1 film critique unit 4 pelvis hips spine including st neck

11

FILM CRITIQUEFILM CRITIQUEUNIT 4UNIT 4

PELVIS HIPS SPINEPELVIS HIPS SPINE

Including ST NeckIncluding ST Neck

1212Hands

Note

Intertrochanteric fx

1515End of

Prosthesis

Device

Not seen

2222Subcapital fxSubcapital fx

3838Intertrochanteric fxIntertrochanteric fx

4242

Osteoporosis Osteoporosis

4545c/o Lt buttock painc/o Lt buttock pain

4949

Osteo arthritisOsteo arthritis

5050Pagets sarcomaPagets sarcoma

5959

Name of “view” for acetabulum?Name of “view” for acetabulum?

6060

This is not a

Axiolateral HIP !

What is it?

INF/SUP Shoulder

6161No gonad shieldNo gonad shield

6666DISCLOCATED SI JT CADISCLOCATED SI JT CA

6969C-1 ring fxC-1 ring fx

7676

Jefferson’s fxJefferson’s fx

a burst fx of C-1 –atlas = results from compression of the C.SP – may also be associated with fx of C-2 (axis)

May or may not involve the transverse ligament

7777Rheumatoid arthritisRheumatoid arthritis

8383Hangmans fxHangmans fx

8686

Ankylosing Spondylitis Ankylosing Spondylitis

8888

Hangman fxHangman fx

100100

101101

102102

103103

pointing to the superior and inferior vertebral notches on adjacent vertebrae. The pedicles form pointing to the superior and inferior vertebral notches on adjacent vertebrae. The pedicles form the intervertebral foramina; however, the atlas does not have pedicles nor does it form any the intervertebral foramina; however, the atlas does not have pedicles nor does it form any

intervertebral foraminaintervertebral foramina

104104

torticolistorticolis

105105Spaces not well seen -calcification of ligaments

106106

107107

108108

109109

110110

111111

112112

113113

114114

115115

116116

117117

118118

119119

120120

121121

122122

123123

CA mets transverse processCA mets transverse process

124124

125125

126126

127127

128128

129129

fxfx

130130

131131

132132

133133

134134

135135

136136

137137

138138 A body E transverse process D pedicle O superior articular

facet, left P pars

interarticularis, left R inferior articular

facet, left I apophyseal

(interfacetal) joint, left V disk space

139139

140140

141141

142142

Calc disc comp fx osteopCalc disc comp fx osteop

143143

144144

145145

146146

147147

148148

149149

150150

Facets distroyed

151151

152152

153153

spondylolithesisspondylolithesis

154154

155155

spondylolythesisspondylolythesis

156156

sacralizationsacralization

157157

158158

spurringspurring

159159

“CAGE” POST OP FOR HERNIATED DISK

160160

161161

SPINE CRITIQUESPINE CRITIQUEadditional informationadditional information

for Traumafor Trauma

Copyright -2006 Nicholas Joseph Jr. Copyright -2006 Nicholas Joseph Jr. www.ceessentials.net/. www.ceessentials.net/.

162162 Trauma imaging of the cervical spine has specific Trauma imaging of the cervical spine has specific

diagnostic criteria that must be met in order to properly diagnostic criteria that must be met in order to properly evaluate each patient. In addition to these radiographic evaluate each patient. In addition to these radiographic standards, there are patient care standards that are standards, there are patient care standards that are practiced as spine precautions. For trauma imaging the practiced as spine precautions. For trauma imaging the patient presents on a spine board and in a cervical patient presents on a spine board and in a cervical collar. Besides spine precautions there may be collar. Besides spine precautions there may be abdominal and pelvic precautions, and even precautions abdominal and pelvic precautions, and even precautions for extremities. Before aggressively imaging the spine for extremities. Before aggressively imaging the spine the radiographer should get a good understanding of the the radiographer should get a good understanding of the patient’s condition and their trauma score. Obviously you patient’s condition and their trauma score. Obviously you would not think of raising the arms to get a Swimmer’s would not think of raising the arms to get a Swimmer’s view on a patient with bilateral humerus and shoulder view on a patient with bilateral humerus and shoulder fractures. There are alternative methods for imaging fractures. There are alternative methods for imaging these patients, mainly computerized tomography. But these patients, mainly computerized tomography. But when requested, the standard views of the cervical spine when requested, the standard views of the cervical spine are the horizontal beam lateral and Swimmer’s view, AP, are the horizontal beam lateral and Swimmer’s view, AP, and open-mouth odontoid view.and open-mouth odontoid view.

163163 The horizontal beam lateral is performed on every trauma patient presented with a cervical spine request. Until proven otherwise it is assumed that there is a vertebral fracture or dislocation. Both a lateral and a horizontal beam Swimmer’s view are made to completely evaluate the entire cervical spine and cervicothoracic junction. The lateral view is generally the first image taken because it provides the most information about the spine quickly. In some institutions this view is requested as a portable survey. Others will stabilize the patient and bring them to the radiology department to complete all radiographic images at one time. Whatever the institutional procedure the lateral view is always a part of the trauma spine survey.

The lateral is followed by an AP view that may include the open-mouth odontoid view on patients that are conscious and not intubated. While these views are usually sufficient to evaluate the cervical spine the radiologist or emergency room physician may ask for additional views to complete the survey.

