Students should be able to identify the following structures on radiographic images:
body, vertebral arch, vertebral foramen, vertebral canal, intervertebral disks, transverse processes, spinous process, laminae, pedicle, superior articular process, inferior articular process, zygapophyseal joints (a.k.a.. apophyseal jts. or interarticular facet joints), atlas, axis, dens (odontoid), vertebra prominens, transverse foramina, articular pillar
AP Axial Cervical Spine
CR Location & Positioning
- SID: 40 inches (102 cm) or department standard
- Patient position: Supine or upright AP with shoulders level; midsagittal plane centered
- Adjustments: Elevate/protrude chin so occlusal plane is roughly perpendicular to IR; avoid mandibular overlap of mid-cervicals
- CR: 15–20° cephalad to C4 (at or just below thyroid cartilage), centered midline
- Pt. Instructions: Suspend breathing; don’t swallow
- Exposure: Short exposure time; grid/DR per protocol
Evaluation Criteria
- Coverage: C3 through at least T2 visible with surrounding soft tissues included
- Rotation checks: Spinous processes midline; SC joints equidistant to spine; mandibular angles symmetric
- Motion checks: Sharp cortical margins and trabeculae; airway edges distinct
- Technique checks: Open intervertebral disk spaces from cephalic angle; adequate penetration through shoulders; no saturation
- Clinical aim: Survey vertebral bodies, disk spaces, hardware, or cervical ribs as applicable
AP Open-Mouth (Odontoid)
CR Location & Positioning
- SID: 30–40 inches per department protocol
- Patient position: Supine or upright; mouth wide open
- Adjustments: Align lower margin of upper incisors with mastoid tips so occlusal plane is perpendicular to IR; slight head tilt as needed
- CR: Perpendicular through open mouth to midline at C1–C2
- Pt. Instructions: Keep mouth open; softly say “ah” to depress tongue; suspend breathing
- Exposure: Short exposure; tight collimation
Evaluation Criteria
- Coverage: Dens, C1 lateral masses, and C2 body included; atlantoaxial joints visible
- Rotation checks: Mandibular rami equidistant from dens; lateral masses symmetric
- Motion checks: No motion of jaw or tongue; crisp dentition and dens margins
- Technique checks: Tongue not over C1–C2; no incisors or skull base superimposing dens
- Clinical aim: Assess dens integrity and C1–C2 alignment
Lateral Cervical Spine (Grandy)
CR Location & Positioning
- SID: 60–72 inches
- Patient position: True lateral, seated or standing, shoulder against detector
- Adjustments: Depress shoulders (equal weights if safe); elevate chin slightly or protrude mandible to clear C1–C2; MSP vertical
- CR: Horizontal, perpendicular to C4; top of IR about 1 inch above EAM
- Pt. Instructions: Suspend on full expiration to lower shoulders; hold still
- Exposure: Short time; grid or high kVp per protocol
Evaluation Criteria
- Coverage: C1 through at least C7 and ideally T1; prevertebral soft tissues included
- Rotation checks: Zygapophyseal joints superimposed; articular pillars aligned; mandibular rami nearly superimposed
- Motion checks: Sharp endplates and spinous tips; no swallow blur
- Technique checks: Open disk spaces; adequate penetration through shoulders; visible soft tissue detail
- Clinical aim: Evaluate alignment, disk height, facet relationships, and prevertebral swelling
Cervicothoracic Lateral (Swimmer’s)
CR Location & Positioning
- SID: 60–72 inches
- Patient position: Lateral (upright preferred or recumbent)
- Adjustments: Raise arm closest to IR overhead; depress opposite shoulder; MSP parallel; head neutral lateral
- CR: Perpendicular to C7–T1 (2 inches above jugular notch); 3–5° caudal if shoulder can’t depress
- Pt. Instructions: Suspend breathing; minimize motion
- Exposure: Consider breathing technique only if immobilized; use compensating filter if available
Evaluation Criteria
- Coverage: C5–T3 region with C7–T1 clearly demonstrated
- Rotation checks: Humeral heads offset (one anterior, one posterior) with minimal superimposition on spine
- Motion checks: Sharp vertebral margins despite shoulder thickness
- Technique checks: Sufficient penetration to see vertebrae between shoulders; good soft tissue detail
- Clinical aim: Visualize C7/T1 when standard lateral is inadequate
Posterior Oblique Cervical Spine (RPO/LPO) – AP Axial Obliques
CR Location & Positioning
- SID: 60–72 inches
- Patient position: Upright preferred; posterior oblique 45° with shoulder against IR
- Adjustments: Keep head aligned at same 45° as torso; elevate/protrude chin to clear upper spine without rotating superior vertebrae
- CR: 15–20° cephalad to C4; center to spine
- Pt. Instructions: Suspend breathing; hold still
- Exposure: Short exposure; tight collimation
Evaluation Criteria
- Coverage: C2–C7 intervertebral foramina and pedicles
- Rotation checks: Foramina “side up” open and uniform; pedicles of elevated side in profile
- Motion checks: Crisp foraminal walls; no swallow blur
- Technique checks: Open disk spaces; occiput and mandible not obscuring C1–C2
- Clinical aim: Demonstrate intervertebral foramina on the elevated side
Anterior Oblique Cervical Spine (RAO/LAO) – PA Axial Obliques
CR Location & Positioning
- SID: 60–72 inches
- Patient position: Upright preferred; anterior oblique 45°
- Adjustments: Chin elevated/protruded to clear upper spine; align head with torso (avoid extra head turn)
- CR: 15–20° caudad to C4; center to spine
- Pt. Instructions: Suspend breathing
- Exposure: Short exposure; tight collimation
Evaluation Criteria
- Coverage: C2–C7 intervertebral foramina and pedicles
- Rotation checks: Foramina “side down” open and uniform; pedicles of dependent side in profile
- Motion checks: Sharp foraminal margins
- Technique checks: Open disk spaces; no mandibular or occipital superimposition on C1–C2
- Clinical aim: Demonstrate intervertebral foramina on the dependent side
Supplemental Projections
Lateral Flexion and Extension Cervical Spine
CR Location & Positioning
- SID: 60–72 inches
- Patient position: True lateral upright
- Adjustments: Flexion—tuck chin toward chest; Extension—elevate chin and look slightly up; keep shoulders depressed and in same plane
- CR: Horizontal to C4
- Pt. Instructions: Suspend breathing; move only head/neck as directed
- Exposure: Short time; obtain only after stability is cleared per protocol
Evaluation Criteria
- Coverage: C1–C7 included on both positions
- Rotation checks: Articular pillars aligned; true lateral maintained in both views
- Motion checks: Clear spinous processes; no swallow blur
- Technique checks: Distinct disk spaces; interspinous spacing widens in flexion and narrows in extension
- Clinical aim: Assess cervical stability and motion limits.
AP Dens (Fuchs)
CR Location & Positioning
- SID: 40 inches
- Patient position: Supine (non-trauma only)
- Adjustments: Elevate chin so line from tip of chin to mastoid tips is vertical; MSP perpendicular
- CR: Perpendicular just distal to chin, centered midline to level of mastoid tips
- Pt. Instructions: Suspend breathing; hold still
- Exposure: Short exposure; tight collimation
Evaluation Criteria
- Coverage: Entire dens within foramen magnum
- Rotation checks: Mandible and cranium symmetric about dens
- Motion checks: Sharp dens margins
- Technique checks: Adequate contrast to see cortical outline within foramen
- Clinical aim: Alternative dens visualization when open-mouth view is inadequate