Lecture 1 CSpine PDF

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...

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 an articulation with the occipital bone No spinous process and vertebral body Anterior portion of the ring is the part where the Dens sits (Odontoid process) The Spinal Cord runs in the Posterior part Transverse processes are longer and sit laterally and slightly inferior Superior process of C1 are large & deeply concave b/c of the occipital condyles of the occipital bone of the cranium C2 – Axis has a strong process called the odontoid (dens) Superior articular processes join with the inferior articular process of the succeeding cervical vertebrae C3-C6 – Typical Vertebrae are narrow and thin Processes are short & wide Spinous process are short with double pointed tips Superior view C3-C6 https://www.theskeletalsystem.net/spine-vertebral-column/cervical-vertebrae.html Anatomy of the Cervical Spine C7 has a long prominent spinous process IMPORTANT LANDMARK Very easily palpable at the base of the neck vertebra promine ns  Do You Remember? Describe the Cervical & Lumbar spinal curves Concave posteriorly Lordotic Curve Compensatory Curves Describe the Thoracic & Sacral spinal curves Convex posteriorly Kyphotic Curve Primary Curves  Cervical Vertebrae BASIC VIEWS  AP “Open Mouth” Projection C1-C2  A.P. Axial Projection of C3-C7  Lateral Projection underlined: expected to know very well and for practical Additional Views  Cervicothoracic Swimmer’s Lateral Position (Twining Method)  Anterior & Posterior Oblique Projections  Lateral Projections (Flexion and Extension) Additional Views (uncommon)  AP Axial Projection – Vertebral Arch Pillars  AP Projection (Ottonello Method) - Wagging Jaw  AP/PA Projection for C1/C2 (Fuchs Method)  PATIENT PREPARATION REMOVE PREVENTABLE ARTIFACTS  Earrings, chains, hairpins, barrettes,  Braids, wet hair, extensions  Dentures, partial plates, retainers, etc.  Clothing, shirts, bra straps  Gum or candy  Pregnancy screening/child-bearing age pg 3 ( no longer a OTIMROEMPQ requirement) In practice… routine based c spine: laterala and AP axial 1- Lateral Projection Alignment and potential artifacts First projection performed for trauma – Horizontal beam lateral projection done for trauma, start with horizontal 2- AP Axial Projection then ap axial then oblique 3- Open Mouth Projection  Indications for Cervical Spine X-rays Chronic neck pain Acute neck pain r/o fracture r/o disc herniation Arthritis degenerative bone/disc or joint disease Limited rage of motion Pathology – r/o metastasis, osteoporosis Radiculopathy Numbness or pain in arms, hands or fingers (Dysfunction of the nerve root due to foramina impingement of that exiting nerve caused by herniated disc or bone spur/osteophyte); the pain or other symptoms often radiate to the part of the body served by that nerve request for c spine if patient has radiculopathy  Indications for Cervical Spine X-rays What is referred Pain? Pain felt in part of the body other than the source Example of general X-ray requisition History: Shoulder Pain Exam requested: C-Spine Routine nerves connect from spine down to fingers common: sciatica, nerve between L5-S1, numbness in toes  Useful Landmarks Meatus – opening leading to the inferior of the body lines must be perpendicular to CR for lateral or oblique of the C-spine AML for Lateral C-spine LML for AP Axial C-spine & Odontoid https://www.semanticscholar.org/paper/WithTeeth%3A-Denture-Preview-in-Augmented-Reality- Amirkhanov-Amirkhanov/b2198c475681f83f4fa23a225c64f1d0209104f8 C-Spine Open Mouth C1/C2 Odontoid Projection PATIENT POSITION Patient in an AP supine or erect position Position the face forward, placing the mandibular angles & mastoid tips at equal distances from the IR Tuck the chin until a line connecting the lower edge of the upper incisors & tip of the mastoid process is aligned perpendicular to the IR upper incisors to base of skulll is better Instruct the patient to open the tip of mastoid process is also the meatal line mouth as widely as possible C-Spine Open Mouth C1/C2 Odontoid Projection angle for trauma C collar CENTRAL RAY no CR angulation, CR is perpendicular to IR Angle the CR 5 degrees cephalically Center the CR to the MSP & midpoint of the open mouth Instruct the patient to keep mouth wide open and to AHHHH during exposure. 