164164Diagnostic Criteria for Imaging the Horizontal Beam Lateral Diagnostic Criteria for Imaging the Horizontal Beam Lateral

Cervical SpineCervical Spine

With the patient on the spine board align the mid-sagittal plane (MSP) perpendicular to the horizontally directed central ray (CR).

Do not pull on the shoulders of a trauma patient; do bring the arms down to their side and the shoulders relaxed and back into the spine board.

All seven cervical vertebrae, and the apophyseal joints of C7/T1, and their posterior quadrilateral architecture must be demonstrated.

A Swimmer’s view may be needed if the three contour lines (anterior and posterior contour lines and laminospinal line) cannot be drawn throughout the entire cervical and first thoracic vertebrae.

Soft tissues such as the retropharangeal space and airway should be visible on the radiograph without using a "hot light."

165165

166166

167167

168168

169169

170170

Has the diagnostic criteria Has the diagnostic criteria for this horizontal beam for this horizontal beam lateral radiograph been lateral radiograph been fulfilled? fulfilled?

What would you suggest What would you suggest to improve the quality of to improve the quality of this film and achieve the this film and achieve the diagnostic standard for a diagnostic standard for a lateral cervical spine lateral cervical spine view? view?

171171 This is a good survey film of the cervical spine; however, there are a

few good points and some concerns about this image that need to be corrected: Cervical vertebrae one through seven are easily demonstrated on this

radiograph. The soft tissue shadows anterior to the spine, like the retropharyngeal

space and airway, are present and adequately visualized. Vertebrae C1, C2, C7, and T1 are underpenetrated affecting a diagnosis

of a subtle fracture. The contrast scale is too high as the density anterior to the airway matches background density.

Because the image is under penetrated through C7/T1 junction, the apophyseal joints of C7/T1 are not adequately visualized.

The three contour lines cannot be drawn through C7/T1; therefore, alignment of the cervical spine upon the thoracic spine cannot be completely evaluated.

This radiograph should be repeated. A repeat of this view with penetration of C1, C2 and C7/T1 should be made. Include this picture with the set of films that completes the diagnostic criteria for the lateral cervical spine.

172172

173173

This is a good radiograph in that C1-T1 are This is a good radiograph in that C1-T1 are demonstrated, their apophyseal joints, and demonstrated, their apophyseal joints, and posterior quadrilateral architecture: posterior quadrilateral architecture:

Notice however, that the patient is intubated and Notice however, that the patient is intubated and motion from the ventilator compromises subject motion from the ventilator compromises subject detail. A shorter exposure time using a higher detail. A shorter exposure time using a higher mA would have reduced this motion. Also having mA would have reduced this motion. Also having the respiratory therapist mechanically hold the respiratory therapist mechanically hold ventilation during the exposure is recommended. ventilation during the exposure is recommended.

The safety pin holding the endotracheal tube The safety pin holding the endotracheal tube should be moved more anterior or replaced with should be moved more anterior or replaced with tape. tape.

174174

175175This picture demonstrates why pulling This picture demonstrates why pulling down on the shoulders of a trauma patient down on the shoulders of a trauma patient for imaging is contraindicated. for imaging is contraindicated.

The airway and other anterior soft tissues The airway and other anterior soft tissues are not visualized due to over collimation. are not visualized due to over collimation.

With this type of injury, more of the base of With this type of injury, more of the base of the skull should have been included. the skull should have been included.

Only 6 vertebrae are demonstrated. C7/T1 Only 6 vertebrae are demonstrated. C7/T1 junction cannot be evaluated. junction cannot be evaluated.

Rather than repeating the view, consult Rather than repeating the view, consult with the radiologist about a CT scan.with the radiologist about a CT scan.

www.ceessentials.netwww.ceessentials.net/ article20.html/ article20.html

176176

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180180

If the technologist had pulled down on the patient’s shoulders to image this person’s spine, paralysis may have occurred.

181181atlantooccipital joints atlantooccipital joints the atlantooccipital joints formed by the condyles of the occipital bone and the the atlantooccipital joints formed by the condyles of the occipital bone and the

superior articular processes of the atlas.superior articular processes of the atlas.

182182

183183 All 7 Cervical vertebrae are well demonstrated; however, All 7 Cervical vertebrae are well demonstrated; however,

the three contour lines cannot be visualized through the the three contour lines cannot be visualized through the 1st thoracic vertebra. Remember, part of the requirement 1st thoracic vertebra. Remember, part of the requirement of a good lateral is evaluating the relationship of the of a good lateral is evaluating the relationship of the cervical spine to the thoracic spine. cervical spine to the thoracic spine.

The apophyseal joints at C7/T1 can be seen but is too The apophyseal joints at C7/T1 can be seen but is too opaque to make a diagnosis. This is due to the thickness opaque to make a diagnosis. This is due to the thickness of both shoulders the central ray (CR) must pass of both shoulders the central ray (CR) must pass through. through.

To complete this study a more penetrated lateral that To complete this study a more penetrated lateral that shows detail through the apophyseal joints at C7/T1, or a shows detail through the apophyseal joints at C7/T1, or a Swimmer’s view should be added. Swimmer’s view should be added.

