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.
Lateral view—Patient 6.
1. Retrolisthesis of C5 (asterisk)
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 ...