clinical radiography

1. Radiographic Critique of a Cervical Spine X-Ray
following Road Traffic Accident
Mamati BA
30/09/15
Radiography Clinical Updates

2. OBJECTIVES
1. Request form Analysis
2. Justification of the procedure
3. Optimization of the exposure
4. Radiographic image critique
5. Conclusion

3. REQUEST FORM ANALYSIS
• 34 year old female.
• History of Road Traffic Accident .
• Referred for cervical spine x-ray.
• To rule out fracture of the cervical spine and
dislocation.
• Patient presented herself walking with no cervical
collar.
• She complained of neck pain.

4. JUSTIFICATION OF THE
PROCEDURE
• Neck injuries range from simple neck pain, to quadriplegia, or even death.
• The spinal cord injury occurs at the time of trauma in 85% of patients and
as a late complication in 15%.
• The initial post-injury period is critical with regard to neurologic recovery
or deterioration. Delayed recognition of an injury or improper stabilization
of the cervical spine may lead to irreversible spinal cord injury and
permanent neurologic damage.
• Plain films (AP,LAT, Open Mouth) provide the quickest way to survey the
cervical spine.
• These three views do not require the patient to move his neck.
• In this case , the views done were Cervical spine AP and Lat.
• NOTE: C7/T1 demonstration

5. OPTIMISATION OF THE PROCEDURE
• The single most important radiographic
examination of the acutely injured cervical
spine is the horizontal-beam lateral
radiograph that is obtained before patient is
moved. This film should be obtained and
examined before any other films are taken. All
7 cervical vertebrae and C7-T1 junction must
be visualized because the cervicothoracic
junction is a common place for traumatic
injury

6. Cont..
In all cervical spine views, a moving or a stationary grid must be
used (lateral is an exception, where an air-gap technique is
generally used).
Minimum KVp range is (70 - 80) KVp.
Optimal exposure is required to show soft tissue as well as proper
bone density of the entire cervical spine. A small focus improves
image detail.
Collimation must strictly be applied in all projections.
Exposure on fully suspended expiration

7. Corresponding LevelLandmark
Cervical 1Mastoid process (skull)1.
Cervical 5Thyroid cartilage2.
Cervical 7Vertebral prominence3.
Thoracic 2-3Suprasternal notch4.
Thoracic 4-5Sternal angle (2 inch below notch)5.
Thoracic 7 (3 – 4 inches below
jugular notch)
Inferior angle of the scapula6.
Thoracic 9-10Xyphoid process7.
Lumber 2-3Inferior costal margin8.
Lumber 4-5Iliac crest9.
Sacral 1-2Anterior superior iliac spine10.
Distal coccyxGreater trochanter11.
2.5 cm inferior to distal coccyxSymphysis public12.
Positioning Bony Landmarks

8. Landmarks

9. POSITIONING
• ERECT,
The patient is side on to the bucky/IR (usually left side is closest to the IR, however
if the patient has torticollis, a wry neck, then direct the central ray to the inner,
concave side)
• Position the midsagittal plane so that it is parallel to the IR
• Position the interpupillary line so that it is perpendicular to the IR (in an erect
patient, this will also be parallel to the floor)
• Raise the chin slighlty, so that the mandible does not superimposed the cervical
spine
• SUPINE,
Position the patient so that the bucky/IR is along one side (usually the left side is
closest to the IR)
• Position the midsagittal plane so that it is parallel to the IR. If the patient is on a
barouche, then this is easily achieved by moving the bed.
Position the interpupillary line so that it is perpendicular to the IR
• Only raise the chin slightly if the possibility of spinal injury has been ruled out, so
that the mandible does not superimpose over the cervical spine
• Traction on arms may be required to see T1

10. Radiographic Image Critique of
the Cervical Spine
• Align the mid-sagittal plane (MSP) to the vertically directed central ray
(CR). The CR is angled 15-20 degrees cephalic. A properly angled CR will
open the intervertebral disk spaces and project the spinous processes
near the inferior intervertebral disk space.
• All of T1 through C3 must be demonstrated. This can be accomplished by
extending the chin, or by tube angulation. Trauma imaging protocol does
not permit the repositioning of the cervical spine by rotating, extension, or
flexion.
• The lateral margins including the skin lines must be demonstrated. A
transverse field size of no less than 6 inches is recommended, and the
position marker placed 3 or more inches from the cassette center.
• Radiographic technique must be adequate to evaluate the vertebral
bodies, spinous processes, articular pillars, and trabecular pattern of bone.
For the AP view the optimal kVp range is between 70-80.

