diagnostic imaging after head and/or neck trauma according to established clinical decision rules—the National Emergency X-Radiography Utilization Study and CCR—which were in use at our Level 1 trauma centre, MDCT imaging performed on a 64-row MDCT scanner using a standard C-spine protocol within 1 h after admission, patient age: 18–50 years. MDCT was performed on two 64-row scanners (VCT64 and HD750; GE, Milwaukee, WI) using a standard scanning protocol for patients with a suspected C-spine trauma: 120 kV, native helical scan with z-axis dose modulation (10–250 mA) at a noise index of 25 using the thinnest detector collimation available (64 × 0.625 mm). Today, it is a clinically well-evaluated and evidence-based fact that MDCT is superior to CR regarding detection of C-spine injuries.4–7, MDCT is becoming increasingly important for C-spine trauma imaging for adults. max., maximum; min., minimum; SD, standard deviation. The anteroposterior diameter of the spinal canal was measured at C1-C7 on T2-weighted sagittal MR images. 5 Everyday Life Hacks for Straightening Your Spine. Figure 5. Imaging of the cervical spine is a routine part of a radiology practice. In the two CCI−/CCI+ study groups, the straight or kyphotic alignment significantly (p = 0.001) predominated over lordosis. No evidence of abnormal post contrast enhancement noted in the lesion. There were no significant differences in age between both patient groups with and without CCI (CCI+ and CCI−). More than 85 percent of people older than age 60 are affected by cervical spondylosis.Most people experience no symptoms from these problems. Among patients with and without CCI, non-lordotic C-spine curves, either straight or kyphotic, statistically significantly (p = 0.001) predominated over lordotic alignment. Otherwise unremarkable cervical spine MRI. Recently, low-dose MDCT protocols were developed and promoted for the use in C-spine imaging, leading to a rapid decrease of the use of CR for C-spine trauma patients in many emergency departments. The detailed results for the control group are shown in Table 2 and Figure 2. In 1975, Weir reviewed 360 asymptomatic patients and found 20 percent to have either straight or reversed cervical curves in … They observed no significant differences between the trauma and non-trauma groups, and they concluded that the coincidental alterations in normal cervical lordosis may not necessarily be related to the trauma itself. While traumatic injuries to the neck (e.g. Study group: absolute rotational angle (ARA) C2–7 values (°), split into cervical spine alignment groups (lordosis, kyphosis and straight) according to defined angle values. This is one of the great challenges that face cervical spine or cervical neck instability patients. CCI, corvical collar immobilization; F, female; M, male; SD, standard deviation. Figure 4. A p-value ≤ 0.05 was considered to be statistically significant. They concluded that the T1 slope from CR is significantly correlated with the T1 slope from MDCT, and so it may be used as a guide for the assessment of the sagittal balance of the C-spine in MDCT. We suppose that the straight alignment of the C3–C5 segments in these patients was due to CCI impact, but the most proximal or distal segments of the C-spine remained partially mobile, probably because the cervical collar was not fastened tightly, hence the angulation result in a generally straightened C-spine. This finding is in agreement with literature data, where the C5/6 segment was proven to be the most mobile segment in the lower C-spine.29,30. A cut-off age of 50 years was imposed to exclude age-dependent degenerative changes of the C-spine, which can impair the normal alignment before trauma. Age- and sex-matched control subjects with cervical spine MR imaging findings reported as normal were selected from the PACS. Regarding the results from the study group, we suppose that supine patients' changes in C-spine alignment are common in MDCT and mainly associated with variations in positioning (Figure 4). Table 3. Emergency radiology: straightening of the cervical spine in MDCT after trauma—a sign of injury or normal variant. 