C-Spine+%26+T-Spine+-+PDF 2.pdf

Radiographic Procedures II Cervical Spine & Thoracic Spine Jena Heflin, MBA, RT(R), CMOM Vertebral Column Forms the central axis of the skeleton Located in the MSP posteriorly Functions: – – – – Encloses & protects spinal cord Support for the trunk Supports skull superiorly Attachment for deep muscl...

Radiographic Procedures II Cervical Spine & Thoracic Spine Jena Heflin, MBA, RT(R), CMOM Vertebral Column Forms the central axis of the skeleton Located in the MSP posteriorly Functions: – – – – Encloses & protects spinal cord Support for the trunk Supports skull superiorly Attachment for deep muscles of the back and ribs 1 Vertebral Divisions Cervical Thoracic Lumbar Sacrum Coccyx = 7 = 12 = 5 = 1 = 1 26 Adult’s Vertebral Column = 26 bones Young Child’s Vertebral Column = 33 bones Complete Figure 1-7 2 Vertebral Curvatures Lordotic Curves – convex anteriorly – Cervical and Lumbar – Known as secondary or compensatory curves – Lordosis – any abnormal increase in the anterior convexity of the lumbar or cervical curves Kyphotic Curves – concave anteriorly – Thoracic and Pelvic – Known as primary curves (present at birth) – Kyphosis – any abnormal increase in the anterior concavity of the thoracic or pelvic curves Lateral Curves – Scoliosis – abnormal lateral curvature of the spine Vertebral Curvatures 3 Complete Figure 8-9 Typical Vertebral Anatomy A typical vertebra is composed of a body and a vertebral arch – Vertebral Body - thick, weight-bearing anterior part – Vertebral Arch - ring or arch of bone extending posteriorly from the vertebral body Vertebral Foramen – Circular opening formed by the vertebral body and arch – When vertebrae are stacked, all the vertebral foramen form the vertebral canal 4 Typical Vertebral Anatomy Typical Vertebral Anatomy Pedicle – extends posteriorly from vertebral body; forms the sides of the vertebral arch Lamina – extends posteriorly from each pedicle Transverse Process – extends laterally from the junction of the pedicle and lamina Spinous Process – extends posteriorly from the midline junction of the laminae – Most posterior extension of the vertebrae 5 Typical Vertebral Anatomy Typical Vertebral Anatomy Four articular processes – – – – Arise from the junction of the pedicles and laminae Articulate with vertebrae above and below 2 Superior Articular Processes 2 Inferior Articular Processes Zygapophyseal Joint – articulation between the superior and inferior articular processes Intervertebral Foramina – Formed by the inferior vertebral notch of a vertebra and the superior vertebral notch of the articulating vertebra – Spinal nerves and blood vessels pass through the intervertebral foramina 6 Typical Vertebral Anatomy Intervertebral Disks Seperates the vertebral bodies – Account for one fourth the length of the spine – Consists of two part: Nucleus Pulposus – central mass of soft, pulpy material Annulus Fibrosus – outer fibrocartilaginous disk Herniated Nucleus Pulposus (HNP) – Protrusion or rupture of the nucleus pulposus – a.k.a. “Slipped Disk” – Best seen using MRI 7 Intervertebral Disks Cervical Vertebrae Unique Characteristics: Transverse Foramina – Hole in each transverse process – Vertebral artery, vein, and nerve pass through Bifid Spinous Process Tips – C2 to C6 have double-pointed spinous processes Overlapping Vertebral Bodies – Cervical vertebrae’s anterior edge is slightly more inferior, causing slight overlapping Articular Pillars – Short, thick columns of bone between the superior and inferior articular processes 8 Cervical Vertebrae Superior Aspect Lateral Aspect Unique Cervical Vertebrae Atlas (C1) – Contains NO vertebral body – Short spinous process – Divided into an anterior arch and posterior arch Separated by the transverse atlantal ligament 9 Unique Cervical Vertebrae Axis (C2) – Dens (a.k.a. odontoid process) projects from the upper surface of the body into the atlas (C1) – Dens acts as a pivot to allow the head to rotate side to side – Has a horizontal spinous process Unique Cervical Vertebrae C7 – Termed “Vertebral Prominens” due