Cervical Spine Imaging Quiz

Course Agenda

• Course Plan Overview
• Discussion on Clinical Experience
• Lecture

Cervical Spine Imaging Objectives

• Perform Basic Cervical Spine Projections
• Understand Indications for Cervical Spine Imaging
• Develop Basic Image Critique Skills

Cervical Vertebrae Anatomy

• C1 (Atlas): Located at the top of the spine, no spinous process or body, forms articulation with occipital bone, dens (odontoid process) situated in the anterior ring
• C2 (Axis): Has a strong odontoid process, superior articular processes join with inferior processes of succeeding cervical vertebrae
• C3-C6 (Typical Vertebrae): Narrow and thin processes; Spinous processes are short with double pointed tips
• C7: Has a long prominent spinous process, easily palpable at the base of the neck, called vertebra prominens

Cervical & Lumbar Spinal Curves

• Concave posteriorly - Lordotic Curve
• Compensatory Curves

Thoracic & Sacral Spinal Curves

• Convex posteriorly - Kyphotic Curve
• Primary Curves

Cervical Vertebrae Views

• AP "Open Mouth" Projection (C1-C2)
• AP Axial Projection (C3-C7)
• Lateral Projection
• Cervical Thoracic Swimmer's Lateral (Twining Method)
• Anterior & Posterior Oblique Projections
• Lateral Projections (Flexion and Extension)
• AP Axial Projection (Ottonello Method) - Wagging Jaw
• AP/PA Projection (Fuchs Method)

Patient Preparation for Cervical Spine Imaging

• Remove preventable artifacts (earrings, chains, hairpins, barrettes, braids, wet hair, extensions, dentures, partial plates, retainers, clothing, shirts, bra straps, gum or candy)
• Pregnancy screening/child-bearing age assessment (pg 3)

Cervical Spine X-ray Indications

• Chronic neck pain
• Acute neck pain
• Rule out fracture
• Rule out disc herniation
• Arthritis (degenerative bone/disc or joint disease)
• Limited range of motion
• Pathology (rule out metastasis, osteoporosis)
• Radiculopathy (numbness or pain in arms, hands or fingers due to nerve root compression)

Important Landmarks for Cervical Spine Imaging

• Meatus (opening leading to the inferior of the body)
• Glabelloalveolar (GAL)
• Glabellomeatal (GML)
• Orbitomeatal (OML)
• Infraorbitomeatal (IOML)
• Acanthiomeatal (AML)
• Lips-meatal (LML)
• Mentomeatal (MML)
• Interpupillary Line
• Occlusal Plane

C-Spine Open Mouth Projection (C1/C2 Odontoid)

• Patient Position: AP supine or erect, face forward, mandibular angles & mastoid tips equidistant from IR, tuck chin until a line connecting lower incisors & mastoid tip is perpendicular to IR
• Instruct patient to open mouth as wide as possible

C-Spine Open Mouth Projection (C1/C2 Odontoid) Central Ray

• No angulation, CR perpendicular to IR
• Angle 5 degrees cephalically
• Center the CR to the MSP & midpoint of the open mouth
• Instruct patient to keep mouth wide open & to AHHHHH
• 75 +/- 5 kV range

C-Spine Open Mouth Projection (C1/C2 Odontoid) Image Analysis

• Atlas symmetrically seated on axis
• Spinous process of axis aligned with midline
• Mandibular rami equidistant from dens
• Atlantoaxial joint open, dens center of exposure field

Cervical Rotation (Image Analysis)

• Distance between mandibular rami & lateral masses
• Side with greater distance indicates the side of rotation

Cervical Projection (Image Analysis)

• Lateral cervical projection demonstrates how the upper incisors, occipital base, & mastoid tip relate perpendicularly.
• Upper incisors positioned at long OID, causing magnification.
• 5 degrees cephalic needed to project magnified upper incisors away from the dens.

