Radiographic Positioning of the Cervical Spine
Section objectives: Cervical Spine Series
At the conclusion of this course the student doctor should;
1 Be able to efficiently conduct all parts of a 3, 5, or 7 view cervical spine series and ancillary views including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2. Be able to identify the significant anatomy demonstrated on each view of the series.
Standard Cervical Spine Series
3 View Cervical Series
5 View Cervical Series
7 View Cervical Series (Davis series)
Optional Cervical Spine Views
Organizing the Series
Make the series flow with least motion and most time efficiency.
Perform-n 40" first: APLC and @APOM.
Perform 72" last: Neutral lateral, R/L obliques, flex/ext.
Special Considerations
Trauma series: Perform neutral lateral first and check it.
APLC 2nd, APOM 3rd and check each.
Then obliques.
Finish flex/ext only if 50% of normal motion is present.
If any fractures, refer.
Radiographic Positioning #5822 1 last updated: May, 99
Radiographic Positioning of the Cervical Spine
A-P Lower Cervical (APLC)
PREPARE THE ROOM
Cassette: black, 8" x 10", lengthwise (flash up, away from lung apices)
Tube: 40" FFD, 15° cephalad tube tilt (varies according to patient)
Technique: 70 kVp, small focal spot
Measure: through central ray at appropriate angle
If patient measures <: 12 cm do not use grid, (non-bucky)
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient can be seated or standing (less motion if seated)
Have patient extend neck so that the mandible and EOP are parallel to
the floor.
Central ray: Aim at C6 (bottom of thyroid cartilage) and center film to central ray.
(Note the angle)
Collimation: Top of collimation at bottom of mandible, bottom include apices of lungs.
Side-to-side soft tissue.
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: APLC
· C3 to T1 should be clearly visualized.
· No rotation, spinous processes should be equidistant from spinal borders.
· Intervertebral disc angles should be open indicating correct central ray angle.
· Optimum exposure should demonstrate both bone and soft tissue density.
· Patient identification and RIL marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 2 last updated: May, 99
Radiographic Positioning of the Cervical Spine
A-P Open Mouth (APOM)
PREPARE THE ROOM
Cassette: black, 8" x 10", crosswise
Tube: 40" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: Use APLC measurement + 3 cm, increased technique due to strict
Collimation.
If patient measures < 12 cm do not use grid, (non-bucky)
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: Patient is fully gowned with no jewelry, hairpins, glasses, false teeth or
dental appliances, etc.
Patient can be seated or standing (less motion if seated)
Have patient slightly extend head so that the bottom of the top teeth are level with the EOP (parallel to the floor)
Hold the patient's head so that they do not flex or extend and ask them to
open their mouth wide by dropping their lower jaw.
Central ray: Should pass just below the top teeth in midline (aim at uvula), center the
cassette to the central ray.
Collimation: Open to the acanthion and mental symphysis vertically, laterally to include
mastoid processes. (~4" x 4")
Marker: R or L.
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: APOM
· The atlas and axis must be clearly seen through the open mouth.
· C1/2 zygapophyseal joints should be clearly demonstrated.
·
Optimum position is achieved if the base of the occiput and bottom of the maxillary
incisors are superimposed.
· Optimum exposure should demonstrate both bone and soft tissue density.
· Patient identification and RIL marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 3 last updated: May, 99
Radiographic Positioning of the Cervical Spine
Natural Lateral Cervical
PREPARE THE ROOM
Cassette: black, 8" x 10", lengthwise (tall, flash down)
Tube: 72" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: Across the trapezius muscle at the base of the neck
If patient measures < 12 cm do not use grid, (non-bucky)
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient can be seated or standing (less motion if seated)
Assure a true lateral position with no rotation of the pelvis, shoulders,
or head.
Patient is seated or standing "with good posture", left shoulder touching
bucky (if used), and eyes directly forward.
Have patient relax shoulders and drop them as far as possible (do just
before exposure because this is difficult to maintain).
Central ray: Through C4 with film centered to this.
Collimation: Laterally to soft tissues and film size vertically.
Marker: L, above the shoulder but below the mandible.
EXPOSURE
Patient directions: "Take a breath in, now blow it out. Hold still, don't move" - expose.
· Suspended expiration helps keep shoulders depressed.
EVALUATION CRITERIA: Neutral Lateral Cervical
·
Cl through C7 should be entirely visualized (if C7 is not seen, must add swimmer's view
to series).
· Mandibular rami should be superimposed over each other but not over upper cervicals.
·
Optimum exposure should demonstrate soft tissue including margins of the air column, as
well as proper bone density of the entire cervical vertebrae.
· Do not put flash down if concerned with spinous process fracture.
· If flash up, do not obscure ADI.
·
10" x 12" film (tall) can be used to include sella turcica in patients with apparent
spondylogenic headaches or visual disturbances.
· Patient identification and L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 4 last updated: May, 99
Radiographic Positioning of the Cervical Spine
R or L Posterior Oblique
PREPARE THE ROOM
Cassette: black, 8" x 10", lengthwise (tall, flash down)
Tube: 72" FFD, 15° cephalad tube tilt
Technique: 70 kVp, small focal spot
Measure: Obliquely across the trapezius muscle at the base of the neck
If patient measures < 12 cm do not use grid, (non-bucky)
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: Patient is fully gowned with no jewelry, hairpins, glasses, etc.
Erect position preferred) or recumbent if required.
Center spine to midline of table or bucky.
Patient is angled at 45° with appropriate shoulder touching bucky.
Head is turned midpoint between looking straight ahead and parallel to
Bucky (67.5° angle from tube).
Central ray: Through C4 with film centered to this (remember tube tilt).
Collimation: Laterally to soft tissues and film size vertically.
Marker: RPO or LPO are ideal markers.
