Cervical Vertebrae Imaging Techniques Quiz
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Questions and Answers

What adjustment must be made to the angle of the tube to ensure proper projection of the upper incisors away from the dens?

  • 5 degrees cephalic (correct)
  • 10 degrees lateral
  • 5 degrees caudal
  • No adjustment needed

    • If the head is tilted too far back during the procedure, what might be obstructed?

  • Intervertebral spaces
  • The occipital base (correct)
  • Cervical spine alignment
  • The dens (correct)

    • What is the likely outcome of forgetting to angle the tube 5 degrees cephalic?

  • Dens will be superimposed (correct)
  • Upper incisors will be visible
  • Intervertebral spaces will be distorted
  • Clear imaging of lateral masses

    • During the imaging process, what is a necessary action to correct the patient’s positioning if the chin is not tucked in?

    <p>Tuck the chin in more</p> Signup and view all the answers

    What might happen if the occipital base shifts during trauma?

    <p>Dens and atlantoaxial joint will be misaligned</p> Signup and view all the answers

    What happens to the vertebral bodies when positioned closer to the image receptor (IR)?

    <p>They move toward the side positioned closer to the IR.</p> Signup and view all the answers

    How do the spinous processes move in relation to the image receptor?

    <p>They move toward the side positioned farther from the IR.</p> Signup and view all the answers

    In a kyphotic patient, what curvature is typically observed in the cervical vertebrae?

    <p>Excessive lordotic curvature.</p> Signup and view all the answers

    What is necessary to ensure open intervertebral spaces during an upright AP axial projection of the cervical vertebrae?

    <p>Increase the CR angulation.</p> Signup and view all the answers

    What results from not using enough cephalic angulation during imaging?

    <p>The jaw is lower than the skull.</p> Signup and view all the answers

    What occurs when there is too much cephalic angulation during cervical vertebrae imaging?

    <p>Each spinous process falls within the inferior adjoining vertebral body.</p> Signup and view all the answers

    In the context of cervical spine positioning, how should the head be oriented during an AP axial projection?

    <p>Projected cephalically.</p> Signup and view all the answers

    What happens to the uncinate processes when excessive cephalic angulation is applied?

    <p>They become elongated.</p> Signup and view all the answers

    What occurs when there is too much angulation at the atlantoaxial joint?

    <p>The atlantoaxial joint space is closed</p> Signup and view all the answers

    How should one adjust CR angulation when the patient's chin is tilted upward due to a cervical collar?

    <p>Increase angulation by approximately 10 degrees caudally</p> Signup and view all the answers

    What anatomical landmark is used to determine the needed CR angulation?

    <p>IOML</p> Signup and view all the answers

    What happens if the patient cannot open their mouth during an imaging procedure?

    <p>Proceed with a closed mouth projection only</p> Signup and view all the answers

    What is a consequence of having too much angulation when imaging the base of the skull?

    <p>The upper incisors are positioned too superiorly</p> Signup and view all the answers

    What is the recommended first step if the cervical collar limits the lowering of the lower jaw?

    <p>Attempt to get the patient to drop their lower jaw</p> Signup and view all the answers

    Why is it necessary to angle the CR downwards when dealing with a patient experiencing trauma?

    <p>To avoid superimposing the occipital base and atlantoaxial joint space</p> Signup and view all the answers

    What should be avoided when imaging if the patient cannot open their mouth?

    <p>Adjusting head rotation</p> Signup and view all the answers

    What does the term 'meatus' refer to in the context of anatomical landmarks?

    <p>An opening leading to the interior of the body</p> Signup and view all the answers

    What is the appropriate alignment for the lower edge of the upper incisors during an open mouth C1/C2 odontoid projection?

    <p>Perpendicular to the IR</p> Signup and view all the answers

    What is the function of instructing the patient to 'AHHHH' during exposure for the C-Spine Open Mouth projection?

    <p>To prevent movement of the mandible and position the tongue correctly</p> Signup and view all the answers

    What is the central ray (CR) requirement for the C-Spine Open Mouth projection?

    <p>Perpendicular to the IR with no angulation</p> Signup and view all the answers

    In preparing for a C-Spine X-ray, what is the method for positioning the patient?

    <p>Patient in an AP supine or erect position with face forward</p> Signup and view all the answers

    Which vertebrae are specifically targeted during the C-Spine Open Mouth projection?

    <p>C1 and C2</p> Signup and view all the answers

    What potential condition is indicated by numbness in toes, related to nerve issues?

    <p>Sciatica</p> Signup and view all the answers

    During a lateral or oblique view of the C-Spine, what must the lines be?

    <p>Perpendicular to the CR</p> Signup and view all the answers

    What is the primary goal of the C-Spine Lateral Cervicothoracic/Swimmers projection?

