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CT

CT Cervical Spine wo

Here's a template you can use for your preliminary report on a cervical spine CT.

Normal

Here is the normal template you can use for your preliminary report on a cervical spine CT.

Vertebral height and alignment maintained.
Facet joints congruent.
Normal prevertebral soft tissue thickness.
Lung apices clear.

The preliminary report documents immediately actionable items. The full radiologist report is more comprehensive. For example, in trauma cases, the radiologist report may provide a general assessment of degenerative change, highlighting areas of severe spinal canal stenosis.

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Medicine is a team effort. Errors in reading spine studies can result in paralysis and death. It takes hours to get oriented to spine imaging, but it takes years to master the skill. Consult a radiologist before taking action on your preliminary assessment, whether you think the study is negative or positive. Your preliminary assessment will help to reduce time to treatment by accelerating review by a radiologist.

Reporting Abnormal Findings

Replace the normal template with one or more of these phrases when you see an acute finding.

Structure Abnormal Phrases to Know
Vertebral height and alignment (Displaced|nondisplaced) dens fracture.
X mm (anterolisthesis|posterolisthesis) of C3 on C4.
Unknown age compression fracture at C3.
Acute fracture of C3 vertebral body.
Facet joints Distracted (left|right|bilateral) facet joint at C3-C4.
Perched (left|right|bilateral) facet at C3-C4.
Jumped (left|right|bilateral) facet at C3-C4.
Fracture involving (left|right|bilateral) (superior|inferior) articulating facet at C3-C4.
Prevertebral soft tissues Prevertebral soft tissue thickening predominating at C2-C5.
Lung apices (Right|left) apical pulmonary (nodule|mass).
(Trace|moderate|large) (right|left) apical pneumothorax.

*The C3-C4 level is just a placeholder for whichever level is relevant to your case.

Here are some high-yield diagnostic tips:

  • CT Cervical spine wo is an excellent starting point to evaluate for suspected cervical spine trauma.
  • Acute fractures may or may not affect vertebral height and alignment.
  • Worried about ligamentous injury? Order an MR Cervical Spine wo.
  • Do you see spondylolisthesis (anterolisthesis or posterolisthesis)? This is most commonly caused by degenerative change, but in the setting of trauma, check for associated fractures or facet dislocations.
  • Prevertebral soft tissue thickening is a relatively insensitive sign of trauma.
  • Cord contusions, epidural hematoma, and osteomyelitis are better assessed with MRI.