DOI: 10.1148/rg.233025121
Pediatric Cervical Spine: Normal Anatomy, Variants, and Trauma1
Elizabeth Susan Lustrin, MD,
Sabiha Pinar Karakas, MD,
A. Orlando Ortiz, MD, MBA,
Jay Cinnamon, MD,
Mauricio Castillo, MD,
Kirubahara Vaheesan, MD,
James H. Brown, MD,
Alan S. Diamond, MD,
Karen Black, MD and
Sudha Singh, MD
1 From the Department of Radiology, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040 (E.S.L., S.P.K., J.C., K.V., J.H.B., A.S.D., S.S.); the Department of Radiology, Winthrop University Hospital, Mineola, NY (A.O.O.); the Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC (M.C.); and the Department of Radiology, North Shore University Hospital, Manhasset, NY (K.B.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received July 10, 2002; revision requested August 21 and received December 9; accepted January 29, 2003. Address correspondence to S.P.K. (e-mail: otter102@earthlink.net).
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Figure 1a. Drawings (a) and axial computed tomographic (CT) scan (b) through C1 in an infant show the ossification centers of C1 with open synchondroses (arrows). Note the segmented tip of the dens (arrowhead in b).
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Figure 1b. Drawings (a) and axial computed tomographic (CT) scan (b) through C1 in an infant show the ossification centers of C1 with open synchondroses (arrows). Note the segmented tip of the dens (arrowhead in b).
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Figure 2a. Drawings (a) and axial CT scan (b) through C2 in an infant show the ossification centers of C2 with open synchondroses (arrows).
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Figure 2b. Drawings (a) and axial CT scan (b) through C2 in an infant show the ossification centers of C2 with open synchondroses (arrows).
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Figure 3a. Drawings (a) and axial CT scan (b) through C3 in an infant show the ossification centers of C3 with open synchondroses (arrows).
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Figure 3b. Drawings (a) and axial CT scan (b) through C3 in an infant show the ossification centers of C3 with open synchondroses (arrows).
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Figure 4. Coronal reformatted CT scan of the cervical spine in an infant shows open synchondroses (arrows).
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Figure 5a. Drawing (a) and sagittal reformatted CT scan (b) of the upper cervical spine show the normal ligamentous anatomy and atlanto-occipital articulation. 1 = tectorial membrane, 2 = apical ligament, 3 = atlanto-occipital ligament, 4 = anterior longitudinal ligament.
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Figure 5b. Drawing (a) and sagittal reformatted CT scan (b) of the upper cervical spine show the normal ligamentous anatomy and atlanto-occipital articulation. 1 = tectorial membrane, 2 = apical ligament, 3 = atlanto-occipital ligament, 4 = anterior longitudinal ligament.
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Figure 6a. Sagittal (a) and axial (b) T1-weighted MR images through the cervical spine of a 7-year-old girl who experienced minor trauma show a hyperintense epidural hematoma at the C7-T1 level (arrow). The spinal cord is displaced to the right.
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Figure 6b. Sagittal (a) and axial (b) T1-weighted MR images through the cervical spine of a 7-year-old girl who experienced minor trauma show a hyperintense epidural hematoma at the C7-T1 level (arrow). The spinal cord is displaced to the right.
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Figure 7. Lateral radiograph of the cervical spine in a 2-year-old girl shows an increased but still normal atlantoaxial distance (arrow). Note that the widened prevertebral soft-tissue component is also normal.
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Figure 8. Open-mouth radiograph demonstrates a pseudo-Jefferson fracture with pseudospread of the atlas on the axis (arrow).
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Figure 9. Drawings illustrate the posterior cervical line and show that the anterior edges of the spinous processes of C1, C2, and C3 should line up within 1 mm of each other in both flexion and extension. (Reprinted, with permission, from reference 20.)
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Figure 10. Lateral radiograph of the cervical spine in a pediatric patient shows pseudosubluxation at the C2-C3 level (arrow).
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Figure 11. Lateral radiograph of the cervical spine in a pediatric patient shows normal anterior wedging of multiple cervical vertebral bodies, most prominently at the C3 level (arrow).
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Figure 12a. (a) Lateral extension radiograph of the cervical spine shows normal bone alignment. (b, c) Coronal (b) and sagittal (c) T2-weighted MR images of the cervical spine show normal bone alignment but focal increased signal intensity in the upper cervical spinal cord (arrow), a finding that is consistent with edema or hemorrhage of the cord (SCIWORA).