to the long, prominent spinous process – Easily palpable landmark 10 Thoracic Vertebrae Unique Characteristics: – Costal Facets (articulation with ribs) – Long spinous process projecting inferiorly Increase in size from the 1st to the 12th Bodies of T1-T2 resemble cervical vertebrae Bodies of T10-T12 resemble lumbar vertebrae Bodies of T3-T9 are triangular-shaped Thoracic Vertebrae Superior Aspect Lateral Aspect 11 Radiographic Considerations Positioning rotations needed for demonstration of intervertebral foramina and zygapophyseal joints Area of Spine Cervical Spine Thoracic Spine Intervertebral Foramina Zygapophyseal Joint 45° oblique AP – up side PA – down side Lateral Lateral 70° oblique AP – up side PA – down side Refer to Merrill's Vol. 1, p.379 Radiographic Considerations C-Spine: 45º Obl T-Spine: 70º Obl 12 Topographic Landmarks Cervical Region C1 = Mastoid Tip C2-C3 = Gonion C5 = Thyroid Cartilage C7 = Vertebral Prominens (end of C-spine) Thoracic Region T2-T3 = Manubrial Notch (Jugular, Suprasternal) T4-T5 = Level of Sternal Angle T10 = Level of Xiphoid Process Topographic Landmarks 13 Anatomy Review Positioning rotations needed for demonstration of intervertebral foramina and zygapophyseal joints Area of Spine Cervical Spine Thoracic Spine Intervertebral Foramina Zygapophyseal Joint 45° oblique AP – up side PA – down side Lateral Lateral 70° oblique AP – up side PA – down side Refer to Merrill's Vol. 1, p.379 What position is this? LPO Position 14 What structure is seen? Right Intervertebral Foramina Remember, for AP obliques, we are looking at the upside What position is this? RAO Position 15 What structure is seen? Right Intervertebral Foramina Remember, for PA obliques, we are looking at the downside What position is this? RPO Position 16 What structure is seen? Left Zygapophyseal Joints Remember, for AP obliques, we are looking at the upside Complete 2 Images 17 Image Analysis Presentation of radiographs, pertinent anatomy, and positioning criteria General Considerations 10 x 12 IRs for c-spine 14 x 17 IRs for t-spine Collimate down to the spine (side-to-side) Use half-lead apron for shielding Breathing instructions vary 18 Left Lateral C-Spine 72-inch SID Patient in left lateral position at upright bucky Top of IR 1-inch above EAM MSP // with plane of IR CR ⊥ to C4, posterior to EAM Utilizing weights will help the patient depress the shoulders Elevate chin slightly Taken on expiration If C7 is clipped, do a Swimmers view Left Lateral C-Spine Structures Seen All 7 cervical vertebrae and at least 1/3 of T1 Neck extended so that mandiblular rami do not overlap C1 & C2 Demonstrates open zygapophyseal joints & intervertebral disk spaces Spinous processes in profile 19 AP Axial C-Spine 40-inch SID Angle 15-20° cephalic CR ⊥ to C4 (most prominent part of thyroid cartilage) Occlusal plane and mastoid tips in the same plane and ⊥ to the IR Taken on suspended respiration (no swallowing) AP Axial C-Spine Structures Seen C3 – T2 seen Open intervertebral disk spaces (C3-T2) Superimposed transverse, spinous, and articular processes Mandible out of area of interest 20 45° Axial Oblique C-Spine Can be done AP (RPO/LPO) or PA (RAO/LAO) Rotate patient’s body and head 45 degrees Angle CR 15-20° cephalic for AP obliques (caudal for PA obliques) CR enters at level of C4 Top of IR 1-inch above EAM Taken on suspended respiration 45° Axial Oblique C-Spine Structures Seen RPO/LPO - Intervertebral foramina demonstrated on the up side RAO/LAO – Intervertebral foramina demonstrated on the down side Open intervertebral disk spaces Elevated chin so there is no superimposition over C1 & C2 LPO 21 AP Open Mouth C-Spine 40-inch SID A 30-inch SID is recommended to increase the field of view of the odontoid area, but many protocols use a standard 40-inch SID Patient should open mouth as wide as possible Line up the top of the teeth with the base of the skull (or mastoid tip) Collimate down to 5 x 5 CR ⊥ MSP, just below upper teeth Exposure is made while the patient is phonating “ah” softly This places the tongue on the floor of the