Positioning notes: C-spine & Soft tissue neck

what is number 3 of the atlas?

vertebral foramen

what is number 4 of the atlas?

transverse process

what is number 5 of the atlas?

transverse foramen

what is number 1 on the axis?

dens (odontoid process)

what is number 2 on the axis?

spinous process

what is number 3 on the axis?

inferior articular process

what is number 4 on the axis?

transverse process

what is number 5 on the axis?

body

what is number 6 on the axis?

transverse foramen

what is number 7 on the axis?

superior articular facet

what is number 8 on the axis?

anterior articular facet for atlas

what is number 9 on the axis?

dens [odontoid process]

what is number 10 on the axis?

spinous process

what is number 1 on this odontoid x-ray?

upper incisors

what is number 2 on this odontoid x-ray?

odontoid process

what is number 3 on this odontoid x-ray?

zygapophyseal joint space (C1-C2)

what is number 4 on this odontoid x-ray?

body (C2)

what is number 5 on this odontoid x-ray?

bifid spinous process (C2)

what is number 6 on this odontoid x-ray?

lateral mass (C1)

what is number 7 on this odontoid x-ray?

inferior articular surface (C1)

what is number 8 on this odontoid x-ray?

superior articular surface (C2)

C-spine protocol for Adult

AP, Odontoid, RAO, LAO, lateral

C-spine protocol for pediatric (2-18)

AP, Lateral, odontoid

C-spine protocol for pediatric (under 2)

AP & lateral

pediatric patients with trauma surgeon present get what view?

lateral only (unless trauma surgeon says otherwise)

left lateral c-spine technique

85 kVp, 8 mAs

left lateral c-spine

• 10×12 LW

• 72” SID

• center @ C4

• suspended expiration

• C1-C7 & 1/3 of T1 is needed

cone down lateral purpose

if did not get C7-T1 on routine lateral

cone-down lateral technique

96 kVp, 28 mAs

cone down lateral c-spine

• 72” SID

• 4×17 LW collimation

• center @ thickest part of shoulder

• suspended expiration

• C2-T1 needed

swimmer’s lateral purpose

only perform if unable to visualize C7-T1 on cone down

swimmer’s lateral technique

96 kVp, 28 mAs

swimmer’s lateral c-spine

• 40” SID

• 10×12 LW collimation

• Center @ C7-T1 (2” above jugular notch)

• suspended expiration

• C5- T4 visualized through separation of humeral heads

AP axial c-spine technique

85 kVp, 3.2 mAs

AP axial c-spine

• 40” SID

• 10×12 LW collimation

• angle 15-20 degrees CEPHALAD to C4 (thyroid)

• suspended respiration

• C3 to T2 visualized

Odontoid technique

85 kVp, 3.6 mAs

Odontoid c-spine

• 40” SID

• 5×5 collimation

• Center to open mouth

• suspended respiration

merrill’s recommendation for odontoid SID

30” (to increase FOV)

AP fuchs purpose

only done when upper dens not visible on good odontoid

(should NOT be done when fx is present)

AP fuchs technique

85 kVp, 7.1 mAs

AP fuchs c-spine

• 40” SID

• 5×5 collimation

• center just inferior to top of chin

  • suspended respiration

PA axial obliques (RAO & LAO) technique

85 kVp, 10 mAs

PA axial obliques (RAO & LAO) c-spine

• 40” SID

• 10×12 LW collimation

• 45 degree obliquity

• Center 15-20 degrees caudad at level of C5

• suspended respiration

• open foramina from C2-C3 to C7-T1

  • need C1-T1

additional oblique notes: SUPINE

Angle the tube 15 degrees cephalad and mark the side against the IR anterior to the neck

Special view: C-spine: Cross table lateral (trauma)

• attending physician or radiologist must review this image to r/o fx or dislocation before removing collar or performing other projections

Lateral Flexion & extension: notes

**should not be attempted unless a cervical spine pathology or fracture has been RULED OUT

• 72” SID

• 8×10 or 10×12 LW

• center at C4

• marker placed posteriorly (annotate flexion & extension)

• suspended EXPIRATION

Flexion & extension: C-spine merrills SID

60-72” (to compensate for increase in OID)

flexion & extension : C-spine- purpose

Demonstrate the normal anteroposterior movement or absence of movement resulting from trauma or disease (motility of cervical spine, discs and zygapophyseal joints). Frequently performed to rule out “whiplash” type or injury or to follow up after spinal fusion surgery.