It is not clear if this is a trauma image since it has the It is not clear if this is a trauma image since it has the characteristics of an upright film. Nevertheless, the characteristics of an upright film. Nevertheless, the pharyngeal structures and airway must be seen on all pharyngeal structures and airway must be seen on all cervical spine radiographs. cervical spine radiographs.

184184

What do you think is What do you think is good about this good about this radiograph? radiograph?

What do you think is What do you think is needed to make this needed to make this image part of a image part of a completed lateral completed lateral cervical spine study? cervical spine study?

185185 This lateral is well positioned. Notice that the mandibular This lateral is well positioned. Notice that the mandibular

condyles are superimposed on this trauma lateral view. condyles are superimposed on this trauma lateral view. All apophyseal joints are superimposed, and the All apophyseal joints are superimposed, and the

posterior quadrilateral architecture of all cervical posterior quadrilateral architecture of all cervical vertebrae can be evaluated. vertebrae can be evaluated.

The junction of C7/T1 is seen, but is not adequately The junction of C7/T1 is seen, but is not adequately penetrated. It is these almost good radiographs that abut penetrated. It is these almost good radiographs that abut against the line of malfeasance. against the line of malfeasance.

The image is good for the pharyngeal shadow and The image is good for the pharyngeal shadow and airway. An appropriate amount of part collimation is also airway. An appropriate amount of part collimation is also seen. seen.

To complete this study a more penetrated lateral that To complete this study a more penetrated lateral that shows detail through the apophyseal joints at C7/T1, or a shows detail through the apophyseal joints at C7/T1, or a Swimmer’s view should be added. Swimmer’s view should be added.

186186

Would you pull down Would you pull down on this patient’s on this patient’s shoulders to see shoulders to see C7/T1? C7/T1?

Why or why not? Why or why not?

What is missing from What is missing from the diagnostic criteria the diagnostic criteria on this radiograph? on this radiograph?

187187 No! Never pull down on the shoulders of a trauma No! Never pull down on the shoulders of a trauma patient!patient!

Notice the bilateral jumped facets at C6/C5. Notice the bilateral jumped facets at C6/C5. The technologist does not need to be overly aggressive The technologist does not need to be overly aggressive

in this scenario; a consultation with the radiologist may in this scenario; a consultation with the radiologist may be the best alternative after attempting a single be the best alternative after attempting a single Swimmer’s view. Swimmer’s view.

Include an overlapping Swimmer’s view of T1/C7 thru C5 Include an overlapping Swimmer’s view of T1/C7 thru C5 to complete this study. If this fails to give good images, to complete this study. If this fails to give good images, then a CT scan may be done following consultation with then a CT scan may be done following consultation with the radiologist. the radiologist.

The three contour lines must be seen through T1 to The three contour lines must be seen through T1 to complete the diagnosis. complete the diagnosis.

The position marker should never obscure soft tissues, The position marker should never obscure soft tissues, and the anterior skin line should be visualized when and the anterior skin line should be visualized when evaluating the traumatic cervical spine. Air in the neck evaluating the traumatic cervical spine. Air in the neck fascia could indicate trauma elsewhere. fascia could indicate trauma elsewhere.

188188

If this was your If this was your patient, and this is the patient, and this is the image you got on image you got on your CTL trauma your CTL trauma cervical spine view, cervical spine view, what would you do what would you do next? next?

189189

190190 We’ve all had this type of difficult to image patient. Here We’ve all had this type of difficult to image patient. Here

only three proximal vertebrae are demonstrated on the only three proximal vertebrae are demonstrated on the lateral view. This lateral and two Swimmer’s views bring lateral view. This lateral and two Swimmer’s views bring home the point that you can shoot a lot of radiographs, home the point that you can shoot a lot of radiographs, but unless you can meet the diagnostic criteria for but unless you can meet the diagnostic criteria for evaluating the spine your mission is incomplete. evaluating the spine your mission is incomplete.

Since pulling down on the shoulders of this patient is Since pulling down on the shoulders of this patient is contraindicated, two Swimmer’s views were attempted contraindicated, two Swimmer’s views were attempted with marginal results. with marginal results.

Ultimately, only a CT scan will be able to contribute Ultimately, only a CT scan will be able to contribute information sufficient for diagnostic clearance of this information sufficient for diagnostic clearance of this patient’s spine. But what is important here is to inform patient’s spine. But what is important here is to inform the radiologist when you cannot achieve the diagnostic the radiologist when you cannot achieve the diagnostic criteria for plain film interpretation without excessive criteria for plain film interpretation without excessive repeat radiographs on this patient. Let the physician repeat radiographs on this patient. Let the physician make the judgment call on what to do beyond your make the judgment call on what to do beyond your reasonable attempts to get good images. reasonable attempts to get good images.

191191

What is your critique What is your critique of this radiograph? of this radiograph?

What would you do if What would you do if your patient refuses your patient refuses to remove their to remove their earrings, necklace, earrings, necklace, etc? etc?

