IP2 Lecture Notes: Cervical & Thoracic Spine PDF

**Week 6 Lecture Notes- Cervical Spine and Thoracic Spine** 1. **Revision on Spinal Anatomy** [Kyphosis and Lordosis ] Kyphosis: Primary curve, noted in the thoracic and sacral spine Lordosis: Secondary curve, noted in the cervical and lumbar spine 33 vertebrae: - 7 cervical - 12 thoraci...

**Week 6 Lecture Notes- Cervical Spine and Thoracic Spine** 1. **Revision on Spinal Anatomy** [Kyphosis and Lordosis ] Kyphosis: Primary curve, noted in the thoracic and sacral spine Lordosis: Secondary curve, noted in the cervical and lumbar spine 33 vertebrae: - 7 cervical - 12 thoracic - 5 lumbar - 5 sacral and 4 coccygeal  [A typical vertebra ] Vertebral body anteriorly Vertebral arch posteriorly Processes: - Transverse processes - Spinous process Foramina- Vertebral and Intervertebral [The cervical vertebrae ] - Transverse foramen in transverse process that transmits vertebral artery (not c7), vein and nerves - Small, bifid spinous process [The Atypical cervical vertebrae ] C1 -- Atlas No body or spinous process 2 lateral masses and 2 arches Superior articular facet to condyles in atlanto-occipital joint Inferior articular facet to C2 (axis) C2 -- Axis Odontoid process (dens) extends superiorly 2 lateral masses [Thoracic vertebrae ] - Articular facets for ribs long, downward slope of spinous process  [Lumbar vertebrae ] - Large vertebral bodies - Small vertebral foramen [Vertebral differences ]  [Sacrum ] - 5 segments fuse after puberty **Sacral canal** Extension of vertebral canal - **Sacral foramina**: Located within the lateral masses and allow passage of nerves. - **Auricular surfaces** on lateral aspect Articulate with ilium to form the sacroiliac joint (SIJ) - **Sacral promontory** Prominent ridge on anterior of S1 segment Landmarks border between abdominal and pelvic cavities [ ] [Coccyx ] - 4 vertebrae fused into a triangular bone - Forms part of the floor of the pelvis [Spinal Joints ] Atlanto-occipital joint - Between occipital condyles and superior articular surface of atlas Atlantoaxial joint - Made up of three joints: - Synovial joint between anterior surface of dens and posterior aspect of anterior arch of atlas - Synovial joint between each lateral mass of atlas and axis Facet joints - Between articular process of neural arches of vertebrae Sacroiliac joint - Between auricular surface of sacrum and ilium 2. **C and T Spine Patient Preparation Lecture Slides** [C-spine: Patient Preparation ] Consider the area being radiographed -- what is being included - Remove jewellery - Earrings - Necklaces - Glasses - Remove objects in the mouth for the peg view - Plates - Retainers - Tongue studs - Remove clothing that will show up on radiographs - Thick collars - Buttons/studs/zippers - Prints/bling - Remove hair/hair accessories [T-spine: Patient Preparation ] Consider the area being radiographed -- what is being included - Remove jewellery - Necklaces - Remove clothing that will show up on radiographs - Thick collars - Buttons/studs/zippers - Prints/bling - Bras with underwires and clasps (metal or thick plastic) - Remove hair/hair accessories from spine - Provide a gown - Explain how to put it on (if necessary) - Assist if required - Don't forget to get your patient changed after the examination 3. **Radiographs of the C-spine** [Clinical Indications ] - Trauma - Paraesthesia in the upper extremities - Persistent headaches - Osteoarthritis - Rheumatoid arthritis [Projections ] - AP - AP open mouth C1 and C2 (peg) - Oblique (AP and PA) - Lateral - Cervicothoracic lateral (swimmers) [AP C-SPINE ] +-----------------------------------+-----------------------------------+ | **Parameter** | **Details** | +-----------------------------------+-----------------------------------+ | **Collimation** | C1-T2; Neck skin margins | +-----------------------------------+-----------------------------------+ | **Landmarks** | \- EAM -- 2.5 cm above C1 | | | | | | \- Mastoid process -- tip at C1 | | | | | | \- Sternal notch -- T2-T3 | +-----------------------------------+-----------------------------------+ | **Centre Point** | C4 (Adams apple helps locate it); | | | Lower margin of thyroid cartilage | | | at C5; Accounts for cephalic tube | | | angulation | +-----------------------------------+-----------------------------------+ | **Tube Angulation** | 15-20 degrees cephalic | +-----------------------------------+-----------------------------------+ | **Side Marker** | Left or right on the correct | | | side, laterally and midpoint of | | | the neck | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- **kV**: 70-85 | | | | | | \- **Penetration**: Adequate | | | penetration through C3-T2; C1 and | | | C2 are superimposed by the base | | | of skull and mandible | | | | | | \- **Contrast**: Appropriate to | | | demonstrate soft tissue, bony | | | margins, and trabeculae patterns | | | (low kV = high contrast; high kV | | | = decreased contrast) | | | | | | \- **mAs**: **SNR** is low if | | | mottle is present; if too high, | | | minimal mottle but high patient | | | dose -- check EI if available | | | (low mAs = low SNR; high mAs = | | | high SNR) | | | | | | **Burnout**: Loss of contrast in | | | low-attenuating areas | | | | | | \- **Time**: No motion artifact; | | | time is appropriate for that | | | patient | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | C3 -- T2 vertebrae and | | | intervertebral joint spaces | | | demonstrated in anterior to | | | posterior orientation; no | | | rotation | +-----------------------------------+-----------------------------------+ | **Head Position (YES Motion)** | Interverteb | | | ral | | | disc spaces demonstrated; 15-20 | | | degrees cephalic tube angulation | | | aligns beam with intervertebral | | | joint spaces; proper chin | | | position prevents superimposition | | | of skull over vertebrae | +-----------------------------------+-----------------------------------+ | **Rotation (NO Motion)** | Spinous processes centered in | | | vertebral bodies; | | | sternoclavicular joints | | | equidistant from lateral margins | | | of vertebral column; rotation can | | | shift these