Download film critique unit 4

FILM CRITIQUE
UNIT 4
PELVIS HIPS SPINE
Including ST Neck
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Hands
Note
Intertrochanteric fx
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End of
Prosthesis
Device
Not seen
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Subcapital fx
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Intertrochanteric fx
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Osteoporosis
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c/o Lt buttock pain
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Osteo arthritis
Pagets sarcoma
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Name of “view” for acetabulum?
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This is not a
Axiolateral HIP !
What is it?
INF/SUP Shoulder
No gonad shield
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DISCLOCATED SI JT
CA
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C-1 ring fx
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Jefferson’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
Rheumatoid arthritis
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Hangmans fx
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Ankylosing Spondylitis
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Hangman fx
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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 intervertebral foramina
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torticolis
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Spaces not well seen -calcification of ligaments
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CA mets transverse process
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fx
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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
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Calc disc
comp fx osteop
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Facets distroyed
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spondylolithesis
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spondylolythesis
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sacralization
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spurring
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“CAGE”
POST OP FOR HERNIATED DISK
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SPINE CRITIQUE
additional information
for Trauma
Copyright -2006 Nicholas Joseph Jr.
www.ceessentials.net/.
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Trauma imaging of the cervical spine has specific
diagnostic criteria that must be met in order to properly
evaluate each patient. In addition to these radiographic
standards, there are patient care standards that are
practiced as spine precautions. For trauma imaging the
patient presents on a spine board and in a cervical collar.
Besides spine precautions there may be abdominal and
pelvic precautions, and even precautions for extremities.
Before aggressively imaging the spine the radiographer
should get a good understanding of the patient’s
condition and their trauma score. Obviously you would
not think of raising the arms to get a Swimmer’s view on
a patient with bilateral humerus and shoulder fractures.
There are alternative methods for imaging these
patients, mainly computerized tomography. But when
requested, the standard views of the cervical spine are
the horizontal beam lateral and Swimmer’s view, AP, and
open-mouth odontoid view.
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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.
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Diagnostic Criteria for Imaging the Horizontal Beam Lateral
Cervical Spine
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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."
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Has the diagnostic criteria
for this horizontal beam
lateral radiograph been
fulfilled?
What would you suggest
to improve the quality of
this film and achieve the
diagnostic standard for a
lateral cervical spine
view?
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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:
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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.
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This is a good radiograph in that C1-T1 are
demonstrated, their apophyseal joints, and
posterior quadrilateral architecture:
Notice however, that the patient is intubated and
motion from the ventilator compromises subject
detail. A shorter exposure time using a higher
mA would have reduced this motion. Also having
the respiratory therapist mechanically hold
ventilation during the exposure is recommended.
The safety pin holding the endotracheal tube
should be moved more anterior or replaced with
tape.
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This picture demonstrates why pulling
down on the shoulders of a trauma patient
for imaging is contraindicated.
 The airway and other anterior soft tissues
are not visualized due to over collimation.
 With this type of injury, more of the base of
the skull should have been included.
 Only 6 vertebrae are demonstrated. C7/T1
junction cannot be evaluated.
 Rather than repeating the view, consult
with the radiologist about a CT scan.
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www.ceessentials.net/ article20.html
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If the technologist had pulled down on the patient’s shoulders to
image this person’s spine, paralysis may have occurred.
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atlantooccipital joints
the atlantooccipital joints formed by the condyles of the occipital bone and the
superior articular processes of the atlas.
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All 7 Cervical vertebrae are well demonstrated; however,
the three contour lines cannot be visualized through the
1st thoracic vertebra. Remember, part of the requirement
of a good lateral is evaluating the relationship of the
cervical spine to the thoracic spine.
The apophyseal joints at C7/T1 can be seen but is too
opaque to make a diagnosis. This is due to the thickness
of both shoulders the central ray (CR) must pass
through.
To complete this study a more penetrated lateral that
shows detail through the apophyseal joints at C7/T1, or a
Swimmer’s view should be added.
