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Female abnormal cervical spine x ray3/21/2024 Is a radiopaque foreign body visible (see Figures 4-11 and 4-14 )? Is air visible in the soft tissues of the neck, indicating potential pneumomediastinum, prevertebral air, esophageal or tracheal perforation, or retropharyngeal abscess? Is the airway narrowed by concentric inflammation, producing a “steeple sign” characteristic of croup (see Figure 4-8 )? Is the airway deviated laterally or narrowed, suggesting an extrinsic mass? As you interpret an x-ray, ask yourself each of these questions, rather than simply looking at the x-ray, and assess the x-ray for relevant findings. Like a focused assessment with sonography for trauma (FAST), the soft-tissue neck film should be assessed by the emergency physician with several specific clinically relevant questions in mind. Portable anterior–posterior (AP) and lateral soft-tissue neck x-rays provide basic information about the airway, as described earlier. What Information Can Be Gleaned from a Portable Soft-Tissue Neck X-ray? How Should It Be Interpreted? Examples include vascular dissections, abscesses, and subtle soft-tissue masses that may not be seen on x-ray. This leaves an array of potentially devastating forms of neck pathology that are poorly assessed with x-ray. Instead, one soft-tissue structure may abut a second soft-tissue structure, and these are indistinguishable on x-ray. Unfortunately, many of the soft-tissue abnormalities of interest to us as emergency physicians may not involve such a contrast. For this reason, x-rays can demonstrate abnormal soft-tissue air ( Figures 4-3 to 4-5 ), deviation or compression of normal air-filled structures (the trachea particularly) ( Figures 4-3 and 4-6 to 4-10 ), air–fluid levels suggesting abscess, and radiopaque foreign bodies ( Figures 4-11 to 4-15 ), as all of these involve a contrast between two key tissue densities. When two tissues of different density abut one another, the transition is clear. As we discuss in detail in Chapter 5 with regard to chest x-ray, two adjacent structures with the same basic tissue density are indistinguishable on x-ray no border is seen separating them. X-ray relies on differentiation of adjacent structures using four basic tissue densities: air, fat, water (which includes soft tissues, both solid organs such as muscle and fluids such as blood), and bone (sometimes called metal density ). Plain x-ray ( Figures 4-1 and 4-2 ) provides limited information about the soft tissues of the neck. Fluoroscopy is discussed later with regard to esophageal pathology. First we consider some general principles regarding the available imaging modalities: x-ray, CT, ultrasound, and MRI. Some soft-tissue neck abnormalities are best assessed with neither x-ray nor CT but rather with ultrasound, magnetic resonance imaging (MRI), fluoroscopy, or techniques such as bronchoscopy and esophagoscopy. Dilemmas for the practitioner include whether imaging is required and, if so, whether to screen with a limited test such as x-ray, rather than incurring the additional cost and radiation exposure of computed tomography (CT). Instead, the differential diagnosis under consideration should drive the imaging decision, based on expected features of the pathology and the capabilities of each modality. Given the range of potential pathology discussed earlier, it should come as little surprise that no single clinical decision rule can be used to inform decisions for soft-tissue neck imaging. Who Needs Soft-Tissue Imaging? Which Imaging Modality Should Be Used? Imaging of the soft tissues of the cervical spinal cord and ligaments are discussed in Chapter 3. In this chapter, we explore the modalities available for soft-tissue cervical imaging, discuss clinical indications for imaging in a variety of chief complaints, and review some characteristic findings of important pathology, using the figures throughout the chapter. Imaging of the neck often is performed with imaging of the head or chest, as structures passing through the neck extend into these adjacent body regions. Fascial planes connect compartments of the neck with the mediastinum and thoracic prevertebral spaces, posing a risk of spread of infection from the neck to these regions. Remember that referred pain from other regions of the body may present with neck pain, so a broad differential diagnosis should be entertained in formulating an imaging plan. The neck contains vascular, nerve, airway, gastrointestinal, and bony structures, any of which may be the source of pain. Imaging of soft tissues of the neck can be essential in the evaluation of patients with a variety of chief complaints, including neck trauma, ingested or aspirated foreign body, nontraumatic neck pain and swelling, dysphagia and voice change, visible or palpable mass, and central nervous system complaints with possible vascular causes.
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