alignments | +-----------------------------------+-----------------------------------+ | **Tilt (MAYBE Motion)** | Alignment with the long axis of | | | the IR; changes beam angulation | | | relative to anatomy, leading to | | | inconsistent appearances across | | | the image | +-----------------------------------+-----------------------------------+ | **Patient Position** | Patient stands against the bucky | | | or is supine on the table; arms | | | by their side; ensure no rotation | | | (NO direction), tilt (MAYBE | | | direction), or improper chin lift | | | (YES direction) | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- **SID**: 110 cm (small OID due | | | to patient against the bucky) | | | | | | \- **Grid Use**: Scatter may be | | | problematic for larger patients | | | | | | \- **AEC Use**: C-spine over the | | | central chamber; no unwanted | | | anatomy | +-----------------------------------+-----------------------------------+ | **Respiration** | Suspended respiration | | | (inspiration and hold) to prevent | | | movement | +-----------------------------------+-----------------------------------+ [AP OPEN MOUTH C1-2] +-----------------------------------+-----------------------------------+ | **Parameter** | **Details** | +-----------------------------------+-----------------------------------+ | **Included Anatomy** | C1-C2 | +-----------------------------------+-----------------------------------+ | **Landmarks** | \- Base of skull | | | | | | \- Upper central incisors | | | | | | \- Mastoid tips | | | | | | \- Open mouth | +-----------------------------------+-----------------------------------+ | **Centre Point** | C2 - middle of the open mouth | +-----------------------------------+-----------------------------------+ | **Side Marker** | Left or right on the superior | | | corner | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- **kV**: 70-85 | | | | | | \- **mAs**: SNR too low if mottle | | | is present; if too high, the | | | patient dose increases | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | | +-----------------------------------+-----------------------------------+ | **YES (Head Tilt)** | - Upper | | | central incisors aligned with the | | | base of the skull | | | | | | \- Head tilt can achieve this | | | alignment | | | | | | \- Mouth opened sufficiently to | | | lower lateral mandibular teeth | | | below the atlantoaxial joints | | | | | | \- Clear visibility of the | | | odontoid process | +-----------------------------------+-----------------------------------+ | **NO (Rotation)** | \- Spinous process of C2 is | | | centrally located within the | | | vertebral body, indicating no | | | rotation | | | | | | \- Lateral masses and transverse | | | processes are equidistant from | | | the mandible | +-----------------------------------+-----------------------------------+ | **MAYBE (Tilt)** | \- Readability is aligned with | | | the long axis of the IR | | | | | | \- Properly centered beam | | | perpendicular to the coronal | | | plane does not impact | | | beam-anatomy alignment or image | | | appearance | +-----------------------------------+-----------------------------------+ | **Patient Position** | \- Patient stands with their back | | | against the bucky or is supine on | | | the table | | | | | | \- Arms comfortably by their side | | | | | | \- Ensure no rotation (NO | | | direction) or tilt (MAYBE | | | direction) | | | | | | \- Adjust the head so the upper | | | incisors align with the base of | | | the skull (YES direction) | | | | | | \- Ensure the mouth is opened as | | | wide as possible | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- **SID**: 110 cm | | | | | | \- **Grid Use**: Grid | | | | | | \- **AEC**: C1-C2 over central | | | chamber; AEC not recommended due | | | to base of skull and teeth also | | | being over the chamber | | | | | | \- **Respiration**: Suspended | | | respiration (inspiration) to | | | prevent movement | +-----------------------------------+-----------------------------------+ [AP and PA Oblique C-spine] Included anatomy - Cervical vertebrae - Skin margins Landmarks - EAM, Mastoid process and sternal notch Centre point - C4 - Lower margin of thyroid cartilage- most prominent part at C5 - Accounts for cephalic tube angulation Beam direction: - ◦ 15-20 degrees **cephalic** tube angulation for **posterior obliques** - ◦ The intervertebral foramen are open in the superior to inferior direction - - ◦ 15-20 degrees **caudal** tube angulation for **anterior obliques** - ◦ The intervertebral foramen are open in the superior to inferior direction Side marker - Left and right on correct side in the middle of neck Exposure factors - kV: 70-85 - to ensure penetration through cervical vertebrae - appropriate to demonstrate the soft tissue, bony margins and trabeculae patterns - mAs: if too low mottle will be present but if too high dose will be excessive **Anatomy demonstrated** - C2-C7 intervertebral foramina -- aligned with the beam - C2-C7 pedicles in profile- perpendicular to the beam YES: ◦ Chin raised so that the angle of the mandible does not overlie the spine No: ◦ Chin rotated so that it does not overlie the spine -- the patients mandible should be in a lateral orientation with both angles superimposed ◦ The intervertebral foramen are open in the anterior to posterior direction - The patient should be rotated so that their sagittal plane is 45 degrees **Patient position:** Patient stands against the vertical bucky- either in anterior or posterior orientation The patient is rotated so their midsagittal plane is 45 degrees (no direction) ◦ Anterior obliques have the patient's anterior aspect against the bucky ◦ Posterior obliques have the patient's posterior aspect against the bucky Arms ◦ Posterior oblique - comfortably by their side ◦ Anterior oblique - the arm on the raised side is placed on the bucky for stability To remove the chin from the spine, raise the chin (yes direction) and then rotate the head into a lateral position (no direction) Central ray direction: ◦ Anterior oblique - Tube is angled 15-20 cephalically to align the beam with the intervertebral