It is not clear if this is a trauma image since it has the
characteristics of an upright film. Nevertheless, the
pharyngeal structures and airway must be seen on all
cervical spine radiographs.
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What do you think is
good about this
radiograph?
What do you think is
needed to make this
image part of a
completed lateral
cervical spine study?
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This lateral is well positioned. Notice that the mandibular
condyles are superimposed on this trauma lateral view.
All apophyseal joints are superimposed, and the
posterior quadrilateral architecture of all cervical
vertebrae can be evaluated.
The junction of C7/T1 is seen, but is not adequately
penetrated. It is these almost good radiographs that abut
against the line of malfeasance.
The image is good for the pharyngeal shadow and
airway. An appropriate amount of part collimation is also
seen.
To complete this study a more penetrated lateral that
shows detail through the apophyseal joints at C7/T1, or a
Swimmer’s view should be added.
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Would you pull down
on this patient’s
shoulders to see
C7/T1?
Why or why not?
What is missing from
the diagnostic criteria
on this radiograph?
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No! Never pull down on the shoulders of a trauma 187
patient!
Notice the bilateral jumped facets at C6/C5.
The technologist does not need to be overly aggressive
in this scenario; a consultation with the radiologist may
be the best alternative after attempting a single
Swimmer’s view.
Include an overlapping Swimmer’s view of T1/C7 thru C5
to complete this study. If this fails to give good images,
then a CT scan may be done following consultation with
the radiologist.
The three contour lines must be seen through T1 to
complete the diagnosis.
The position marker should never obscure soft tissues,
and the anterior skin line should be visualized when
evaluating the traumatic cervical spine. Air in the neck
fascia could indicate trauma elsewhere.
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If this was your
patient, and this is the
image you got on
your CTL trauma
cervical spine view,
what would you do
next?
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We’ve all had this type of difficult to image patient. Here
only three proximal vertebrae are demonstrated on the
lateral view. This lateral and two Swimmer’s views bring
home the point that you can shoot a lot of radiographs,
but unless you can meet the diagnostic criteria for
evaluating the spine your mission is incomplete.
Since pulling down on the shoulders of this patient is
contraindicated, two Swimmer’s views were attempted
with marginal results.
Ultimately, only a CT scan will be able to contribute
information sufficient for diagnostic clearance of this
patient’s spine. But what is important here is to inform
the radiologist when you cannot achieve the diagnostic
criteria for plain film interpretation without excessive
repeat radiographs on this patient. Let the physician
make the judgment call on what to do beyond your
reasonable attempts to get good images.
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What is your critique
of this radiograph?
What would you do if
your patient refuses
to remove their
earrings, necklace,
etc?
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Yes this is a good radiographic decision and
resulting image. The so-called shoot through lateral
is a more penetrated radiograph with excessive
radiographic density and penetration through the
part. In the picture to the left we see that the
apophyseal joints of C7/T1 are clearly visible, the
posterior bony quadrilateral architecture of C7 and
T1 are well demonstrated. The three contour lines:
anterior, posterior, and laminospinal can be drawn
through T1.
The picture to the right is a magnification through
the area of C7/T1. Notice the rib attachment to T1
and the well-penetrated apophyseal joints of C7/T1.
This view is actually more diagnostic than its more
commonly done cousin the Swimmer’s view
because the humerus does not overshadow the
spine.
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What could be done
to make it a better
picture?
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The most obvious observation is the earrings that should
have been removed. Don’t try to get by with leaving
earrings and glasses on because a repeat film means
more exposure to the patient. If they cannot be removed,
then tape the ear up as much as possible.
Tighter collimation for this view could have been applied.
Collimation improves radiographic contrast and reduces
patient dose.
The textile material composing this soft cervical collar
presents a regular pattern that will be ignored by the
radiologist.
This patient is leaning slightly towards the upright bucky,
perhaps for balance. This has caused the apophyseal
joints to be slightly tilted so that they are not
superimposed. When this view is repeated because of
the earrings, sit the patient in a chair and reposition for a
true lateral. The apophyseal joints will be aligned and the
spacing between the vertebral bodies will be better
demonstrated.
