Info Images Findings Impression Reco/Acuity Case Images View Images / Launch Visage Case Notes History 53 yo male with neck pain after fall. Exam frontal, lateral, odontoid views, flexion and extension views Prior Study none Dicom View Reference Material
Section 1 Submit Findings C441 Findings Technique The craniocervical junction and/or C7-T1 are not entirely included on the exam. Yes No The exam is over or under penetrated. Yes No The exam is limited by overlying structures, bones or soft tissues, body habitus, patient positioning, support devices, or motion. Yes No Prevertebral and paravertebral soft tissues The soft tissues anterior to C1-C7 are widened or the prevertebral fat stripe is not seen. Yes No The paravertebral soft tissues are abnormally widened. Yes No There is calcification, foreign body, abnormal air, or other abnormal density in the prevertebral or paravertebral soft tissues. Yes No Spinal alignment The distance between the basion and the posterior axial line is > 12 mm. Yes No The distance between the basion and the tip of the dens is > 12 mm. Yes No The atlanto-axial joint distance is > 2 mm on the lateral view. Yes No The distance between the dens and the lateral masses of C1 is abnormally asymmetrically widened on an odontoid or AP view. Yes No The lateral mass(es) of C1 abnormally override(s) the articular pillar(s) of C2 on an odontoid or AP view. Yes No The anterior vertebral body line, posterior vertebral body line, articular pillar line, and/or spinolaminar line is/are abnormal. Yes No The articular pillars or lateral masses, lamina, or other posterior elements are rotated or displaced into the spinal canal or the interlaminar clear zone of the spinal canal. Yes No The visualized spinous processes are malaligned on the AP view or distracted on the lateral view. Yes No There is reversal or straightening of the normal lordosis or abnormal angulation/curvature or motion of the cervical spine on frontal, lateral, flexion and/or extension views. Yes No Vertebral bodies, posterior elements, and base of skull There is a fracture or deformity of the base of the skull or occipital condyles. Yes No There is a fracture or deformity of the anterior or posterior arch of C1. Yes No There is a fracture or deformity of the lateral mass(es) of C1. Yes No There is a fracture or deformity of the dens or C2 vertebral body. Yes No There is a fracture or deformity of the pars interarticularis/articular pillars or other posterior elements of C2. Yes No There is a fracture or distraction of a C3-T1 vertebral body, transverse or spinous process, or other posterior element. Yes No There is evidence of an end plate avulsion or other fracture. Yes No There is displacement of a fracture fragment into the soft tissues, spinal canal, or interlaminar clear zone of the spinal canal. Yes No There is anterior wedging or compression of a vertebral body or end plate. Yes No There is evidence of an aggressive disease process manifest as a lytic, sclerotic, or destructive abnormality of a vertebral body, end plate, pedicle, lamina, articular pillar, transverse or spinous process. Yes No There is focal or diffuse abnormal mineralization. Yes No Disc spaces and facet joints There is distraction or focal widening of a disc space. Yes No There is anterolisthesis, retrolisthesis, subluxation, or rotational abnormality of a disc space. Yes No There is widening, rotational abnormality, or displacement of facets at any motion segment (e.g. locked or jumped, perched facets, or fracture dislocation). Yes No There is disc space narrowing with or without erosive or sclerotic changes of the end plates other than from degenerative change. Yes No There is facet joint narrowing or sclerosis other than from degenerative change. Yes No Additional soft tissues and bones (neck, airway, upper thorax, ribs) The included maxillofacial region, thoracic spine, ribs, or other bones of the upper thorax are abnormal. Yes No There is air or a foreign body or other abnormality in the soft tissues of the lower head, neck or upper thorax. Yes No There is an apical mass, thickening, pleural cap or effusion, or pneumothorax. Yes No The airway is narrowed or displaced. Yes No There are post surgical changes of the bones or soft tissues of the lower head, neck, or upper thorax. Yes No There is an abnormality or complication of post-surgical hardware. Yes No N/A There are support lines or tubes in an abnormal position. Yes No Other findings There are degenerative changes or other existing conditions that might be contributing to symptoms which can or should be further evaluated non-emergently. Yes No