75 +/- 5 kV range WHY? - Prevents movement of the mandible - Places the tongue in the floor of the mouth not to projected it on the Atlas or Axis. C-Spine Open Mouth C1/C2 Odontoid Projection Image Analysis Guidelines lateral masses, intervertebral spaces seen, Atlas is symmetrically seated on the axis with the atlas’s lateral masses at equal distances from the dens L Spinous process of the axis is aligned with the midline of the axis’s body Mandibular rami equidistant from dens (for proper head rotation) Superimposed of the upper incisors & the base of the skull (for proper neck flexion) mandibular rami spinous process Atlantoaxial joint is open Dens is at the center of the exposure field Atlantoaxial jt’s, atlas’s lateral RT Cervical Zygapophyseal Joint masses & transverse processes, the axis’s dens and body (Atlantoaxial Joint) Proper collimation & marker seen  Image Analysis lateral mass rami rami when turned right: the left side is more closed CERVICAL ROTATION the side witht he greater distance is the side rotated WHICH WAY IS THE HEAD TURNED? to the right Distance between the mandibular rami & lateral masses Side that demonstrates the greater distance is the side toward which the face was rotated  Image Analysis only angle 5 degrees cephalic if the dens is not cleared (i.e trauma in collar) The lateral cervical projection demonstrates how the upper incisors, occipital base & mastoid tip are aligned perpendicular to the IR. ** Remember that the upper incisors are positioned at a long OID & will cause magnification ** In order to project the magnified upper incisors away from the dens, a 5-degree cephalic angulation is needed WHY CAN’T I JUST TILT THE CHIN UPWARD INSTEAD? in case of trauma The occipital base would simultaneously be shifted inferiorly causing the dens & atlantoaxial joint to be superimposed (Slide 19) you could tilt it back if that is possible CR: 5 degrees cephalic projects the upper incisors away from the dens if you just move the headfback, the occipital will be in the way, we must angle the ube instead to clear  Image Analysis cant see the dens, they forgot to angle 5 degrees cephalic head is tilted too much MAKE SURE TO ANGLE 5-DEGREES CEPHALIC TO PROJECT THE UPPER INCISSORS AWAY FROM DENS  Image Analysis last image and this one togetehr: send both, you have intervertabral spaces and dens and the lateral masses base of skull head is tilted too far back What happened? ___________ yes Would you repeat? __________ tuck chin in more How do you fix the patient position? ____________ to put base of skull superior to dens  Image Analysis TOO MUCH ANGULATION - Atlantoaxial joint is closed - Upper incisors are positioned too superiorly - The spinous process of the axis at the level of the 3rd vertebral body too much angulation: joint space is closed upper incisors are too far up s p i n o u s p r o c e s s projected too far down  Image Analysis dens is above the teeth still - they did not angle cephalic enough no rotation  TIME TO ADAPT take picture as is even if not radioluscent head is already tilted  Image Analysis because head is extended so far back, we must angle at least 10 degrees down now TRAUMA Direction of the CR must be changed from the standard position Because of the potential of this movement to cause increased injury & the cervical collar worn by these patient’s tilts the chin upward, you must increase the amount of angulation clear lateral c spine first if cant open mouth Approximately 10 degree caudal angulation Because of this upper chin tilting, the occipital base is positioned directly beneath the dens & atlantoaxial joint space & will superimpose it if the CR is not angled caudally to project them inferiorly IOML is used to determine the needed angulation Once the angulation is determined, the attempt to get the patient to drop their lower jaw DO NOT ADJUST HEAD ROTATION OR TILTINGif patient cant open the mouth, dont do open mouth