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What do
you see
that is good
about this
radiograph?
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All seven cervical and all of the 1st thoracic
vertebra are seen. Notice the cupola of the lungs
extending above the thoracic inlet. The cupola is
seen whenever the entire 1st thoracic vertebrae
is seen on a lateral view. It is that portion of the
lung pleura that extends above the superior
thoracic inlet.
Also important are the apophyseal joints and
posterior quadrilateral architecture of each
vertebra is seen from the occiput to T1.
The three contour lines can be easily drawn to
reference alignment of the entire cervical spine.
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Consider this
radiograph of a
patient with a history
for examination of: f/u
interval changes, C2
fracture, check
alignment.
Should anything be
done to improve this
radiograph?
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This is an example of a radiograph in which the
technologist does not need to include all of
C7/T1 like in a trauma survey.
This is a follow up (f/u) film to check alignment of
C2 and the stability of the neck brace support.
This is a good lateral by this scenario. When the
patient history specifies f/u exam and the level of
interest is specified, the diagnostic criteria
applies to all vertebrae above the segment, and
at least the entire vertebra below the segment.
However, the most common radiograph practice
is to include the entire spine on all images.
Summary of Swimmer’s view
Critique
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Apophyseal joints of C7/T1 must be demonstrated
along with the posterior quadrilateral architecture of
all vertebrae.
The radiologist must be able to evaluate the
alignment of the vertebrae evidenced by three
contour lines through the entire cervical spine and
first thoracic vertebra.
Adequate radiographic technique to evaluate for
fractures.
Apply your knowledge to each radiograph you
take, asking did I meet the diagnostic criteria?
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Name this
radiographic view.
Does it meet the
diagnostic criteria for
a lateral cervical
view?
Why does it or does it
not meet the criteria?
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This is a coned Swimmer’s view. It is a
very good one in fact. Let’s review the
main reasons why it meets the
diagnostic criteria for interpretation:
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The apophyseal joints of C7/T1 are
seen (circle) but could be a little more
penetrated.
The three contour lines can be drawn
through the cervicothoracic junction.
The slight motion due to long exposure
technique did not grossly affect the
diagnostic value of this image.
Can you see all three points
mentioned above in the radiograph?
The posterior ribs, apophyseal joints,
and articular pillars are all seen without
superimposition on each other. These
are the hallmarks of a well-positioned
Swimmer’s view that is not rotated.
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coned down Swimmer’s
view.
The white arrow locates the
first rib and first thoracic
vertebra.
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The apophyseal joints of
C7/T1 can be seen.
The three contour lines can
be drawn through T2.
There is good bone detail
for diagnostic evaluation.
Can you see all three
points mentioned above
in the radiograph?
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What could be done
to improve this
Swimmer’s view?
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Notice that the posterior margins of the spine are clipped
because the part is off centered.
The humeral head of the raised arm does partially
obscure anatomical structures; however, not enough to
warrant repeating this view. When positioning for the
Swimmer’s view, be sure the shoulder is brought
downward into the spine board when the arm is
extended over the head.
Because of the positioning of the patient, the exact
attachment of the 1st is a bit difficult to determine. The
apophyseal joints and posterior architecture of C7/T1 are
not optimally demonstrated. Rotation of the part is
obvious because the posterior ribs overlay the spine.
This view should be repeated making the adjustments
mentioned that would improve the image.
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Two reasons why it is difficult to
determine which vertebra is T1,
underpenetration and/or
positioning error. In this
radiograph the long spinous
process of C7 and the thoracic
spinous processes cannot be
easily seen due to part rotation.
The patient’s body rotation is
enough to misalign the
apophyseal joints in the region of
C7/T1. It is almost a guess which
vertebra is T1. Strive to keep the
patient’s mid-sagittal plane aligned
when one arm is raised and the
other depressed.
Yet, this is an adequate
Swimmer’s view because the
apophyseal joints of C7/T1 are
clearly visualized (white circle).
The alignment of the vertebrae
superiorly and inferiorly can also
be determined.