    <p>To separate overlapping structures</p> Signup and view all the answers

    When should the C-Spine Lateral Cervicothoracic/Swimmers projection be performed?

    <p>When C7/T1 is not demonstrated on lateral cervical spine images</p> Signup and view all the answers

    What adjustment is needed if the patient cannot depress their shoulder during the projection?

    <p>Use a 5-degree caudal CR angulation</p> Signup and view all the answers

    Which anatomical alignment is essential for a successful C-Spine Lateral Cervicothoracic/Swimmers projection?

    <p>IPL perpendicular to the IR and MSP parallel with the IR</p> Signup and view all the answers

    How is the Central Ray positioned for this projection?

    <p>Centered at MCP 1-inch superior to the jugular notch or at the level of vertebral prominens</p> Signup and view all the answers

    What imaging criteria indicates that the C-Spine Lateral Cervicothoracic/Swimmers projection has been successful?

    <p>Open intervertebral disk spaces</p> Signup and view all the answers

    Which factor influences the required kilovoltage peak (kVp) when performing this projection?

    <p>The thickness of the patient's shoulders</p> Signup and view all the answers

    How can C7 be identified on a lateral cervicothoracic projection?

    <p>It is shown underneath the elevated clavicle</p> Signup and view all the answers

    What is the primary purpose of conducting C-Spine Lateral HyperFLEXION and HyperEXTENSION procedures?

    <p>To assess the motility and stability of the cervical spine</p> Signup and view all the answers

    What must be ruled out before attempting the C-Spine Lateral HyperFLEXION and HyperEXTENSION procedures?

    <p>Cervical spine pathology or fracture</p> Signup and view all the answers

    In the flexion position during the procedure, how should the patient's head be positioned?

    <p>Dropped forward, chin to chest</p> Signup and view all the answers

    When aligning the central ray for imaging, at which level should it be centered?

    <p>C4</p> Signup and view all the answers

    What position should the patient be in for the C-Spine Lateral HyperEXTENSION?

    <p>True lateral position, either seated or erect</p> Signup and view all the answers

    Which of the following describes the image characteristics of the cervical spine in flexion?

    <p>C1-C7 spinous processes widely separated</p> Signup and view all the answers

    Which additional view is recommended when the upper half of the dens is not clearly shown in the open mouth position?

    <p>AP projection - Fuch's method</p> Signup and view all the answers

    What should be avoided if fracture or degenerative disease of the upper cervical region is suspected?

    <p>Attempting the Fuch’s method</p> Signup and view all the answers

    What is the recommended SID for C-Spine Lateral HyperFLEXION and HyperEXTENSION imaging?

    <p>72 inches</p> Signup and view all the answers

    What occurs to the mandible in a normal patient during the extension position?

    <p>Becomes horizontal</p> Signup and view all the answers

    Study Notes

    Agenda

    • Course plan overview
    • Discussion on clinical experience
    • Lecture

    Objectives

    • Perform basic cervical spine projections
    • Indications for cervical spine imaging
    • Basic image critique

    Anatomy of the Cervical Spine

    • C1 (Atlas): Located at the top of the spine, forms articulation with the occipital bone, lacks spinous process and vertebral body
    • Dens (Odontoid process) of C2 (Axis): Located in the anterior portion of the ring, supporting the spinal cord
    • Transverse processes of C1: Are longer and sit laterally and slightly inferior
    • Superior articular processes of C1: Are large and deeply concave
    • Odontoid process of C2: strong and connected to the occipital bone condyles
    • C3-C6 Vertebrae (Typical Vertebrae): Narrow and thin, with short and wide processes, having double-pointed tips. Their superior and inferior articular processes connect to the succeeding cervical vertebrae
    • C7 (Vertebra Prominens): Has a long prominent spinous process that's easily palpable at the base of the neck. It represents a key landmark

    Cervical & Lumbar Spinal Curves

    • Concave posteriorly
    • Lordotic curve
    • Compensatory curves

    Thoracic & Sacral Spinal Curves

    • Convex posteriorly
    • Kyphotic curve
    • Primary curves

    Basic Cervical Views

    • AP "Open Mouth" Projection (C1-C2)
    • AP Axial Projection (C3-C7)
    • Lateral Projection
    • Other, supplemental views, including:
      • Cervicothoracic Swimmer's Lateral Position (Twining Method)
      • Anterior & Posterior Oblique Projections
      • Lateral Projections (Flexion and Extension)
      • AP Axial Projection (Ottonello Method) - Wagging Jaw
      • AP/PA Projection for C1/C2 (Fuchs Method)

    Patient Preparation

    • Remove preventable artifacts (earrings, chains, hairpins, braids, wet hair, extensions, dentures, partial plates, retainers, clothing, shirts, bra straps, gum or candy)
    • Specifics for pregnancy screening/childbearing age (no longer an OTIMROEMPQ requirement)

    In practice...

