1. Cervical and Thoracic Spine

2. Evaluation Criteria Structures shown Position/projection
Collimation/central ray
Exposure criteria
Acceptable and unacceptable C & T spine based on errors i.e.:
Motion
Collimation
Positioning
Exposure factors
Side markers and patient demographic information
Every time a radiographer completes an image, an evaluation must be made to determine whether the image is diagnostically optimal for the radiologist to provide an accurate diagnosis. A radiologist should NEVER have to return an image for repeat if proper evaluation of the image is done by the radiographer.
Here are five basic criteria for radiographic evaluations and critique. These should be used every time a radiographic image is performed.

3. Introduction <Image 0 and 1>
The vertebral column is comprised of approximately 33 separate bones, called vertebrae. The vertebrae are generally considered in four primary divisions: cervical, thoracic, lumbar, and sacrum and coccyx. The bones in each have features that distinguish them from other types of vertebrae.
The uppermost seven are the cervical vertebrae and bear little resemblance to the other vertebrae. The most easily identified distinctive feature of the cervical vertebrae is the foramen in the transverse process, called the transverse foramen. The cervical vertebrae are the smallest of the moving vertebrae. The typical cervical vertebra has two main parts, a body and a vertebral arch. The vertebral arch surrounds the vertebral foramen, which is comparatively large and triangular rather than round. The vertebral foramen protect and house the spinal cord and the surrounding structures.
The thoracic spine consists of twelve vertebrae. At the superior end the vertebrae are small and resemble cervical vertebrae. As the vertebrae become larger toward the inferior end, they tend to resemble a typical lumbar vertebra. Other than size, each of the thoracic vertebrae has a similar bony process. Unlike the cervical vertebrae they possess no transverse foramen. The thoracic spine normally has a convex curvature. Abnormal accentuation of this curve is called kyphosis and may result in a hunchback. Abnormal lateral curve of the thoracic spine is called scoliosis. Kyphosis may occur in isolation or may occur with scoliosis (kyphoscoliosis), increasing the thoracic deformity.

4. AP and Lateral Cervical Spine Basics
<Images 2-3>
Routine images of the cervical spine include: AP, obliques, AP open mouth odontoid, lateral, and swimmer’s lateral. Alternate positions/projections consist of: AP wagging jaw (Otonello), AP odontoid process (Fuchs), PA odontoid process (Judd), flexion/extension laterals and AP vertebral arch. Only the routine positions/projections will be discussed in video. Imaging examinations of the cervical spine is performed to investigate degenerative disease and cases of trauma.

5. AP & Lateral Imaging Criteria
Technical Considerations
Regular IR
Grid
kVp range: 75-80
AP:
SID: 40 inches (100 cm)
IR size 10 x 12 inch (24x30 cm)
Lateral:
SID: 72 inches (180 cm)
IR size 10 x12 inch (24x30 cm)
Patient Position
Patient is supine with midsagittal plane (MSP) centered to the midline of the table.
Erect or seated with left side against the IR
Part Position
AP :
Adjust so there is no rotation of the head or body
Extend the neck so that a line from the lower edge of the upper incisors to the mastoid tips (occlusal plane) is perpendicular to the IR
Lateral :
Center the midcoronal plane to the midline of the IR
Adjust the body so the MSP is parallel to the IR
Depress the shoulder
Raise the chin slightly to prevent overlap of the mandibular rami on the upper vertebrae
Central Ray (CR)
CR directed to C5 (thyroid cartilage) with a 15 to 20 degree cephalad angle
Top of the IR should be placed about 2 inches (5 cm) above the EAM
CR is directed perpendicular to center of film at the level of the upper margin of the thyroid cartilage
Patient Instructions
“Take a deep breath, let it all out. Don’t breathe or move.”
Evaluation Criteria
Image should include C3-T2
There should be no rotation as evidenced by equal distance from spinous processes to spinous borders on each side
Intervertebral disk space should be open
Base of skull and mandible will overlap C1 and C2
Should include all seven cervical vertebrae
There should be no rotation as evidenced by superimposition or close approximation of the two mandibular rami
Mandibular rami should not be superimposed over upper cervical vertebrae
Additional Information:
This position may also be performed with the patient in an erect position
To help depress the shoulders, the patient can hold equal weight (sandbags) in each hand or pull up with both hands on a long strip of gauze under the feet
If it is not possible to depress the shoulders sufficiently to visualize the lower cervical vertebrae a separate swimmer’s lateral should be performed.
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Technical Considerations
Evaluation Criteria
Additional Information