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Figure 12b. (a) Lateral extension radiograph of the cervical spine shows normal bone alignment. (b, c) Coronal (b) and sagittal (c) T2-weighted MR images of the cervical spine show normal bone alignment but focal increased signal intensity in the upper cervical spinal cord (arrow), a finding that is consistent with edema or hemorrhage of the cord (SCIWORA).
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Figure 12c. (a) Lateral extension radiograph of the cervical spine shows normal bone alignment. (b, c) Coronal (b) and sagittal (c) T2-weighted MR images of the cervical spine show normal bone alignment but focal increased signal intensity in the upper cervical spinal cord (arrow), a finding that is consistent with edema or hemorrhage of the cord (SCIWORA).
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Figure 13. Sagittal T2-weighted MR image of the cervical spine in a pediatric patient shows a C2 fracture with disruption of the tectorial membrane (arrow), findings that indicate a severe and unstable injury.
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Figure 14a. (a) Sagittal reformatted CT scan demonstrates a false-positive finding of increased C2-occiput distance (arrow). (b) Sagittal T2-weighted MR image reveals incomplete ossification of the dens (arrow), which led to the false-positive finding in a.
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Figure 14b. (a) Sagittal reformatted CT scan demonstrates a false-positive finding of increased C2-occiput distance (arrow). (b) Sagittal T2-weighted MR image reveals incomplete ossification of the dens (arrow), which led to the false-positive finding in a.
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Figure 15a. Drawings illustrate the Wachenheim clivus line (a) and the Powers ratio (b), two different methods for evaluating craniocervical junction injury.
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Figure 15b. Drawings illustrate the Wachenheim clivus line (a) and the Powers ratio (b), two different methods for evaluating craniocervical junction injury.
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Figure 16a. Axial CT scan through C1 (a) and three-dimensional (3D) reformatted CT scan of the upper cervical spine (b) obtained in a 6-year-old boy show anterior and posterior ring fractures of C1 (arrows).
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Figure 16b. Axial CT scan through C1 (a) and three-dimensional (3D) reformatted CT scan of the upper cervical spine (b) obtained in a 6-year-old boy show anterior and posterior ring fractures of C1 (arrows).
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Figure 17a. (a) Axial T1-weighted MR image obtained at the level of the craniocervical junction shows loss of normal flow void in the left vertebral artery (arrow). (b) Axial T2-weighted MR image through the upper cervical spine shows bilateral vertebral artery dissection (arrows).
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Figure 17b. (a) Axial T1-weighted MR image obtained at the level of the craniocervical junction shows loss of normal flow void in the left vertebral artery (arrow). (b) Axial T2-weighted MR image through the upper cervical spine shows bilateral vertebral artery dissection (arrows).
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Figure 18a. Lateral radiograph of the cervical spine (a), axial CT scans (b), coronal CT scan (c), and 3D reformatted CT scan (d) through C1-C2 in a 12-year-old girl show atlantoaxial rotatory subluxation.
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Figure 18b. Lateral radiograph of the cervical spine (a), axial CT scans (b), coronal CT scan (c), and 3D reformatted CT scan (d) through C1-C2 in a 12-year-old girl show atlantoaxial rotatory subluxation.
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Figure 18c. Lateral radiograph of the cervical spine (a), axial CT scans (b), coronal CT scan (c), and 3D reformatted CT scan (d) through C1-C2 in a 12-year-old girl show atlantoaxial rotatory subluxation.
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Figure 18d. Lateral radiograph of the cervical spine (a), axial CT scans (b), coronal CT scan (c), and 3D reformatted CT scan (d) through C1-C2 in a 12-year-old girl show atlantoaxial rotatory subluxation.
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Figure 19. Drawings illustrate the Fielding classification scheme for atlantoaxial rotatory fixation. Type I demonstrates no displacement of C1, type II demonstrates 3-5 mm of anterior displacement of C1 and is associated with abnormality of the transverse ligament, type III demonstrates over 5 mm of anterior displacement of C1 on C2 and is associated with deficiency of the transverse and alar ligaments, and type IV demonstrates C1 displacement posteriorly. Arrows indicate direction of movement.