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Why do some radiologist 208
require the full C-spine
Swimmer’s view over the
coned down view?
Is this an adequate Swimmer’s
view?
Some radiologists prefer the
full C-spine Swimmer’s view
because it is easier to
determine where C7/T1
junction is and to assess the
alignment of the lower
vertebrae,
Image detail particularly of the
posterior architecture of C7/T1
is lost because image detail is
enhanced by coning or tight
collimation
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This is a well-positioned
radiograph and optimal
exposure. But notice that the
snap on the gown
overshadows a portion of C7
and all of the quadrilateral
architecture of C6. This is not
acceptable. Otherwise, this
would be a great Swimmer’s
view since the apophyseal
joints of C7/T1 are well
visualized. The seventh
cervical vertebra is obstructed
by the snap, which defeats the
purpose for this view.
By now you should be pretty
good at determining which
vertebra is T1. Did you get it
correct?
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Next, observe that the 7th
cervical vertebra has no rib
attachment, and as its name
(vertebra prominens) implies, it
has a long spinous process
that is not bifid (white arrow).
Note the rib attachment to the
first thoracic vertebra (long
yellow arrow).
All apophyseal joints,
especially C7/T1 so easily
seen on this radiograph (short
yellow arrow) must be seen on
the Swimmer’s view when is it
made.
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This radiograph is difficult to critique
because of the poor radiographic contrast. A
good radiographer can make a good
radiograph even under the most difficult
patient conditions.
Adequate penetration is demonstrated; but
because of the graininess due to technical
factors subject detail is lacking. Increasing
the mAs, using high ratio grid, and using
tighter collimation will optimize the subject
detail.
To find T1 on this radiograph we must
identify the 1st rib. It has an attachment to
the manubrium at the clavicular notch
anteriorly (white arrow). Just below it is the
1st costal cartilage where the 1st rib
attaches. The yellow arrow indicates the first
rib and T1.
The apophyseal joints of C7/T1 are seen but
without good subject contrast. The
alignment of the vertebrae can be
determined because the positioning is good.
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Diagnostic Criteria for Imaging
the AP Cervical Spine
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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.
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The diagnostic standard for the AP
cervical spine view includes:
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C3 through T1 should be seen
when the CR is angled 15-20
degrees cephalic with the spine in
a support collar.
The lateral margins of the skin
should be included on the image.
Radiograph density should include
good penetration of C3 and
throughout the spine so that bone
and soft tissues are visualized.
Did you notice that the lateral
margins of the film are over
collimated? Important soft tissues
of the neck and its precervical
fascia are important to
radiographic diagnosis. This
radiograph should be repeated.
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Is this a good
AP cervical
spine
radiograph that
meets all of the
diagnostic
criteria?
215
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What could
be done to
improve the
quality of
this
radiograph?
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216
The hairpins should have been removed.
The exception is made for a trauma patient (e.g.
MVA, FALL, etc) in a cervical collar appropriately
strapped to a spine board. In such case an “as
is” image should be done first.
If this image did not have such a high
radiographic contrast C3 could have been
visualized.
Many technologists have trouble with the proper
kVp setting for the AP view.
If the positioning allows for demonstration of C3
then the radiographic technique should also! A
variable mAs with a kVp between 75-80 is
recommended.
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Here is an example of the
head being extended too far.
This view resembles a reverse
Water’s view for profiling the
odontoid tip (Fuchs).
Also notice that the
radiographic technique is
inadequate. This low contrast
image shows poor bone detail.
In addition good patient
positioning, subject detail must
be adequate for soft tissues
and bone detail.
Repeat this image with the
head tilted downward.
Use a higher ratio grid, or
select a technique that allows
for an increase in the mAs of at
least a 15% reduction in kVp to
improve subject contrast. Not
using above 80 kVp initially will
be less radiation to the patient
than a repeated film
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Diagnostic Criteria for Imaging the Open- 219
mouth odontoid view of the Cervical Spine
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Position the patient so that the upper incisors are
superimposed over the base of the skull’s external occipital
protuberance. This can be accomplished by placing the
acanthiomeatal line perpendicular to the tabletop.