192192

193193

194194 Yes this is a good radiographic decision and resulting Yes this is a good radiographic decision and resulting image. The so-called shoot through lateral is a more image. The so-called shoot through lateral is a more penetrated radiograph with excessive radiographic penetrated radiograph with excessive radiographic density and penetration through the part. In the density and penetration through the part. In the picture to the left we see that the apophyseal joints of picture to the left we see that the apophyseal joints of C7/T1 are clearly visible, the posterior bony C7/T1 are clearly visible, the posterior bony quadrilateral architecture of C7 and T1 are well quadrilateral architecture of C7 and T1 are well demonstrated. The three contour lines: anterior, demonstrated. The three contour lines: anterior, posterior, and laminospinal can be drawn through T1. posterior, and laminospinal can be drawn through T1.

The picture to the right is a magnification through the The picture to the right is a magnification through the area of C7/T1. Notice the rib attachment to T1 and area of C7/T1. Notice the rib attachment to T1 and the well-penetrated apophyseal joints of C7/T1. the well-penetrated apophyseal joints of C7/T1.

This view is actually more diagnostic than its more This view is actually more diagnostic than its more commonly done cousin the Swimmer’s view because commonly done cousin the Swimmer’s view because the humerus does not overshadow the spine. the humerus does not overshadow the spine.

195195

What could be done What could be done to make it a better to make it a better picture? picture?

196196 The most obvious observation is the earrings that should The most obvious observation is the earrings that should have been removed. Don’t try to get by with leaving have been removed. Don’t try to get by with leaving earrings and glasses on because a repeat film means earrings and glasses on because a repeat film means more exposure to the patient. If they cannot be removed, more exposure to the patient. If they cannot be removed, then tape the ear up as much as possible. then tape the ear up as much as possible.

Tighter collimation for this view could have been applied. Tighter collimation for this view could have been applied. Collimation improves radiographic contrast and reduces Collimation improves radiographic contrast and reduces patient dose. patient dose.

The textile material composing this soft cervical collar The textile material composing this soft cervical collar presents a regular pattern that will be ignored by the presents a regular pattern that will be ignored by the radiologist. radiologist.

This patient is leaning slightly towards the upright bucky, This patient is leaning slightly towards the upright bucky, perhaps for balance. This has caused the apophyseal perhaps for balance. This has caused the apophyseal joints to be slightly tilted so that they are not joints to be slightly tilted so that they are not superimposed. When this view is repeated because of superimposed. When this view is repeated because of the earrings, sit the patient in a chair and reposition for a the earrings, sit the patient in a chair and reposition for a true lateral. The apophyseal joints will be aligned and the true lateral. The apophyseal joints will be aligned and the spacing between the vertebral bodies will be better spacing between the vertebral bodies will be better demonstrated. demonstrated.

197197

What do What do you see you see that is good that is good about this about this radiograph? radiograph?

198198 All seven cervical and all of the 1st thoracic All seven cervical and all of the 1st thoracic

vertebra are seen. Notice the cupola of the lungs vertebra are seen. Notice the cupola of the lungs extending above the thoracic inlet. The cupola is extending above the thoracic inlet. The cupola is seen whenever the entire 1st thoracic vertebrae seen whenever the entire 1st thoracic vertebrae is seen on a lateral view. It is that portion of the is seen on a lateral view. It is that portion of the lung pleura that extends above the superior lung pleura that extends above the superior thoracic inlet. thoracic inlet.

Also important are the apophyseal joints and Also important are the apophyseal joints and posterior quadrilateral architecture of each posterior quadrilateral architecture of each vertebra is seen from the occiput to T1. vertebra is seen from the occiput to T1.

The three contour lines can be easily drawn to The three contour lines can be easily drawn to reference alignment of the entire cervical spine. reference alignment of the entire cervical spine.

199199

Consider this Consider this radiograph of a radiograph of a patient with a history patient with a history for examination of: f/u for examination of: f/u interval changes, C2 interval changes, C2 fracture, check fracture, check alignment. alignment.

Should anything be Should anything be done to improve this done to improve this radiograph? radiograph?

200200 This is an example of a radiograph in which the This is an example of a radiograph in which the

technologist does not need to include all of technologist does not need to include all of C7/T1 like in a trauma survey. C7/T1 like in a trauma survey.

This is a follow up (f/u) film to check alignment of This is a follow up (f/u) film to check alignment of C2 and the stability of the neck brace support. C2 and the stability of the neck brace support.

This is a good lateral by this scenario. When the This is a good lateral by this scenario. When the patient history specifies f/u exam and the level of patient history specifies f/u exam and the level of interest is specified, the diagnostic criteria interest is specified, the diagnostic criteria applies to all vertebrae above the segment, and applies to all vertebrae above the segment, and at least the entire vertebra below the segment. at least the entire vertebra below the segment. However, the most common radiograph practice However, the most common radiograph practice is to include the entire spine on all images. is to include the entire spine on all images.

201201Summary of Swimmer’s view Summary of Swimmer’s view

CritiqueCritique Apophyseal joints of C7/T1 must be demonstrated Apophyseal joints of C7/T1 must be demonstrated

along with the posterior quadrilateral architecture of along with the posterior quadrilateral architecture of all vertebrae. all vertebrae.

The radiologist must be able to evaluate the The radiologist must be able to evaluate the alignment of the vertebrae evidenced by three contour alignment of the vertebrae evidenced by three contour lines through the entire cervical spine and first lines through the entire cervical spine and first thoracic vertebra. thoracic vertebra.

Adequate radiographic technique to evaluate for Adequate radiographic technique to evaluate for fractures. fractures.