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Figure 20. Lateral radiograph of the cervical spine in a 16-year-old girl with a history of Down syndrome demonstrates atlantoaxial subluxation (arrow).
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Figure 21. Lateral radiograph of the cervical spine in an 18-year-old man who had died from injuries sustained in a motor vehicle accident shows pronounced atlantoaxial disruption.
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Figure 22a. (a, b) Sagittal T1-weighted (a) and T2-weighted (b) MR images of the upper cervical spine show atlantoaxial dislocation. (c, d) Axial CT scan (c) and 3D reformatted CT scan (d) through the C1-C2 region show a small bone fragment (long arrow) between the anterior arch of C1 and the odontoid process, a finding that is consistent with os odontoideum. There is also an increased ADI. Note the unfused anterior arch of C1 (short arrow), which is a normal variant.
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Figure 22b. (a, b) Sagittal T1-weighted (a) and T2-weighted (b) MR images of the upper cervical spine show atlantoaxial dislocation. (c, d) Axial CT scan (c) and 3D reformatted CT scan (d) through the C1-C2 region show a small bone fragment (long arrow) between the anterior arch of C1 and the odontoid process, a finding that is consistent with os odontoideum. There is also an increased ADI. Note the unfused anterior arch of C1 (short arrow), which is a normal variant.
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Figure 22c. (a, b) Sagittal T1-weighted (a) and T2-weighted (b) MR images of the upper cervical spine show atlantoaxial dislocation. (c, d) Axial CT scan (c) and 3D reformatted CT scan (d) through the C1-C2 region show a small bone fragment (long arrow) between the anterior arch of C1 and the odontoid process, a finding that is consistent with os odontoideum. There is also an increased ADI. Note the unfused anterior arch of C1 (short arrow), which is a normal variant.
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Figure 22d. (a, b) Sagittal T1-weighted (a) and T2-weighted (b) MR images of the upper cervical spine show atlantoaxial dislocation. (c, d) Axial CT scan (c) and 3D reformatted CT scan (d) through the C1-C2 region show a small bone fragment (long arrow) between the anterior arch of C1 and the odontoid process, a finding that is consistent with os odontoideum. There is also an increased ADI. Note the unfused anterior arch of C1 (short arrow), which is a normal variant.
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Figure 23. Sagittal midline T1-weighted MR image of the craniocervical junction shows an odontoid synchondral fracture and posterior dislocation of the upper cervical spine with spinal cord injury.
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Figure 24. Lateral radiograph of the cervical spine in a 2-year-old girl with a history of nonaccidental trauma shows fracture through the pars interarticularis and posterior spinous process of C2 (arrow), a finding that is consistent with hangman fracture. Note the increased thickness of the prevertebral soft tissues.
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Figure 25. Sagittal T1-weighted MR image of the cervical spine shows a hangman fracture with ligamentous injury and extensive prevertebral and epidural hematoma.
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Figure 26a. Sagittal (a) and axial (b) T2-weighted MR images of the cervical spine show posterior epidural hematoma (arrow), which exerts mass effect on the spinal cord.
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Figure 26b. Sagittal (a) and axial (b) T2-weighted MR images of the cervical spine show posterior epidural hematoma (arrow), which exerts mass effect on the spinal cord.
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Figure 27a. Sagittal T2-weighted MR image of the cervical spine (a) and axial CT scans through the C5 vertebra (b) show a compression fracture with prevertebral hematoma (arrow in a), with disruption of the anterior longitudinal ligament and extensive spinal cord contusion.
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Figure 27b. Sagittal T2-weighted MR image of the cervical spine (a) and axial CT scans through the C5 vertebra (b) show a compression fracture with prevertebral hematoma (arrow in a), with disruption of the anterior longitudinal ligament and extensive spinal cord contusion.
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Figure 28a. Lateral radiograph (a) and sagittal T1-weighted MR image (b) of the cervical spine show bilateral facet dislocations of C4 on C5 (arrow).
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Figure 28b. Lateral radiograph (a) and sagittal T1-weighted MR image (b) of the cervical spine show bilateral facet dislocations of C4 on C5 (arrow).
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Figure 29. Sagittal T1-weighted MR image of the upper thoracic spine shows atrophy of the spinal cord (arrow) due to previous injury sustained at birth during a breech delivery.
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Copyright © 2003 by the Radiological Society of North America.
