THE NECK

Anna Ben Ely MD

Paul Gottlieb MD
 Spine

33 vertebræ :
• Cervical C –7
• Thoracic Th –12
• Lumbar L – 5 (L1-5)
• Sacral S -5 (fixed vertebræ)
• Coccygeal C- 4 (fixed vertebræ)
 Vertebra
• Body
• Posterior part:
– vertebral foramen
– vertebral or neural arch
• consists of 2 pedicles
and 2 laminæ
• supports 7 processes:
4 articular,
2 transverse,1 spinous
  
 Spine
intervertebral foramina:
• transmit spinal nerves
• between transverse
processes in cervical
region, and in front of
them in thoracic and
lumbar regions   
 Cervical spine
• foramen in
transverse
processes
 C1- Atlas
• No body
• No spinous
process
• Ring-like:
– anterior arch
– posterior arch
– 2 lateral masses
 C2 - Axis
• Dens - from the
upper surface of
the body
C-spine lateral anatomy
C-spine AP anatomy
C Spine open mouth-dens
 Examination of cervical
spine
.1 Cross - table
LATERAL: view
vertebral 7 •
bodies must be
seen
lines 5 •
C1-2 area •
Disk spaces •
Cervical •
C - spine initial radiograph after diving into
a shallow pool

C1

C2

C3

C4

C5
C - spine initial radiograph after diving into
a shallow pool
with the shoulders lowered

C1
C 7 is not
C2 visualized -

C3 the
shoulders
C4 must be
lowered
Dislocation C5 even more
of C5 on C6
C6
Spine anatomy
Swimmer's view
 Examination of cervical
spine
.1 Cross - table
LATERAL: view
vertebral 7 •
bodies must be
seen
lines 5 •
C1-2 area •
Disk spaces •
Cervical •
‫‪Examination of cervical spine‬‬
‫קו ‪ - 1‬רקמות הרכות ‪:‬‬
‫מספר ממ’ בגובה‬
‫‪C1-3‬‬
‫ורוחב של פחות‬
‫מגוף‬
‫החוליה בגובה ‪C4-‬‬
‫‪7‬‬

‫קו ‪ - 2‬גבול הקדמי של‬

‫החוליות‬

‫קו ‪ - 3‬גבול האחורי של‬

‫‪5‬‬ ‫גופי החוליות‬
 Examination of cervical
spine
.1 Cross - table
LATERAL: view
vertebral 7 •
bodies must be
seen
lines 5 •
C1-2 area •
Disk spaces •
Cervical •
Atlanto-Axial relationship
 Examination of cervical
spine
.1 Cross - table
LATERAL: view
vertebral 7 •
bodies must be
seen
lines 5 •
C1-2 area •
Disk spaces •
Cervical •
Reversal
lordosis
 C - spine radiograph

• Soft tissue
swelling
Anterior gaping

C3
Dislocated de
 Examination of cervical
spine
2. If LATERAL C - spine view
appear normal and if the
patient can cooperate FLEXION
and EXTENSION views are
obtained
) patient makes them without
help ! (
C-spine LAT ANATOMY
Flexion
Extension
 Examination of cervical
spine
3. Anterior
view with
closed mouth:

• lower cervical
spine
• alignment
• oblique
fractures
 Examination of cervical
spine
4. Open-mouth
view of dens:
• Dens
• C1 )inferior
and
lateral margins
(
• C2 )superior
and lateral
 Examination of cervical
spine
5. Oblique
views:
Neural
foramina )C2-
T1(
Articular
facets
C spine LAO anatomy
C spine RAO anatomy
C SPINE MRI ANATOMY
C SPINE MRI ANATOMY
ANATOMY
 Examination of cervical
spine
6. Computed
tomography:

• Narrow slices
• Bone window
• MPR
C SPINE CT ANATOMY
C SPINE CT ANATOMY
C SPINE CT ANATOMY
C SPINE CT ANATOMY
)CT-myelo(