mouth so it doesn’t cover C1-2 AP Open Mouth C-Spine Structures Seen Dens free of superimposition by the occipital bone C1 & C2 articulation Superimposed occlusal plane and the base of the skull Shadow of tongue not projected over C1C2 22 AP or AP Axial Dens Projection (Fuch’s or Modified Fuch’s Method) 40-inch SID CR: 0° Modified Fuch’s requires up to an angle of 30° cephalic; CR enters // to MML Hyperextend the neck until the tip of the chin and mastoid processes are vertical (MSP ⊥ with plane of IR) CR enters between the mandibular angles, just distal to the tip of the chin Dens will be projected within the foramen magnum Do NOT attempt if fracture of the upper cervical region is suspected. AP or AP Axial Dens Projection (Fuch’s or Modified Fuch’s Method) Structures Seen Entire dens within foramen magnum Symmetry of mandible, cranium, and vertebrae, indicating no rotation of the head or neck 23 Left Lateral C-Spine Hyperflexion & Hyperextention Views 72-inch SID Patient in left lateral position at upright bucky Top of IR 2-inches above EAM MSP // with plane of IR CR ⊥ to C4, posterior to EAM Hyperflexion: Ask pt. to drop head forward Hyperextension: Ask pt. to elevate chin Taken on suspended respiration Flexion Extension Non-Routine C-Spine Views Structures Seen HyperFlexion Demonstrates motility of all 7 cervical vertebrae Flexion: spinous processes well separated Extension: spinous processes in close proximity Rules out whiplash injury HyperExtension 24 Trauma C-Spine Views Cross-Table Lateral 72-inch SID (if possible), may use 40-inch SID if needed Same positioning criteria as routine Lateral C-spine (CR ⊥ to C4) All trauma views are taken with the cervical collar on Demonstrate all 7 cervical vertebrae; do a Swimmers if top of T1 is not seen Other trauma views include AP Axial and AP Open Mouth Left Lateral Soft Tissue Neck 40-inch SID Pt. in left lateral position at upright bucky MSP // with plane of IR Depress shoulders as much as possible CR ⊥ C4 to demonstrates larynx, laryngeal pharynx, and upper end of esophagus For nasopharynx, CR enters 1-inch below EAM For oropharynx, CR enters at the level of the mandibular angle Options for breathing instructions: Expose while patient is phonating “eeeeeee” Expose during inhalation Expose while doing the Valsalva maneuver 25 Left Lateral Soft Tissue Neck Inhalation Phonating “eee” Valsalva Distends the supraglottic larynx and laryngeal pharynx with air Demonstrates vocal cords and evaluates for cleft palate Distends the subglottic larynx and trachea with air AP Soft Tissue Neck 40-inch SID Pt. in AP position (upright or supine) Extend pt.’s head slightly to prevent mandibular shadow from obscuring area of interest CR ⊥ C4 Taken during inspiration May also be taken while doing the Valsalva maneuver Structures Seen Throat filled with air No rotation or overlap Area from base of skull to lung apicies 26 AP T-Spine 40-inch SID Patient supine; flex knees to bring spine closer to IR CR ⊥ to T7 Halfway between jugular notch and xiphoid process IR about 1½ - 2 inches above the shoulders Collimate in to spine Using a wedge filter will provide even density If used, kVp by 5 Expose on expiration AP T-Spine Structures Seen All 12 thoracic vertebrae Include C7 and L1 Spinous processes at the midline of the vertebral bodies Collimation to the spine 27 Swimmer’s View 40-inch SID Angle CR caudally 0-5° if needed Pt. is in left lateral position Elevate the left arm; depress the right arm Rotate right shoulder back slightly; keep body lateral CR @ C7-T1 (cervicothoracic region), 2 in. above jugular notch Top of IR at top of ear If wedge filter is used kVp by 5 Trauma: may have to perform if C7-T1 is not see on x-table lateral c-spine (done supine on stretcher) Taken on expiration Swimmer’s View (a.k.a. Twining, Pawlow, or Cervicothoracic) Structures Seen Lateral projection of C5-T4 Humeral heads minimally superimposed Adequate x-ray penetration through the shoulder region * Some facilities may want C1 included to allow easy counting of vertebrae 28 Left Lateral T-Spine 40-inch SID Top