11. PACEMAN
• (P) - Position:
– Is the patient in the correct position?
– Is the patient rotated?
– Does the image correctly show any needed joint
spaces?
• (A) - Area:
– Is enough of the area being filmed covered? eg: In an
abdominal film is pubic symphysis to diaphragms
covered?
– Have you exposed an area that is not required?
• (C) - Collimation:
– Is the image properly collimated? eg is four way
collimation seen on an extremities film?
• (E) - Exposure:
– Were the exposure factors set correctly?
– Does the image show the correct contrast and density?
– Are there any factors that need to be changed to
produce a better image?
(M) - Markers:
Have markers been placed on the
image?
Are they correctly identifying left and
right?
(A) - Aesthetics:
Is the image nice to look at?
Is it centered on the film?
Is there four way collimation?
(N) - Name:
Does the image correctly identify the
patient?
Does it have any other relevant
identification details? eg episode
number or department labels?

12. PACEMAN
• Positioning
No rotation is evidenced by
The posterior vertebral bodies are
superimposed (see notes below)
– The zygopophyseal joints are
seen open
– No tilt is evidenced by
The intervertebral disc spaces of
the cervical spine are all open
(see notes below)
• No superimposition of the mandible
over the cervical spine
• Area Covered
All of the cervical vertebrae are
shown, including spinous processes
and the C7-T1 joint space and 1/3 of
T1. Also the anterior soft tissue of the
neck and airway are seen.
Collimation
Centre: C4
Shutter A: Open to show the EAMs
superioly and the C7-T1 joint space
and 1/3 of T1 inferiorly
Shutter B: Open to show the soft
tissue of the neck anteriorly, and the
spinous processes of the cervical
spine posteriorly
Exposure
Sufficient contrast and density to show
the anterior soft tissue of the neck,
including the airway.
Minimal patient motion and sufficient
contrast and density to show sharp,
clear cortical margins and bony
trabecular markings of the cervical
vertebrae

13. Image critique
LATERAL VIEW AP VIEW

14. The 5 lines of
stability
1. Prevertebral (anterior) soft tissue
2. Anterior vertebral bodies
3. Posterior vertebral bodies
4. Spino-lamina line
5. Tips of spinous processes

16. CONCLUSION
• Vertebrae to be visualized are from T1 through
C3.
• The lateral margins of the skin must be
included on all AP cervical spine views.
• Adequate radiographic technique to evaluate
for fractures, jumped facets, and alignment of
the lateral margins of the vertebrae.

17. References
1. https://www.med-ed.virginia.edu/courses/rad/cspine searched on 29 Sept 2015.
2. https://www.ceessentials.net/article20.html#apCSpine searched on 29 Sept
2015.
3. Bontrager L. Kenneth, ( )Text book of radiographic positioning and related
anatomy;5th, 6th edition.
4. http://www.sor.org/system/files/article/201109/022_Michael_Fell_C_Spine_Articl
e.pdf. searched on 29 Sept 2015.
5. http://www.ouh.nhs.uk/services/referrals/radiology/documents/justification-
guidelines.pdf searched on 29 Sept 2015.
6. http://backtochiropractic.net/PDF/X-Ray%20Guidelines.pdf searched on 29 Sept
2015.
7. http://emedicine.medscape.com/article/397563-overview searched on 29 Sept
2015.
8. http://regionsemstudentworkshops.pbworks.com/w/page/14153858/C-
spine%20workshop. searched on 30 Sept 2015.
9. http://www.wikiradiography.net/page/Cervical+Spine+-++Lateral searched on 30
Sept 2015.