foramina ◦ Posterior oblique - Tube is angled 15-20 **Technical factors:** - SID-110cm - Grid - AEC- C-spine is over the central chamber - Suspended respiration +-----------------------------------+-----------------------------------+ | **Parameter** | **Details** | +-----------------------------------+-----------------------------------+ | **Included Anatomy** | \- Cervical vertebrae | | | | | | \- Skin margins | +-----------------------------------+-----------------------------------+ | **Landmarks** | \- EAM | | | | | | \- Mastoid process | | | | | | \- Sternal notch | +-----------------------------------+-----------------------------------+ | **Centre Point** | \- C4 | | | | | | \- Lower margin of thyroid | | | cartilage at C5 (most prominent | | | part) | | | | | | \- Accounts for cephalic tube | | | angulation | +-----------------------------------+-----------------------------------+ | **Beam Direction** | \- **Posterior Obliques**: 15-20 | | | degrees cephalic tube angulation; | | | intervertebral foramina are open | | | in the superior to inferior | | | direction | | | | | | \- **Anterior Obliques**: 15-20 | | | degrees caudal tube angulation; | | | intervertebral foramina are open | | | in the superior to inferior | | | direction | +-----------------------------------+-----------------------------------+ | **Side Marker** | Left and right on the correct | | | side in the middle of the neck | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- **kV**: 70-85 for adequate | | | penetration through cervical | | | vertebrae and proper | | | demonstration of soft tissue, | | | bony margins, and trabeculae | | | patterns | | | | | | \- **mAs**: If too low, mottle | | | will be present; if too high, | | | dose will be excessive | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | - C2-C7 | | | intervertebral foramina aligned | | | with the beam | | | | | | \- C2-C7 pedicles in profile, | | | perpendicular to the beam | +-----------------------------------+-----------------------------------+ | **YES (Chin Position)** | \- Chin raised so that the angle | | | of the mandible does not overlie | | | the spine | +-----------------------------------+-----------------------------------+ | **NO (Rotation)** | \- Chin rotated so that it does | | | not overlie the spine; the | | | patient\'s mandible should be in | | | a lateral orientation with both | | | angles superimposed | | | | | | \- The intervertebral foramina | | | are open in the anterior to | | | posterior direction; the patient | | | should be rotated so their | | | sagittal plane is at a 45-degree | | | angle | +-----------------------------------+-----------------------------------+ | **Patient Position** | \- Patient stands against the | | | vertical bucky in either anterior | | | or posterior orientation | | | | | | \- Patient rotated so that their | | | midsagittal plane is 45 degrees | | | (NO direction) | | | | | | \- **Anterior Obliques**: | | | Patient's anterior aspect against | | | the bucky | | | | | | \- **Posterior Obliques**: | | | Patient's posterior aspect | | | against the bucky | | | | | | \- **Arms**: For posterior | | | oblique, arms comfortably by the | | | side; for anterior oblique, arm | | | on the raised side is placed on | | | the bucky for stability | | | | | | \- Remove the chin from the spine | | | by raising it (YES direction) and | | | rotating the head into a lateral | | | position (NO direction) | +-----------------------------------+-----------------------------------+ | **Central Ray Direction** | \- **Anterior Oblique**: Tube | | | angled 15-20 degrees cephalically | | | to align the beam with the | | | intervertebral foramina | | | | | | \- **Posterior Oblique**: Tube | | | angled 15-20 degrees | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- **SID**: 110 cm | | | | | | \- **Grid**: Yes | | | | | | \- **AEC**: C-spine over the | | | central chamber | | | | | | \- **Respiration**: Suspended | | | respiration | +-----------------------------------+-----------------------------------+ [Lateral C-spine ] +-----------------------------------+-----------------------------------+ | **Parameter** | **Details** | +-----------------------------------+-----------------------------------+ | **Included Anatomy** | - C1-T1 | | | vertebrae | | | | | | \- Skin margins | +-----------------------------------+-----------------------------------+ | **Landmarks** | \- EAM (External Acoustic Meatus) | | | | | | \- Mastoid process | | | | | | \- C7 spinous process-body of T1 | | | | | | \- Sternal notch | +-----------------------------------+-----------------------------------+ | **Centre Point** | \- C4, at the upper margin of the | | | thyroid cartilage | +-----------------------------------+-----------------------------------+ | **Side Marker** | \- Below the mandible, above the | | | shoulder | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- **kV**: 70-85 | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- C1-T1 vertebrae in a lateral | | | orientation | | | | | | \- Open intervertebral joint | | | spaces | +-----------------------------------+-----------------------------------+ | **YES (Positioning)** | \- Mandibular rami are positioned | | | anterior to the spine (not | | | superimposing) | | | | | | \- Shoulder is below the C7/T1 | | | level (dependent on patient | | | mobility) | +-----------------------------------+-----------------------------------+ | **NO (Rotation Check)** | \- The patient should not be | | | rotated | | | | | | \- Left and right articular | | | pillars should be near | | | superimposed (anterior to | | | posterior) | | | | | | \- Left and right zygapophyseal | | | joints should be near | | | superimposed (anterior to | | | posterior) | | | | | | \- Posterior border of the | | | vertebral bodies should appear | | | superimposed (anterior to | | | posterior) | +-----------------------------------+-----------------------------------+ | **MAYBE (Tilt Check)** | \- Ensure the central ray is | | | perpendicular to the sagittal | | | plane | | | | | | \- Left and right articular | | | pillars should be near | | | superimposed (superior to | | | inferior) | | | | | | \- Left and right zygapophyseal | | | joints should be near | | | superimposed (superior to | | | inferior) | | | | | | \- Superior and inferior borders | | | of the vertebral bodies are | | | superimposed (superior to | | | inferior) | +-----------------------------------+-----------------------------------+ | **Patient Position** | \- Patient stands with their side | | | against the vertical bucky; | | | shoulder touching for stability | | | and to minimize OID | | | (Object-to-Image Distance) | | | | | | \- Arms by their side; shoulders | | | relaxed and depressed to drop | | | them below the C7/T1 level (YES | | | direction) | | | | | | \- Adjust the patient\'s mandible | | | to sit anterior to the spine (YES | | | direction) | | | | | | \- Ensure the patient is not | | | rotated (NO direction); the | | | central ray should travel along | | | the coronal plane | | | | | | - Ensure | | | the patient is not tilted/leaning | | | toward or away from the bucky | | | (MAYBE direction) | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- **SID**: 150-180 cm | | | | | | \- **AEC**: Spine over the | | | central chamber | | | | | | \- **Respiration**: Suspended | | | respiration (inspiration) | +-----------------------------------+-----------------------------------+ [Flexion and extension views ] Extension view flexion [Swimmers lateral C-spine ] +-----------------------------------+-----------------------------------+ | **Parameter** | **Details** | +-----------------------------------+-----------------------------------+ | **Included Anatomy** | \- C5-T3 intervertebral disc | | | spaces | +-----------------------------------+-----------------------------------+ | **Landmarks** | - Sternal | | | notch | | | | | | \- C7 spinous process | +-----------------------------------+-----------------------------------+ | **Centre Point** | \- T1, approximately 4 cm above | | | the sternal notch | +-----------------------------------+-----------------------------------+ | **Side Marker** | \- Consider placement relative to | | | anatomy---anteriorly and superior | | | to the shoulders | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- **kV**: 75-95 | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- C5-T3 in a true lateral | | | orientation | | | | | | \- C7/T1 intervertebral disc | | | space | +-----------------------------------+-----------------------------------+ | **YES (Positioning)** | \- The humerus closest to the | | | image receptor is extended | | | superiorly with the humeral head | | | above the C7/T1 junction | | | | | | \- The humerus furthest from the | | | image receptor is extended | | | inferiorly with the humeral head | | | below the C7/T1 junction | +-----------------------------------+-----------------------------------+ | **NO (Rotation Check)** | \- Ensure the patient is not | | | rotated | | | | | | \- Left and right articular | | | pillars should be near | | | superimposed (anterior to | | | posterior) | | | | | | \- Left and right zygapophyseal | | | joints should be near | | | superimposed (anterior to | | | posterior) | | | | | | \- Posterior borders of the | | | vertebral bodies should appear | | | superimposed (anterior to | | | posterior) | +-----------------------------------+-----------------------------------+ | **MAYBE (Tilt Check)** | \- Ensure the central ray is | | | perpendicular to the sagittal | | | plane | | | | | | \- Left and right articular | | | pillars should be near | | | superimposed (superior to | | | inferior) | | | | | | \- Left and right zygapophyseal | | | joints should be near | | | superimposed (superior to | | | inferior) | | | | | | \- Superior and inferior borders | | | of the vertebral bodies are | | | superimposed on themselves | | | (superior to inferior) | +-----------------------------------+-----------------------------------+ | **Patient Position** | \- Patient stands with their side | | | against the vertical bucky; | | | shoulder touching for stability | | | and to minimize OID | | | (Object-to-Image Distance) | | | | | | \- **Arms (YES direction):** | | | Closest to the bucky is raised | | | above the head; furthest from the | | | bucky is relaxed by their side, | | | shoulder depressed and rolled | | | posterior | | | | | | \- Ensure the patient is not | | | rotated (NO direction) | | | | | | - Ensure | | | the patient is not tilted/leaning | | | toward or away from the bucky | | | (MAYBE direction) | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- **SID**: 150-180 cm | | | | | | \- **Grid**: Used | | | | | | \- **AEC**: C-spine over the | | | central chamber | | | | | | \- **Respiration**: Suspended | | | respiration | +-----------------------------------+-----------------------------------+ 4. **Cervical Spine Interpretation Guide and Pathologies Lecture** [Cervical Spine interpretation guidance ] Lateral - 4 lines of alignment- smooth, unbroken arcs - Anterior vertebral line - Posterior vertebral line - Spinolaminar line - Posterior spinous line - Check the shape of the vertebral bodies and that they are intact - The way you measure the vertebral space is measuring the distance from the anterior vertebral bodies to the posterior pharynx - Disc spaces should be uniform height - Recognising the anterior arch of C1 - Check the distance between the dens and the arch of C1 - Check the soft tissues and trabecular pattern  AP - Check the spinous processes - They should be in a straight line - They should be approximately equal distance apart - Mindful of bifid tips AP Open Mouth - Lateral margins of C1 should align with the lateral margins of C2 - The joint spaces on either side of the dens should be equal - Careful of rotation Cervical Spine normal variants - Cervical ribs [Cervical Spine Pathologies ] Check the spinal alignment lines- what can you see?  