projection, theres no point  Image Analysis CERVICAL COLLAR LIMITATIONS Sometimes the collar prevents the lowering of the lower jaw WHAT DO WE DO? Have ordering physician or nurse remove the front of the cervical collar so that the patient can drop the jaw without adjusting the head or neck position After the projection is taken, have the ordering physician return the front of the cervical collar to its proper position  Image Analysis upper incisors are above, and dens is superimposed over skull NOT ENOUGH ANGULATION FOR TRAUMA Causes the upper incisors to be demonstrated superior to the dens & the dens to be superimposed over the occipital base need to angle 10 degrees caudal  Image Analysis rotated towards the right tube pushes the dens , too much angulation angled too much: caudad = occipital moves up, structures are elongated not enough = occipial moves down TOO MUCH ANGULATION FOR TRAUMA The occipital base is demonstrated superior to the dens & the upper incisors are superimposed over the dens  C-Spine AP Axial Projection PATIENT POSITION Patient in an AP supine or erect position Position the face forward, placing the mandibular angles & mastoid tips at equal distances from the IR Align the lower surface of upper incisors & the tip of the mastoid process perpendicular to the IR Align the midline of the neck with the midline of the IR & grid  Cervical Spine AP AXIAL Projection CENTRAL RAY Directed through C4 at an angle of 15 to 20 degrees cephalad ERECT – Angle 20 degrees SUPINE – Angle 15 degrees L KYPHOTIC – Angle > 20 degrees laying down: less lordosis than when standing 75 +/- 5 kV range CR enters at most prominent point of the thyroid cartilage “Adam’s Apple” OR Center the CR to the MSP at a level halfway btw the EAM (external auditory meatus) & the jugular notch  Do you Remember? ** The degree of CR angulation needed to obtain open intervertebral disk spaces & to align the spinous processes within them accurately depends on the degree of cervical lordotic curvature ** Supine – the gravitational pull placed on the middle cervical vertebrae puts the Cervical Spine more straight p.459 (Image Analysis) intervertebral spaces free of superimposition to open: angle tube Slope of vertebral bodies are 150 – 200 depending on patient position  C-Spine AP Axial Projection CR needs to be parallel with the intervertebral disk spaces in order to open them up since the anterior aspect of the vertebral bodies slopes downwards  Cervical Spine AP AXIAL Projection Image Analysis Guidelines for head position and chin tucking is done well Spinous processes are aligned with the midline of the cervical bodies Mandibular angles & mastoid tips are at equal distances from the cervical bodies centered at C4/thyroid cartillage Articular pillars & pedicles are symmetrically visualized lateral to the cervical bodies Distances from the vertebral column to the medial clavicular ends are equal Intervertebral disk spaces are open Vertebral bodies are demonstrated without distortion Each vertebra’s spinous process is intervertebral disc spaces must be open visualized at the level of it’s inferior intervertebral disk spaces include C3-C7, T1 max T2 clavicles can indicate rotation  C-Spine AP Axial Projection Image Analysis Guidelines continued… 3rd cervical vertebral is demonstrated in it’s entirety Occipital base & mandibular mentum are superimposed C4 is at the center of the exposure field Area from superior portion of C3 to T2 is included Proper collimation & marker seen foreshortening on clavicle of side it is rotated on  Image Analysis WHAT DO WE SEE WHEN THERE’S ROTATION - If the mandibular angles & mastoid tips are not demonstrated at equal distances from the cervical vertebrae - If the spinous processes are not demonstrated at equal distances from the cervical vertebrae - If the pedicles & articular pillars are not symmetrically demonstrated lateral to the vertebral bodies - If the medial ends of the clavicles are not demonstrated at equal distances from the vertebral column Image Analysis spinous process is on the R side, rotated left Which way is this patient rotated? The vertebral bodies move toward the