This is a 21 year old male with complaints of shoulder and neck pain. Carefully review your ABC's and see if you notice anything wrong. What type of image is this? Why was it taken? What would be his symptoms? Describe a few and let your other classmates chime in as you progress.
Please complete the post 4/24/2013.
I am going to throw a guess out there starting with this being a R posterior oblique radiograph view, which provides good representation of intervertebral foramina. My second guess is saying perhaps it is indicating a cervical rib on the R. Neck and shoulder pain would not be surprising since this could involve compression of the brachial plexus as well as related vasculature. This could result in symptoms related to thoracic outlet syndrome, such as numbness/tingling down into his shoulder and arm, possibly in an ulnar nerve distribution, and could also include symptoms related to vascular compromise.
ReplyDeleteJudging by the position of the patient this is either a left anterior oblique projection or a right posterior oblique projection as the patient's left intervertebral foramina can be distinctly identified. The intervertebral spaces appear to be normal and would not account for the patient's symptoms. However, I agree with Rachel that there appears to be a cervical rib coming off of the C7 vertebral body. This can produce signs and symptoms of thoracic outlet syndrome due to compressing the subclavian artery and brachial plexus. An additional clinical test to rule in this diagnosis would be Adson's test of abduction and ER of the shoulder with palpation of the radial artery.
ReplyDeleteI agree that this is a right posterior oblique view. It shows the intervertebral foramina, uncovertebral joints, facet joints, and pedicles of the cervical vertebrae. This view also shows the first 3-4 ribs as well as the proximal ends of both clavicles. I also agree that this patient has cervical ribs, and looks as if the left rib is fractured which would explain his shoulder/neck pain.
ReplyDeleteWhen looking in the imaging book, the position of the head would indicate a right posterior oblique as Cassie mentioned although the image is not as clear as those in the book. I too thought that this patient had cervical ribs with the left being fractured as Dusty mentioned. The spacing in the lower cervical spine looks limited but that could be due to the view. I am assuming that is the hyoid bone in his neck which looks very peculiar and he appears to have abnormalities with the anterior soft tissue. I'm not sure what I see. This image is confusing me.
ReplyDeleteLike the others have said, the view is an oblique positioning of some sort, but what caught my eye at first glance was the (most likely) fractured rib on the L, which could account for the aforementioned clinical presentation. However, it may appear, from the image, that the individual has bilateral cervical ribs, which could also account for the said s/s, and equally leads me to ask, "what kind of shoulder and neck pain is involved?" Is it bilateral? Unilateral? Could the individual point to a single location of pain? And what kind of pain was involved? A clearer clinical presentation would greatly help understand the image.
ReplyDeleteThis view does appear similar to a right posterior oblique view. If that is the case, then the left intervertebral foramina are imaged. The intervertebral foramina is one of the main observations mentioned by our book that is clear from this view, and the foramina in the above image appear to be normal and spaced properly. Courtney mentioned the visible hyoid bone in the neck that does seem unusual because none of the other examples of the oblique view in the book display such a prominent hyoid. I agree that the most likely cause of the patient's symptoms appear to be the left fractured cervical rib, especially if his pain is only on the left side.
ReplyDeleteI agree that this is a posterior oblique view of the cervical spine. I first noticed the apparent rib fracture on the left and that this is a cervical rib. I agree that it could cause symptoms similar to thoracic outlet such as pain, numbness/tingling, UE weakness, and vascular symptoms. I wonder if this patient would have pain related to inhalation and exhalation. The dark area is most likely the airway. I think it is interesting that you can see the hyoid since, as mentioned above, it doesn't really show up in the images in the book. But you can also see the outline of the soft tissue much better in this image than in a lot of the book images, so maybe it had higher exposure. Underexposed = whiter image; Overexposed = darker image
ReplyDeleteThis looks like a right posterior oblique view. The IV foramen on the left appear normal. What I notice is the articulation between C6-7 and C7-T1; C7 looks odd, almost as if it's tilted anteriorly. Compared to the other articulations, the disk space between C6 and C7 is wider anteriorly, and the disk space between C7 and T1 is limited anteriorly, possibly causing a bulging or herniated disk at that level. If that was the case, I would imagine this pt would have sensory and motor changes in the C8 nerve root distribution as well as neck and shoulder pain, either unilaterally or bilaterally. It could just be the oblique view that is throwing me off, but just a guess!