Apply your knowledge to each radiograph you Apply your knowledge to each radiograph you take, asking did I meet the diagnostic criteria? take, asking did I meet the diagnostic criteria?

202202

Name this Name this radiographic view. radiographic view.

Does it meet the Does it meet the diagnostic criteria for diagnostic criteria for a lateral cervical a lateral cervical view? view?

Why does it or does it Why does it or does it not meet the criteria? not meet the criteria?

203203

This is a coned Swimmer’s view. It is a This is a coned Swimmer’s view. It is a very good one in fact. Let’s review the very good one in fact. Let’s review the main reasons why it meets the main reasons why it meets the diagnostic criteria for interpretation: diagnostic criteria for interpretation:

The apophyseal joints of C7/T1 are The apophyseal joints of C7/T1 are seen (circle) but could be a little more seen (circle) but could be a little more penetrated. penetrated.

The three contour lines can be drawn The three contour lines can be drawn through the cervicothoracic junction. through the cervicothoracic junction.

The slight motion due to long exposure The slight motion due to long exposure technique did not grossly affect the technique did not grossly affect the diagnostic value of this image. diagnostic value of this image.

Can you see all three points Can you see all three points mentioned above in the radiograph? mentioned above in the radiograph? The posterior ribs, apophyseal joints, The posterior ribs, apophyseal joints, and articular pillars are all seen without and articular pillars are all seen without superimposition on each other. These superimposition on each other. These are the hallmarks of a well-positioned are the hallmarks of a well-positioned Swimmer’s view that is not rotated. Swimmer’s view that is not rotated.

204204

coned down Swimmer’s coned down Swimmer’s view. view.

The white arrow locates the The white arrow locates the first rib and first thoracic first rib and first thoracic vertebra. vertebra. The apophyseal joints of The apophyseal joints of

C7/T1 can be seen. C7/T1 can be seen. The three contour lines can The three contour lines can

be drawn through T2. be drawn through T2. There is good bone detail There is good bone detail

for diagnostic evaluation. for diagnostic evaluation. Can you see all three Can you see all three

points mentioned above points mentioned above in the radiograph? in the radiograph?

205205

What could be done What could be done to improve this to improve this Swimmer’s view? Swimmer’s view?

206206 Notice that the posterior margins of the spine are clipped Notice that the posterior margins of the spine are clipped

because the part is off centered. because the part is off centered. The humeral head of the raised arm does partially The humeral head of the raised arm does partially

obscure anatomical structures; however, not enough to obscure anatomical structures; however, not enough to warrant repeating this view. When positioning for the warrant repeating this view. When positioning for the Swimmer’s view, be sure the shoulder is brought Swimmer’s view, be sure the shoulder is brought downward into the spine board when the arm is downward into the spine board when the arm is extended over the head. extended over the head.

Because of the positioning of the patient, the exact Because of the positioning of the patient, the exact attachment of the 1st is a bit difficult to determine. The attachment of the 1st is a bit difficult to determine. The apophyseal joints and posterior architecture of C7/T1 are apophyseal joints and posterior architecture of C7/T1 are not optimally demonstrated. Rotation of the part is not optimally demonstrated. Rotation of the part is obvious because the posterior ribs overlay the spine. obvious because the posterior ribs overlay the spine. This view should be repeated making the adjustments This view should be repeated making the adjustments mentioned that would improve the image. mentioned that would improve the image.

207207 Two reasons why it is difficult to Two reasons why it is difficult to determine which vertebra is T1, determine which vertebra is T1, underpenetration and/or underpenetration and/or positioning error. In this positioning error. In this radiograph the long spinous radiograph the long spinous process of C7 and the thoracic process of C7 and the thoracic spinous processes cannot be spinous processes cannot be easily seen due to part rotation. easily seen due to part rotation. The patient’s body rotation is The patient’s body rotation is enough to misalign the enough to misalign the apophyseal joints in the region of apophyseal joints in the region of C7/T1. It is almost a guess which C7/T1. It is almost a guess which vertebra is T1. Strive to keep the vertebra is T1. Strive to keep the patient’s mid-sagittal plane aligned patient’s mid-sagittal plane aligned when one arm is raised and the when one arm is raised and the other depressed. other depressed.

Yet, this is an adequate Yet, this is an adequate Swimmer’s view because the Swimmer’s view because the apophyseal joints of C7/T1 are apophyseal joints of C7/T1 are clearly visualized (white circle). clearly visualized (white circle). The alignment of the vertebrae The alignment of the vertebrae superiorly and inferiorly can also superiorly and inferiorly can also be determined. be determined.

208208 Why do some radiologist Why do some radiologist require the full C-spine require the full C-spine Swimmer’s view over the Swimmer’s view over the coned down view? coned down view? Is this an adequate Swimmer’s Is this an adequate Swimmer’s view?view?