6. Knowledge Check
Why is a 72 inch SID (180 cm) used on the lateral cervical spine?
Easier for the patient
Increases the magnification
Decreases the magnification
Magnification is the same at 72 (180 cm) or 40 inch (100 cm) SID

7. AP Odontoid and Oblique Basics
<Images 5 and 6>
The AP odontoid open mouth position demonstrates the first two cervical vertebrae free of superimposition. The oblique position PA projection demonstrates the open intervertebral foramina and pedicles closest to the IR (the side down). Both sides are performed for comparison.

8. AP Odontoid and Oblique Imaging Criteria
Technical Considerations
Regular IR
Grid
kVp range: 75-80
AP Odontoid Open Mouth:
SID: 40 inches (100 cm)
IR size 10 x 12 inch (24x30 cm)
Oblique:
SID: inches (when done with wall bucky)
Patient Position
Patient is supine with midsagittal plane (MSP) centered to the midline of the table
Erect or seated with the body at a 45 degree angle from the PA position to the IR
Part Position
Adjust so there is no rotation of the head or body
Extend the neck so that a line from the lower edge of the upper incisors to the mastoid tips (occlusal plane) is perpendicular to the IR
Have the patient open mouth by lowering the lower mandible
Adjust the whole body to form an angle of 45 degrees with the plane of the IR
Patient’s head should look straight ahead and chin should be extended slightly
Central Ray (CR)
CR directed perpendicular through the center of the open mouth
Directed to C4 (upper margin of the thyroid cartilage)
CR angled degrees caudal
Patient Instructions
“Take a deep breath, let it all out. Don’t breathe or move.”
Evaluation Criteria
C1 and C2 should be clearly demonstrated through the open mouth
C1-C2 zygapophyseal joints should be clearly visible on the image
If the lower edge of the upper incisors and the base of the skull are superimposed, the position cannot be improved
Upside Intervertebral foramina and disk spaces should be open
All seven cervical vertebrae should be seen
Chin should be sufficiently elevated so the mandiblular rami do not overlap C1
Additional Information:
Patient should not open his mouth until just before the exposure is made, because this position is somewhat uncomfortable and difficult to maintain
Care must be taken that only the lower jaw is moved when the mouth is opened, maintaining the position of the spine
If the upper incisors obscure the vertebrae, the chin needs to be elevated
If the base of the skull obscures the vertebrae, the chin must be depressed more
Take care that the center AEC has full primary beam collimation
These projections may also be performed with the patient in a recumbent position, although the erect or seated position is preferred
These projections may also be performed with the patient rotated 45 degrees from the AP position
With the AP position the CR is then directed to C4 at a 15 to 20 degree cephalad angle
Some department protocols call for these projections to be performed at 72 inch SID (180cm) the same as the lateral position
Take care that the patient remains centered to the AEC
>
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Guidelines
Evaluation Criteria
Additional Information

9. Knowledge Check <Image 10, Answers Image 9>
1. Label the following anatomy:
C1, C2, Right superior lateral mass, Left inferior lateral mass,
<Image 8, Answers Image 7>
2. Label the following anatomy:
Pedicles, Dens, Superior articulating facets, Spinous process, Right first rib, Inferior articulating facets, Left neural foramina

10. Swimmer’s Lateral Basics
<image 11>
The most common reason for performing the swimmer’s lateral for either the cervical spine or the thoracic spine is trauma to the upper thoracic or lower cervical vertebra. The swimmer’s lateral will demonstrate the junction between C7 and T1 and the first three to four thoracic vertebrae, which are not visualized on the routine lateral thoracic spine images.

