Cross-Table Lateral C-Spine

Aka: Cross-Table Lateral C-Spine, Lateral Cervical Spine XRay, Lateral C-Spine XRay, Cervical Spine XRay Lateral View Interpretation, Cervical Spine Sagittal View

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II. Indications

  1. Cervical Spine XRay in Acute Traumatic Injury

III. Evaluation: General

  1. Mnemonic: ABCDS
    1. Adequate film and Alignment
    2. Bony landmarks
    3. Cartilaginous space and curvature
    4. Discs
    5. Soft tissue spaces
  2. Anatomy
    1. Odontoid (C2) Lateral
      1. orthoSpineVertebraeCervical2LateralGrayBB88.gifLewis (1918) Gray's Anatomy 20th ed (in public domain at Yahoo or BartleBy)
    2. Vertebra Lateral
      1. orthoSpineVertebraeGrayBB83.gifLewis (1918) Gray's Anatomy 20th ed (in public domain at Yahoo or BartleBy)
    3. Vertebra from above
      1. orthoSpineVertebraeGrayBB82.gifLewis (1918) Gray's Anatomy 20th ed (in public domain at Yahoo or BartleBy)

IV. Evaluation: Adequate film criteria

  1. Visualize all seven Vertebrae (including C7-T1)
    1. Major pitfall: Inadequate visualization of the entire Cervical Spine from C1 to the top of T1
    2. C7-T1 is a common site of Cervical Spine Injury
      1. Visualization of the C7-T1 interface is critical
  2. Maneuvers to enhance view of lower C-Spine C7-T1 (pulling Shoulders down and out of the way)
    1. Pull down on arms during cross-table lateral
    2. Swimmer's View
    3. Cervical Spine CT

V. Evaluation: Alignment

  1. Assessment criteria
    1. Landmarks should line up with <3mm discrepancy
  2. Curvature
    1. Normal lordotic curvature of the Cervical Spine
  3. Landmarks: 4 Aligment Lines
    1. Anterior Vertebral body line
    2. Posterior Vertebral body line
    3. Spinolaminar line (posterior margin of the spinal canal, anterior to spinous process)
    4. Spinous process line
      1. Middle of anterior spinous process lines up C1-C3
  4. Normal variants: Pseudosubluxation of C2 and C3
    1. Normal in children
      1. Related to large occiput altering c-spine positioning in the supine position (cross-table lateral)
      2. Seen in 20-40% of children under age 8 years
      3. Pseudosubluxation may also be seen in up to 14% of children at C3-4
    2. Swishchuk's Line can be used to confirm pseudosubluxation
      1. Spinolaminar line drawn from C1 to C3
      2. C2 spinolaminar line should fall within 1 mm of the C1-C3 line
  5. Abnormal findings
    1. Subluxation of >=3 mm is abnormal
    2. Angulation >11 degrees is unstable

VI. Evaluation: Bony landmarks

  1. Visualize C1 anterior and posterior arch
  2. Trace odontoid outline from C2 Vertebrae for defects
  3. Trace the ring-like appearance of C2 Vertebral body (lateral masses)
  4. Trace unbroken outline of each Vertebrae
  5. Evaluate the alignment of the articulating facets and pedicles (immediately behind the Vertebral body)
    1. Facets have parallel aligment (roof shingle-like) without overlap
    2. Small linear space maintained between each facet
    3. Overlap may suggest possible facet dislocation
  6. Spinous process
    1. Each level of spinous process should parallel the adjacent superior and inferior spinous process
    2. Splaying out between spinous processes may suggest Fracture

VII. Evaluation: Cartilaginous Space

  1. Predental space (atlanto-dens interval, anterior atlanto-odontoid space)
    1. Atlas anterior margin (C1) to Odontoid process or dens (C2)
  2. Normal values
    1. Adult: <=3mm
    2. Child: <=4-5mm

VIII. Evaluation: Discs

  1. Assess symmetry of disc spaces
  2. Observe for avulsion Fractures off the Vertebral bodies
    1. Superior avulsion Fractures are stable
    2. Inferior avulsion Fractures are unstable

IX. Evaluation: Soft Tissue spaces

  1. Normal Fat tissue stripe <3 mm
  2. Maximum normal width of soft tissue stripe anterior to Vertebral bodies (Mnemonic: 6 at 2 and 22 at 6)
    1. Normal C1 stripe <10 mm
    2. Normal C2 stripe: <6 mm (less than half Vertebral body width C1-4)
    3. Normal C5-6 stripe: <22 mm in adults, <14 mm in children (approximately Vertebral width C5-7)
  3. Normal Pre-Dens Space (between C1 anterior arch and C2 odontoid)
    1. Abnormally increased space is suggestive of ligamentous instability (e.g. Rheumatoid Arthritis, Downs Syndrome)
    2. Adult: <3 mm
    3. Child: <5 mm

X. References

  1. Ouellette and Tetreault (2015) Clinical Radiology, Medmaster, Miami, p. 42-50
  2. Tubbs and Janicki (2025) Mastering Emergency Imaging, CCME, accessed 8/7/2026

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