side positioned closer to the IR & the spinous processes move toward the side positioned farther from the IR Upper (C1-C4) and lower (C5-C7) can demonstrate rotation independently If the head is rotated or if the thorax is rotated spinous process are furthest from IR  Image Analysis Kyphosis The kyphotic patient demonstrates an exaggerated kyphotic curvature of the thoracic vertebrae that will cause excessive lordotic curvature of the cervical vertebrae To demonstrate the cervical vertebrae with open intervertebral spaces for an upright AP axial projection, it will be necessary to adjust the degree of CR angulation above what is routinely done  Image Analysis = kyphotic patient have a more lordotic c spine processes must angle more  Image Analysis NOT ENOUGH CEPHALIC ANGULATION jaw is lower than the skull Closed intervertebral disk spaces Distorded vertebral bodies Each vertebra’s spinous process is demonstrated within it’s vertebral body spinous processes shoudl be in between intervertebral spaces jaw should be projected superiorly intervertebral spaces are closed  Image Analysis TOO MUCH CEPHALIC ANGULATION Closed intervertebral disk spaces uncinate process is very elongated here Each vertebra’s spinous process is demonstrated within the inferior adjoining vertebral body the more we angle cephalically, the more the spinous processes move down Elongated uncinate processes https://upload.wikimedia.org/wikipedia/commons/e/e1/Cervical_Spine_- C3_and_C4_vertebrae_along_with_uncinate_process.png  Image Analysis MANDIBULAR MENTUM & OCCIPITAL BASE How do we position the head when positioning AP Axial Projection? lower surface of the upper incisors is perpendicular to IR This is achieved when the lower surface of the upper incisors & the tip of mastoid process is aligned perpendicular to the IR By doing that, you would think that it would cause the base of skull & the mandible to superimpose on the upper cervical vertebrae… This will not be the case because of the cephalad CR angulation used that will project the mandible superiorly for kyphotic patients, best done supine lying down on table, with small sponge under the neck  Image Analysis chin is lower than the skull blocking C3 If the mandibular mentum is positioned superior If the mandibular mentum is positioned inferior to the occipital base (head tilted too far to the occipital base (chin tucked in too far backward) the upper cervical vertebrae are downward), it is superimposed over the superior superimposed over the occiput cervical vertebrae  Image Analysis CERVICAL TRAUMA Any cervical projections done on a trauma patient, obtain the images with the patient positioned as is The first image that is taken is the? horizontal _________ lateral beam projection (for C-spine) Do not attempt to remove the cervical collar or adjust the head or body rotation, mandible position or vertical titling Any attempt to move the head or spine may result in greater injury to the vertebrae or spinal cord Spinal cord injuries may occur from mishandling the patient after the initial injury has taken place  C-Spine Lateral Projection PATIENT POSITION Patient in an AP supine or erect position Midcoronal plane passing through mastoid tip centered to IR Align IPL perpendicular to the IR Elevate chin, positioning the AML parallel to floor Protract chin to prevent mandibular superimposition on spine Depress the shoulders as much as possible Have patient hold under the chair Suspend at end of full expiration to depress shoulders  C-Spine Lateral Projection CENTRAL RAY Center the CR to the MCP at a level halfway between EAM & the jugular notch OR Perpendicular to a point 1-inch distal to the adjacent mastoid tip SID 72 inch to compensate for larger OID 75 +/- 5 kV range if spine is further from IR, 72 SID WHY? Reduces magnification to compensate for OID therefore greater spatial resolution Place 5-10 lbs weights on the arm at the elbow use weight in elbow or ask to grab chair or point down if shoulders are broad  C-Spine Lateral Projection Image Analysis Guidelines most structures are superimposed L Anterior/posterior/superior/inferior aspects of the right and