1]. It was also observed that in both trauma patient groups, straight alignment and segmental kyphosis appeared in 19–21% of the cases, and it was more common at the C5/6 segment. Follow these hacks each day to improve, protect, and straighten your spine. In a healthy spine, your neck should look like a very wide C, with the curve pointing toward the back of your neck. 32 years experience Diagnostic Radiology Loss: of cervical lordosis means straightening of the normal curve of the cervical spine. The difference between lordotic and non-lordotic alignments was statistically significant (p < 0.05). Now a brand-new research study reveals that it can likewise cause reduced blood circulation to the back of the brain. A thorough survey of the literature on this topic revealed controversial opinions on the significance of a “normal” cervical curve in lateral CR radiographs.7,17–21. The differences of distribution of C-spine alignment among supine patients with and without CCI can be seen in Table 3. A thorough survey of the literature on this topic revealed controversial opinions on the significance of a “normal” cervical curve in lateral CR radiographs. Children randomly suffer from this problem. Approximately 2–3% of all trauma patients in emergency departments suffer from cervical spine (C-spine) injury.1 The incidence of C-spine injuries in association with brain injuries among adult trauma patients ranges from 1.7% to 8% and is actually <1% among neurologically intact and alert patients, leading to a large number of normal imaging studies.1–3, The overall sensitivity of conventional radiography (CR) for detecting C-spine injuries is only 39–52% compared with a sensitivity of 90–98% for multidetector CT (MDCT) reported in recent publications, the latter being by far superior to CR. MRI of cervical spine revealed altered signal intensity of C5 vertebral body in the form of T2/STIR hyperintensity and T1 hypointensity suggestive of marrow oedema [Fig. A comparison of the CCI+ group vs the CCI− group revealed a slightly smaller number of kyphotic (10% vs 18%, p = 0.34) and lordotic (21% vs 33%, p = 0.33) alignments. Table 2. Approximately 2–3% of all trauma patients in emergency departments suffer from cervical spine (C-spine) injury. Following the analysis of our non-traumatized control group, we found that even in this group “straight” alignment in supine patients is statistically significantly predominant over lordotic alignment (60% vs 35%, respectively), and even if straight and kyphotic alignments were pooled, there were no statistical differences (control group 65% vs CCI− 67%) to the study group without CCI. The RRA measurements for the patient groups with CCI (CCI+) showed segmental kyphosis in 17 (21%) individuals: 58% (n = 10) of them at the C5/6 level (mean +8.81, SD 3.22°), 29% (n = 5) of them at the C4/5 level (mean +7.83, SD 2.93°) and 12% (n = 2) of them at the C2–C4 level (mean +6.00, SD 2.00°) (Figure 4). car accident) may be a direct cause of straightening of the neck curve, there are other issues that may straighten our cervical spine … That the neck has a typical curve is an essential and frequently neglected issue. Helliwell et al20 reported in their cross-sectional study that 42% of their normal patient population—without significant complaints or neck pain or history of trauma—revealed a straight alignment of the C-spine in upright CR, and about 33% of these patients showed a cervical kyphosis, also probably reflecting differences in positioning. [3-9] The goal of cervical spine imaging is to determine the presence of an injury and to define its extent, particularly with respect to instability. Axial T2 Large left posterior paracentral and lateral recess disc extrusion at C5/6 level resulting in indentation of thecal sac and stenosis of the corresponding left neural foramina. © 2016 The Authors. This is possibly secondary to mucle spasm. A comparison of the patient groups with CCI (CCI+) and without CCI (CCI−) showed a slightly lower number of patients with either kyphotic (10% vs 18%, p = 0.34) or lordotic (21% vs 33%, p = 0.33) alignment, but these differences were not statistically significant. CCI, cervical collar immobilization; max., maximum; min., minimum; SD, standard deviation. The absolute rotational angle of the posterior surface of C2 and C7 (ARA C2–7) (Figure 1) was drawn from the angle (in degrees) between the posterior surface lines of the vertebral bodies of C2 and C7, representing the cervical alignment. While the diagnostic benefit of MDCT is undoubted, concerns have been raised about the increasing use of MDCT and the resulting increase in radiation exposure to patients compared with prior CR.11–14, Following today's established clinical indication guidelines such as the National Emergency X-Radiography Utilization Study (NEXUS) and Canadian Cervical Spine Rule (CCR), which are based on comprehensive prospective multicentre studies; CR imaging can be used instead of CT only for neurologically intact and alert patients, who are considered low risk. A consecutive series of 900 patient files with suspected C-spine trauma were initially extracted from the institutional radiology information system. CCI, cervical collar immobilization; max., maximum; min., minimum; SD, standard deviation. Motor vehicle collisions are the predominant mechanism in children under 8 years old; older children most commonly sustain sports-related injuries [].Child abuse should also be considered in the young child with a suspected whiplash mechanism of CSI. Axial MRI C6-C7. The emerging role of MDCT in C-spine evaluation raised the question as to what extent changes in C-spine alignment may be considered normal for immobilized and non-immobilized patients after trauma. Table 2. For the purpose of these studies, however, imaging was performed in the upright position and mostly without CCI.18,22,23, The emerging role of MDCT in C-spine evaluation raised the question as to what extent changes in C-spine alignment may be considered normal for immobilized and non-immobilized patients after trauma. CCI has a straightening effect on the cervical alignment. Moreover, intraindividual alignment differences were found in the same patient, from different MDCT studies performed as follow-up examinations at two different dates with the same protocol using the same MDCT scanners (Figure 3). The condition describes a spinal state in which the normal lumbar or cervical region is reduced in its degree of front to back curvature, also medically known as hypolordosis. The RRA measurements for the patient groups with CCI (CCI+) showed segmental kyphosis in 17 (21%) individuals: 58% (n = 10) of them at the C5/6 level (mean +8.81, SD 3.22°), 29% (n = 5) of them at the C4/5 level (mean +7.83, SD 2.93°) and 12% (n = 2) of them at the C2–C4 level (mean +6.00, SD 2.00°) (Figure 4). There were no significant differences in age between both patient groups with and without CCI (CCI+ and CCI−). I just got my MRI report:Straightening of cervical lordossis. The straight cervical spine: does it indicate muscle spasm? In the group with CCI (CCI+), 69% (n = 55) of the patients revealed a straight alignment, 10% (n = 8) had a kyphotic alignment and 21% (n = 17) showed a lordotic alignment. Concerning interobserver variability, none of the recorded differences between angle values observed by the two independent readers proved to be statistically significant (, There were no significant differences in age between both patient groups with and without CCI (CCI+ and CCI−). Today, it is a clinically well-evaluated and evidence-based fact that MDCT is superior to CR regarding detection of C-spine injuries.4–7, MDCT is becoming increasingly important for C-spine trauma imaging for adults. The radiographic findings may be subtle. max., maximum; min., minimum; SD, standard deviation. MDCT is becoming increasingly important for C-spine trauma imaging for adults. A comparison of the CCI+ group vs the CCI− group revealed a slightly smaller number of kyphotic (10% vs 18%, p = 0.34) and lordotic (21% vs 33%, p = 0.33) alignments. As the standard of care for the diagnosis of C-spine trauma is shifting from CR to MDCT, a re-evaluation of normal anatomic alignment is needed. Therefore no consensus decisions were necessary. However, in both groups, male patients (61% and 71%) tended to be more involved in traumatic accidents (Table 1). However, it shows that C-spine alignment in MDCT is intraindividually variable, most likely depending on the patient's position on the CT table, as other factors remained unchanged. While the diagnostic benefit of MDCT is undoubted, concerns have been raised about the increasing use of MDCT and the resulting increase in radiation exposure to patients compared with prior CR.11–14, Following today's established clinical indication guidelines such as the National Emergency X-Radiography Utilization Study (NEXUS) and Canadian Cervical Spine Rule (CCR), which are based on comprehensive prospective multicentre studies; CR imaging can be used instead of CT only for neurologically intact and alert patients, who are considered low risk. MDCT is becoming increasingly important for C-spine trauma imaging for adults. All humans acquire a cervical curve or “lordodic curve” when they begin to crawl and raise their