Soft tissue and bone in the shoulder obscure visibility of the lower cervical vertebrae in lateral spine x-rays. The patient should have been instructed to relax their shoulders and the exposure taken on exhalation to improve visibility. Several errors are noted in the waters view radiograph including underexposure, improper collimation and positioning artifacts. Positioning and prepping the patient correctly is important for diagnostic quality medical images.

2. • Soft tissue and bone of shoulder
Superimposed over lower
cervical vertebrae.
Requires a swimmers.
• Patient should have been given
instructions to relax shoulders
and exposure taken on exhalation
to keep shoulder muscle and
tissue out of view of C-7 T-1.
Spinous
Process C-1
Zygapophyseal
Joints C-3 & 4
Posterior Arch
Intervertebral
Space
Lateral C-Spine
• No Marker Visible

3. Acceptable Lateral C-Spine
Vertebral bodies, intervertebral
joint spaces, articular pillars,
Spinous processes, and
Zyapophyseal joints all well
Demonstrated. Joint space
Between C-7 and T-1 visible.
Extension teardrop fracture
Spinous
process
Posterior arch
Zygapophyseal
joint Intervertebral space
Articular
pillar
Joint space between C-7 and T1

4. Lateral C-spine
Swimmers

5. Odontoid
Dens, C-2
Lateral Masses and
Space between superior
articlating surface of C-2

6. Waters for Sinuses
• Image is underexposed
• Image was not
properly collimated
• There are artifacts in the image
patient was not properly prepped
• There is rotation and “tilt” due to
poor positioning

7. Acceptable Waters
Properly collimated,
No rotation of MSP or
intepupilary baselines
Proper Anatomical
Marker in image
Frontal sinus
Bony nasal septum
Anterior nasal spine
Maxillary sinus
Coronoid process
Maxilla
Mastoid process
Superior orbital
Rim
Zygomatic bone
Zygomatic arch
Petrus ridge
Mandible
Odontoid process

8. On this Right Lateral Decubitus, portions of the ascending and descending colon
Have been clipped making diagnosis difficult. Care should be taken to ensure entire
Anatomy is within the image for diagnostic quality.
Left or
splenic
flexure
Right or hepatic
Flexure, lower
due to liver
Sigmoid
Colon
Descending
Colon
Transverse
colon
Ascending
colon

9. The pictured radiograph was made in the
right lateral decubitus position. It is part of
a series of radiographs made during an air-
contrast (double-contrast) BE examination.
A double-contrast examination of the large
bowel is performed to see through the
bowel to its posterior wall and to visualize
any intraluminal (eg, polypoid) lesions or
masses. Various body positions are used to
redistribute the barium and air. To
demonstrate the medial and lateral walls
of the bowel, decubitus positions are
performed. The radiograph presents a
right lateral decubitus position, because
the barium has gravitated to the right side
(the side of the hepatic flexure). The air
rises and delineates the medial side of the
ascending colon and the lateral side of the
descending colon. The posterior wall of the
rectum could be visualized using the
ventral decubitus position and a horizontal
beam lateral of the rectum.
Right colic flexure
Left colic
flexure
Ascending colon
Transverse
colon
Descending
colon
Sigmoid colon
Barium/Air levels

10. The End ?

11. References
Bontrager, Kenneth L and Lampignano. 2014. Textbook of radiographic
positioning and related anatomy. Mosby Inc. St. Louis, MO. Print.
Saia, Dorothy A .MA, RT(R), (M). 2008 . Lange’s Q&A., 9th ed. Mcgraw-Hill
United States of America. Print
www.learningradiology.com