Straightening of the C-spine alignment is related to neck positioning and active patient control. Study group: absolute rotational angle (ARA) C2–7 values (°), split into cervical spine alignment groups (lordosis, kyphosis and straight) according to defined angle values. The understanding of what treatment may help them the best and the controversies and confusion that surround these treatments. MDCT is becoming increasingly important for C-spine trauma imaging for adults. Therefore, the data drawn from this study could not be compared with other authors using MDCT, and a comparison with other studies based on upright CR imaging is methodically difficult and limited in this context. All humans acquire a cervical curve or “lordodic curve” when they begin to crawl and raise their heads in that crawling position. no obvious signs of injury to the head, neck and spine; exclusion of skull and vertebral fractures as well as intra- and extra-axial haematoma and ligamentous injuries, which can alter the alignment by itself. This could also increase the number of “straight” C-spine cases among patients with CCI and the difference in C-spine alignment distribution between both trauma patient groups. 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. Moreover, the clinician must be aware of the “false positive” sign: a straightened cervical curve or a reserved cervical curve not resulting from trauma or pain. At C4- C5, grade 1 retrolisthesis. 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). What Causes the Neck to Straighten? The resulting average ARA C2–7 values for both patient groups are represented in Table 3. The taper ratio of the spinal canal was calculated with the regression line. Most studies addressing this issue have focused on lordosis measurements using CR imaging for patients without a history of head/neck trauma. 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. 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 (, Incidence of cervical spine injuries in association with blunt head trauma, Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics, Clinical characterization of comatose patients with cervical spine injury and traumatic brain injury, Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis, Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS), Evaluation of a dedicated MDCT protocol using iterative image reconstruction after cervical spine trauma, Roentgenographic findings of the cervical spine in asymptomatic people, Polytrauma: optimal imaging and evaluation algorithm, Importance of multidetector CT imaging in multiple trauma. 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. Table 3. 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. Today, it is a clinically well-evaluated and evidence-based fact that MDCT is superior to CR regarding detection of C-spine injuries. The SEM for the PTM Harrison (1° < SEM < 2°) is lower than the reported values for the Cobb method (3° < SEM < 10°), and it is considered to be both more reliable and reproducible. In a healthy spine, your neck should look like a very wide C, with the curve pointing toward the back of your neck. 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). A new precision measurement protocol and normal motion data of healthy adults, Mean age (years) irrespective of gender (SD), Signs of initial degenerative spine disease (%), Mean age (years) for patients with initial degenerative spine disease (SD). Marshall et al26 reported a correlation of reduced cervical lordosis measurements following motor vehicle accidents, although the differences in lordosis values between analysed groups were not statistically significant. [In German. From these results, it can be concluded that segmental kyphosis in the group generally considered “straight” appeared mostly at segment C4–6, however, without a statistically significant difference between both patient groups. 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°). no obvious signs of injury to the head, neck and spine; exclusion of skull and vertebral fractures as well as intra- and extra-axial haematoma and ligamentous injuries, which can alter the alignment by itself. Another group, Beltsios et al,22 recently studied the incidence of normal cervical lordosis among 60 and 100 healthy patients using MDCT and compared their results with the changes in patients with a neck injury, applying CR and MDCT. 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−). Fluid-sensitive sequences on MRI may show high signal in the posterior soft tissues, corresponding to … 2]. Based on prior published data, the following cut-off angle/alignment values were defined to group the patients as follows: lordosis <−13°; straight −13° to +6°; kyphosis >+6°. A spinal MRI, or magnetic resonance imaging, uses powerful magnets, radio waves, and a computer to make clear, detailed pictures of your spine. Therefore “straightening” of the C-spine alone should not be considered a reliable pathological imaging sign in screening trauma patients undergoing MDCT. The cervical spine usually has a lordotic curvature (posterior concavity) This lordosis may be lost when the neck is held by immobilisation devices - as in this image There are no published scientific data to date based on supine MDCT C-spine alignment measurements among trauma patients with or without CCI. 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. In addition, a control group (n = 20) of normal non-traumatized patients was established, aged 18–50 years, that underwent head/neck MDCT for oncologic imaging. 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. How cervical spine instability pinches on arteries and disrupts, impedes, and retards blood flow into the brain. 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. Radiologic evaluation of the pediatric cervical spine can be even more challenging due to the wide range of normal anatomic variants and synchondroses, combined with various injuries and biomechanical forces that are unique to children. As no definite C-spine curve angles and cut-off values have been reported in literature so far for patients in the supine position undergoing MDCT with or without CCI, values for ARA C2–7 were adapted from literature data for patients undergoing upright CR imaging. CCI, cervical collar immobilization; max., maximum; min., minimum; SD, standard deviation. Roentgenographic variations in the normal cervical spine, Sagittal alignment of the cervical spine after neck injury, Roentgenographic signs of cervical injury, Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis, Relationship between alignment of upper and lower cervical spine in asymptomatic individuals, Correlation of cervical lordosis measurement with incidence of motor vehicle accidents. 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). 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. 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. Another line (B) is traced along the posterior aspect of the intervening cervical vertebral bodies. 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). car accident) may be a direct cause of straightening of the neck curve, there are other issues that may straighten our cervical spine … Axial reconstructions were calculated with a slice thickness of 1.25 mm and a high-resolution bone kernel, 2.5 mm and a soft-tissue kernel, and 0.65 mm for multiplanar reconstructions, applying slice thickness of 2 mm in the coronal and sagittal orientations. 