heads in that crawling position. The “C” shape points towards the back region of the neck. In the group with CCI (CCI+), there was a significantly higher number of patients with a straight C-spine alignment (69% vs 49%, p = 0.05). The cervical spine displays a slight curve convex to the right side and the normal cervical lordosis is also relatively straightened. It can be concluded that non-lordotic, straightened or kyphotic C-spine alignment in supine adult single-trauma patients with or without CCI undergoing screening MDCT is most likely based on a normal biomechanical reaction of the C-spine to position changes, active patient control or due to the immobilization device itself. Following today's established clinical indication guidelines such as the National Emergency X-Radiography Utilization Study (NEXUS) and Canadian Cervical Spine Rule (CCR), which are based on comprehensive prospective multicentre studies; CR imaging can be used instead of CT only for neurologically intact and alert patients, who are considered low risk. The comparison with the control group supports our hypothesis that straightening of the C-spine alignment curve in adult single C-spine trauma patients could be considered a biomechanical variation due to neck and shoulder girdle positioning during MDCT scanning or active patient C-spine control. In the group without CCI (CCI−), 49% (n = 39) had a straight alignment, 18% (n = 14) a kyphotic alignment and 33% (n = 27) a lordotic alignment (Figure 4). Most studies addressing this issue have focused on lordosis measurements using CR imaging for patients without a history of head/neck trauma. The detailed results for the control group are shown in Table 2 and Figure 2. Recently, low-dose MDCT protocols were developed and promoted for the use in C-spine imaging, leading to a rapid decrease of the use of CR for C-spine trauma patients in many emergency departments. In both trauma patient groups, but mainly among patients with CCI+, it was also noted that sharp segmental lordosis was mostly visualized because of negative (lordotic) angulation for the C2/3 or C6/7 segments in otherwise generally straight C-spine alignments (Figure 5). ], CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison, ACR appropriateness criteria on suspected spine trauma, Increasing utilization of computed tomography in the adult emergency department, 2000–2005, National trends in CT use in the emergency department: 1995–2007, Medical radiation exposure in the U.S. in 2006: preliminary results, The Canadian C-spine rule for radiography in alert and stable trauma patients, Neck pain: a long-term follow-up of 205 patients, The curve of the cervical spine: variations and significance, The association between cervical spine curvature and neck pain. Interobserver reliability and discrepancies in angle measurements between patient groups as well as patient sex, age and signs of initial degenerative spine disease were analysed and compared across all groups. The difference between lordotic and non-lordotic alignments was statistically significant (p < 0.05). We suppose that the straight alignment of the C3–C5 segments in these patients was due to CCI impact, but the most proximal or distal segments of the C-spine remained partially mobile, probably because the cervical collar was not fastened tightly, hence the angulation result in a generally straightened C-spine. The absolute rotational angle of the posterior surface of C2 and C7 (ARA C2–7) (Figure 1) was drawn from the angle (in degrees) between the posterior surface lines of the vertebral bodies of C2 and C7, representing the cervical alignment. It was also observed that in both trauma patient groups, straight alignment and segmental kyphosis appeared in 19–21% of the cases, and it was more common at the C5/6 segment. It was also observed that in both trauma patient groups, straight alignment and segmental kyphosis appeared in 19–21% of the cases, and it was more common at the C5/6 segment. Two independent readers evaluated retrospectively the alignment, determined the absolute rotational angle of the posterior surface of C2 and C7 (ARA C2–7) and grouped the results for lordosis (<−13°), straight (−13 to +6°) and kyphosis (>+6°). To our knowledge, no study has been performed to date to investigate changes in the C-spine alignment in MDCT imaging of the C-spine after trauma and as to whether CCI significantly influences the values of normal cervical lordosis measurements. Cervical lordosis. There