    • Lateral Projection (alignment, potential artifacts, first projection for trauma using horizontal beam lateral projection)
    • AP Axial Projection
    • Open Mouth Projection

    Indications for Cervical Spine X-rays

    • Chronic neck pain
    • Acute neck pain
    • Rule out fractures
    • 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)
    • Referred Pain (pain felt in a body part other than the source)

    Useful Landmarks

    • Meatus (opening leading to the inferior of the body)
    • Glabelloalveolar (GAL)
    • Glabellomeatal line (GML)
    • Orbitomeatal line (OML)
    • Infraorbitomeatal line (IOML) or Reid's base line
    • Acanthiomeatal line (AML)
    • Lips-meatal line (LML)
    • Mentomeatal line (MML)
    • Interpupillary line
    • Occlusal plane

    C-Spine Open Mouth C1/C2 Odontoid Projection

    • Patient position: AP supine or erect, face forward, mandibular angles & mastoid tips at equal distances from the IR, tuck chin, align lower edge of upper incisors and mastoid tip perpendicular to the IR, instruct patient to open mouth widely
    • Central ray: Perpendicular to IR, Angle 5 degrees cephalically, center to MSP & midpoint of open mouth, instructed to keep mouth wide open during exposure, 75+/- 5 kV range
    • Purpose: Prevents mandible movement, places the tongue, and prevents it's projection on the Atlas or Axis

    C-Spine Image Analysis Guidelines

    • Symmetry of atlas on axis (lateral masses equal distance from dens)
    • Axis spinous process aligned with axis body midline
    • Mandibular ram equidistant from dens
    • Odontoid (dens) centrally located in the exposure field
    • Atlantoaxial joint open
    • Proper collimation and marker

    C-Spine Image Analysis - Rotation

    • Distance between mandibular rami and lateral masses
    • Side with greater distance indicates rotation direction

    C-Spine Image Analysis - Angulation

    • Upper incisors not aligned perpendicular to the IR
    • 5° cephalic angulation needed for upper incisors
    • Upward tilting instead of chin tilt, superimposed dens and atlantoaxial joints

    C-Spine AP Axial Projection

    • Patient position: supine or erect, face forward, mandibular angles and mastoid tips at equal distances from the IR, lower surface of upper incisors and tip of mastoid process perpendicular to the IR, align the midline of the neck with the midline of the IR and grid
    • Central ray: Directed through C4 at 15-20 degrees cephalad, for supine 15 degrees, for erect 20 degrees, for kyphotic angle > 20 degrees, enter at most prominent point of thyroid cartilage (Adam's Apple), center CR to the MSP at a level halfway between the EAM and the jugular notch.
    • 75 +/- 5 kV range

    C-Spine Image Analysis - Lordotic Curvature

    • Degree of CR angulation needed to obtain open intervertebral disk spaces and align spinous processes within them
    • Supine: Gravitational pull places middle cervical vertebrae more straight
    • Intervertebral spaces free of superimposition
    • Correct tube angulation for a correct image

    C-Spine Image Analysis - Rotation

    • Mandibular angles and mastoid tips distance from the cervical vertebrae
    • Spinous processes' distance from the cervical vertebrae
    • Pedicles and articular pillars' lateral symmetry from the vertebral bodies
    • Clavicles medial ends distance from vertebral column

    C-Spine Lateral Projection

    • Patient position: AP supine or erect, midcoronal plane passing through the mastoid tip centered to IR, chin elevation, align IPL perpendicular to IR, parallel chin to floor to prevent mandible superimposition on spine, depress shoulders, patient holds under chair and suspend at end of full exhalation
    • Central ray: perpendicular to 1-inch distal point of the adjacent mastoid tip, SID 72 inches, 75 +/-5 kV range, if spine further from IR, 72 SID use weigh to depress shoulder for 5-10 lbs weight.