left articular pillars and the right and left zygapophyseal joints of each cervical vertebra are superimposed. Mandibular rami are superimposed Spinous processes are in profile Intervertebral disk spaces open Posterior arch of C1 and spinous process of C2 are in profile without occipital base superimposition (degree of elevation of the chin) Bodies of C1 and C2 seen without mandibular superimposition The cranial cortices are superimposed Sella turcica, clivus, C1-C7 & half of T1 are included in the exposure field Proper collimation & marker seen left side is closer to the IR, for chest done so heart isnt magnified  Image Analysis Lateral Flexion of Cervical Vertebrae if hole is seen, had is tilted towards ir Lateral flexion of the cervical vertebrae results when the interpupillary line (IPL) is not aligned perpendicular to the IR and the shoulders are not placed on the same horizontal plane tilted left: vertebral foramen of th C2 axis, will be seen If the head was tilted toward the IR, there is a separation between the right and left articular pillars and zygapophyseal joints of the upper cervical vertebrae, the inferior cortices of the cranium and the mandibular rami are demonstrated without superimposition, and the vertebral Type text here foramen of C1 is demonstrated  Image Analysis If the head and upper cervical vertebral column were tilted away no hole from the IR, there is a separation between the right and left articular pillars and zygapophyseal joints of the upper cervical vertebrae, the inferior cortices of the cranium and the mandibular rami are demonstrated without superimposition, and the posterior arch of C1 remains in profile head tilted far from IR  Image Analysis magnified mandible, far from IR Type text here Cervical rotation can be detected on a lateral cervical projection by evaluating each vertebra for anterior and posterior pillar superimposition and for zygapophyseal joint superimposition rotated towards the right When the torso or the cranium is indicates rotation rotated, the pillars and zygapophyseal joints on one side of the vertebra move anterior to those on the other side and one mandibular ramus is anterior to the other  Lateral Horizontal Beam shoot-through Must include Clivus to C7-T1. Must demonstrate prevertebral fat stripe Same image critique criteria as for routine lateral Indicate horizontal beam with annotation "BROW up"= shoot through dont ask to depress shoulders if trauma, get what you get must include clivus  Image Analysis Importance of Including the Clivus The clivus, a slanted structure that extends posteriorly off the sella turcica, and the dens, should be included on a lateral cervical projection as they are used by the reviewer to determine cervical injury. A line drawn along the clivus should point to the tip of the dens on the normal upper lateral cervical vertebral projection clivus points down to the dens  C-Spine AP/PA Axial Oblique Projection Performed to demonstrate Cervical Intervertebral Foramina and Pedicle in profile Formed by superior and inferior surfaces of pedicles Are situated at 450 to MSP Are situated at 150 angle with slope of the bodies of the vertebrae to see the pedicles, the vertebrae must be positioned oblqiue 45 degrees MSP is at 45 degrees and angle tube 15 up or down depending  C-Spine AP/PA Axial Oblique Projection degenerative disc space can be seen Performed to evaluate Stenosis of Intervertebral Foramina that may cause nerve root compression Show fractures of the articular processes & obscure dislocations & subluxations Narrowing of joint space due to clogging by debris from degenerative disease Example – osteoarthritis, bone spur and new bone formation, herniated disc protrusion Rt & Lt side are obtained to demonstrate the foramina & pedicles on both sides of the cervical vertebrae ossification of the bone  C-Spine AP/PA Axial Oblique Projection PATIENT POSITION best done standing SID 72 Begin with the patient in an AP supine or erect position Rotate the patient until the MCP is at 45 degree angle to the IR Align IPL parallel to the floor OR elevate the chin until AML is aligned parallel with the floor (to prevent hyperextension of neck) Align the cervical vertebral column parallel with the IR Oblique head – Rotate the head with the torso, aligning MSP at a 45 degrees angle with the IR Lateral head – Turn the face away from the side of interest until the head’s MSP is aligned parallel with the IR BOTH RIGHT AND LEFT OBLIQUE PROJECTIONS ARE DONE  C-Spine AP/PA Axial Oblique Projection CENTRAL RAY RAO or LPO for right side, we see the right intervertebral foramina PA AXIAL OBLIQUE obliques done PA usually Angle the CR 15-20 degrees caudally To allow for the caudal angulation of the CR, C3 center the IR at the level of C5, 1-inch inferior to the most prominent point of the thyroid cartilage for PA, angle caudad SID 72 inch for AP, angle cephalic 75 +/- 5 kV range The intervertebral foramina & pedicles CLOSEST to the IR are demonstrated AP AXIAL OBLIQUE Angle the CR 15-20 degrees cephalically 5TH Center the IR to the 3rd cervical body – 1-inch superior to the most prominent point of the thyroid cartilage SID 72 inch 75 +/- 5 kV range The intervertebral foramina & pedicles FARTHEST to the IR are demonstrated OTIMROEPMQ recommends the PA projections to reduce AP targets thyroid dose to radiosensitive organs  C-Spine AP/PA Axial Oblique Projection Two ways to position the head: this method is best Head placed in true Head rotated 450 with body lateral position C1 and c2 are blocked from jaw because head was oblique sella turcica formina are open clivus  C-Spine AP/PA Axial Oblique Projection Head rotated 450 with body Disadvantage of having the head in an oblique 45- degrees C1 and C3 demonstrated with mandibular superimposition  C-Spine AP/PA Axial Oblique Projection move just the chin away from IR to have a lateral head after positioning the oblique Image Analysis Guidelines C2 through C7 intervertebral foramina are open, demonstrating uniformity Intervertebral disk spaces are open Cervical bodies are seen as individual structures & are uniform in shape Lateral Head – will demonstrate C1-C3 C2 without mandibular superimposition Rt & Lt posterior cortices of the mandible C3 are aligned C4 is at the center of the exposure field C4 LAO & RPO – LEFT pedicles are seen in C5 profile & right pedicles are aligned with the C6 for pa anterior vertebral bodies C7 RAO & LPO – RIGHT pedicles are seen in profile & left pedicles are aligned with the anterior vertebral bodies C1-C7, T1 & surrounding tissues are included Proper collimation & marker seen LAO  Image Analysis Insufficient Cervical Obliquity If the cervical vertebral obliquity is less than 45-degrees, the intervertebral foramina are narrowed or obscured and the pedicles of interest are foreshortened  Image Analysis Excessive Cervical Obliquity If the cervical vertebrae are rotated more than 45-degrees, the pedicles of interest are partially foreshortened The opposite pedicles are aligned with the midline of the vertebral bodies, and the zygapophyseal joints that are demonstrated without vertebral body superimposition are demonstrated in profile looks more like a lateral, more superimposition, more elongation of spinous processes larger intervertebral foramen Because it is possible for the upper and lower cervical vertebrae to be rotated to different degrees on the same projection, one needs to evaluate the entire cervical vertebrae for proper rotation  Image Analysis What do we see? Are all areas of interest included? IMAPES? horizontal beam lateral projection missing C7 and T1, would need to add a swimmers view  C-Spine Lateral Cervicothoracic/Swimmers/Twinning Method GOAL OF THIS PROJECTION? To separate overlapping structures! PEFORMED WHEN C7/T1 NOT DEMONSTRATED ON LATERAL CERVICAL SPINE C7/T1 POST OP C7/TI PATHOLOGY  C-Spine Lateral Cervicothoracic/Swimmers/Twinning Method PATIENT POSITION Position the patient in an erect or recumbent lateral position Recumbent – Flex knee & hips for support for trauma only Upright – Distribute patient’s weight on both feet equally Align MCP perpendicular with the IR Elevate the arm positioned closer to the IR above the head as high as the patient can allow Place the opposite arm against the patient’s