Some radiologists prefer the Some radiologists prefer the full C-spine Swimmer’s view full C-spine Swimmer’s view because it is easier to because it is easier to determine where C7/T1 determine where C7/T1 junction is and to assess the junction is and to assess the alignment of the lower alignment of the lower vertebrae, vertebrae,

Image detail particularly of the Image detail particularly of the posterior architecture of C7/T1 posterior architecture of C7/T1 is lost because image detail is is lost because image detail is enhanced by coning or tight enhanced by coning or tight collimation collimation

209209 This is a well-positioned This is a well-positioned

radiograph and optimal radiograph and optimal exposure. But notice that the exposure. But notice that the snap on the gown snap on the gown overshadows a portion of C7 overshadows a portion of C7 and all of the quadrilateral and all of the quadrilateral architecture of C6. This is not architecture of C6. This is not acceptable. Otherwise, this acceptable. Otherwise, this would be a great Swimmer’s would be a great Swimmer’s view since the apophyseal view since the apophyseal joints of C7/T1 are well joints of C7/T1 are well visualized. The seventh visualized. The seventh cervical vertebra is obstructed cervical vertebra is obstructed by the snap, which defeats the by the snap, which defeats the purpose for this view. purpose for this view.

By now you should be pretty By now you should be pretty good at determining which good at determining which vertebra is T1. Did you get it vertebra is T1. Did you get it correct? correct?

210210

Next, observe that the 7th Next, observe that the 7th cervical vertebra has no rib cervical vertebra has no rib attachment, and as its name attachment, and as its name (vertebra prominens) implies, it (vertebra prominens) implies, it has a long spinous process has a long spinous process that is not bifid (white arrow). that is not bifid (white arrow). Note the rib attachment to the Note the rib attachment to the first thoracic vertebra (long first thoracic vertebra (long yellow arrow). yellow arrow).

All apophyseal joints, All apophyseal joints, especially C7/T1 so easily especially C7/T1 so easily seen on this radiograph (short seen on this radiograph (short yellow arrow) must be seen on yellow arrow) must be seen on the Swimmer’s view when is it the Swimmer’s view when is it made. made.

211211

This radiograph is difficult to critique This radiograph is difficult to critique because of the poor radiographic contrast. because of the poor radiographic contrast. A good radiographer can make a good A good radiographer can make a good radiograph even under the most difficult radiograph even under the most difficult patient conditions. patient conditions.

Adequate penetration is demonstrated; but Adequate penetration is demonstrated; but because of the graininess due to technical because of the graininess due to technical factors subject detail is lacking. Increasing factors subject detail is lacking. Increasing the mAs, using high ratio grid, and using the mAs, using high ratio grid, and using tighter collimation will optimize the subject tighter collimation will optimize the subject detail. detail.

To find T1 on this radiograph we must To find T1 on this radiograph we must identify the 1st rib. It has an attachment to identify the 1st rib. It has an attachment to the manubrium at the clavicular notch the manubrium at the clavicular notch anteriorly (white arrow). Just below it is the anteriorly (white arrow). Just below it is the 1st costal cartilage where the 1st rib 1st costal cartilage where the 1st rib attaches. The yellow arrow indicates the attaches. The yellow arrow indicates the first rib and T1. first rib and T1.

The apophyseal joints of C7/T1 are seen The apophyseal joints of C7/T1 are seen but without good subject contrast. The but without good subject contrast. The alignment of the vertebrae can be alignment of the vertebrae can be determined because the positioning is good. determined because the positioning is good.

212212Diagnostic Criteria for Imaging Diagnostic Criteria for Imaging

the AP Cervical Spinethe AP Cervical Spine Align the mid-sagittal plane (MSP) to the vertically directed central Align the mid-sagittal plane (MSP) to the vertically directed central

ray (CR). ray (CR). The CR is angled 15-20 degrees cephalic. The CR is angled 15-20 degrees cephalic. A properly angled CR will open the intervertebral disk spaces and A properly angled CR will open the intervertebral disk spaces and

project the spinous processes near the inferior intervertebral disk project the spinous processes near the inferior intervertebral disk space. space.

All of T1 through C3 must be demonstrated. All of T1 through C3 must be demonstrated. This can be accomplished by extending the chin, or by tube This can be accomplished by extending the chin, or by tube

angulation. angulation. Trauma imaging protocol does not permit the repositioning of the Trauma imaging protocol does not permit the repositioning of the

cervical spine by rotating, extension, or flexion. cervical spine by rotating, extension, or flexion. The lateral margins including the skin lines must be demonstrated. The lateral margins including the skin lines must be demonstrated.

A transverse field size of no less than 6 inches is recommended, A transverse field size of no less than 6 inches is recommended, and the position marker placed 3 or more inches from the cassette and the position marker placed 3 or more inches from the cassette center. center.

Radiographic technique must be adequate to evaluate the vertebral Radiographic technique must be adequate to evaluate the vertebral bodies, spinous processes, articular pillars, and trabecular pattern of bodies, spinous processes, articular pillars, and trabecular pattern of bone. For the AP view the optimal kVp range is between 70-80. bone. For the AP view the optimal kVp range is between 70-80.

213213 The diagnostic standard for the AP The diagnostic standard for the AP

cervical spine view includes: cervical spine view includes: C3 through T1 should be seen C3 through T1 should be seen

when the CR is angled 15-20 when the CR is angled 15-20 degrees cephalic with the spine in degrees cephalic with the spine in a support collar. a support collar.

The lateral margins of the skin The lateral margins of the skin should be included on the image. should be included on the image.

Radiograph density should include Radiograph density should include good penetration of C3 and good penetration of C3 and throughout the spine so that bone throughout the spine so that bone and soft tissues are visualized. and soft tissues are visualized.