The smooth arch of Anterior vertebral line and the Posterior vertebral line is broken here What is this pathology? The superior and inferior articular facets aren't sitting the same way as the surrounding ones= subluxation of the apophyseal joint of the spine rather than a true dislocation Therefore "C4/5 left facet joint is subluxated" [Cervical Spine Pathologies ] (Outlined in separate document!!) Cervical Spine radiographic artefact - Mach effect Optical effect at the margin between areas of slightly different density Looks like a pathology so keep in mind 5. **Radiographs of the T-spine** [AP T-Spine ] +-----------------------------------+-----------------------------------+ | **Parameter** | **Details** | +-----------------------------------+-----------------------------------+ | **Included Anatomy** | \- C7-L1 | +-----------------------------------+-----------------------------------+ | **Landmarks** | \- Sternal notch (T2/T3) | | | | | | \- T1 (4-5 cm above) | | | | | | \- Xiphoid process (T9/T10) | | | | | | \- Lower costal margin (L2/L3) | +-----------------------------------+-----------------------------------+ | **Centre Point** | \- T7, approximately 8-10 cm | | | below the jugular notch or | | | halfway between the sternal notch | | | and the xiphisternum | +-----------------------------------+-----------------------------------+ | **Side Marker** | \- Left or right side marker | | | placed correctly with an | | | \"erect\" annotation | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | - **kV**: | | | 75-90 | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- C7-L1 in an AP orientation | | | | | | \- Intervertebral disc spaces | +-----------------------------------+-----------------------------------+ | **YES (Positioning Check)** | \- Intervertebral disc spaces are | | | clearly demonstrated | +-----------------------------------+-----------------------------------+ | **NO (Rotation Check)** | \- Spinous processes should be | | | located centrally within the | | | vertebral bodies | | | | | | \- Sternoclavicular joints should | | | be equidistant from the lateral | | | margins of the vertebral column | +-----------------------------------+-----------------------------------+ | **MAYBE (Tilt Check)** | \- Ensure readability is | | | maintained | | | | | | \- If the central ray is | | | correctly centered and aligned | | | perpendicular to the coronal | | | plane, any tilt in the \"maybe\" | | | direction should not impact the | | | demonstration of the anatomy | +-----------------------------------+-----------------------------------+ | **Patient Position** | \- **Erect:** Patient stands with | | | their back against the bucky | | | | | | \- **Recumbent:** Patient is | | | supine on the table | | | | | | \- Arms comfortably by their side | | | | | | \- Ensure the patient is not | | | rotated (NO direction) with the | | | central ray traveling along the | | | midsagittal plane | | | | | | \- Ensure the patient is not | | | tilted/leaning or diagonal on the | | | bed (MAYBE direction) | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- **SID**: 110 cm | | | | | | \- **Grid**: Used | | | | | | \- **AEC**: T-spine over the | | | central chamber | | | | | | \- **Respiration**: Expiration to | | | increase the density of the | | | lungs, making the density across | | | the image more uniform | +-----------------------------------+-----------------------------------+ [Lateral T-spine ]  +-----------------------------------+-----------------------------------+ | **Parameter** | **Details** | +-----------------------------------+-----------------------------------+ | **Included Anatomy** | \- T1-L1 vertebral bodies (Note: | | | T1-T3 may not be well visualized | | | due to the humeral head) | +-----------------------------------+-----------------------------------+ | **Landmarks** | \- C7 spinous process (T1) | | | | | | \- Sternal notch (T2-T3) | | | | | | \- Xiphoid process (T9-T10) | | | | | | \- Lower costal margin (L2-L3) | +-----------------------------------+-----------------------------------+ | **Centre Point** | \- T7 | | | | | | \- Approximately 8-10 cm below | | | the sternal notch | | | | | | \- Halfway between the sternal | | | notch and the xiphisternum | +-----------------------------------+-----------------------------------+ | **Side Marker** | \- Placed anteriorly and midway | | | superior | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- **kV**: 80-95 | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- T1-L1 in a lateral orientation | | | | | | \- Intervertebral joint spaces | +-----------------------------------+-----------------------------------+ | **YES (Positioning Check)** | \- Readability is maintained | | | | | | \- Neutral stance with no induced | | | flexion or extension | | | | | | \- If the central ray is | | | correctly centered and aligned | | | perpendicular to the sagittal | | | plane, tilt in the \"yes\" | | | direction should not impact the | | | demonstration of anatomy | +-----------------------------------+-----------------------------------+ | **NO (Rotation Check)** | \- Posterior borders of the | | | vertebral bodies should appear | | | superimposed (anterior to | | | posterior) | +-----------------------------------+-----------------------------------+ | **MAYBE (Tilt Check)** | \- Intervertebral disc spaces | | | should be open (superior to | | | inferior) | +-----------------------------------+-----------------------------------+ | **Patient Position** | \- **Recumbent**: Patient lies in | | | a lateral recumbent position on | | | the bed with their hips and knees | | | flexed. Ensure the pelvis is | | | lateral (NO direction). | | | | | | \- **Erect**: Patient stands with | | | their side against the vertical | | | bucky, shoulder touching for | | | stability to minimize OID. | | | | | | \- **Arms**: | | | | | | \- **Recumbent**: Arms raised, | | | elbows flexed, and hands in front | | | of the face. | | | | | | \- **Erect**: Arms raised, elbows | | | flexed, with hands on top of the | | | head. | | | | | | \- Ensure the patient is not | | | rotated through the shoulders or | | | hips (NO direction), with the | | | central ray traveling along the | | | coronal plane. | | | | | | \- Ensure the patient is not | | | tilted or leaning toward or away | | | from the bucky/table (MAYBE | | | direction). Central ray should be | | | aligned perpendicular to the | | | midsagittal plane (MAYBE | | | direction). | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- **SID**: 110 cm (increase to | | | 150 cm for taller patients to | | | reduce magnification and ensure | | | all thoracic vertebrae are | | | included in the image) | | | | | | \- **Grid**: Used | | | | | | \- **AEC**: Try to overlay the | | | thoracic spine; if not possible | | | due to kyphosis, do not use AEC | | | | | | \- **Respiration**: Suspended | | | respiration suggested; | | | orthostatic breathing technique | | | recommended. | +-----------------------------------+-----------------------------------+ 6. **Thoracic Spine interpretation guide and pathologies** [Thoracic Spine interpretation guide] AP: - Check the para-spinal line of the AP T-spine. Look for localised bulging - Check for widening of the pedicles- could indicate a burst fracture - Check for fractures of the transverse processes Lateral: - Check alignment - Check for loss of height of the vertebral bodies - Check the disc spaces - Look for bony fragments **Week 7 L and SC Spine patient preparation lecture** **L-spine patient preparation:** Consider the area being radiographed -- what is being included ◦ Remove jewellery ◦ Navel piercing ◦ Remove clothing that will show up on radiographs ◦ Buttons/studs/zippers ◦ Prints/embellishments ◦ Bras with underwires and clasps (metal or thick plastic) ◦ Belts ◦ Check pockets ◦ Remove hair/hair accessories from spine Provide a gown ◦ Explain how to put it on (if necessary) ◦ Assist if required ◦ Don't forget to get your patient changed after the examination **SC-spine patient preparation:** Consider the area being radiographed -- what is being included ◦ Remove clothing that will show up on radiographs ◦ Buttons/studs/zippers ◦ Prints/embellishments ◦ Belts ◦ Check pockets Provide a gown ◦ Explain how to put it on (if necessary) ◦ Assist if required ◦ Don't forget to get your patient changed after the examination **Lumbar and Sacrococcygeal Spine Lecture notes** 1. **Lumbar and Sacrococcygeal Spine Anatomy**  **Lateral Spot L5/6** radiographic anatomy  **Oblique Lumbar Spine** radiographic anatomy **AP Sacrococcygeal Spine** radiographic anatomy  **Lateral Sacrococcygeal** Spine radiographic anatomy 2. **Sacroiliac Joints Radiographic Anatomy** **AP Sacroiliac** Joints radiographic anatomy  **Oblique Sacroiliac** Joint radiographic anatomy 3. **Chiropractic Spines**  Learning outcomes: - Xray projections - Patient preparation - Routine erect spinal imaging vs chiropractic imaging **Xray projections:** - C-spine series may consist of: - AP, AP open mouth, Obliques, Lateral (neutral), Flexion/ extension laterals, Swimmers lateral - T-spine Series: - AP, Lateral - L-Spine series may consist of: - AP/PA to include AP pelvis, obliques, lateral (neutral), L5/S1 spot lateral, flexion/ extension laterals ✶ All imaging requested by chiropractors is to be performed erect **Patient preparation:** - When consenting the patient for a chiropractic spine series, explain to the patient that the chiropractor has asked for 'x' number of projections. Some patients may believe they are having "one x-ray to include the whole spine" but this is not true. Some patients may have 17 x-rays taken (or more if extra views or repeats are required). Routine spinal imaging vs chiropractic spine imaging: - All imaging requested by chiropractors is to be performed erect using the same erect positioning instructions in the cervical, thoracic and lumbar spine lectures. - Only **2 main differences** so that alignment can be assessed. - AP open mouth view- open lateral collimation to include both mastoid tips - AP/PA lumber spine- open lateral collimation to include both iliac crests, acetabulum and greater trochanters. **Radiographs of the L Spine Lecture** Clinical Indications - Trauma - Scoliosis - Osteoarthritis - Rheumatoid arthritis - Spina bifida - Spondylolisthesis - Spondylolysis - Spondylosis - Metastases Projections - AP/PA - Oblique AP/PA - Lateral - L5/6 spot lateral **AP/PA L- Spine** +-----------------------------------+-----------------------------------+ | **Category** | **Details** | +-----------------------------------+-----------------------------------+ | **Anatomy Included** | - T12 to S1 | | | | | | \- Sacroiliac joints | +-----------------------------------+-----------------------------------+ | **Landmarks** | \- Xiphoid process (T9-10) | | | | | | \- Lower costal margin (L2-3) | | | | | | \- Iliac crest (L4) | | | | | | \- ASIS (S1-2) | +-----------------------------------+-----------------------------------+ | **Centering Point** | \- L3 (soft tissue of waist) | | | | | | \- Iliac crest (4 cm below L3) | | | | | | \- Lower costal margin | +-----------------------------------+-----------------------------------+ | **Side Marker** | \- Left or right on the correct | | | side | | | | | | \- Consider placement laterally | | | and superiorly | | | | | | \- Annotate if performed erect | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- kV 75-90 | | | | | | \- mAs to maximize SNR | | | | | | \- No motion unsharpness | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- L1-L5 vertebrae in an AP or PA | | | orientation | | | | | | \- Intervertebral joint spaces | | | demonstrated in | | | anterior-to-posterior orientation | | | (better demonstrated in PA) | | | | | | \- AP: Joint spaces are closed | | | | | | \- PA: Joint spaces are open | | | | | |  | +-----------------------------------+-----------------------------------+ | **Patient Position** | **PA/AP Position:** | | | | | | \- Patient stands with their | | | front (PA) or back (AP) against | | | bucky | | | | | | \- Arms comfortably by their side | | | | | | \- Ensure the patient is not | | | rotated (central ray will travel | | | along the midsagittal plane) | | | | | | \- Ensure the patient is not | | | tilted | | | | | | \- Central ray is straight | | | | | |  | | | | | | = | +-----------------------------------+-----------------------------------+ | **Anatomical Position** | **No rotation ("yes and no" | | | roation):** Intervertebral disc | | | spaces are demonstrated | | | | | | \- Spinous processes centrally | | | located