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this is sal here again and i'm still here with my good friend Dr maja Devon from Stanford University.

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In the last video we had looked at adequacy of x-rays for the neck, is the x-ray good enough?

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But now, lets assume that we have good x-rays, now what do we look at?

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Dr Devon: The next step is to look at the alignment, so we talk about the A, B, C's

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The A, B, C's of reading a cerebral-spinal film. A starts with Adequacy, that we went over, and the

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second part of A is Alignment.

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Sal: Ok, so we're still in A, I was expecting something with a B...

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Alright, Alignment. Alright, so this looks like this is about alignment.

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This is about Alignment, and there's four lines that we look at. the first is the anterior vertebral

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body line. Ok, AVBL right over there.

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Exactly, and basically what you're doing is trying to draw a smooth line that connects the anterior aspect,

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the front of, all the vertebral bodies, it should be nice and smooth, it's usually curved, and all the

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points should sort of fit on that line; nothing should be off of that line. That would suggest that

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there was a problem there.

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I see, and anterior as you just said means front.

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Exactly. The next line is going to the back of the vertebral body is the Posterior Vertebral body.

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OK, so not the back of the entire vertabrae, the vertebral body, which is this boxy part right in front.

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Exactly. So, same thing, connecting a line up and down, should be nice and smooth as you've drawn it,

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and nothing should fall off that line, no piece of the vertebral body should fall off of that line as

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you've drawn it.

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Alright, sounds good. And then?

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The next is we connect all the spinal laminar junctions. So this is the spinal laminar line, and it's

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where, sort of the lamina connects to the spinous process.

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Spinous process, sounds like we could make a whole video about that...

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Spinous process, if you look at the back of somebody's neck are those little bumps that you can see...

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Oh, ok, so these triangular things right here...

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Exactly

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Oh, ok, so you are just connecting that line, kind of the front of these triangles, the base of these

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triangles, so to speak.

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Exactly.

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OK, then the last one?

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The last line is the spinous process tips. And again, we're just connecting the top, the tip,

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of all the spinous processes, the little bony projections you can see if you look at the back of

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somebody's neck.

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Right, right.

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And these, too, should generally fall in a nice smooth curve.

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Right, and so the general rule is that if any of these aren't aligned the way that we've drawn here,

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it's a problem.

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Exactly, we call it subluxation, or malalignment, or misalignment...

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OK

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And these all suggest that there is a problem there.

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Which is a big deal, because your spinal cord is going through there

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Absolutely! If you look between the green and the blue line, that's where your actual spinal cord runs.

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Right, right, right down there.

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Exactly.

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I see, so you don't want that to get messed up.

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Alright, so let's look at a few of these x-rays and see if we can, or if anything's wrong, if we can

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spot it.

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Actually, Sal, now that you know how to read cerebrospinal x-rays, I'm going to have you look at the

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first x-ray.

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(Laughing) OK, let's see, so now I'm going to get sued for malpractice! Ok, let's see, alright...

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This one over here, so let me just do the first one. Let me just go over what you told me to do.

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So I'm going to do the anterior side of this vertebral body...

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Exactly.

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I'm learning the words, too, talking like a doctor...OK, so I'm going to draw a line here.

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OK, that looks pretty good.

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Yup

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That looks decent, this still looks decent, and I don't know, that doesn't look great, would this count?

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I mean, this looks like it got shifted over a little bit

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Absolutely.

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I mean, it's not like like a huge shifting, but it's enough to, that it's not easy to draw a line, so,

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so I was right?

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You're absolutely right, and in fact sometimes it's very subtle. You picked up a very subtle abnormality,

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but again, even though it's subtle on the x-ray it can be serious for the patient, so you potentially

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saved their spinal cord and their lives by picking up an injury like this.

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OK, very good. So it's literally something as subtle as that is what you're looking for.

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Exactly. Again, it should be a nice smooth line or nice smooth curve, and as you can see,

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at that junction, it's no longer smooth.

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You don't even have to look at the other lines, you just, any one of these, that don't go on a line,

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that's enough, you say, hey, do something else.

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Exactly, and that's a great important teaching point, which is if you see any abnormality

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on a plain film, or on an x-ray like this, you stop, and you protect their cervical spine,

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and then you get a more important study or better quality study like a CT scan.

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Fascinating. Although if I do look here, it does look like we could have done the PVBL

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and it looks like that also is a little off, too.

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Absolutely.

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Well, let's look at a few more.

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Great

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I don't want to focus too much on my first victory...

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Alright, so it's clear that this person is facing this way, I can see their teeth.

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So let's see what we can do here. Can I give it a shot again?

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Please, please-

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So, AVBL looks pretty good. This is, well, that looks close, it looks close...

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I agree, and potentially again, you've got a very keen eye and you might have picked it up,

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but most people might have overlooked that.

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Ok, so let's try the other lines here. So this one is more obvious, this one is more obvious, there

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is kind of a disconnection right over there.

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Exactly, and this is the PVBL, or the posterior verterbral body line, and you can see clearly that line is not smooth, it doesn't connect,

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and so there is a problem right there at that junction.

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Ok, ok, Alright, so we have this last one right over here. Let's see what I can do, I don't want to

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lose my streak...

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Alright, so anterior side, this actually looks pretty perfect, actually.

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And in fact, it is perfect.

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OK, let me try the next lines here.

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This is the Posterior Vertebral body line

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Let me do that in a color that's easier to see, magenta, alright. It looks ok, ok, it looks ok, I mean

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nothing obvious on that line.

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I would say again that you've got the keen eye, but in this particular case, I'd say it's fine.

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Its within the normal range, as we say.

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Ok, and so let me do the base of those triangles. Let me do, so this is a triangle right over here...

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Again, you want to be a nice smooth curve, everything should fall on that curve...

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So this, I would have to be a little bit generous with my curve to make it go to these guys down here.

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Exactly, exactly. And this is the spinal laminar line, this is the third line of alignment, as you can