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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Cervical Spine
http://pdf-radiology.com
TERMINOLOGY
Synonyms
• Uncovertebral joint (joint of Luschka)
• C1 (atlas), C2 (axis)
Definitions
• Subaxial cervical spine = C3-C7
GROSS ANATOMY
Overview
• Consists of 7 vertebrae (C1-C7)
Normal Anatomy and Techniques
○ Craniocervical junction (CCJ): C1, C2, & articulation with
skull base constitute craniocervical junction
○ Subaxial spine: C3-C7
– C3-C6 typical cervical vertebrae
– C7 has features that differ slightly from C3-C6
Components of Subaxial Cervical Spine
• Bones C3-C7
○ Body
– Small, broader transversely than in AP dimension
– Posterolateral edges of superior surface are turned
upward = uncinate process
○ Vertebral arches
– Pedicle: Delicate, project posterolaterally
– Lamina: Thin and narrow
– Vertebral foramen: Large, triangle-shaped
○ Transverse processes
– Project laterally and contain foramen for vertebral
artery
– Anterior and posterior tubercles are separated by
superior groove for exiting spinal nerve
○ Articular processes
– Superior and inferior articular processes with articular
facets oriented ~ 45° superiorly from transverse plane
– Form paired osseous shafts posterolateral to vertebral
bodies = articular pillars
○ Spinous process: Short and bifid
○ C7 unique features
– Spinous process: Long, prominent
– Transverse process: Short and project inferolaterally
compared with T1 spinous processes, which are long &
project superolaterally
• Intervertebral foramen
○ Oriented anterolaterally below pedicles at ~ 45° to
sagittal plane
• Joints
○ Intervertebral disc
– Narrowest in cervical region
– Thinner posteriorly than anteriorly
– Do not extend to lateral margins of vertebral bodies in
cervical spine → joints of Luschka
○ Uncovertebral joint (joints of Luschka)
– Oblique, cleft-like cavities between superior surfaces
of uncinate processes & lateral lips of inferior articular
surface of next superior vertebra
– Lined by cartilaginous endplate of vertebral body
– No true synovial lining present; contains serum,
simulating synovial fluid
– Uncinate process develops during childhood with
uncovertebral joint forming by fibrillation and
fissuring in fibers of annulus fibrosus
○ Facet (zygapophyseal) joints
– Facet joints oriented ~ 45° superiorly from transverse
plane in upper cervical spine; assume more vertical
orientation toward C7
– Formed by articulation between superior & inferior
articular processes = articular pillars
– Form 2 sides of flexible tripod of bone (vertebral
bodies, right and left articular pillars) for support of
cranium
• Ligaments
○ Anterior & posterior longitudinal, ligamentum flavum,
interspinous & supraspinous ligaments
○ Additional ligaments of CCJ include apical, alar, and
cruciate ligaments
• Biomechanics
○ Subaxial cervical spine shows free motion range relative
to remainder of presacral spine
– Cervical extension checked by anterior longitudinal
ligament & musculature
– Cervical flexion checked by articular pillars &
intertransverse ligaments
IMAGING ANATOMY
Lateral Assessment of Subaxial Spine
• Principles apply equally to radiography, CT, or MR
• Prevertebral soft tissues: Distance between air column
and anterior aspect of vertebral body
○ Adults: < 7 mm at C2 & < 22 mm at C6
○ Child: < 14 mm at C6
• Bony alignment
○ Anterior vertebral line: Smooth curve paralleling
anterior vertebral cortex
– Less important than posterior cortical line
○ Posterior vertebral line: Smooth curve paralleling
posterior vertebral cortex
– Translation > 3.5 mm is abnormal
– Flexion and extension allow physiological offset < 3
mm of posterior cortical margin of successive
vertebral bodies
○ Spinolaminar line: Smooth curve from opisthion to C7
formed by junction of laminae with spinous processes
○ Spinous process angulation: Cervical spinous processes
should converge toward common point posteriorly
– Widening is present when distance is > 1.5x
interspinous distance of adjacent spinal segments
Frontal Assessment of Subaxial Spine
• Lateral masses: Bilateral smooth undulating margins
• Spinous processes: Midline
○ Lateral rotation of 1 spinous process with respect to
others is abnormal
• Interspinous distance: Symmetric throughout
○ Interspinous distance 1.5x distance of level above or
below is abnormal
20
Vertebral body
