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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 mus...

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