of IR 1½ -2 inches above shoulders on avg pt. Pt. is in left lateral position with shoulders and knees on top of each other; bend pt.’s legs for comfort Place hands in “praying” position CR ⊥ to T7, posterior to axillary border Use a breathing technique to blur out ribs and vascular markings Use lead strip behind patient to absorb scatter radiation Left Lateral T-Spine Structures Seen All thoracic vertebrae included on image T1-T3 not well visualized T4-T12 well visualized Include L1 for reference Vertebrae seen clearly through rib and lung shadows Ribs superimposed posteriorly (indicates that the pt. is not rotated) Open intervetebral disk spaces Demonstrates intervertebral foramina on the down side 29 Critical Thinking What would you do? Situation A radiograph of an AP Open Mouth projection of the C-spine reveals that the base of the skull is superimposed over the upper dens. What specific positioning error has occurred? Choice A Choice B The skull is not extended enough The skull is extended too much 30 Situation A patient with a possible cervical spine injury enters the emergency room. The patient is brought in on a backboard. Which projections of the C-spine should be taken, and in what order? Correct Answer: 1. 2. 3. Situation A radiograph taken of an AP T-spine reveals that the upper thoracic region is overexposed while the lower thoracic region is underexposed. What can be done to improve this radiograph? Correct Answer: 31 Assignment See course schedule for reading assignment Optional Reading: Bontrager’s p. 288 – 320 Study Positioning Notes!!! C-Spine & T-Spine Worksheet – Section 1: Exercise 1 – 4, 9, 10 (Q. 1 – 21) – Section 2: Exercise 1 – 3 32 Radiographic Procedures II Lumbar Spine, Sacrum, Coccyx & SI Joints Jena Heflin, MBA, RT(R) Lumbar Spine  Contains 5 lumbar vertebrae  Increase in size from 1st to 5th  Bears the weight of the spine inferiorly  Has a natural lordotic curve  Spinal cord terminates at L1-L2  Common site of back injuries  The intervertebral disks are most commonly injured Anatomy of a Lumbar Vertebra  Body  Deeper anteriorly than posteriorly  Flattened  Transverse Process  Smaller  superior and inferior surfaces than those of the t-spine  L1-L3 are directed laterally  L4-L5 are directed slightly superiorly Pedicles  Strong and directed posteriorly Anatomy of a Lumbar Vertebra  Laminae  Thicker  than cervical or thoracic vertebrae Spinous Process  Large, thick, & blunt  Project posteriorly and horizontally  Mamillary Process  Smooth rounded projection on the back of each superior articular process  Accessory Process  Located process at the back of the root of the transverse Anatomy of a Lumbar Vertebra  Pars Interarticularis   Part of the lamina between the superior and inferior articular processes Unique characteristics of L5  Body is wedge-shaped for articulation with the sacrum  Intervertebral disk is also wedge-shaped  Shorter and smaller spinous process  Thickest transverse process Anatomy of a Lumbar Vertebra  Zygapophyseal Joints   Majority are demonstrated in a 45° oblique position Intervertebral Foramina  Situated at right angles (90°) to the MSP   Exception: L5, which is turned slightly anteriorly Majority are demonstrated in a true lateral position. Complete Figure 1 & 2 Anatomy of a Lumbar Vertebra Anatomy of a Lumbar Vertebra Sacrum  Formed by the fusion of 5 sacral vertebrae  Curved, triangular-shaped bone  Located between the iliac bones of the pelvis (SI Joint)  Female sacrum is more acutely curved  Results in a sharper angle at the junction of the lumbar and pelvic curves  Base = superior surface  Apex = inferior surface Sacrum  Sacral Promontory   Prominent ridge on the base of the sacrum Ala  Wing-like lateral mass on each side of sacral base  Contains articular surface for iliac bones of pelvis Sacrum   Sacral Canal  Located behind the bodies of the sacral segments  Continuation of the vertebral (spinal) canal  Transmits sacral nerves Sacral Foramina  Located on anterior and posterior walls of sacral canal  Passage for sacral nerves and blood vessels Sacrum  Apex