Evaluation of the cervical spine on plain film is done fairly frequently.  This includes settings of both traumatic and atraumatic patients.  Provided here are a systematic approach as well as examples of common cervical neck plain film abnormalities. 

Normal Views

    
Normal AP (anterior-posterior) view of the cervical spine.

Usually obtain three views, PA LAT and Ontontoid. Must see all 7 C-vertebrae (top of T1).  If C7 cannot be visualized, get a swimmers view, if still not, a CT should be considered. Other plain film views include oblique, flexion, and extension.

    
Normal LAT (lateral) view of the cervical spine.

Prevertebral soft tissues should not measure >7mm at level of C3 and C4, and should not be >20mm at the level of C6 ( not as reliable)

(In children, 2/3 width of the C2 Vertebral body at the level of C3 and C4 and not >14mm at the level of C6.)

If C2- C6 soft tissues measure 7-10mm, consider further imaging.  If  > 10mm definitely need additional imaging if reason not apparent on plain film.

    
Normal Odontoid views

Flexion/Extension – The posterior cortical margin of each cervical vertebral body may be offset by as much as 3mm.

Note:  failure to visualize 7  cervical vertebrae is the most common error made in the radiographic assessment of cervical spine injury.

    
Normal Left Anterior Oblique (LAO) position, allows visualization of the Left-sided foramina.

Note: With the head turned to the right (Left Anterior Oblique position), allows visualization of the Left-sided foramina. The foramina to the left side of the vertebral bodies will always be the left neural foramina.

    
Normal Right Anterior Oblique (RAO) position, allows visualization of the Right-sided foramina.

CT scan of T-bone and C1-C2

This section written by:

LCDR Ron Boucher, MC, USN
LT Hugh McSwain, MC, USN

With some assistance from:

CDR Michael Puckett, MC, USN
ENS Robert Post, MC, USNR