C1 ‫ חוליה‬- atlas ‫שת הקדמית של‬

C2 ‫ חוליה‬- axis ‫ של‬DE
C1 ‫ חוליה‬- atlas ‫של‬Lateral ma

subarachnoid spa
spinal co
C1 ‫ חוליה‬- atlas ‫שת האחורית של‬
C SPINE CT ANATOMY
)CT-myelo(

transverse proces
C6 ‫ף החוליה‬
foramen of vertebral arter
spinal cor
lamin

spinous proces
DD for specific back pain
* Degenerative .1 •
Deformity .2 •
Inflammatory & infectious .3 •
Muscular .4 •
Neoplastic .5 •
Metabolic .6 •
Traumatic .7 •
Psychological .8 •

Most common *
 MAJOR PATHOLOGIC ENTITIES
INFECTION:
- Osteomyelitis
- Diskitis
- Epidural abscess
- Meningitis
- Myelitis
- Cord abscess
HEMORRHAGE:
- Acute epidural hemorrhage
- Subacute epidural hemorrhage
VASCULAR DISEASE:
- Aneurysm, AVM
- Hemangioma
- Infarction ( arterial, venous )
 MAJOR PATHOLOGIC ENTITIES ( cont )

DEMYELINATING DISEASE :

- Multiple Sclerosis

- Acute Transverse Myelitis

- Miscellanious Myelopathies
* Radiation
* Aids
* Compression ( HNP, Tumor )
* Toxic / Metabolic : alcohol, Vit B12, etc
 MENINGITIS
- 26 y.o. woman, s/p lumbar surgery, low-grade fever, CSF protein/,
pleocytosis, no organisms ; diff. thickened, enhanc meninges
m/p Aseptic meningitis

Note : diffusely thickened, enhanced meninges

T1+ Gad
 OSTEOMYELITIS OF THE C - SPINE
- Etiopathog : Staphylococcus A.
 Trauma of Spine

• Motor vehicle accident

• Falls
• Sport injuries
 Trauma of Spine

Most common:

Upper (C1-C2) cervical spine

Lower (C5-C7) cervical spine
Thoracolumbar junction (T9-L2)
 Imaging studies
• X-rays
• CT -bones fractures
• MRI- soft tissues, spinal cord, CSF,
neural roots
 Radiology of trauma

• Always get two radiographs at 90

degrees to each other!
• Look for the second fracture!
 Trauma of cervical spine

nterior - flexion forces Following

hyperextension
forces
 FRACTURE OF C1 -
Jefferson’s fracture
• Combination or bust
fracture of C1
• Vertical compression
injury
• Unstable
• Widened lateral
masses of C1 on open-
mouth odontoid view
FRACTURE OF C1 -
Jefferson’s fracture

‫שבר של הלסת‬
‫תחתונה‬
 DENS FRACTURE
# of all cervical % 10

Hyperflexion injury

-Most common
through base of dens
DENS FRACTURE
DENS FRACTURE
 FRACTURE OF C2
Hangman’s fracture
Posterior elements of the C2 fractured
and displaced inferiorly
‫‪FRACTURE OF C2‬‬
‫‪Hangman’s fracture‬‬

‫שבר של אלמנטים‬
‫אחוריים‬
‫ותזוזה של ‪ C2‬קדימה‬
‫לעומת ‪C3‬‬
 Teardrop fracture
Disruption of posterior ligaments and
anterior compression of a vertebral
body
• Hyperflexion
• Most severe and unstable
injury of the C-spine
• Avulsion of antero-inferior
corner of cervical vertebral
body by anterior ligament
TRAUMA

SEVERE BURST
FRACTURE
WITH POSTERIOR
DISLOCATION
OF C5 BODY

COMPRESSED
FRACTURE
OF C6 BODY
Dislocated den
 Unstable cervical spine
fractures
• Flexion teardrop fracture
• Hangman's fracture
• Dens fracture
• Jefferson burst fracture
• Bilateral interfacetal dislocation
• Extension teardrop fracture
• Extension-dislocation
• Extension-fracture-dislocation
Anatomical Considerations
• The neck is a cylinder extending
from the mandible to the thoracic
inlet and from the base of the
skull to the scapulae
• The anterior triangle of the neck
is bordered by the SCMs and the
mandible
• The anterior triangle is divided
into the suprahyoid and
infrahyoid regions by the hyoid
bone