has an oval facet for articulation with the coccyx  Sacral Cornua  Two processes projecting from the posterolateral aspect of the last sacral segment  Joins the coccygeal cornua Coccyx  Composed of 4 rudimentary vertebrae fused into one bone by adulthood  Diminishes in size from base to apex  Base = superior surface  Apex = inferior surface  Curves inferiorly and anteriorly  Coccygeal Cornua  Project superiorly from posterolateral aspect of the first coccygeal segment to join sacral cornua Anatomy of Sacrum/Coccyx Image Analysis Presentation of radiographs, pertinent anatomy, and positioning criteria General Considerations  40-inch SID  14 x 17 IRs for L-Spine  10 x 12 IR for L5-S1 spot  10 x 12 IRs for Sacrum, Coccyx, & SI Joints  Shield breasts and thyroid AP L-Spine  Patient supine  Bend pt.’s knees to bring spine closer to table  Decreases lordotic curve  CR  level of L4 (iliac crest)  Collimate to spine   Some protocols may require collimated to the skin Taken on expiration May be done PA to reduce patient dose AP L-Spine Structures Seen  Demonstrates lumbar bodies, transverse processes and intervertebral disks  Include T11 to distal sacrum  Open intervertebral joints  SI joints equidistant from spine 45° RPO/LPO L-SPINE  Roll patient up 45°  CR 2 inches medial to ASIS and 1½ inches above iliac crest (at level of bottom of the ribs)  Collimate to spine  Taken on expiration May be done RAO/LAO to reduce patient dose 45° RPO/LPO L-SPINE Structures Seen  Zygapophyseal joints of L1-L4 are seen on the down side  To demonstrate the zygapophyseal joint of L5-S1, pt. needs to be obliqued 60  Demonstrates “Scottie Dogs” RPO Scottie Dog Parts Superior Articular Process Ear Transverse Process Nose Pedicle Eye Pars Interarticularis Neck Lamina Body Inferior Articular Process Front Leg Left Lateral L-Spine  Patient in true lateral position  Hips, shoulders, and knees are on top each other, flex knees  Place hands in “praying position”  CR at iliac crest  If L-spine is not horizontal, angle CR 5-8 caudal so it is  with the spine  Use lead strip behind patient to reduce scatter  Taken on expiration Left Lateral L-Spine Structures Seen  Intervertebral foramina of L1-L4 are seen  Open intervertebral disk spaces  Spinous processes in profile  Some protocols may require the entire sacrum to be included L5-S1 Spot  Patient in same position as Left Lateral  Angle CR caudal:  5° - male  8° - female  CR is midway between iliac crest and level of ASIS (2 inches posterior to ASIS and 1.5 inches inferior to iliac crest)  Collimate down at least to 8x10  Taken on suspended respiration L5-S1 Spot Structures Seen  Lateral aspect of L5-S1  Open lumbosacral intervertebral joint  Some protocols may require the entire sacrum be included AP Axial L5-S1  Pt. supine on table with legs extended  Angle CR cephalic:  30° - male  35° - female  If PA, angle caudal  CR enters MSP, 1½ inches superior to pubic symphysis  Collimate down at least to 8x10  Taken on suspended respiration AP Axial L5-S1 Structures Seen  Lumbosacral junction and sacrum  Open intervertebral space between L5S1 AP/PA L-Spine Weight-Bearing  a.k.a. R/L Bending  Pt. standing in AP or PA position at upright bucky   Pt’s arms hang by the sides unsupported Have pt. lean directly lateral as far as possible without rotation and lifting the foot  Try to keep pelvis straight  CR  level of L3  1 radiograph taken with pt. bending toward the right, and the other taken with the pt. bending toward to left  Taken on suspended respiration AP/PA L-Spine Weight-Bearing Structures Seen  Demonstrates mobility of the intervertebral joints  Helpful in localizing joint movement of disk protrusion  No rotation of the patient in bending position Lateral Hyperflexion/Hyperextension  Pt. in left lateral recumbent position  Hyperflexion   Have pt. lean forward and draw the thighs up to flex the spine Hyperextension  Flexion Have pt. lean backward and posteriorly extent the thighs and limbs as much as possible (arch back)  CR  to L3 or level of spinal fusion  Take on suspended respiration  Annotate hyperflexion/ hyperextension Extension Lateral Hyperflexion/Hyperextension Performed to determine whether motion is present in the area of a spinal fusion or to localize a herniated disk Hyperflexion Flexion Extension Hyperextension AP Sacrum  Patient supine  Angle CR 15° cephalic  If performed PA, angle caudal  Collimate to at least 8x10  CR is midway between ASIS and pubic symphysis (2 inches inferior to ASIS)  Taken on suspended respiration AP Sacrum Structures Seen  Sacrum free of foreshortening with sacral curve straightened  Pubic bone not overlapping the sacrum  No rotation AP Coccyx  Patient supine  Angle CR 10° caudal  The tube angle corrects for the curvature  If performed PA, angle cephalic  Collimate to at least 8x10  CR is midway between ASIS and pubic symphysis (2 inches inferior to ASIS)  Taken on suspended respiration AP Coccyx Structures Seen  Anterior aspect of coccyx is seen  Coccygeal segments not superimposed Lateral Sacrum  Patient in true left lateral position  Interiliac plane  to the IR  CR  at the level of the ASIS, and 3½ inches posterior  Collimate to at least 8x10  May be combined to include the coccyx   If so, then open to 10x12 Taken on suspended respiration May have to utilize sponge to straighten out the Sacral area Lateral Sacrum Structures Seen  Lateral aspect of the sacrum (& coccyx if included)  Closely superimposed superior margins of the ischia and ilia Lateral Coccyx  Patient in true left lateral position  CR is 2 inches inferior and 3½ inches posterior to the ASIS  Collimate to at least 8x10  Taken on suspended respiration Lateral Coccyx Structures Seen  Lateral aspect of the coccyxsuperior margins of the ischia and ilia AP Axial SI Joints  Pt. supine on table with legs extended  Angle CR cephalic:  30° - male  35° - female  If PA, angle caudal  CR enters MSP, 1½ inches superior to pubic symphysis  Collimate down at least to 8x10  Taken on suspended respiration AP Axial SI Joints Structures Seen  Symmetric SI joints free of superimposition Include L5-S1 and entire sacrum RPO/LPO SI Joints  Pt. rotated into 25-30 RPO or LPO position  CR enters at level of ASIS, 1-inch medial to elevated side   You are imaging the upside SI joint Taken on suspended respiration RPO/LPO SI Joints Structures Seen  Open SI joint on upside demonstrates left SI joint Scoliosis Series  AP & Lateral views are performed of entire spine  Sometimes lateral is omitted to reduce pt. dose  AP demonstrates lateral curvatures  Lateral demonstrates anterior/posterior curves and  Methods 3 14x17 IRs are used in a scoliosis holder and the images are fused using the CR software  Scoliosis  board is used Refer to positioning notes for criteria What would you do? Critical Thinking Situation A radiograph of an LPO projection of the L-spine reveals that the downside pedicles and zygapophyseal joints are projected over the anterior portion of the vertebral bodies. What specific positioning error has occurred? Choice A Choice B The patient is under-rotated The patient is over-rotated Situation A patient comes to the radiology department for a routine lumbar spine series. She has severe kyphosis. How can the lumbar spine series be modified to accommodate this patient? Correct Answer: Situation A patient with an injury to the coccyx enters the emergency department and is unable to stand. When attempting to perform the AP projection, the patient complains that it is too uncomfortable to lie on his back. What can you do to complete this exam? Correct Answer: Assignment  See course schedule for reading assignment  Study Positioning Notes!!!  L-Spine Worksheet  Section 1: Exercise 5 – 9, 10 (Q. 22 – 25)  Section 2: Exercise 4 – 5 !"#$%&'()*+,-&.+/&'0&12"+($ ! !"#$%&'($)"&*+,$ -.//&*)-$)"#$0+11-$&2$ )"#$/1#.*+1$3+45)($+'6$ 65+/"*+78$.-#6$5'$ *#-/5*+)5&'9 ! :#*4#-$)&$/*&)#3)$)"#$ "#+*)$+'6$1.'7- ! ! !"#$%&'()* ! :)#*'.8 ! ;*#( J(#$%'0$*(+$K#%-0+1#%'02.#%"&$>0)1%)(#$*+6%060*+#$% -*'#%*,%'(),").*+6%&')*6-$ F204(%0).#%&+1()%$-(%-(01%")%0:1&4$%0).%*,% '(),").*+6%#&'*+( ?"'%",%IJ%LMLN%*+4-(#%0:"=(%$"'%",%#-"&21() @&2"#$+&$-$+/2)/&*#-"1#4+)@1$)