Align the mid-sagittal plane (MSP) perpendicular to the
horizontally directed central ray (CR). The part is positioned
for 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 angled so that it is parallel with the infraorbitomeatal
line (IOML).
The lateral margins of C1/C2 should be aligned unless there
is pathological reason for its misalignment. The spinous
process of the axis should be on the mid-sagittal line. The
spacing of the atlantoaxial joints should be equal. Equal
spacing on the lateral borders of the odontoid process; the tip
should be completely seen.
Structures demonstrated are: atlantoaxial joints,
occipitoatlantal joints, odontoid process and body of the axis,
and lateral masses and transverse processes of the atlas.
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In addition to adequately
visualizing C1 and C2, the
following alignments should be
meet when positioning the
patient:
The lateral margins of C1/C2
should be aligned unless there
is pathological reason for its
misalignment.
The spinous process of the
axis should be on the midsagittal line.
The spacing of the atlantoaxial
joints should be equal.
Equal spacing on the lateral
borders of the odontoid
process; the tip should be
completely seen.
221
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Notice that this image is poorly
collimated. There is nothing to
be gained by including the
maxillary sinuses!
Secondly, the upper incisors are
projected above the base of the
skull. The chin should be tucked
down (flexed) to line up the
teeth and base of skull. The
acanthiomeatal line should be
perpendicular to the tabletop.
The atlantoaxial joints are not
opened because of the poor
positioning. Also notice the
rotation of the spinous process
and spacing on the lateral
borders of the odontoid process.
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Don’t be fooled into thinking that this
is a good radiograph just because the
anatomy is present.
The anatomical relationships must be
presented as well.
Here is another example of an open
mouth odontoid view in which the
head is extended too far back.
The chin should be brought down
until the upper teeth are
superimposed over the base of the
skull (arrows). This will require
bringing the acanthiomeatal line
perpendicular to the tabletop. The
spacing of the atlantoaxial joints is
not properly demonstrated.
It is very possible to get a good view
that demonstrates the joint spaces
and odontoid process. Unfortunately,
this view should be repeated.
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Because of the metal
tooth plate it will be
difficult to image the
odontoid tip.
Because the alignment of
the teeth and base of the
skull are adequate
repeating this view may
not yield the desired
result.
Instead, bring the head
down just a little, then
lower the tube to about
20 cm.
Allow the divergence of
the CR to clear the part.
The other option is to add
a Fuchs view.
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Consider that the
Should the image should be repeated!
lateral masses are
covered by dental
fillings; your
positioning becomes
even more critical.
The chin is tucked
down too much!
Slightly tilt the head
backwards. This will
help to demonstrate
more of each lateral
mass and the odontoid
tip.
You still may need to
add a Fuchs view to
demonstrate the
spacing on each side
of the odontoid peg
Collimation???
225
70 degrees for
zygos
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227
228
Breathing
tech
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C7 and L1 must be entirely
demonstrated to evaluate for
subluxation of the thoracic spine.
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Poor centering
poor contrast / spaces not open
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232
Because of
the chest
tube and
intubation,
the
positioning
seen here is
acceptable.
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235
236
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238
It appears there was some difficulty in
locating the lumbosacral junction.
To find L5/S1 you should remember that the
iliac crest is at the level of L4.
This places L5/S1 at approximately 1 inch
below this point. T
there is too much of the lumbar spine
demonstrated and too little of the sacrum.
The collimation is poor
This radiograph must be repeated using the
radiological landmarks for locating L5/S1.
The radiographic exposure technique
should also be changed so that the part is
well penetrated. This is a high contrast film
having poor penetration of the lumbosacral
junction.
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For L5- S1 – is it acceptable?
240
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part is not centered
it is clipped
metal snaps are present
The patient is not
positioned in a true lateral.
A disruption of the
column, or encroachment
on the vertebral canal
cannot be evaluated.
Also, 5% of patients have
spondylolisthesis
secondary to chronic
stress fractures
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242
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244
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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.
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