11. Swimmer’s Lateral for the Cervical and Thoracic Spine Criteria
Technical Considerations
Regular IR
Grid
kVp range: 80-90
SID: 40 inches (100 cm)
IR size 10x12 inch (24x30 cm)
Patient Position
Left lateral recumbent
Part Position
True lateral position with the MSP parallel to the IR
Arm closest to the table is abducted far above the head while the shoulder farthest from the IR should be depressed as much as possible
Rotate the depressed shoulder forward slightly to prevent superimposition of the humeral heads on the vertebral bodies
Central Ray (CR)
CR directed at a 5 to 10 degree caudal angle to the level T1-T2
Patient Instructions
“Take a deep breath, let it all out. Don’t breathe or move.”
Evaluation Criteria
Disk space between C7 and T1 and the first three to four thoracic vertebrae must be visualized
Humeral heads should not be superimposed on the vertebral bodies
Additional Information:
A pillow or sponge should be placed under the patient’s head to prevent it from tilting toward the IR
The patient may be allowed to continue breathing normally during the exposure because this will blur out the thorax shadows, which frequently obscure bony detail
If the patient condition allows, this position may be performed upright
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Guidelines
Evaluation Criteria
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12. Knowledge Check <Image 15, answers on 16)
Label the following anatomy:
C6, T1, T4, Elevated humerus, Elevated clavicle, Depressed clavicle

13. AP and Lateral Thoracic Spine Basics
<(Images #17 & 18
The most common rationale for thoracic spine imaging is trauma and degenerative disease of the spine. Structures best demonstrated on the images include the vertebral bodies, transverse processes pedicles, and intervertebral disk space. On the lateral images the intervertebral foramina are visualized; spinous processes are not well visualized due to their superimposition on the ribs. The upper three to four vertebrae are not visualized due to superimposition from shoulder structures.

14. AP and Lateral Thoracic Spine Criteria
Technical Considerations
Regular IR
Grid
kVp range: 75-80
SID: 40 inches (100 cm)
IR size 14x17 inch (35x43 cm)
Patient Position
AP:
Supine with the MSP centered to the midline of the table
Arms are placed a the patient’s sides
Lateral:
Recumbent left lateral with knees and hips flexed for comfort
Arms are drawn forward at right angles to the body to prevent the scapulae from superimposing on the thoracic spine
Part Position
Scapulae and upper spine are flat on the table with no rotation
Knees may be flexed to bring the spine in closer contact with the table
Place the long axis of the spine parallel to the IR
Sagittal plane should be parallel and the coronal plane perpendicular to the IR
Midaxillary line should be centered to the IR
Central Ray (CR)
CR is perpendicular and directed 3 to 4 inches (8-10 cm) below the jugular notch to the sixth thoracic vertebra
Top of the IR of should be 1-2 inches (3-5 cm) above the top of the shoulder
CR is perpendicular and directed 4 inches (10 cm) below the jugular notch to the seventh thoracic vertebra
Top of the IR should be ½ to 1 inch (1-3 cm) above the top of the shoulder
Patient Instructions
“Take a deep breath, let it all out. Don’t breathe or move.”
Evaluation Criteria
Image must include all thoracic vertebrae
Transverse processes, pedicles, vertebral bodies and intervertebral disk spaces should be demonstrated
Although visible, the transvers processes are normally superimposed on the heads of the ribs
Rotation, as evidenced by the asymmetrical appearance of the transverse processes or pedicles, should be observed
Spinous processes should be in the midline
Image must include at least T4-T12
Posterior ribs should be mostly superimposed indicating minimal rotation
Intervertebral disk spaces and intervertebral foramina should be clearly demonstrated
Additional Information:
Patients with severe kyphosis may be imaged in the prone position with a PA projection or upright.
Some department protocols require collimation to the edge of the transverse processes
Others prefer the collimators to be left open to view the entire thorax, on a 14 x 17 inch (35x 43 cm) IR
Radiographic densities in the thoracic region vary considerably
The air filled trachea overlies the upper vertebrae
The fluid filled heart overlies the mid and lower vertebrae
A wedge filter or the anode-heel effect may be used to help maintain even levels of density from T1-T12
If a pillow is used, care must be taken not to place it under the thoracic vertebra
If a visible downward sag is present in the spine after placing the patient into a lateral position, a small radiolucent sponge should be placed under the thoracolumbar area to make the spine parallel to the IR
To visualize the upper three to four vertebrae, a swimmer’s lateral must be performed
If the patient is unable to lie on the left side, a right lateral may be substituted
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Guidelines
Evaluation Criteria
Additional Information

15. Knowledge Check
Which of the following is an abnormal “hunch back” curve of the thoracic spine?
A. Lordosis
B. Scoliosis
C. Kyphosis
D. None of the above

16. Summary <Images 20 and 17>
Positioning of the cervical and thoracic spines can be tricky especially when the patient has anomalies that require alternate positioning. When the radiographer is familiar with the routine positioning then alternate imaging positions can be used to compensate for the patient anomalies.