    Lateral Cervical Views - Image Analysis Guidelines

    • Superimposition of structures (anterior/posterior/superior/inferior aspects of right/left articular pillars, zygapophyseal joints)
    • Mandibular rami in profile
    • Spinous processes in profile/open intervertebral disk spaces
    • Posterior C1 arch & spinous process of C2 in profile (without occipital base superimposition, and degree of chin elevation)
    • C1 and C2 bodies, without mandibular superimposition
    • Sella turcica, clivus, C1-C7, and half of T1 are all included in the exposure field
    • Proper collimation and marker
    • Positioning for separation of structures

    Lateral Flexibility and Extension Views - Image Analysis

    • Placement on the same horizontal plane
    • If head tilted toward IR, separation between right and left articular pillars and zygapophyseal joints
    • Inferior cortices of the cranium and mandibular rami are demonstrated without superimposition
    • C1 vertebral foramen

    Additional Views (Uncommon)

    • Spread the word (additional views, often not needed as routine)

    AP Projection - Fuchs' Method

    • Patient position: Supine, extend the chin until the tip of the chin and mastoid process are vertical, adjust the head so the MSP is perpendicular to the plane of the grid,
    • Central ray: Perpendicular to the midpoint of the IR, enter the neck on the MSP just distal to the tip of chin, 75 +/- 5 kV range
    • Evaluation criteria: Entire dens lies within the foramen magnum, and no head/neck rotation (symmetrical mandible, cranium and vert.

    AP Projection - Ottonello Method (Wagging Jaw)

    • Patient position: Supine, elevate the chin and place the occlusal surface of the upper incisors and the mastoid tips in the same vertical plane, mandible is rigidly immobilized,
    • Use low mA & long exposure time,
    • Mandibular shadow is blurred by the chewing motion during exposure
    • Central ray: Perpendicular to C4, enters the neck at the most prominent point of the thyroid cartilage
    • Evaluation criteria: Entire cervical spine is recorded with the mandible blurred or obliterated

    AP Axial Projection - Vertebral Arch (Pillars)

    • Patient position: Supine, with MSP of the head perpendicular to the table; if the patient cannot extend their neck, use an oblique approach,
    • Central ray: Directed at C7 at an angle of 25 degrees caudad
    • Angulation determined by the cervical lordosis (more lordosis = more angle), for 75 +/- 5 kV range
    • Evaluation criteria: Vertebral arch structures without overlapping of vertebral bodies & transverse process, open zygapophyseal joints between the articular processes.

    Image Analysis - Trauma Unit

    • First projection: horizontal beam lateral (to evaluate patient prior to any movement)
    • Do not manipulate head/depress shoulders/perform swimmers view unless physician permits

    C-Spine Lateral Cervicothoracic/Swimmers/Twinning Method

    • Goal: Separating overlapping structures
    • Indications: When C7/T1 not demonstrated on lateral cervical spine (post-op, pathology)
    • Patient position: Erect or recumbent lateral position (flex knee and hip for recumbent, distribute weight on both feet for upright, position the MCP perpendicular to the IR, elevate the arm closer to the IR above the head, align opposite arm along the side and depress the shoulder, position the head in lateral position, and ensuring that IPL perpendicular to the IR and MSP parallel with the IR, CR skims shoulder, at same level of T1, increase kVp, to 80-90ish).
    • Central ray: Center CR to MCP 1-inch superior to the jugular notch or prominens.SID 72 inch, and 80 +/- 5 kV range. If the patient cannot depress their shoulder use a 5-degree caudal CR angulation, Exposure occurs during suspended expiration.

    Image Analysis - Cervical Rotation Detection

    • Orientation of mandibular angles and mastoid tips from cervical vertebrae.
    • Spinous processes distance from the cervical vertebrae.
    • Lateral symmetry of pedicles and articular pillars related to vertebral bodies
    • Evaluation of clavicle medial ends, from vertebral column.

    Image Analysis-Obliquity

    • Insufficient obliquity: Less than 45-degree obliquity will result in narrowed intervertebral foramina, obscured or foreshortened pedicles of interest.
    • Excessive obliquity: Greater than 45-degree rotation - opposite pedicles positioned along the midline of the vertebral bodies. Zygapophyseal joints with demonstrated vertebral bodies without superimposition are demonstrated in profile.

    Image Analysis of Kyphosis

    • Excessive kyphotic curvature of thoracic vertebrae result in excessive lordotic curvature of the cervical vertebrae.
    • Demonstrate cervical vertebrae with open intervertebral spaces for an upright AP axial projection, may need adjust of CR angulation above routine.

    Image Analysis - Additional Observations (Uncommon Projections)

    • C-spine AP and PA axial oblique projections;
    • Proper patient positioning is vital - head rotated; rotated 45°, then head's MSP is aligned with the IR;
    • To open the intervertebral spaces;
    • Lateral view for evaluating rotation;
    • The vertebral bodies will be closer or farther from the IR.

    Additional Views (Uncommon)

    • Spread the word (additional views, often not needed as routine)

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    Lecture 1 CSpine PDF

    Description

    Test your knowledge on the proper techniques for imaging cervical vertebrae. This quiz covers adjustments needed for projection angles, patient positioning, and common errors during imaging that affect results. Ensure your understanding of essential practices for cervical radiography.

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