• Clinicians use the following

triangles to navigate neck
anatomy
Anatomical Considerations
• Nasopharynx
• Oropharynx
• Hypopharynx
 Salivary Glands
• Parotid Gland Located on side of
face, anterior to mastoid tip and
external auditory canal, inferior to
zygomatic arch, and superior to the
lower border of the angle of the
mandible
Stenson's duct enters oral cavity through
buccal mucosa opposite upper second
molar
Facial nerve passes through this gland 
• Submandibular Gland Beneath floor
of the mouth, inferior to mylohyoid
muscles and superior to digastric
muscle
Wharton's duct enters the floor of the
mouth near the lingual frenula 
• Sublingual Glands 
• Minor Salivary Glands
C SPINE CT ANATOMY
CERVICAL ,,MAP,,
ANATOMY
 USES OF THYROID U S
• EVALUATE SIZE OF THYROID
• CHARACTER AND NO. OF LESIONS
• DIFFEREATIATE THYROID FROM
EXTRATHYROID MASSES
• FOLLOW-UP AFTER THERAPY
• MONITOR PATIENTS WITH RISK OF
CANCER
• US -GUIDED FNA
 ADVANTAGES OF THYROID
US
• VERY HIGH RESOLUTION [1mm]
• RAPID PROCEDURE
• NO IONIZING RADIATION
• NO PREPARATION
• NON INVASIVE
• LOW COST [=SCINTIGRAPHY]
• IMAGE ADJACENT STRUCTURES
 LIMITATIONS OF THYROID
US

• OPERATOR DEPENDENT
• 7-10 MHz TRANSDUCERS
• MEDIASTINAL AREA NOT SEEN
• RETROTRACHEAL AREA NOT SEEN
 CONGENITAL THYROID
ABNORMALITYS

• AGENESIS
• HYPOPLASIA
• ECTOPIA
 NODULAR THYROID
DISEASE
• HYPERPLASIA AND GOITER
• ADENOMA
• CARCINOMA:
              PAPILLARY
              FOLLICULAR
             MEDULLARY
             ANAPLASTIC
• LYMPHOMA
 DIFFUSE THYROID
DISEASE

• ACUTE SUPPURATIVE THYROIDITIS

• SUBACUTE THYROIDITIS
• HASHIMOTO (CHRONIC LIMPHATIC)
• GRAVES’ DISEASE
• DIFFUSE GOITER
DIFFUSE THYROID DISEASE
US

• NON-SPECIFIC FINDINGS
• > SIZE OF GLAND
• HYPOECHOGENIC TEXTURE
• > CERVICAL LYMPH NODFS
HASHIMOTO
THYROIDITIS
MULTINODULAR GOITER
DIFFUSE GOITER
 THYROID NODULE
• 4-7% -PALPABLE NODULE
• 40% -NODULE ON US
• 50% -NODULE AT AUTOPSY
• F > M
• > AFTER RADIATION
 BENIGN FEATURES OF
THYROID NODULES
• WELL MARGINATED
• MOSTLY CYSTIC+- INTERNAL
DEBRIS
• HYPERECHOGENIC[96% BENIGN]
• PERIPHERAL EGG-SHELL
CALCIFICATION
• THIN HALO
ADENOMA
BENIGN CALCIFICATION

COARSE PERIFERAL EGG-SHELL

 MALIGNANT FEATURE OF
THYROID NODULS
• SOLID
• HYPOECHOIC
• IRREGULAR MARGINS
• FINE,PUNCTATE,INTERNAL
CALCIFICATIONS
MEDULLARY CA
• 5%
• HORMON  CALCITONIN
• 20% FAMILAL
• COMPONENT OF MEN 2
MICROCALCIFICATION
US DOES NOT RELIABLY
DIFFERENTIATE
MALIGNANT FROM
BENIGN LESIONS
FNA
Lymph nodes
• Typical
ultrasonographic
appearance of a benign
hyperplastic lymph
node.
•
Thank you