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A 54-year-old man presented to the ED with neck, shoulder, and upper back pain. One day earlier, he had fallen six feet from a ladder. He landed feet first, then onto his back. He did not lose consciousness. He was able to get up by himself after the fall and felt that he was “alright.” The next day, he decided to see a doctor because of persistent neck and shoulder pain. He was ambulatory on arrival to the ED.

On examination, he appeared healthy and in no apparent distress, resting comfortably on the stretcher. There was tenderness of the posterior neck, upper back, and right trapezius area. There were no signs of head trauma. He had normal strength, sensation, and reflexes in all four extremities. His neck was then immobilized in a hard plastic cervical collar.

The cervical spine radiographs are shown in Figure 1. Shoulder radiographs were normal. (A Fuchs [submental] view of the dens was obtained rather than an open mouth view.)

  • Are there any abnormal findings in these radiographs?
  • How would you manage this patient?

The fact that a patient is able to walk into the ED one day after a traumatic event should not dissuade you from considering that he has suffered a serious or unstable cervical spine injury.

In this patient, the lateral radiograph is of good technical quality—all seven vertebrae are visible. The patient’s positioning is rotated such that the left and right lateral masses are not superimposed (Figure 2). Examination of the bones reveals no fracture, although there are chronic degenerative changes (spondylosis) of C4, C5, and C6—mild loss of vertebral body height, osteophytes, and anterior ligamentous calcification. This is not unexpected in a patient of his age.

Figure 2

Lateral view—Patient 6.

Findings include:

1. Retrolisthesis of C5 (asterisk) on C6;

2. Degenerative changes (osteophytes and anterior longitudinal ligament calcification) of the C4, C5, and C6 vertebral bodies (arrowheads);

3. Convexity (budge) in prevertebral soft tissues at C5–C6 and narrowing at C7 (arrows).

The overall alignment of the vertebral column appears normal. In patients with degenerative changes, alignment of the anterior surfaces of the vertebral bodies is difficult to assess because of vertebral body osteophytes. Alignment can be assessed more accurately using the posterior surfaces of the vertebral bodies. In this patient, C5 is displaced 3 mm posteriorly with respect to C6 (asterisk). This is termed retrolisthesis.

Malalignment may be due to an acute traumatic injury–a fracture or ligamentous ...

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