Cervical Spine (Plain X-ray)

Relevant Social Security Medical Listings

  • Listing 1.04      Disorders of the Spine (Adults)
  • Listing 101.04 Disorders of the Spine (Children)
  • Listing 13.11 Skeletal System Cancer (Adults)

Type

Objective/X-ray (Spine)

Can SSA Purchase?

Yes.

Purpose

Plain x-rays of the cervical spine can be used to diagnose:

  • Metastatic cancerous lesions.
  • Osteoarthritis.
  • Inflammatory conditions such as ankylosing spondylitis.
  • Intervertebral disc disease.
  • Osteoporosis.
  • Vertebral body fractures.
  • Postsurgical changes.

General

From the head downward, the bony spine (vertebral column) consists of 7 cervical (C1 – C7), 12 thoracic (T1 – T12), 5 lumbar (L1 – L5), and 5 fused sacral vertebrae (sacrum), ending with a small bone called the coccyx. The vertebral bodies are cushioned and separated by non-bony intervertebral disks each consisting of fibrous tissue surrounding a more elastic core called a nucleus pulposus.

Technique

An anterior-posterior (AP) x-ray view is taken with the patient supine, which shows vertebral bodies below the level of the 3rd cervical vertebral body (C3). Higher vertebral bodies in the cervical spine are seen by taking the x-ray through the patient’s open mouth while in the supine position. A lateral x-ray of the cervical spine may be taken with the patient either upright or supine. Additional (e.g., oblique) views may be taken as the individual case warrants.

Interpretation

Cancer that has spread (metastasized) to the spine, such as breast or prostate cancer, may be seen as destructive areas in the vertebral bodies, more often present in the lumbar and thoracic spine than the lumbar spine. However, bone scanning is a more sensitive procedure for detecting metastatic bone lesions.

Osteoarthritis (OA) is one of the most common disorders affecting the cervical spine. OA is also known as degenerative arthritis, degenerative joint disease (DJD), and hypertrophic arthritis. Such arthritis may cause outgrowths of bone called osteophytes (spurs), which in severe cases can fuse adjacent vertebrae together. Osteoarthritis may also overgrow and fuse the vertebral facets where vertebral bodies attach to each other. The intervertebral neuroforamina, or holes in vertebral bodies where the spinal nerves exit, may be narrowed (encroached) by osteoarthritic changes.

In the spine, the term spondylosis is frequently encountered on medical reports. Technically, spondylosis means the ankylosis or bony fusion of a joint. However, it is most often used to refer to the degenerative changes in the spine in a broad sense that includes a combination of osteoarthritis (osteophytes, ligamentous calcification, neuroforaminal narrowing) and degenerative disc disease (DDD).

Ankylosing spondylitis (AS) in advanced form causes bony fusion of vertebrae to each other by syndesmophytes. Syndesmophytes are bony outgrowths from the edges of vertebral bodies that may grow to and fuse with adjacent vertebral bodies, causing a “bamboo-spine” appearance. There is also calcification of the spinal ligaments, and fusion of the joints between the sacrum and iliac bones (sacroiliac or SI joints). There is a straightening of the lumbar spine. Additionally, there is a pattern of vertebral body erosion that produced a squaring of vertebral bodies, and arthritic involvement of the hip joints. Intervertebral disc spaces are preserved. The progression of ankylosing spondylitis over time is upward from lumbar to thoracic to cervical spine. When ankylosing spondylitis is suspected, x-rays of the lumbosacral, thoracic, and cervical spine are necessary to appreciate the full extent of the disease; also the hip and sacroiliac joints cannot be seen on cervical films.

A common finding in older individuals is disease of the intervertebral discs that cushion the vertebral bodies and permit flexibility of the spine. These discs cannot be seen on plain x-rays, and unlike Computerized Tomographic Scanning of Spine, Magnetic Resonance Imaging (MRI) of Bone, and Myelography, a diagnosis of a herniated nucleus pulposus (HNP or “slipped disc”) cannot be made. However, as discs deteriorate as a result of age they lose their water content and tend to lose their thickness. Degenerative disc disease (DDD) can therefore be diagnosed on plain x-rays by narrowing of the intervertebral spaces between the vertebral bodies. In some instances, DDD is so severe that the intervertebral spaces are nearly gone.

Osteoporosis is a loss of bone mass per unit volume of bone, i.e., a loss of bone density. Osteoporosis can be significant and still not be visible on plain x-rays, though it can be detected on more sensitive Bone Densitometry. Nevertheless, advanced osteoporosis may result in such severe thinning of bone that the vertebral bodies appear faint even on plain x-rays.

Vertebral body fractures may result from either trauma or osteoporosis. Often, such fractures are compression fractures because the injured vertebra is crushed along its axis with a loss of height. Compression fractures can be of any degree of severity. If the interpreting physician states that there is a 40% compression fracture of a vertebra, it means that vertebra has lost 40% of its height from being crushed and collapsing along its axis. In the case of severe osteoporosis, compression fractures may take place without any evident trauma. Osteoporotic compression fractures most often occur in the thoracic spine and are not usually seen in the neck.

Plain x-rays of the spine are useful in evaluating the post-surgical status of some surgical procedures, such as the integrity of a surgical bony fusion of vertebral bodies that has been carried out to increase spinal stability and decrease pain.

Examples

Example 1

Cervical Spine Series

History:
Motor vehicle accident.

Findings:
AP, lateral, oblique, flexion, extension, and cross-table lateral views were obtained. No fracture or subluxation is seen. Cervical spondylosis is noted with disc space narrowing at C5 – 6 and C6 – 7. Anterior spurs are also noted at these levels. Oblique views demonstrate bilateral neuroforaminal encroachment at C5 – 6 due to the osteophytic spurs. The posterior spinous processes are intact. The C1 – 2 articulation appears normal. No perivertebral soft tissue abnormality is seen. Anterior spurs are also seen at C4 – 5, best visualized on the cross-table lateral views.

Impression:

  1. Cervical spondylosis involving C4 – 5, C5 – 6, and C6 – 7. Bilateral neuroforaminal encroachment at C5 – 6 is present.
  2. No fracture or subluxation is seen.
  3. In view of the history of trauma, clinical correlation is suggested to see whether soft collar immobilization is indicated.