ReplyDeleteI am going to have to agree with most of my classmates in saying that this is an oblique view which provides a good view of the IV foramen and from research looks to be the view of choice for patients with pain or altered sensation in their upper limbs. Due to the fact that his IV foramen appear normal I am going to say that their appears to be a cervical rib which also appears to be fractured in this image causing the pain. Therefore if the fracture is not what is causing his neck/shoulder pain, with a cervical rib you can get thoracic outlet s/s which could be causing the neck/shoulder pain as well. I would also have to agree with Jenna as well though in that they junctions between C6-7 and C7-T1 appear odd as far a disc space and vertebral bodies but like her that could just be that I am not familiar with this image view as well. Therefore, I would probably check into thoracic outlet special tests and asking about temperature changes in the hand, if there are radiating symptoms and where, and if not then I would assume fracture in this case.
ReplyDeleteThis is a posterior oblique view of the cervical spine. There appears to be decreased joint space between C6-7 and C7-T1, but that could be due to the positioning of the patients neck. The data in the upper right-hand corner leads me to believe that the series of x-rays included flexion or extension of some degree. One of the initial things I noticed was the decreased space of the foramina, especially from C2-5. The positioning of C7 and T1 appears to be abnormal, but I’m not sure exactly how to describe it. I feel that in this patient’s case, I would need to see the other c-spine views to make a determination of what the actual diagnosis is.
ReplyDeleteI agree with the posterior oblique view. The first thing I noticed was what looks like a fracture of a cervical rib on the patient's left side. Like my classmates have said this could cause the s/s the patient is complaining of as well as potentially thoracic outlet syndrome due to bilateral cervical ribs.
ReplyDeleteRight posterior oblique view. You can tell by positioning of the head.
ReplyDeleteLooks like he has a broken 1st rib.
Probably had signs/symptoms mimicking/related to thoracic outlet syndrome, tenderness with palpation, limited shoulder ROM due to pain, pain maybe with breathing forcefully. Hopefully nothing has punctured internal structures surrounding this area (subclavian artery, brachial plexus, top of the lung).
Direct contact may have caused this, MVA or contact sports.
I believe this a L posterior oblique view. When I first looked at the image, what caught my attention was the L rib fracture. After staring at the image and counting vertebrae, I think there is a chance this patient has bilateral cervical ribs, as everyone else has mentioned as well. I think it possible this patient may complain of pain with breathing (both inspiration and expiration) due to the movement of the ribs and chest. Because of the cervical ribs, it is probable the patient has thoracic outlet syndrome. I would expect a + Roos' test and complaints of sharp, burning, or aching pain in the neck or down the arm into the hand due to the involvement of the brachial plexus and subclavian artery/vein.
ReplyDeleteI agree with many of my classmates; it looks like he may possibly have a fracture of his left cervical rib. This could be the cause of his shoulder and neck pain. I would also guess that he has radicular signs and symptoms down his left arm from the cervical rib and fracture compressing on arteries and nerves. This injury would be more common with a traumatic injury. But I am guessing they took this oblique view because of radicular s/s and they wanted to view the intervertebral foramina to assess for bony encroachment on the spinal nerves.
ReplyDeleteThis image is a R oblique view which was possibly taken due to suspension of narrowed intervertebral foramina encroaching on spinal nerves due to subjective complaints of radicular signs and symptoms. Upon viewing the radiograph, the presence of the anomaly of bilateral cervical ribs is seen with a fracture of the L. Loss of cervical lordosis is noted as well. This injury was most likely due to trauma and that would be another reason to take a radiograph. Symptoms of a fractured cervical rib may include neurologic signs due to compression of the brachial plexus (pain in shoulder/neck, aching in arm/hand, numbness and tingling especially if only L-sided) or vascular due to compression of the arteries/veins below the clavicle (pain and swelling in arm, throbbing, pallor).