R or L placed on appropriate side above the shoulder but below the
mandible (will appear on film to be ahead, anterior, of the spine).
EXPOSLRE
Patient directions: "Take a breath in, now blow it out. Hold still, don't move" - expose.
EVALUATION CRITERIA: Posterior Obliques.
· Cl through C7 should be clearly visualized with open intervertebral spaces and open intervertebral disc spaces.
· Rami of mandible should not superimpose upper cervical vertebrae.
· Base of skull should not superimpose Cl.
· RPO shows left foramina, LPO shows right foramina.
·
Optimum exposure should demonstrate soft tissue including margins of the air column, as
well as proper bone density of the entire cervical vertebrae.
·
Patient identification and proper marker should be clearly visible without blocking
anatomy.
Note: Anterior oblique views demonstrate ipsilateral foramina. Tube tilt is 15°
caudad for
anterior oblique imaging.
Radiographic Positioning #5822 5 last updated; May, 99
Radiographic Positioning of the Cervical Spine
Cervical Flexion Lateral
PREPARE THE ROOM
Cassette: black, 8" x 10", crosswise (wide, flash up)
Tube: 72" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: Across the trapezius muscle at the base of the neck
If patient measures < 12 cm do not use grid, (non-bucky)
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient can be seated or standing (less motion if seated)
Begin with patient in same position as for neutral lateral.
Give directions to "tuck in chin and then look to floor".
NEVER push them further.
Put them in this position just before making exposure, this position is uncomfortable!
Central ray: Through C4 with film centered to this.
Collimation: Laterally to behind the eyes and including all the spine, and film size vertically.
Marker: L.
EXPOSURE
Patient directions: "Take a breath in, now blow it out. Hold still, don't move" - expose.
EVALUATION CRITERIA: Cervical Flexion Lateral
· Cl through C7 should be entirely visualized.
· Mandibular rami should be superimposed over each other but not over upper cervicals.
·
Optimum exposure should demonstrate soft tissue including margins of the air column, as
well as proper bone density of the entire cervical vertebrae.
· Patient identification and L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 6 last updated: May, 99
Radiographic Positioning of the Cervical Spine
Cervical Extension Lateral
PREPARE THE ROOM
Cassette: black, 8" x 10", lengthwise (tall, flash down)
Tube: 72" FFD, no tube tilt
Technique: 70 kVp, small focal spot
Measure: Across the trapezius muscle at the base of the neck
If patient measures < 12 cm do not use grid, (non-bucky)
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient can be seated or standing (less motion if seated)
Begin with patient in same position as for neutral lateral.
Give directions to "look up to ceiling as far as comfortable".
NEVER push them further
Put them in this position just before making exposure, this position could
cause vascular compromise!
Central ray: Through C4 with film centered to this.
Collimation: Laterally to soft tissue, and film size vertically.
Marker: L.
EXPOSURE
Patient directions: "Take a breath in, now blow it out. Hold still, don't move" - expose.
EVALUATION CRITERIA: Cervical Extension Lateral
· Cl through C7 should be entirely visualized.
· Mandibular rami should be superimposed over each other but not over upper cervicals.
·
Optimum exposure should demonstrate soft tissue including margins of the air column, as
well as proper bone density of the entire cervical vertebrae.
· Patient identification and L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 7 last updated: May, 99
Radiographic Positioning of the Cervical Spine
Swimmer's Lateral
PREPARE THE ROOM
Cassette: black, 8" x 10", lengthwise (tall, flash down)
Tube: 40" FFD, 5° caudad tube tilt
Technique: 90 kVp, large focal spot (like for L/S)
Measure: From right SCM to L axilla
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: Patient is fully gowned with no jewelry, hairpins, glasses, etc.
Keeping head parallel to film, slightly twist shoulders so that left arm
reaches forward and up (approx.450), right arm grasps posterior thigh with
slight inferior traction.
Central ray: Through C7 (vertebra prominens) with film centered to CR.
Collimation: To film size.
Marker: L.
EXPOSURE
Patient directions: "Take a breath in, now blow it out. Hold still, don't move" - expose.
EVALUATION CRITERIA: Swimmer's Lateral
· Vertebral rotation should appear to be minimal.
· C4 to T3 should be seen in profile.
· Humeral heads should be separated vertically.
· The magnified humeral head, which is farthest from the film, should appear distal to
T4/T5.
· Patient identification and L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 8 last updated: May, 99
Radiographic Positioning of the Cervical Spine
R or L Pillar Views
PREPARE THE ROOM
Cassette: black, 8" x 10", LW (tall, flash down)
Tube: 40" FFD, 45° caudad tube tilt
Technique: 70 kVp, small focal spot
Measure: through central ray at appropriate angle
If patient measures >20 cm must use grid
Filter/shield: gonad (½ apron)
PREPARE THE PATIENT
Position: Patient is fully gowned with no jewelry, hairpins, glasses, etc.
Patient supine, slightly extend, and rotate head 45° to opposite side.
Put them in position just before making exposure, this position could
cause vascular compromise.
Central ray: Aim at C3/4 and center film to central ray.
(Note the angle)
Collimation: Open to fill cassette vertically, side-to-side half of cervical spine under
study.
Marker: Appropriate R or L marker. Mark the contralateral side of rotation.
EXPOSURE
Patient directions: "Hold still, don't move" - expose.
EVALUATION CRITERIA: Pillar View
· If patient is standing, imaging is performed P-A with a 35° cephalad tube tilt.
· Remember to adjust for tube tilt.
· All facet joints from Cl to T1 should be visualized.
· Optimum exposure should demonstrate both bone and soft tissue density.
· Patient identification and R/L marker should be clearly visible without blocking anatomy.
Radiographic Positioning #5822 9 last updated; May, 99