5'8 Neutral Lateral Cervical Spine

1
5.8 Neutral Lateral Cervical Spine

• Part of all cervical spine series.
• Hang the non-Bucky film holder on top of Bucky.
  Slide upper film holder up to place film in
  holder. Center holder and film to beam.

2
Neutral Lateral Cervical Spine

• Measure Lateral at C-4.
• Protection Half Apron
• SID 72 using non-Bucky film holder.
• Film 8 x 10 Regular I.D. Down Portrait with
  anterior head carriage 10 x 12 I.D. Regular
  Down Portrait.

3
Neutral Lateral Cervical Spine

• Patient in lateral position. Acanthiomeatal line
  perpendicular to film.
• Intrapupillary line perpendicular to film.
• Shoulder should touch the film.

4
Neutral Lateral Cervical Spine

• Horizontal CR at level of C-4. Proper head
  extension is critical to proper placement.
• Vertical CR through EAM.
• Center film to horizontal CR.

5
Neutral Lateral Cervical Spine

• Give the patient the sandbags. Ask patient to
  relax their shoulders.
• For broad shoulder, pull shoulders back.
• Collimation top to bottom EAM to T-1 or less
  than film size.

6
Neutral Lateral Cervical Spine

• Collimation side to side Skin of neck.
• Breathing Instructions Take a small breath in,
  now blow it out and hold it out. Full expiration
• Make exposure
• Carefully remove film from holder.

7
Neutral Lateral C-spine Film

• Need to see down to C-7 and T-1 disc space.
• Mandibles should be superimposed. No head
  rotation.
• Need to see posterior aspect of hard palate to
  draw Mc Gregors line.

8
Neutral Lateral C-spine Film

• If the patient is anterior weight bearing, use a
  10 x 12 regular speed cassette in the
  portrait orientation.

9
5.9 Flexion and Extension Lateral Cervical Spine
Views

• Taken as part of the Davis Series
• Can replace the oblique views in the complete
  cervical spine series.
• Taken after the Neutral Lateral. If acute patient
  review, limited cervical films before doing
  either flexion or extension views.
• Do extension lateral before flexion because
  little equipment change will be needed.

10
Extension Lateral Cervical Spine

• During extension, patient may become dizzy. Watch
  patient carefully.
• Patient must determine the range of motion. Dont
  force farther than they can tolerate.

11
Extension Lateral Cervical Spine

• Measure Lateral at C-4.
• Protection Half Apron
• SID 72 non Bucky
• Film 8 x 10 I.D. down Portrait
• Marker L for left side to film and EXT or
  arrow pointing backwards to indicate extension.

12
Extension Lateral Cervical Spine

• Patient standing or seated in lateral position.
• Intrapupillary line perpendicular to film.
• Patient given sandbags to pull shoulders down.
• Patient asked to extend head back as far as they
  can tolerate.

13
Extension Lateral Cervical Spine

• Horizontal Central Ray level of C-4.
• Vertical Central Ray through EAM with full
  extension.
• Film centered to Horizontal CR.
• Collimation Top to Bottom EAM to T-1

14
Extension Lateral Cervical Spine

• Collimation Side to Side skin of neck.
• Breathing Instructions Take a small breath in
  and blow it out.Hold it out and remain perfectly
  still. Full expiration.
• Make exposure.
• Tell patient to relax. Carefully remove film from
  film holder

15
Extension Lateral C-spine Film

• Must see from C-1 to T-1
• Mandible should be superimposed, no evidence of
  skull rotation.
• Borders of collimation should be seen.

16
5.10 Flexion Lateral Cervical Spine

• Extremely important to let patients set limit of
  motion.
• Chin must be tucked into chest before asking
  patient to flex neck forward.

17
Flexion Lateral Cervical Spine

• Measure Lateral at C-4
• Protection Half apron
• SID 72 non-Bucky
• Film 10 x 8regular speed cassette I.D. up
  Landscape or 8 x 10 turned sideways.
• Markers L for left side to film and FLEX or
  arrow pointing forward to indicate flexion.