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Cervical Spine
Normal Anatomy and Techniques
GRAPHICS
Anterior tubercle
Transverse foramen
Pedicle
Vertebral canal
Uncinate process
Superior articular process
Inferior articular process
Groove for exiting spinal nerve
Posterior tubercle
Superior articular facet
Lamina
Spinous process
Intervertebral disc
Uncovertebral joint
Articular pillar
Transverse process
Transverse process
Neural (intervertebral) foramen
Groove for exiting spinal nerve
(Top) Graphic of a typical cervical vertebra viewed from above demonstrates important morphology. The vertebral body is broader
transversely than in the AP dimension, the central vertebral canal is large and triangular in shape, the pedicles are directed
posterolaterally, and the laminae are delicate and give rise to a spinous process with a bifid tip. Lateral masses contain the vertebral
foramen for passage of vertebral artery and veins. (Middle) Frontal graphic of subaxial cervical spine with cutout shows the
intervertebral disc and uncovertebral joints. Paired lateral articular pillars are formed by articulation between the superior and inferior
articular processes. (Bottom) Lateral graphic of 2 consecutive typical cervical vertebrae with cutout shows facet (zygapophyseal) joint
detail. Note also the prominent groove on the superior surface of the transverse process for exiting spinal nerves.
Vertebral body
Superior articular process & facet
Pars interarticularis
Facet joint
Spinous process
Inferior articular process & facet
21
GRAPHIC & 3D VRT NECT
http://pdf-radiology.com
Cervical Spine
C1, atlas
C2, axis
Normal Anatomy and Techniques
Transverse process
Neural foramen
Groove for exiting spinal nerve
C1 root exiting above C1
C2 root exiting at C1-C2 level
C3 root exiting at C2-C3 level
C4 root exiting at C3-C4 level
C5 root exiting at C4-C5 level
C6 root exiting at C5-C6 level
C7 root exiting at C6-C7 level
C8 root exiting at C7-T1 level
T1 root exiting at T1-T2 level
Occipital condyle
C1 lateral mass
Body C2
C2-C3 facet joint
Inferior articular facet C3
Superior articular facet C4
(Top) Coronal graphic of the cervical spine shows vertebrae and corresponding cervical nerves. The vertebrae are numbered and are
shown with their exiting nerves. There are 8 cervical nerves, with the C1 nerve exiting above the C1 body and the C2 nerve exiting at the
C1-C2 level. The C8 nerve exits at C7-T1. Below this level, the thoracic roots exit below their respective numbered vertebrae. The roots
exit inferiorly within the neural foramen along the bony groove in the transverse process. (Bottom) Coronal 3D-VRT examination shows
the cervical spine, viewed posteriorly with the dorsal elements partially removed to show the dorsal vertebral body surface. The
concept of the cervical articular pillars is well shown in this view with the facets forming paired columns of bone with superior and
inferior articulating facets.
Odontoid process
Articular pillar
22
Cervical lateral masses pillars
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Intervertebral disc space
Cervical Spine
Normal Anatomy and Techniques
RADIOGRAPHY
C3 body
C4 body
C6 uncinate process
C7 transverse process
T1 transverse process
Clavicle
C2 body
Anterior cortical margin, C3
Prevertebral soft tissues
C7 pedicle
1st rib
Posterior arch C1
Inferior articular facet C2
Superior articular facet C3
Corticated margin defining
spinolaminar line
Posterior cortical margin, C6
(Top) AP plain film view shows the cervical spine. The articular facets are viewed obliquely in this projection and therefore not defined,
giving the appearance of smoothly undulating lateral columns of bone. The superior and inferior vertebral endplate margins are sharp,
with regular spacing of the intervertebral discs. The spinous processes are midline. The C7 transverse process is directed inferolaterally
compared with T1, which is directed superolaterally. (Bottom) Lateral radiograph shows the cervical spine. The prevertebral soft tissues
should form a defined, abrupt "shelf" at approximately C4/5 where the hypopharynx/esophagus begins, hence thickening the
prevertebral soft tissues. The bony cervical spine is aligned, from anterior to posterior, with the anterior vertebral body margins, the
posterior vertebral body margins, and the ventral margins of the spinous processes (spinolaminar line).