Did you notice that the lateral Did you notice that the lateral margins of the film are over margins of the film are over collimated? Important soft tissues collimated? Important soft tissues of the neck and its precervical of the neck and its precervical fascia are important to fascia are important to radiographic diagnosis. This radiographic diagnosis. This radiograph should be repeated. radiograph should be repeated.

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Is this a good Is this a good AP cervical AP cervical spine spine radiograph that radiograph that meets all of the meets all of the diagnostic diagnostic criteria? criteria?

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What could What could be done to be done to improve the improve the quality of quality of this this radiograph? radiograph?

216216 The hairpins should have been removed. The hairpins should have been removed. The exception is made for a trauma patient (e.g. The exception is made for a trauma patient (e.g.

MVA, FALL, etc) in a cervical collar appropriately MVA, FALL, etc) in a cervical collar appropriately strapped to a spine board. In such case an “as strapped to a spine board. In such case an “as is” image should be done first. is” image should be done first.

If this image did not have such a high If this image did not have such a high radiographic contrast C3 could have been radiographic contrast C3 could have been visualized. visualized.

Many technologists have trouble with the proper Many technologists have trouble with the proper kVp setting for the AP view. kVp setting for the AP view.

If the positioning allows for demonstration of C3 If the positioning allows for demonstration of C3 then the radiographic technique should also! A then the radiographic technique should also! A variable mAs with a kVp between 75-80 is variable mAs with a kVp between 75-80 is recommended. recommended.

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218218 Here is an example of the Here is an example of the head being extended too far. head being extended too far. This view resembles a reverse This view resembles a reverse Water’s view for profiling the Water’s view for profiling the odontoid tip (Fuchs). odontoid tip (Fuchs).

Also notice that the Also notice that the radiographic technique is radiographic technique is inadequate. This low contrast inadequate. This low contrast image shows poor bone detail. image shows poor bone detail. In addition good patient In addition good patient positioning, subject detail must positioning, subject detail must be adequate for soft tissues be adequate for soft tissues and bone detail. and bone detail.

Repeat this image with the Repeat this image with the head tilted downward. head tilted downward.

Use a higher ratio grid, or Use a higher ratio grid, or select a technique that allows select a technique that allows for an increase in the mAs of for an increase in the mAs of at least a 15% reduction in kVp at least a 15% reduction in kVp to improve subject contrast. to improve subject contrast. Not using above 80 kVp Not using above 80 kVp initially will be less radiation to initially will be less radiation to the patient than a repeated filmthe patient than a repeated film

219219Diagnostic Criteria for Imaging the Open-mouth Diagnostic Criteria for Imaging the Open-mouth odontoid view of the Cervical Spineodontoid view of the Cervical Spine

Position the patient so that the upper incisors are superimposed Position the patient so that the upper incisors are superimposed over the base of the skull’s external occipital protuberance. This over the base of the skull’s external occipital protuberance. This can be accomplished by placing the acanthiomeatal line can be accomplished by placing the acanthiomeatal line perpendicular to the tabletop. perpendicular to the tabletop.

Align the mid-sagittal plane (MSP) perpendicular to the Align the mid-sagittal plane (MSP) perpendicular to the horizontally directed central ray (CR). The part is positioned for horizontally directed central ray (CR). The part is positioned for non-trauma patients by having them raise or tuck their chin to non-trauma patients by having them raise or tuck their chin to achieve alignment. If the patient is in a cervical collar the CR is achieve alignment. If the patient is in a cervical collar the CR is angled so that it is parallel with the infraorbitomeatal line angled so that it is parallel with the infraorbitomeatal line (IOML). (IOML).

The lateral margins of C1/C2 should be aligned unless there is The lateral margins of C1/C2 should be aligned unless there is pathological reason for its misalignment. The spinous process of pathological reason for its misalignment. The spinous process of the axis should be on the mid-sagittal line. The spacing of the the axis should be on the mid-sagittal line. The spacing of the atlantoaxial joints should be equal. Equal spacing on the lateral atlantoaxial joints should be equal. Equal spacing on the lateral borders of the odontoid process; the tip should be completely borders of the odontoid process; the tip should be completely seen. seen.

Structures demonstrated are: atlantoaxial joints, occipitoatlantal Structures demonstrated are: atlantoaxial joints, occipitoatlantal joints, odontoid process and body of the axis, and lateral joints, odontoid process and body of the axis, and lateral masses and transverse processes of the atlas. masses and transverse processes of the atlas.

220220 In addition to adequately In addition to adequately

visualizing C1 and C2, the visualizing C1 and C2, the following alignments should be following alignments should be meet when positioning the meet when positioning the patient: patient:

The lateral margins of C1/C2 The lateral margins of C1/C2 should be aligned unless there should be aligned unless there is pathological reason for its is pathological reason for its misalignment. misalignment.

The spinous process of the The spinous process of the axis should be on the mid-axis should be on the mid-sagittal line. sagittal line.

The spacing of the atlantoaxial The spacing of the atlantoaxial joints should be equal. joints should be equal.

Equal spacing on the lateral Equal spacing on the lateral borders of the odontoid borders of the odontoid process; the tip should be process; the tip should be completely seen. completely seen.