18
Flexion Lateral Cervical Spine

• Patient standing or seated in lateral position.
  Intrapupillary line parallel to film.
• Give patient the sandbags.
• From neutral position tell patient to tuck their
  chin into their chest. Flex neck forward as far
  as possible

19
Flexion Lateral Cervical Spine

• Horizontal Central Ray level of C-4. This will
  be lower than the neutral lateral.
• Vertical Central Ray at the body of C-4 or mid
  way between EAM and T-1.
• Center film to horizontal CR.

20
Flexion Lateral Cervical Spine

• Collimation Top to Bottom EAM to T-1
• Collimation Side to Side EAM to T-1
• Breathing Instructions Full expiration
• Make exposure
• Tell patient to breathe and relax. Remove film
  with care.

21
Flexion Lateral C-spine Film

• Must see from C-1 to T-1.
• Mandibles superimposed with no evidence of
  rotation.
• Markers should be visible.
• Evidence of collimation.

22
Cervical Spine Pillars Projections

• Supplemental views of the cervical spine
• Oblique views always taken in pairs.
• Can be taken erect or recumbent.
• Taken to rule out fractures of the lateral masses
  resulting from an extension and rotation mode of
  injury.

23
5.11 A-P Pillars Projection

• This Pillars Projection is rarely taken because
  the patient generally can not tolerate the
  extreme extension required to take the view.

24
A-P Pillars Projection

• Measure A-P at C-4
• Protection Half Apron
• SID 40 Table Bucky
• Tube angle 25 to 30 degrees caudal
• Film 8 x 10 regular I.D. down Portrait
• Special equipment large 45 degree sponge.

25
A-P Pillars Projection

• Patient lies A-P on table.
• Large 45 degree sponge placed under shoulder.
• Patient extend neck until head touches table
• Mentameatal line should be at least perpendicular
  to film and ideally greater at 100 to 120 degrees.

26
A-P Pillars Projection

• Collimation vertical skin of neck
• Breathing Instructions Dont breathe, move or
  swallow. Suspended respiration
• Make exposure
• Instruct patient to breathe and relax. Carefully
  remove sponge

27
A-P Pillars Projection Film

• Visualization of the lateral masses and spinous
  processes of the cervical spine.
• There should be no rotation.

28
Oblique Pillars Projection

• The oblique Pillars Projections are the most
  commonly pillars views taken.
• They can be taken A-P or P-A.
• They are always taken in pairs.

29
5.12 A-P Oblique Pillars Projection

• Measure A-P at C-4
• Protection Half Apron
• SID 40 Bucky
• Tube angle 35 to 40 caudal
• Film 8 x 10 regular with I.D. down Portrait
• Patient lies or sits A-P with head turned 45 to
  50

30
A-P Oblique Pillars Projection

• Horizontal Central Ray C-5
• Vertical Central Ray mid-sagittal
• Center film to HR.
• Collimation Top to Bottom C-1 to T-2
• Collimation Side to Side skin of neck

31
A-P Oblique Pillars Projection

• Breathing Instructions Suspended Respiration
• Make exposure and let patient relax.
• To visualize the lower cervical and upper
  thoracic spine, increase head rotation to 60 or
  70.

32
Oblique Pillars Projection Film

• Should visualize the lateral masses and spinous
  processes of each cervical vertebra.
• Always done in pairs to see both lateral masses

33
5.13 P-A Oblique Pillars Projection

• Measure A-P at C-4
• Protection Half Apron
• SID 40 Bucky
• Tube angle 35-40 cephalad
• Film 8 x 10 I.D. down
• Patient seated P-A to Bucky. Head turned 45 to 50
  degrees for C2- C-7 lateral masses.

34
P-A Oblique Pillars Projection

• Horizontal CR C-5
• Vertical CR mid-sagittal
• Center film to HR.
• Collimation top to bottom C-1 to T-1
• Collimation side to side skin of neck.

35
P-A Oblique Pillars Projection

• Breathing Instructions suspended respiration
• Make exposure
• Tell patient to breathe and relax.
• To evaluate C-7 to T-4, increase head rotation to
  60 to 70 degrees.

36
Oblique Pillars Projection Film

• Should visualize the lateral masses and spinous
  processes of each cervical vertebra.
• Always done in pairs to see both lateral masses

37
Oblique Pillars Projection

• If the patient is anterior weight bearing or has
  a kyphotic thoracic curve, the anterior oblique
  pillars will generally not work.