are no published scientific data to date based on supine MDCT C-spine alignment measurements among trauma patients with or without CCI. Three patients from the control group underwent MDCT of the C-spine repeatedly (in 2- to 3-month intervals), and there were obvious deviations in the C-spine alignment between individual examinations. Straightening of the cervical spine with loss of physiologic lordosis representing paraspinal muscle stiffness. The absolute rotational angle of the posterior surface of C2 and C7 (ARA C2–7) (. In the two CCI−/CCI+ study groups, the straight or kyphotic alignment significantly (p = 0.001) predominated over lordosis. A cut-off age of 50 years was imposed to exclude age-dependent degenerative changes of the C-spine, which can impair the normal alignment before trauma. For the purpose of these studies, however, imaging was performed in the upright position and mostly without CCI. All measurements were performed on standard picture archiving and communication system workstations (AGFA Impax™; Agfa Healthcare, Köln, Germany) using the manufacturer's software for angle measurements. Published by the British Institute of Radiology, Institute for Diagnostic and Interventional Radiology, HELIOS Clinic München West & München Perlach, Munich, Germany, Institute for Clinical Radiology, Ludwig-Maximilians-University, Munich, Germany, Department of Radiology, University of Latvia, Riga, Latvia, Department of Radiology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy, European Society of Emergency Radiology (ESER), Vienna, Austria, 160 consecutive patients after C-spine trauma admitted to a Level 1 trauma centre received MDCT according to Canadian Cervical Spine Rule and National Emergency X-Radiography Utilization Study indication rule; subgroups with and without cervical collar immobilization (CCI +/−) were compared with a control group (, In the two CCI−/CCI+ study groups, the straight or kyphotic alignment significantly (. B, AP view, radiographic examination of the cervical spine.Rotational injuries and fractures of the lateral masses may be evident. ], CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison, ACR appropriateness criteria on suspected spine trauma, Increasing utilization of computed tomography in the adult emergency department, 2000–2005, National trends in CT use in the emergency department: 1995–2007, Medical radiation exposure in the U.S. in 2006: preliminary results, The Canadian C-spine rule for radiography in alert and stable trauma patients, Neck pain: a long-term follow-up of 205 patients, The curve of the cervical spine: variations and significance, The association between cervical spine curvature and neck pain. If this starts to straighten, curve up, or bows in the opposite direction, cervical kyphosis develops. Cervical Spine Trauma: Pearls and Pitfalls Accurate diagnosis of acute cervical spine injury requires cooperation between clinician and radiologist, a reliable and repeatable approach to interpreting cervi-cal spine CT, and the awareness that a patient may have a significant and unstable ligamentous injury despite normal findings. Student's t-test was used to determine the statistical significance of angle values between the two groups and for each subtype of cervical alignment (IBM Corp., New York, NY; formerly SPSS® Inc., Chicago, IL). By the time a child is 810 years old… Based on the ARA value, patients were classified as lordotic, kyphotic or straight. The control group revealed no significant differences. Table 1. Straightening of the C-spine alignment in MDCT alone is not a definitive sign of injury. Possible discrepancies between the readers were resolved by consensus decision. The comparison with the control group supports our hypothesis that straightening of the C-spine alignment curve in adult single C-spine trauma patients could be considered a biomechanical variation due to neck and shoulder girdle positioning during MDCT scanning or active patient C-spine control. Most studies addressing this issue have focused on lordosis measurements using CR imaging for patients without a history of head/neck trauma. Reassessment of the craniocervical junction: normal values on CT, Sagittal plane segmental motion of the cervical spine. There is no difference in the segmental kyphotic frequency between the two groups based on RRA measurements. Other patients, even single-trauma cases among adults, should be treated as high-risk patients and regularly undergo