side & instruct the patient to depress the shoulder Place head in lateral position, ensuring that IPL is perpendicular to the IR & MSP parallel with the IR CR skims through top of shoulder , scapula is at same level of T1 depressed the shoudler further from IR increase kVp (to 80-90 ish, more tissue to go through  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 vertebral prominens** SID 72 inch 80 +/- 5 kV range (increase 5-10) T1 If patient is unable to depress shoulder, use a 5-degree caudal CR angulation because of clavicle Exposure is taken on suspended expiration ** C7 is known as the vertebral prominens because of it’s prominent spinous process  C-Spine Lateral Cervicothoracic/Swimmers/Twinning Method Image Analysis Guidelines Rt & Lt cervical zygapophyseal joints, articular pillars & the posterior ribs are superimposed 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 the area of interest to avoid scatter & place marker in the exposure field if we cant see C7-T1, we do the swimmers or if shoulders are too thick for lateral T spine  C-Spine Lateral Cervicothoracic/Swimmers/Twinning Method clavicle projected up C7 can be identified on a lateral cervicothoracic projection by locating the elevated clavicle, it normally is shown transversing the C7 vertebrae  C-Spine Lateral Cervicothoracic/Swimmers/Twinning Method What structures are we trying Separate? ________ Name two ways that we can separate these structures? _____________ _____________  C-Spine Lateral HyperFLEXION & HyperEXTENSION NOT for trauma common for whiplash and ligament stability ** This procedure must not be attempted until cervical spine pathology or fracture has been ruled out Functional Studies to show : Motility/range of motion of cervical spine (C1-C7) Ligament stability (WHIPLASH) Alignment - Spondylolisthesis Routine for pre – op intubation for patients with known C-Spine pathology Post op Spinal Fusion Never on trauma patients! C-Spine Lateral HyperFLEXION & HyperEXTENSION PATIENT POSITION Position the patient in true lateral position, either seated or erect Distribute patient’s weight on both feet equally Place head in lateral position, ensuring that IPL is perpendicular to the IR & MSP parallel with the IR Do not force movement, gently have patient Extension – Elevate the chin as move into position much as possible, placing the cervical vertebrae in a maximum extended position Flexion – Drop the head forward & then draw the chin as close as possible to the chest, placing the cervical vertebrae in a maximum flexed position C-Spine Lateral HyperFLEXION & HyperEXTENSION CENTRAL RAY Center CR at the level of C4 (level of upper margin of thyroid cartilage) Top of IR is about 2-inches above the EAM SID 72 inch 75 +/- 5 kV range COLLIMATION Flexion – Light should extend from EAM anteriorly to C7 spinous process posteriorly Extension – Light should extend from midmandible anteriorly to C7 spinous process posteriorly C-Spine Lateral HyperFLEXION & HyperEXTENSION Image Analysis Guidelines LT Flexion FLEXION Body of mandible almost vertical in a normal patient C1-C7 spinous processes in profile, elevated & widely separated Intersegmental alignment of the cervical spine Superimposed zygapophyseal joints & open intervertebral disk spaces C1-C7 in true lateral position Proper collimation & marker seen with annotation less lordosis in the spine turn collimator box is needed for projections  C-Spine Lateral HyperFLEXION & HyperEXTENSION Image Analysis Guidelines Extension Body of mandible almost horizontal in a normal patient C1-C7 spinous processes in profile, depressed & closely spaced Intersegmental alignment of the cervical spine Superimposed zygapophyseal joints & open intervertebral disk spaces C1-C7 in true lateral position Proper collimation & marker seen with annotation know what is included and what is supposed to look like LT EXTENSION Additional views (uncommon)  AP PROJECTION - FUCH’S METHOD Fuch’s recommended the AP Projection to show the dens when it’s upper half is not clearly shown in the open mouth position POSITION This patient position must not be attempted if fracture or degenerative disease