ReplyDeleteThis is a right posterior oblique view. The intervertebral joint spaces were the first thing I noticed on the film. The intervertebral joint spaces of the upper and mid cervical vertebral bodies appear normal; however, there appears to be decreased intervertebral joint space at C6-C7 and C7-T1. Also, the vertebral body of C7 does not seem to be correctly aligned with that of T1; it appears more anterior. This could indicate degenerative changes or a possible slippage of the vertebral body forward on T1. Decreased intervertebral joint space would likely cause irritation of the C7 and T1 nerve roots which would lead to patient report of numbness/tingling and pain in the C7 and T1 dermatomes; with compression of the nerve roots, the patient may have some weakness in the muscles innervated by C7 and T1. After reading what classmates had written, I noticed the fractured rib on the left. I also thought it was interesting that the hyoid bone and soft tissue are easily visible on this radiograph; the anterior soft tissue appears abnormal compared to the posterior soft tissue.
ReplyDeleteAs most of my classmates have mentioned, I would consider this to be a right posterior oblique view. I noticed the the cervical ribs and the fracture on the left, as well. There appears to be increased density on the anterior aspect of the cervical region. I would be concerned with the fractured rib causing significant irritation to the bracial plexus, even possibly causing a lesion.
ReplyDeleteTo kind of go along with what Lindsey was saying with the C7 being more anterior (especially due to attachment of R first rib being where it is), I think that this could have been due to some sort of compression fracture of anterior vertebral body of C7. This could have occurred following MVA or some other sort of traumatic injury as stated above by others. I don't think the alignment abnormality is due to degenerative changes as patient is only a 21 year old.
ReplyDeleteThis is an oblique radiograph demonstrating a cervical rib at C7. I think that this patient has s/s of TOS and they were probably taking a radiograph to further assess this patient as he is 21 years old and probably has radicular symptoms due to compression of the brachial plexus as well as cervical/neck/R shoulder pain.
ReplyDeleteI am going to have to agree with my classmates that this is a right posterior oblique view of the c-spine. This view allows you to assess the intervertebral foramen, which may have been the purpose of the radiographs since the patient was complaining of neck and shoulder pain. The x-rays also show bilateral cervical ribs, with the left showing some sort of deformity. I think the cause of his neck/shoulder pain is secondary to the cervical ribs causing thoracic outlet syndrome. Various special tests, such as Roo's, Adson's, or Allen's can be utilized to further help diagnose what is going on.
ReplyDeleteI believe this is a left anterior oblique view of the c-spine. The patient has Bilat cervical ribs, but there appears to be a possible fracture of the L rib as there is a radioluscent area in the midportion of the rib with irregular/jagged borders. The radiograph would seem to suggest possible TOS due to the cervical ribs, but the IV foramina do not appear to be narrowing or obstructed. With the L rib fracture, there could be some serious medical conditions if the subclavian artery and or vein have been affected by the fractured bone.
ReplyDeleteI think that this is a left anterior oblique view of the cervical spine. With this view you can assess the intervertebral foramen which is a possibility of why the radiograph was taken in the first place due to the patient's symptoms. Upon examination of the radiograph, there appears to be fracture of the left cervical rib which could be causing signs and symptoms of thoracic outlet syndrome.
ReplyDeleteThis image is an oblique view of the c-spine, not sure if R or L side. Typically, this type of radiograph is taken to better view the intervertebral foramina, uncovertebral joints, facet joints, and pedicles of the cervical vertebrae. Right off the bat I noticed the decreased intervertebral space of C6-T1(ish), unusual for a 21 y.o. These radiographs were taken secondary to his neck/shoulder pain, just to rule anything out. This patient also has bilat cervical ribs, with a fx of the L side. This could cause signs of TOS (either neurogenic or vascular problems). Further special testing would be warrented, such as Adson's, Roos...
ReplyDeleteLike the rest of my classmates have pointed out, this looks like a right posterior oblique view. The patient appears to have bilateral cervical ribs, and appears to have a left rib fracture. Some more serious diagnoses associated with 1st rib fractures could include pneumothorax, subcutaneous emphysema, and a collapsed lung. These other diagnoses would require more views assess.