38
5.14 Cervical Spine Positioning

• All views taken on 8 x 10 Regular Cassettes.
  One view taken with 8 x 10 turned 10 x 8.
• I.D. Down for all views except when film turned
  10 x 8.
• Radiation Protection Half lead apron
• Measurements at level of C-4. Top of the Adams
  Apple.

39
Cervical Spine Positioning

• All lateral views are taken at 72 SID using the
  Non-Bucky Film Holder.
• The I.D. is down for all views except the flexion
  lateral when the film is turned to 10 x 8
• The A-P and Posterior Oblique Views have a 15-20
  cephalad tube angle.

40
Cervical Spine Positioning

• Anterior Oblique Views use a 15 to 20 caudal
  tube angle.
• All oblique views have the patient turned 40 to
  45 with the head turned to a lateral position.
• The acanthiomeatal line is perpendicular to the
  film for all routine views except the Fuchs and
  Flexion and Extension Views.

41
Cervical Spine Positioning

• Take the Neutral Lateral View first.
• It is the only 72 view unless flexion
  extension views are needed.
• By viewing it before taking the APOM, you will be
  able to determine if any tube angle is needed.

42
Cervical Spine Positioning

• Limited C-spine Neutral Lateral, A-P and
  APOM
• Complete C-spine Limited Oblique or
  Flexion Extension
• Davis Series Limited Oblique and Flexion
  and Extension

43
Cervical Spine Positioning

• If patient is acute Take the Neutral Lateral,
  A-P and APOM and review the films before taking
  flexion and extension views.
• Let patient set the range of motion for flexion
  and extension views. Do not force the patient
  beyond their tolerance.
• Patient must tuck chin into chest before flexion
  on the Flexion Lateral.

44
C-spine Problems

• The angles of the mandible should be
  superimposed.
• The I.D. is in the wrong location.

45
Poor Gowning Ear Ring

• A single ear ring on a lateral cervical spine
  view.

46
Poor Gowning Pins in Hair

• Bobby pins can ruin cervical or skull radiographs.

47
Poor Gowning Hair in Pony Tail

• Most bands used for pigtails or ponytails have
  have metal clips.
• There appears to be an ear ring also.

48
Poor Gowning Wet Hair

• The patients hair is wet. Combined with the
  ponytail resulted in significant artifacts.

49
Poor Gowning Mousse

• This patient had dreadlocks with lots of mousse
  in the hair.

50
Poor Gowning Mousse

• The A-P c-spine was repeated with the hair in
  pigtails.

51
Poor Gowning Bra

• The complete study of a brassiere.
• P-A Lateral Views

52
Cervical Spine Positioning Errors

• Horizontal CR too low so the EAM and part of
  upper c-spine missed.
• EAM must be in collimation and film properly
  centered to avoid missing anatomy.

53
Cervical Spine Positioning Errors

• I.D. in wrong location so it blocks part of
  C-1.
• Note that the oblique view provides a good look
  at C-7 T-1.

54
Thoracic Spine Chest

• In the thoracic region, film is centered to
  patient.
• The horizontal central ray is centered to the
  film.
• Thoracic Spine views will require compensating
  filters. Always complete positioning and
  collimation before installing filters

55
Thoracic Spine

• Routine Views A-P and Lateral
• Supplemental Swimmers
• A-P measure over shoulder in contact with sternum
  and thoracic spine.
• Lateral measurement is sub axillary.

56
6.2 A-P Thoracic Spine

• Measure A-P over shoulder
• Protection Half Apron
• SID 40 Bucky
• No tube angle
• Film 7 x 17 regular I.D. down Portrait
• Patient stands A-P with back touching Bucky.

57
A-P Thoracic Spine

• Locate C-7. Position top of film two inches above
  C-7.
• Make sure there is no patient rotation
• Horizontal central ray centered to film.
• Vertical central ray mid-sagittal.

58
A-P Thoracic Spine

• Locate the 40 Cervicothoracic or Thyroid Filter.
• Place on top of collimator.
• When installed, the thick part goes toward the
  cervical spine.

59
A-P Thoracic Spine

• Collimate Top to Bottom C-7 to L-1 or slightly
  less than film size.
• Collimate side to side 5 or less than film
  size.
• Place 40 cervicothoracic filter into filter rack
  with thickest part up.
• Slide down until light is seen at top.