within vertebral bodies | | | | | | \- Transverse processes | | | equidistant from lateral margins | | | of the vertebral column | | | | | | \- SI joints equidistant from | | | spinous processes | | | | | | \- If the patient looks towards | | | their right, spinous processes | | | move towards the left, and vice | | | versa | | | | | | **Maybe:** Only affects | | | readability | | | | | | \- Due to the use of a straight | | | tube, will not change the | | | alignment of the divergent rays | | | with the anatomy | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- SID 110 cm (consider patient | | | size) | | | | | | \- Use GRID | | | | | | \- AEC use (L spine over central | | | chamber, avoid unwanted anatomy | | | over AEC) | | | | | | \- Suspended expiration | +-----------------------------------+-----------------------------------+ **Oblique L-spine** +-----------------------------------+-----------------------------------+ | **Category** | **Details** | +-----------------------------------+-----------------------------------+ | **Anatomy Included** | \- Lumbar vertebrae | +-----------------------------------+-----------------------------------+ | **Landmarks** | - Xiphoid | | | process (T9-10) | | | | | | \- Lower costal margin (L2-3) | | | | | | \- Iliac crest (L4) | | | | | | \- ASIS (S1-2) | +-----------------------------------+-----------------------------------+ | **Centering Point** | \- L3 | | | | | | \- Iliac crest (4 cm below L3) | | | | | | \- Lower costal margin | +-----------------------------------+-----------------------------------+ | **Side Marker** | \- Left AND right on the correct | | | side | | | | | | \- Consider placement laterally | | | and superiorly | | | | | | \- Annotate if erect | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- kV 75-90 | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- L1-4 zygapophyseal joints | | | aligned with the beam | | | | | | \- Lamina perpendicular to the | | | beam | | | | | | \- Scotty dogs aligned with the | | | beam | | | | | | The grey line indicates where the | | | zygapophyseal joint we're trying | | | to demonstrate is. At 45 degrees | | | to the midline. | | | | | | The dotted line is the lamina. | | | Sits at 45 degrees to the | | | midsagittal plane. | +-----------------------------------+-----------------------------------+ | **Patient Positioning** | \- Patient stands 45 degrees to | | | the bucky | | | | | | \- Arms away from body on | | | handlebars | | | | | | \- Anterior oblique: patient\'s | | | front against the bucky | | | | | | \- Posterior oblique: patient\'s | | | back against the bucky | | | | | | \- Central ray is vertical when | | | using the bed, horizontal when | | | using the vertical bucky | +-----------------------------------+-----------------------------------+ | **Anatomical Position/ Rotation** | \- **Correct Rotation:** | | | | | | \- Zygapophyseal joints open in | | | the anterior to posterior | | | direction, and the lamina is in | | | profile | | | | | | \- Sagittal plane rotated 45 | | | degrees | | | | | | \- Pedicle between midline and | | | lateral aspect of the vertebral | | | body | | | | | | \- Intervertebral joint spaces | | | are open | | | | | |  | | | | | | \- **Incorrect Rotation (Too | | | flat- AP or PA):** | | | | | | \- Pedicle (eye of the Scotty | | | dog) moves closer to the lateral | | | margin of the vertebral body, | | | indicating the patient is too AP | | | or PA | | | | | | \- **Incorrect Rotation (Too | | | Lateral):** | | | | | | \- Pedicle moves centrally to the | | | vertebral body, spinous processes | | | move into profile out the back, | | | indicating the patient is too | | | lateral | +-----------------------------------+-----------------------------------+ | **Technical Factors** | - SID 110 | | | cm | | | | | | \- Use GRID | | | | | | \- AEC over the central chamber | | | | | | \- Suspended expiration | +-----------------------------------+-----------------------------------+ The circle that the arrow is pointing to is the pedicle and makes the eye of the dog. In front of the eye there's the transverse process which is the nose of the dog. Following the nose up there's the superior articular process apart of the zygapophyseal joint, that is the dogs ear. Coming down the inferior articular process which is apart of the inferior zygapophyseal joint is the front leg. The body is the lamina. The part of the lamina that makes up part of the neck of the dog, is the pars lenticularis which is commonly fractured. **Lateral L-spine** +-----------------------------------+-----------------------------------+ | **Category** | **Details** | +-----------------------------------+-----------------------------------+ | **Included Anatomy** | T12-S1 | +-----------------------------------+-----------------------------------+ | **Landmarks** | Lower | | | costal margin - L2-3 | | | | | | Iliac crest - L4 | | | | | | ASIS - S1-2 | +-----------------------------------+-----------------------------------+ | **Centring Point** | L3 - just above iliac crest | +-----------------------------------+-----------------------------------+ | **Side Marker** | Left or right indicating the side | | | closest to IR (anterior or | | | superior) | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | kV 80-90 | | | | | | mAs sufficient for contrast | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- T12-S1 | | | | | | \- Intervertebral disc spaces | | | open | | | | | | \- Intervertebral foramina | +-----------------------------------+-----------------------------------+ | **Anatomical Position** | \- CR perpendicular to the | | | midsagittal plane and correct | | | centring will maintain alignment | | | of anatomy with ray paths | | | | | | \- Posterior borders of the | | | vertebral bodies should be | | | superimposed | | | | | |  | | | | | | No rotation vs rotation | | | | | | \- Superior and inferior borders | | | of the vertebral bodies are | | | superimposed on themselves | | | (superior to inferior) | | | | | | \- Intervertebral foramina are | | | open in the superior to inferior | | | direction | | | | | | \- Check for patient