Ross Hauser, MD. Reviews of Diagnostic Imaging Technology for Cervical Spine Instability

Ross Hauser, MD. Reviews of Diagnostic Imaging Technology for Cervical Spine Instability

The structural and clinical effects of upper and lower cervical instability and whiplash injury can be readily observed and quantified with advanced imaging technology. These new technologies and the resultant understanding of the biomechanics and neuropathology of cervical instability and whiplash injuries are of critical importance in the treatment of these injuries and in proving their existence in the medical-legal realm. These imaging modalities are readily available. However, analysis of the results is a timely and complex task. These modalities are as follows:

Cervical Digital Motion X-ray (C-DMX)

Cervical Digital Motion X-ray (C-DMX) – This modality is essentially a video-fluoroscopic x-ray movie of the spine in motion. The procedure is completed with a device resembling a conventional C-arm. However, far less radiation is utilized than theoretically would be emitted with a conventional C-arm, due to the use of digital processing technology.

A DMX of the spine allows for a continuous and detailed examination of cervical spinal movement.  DMX allows unrestricted assessment of C0-C7 motion in multiple dimensions including sagittal, rotational, and frontal planes. DMX studies typically include moving the head and neck through protraction, retraction, flexion, extension, rotation, and lateral flexion; while observing in real-time, the motion of the cervical vertebrae from C0-C7.

The DMX studies show the functional integrity of the ligaments in the cervical spine, specifically the anterior and posterior longitudinal, supraspinous, interspinous, ligamentum flavum, facet capsular ligaments, transverse, and alar ligaments. Conventional cervical spinal X-rays are static views of the spine as a snapshot in time and, perforce, cannot evaluate the spine in real-life motion. The DMX is a comprehensive movie of the cervical spine in all axes of movement and includes the open-mouth odontoid view in motion, which is the critical view of the C1-C2 vertebral relationship during lateral flexion.

The digital motion x-ray is explained and demonstrated below.

Critical relationships observed and quantified in the DMX analysis include:

DMX Facet relationships and ligamentous instability, expressed as facet gapping in cervical flexion in oblique and AP spinal views

Foraminal compression during oblique flexion-extension views

DMX Anterolisthesis (forward slip) and retrolisthesis (posterior slip) in flexion and extension.

DMX demonstrating C1 lateral flexion and extension sequences

In this image, the caption reads Digital Motion X-ray demonstrating severe bilateral atlantoaxial (C1-C2) instability with open mouth view and lateral neck flexion.

In this image the caption reads Digital Motion X-ray demonstrating severe bilateral atlantoaxial (C1-C2) instability with open mouth view and lateral neck flexion.

Right posterior malrotation of C2

In this image – the caption reads Right posterior malrotation of C2. In this open-mouth view, the C2 spinous process is to the right of the midline in comparison to the dens of the C2. These malrotations, when present chronically, are a sign of C1-C2 instability.

Magnetic Resonance Imaging

Three cross-sections of upper spinal cord MRI.

In this image, the caption explains Three cross-sections of upper spinal cord MRI. In the A Image: Normal MRI. In the B image: Partial blockage of cerebrospinal fluid posteriorly. C image: Complete blockage of cerebrospinal fluid posteriorly.

The Circle of Willis, the convergence of several arteries at the bottom of the brain as seen with an MRI angiogram.

In positional upright weight-bearing MRI, the patient is seated or standing in a specialized MRI scanner. A secondary coil is placed around the target region, such as the cervical spine, and the patient is placed in stressed positions, such as flexion, extension, or lateral flexion. With analogy to the DMX concept, CpMRI is a more “realistic” representation of the target, such as the cervical spine, under physiological conditions. It is not quite “motion,” as the patient must be perfectly still to achieve usable images, but the next option. The pathology that is visualized includes injured alar or transverse ligaments with stress applied to them in lateral flexion, cervicomedullary junctional compression by the mass effect of C1 capsulosynovitis during flexion, and accentuated cervical herniated discs, that are larger and more easily seen during extension.


We hope you found this article informative and it helped answer many of the questions you may have surrounding imaging for cervical spine problems. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form


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