MDCT.5,15,16, Recently, low-dose MDCT protocols were developed and promoted for the use in C-spine imaging, leading to a rapid decrease of the use of CR for C-spine trauma patients in many emergency departments.6, Loss of lordosis and straightening are often considered to be signs of muscular strain of the C-spine and have served as an indirect sign of cervical trauma or distortion in CR imaging for a long time.7,17 However, it remains unclear whether or to what extent C-spine straightening can be observed in MDCT, and what impact cervical collar immobilization (CCI) can have on the straightening, which is obligatory for patients with assumed C-spine trauma.7,18–21, Most studies addressing this issue have focused on lordosis measurements using CR imaging for patients without a history of head/neck trauma. The RRA measurements for the patient group without CCI (CCI−) revealed segmental kyphosis in 15 (19%) patients: 33% (n = 5) of them at the C5/6 level (mean +5.80, SD 1.3), 18% (n = 3) of them at the C4/5 level (mean +6.60, SD 1.52), 26% (n = 4) of them at the C3/4 level (mean +6.50, SD 1.91) and 13% (n = 2) of them at the C2/3 level (mean +5.00, SD 1.00). This finding is in agreement with literature data, where the C5/6 segment was proven to be the most mobile segment in the lower C-spine. Two experienced, board-certified (7 and 12 years in radiology), independent, blinded readers evaluated all 160 data sets and performed all angle measurements on sagittal multiplanar reconstruction images. Published by the British Institute of Radiology, Institute for Diagnostic and Interventional Radiology, HELIOS Clinic München West & München Perlach, Munich, Germany, Institute for Clinical Radiology, Ludwig-Maximilians-University, Munich, Germany, Department of Radiology, University of Latvia, Riga, Latvia, Department of Radiology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy, European Society of Emergency Radiology (ESER), Vienna, Austria, 160 consecutive patients after C-spine trauma admitted to a Level 1 trauma centre received MDCT according to Canadian Cervical Spine Rule and National Emergency X-Radiography Utilization Study indication rule; subgroups with and without cervical collar immobilization (CCI +/−) were compared with a control group (, In the two CCI−/CCI+ study groups, the straight or kyphotic alignment significantly (. The overall sensitivity of conventional radiography (CR) for detecting C-spine injuries is only 39–52% compared with a sensitivity of 90–98% for multidetector CT (MDCT) reported in recent publications, the latter being by far superior to CR. [In German. Straightening of the C-spine alone is not a definitive sign of injury but is a biomechanical variation due to CCI and neck positioning during MDCT or active patient control. Having been accepted as the imaging modality of choice for cases of multiple trauma for more than a decade, MDCT is now also the preferred imaging modality for single-trauma cases among adult patients. Today, it is a clinically well-evaluated and evidence-based fact that MDCT is superior to CR regarding detection of C-spine injuries. In the group without CCI (CCI−), compared with the group with CCI (CCI+), C-spine alignment was more heterogeneous among a reduced number of patients with straight C-spine alignment, and there was a slight increase in kyphotic and lordotic alignments. For this control group, the same exclusion criteria were applied, if applicable, as for the study group. C-spine - Straightened lordosis - Lateral. However, plain film radiography remains a first-line imaging modality used in the evaluation of patients with suspected cervical spine injury prior to transfer for cross-sectional imaging. In addition, different methods can be used to measure cervical lordosis, although the four-line Cobb method at C2–C7 and the Harrison posterior tangent method (PTM Harrison) are widely acknowledged to be the most reliable.7,17,19 The standard error of measurement (SEM) for the PTM Harrison is lower than for the Cobb method and was therefore used in this study. mild disc space narrowing as noted at c-4 c-5. From this pool, 160 continuous MDCT examinations (study group) that met the following criteria were considered for the study: The study group was divided into two subgroups: (1) with CCI (, MDCT was performed on two 64-row scanners (VCT64 and HD750; GE, Milwaukee, WI) using a standard scanning protocol for patients with a suspected C-spine trauma: 120 kV, native helical scan with.