of the upper cervical region is suspected Extend the chin until the tip of the chin and the tip of the mastoid process are vertical WHY are we doing that? For the dens to lie within the circular foramen magnum Adjust the head so that the MSP is perpendicular to the plane of the grid  AP PROJECTION - FUCH’S METHOD CENTRAL RAY Perpendicular to the midpoint of the IR, enters the neck on the MSP just distal to the tip of chin 75 +/- 5 kV range EVALUATION CRITERIA Entire dens within the foramen magnum dens is in foramen magnum No rotation of the head or neck, demonstrated by symmetry of the mandible, cranium & vertebrae AP PROJECTION – OTTONELLO METHOD Also known as “Wagging Jaw” Mandibular shadow is blurred by having the patient perform a chewing motion of the mandible during the exposure The patient's head must be rigidly immobilized to prevent movement of the vertebrae Exposure time must be long to prevent mandible from obscuring the ROI Use an exposure technique with low mA & long exposure time (longer than 1 sec) for C1 and C2, positioned with no angulation and ask to move jaw down with long exposure AP PROJECTION – OTTONELLO METHOD POSITION Place the patient in supine position Adjust the patient's head so that the MSP is aligned with the lower body and is perpendicular to the table Elevate the patient's chin enough to place the occlusal surface of the upper incisors and the mastoid tips in the same vertical plane Immobilize the head, and have the patient practice opening and closing the mouth until the mandible can be moved smoothly without striking the teeth together AP PROJECTION – OTTONELLO METHOD CENTRAL RAY Perpendicular to C4, central ray enters at the most prominent point of the thyroid cartilage EVALUATION CRITERIA Entire cervical spine with the mandible blurred or obliterated  AP AXIAL PROJECTION – VERTEBRAL ARCH (PILLARS) Must not attempted until cervical spine pathology or fracture has been ruled out CR angulation used projects the vertebral arch free of anteriorly vertebral bodies & transverse process Also useful for showing the cervicothoracic spinous processes in patient’s with whiplash injury  AP AXIAL PROJECTION – VERTEBRAL ARCH (PILLARS) POSITION With the MSP of the head perpendicular to the table, fully extend the patient's neck If patient cannot tolerate full extension, an AP Axial oblique projection is recommended CENTRAL RAY Directed at C7 at an 25 degrees caudad Angulation is determined by the cervical lordosis ↑ cervical curve = ↑ angulation ↓ cervical curve = ↓ angulation 75 +/- 5 kV range  AP AXIAL PROJECTION – VERTEBRAL ARCH (PILLARS) EVALUATION CRITERIA Vertebral arch structures without overlapping of the vertebral bodies & transverse processes Articular processes Open zygapophyseal joints btw the articular processes X No angulation  Image Analysis A patient arrives in the ER on a backboard with a possible cervical spine injury. WHICH PROJECTION OF THE CERVICALE SPINE WILL BE PERFORMED FIRST? horizontal beam lateral projection ANSWER: _____________________________  Image Analysis DO NOT MANIPULATE HEAD, DEPRESS SHOULDERS OR PERFORM SWIMMERS VIEW UNLESS PHYSICIAN PERMITS - OTIMROEMPQ What is wrong this picture???? sponge behind the head  OTIMROEPMQ Merrill’s p.471 Shoulder depression Assisting with lead apron instead take lateral and a spot image (swimmers view to see C7 and T1) our order says do not depress shoulders if a cervical spine trauma IMAGE ANALYSIS horizontal beam lateral projection TRAUMA UNIT TRAUMA  Image Analysis Patient’s mouth is closed incisors touching CR is angled perpendicular to IR Rotation seen of the cervical bodies (look at spinous processes) How would the technologist correct this? _____________________________ patient is rotated towards the left, spinous process are seen not in the center _____________________________ to project the upper incisors superior to the dens Position the patient in a _________ _________, placing the shoulders at equal distances from the IR BONUS! turn patient to the right, they are turned towards IR rn the larger space bewteen vertebral body and transverse foramina indicated the side turned towards IR