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. However, when there is … However, in both groups, male patients (61% and 71%) tended to be more involved in traumatic accidents (Table 1). Other authors, such as Grob et al,19 also could not demonstrate a correlation between cervical alignment changes, straightening or kyphosis and neck pain and muscle spasm. The differences of distribution of C-spine alignment among supine patients with and without CCI can be seen in Table 3. 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. A consecutive series of 900 patient files with suspected C-spine trauma were initially extracted from the institutional radiology information system. B, AP view, radiographic examination of the cervical spine.Rotational injuries and fractures of the lateral masses may be evident. However, in both groups, male patients (61% and 71%) tended to be more involved in traumatic accidents (, Among patients with and without CCI, non-lordotic C-spine curves, either straight or kyphotic, statistically significantly (, A comparison of the patient groups with CCI (CCI+) and without CCI (CCI−) showed a slightly lower number of patients with either kyphotic (10%, The ARA measurements for the patient groups with and without CCI showed predominantly straight alignments (69%) (ARA −13 to +6°), The RRA measurements for the patient group without CCI (CCI−) revealed segmental kyphosis in 15 (19%) patients: 33% (, The resulting average ARA C2–7 values for both patient groups are represented in, 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%, 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 (. This supports an earlier stated hypothesis of the stabilizing and therefore straightening effect of CCI on the C-spine. Straightening of the C-spine alignment is related to neck positioning and active patient control. The condition is also called cervical kyphosis. The difference between lordotic and non-lordotic alignments was statistically significant (p < 0.05). 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. 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. 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). We aimed to define the normal anatomic variability in MDCT in a screening population after trauma with and without CCI and in comparison with a non-trauma control group; obvious injuries were initially excluded. The straight cervical spine: does it indicate muscle spasm? 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. The cervical curve aids in the stabilization of both the head and the spine. 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. Statistically, however, the differences were of no significance. 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). In a current publication, Jun et al,27 analysed 50 asymptomatic patients with regard to parameters such as T1 slope, Cobb angle at C2–C7 and thoracic inlet angle of the cervical sagittal alignment obtained from cervical MDCT and from CR. 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. A new precision measurement protocol and normal motion data of healthy adults, Mean age (years) irrespective of gender (SD), Signs of initial degenerative spine disease (%), Mean age (years) for patients with initial degenerative spine disease (SD). The number of patients with straight C-spine alignment was higher in the CCI+ group (CCI+ 69% vs CCI− 49%, p = 0.05). Lordotic straightening is a diagnostic conclusion often seen on MRI reports. 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 (n = 20) of non-traumatized patients. 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. A consecutive series of 900 patient files with suspected C-spine trauma were initially extracted from the institutional radiology information system. 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 (. A thorough survey of the literature on this topic revealed controversial opinions on the significance of a “normal” cervical curve in lateral CR radiographs. Table 1. The purpose of this study was:to evaluate whether statistically significant differences in the cervical alignment, lordosis, kyphosis or straightening can be observed in adult patients undergoing MDCT after single trauma exposureto evaluate whether loss of lordosis or straightening of the C-spine in the supine position alone can be considered a significant MDCT finding when screening for C-spine injuries andto evaluate the influence of CCI on the cervical alignment in patients undergoing MDCT after head/neck trauma. Straightening of the cervical spine in the acute setting may be secondary to muscular trauma, and a focal kyphosis may ensue at a later time. 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. Diagnosis 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. 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. Patient demographics, age and incidence of degenerative spine disease did not differ from the study group. 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. 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. The cervical spine series is a set of radiographs taken to investigate the bony structures of the cervical spine, albeit commonly replaced by the CT, the cervical spine series is an essential trauma radiograph for all radiographers to understand. 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. The radiographic findings may be subtle. 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. Straightening of the cervical lordosis, then, means straightening of the normal neck curve. For this control group, the same exclusion criteria were applied, if applicable, as for the study group. ], 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. Emergency radiology: straightening of the cervical spine in MDCT after trauma—a sign of injury or normal variant. They concluded that loss of cervical lordosis is most likely a predictor of muscle spasm caused by pain in the neck. 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. 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. The relative rotational angle (RRA) was determined by measurements of the posterior surface of neighbouring segments and were significant at >±4°.19, As no definite C-spine curve angles and cut-off values have been reported in literature so far for patients in the supine position undergoing MDCT with or without CCI, values for ARA C2–7 were adapted from literature data for patients undergoing upright CR imaging.7,17,19,24,25. The absolute rotational angle of the posterior surface of C2 and C7 (ARA C2–7) (. Rojas et al28 examined the normal anatomic relationships of the occipitovertebral articulation in MDCT, finding significantly different values between MDCT and plain CR radiographs and proposing new normal MDCT values for the adult population. CCI has a straightening effect on the cervical alignment. [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. 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. 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. 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. Possible discrepancies between the readers were resolved by consensus decision. Imaging of the cervical spine is a routine part of a radiology practice. 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. Shown in Table 2 and Figure 2, corvical collar immobilization ; max., maximum ;,... ” when they begin to crawl and raise their heads in that crawling position was with... 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