C7 spinous process
23
RADIOGRAPHY & 3D VRT NECT
http://pdf-radiology.com
C2 pedicle
Normal Anatomy and Techniques
C3 body
Cervical Spine
C4 body
C5-C6 neural foramen
C6 pedicle
C7 uncinate process
C3 body
C4 body
Uncinate process
Articular pillar
C6 spinous process
C6 lamina
C2-C3 neural foramen
C3-C4 neural foramen
C5 transverse process
C7 spinous process
24
(Top) Oblique radiograph of the cervical spine best demonstrates the neural foramina, as these are oriented obliquely at ~ 45° from the
sagittal plane. With the patient rotated to the left, the radiograph demonstrates the right-sided foramina. The anterior boundary of the
neural foramina includes the uncinate process, intervertebral disc, and vertebral body. The posterior boundary is the facet joint
complex. The articular pillar facet joints are viewed obliquely and therefore are not well defined. The lamina is seen end-on and hence is
sharply corticated. (Bottom) Oblique 3D-VRT examination of the cervical spine shows the neural foramina end-on. The groove on the
superior surface of the transverse processes for the exiting spinal nerves is well shown.
Cervical Spine
http://pdf-radiology.com
Normal Anatomy and Techniques
AXIAL BONE CT
C5 body
Posterior tubercle transverse process
Basivertebral veins
Lamina
C5 body
Neural foramen
Uncinate process C6
Lamina
Anterior tubercle transverse process
Transverse foramen
C5 pedicle
Vertebral canal
Spinous process (bifid)
Anterior tubercle transverse process
Neural foramen
Vertebral canal
Spinous process
C5-C6 intervertebral disc
Uncinate process C6
Facet pillar
Lamina
(Top) Image through mid C5 body at the pedicle level is shown. The transverse foramina are prominent at this level, with the round,
sharply marginated transverse foramen encompassing the vertical course of the vertebral artery. The anterior and posterior tubercles
give rise to muscle attachments in the neck. The vertebral body is interrupted along the posterior cortical margin for the passage of the
basivertebral venous complex. (Middle) In this image at the inferior C5 body level, the uncinate process arising off of the next inferior
vertebral body is coming into view. The inferior margins of the transverse processes are incompletely visualized. The spinous process is
well seen joining with the thin lamina. (Bottom) View at C5-C6 level shows the next neural foraminal level bound by uncovertebral joint
anteriorly and facet posteriorly.
Neural foramen
Superior articular facet
Facet joint
Inferior articular facet
Spinous process
25
AXIAL BONE CT
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Cervical Spine
C4 inferior endplate
C4-C5 intervertebral disc
Facet joint
Normal Anatomy and Techniques
C4 inferior endplate
Transverse process
C4-C5 intervertebral disc
Lamina
Facet joint
Lamina
Uncinate process C5
Neural foramen
Superior articular facet
Inferior articular facet
Spinal cord
Uncinate process C5
C5 pedicle
Superior articular facet
Spinal cord
Posterior tubercle transverse process
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C5 body
Anterior tubercle transverse process
Transverse foramen
C5 pedicle
Spinal cord
Lamina
Spinous process
(Top) This is the 1st of 6 axial bone CT images presented from superior to inferior through the cervical spine starting at the C4-C5 level.
The cup-shaped intervertebral disc of the cervical region is seen centrally, bound along the posterolateral margin by the uncinate
processes. The uncinate process defines the joint of Luschka between adjacent vertebral segments. The neural foramina exit at around
45° in an anterolateral direction, bound posteriorly by the superior articular process. (Middle) In this image through the inferior margin
of the intervertebral disc, the gracile pedicles arise obliquely from the posterolateral margins of the vertebral bodies. The bony canal is
large relative to the posterior elements and assumes a triangular configuration. (Bottom) In this image through the C5 body level, the
transverse process contains the transverse foramen for the vertebral artery.