evaluation criteria: flexion & extension c-spine

• all 7 vertebrae in true lateral

  • no rotation or tilt of cervical spine

    • superimposed z- joints & open intervertebral disk spaces

    • superimposed or nearly superimposed rami of the mandible

    • spinous processes shown in profile

  • Flexion- body of mandible almost vertical & all 7 spinous processes in profile, elevated, & widely separated

  • extension- body of mandible almost horizontal & all 7 spinous processes in profile, depressed, & closely spaced

AP axial obliques (RPO & LPO): purpose

• foramina farthest (OPPOSITE) from IR are demonstrated, opened, from C2-C7, T1. opened disk spaces

AP axial obliques (RPO & LPO)- angle

15-20 degree cephalad,

trauma axial oblique c-spine notes

• do not use grid (double angle will cause grid cut off)

• mark side opposite from tube

• when CR enters right side, left foramina and disk spaces are demonstrated

• when CR enters the left side, right disk spaces & foramina are demonstrated

Soft tissue neck (upper airway) routine views

lateral only

Soft tissue neck (upper airway) if ordered for foreign body

AP as well as lateral

left lateral: soft tissue neck technique

65-70 kVp, 3.2 mAs

left lateral soft tissue neck

• 40” SID

• 10×12 LW collimation

• Center @ C4 (slightly anterior to EAM)

• slow inspiration through the MOUTH

• air filled trachea down to level of T1

additional note for pediatric patients for lateral soft tissue neck

Image is then taken on inspiration.

additional note: lateral soft tissue neck: merrills

patient should clasp hands behind the body & rotate the shoulders posteriorly to keep the arms from obscuring

jugular notch is at the level of

T2/T3

c2 appears taller than other cervical vertebra because ….

the dens

mastoid tip lies at __

C1

gonion lies at

C2-C3

pedicle

above & below foramina

intervertebral foramina

openings between pedicles

angle that intervertebral foramina lie in

45 degree from sternal plane & 15 degree from horizontal plane

what is the true lateral position

z joints (zygapophyseal joints)

secondary curve occurs

after birth

C1=

atlas

c2=

axis

c7=

vertebral prominence

z-joints lies around

C1

body on odontoid image lies around

c2

lateral mass lies around

c1

RAO=

right side being viewed (facing the board)

observes CLOSEST to board

RPO=

oPPosite is being viewed

jefferson fx is at the level of

c1

hangman fx is at the level of

c2

unique characteristics of c3-c6 vertebrae

1. bifid spinous process

2. pillars

3. foramina

what is part of 2 organ systems

pharynx

swimmers centering is

c7-t1

body of mandible on flexion should be

vertical

body of mandible in extension should be

horizontal

if the shoulder is not properly depressed for a swimmers lateral what angle should you put on?

3-5 degree caudad

vertebrae needed on lateral cspine

all 7 & at least 1/3 of T1

if the upper incisors are projected over the dens this means what?

chin is down

if the base of the skull is projected over the dens this means what?

chin is raised too high

on a fuchs, if the chin is over the dens & there is a “gap” above the dens=

chin is down, not enough angle

on a fuchs, if the tip of the dens is not in the foramen magnum & there is a “gap” beneath it=

chin is up, too much angle

what forms the z joints

superior & inferior articular processes

what are the openings between the pedicles?

intervertebral foramina

little or no angle on AP=

closed spaces; spinous process & chin superimposed over C3

tilt vs rotation on lateral

Tilt= z-joints are above/ below each other

Rotation= z-joints are next to each other

rotation on swimmers view

• rami are off side to side & intervertebral foramina are seen

on odontoid if upper incisors overlap dens this means

chin not raised enough

on odontoid if base of skull is overlapping the dens & the dens is touching the foramen magnum=

chin raised too high

on a LAO/RAO, if the pedicles are off the border of the vertebral body & you can see the spinous process off the back (looks lateral), this means it is

over rotated

on a LAO/RAO, if there are “hills” on the front w/ intervertebral foramina closed off (looks AP), it is

under rotated

when to repeat for chin on soft tissue neck

if chin is in trachea