rotation by | | | ensuring the spinous processes | | | are central and posterior borders | | | of the vertebral bodies are | | | aligned | +-----------------------------------+-----------------------------------+ | **Patient Position** | \- **Erect:** Standing with side | | | against the vertical bucky to | | | minimize OID and for stability | | | | | | \- **Recumbent:** Lays on their | | | side on the table with knees | | | flexed up | | | | | | \- **Arms:** Raised in erect | | | position with hands on the head; | | | in recumbent, placed on the | | | pillow in front of the face | | | | | | \- Ensure the patient isn't | | | rotated and the central ray | | | travels along the coronal plane | | | | | | \- Central ray aligned | | | perpendicular to the midsagittal | | | plane | +-----------------------------------+-----------------------------------+ | **Technical Factors** | - SID 110cm | | | | | | \- Grid | | | | | | \- Use AEC; place L-spine over | | | the central chamber | | | | | | \- Suspended expiration | +-----------------------------------+-----------------------------------+ **Flexion and extension views** **L5-S1 spot lateral** +-----------------------------------+-----------------------------------+ | **Category** | **Details** | +-----------------------------------+-----------------------------------+ | **Included Anatomy** | L5-S2 | +-----------------------------------+-----------------------------------+ | **Landmarks** | - Iliac | | | Crest: L4 | | | | | | \- ASIS: S1-S2 | | | | | | \- PSIS: S1-S2 | +-----------------------------------+-----------------------------------+ | **Centring Point** | \- L5/S1 | | | | | | \- 4 cm below the iliac crest | | | | | | \- 5 cm posterior to the ASIS | +-----------------------------------+-----------------------------------+ | **Side Marker** | \- In front of sacrum | | | | | | \- Annotate if erect | +-----------------------------------+-----------------------------------+ | | | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | kV: 85-95 | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- L5-S2 in a true lateral | | | orientation | | | | | | \- L5-S1 intervertebral disc | | | space | +-----------------------------------+-----------------------------------+ | **Evaluation Criteria** | **Yes:** | | | | | | \- Correct centring with straight | | | tube | | | | | | **No:** | | | | | | \- Posterior borders of L5 should | | | be superimposed | | | | | | \- Greater sciatic notches should | | | be superimposed in the anterior | | | to posterior direction | | | | | | **Maybe:** | | | | | | \- Central ray perpendicular to | | | the sagittal plane | | | | | | \- Inferior borders of vertebral | | | body of L5 are superimposed | | | | | | \- Superior borders of S1 are | | | superimposed | +-----------------------------------+-----------------------------------+ | **Patient Position** | Same as LATERAL | +-----------------------------------+-----------------------------------+ | **Technical Factors** | \- SID: 110 cm | | | | | | \- Grid | | | | | | \- AEC used for central chamber | | | over L5/S1 | | | | | | \- Suspended expiration | +-----------------------------------+-----------------------------------+ **Radiographs of the Sacrococcygeal spine and sacroiliac joints** [Clinical indications ] - Trauma - Arthropathies [Projections ] Sacroiliac joints ◦ AP/PA ◦ Obliques (AP and PA) Sacrum ◦ AP ◦ Lateral Coccyx ◦ AP ◦ Later **AP/PA Sacrum/ SIJs** +-----------------------------------+-----------------------------------+ | **Category** | **Details** | +-----------------------------------+-----------------------------------+ | **Anatomy Included** | \- **Extent of the Collimation:** | | | | | | \- **Sacrum:** | | | | | |   - Sacrum | | | | | |   - L5/S1 joint | | | | | |   - Sacroiliac joints | | | | | | \- Pubic symph | | | | | | \- **Sacroiliac Joints:** | | | | | |   - SIJs | +-----------------------------------+-----------------------------------+ | **Landmarks** | \- Iliac crest (L4) | | | | | | \- ASIS (S1-2) | | | | | | \- PSIS (S1-2) | | | | | | \- Pubic symphysis | | | | | | \- Greater trochanters | +-----------------------------------+-----------------------------------+ | **Centring Point** | \- **Sacrum:** | | | | | |   - 5 cm superior to the pubic | | | symphysis on the midline (AP) | | | | | | \- **Sacroiliac Joint:** | | | | | |   - 5 cm below the ASIS (AP) | +-----------------------------------+-----------------------------------+ | **Side Marker** | - Place on | | | the correct side (left or right) | | | | | | \- Consider placement: | | | | | |   - Laterally | | | | | |   - Inferiorly | | | | | | \- Annotate if performed erect | +-----------------------------------+-----------------------------------+ | **Exposure Factors** | \- 75-90 kV | +-----------------------------------+-----------------------------------+ | **Anatomy Demonstrated** | \- **Sacrum:** | | | | | |   - L5 (L5/S1 joint space) | | | | | |   - Sacrum | | | | | |   - SIJs | | | | | | \- **SIJs:** | | | | | |   - L5 (L5/S1 joint space) | | | | | |   - SIJs | +-----------------------------------+-----------------------------------+ | **Positioning** | **YES:** | | | | | | \- Sacrum centring should align | | | with the middle of the sacral | | | curve to open the curve with | | | diverging rays, resulting in | | | minimal foreshortening | | | | | | \- Pubis should not superimpose | | | the sacral foramina (may | | | superimpose the coccyx) | | | | | | \- SIJs should demonstrate | | | minimal foreshortening with | | | correct centring and tube | | | angulation | | | | | | **NO:** | | | | | | \- L5 spinous process should be | | | centrally located within the | | | vertebral body | | | | | | \- SI joints should be | | | equidistant from the spinous | | | processes | | | | | | \- Coccyx should be aligned with | | | the pubic symphysis | | | | | | **MAYBE:** | | | | | | \- Sacrum should be aligned with | | | the midline of the IR; any tilt | | | may misalign the anatomy due to | | | the tube angle | +-----------------------------------+-----------------------------------+ | **Patient Position** | \- **AP/PA:** Patient stands with | | | their fro