60
A-P Thoracic Spine

• Pull filter up to close off light at top.
• Make sure film is pushed into Bucky.
• Breathing Instructions Take a deep breath in
  and hold it. Inspiration
• Make exposure
• Tell patient to breathe and relax.

61
A-P Thoracic Spine Film

• Need to visualize from T1 to L1.
• No rotation Sternoclavicular joints equal
  distance from spine.
• Full inspiration with diaphragms down.
• Equal exposure from T-1 to T-12.

62
AP T-spine Positioning Error

• The filter was placed to the lower half of the
  film.
• Filter goes to the top of the film.
• Bring down until you see light at top and back up
  to close off light.

63
A-P T-spine Error

• The top of the film is placed 2 inches above the
  shoulder, not C-7 so the upper thoracic spine is
  not on the film.
• Most common error.

64
6.3 Lateral Thoracic Spine

• Measure Lateral sub- axillary.
• Protection Half apron
• SID 40 Bucky
• Film 14 x 17 regular I.D. up Portrait. Small
  patient with little lordotic curve may use a 7 x
  17 regular film with I.D. down Portrait

65
Lateral Thoracic Spine

• Locate point filters per technique chart.
• Patient stands lateral with shoulder touching
  Bucky.
• Top of film is two inches above C-7.
• Patient places hands together with arms parallel
  to floor.

66
Lateral Thoracic Spine

• Horizontal central ray centered to film.
• Vertical central ray just posterior to head of
  humerus.
• Collimation top to bottom T-1 to L-1 or slightly
  less than film size.
• Collimation side to side posterior skin.

67
Lateral Thoracic Spine

• Place point filters below the axilla or
  horizontal central ray.
• Instruct patient to pull elbows together.
• Breathing Instructions Take a deep breath
  in and hold it. Dont move.
• Make exposure and tell patient to relax.

68
Lateral Thoracic Spine Film

• Should see from T-1 to T-12.
• No Rotation Ribs superimposed.
• If patient was able to have elbow touch,
  shoulders will be anterior to T-spine.

69
Lateral T-spine Errors

• Point filters placed at top of image instead of
  the bottom of the image.
• Too much rotation, ribs not superimposed.
• Ribs magnified are the side away from film.

70
Lateral T-spine Error

• Wrong breathing instructions.
• Taken on expiration so the lungs are not filled
  with air.
• Under exposed.
• Note rotation

71
Lateral T-spine Error

• Wrong film size and too low.
• A small patient can be done with the 7 x 17 but
  the collimation must include the posterior soft
  tissue .

72
Lateral T-spine Error

• The I.D. is down whenever we use the 7 x 17
  film.
• Using the 7 x 17 requires tight collimation and
  precise positioning.
• Improves contrast.

73
Lateral T-spine Error

• No collimation.
• Patient over exposed.
• Vertical CR not posterior to head of humerus.
• Always collimate to posterior skin.

74
6.4 Swimmers Projection

• Taken when lateral cervical or thoracic spine
  fails to demonstrate lower cervical or upper
  thoracic spine.
• Only thoracic spine view with landmarks for beam
  placement.

75
Swimmers Projection

• Measure lateral sub-axillary
• Protection Half Apron
• SID 40 Bucky
• Tube angle Normally none but large patient that
  cannot achieve separation of shoulders may need 5
  degrees caudal.
• Film 10 x 12 regular I.D. up Portrait

76
Swimmers Projection

• Patient stands lateral. Arm next to Bucky raised
  over head. Other arm grasps sandbag. Patient
  rotated posteriorly 5 to 10 degrees off of true
  lateral.
• Horizontal central ray at level of
  sternoclavicular joints.
• Vertical central ray Head of humerus away from
  Bucky.

77
Swimmers Projection

• Center film to HR.
• Push film into Bucky.
• Collimation slightly less than film size.
• Breathing Instructions Take small breath in
  and blow it out. Hold it out and dont move.
  Expiration
• Make exposure and have patient relax.

78
Swimmers film

• Should visualize the upper thoracic spine and
  C-7.
• Minimize rotation of body to as close to lateral
  as possible.
• Key to view is shoulder separation.

79
End of Lecture

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