221221 Notice that this image is poorly Notice that this image is poorly

collimated. There is nothing to collimated. There is nothing to be gained by including the be gained by including the maxillary sinuses! maxillary sinuses!

Secondly, the upper incisors are Secondly, the upper incisors are projected above the base of the projected above the base of the skull. The chin should be tucked skull. The chin should be tucked down (flexed) to line up the down (flexed) to line up the teeth and base of skull. The teeth and base of skull. The acanthiomeatal line should be acanthiomeatal line should be perpendicular to the tabletop. perpendicular to the tabletop. The atlantoaxial joints are not The atlantoaxial joints are not opened because of the poor opened because of the poor positioning. Also notice the positioning. Also notice the rotation of the spinous process rotation of the spinous process and spacing on the lateral and spacing on the lateral borders of the odontoid process. borders of the odontoid process.

222222

223223 Don’t be fooled into thinking that this Don’t be fooled into thinking that this is a good radiograph just because the is a good radiograph just because the anatomy is present. anatomy is present.

The anatomical relationships must be The anatomical relationships must be presented as well. presented as well.

Here is another example of an open Here is another example of an open mouth odontoid view in which the mouth odontoid view in which the head is extended too far back. head is extended too far back.

The chin should be brought down The chin should be brought down until the upper teeth are until the upper teeth are superimposed over the base of the superimposed over the base of the skull (arrows). This will require skull (arrows). This will require bringing the acanthiomeatal line bringing the acanthiomeatal line perpendicular to the tabletop. The perpendicular to the tabletop. The spacing of the atlantoaxial joints is spacing of the atlantoaxial joints is not properly demonstrated. not properly demonstrated.

It is very possible to get a good view It is very possible to get a good view that demonstrates the joint spaces that demonstrates the joint spaces and odontoid process. Unfortunately, and odontoid process. Unfortunately, this view should be repeated.this view should be repeated.

224224 Because of the metal Because of the metal

tooth plate it will be tooth plate it will be difficult to image the difficult to image the odontoid tip. odontoid tip.

Because the alignment of Because the alignment of the teeth and base of the the teeth and base of the skull are adequate skull are adequate repeating this view may repeating this view may not yield the desired not yield the desired result.result.

Instead, bring the head Instead, bring the head down just a little, then down just a little, then lower the tube to about lower the tube to about 20 cm. 20 cm.

Allow the divergence of Allow the divergence of the CR to clear the part. the CR to clear the part. The other option is to add The other option is to add a Fuchs view.a Fuchs view.

225225 Consider that the Consider that the lateral masses are lateral masses are covered by dental covered by dental fillings; your fillings; your positioning becomes positioning becomes even more critical. even more critical.

The chin is tucked The chin is tucked down too much! down too much! Slightly tilt the head Slightly tilt the head backwards. This will backwards. This will help to demonstrate help to demonstrate more of each lateral more of each lateral mass and the odontoid mass and the odontoid tip. tip.

You still may need to You still may need to add a Fuchs view to add a Fuchs view to demonstrate the demonstrate the spacing on each side spacing on each side of the odontoid peg of the odontoid peg

Collimation???Collimation???

Should the image should be repeated!

22622670 degrees for zygos

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Breathing tech

229229

C7 and L1 must be entirely demonstrated to evaluate for subluxation of the thoracic spine.

230230

Poor centering poor contrast / spaces not open

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Because of the chest tube and intubation, the positioning seen here is acceptable.

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238238 It appears there was some difficulty in It appears there was some difficulty in

locating the lumbosacral junction. locating the lumbosacral junction. To find L5/S1 you should remember that To find L5/S1 you should remember that

the iliac crest is at the level of L4. the iliac crest is at the level of L4. This places L5/S1 at approximately 1 inch This places L5/S1 at approximately 1 inch

below this point. Tbelow this point. T there is too much of the lumbar spine there is too much of the lumbar spine

demonstrated and too little of the sacrum.demonstrated and too little of the sacrum. The collimation is poor The collimation is poor This radiograph must be repeated using the This radiograph must be repeated using the

radiological landmarks for locating L5/S1. radiological landmarks for locating L5/S1. The radiographic exposure technique The radiographic exposure technique

should also be changed so that the part is should also be changed so that the part is well penetrated. This is a high contrast film well penetrated. This is a high contrast film having poor penetration of the lumbosacral having poor penetration of the lumbosacral junction. junction.

239239For L5- S1 – is it acceptable?For L5- S1 – is it acceptable?

240240 part is not centeredpart is not centered it is clippedit is clipped metal snaps are present metal snaps are present The patient is not The patient is not

positioned in a true positioned in a true lateral. lateral.

A disruption of the A disruption of the column, or encroachment column, or encroachment on the vertebral canal on the vertebral canal cannot be evaluated. cannot be evaluated.

Also, 5% of patients have Also, 5% of patients have spondylolisthesis spondylolisthesis secondary to chronic secondary to chronic stress fracturesstress fractures

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Special thanks to the radiographers and physicians at Regions Hospital in St. Paul, Minnesota, a Level I trauma center, for their

expert advice and radiographs.

1 film critique unit 4 pelvis hips spine including st neck

Documents

sacralization slide

spondylolythesis slide

spondylolithesis slide

spurring slide

torticolis slide

osteoporosis slide

intertrochanteric fx

ring fx slide