thickness at the C3 level. Attention to pre-vertebral soft tissue swelling is as important as attention to bony anatomy. In some cases, it may be the only radiological sign in 30-40% of patients presenting with an acute central cord syndrome . All seven cervical vertebrae, as well as the C7-T1 junction, need to be visualized . Caudal traction of the arms or a "swimmer's view" might be necessary to visualize this junction. Contraindications to this maneuver include atlanto-occipital, atlanto-axial or other pathologies identified in the initial view. An AP view, as well as an open mouth or odontoid view, are usually all that are needed to adequately visualize the cervical spine. Limitations of plain radiographs include difficulty in identifying injuries to the ligaments, over and underexposure, as well as decreased visualization of the occipitocervical, cervicothoracic and thoracolumbar transitional areas.
Areas not adequately visualized or fractures identified by plain films should be further explored with CT scanning. The advent of spiral CT scanning has made image acquisition more feasible, especially in specialized trauma centers. In our institution, patients who complain of neck pain, in the absence of visible fractures on plain films, have fallen from heights greater than 10 feet, have been involved in highspeed motor vehicle accidents, are unconscious or have an associated head injury, automatically undergo a specialized imaging protocol of the spine, which examines the occiput to T4 with 3-mm cuts and sagittal and coronal reformations through the area . CT scanning is more sensitive for fractures of the posterior elements and bone displacement is also better appreciated with CT scanning . Limitations of this technology include missing fractures that lie parallel to the plane of imaging. The use of reformations has made this less of an issue of concern.
MRI has limited sensitivity for fractures, but it is the study of choice to image the neural elements. It is indicated in the patient with unexplained neurological injury, worsening neurological status and incongruent skeletal and neurological examination. It is also indicated after fracture-dislocations are reduced in the emergent setting. MRI is helpful in showing spinal cord compression, intramedullary edema and hemorrhage, disc disruption, ligamen-tous injury and vascular occlusion. Chronic responses to injury, such as myelomalacia and syrinx formation, are also better visualized with MRI. Sagittal T2-weighted images are useful in assessing most of the above. MRA has also found a role in the patient suspected of having a vertebral artery injury. This should always be suspected in patients with altered mental status and fractures that involve the transverse processes .
Emergency myelography is reserved for situations in which an MRI cannot be obtained or there is a contraindication to MRI, such as a pacemaker.
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