This document provides an evaluation of an AP axial cervical spine x-ray image. The evaluation identifies several issues with the image including a lack of patient positioning markers, improper centering and alignment of the cervical spine, and artifacts from clothing and equipment. Based on the criteria outlined for an acceptable AP axial cervical spine image, this image does not meet standards and should be rejected. Corrections such as adding positioning markers, adjusting the cervical spine alignment, and removing artifacts are needed before accepting the image.

1. Image Evaluation:
AP Axial C-Spine
Alexa Gergel
RADS-216

2. HIPAA
Compliance
• This image is
HIPAA compliant.
• This image does not
violate patient
confidentiality.

3. Marker and
Patient ID
• A correct post-processed
RT anatomical side
marker is visible in the
image. In addition, a
technologist identifier
should be included.
• The annotated RT side
marker is placed
correctly in the image.

4. Marker and
Patient ID
• There are no markers
superimposing pertinent
anatomy.
• Additional markers that
are necessary for this
image include an up or
down arrow indicating
the position of the
patient. This patient was
likely supine, and would
require a down arrow.
This was not used in the
original image.

5. Marker and
Patient ID
• The image is displayed
correctly based on
marker placement.

6. Radiation
Hygiene
• There must be at least
three sides of beam
restriction on an
image.
• The beam restriction
demonstrated on this
image is acceptable
because 4 sides of
collimation appear
to be demonstrated.

7. Radiation
Hygiene
• Beam restriction is the
primary source of gonadal
shielding. At least 3 sides of
beam restriction are
necessary, and one of those
needs to be on the side
closest to the gonads for
adequate gonadal shielding.
In addition, a gonadal shield
must be provided if the
gonads are within 5 cm of
the primary beam and
shielding will not obstruct
any anatomy of interest.

8. Radiation
Hygiene
• There is evidence
indicating appropriate
use of shielding. There
is adequate beam
restriction on the side
closest to the gonads.
• In addition, a shield
would not obstruct
any anatomy of
interest, and should be
used.

9. Routine Positions/Projections
• A routine Cervical Spine study will include:
AP Axial
(15˚ to 20˚
cephalad
angulation)
(Supine or
Erect)
Lateral
(Right or Left)
(Erect or
Supine)
AP Axial 45˚
Oblique
(LPO)
AP Axial 45˚
Oblique
(RPO)

10. Completeness of
Position/
Projection
• This image does
comply with one of
the routine
positions/projections
—the AP axial
position/projection.
• All anatomical parts
are not correctly
visualized.

11. Artifact
Identification
• There are preventable
physical artifacts visible
in the image.
• There are body parts
that are superimposed
that should not be. The
mandible is
superimposed over the
upper cervical vertebra.

12. Artifact
Identification
• Hospital
paraphernalia is
visible in the image.
The patient appears to
be wearing a cervical
collar which is shown
in the image.

13. Artifact
Identification
• Patient
clothing/belongings are
visible in the image. The
patient’s bra is shown
at the bottom of the
image.
• There does not appear
to be any indwelling
artifacts/foreign bodies
visible in the image.

14. Artifact
Identification
• Excess fog is not
visible or degrading
overall image quality.
• There does not
appear to be any
CR/DR artifacts
visible in the image.

15. Image
Sharpness
• “Gross” voluntary motion
does not appear to be
visible in the image.
• Excessive quantum mottle
(or image noise) does not
appear to be visible in the
image.
• There does not appear to
be evidence of double (or
previous/ghosted)
exposure visible in the
image.

16. Image
Sharpness
• Grid lines, grid artifact,
&/or grid cut-off are
expected because a
reciprocating or
stationary grid would
likely be used, but do
not appear to be visible
in the image because a
high frequency grid may
have been used

17. Image
Sharpness
• Size distortion does not
appear to be greater
than expected—there is
some degree of
distortion expected
because the object being
imaged is three-
dimensional.
• Shape distortion does
not appear to be caused
by poor CR/IR/Part
Alignment

18. Accurate Part
Positioning
• The part is not
completely aligned to
the longitudinal axis and
the image media.
• The part is not
accurately centered to
the image media. It
should be centered at
the level of C4.
• The CR does not appear
to be centered within 1
cm of the anatomical
part.
C6
c4

19. Accurate Part
Positioning
• The CR does appear to be
adequately aligned with
the image media.
• The CR’s alignment does
conform to an accepted
IR exposure recognition
template/field—4 sides of
collimation.

20. Accurate Part Positioning
Positioning Criteria for AP
Axial C-Spine according to
Merrill’s Atlas:
• Place the patient in the supine or
upright position with the back
against the IR holder.
• Center MSP of patient’s body to
the midline of the table or vertical
grid device.
• Extend the chin enough so that the
occlusal plane is perpendicular to
the tabletop—preventing
superimposition of the mandible
and mid-cervical vertebrae.
• Center the IR at the level of C4
• Adjust the head so that the MSP is
in straight alignment and
perpendicular to the IR.
• Suspend respiration
• CR directed through C4 at an angle of 15 to
20 degrees cephalad
• Adjust collimation 10 in. lengthwise an 1
inch beyond the skin shadow on the sides

21. Accurate Part
Positioning
Evaluation Criteria for
AP Axial C-Spine according
to Merrill’s atlas:
• Evidence of proper collimation
• Area from superior portion of C3
to T2 and surrounding soft tissue
• Shadows of the mandible and
occiput superimposed over the
atlas and most of the axis
• Open intervertebral disk spaces
• Spinous processes equidistant to
the pedicles and aligned with the
midline of the cervical bodies
• Mandibular angles and mastoid
processes equidistant to the
vertebrae

22. Accurate Part
Positioning
• Based on the previous
criteria, the
anatomical part is
not correctly
positioned.

23. Judicious
Exposure
Technique
• The most radiolucent
structure is air
within the trachea.
This is visible in the
image.
• The most radiopaque
structure in the image
is bony cortex of the
mandible. This is
seen in the image.

24. Judicious
Exposure
Technique
• This image
demonstrates long-scale
contrast (window
width).
• This image displays
adequate brightness
(window level) and
would likely
demonstrate an EI level
within normal range.

25. Accept/Reject?
This image does not meet
minimum established standards
and should be rejected.
• Required corrections for this
image:
• Include a “down” arrow indicate
patient position
• The technologist should use their
own marker with their ID
• Center CR and IR to C4 to
include C3 through T2 in the
image
• Raise mandible if possible in
order to demonstrate C3
• If the image only displays up to
T2, the bra artifact will not be
shown
• Align part to longitudinal axis of
the IR
123

26. References:
Frank, E. D., Long, B. W., Smith, B. J., & Merrill, V.
(2012). Merrill's atlas of radiographic
positioning & procedures. St. Louis, MO:
Elsevier/Mosby.
McQuillen-Martensen, K. (2011). Radiographic image
analysis. St. Louis, MO: Saunders/Elsevier.
• http://www.wikiradiography.net/page/Odontoid-
lateral+mass+Asymmetry image link
• https://hfu-
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