Cervical Spine
http://pdf-radiology.com
Normal Anatomy and Techniques
SAGITTAL T2 MR
Occipital condyle
C1 lateral mass
Vertebral artery in C2 transverse
foramen
C5-C6 neural foramen
C6 transverse process
Vertebral artery
Posterior arch C1
C2 pars interarticularis
Inferior articular facet C2
Superior articular facet C3
C4-C5 facet joint
C6-C7 facet joint
C5 facet
C5-C6 facet joint
Vertebral artery entering transverse
Prevertebral soft tissues
Ventral dural margin/posterior
longitudinal ligament
C6-C7 intervertebral disc
Cerebrospinal fluid
(Top) The 1st of 3 sagittal T2 MR images viewed from lateral to medial is shown. The view through the articular pillars demonstrates
normal alignment of the facet joints. The rhomboidal configuration of the cervical facets is noted, with their complementary superior
and inferior articular facets. The exiting spinal nerves run in the groove along the superior aspect of transverse processes. (Middle) More
medial section shows the overlapping facets at each level and the flow void of the vertebral artery within the transverse foramen.
(Bottom) Midline image shows the relationship of the cervical cord, vertebral bodies, and spinous processes with smooth, straight
margins and alignment. The posterior dural margin merges with the ligamentum flavum and the low signal of the spinous process
cortex. The anterior dural margin merges with the posterior body cortex and posterior longitudinal ligament.
foramen
1st rib
Anterior arch C1
Spinous process C2
C2 body
Ligamentum nuchae
Interspinous ligament
Dorsal dura margin
Spinal cord
27
AXIAL T2 MR
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Cervical Spine
Anterior atlantoaxial joint
Odontoid process
C1 lateral mass
Normal Anatomy and Techniques
Vertebral body C2/base of odontoid
Vertebral artery flow void
Vertebral artery
Anterior arch C1
Transverse ligament
Transverse foramen
Spinal cord
Cerebrospinal fluid
Atlantoaxial joint/superior articular facet
C2
Anterior internal venous plexus/epidural
fat
Spinal cord
Cerebrospinal fluid
28
Vertebral artery
C2 body
Neural foramen
Lamina
(Top) The 1st of 6 axial T2 MR images from superior to inferior beginning at the level of the anterior arch of C1 is shown. The anterior
atlantodental joint is well identified, bound by the low signal cortical margins of the anterior odontoid and anterior arch of C1.
Posterior to the odontoid is the low signal transverse ligament complex. (Middle) In this image at odontoid/C2 body level, the base of
the odontoid is at the level of the lateral atlantoaxial articulation. This joint is sloped, being more superior at the medial margin. The
vertebral arteries are identified by their flow voids located just lateral to the lateral masses and passing superiorly toward the C1
transverse foramen. (Bottom) In this image at the C2 body level, the relationship of the vertically oriented vertebral artery to the neural
foramen is highlighted.
Cerebrospinal fluid
Spinal cord
Spinous process
Cervical Spine
http://pdf-radiology.com
Normal Anatomy and Techniques
AXIAL T2
Vertebral endplate
Uncinate process
CSF flow artifact
Transverse process
Articular pillar
Ligamentum flavum
Intervertebral disc
Vertebral artery flow void
Spinal cord
Vertebral artery
Pedicle
Spinal cord
(Top) In this image at the C2-C3 disc level, the intervertebral disc is fully visualized as low signal, with the bounding posterior lateral
uncovertebral joints. (Middle) Image through the pedicles of C3 is shown. Pedicles are delicate and are directed posterolaterally from
the vertebral body. The superior and inferior articular processes and intervening facet joints form the articular pillars. Prominent
vertebral artery flow voids are seen within the transverse foramina of the transverse processes. (Bottom) Image through the neural
foramina of C3 is shown, which are oriented ~ 45° anterolaterally. The posterior margin of the neural foramen is the facet joint; the
ventral margin is the disc and uncinate process.
C3 inferior endplate
Facet joint
Lamina
Spinous process
Vertebral artery
Neural foramen
Cerebrospinal fluid
Spinal cord
29