ReplyDeleteThis radiographic image is a right posterior oblique view of the cervical spine. This view shows each cervical intervertebral foreamen and allows the practitioner to asses whether the foreamen space is normal or decreased which might be causing this patients shoulder and neck pain, but this view shows normal intervertebral foreamen spacing. Like my classmates have stated this view shows cervical ribs and the Left 1st rib looks to have a fracture. With the fracture the patient would demonstrate acute severe pain to palpation or ultrasound over the first rib. If the fracture isn’t the cause of the patients pain then it is probably due to Thoracic Outlet Syndrome from the cervical rib. I would test for Thoracic Outlet Syndrome with Roos, Adson’s, Costoclavicular, and Wright’s tests.
ReplyDeleteThis radiograph is a R posterior oblique view of the cervical spine. This radiographic view is great for the assessment of intervertebral foramen. It would appear that there is decreased intervertebral foramen space that could potentially put pressure on exiting nerves. There appears to be a fracture of the L cervical rib. This radiograph would have been taken to rule out bony involvement that could potentially lead to radiating symptoms. If there was compression at lower cervical spine, the patient could experience hand and arm weakness accompanied by paresthesia.
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ReplyDeleteThis looks like a right posterior oblique view of the c-spine, which allows you to see the left intervertebral foramina. I keep counting the cervical vertebrae, and to me, it looks like he has an anomaly of a rib connecting to C7, which could be producing his neck and arm pain secondary to compression of anterior nerves and vessels. If I counted wrong, here are some other thoughts:
ReplyDeleteThe IV space between C6-T1 seems to be diminished, which can lead to cervical nerve root compression and symptoms of neck and shoulder pain. However, the decreased joint space is inconsistent with his young age so maybe there is some type of c-spine fracture present that I am missing (or even an extra rib). I don't think there is a rib fracture because there probably would have been reports of pain with inspiration. I also noticed that this young male seems to have a very muscular physique in his upper traps and pecs. Men with this body type tend to adopt a posture with a forward head and rounded shoulders that can produce symptoms of neck and shoulder pain and due to the compression of anterior structures, eventually lead to thoracic outlet syndrome. Some special tests for TOS include Adson's, Roo's,or Allen's.
p.s. you should give this picture to the author of the book because it's much more defined than the examples they have :)
This is a right posterior oblique view of the c-spine. Oblique views allow you to see the intervertebral foramina, uncovertebral joints, facet joints, and pedicles. In this position, you see the left intervertebral foramina. I think this view shows narrowed foramina openings at C5-C6, C6-C7, which could cause some nerve irritation and nerve s/s in the C5, C6, C7 nerve distributions, causing most of this patient's s/s. I think there is also decreased disc space between the C5-C6, C6-C7 vertebral bodies too. Some of this patient's s/s could be the result of the cervical ribs at C7, compressing nerves and vasculature in the anterior region of the neck.
ReplyDeleteI first noticed decreased intevertebral joint spaces between C5-T1. Since the patient is only 21 years old, I’m not convinced that he has degeneration of his joints yet, but without knowing his history, it could be a possibility. It’s possible the nerve roots of C5-T1 may be compressed since there’s some narrowing of the intervertebral joints, which would present as radicular symptoms in his arm. It also appears that there’s a fracture of the cervical rib on the left.
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ReplyDeleteAs mentioned by most classmates, I also believe this is a R posterior oblique view of the cervical spine. The first aspect of this radiograph I noticed was the presence of cervical ribs, as well as a possible fracture of the L cervical rib. I would expect this patient to have no symptoms or mild s/s similar to thoracic outlet syndrome prior to the fracture due to the compression the cervical ribs would place on the brachial plexus and surrounding vasculature. After the fracture, these s/s may significantly increase and the pt may have some local swelling associated with this. There is also some decrease in disc/joint space at the lower aspects of the cervical spine. This would also lead to some radiculopathy s/s. So, it is possible that this patient would present with both thoracic outlet as well as radiculopathy s/s. After reading a few research articles on isolated fracture of the cervical ribs, one of the main causes I found was carrying heavy backpacks. Because this is a 21 year old male, it is likely that this could have been the cause of the cervical rib fracture.
ReplyDeleteAgain excellent comments. You are right that this is a very nice image. The image is a what I believe to be a right posterior oblique view demonstrating a fractured cervical rib. He does have these bilaterally. I agree with you that the image has to also show the hyoid bone. He definitely has pain with neck or shoulder motions. I believe he was injured lifting weights.
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