Cervical Projection (Trauma)(Image Analysis)

• Angle CR at least 10 degrees down since head is extended
• Use IOML to determine angulation
• Don't adjust head rotation/tilting if patient cannot open mouth

Cervical Collar Limitations

• Sometimes collar prevents jaw lowering
• Have the ordering physician or nurse remove the front of the collar so the patient can drop the jaw without adjusting the head/neck
• After the projection is taken, have the ordering physician return the front of the cervical collar to its proper position

Not Enough Angulation for Trauma

• Upper incisors demonstrated superior to the dens
• Dens superimposed over occipital base
• Need 10-degrees caudal angle

Too Much Angulation for Trauma

• Occipital base superior to the dens
• Upper incisors superimposed over the dens

C-Spine AP Axial Projection

• Patient position: AP supine or erect, face forward, mandibular angles & mastoid tips equidistant from IR, align the lower surface of upper incisors & tip of mastoid process perpendicular to IR
• Align the midline of the neck, with the midline of the IR and grid.
• Central Ray: Directed through C4, at an angle of 15 to 20 degrees cephalad. Use 75 +/- 5 kV range

C-Spine Lateral Cervicothoracic (Swimmers/Twinning) Method

• Goal: Separate overlapping structures
• Performed when C7/T1 not demonstrated on lateral cervical spine
• Patient position: Erect or recumbent lateral, flex knee & hips for support (trauma only), ensure weight on feet, align MCP perpendicular with IR, elevate arm positioned closer to IR as high as patient can, place opposite arm against patient's side, instruct the patient to depress the shoulder, place head in lateral position

C-Spine Lateral Cervicothoracic (Swimmers/Twinning) Method - Central Ray

• Center CR to the MCP at a level 1 inch superior to the jugular notch or at the level of the vertebral prominens
• SID 72 inch
• 80 +/- 5 kV range (increase 5-10 if patient unable to depress shoulder)
• CR angulation: 5 degrees caudal if clavicle obscures exposure

C-Spine Lateral Cervicothoracic (Swimmers/Twinning) Method - Image Analysis

• Rt & Lt cervical zygapophyseal joints, articular pillars, & posterior ribs are superimposed
• The humerus that is elevated is aligned with the vertebral column
• C5-C7 are demonstrated without shoulder superimposition
• Intervertebral disk spaces are open
• Vertebral bodies are demonstrated without distortion
• T1 is at the center of the exposure field; collimate to area of interest to avoid scatter, and place marker in exposure field.

Additional Views (uncommon)

• These include, but aren't limited to, the following: AP projection—Fuchs’s method; AP projection—Ottonello method; AP axial projection—vertebral arch (pillars).

AP Projection—Fuchs’s Method

• Patient position: Supine, extend chin until tip of chin and tip of the mastoid process are vertical
• Central Ray: Perpendicular to the midpoint of the IR, enters the neck on the MSP just distal to the tip of chin
• Evaluation criteria: Entire dens within the foramen magnum

AP Projection—Ottonello Method

• Often called “Wagging Jaw”
• Patient performs a chewing motion of the mandible during exposure
• Immobilize the head to prevent movement
• Long exposure time is necessary

AP Axial Projection—Vertebral Arch (Pillars)

• CR angulation projects the vertebral arch free of anteriorly vertebral bodies & transverse processes
• Useful for visualizing cervicothoracic spinous processes in whiplash injury
• Position: MSP perpendicular to the table, then fully extend patient’s neck. If full extension can't be tolerated, an AP axial oblique projection is recommended.
• Central ray: Directed at C7 at a 25° caudad angle

AP Axial Projection—Vertebral Arch (Pillars) - Evaluation Criteria

• Vertebral arch structures without overlapping of the vertebral bodies & transverse processes
• Articular processes
• Open zygapophyseal joints between the articular processes

Test your knowledge on the proper techniques and positioning for lateral radiography of the cervical spine. This quiz covers key aspects such as centering, chin positioning, and central ray direction, along with the rationale for recommended SID distances. Enhance your understanding of radiographic practices for the C-spine.