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Application of imaging > Imaging of the thoracic, lumbar & cervical spine > Flashcards

Imaging of the thoracic, lumbar & cervical spine Flashcards

1
Q

lanes and surface landmarks

A

EAM
Mastoid tip
Occiput
Thyroid cartilage

ASIS
Sternal notch
PSIS
Lower costal margin
Xyphoid sternum

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2
Q

Spinal anatomy

A

The vertebral column has four curvatures, the cervical, thoracic, lumbar, and sacrococcygeal curves.

The thoracic and sacrococcygeal curves are primary curves retained from the original feotal curvature.

The cervical and lumbar curves develop after birth and thus are secondary curves

Primary Curves x2
thoracic and sacrococcygeal
Secondary curves x2
cervical and lumbar

Lordotic Curves- upright spine

Kyphotic Curves- curved spine

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3
Q

2 main functions of the spine

A

Protect spinal cord and protect posture.

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4
Q

Spinal stability

A

The junctions of the
curves create natural
areas of weakness

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5
Q

Stable fracture

A

1 Column

Often managed conservatively

A weight bearing fracture in some cases

Does not usually involve spinal cord injury

Can become multi-column if managed incorrectly

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6
Q

unstable fracture

A

Multi column

Requires correction/surgery

Integrity of spinal cord at risk

Possible instantaneous paralysis

Not a weight bearing injury

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7
Q

Common clinical indications

A

Blunt trauma
Axial loading
Hyper-extension, hyper-flexion
Degenerative change
OA/RA
Congenital cause

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8
Q

Lumbar Spine Specific clinical indications

A

Trauma
Pain (sudden onset or longstanding & increasing)
?osteoporotic collapse
? Bone primary/hot spot
? Osteomyelitis
SI joint lesion

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9
Q

L-SPINE AP PROJECTION PATIENT POSITION

A
  • Patient supine on x-ray table
  • M-S plane in midline at right angles to the cassette
  • Patient’s head on pillow, arms by side
  • ASIS equidistant from table top
  • Shoulders equidistant from table top
  • Hips and knees flexed
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10
Q

L-SPINE CENTRING POINT

A

Central ray vertical to the image receptor
Midline at level of lower costal margin
Expose on arrested expiration

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11
Q

TOP TIPS - AP

A

Spinous processes not in midline of vertebral bodies- Rotation of the spine;
MSP not perpendicular to table top
? scoliosis

Intervertebral disc spaces not clearly demonstrated- ? Excessive lordosis – bend hips and knees;
Angle x-ray beam to different sides of the curve

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12
Q

L-SPINE LATERAL PATIENT POSITION

A

SUPINE: Lay patient on table in the lateral position

M-S plane parallel and middle of axilla coincident with midline of table.

Arms raised and folded over head

Vertebral column parallel to cassette

ASIS superimposed

Shoulders superimposed

Can be done standing/erect too

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13
Q

L-SPINE LATERAL CENTRING POINT

A

Central ray vertical to the image receptor

8-10cm anterior to spinous processes at level
of lower costal margin (L3)

Expose on arrested expiration

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14
Q

L-spine image criteria

A

Bony cortex and trabeculae seen.

Intervertebral disk spaces demonstrated.

Bodies of T12-L5/S1 demonstrated.

Vertebral endplates superimposed.

Cortices at the posterior and anterior margins of the vertebral body should also be superimposed. (No double edges)

The imaging factors selected must produce an image density sufficient for diagnosis from T12 to L5/S1, including the spinous processes.

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15
Q

TOP TIPS - Lateral

A

Vertebral bodies not superimposed- Rotation of the spine; MSP not parallel to table top; ensure hips and shoulders are superimposed

Intervertebral disc spaces not clearly demonstrated- ? Scoliosis – consider turning patient onto opposite side

L5/S1 not clearly demonstrated- Inadequate kVp to penetrate area – consider L5/S1 projection

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16
Q

L-SPINE- & ADDITIONAL SPINAL PROJECTIONS

A

AP L5/S1 projection
PA sacrum
Lateral sacrum
Posterior/anterior obliques
Horizontal Beam lateral
Sacro-iliac joints (prone and posterior obliques)
Lateral flexion and lateral extension
Side-bending APs
Erect spine

1,4,5,7,8,9 can be used for additional lumbar spine views

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17
Q

L5/S1 LATERAL patient position and entering point

A

PATIENT POSITION
Same as lateral L-spine

CENTRING POINT
Central ray vertical to the image receptor
8cm anterior L5 spinous process
PSIS

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18
Q

L5-S1 Anteroposterior projection

A

Patient is supine.
Angling around 30 degrees cranially on this projection allows better visualisation through the L5-S1 disc space due to the lumbar spines natural lordotic curvature

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19
Q

SACRUM PA

A

Patient is prone
Central ray perpendicular to IR then angled caudally 10° -25°
Midway between PSIS
Ensures x-ray beam is 90° to sacrum

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20
Q

Sacro-iliac joints

A

To position patient in order to bring the SI joint 90° to the imaging plate and enable the diverging x-ray beam to pass through the joint rather than across the joint (PA not AP).

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21
Q

SACRUM LATERAL

A

Centered over the sacrum, this view is usually performed under specialist request and helps tovisualise pathology of the sacrumand coccyxNot performed very often

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22
Q

Left and right posterior oblique L-spine

A

To demonstrate the pars interarticularis. Side closest to the IR is demonstrated.

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23
Q

Horizontal Beam Lateral Lumbar Spine

A

To avoid moving the trauma patient and avoid exacerbating their injury and causing potential paralysis

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24
Q

Lateral flexion and extension (Lumbar)

A

To assess the degree of movement/flexibility in the spine with the patient flexed forwards and extended backwards – Specialist orthopaedic request.

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25
Q

Erect PA spine (WHOLE SPINE)

A

To assess the affect of gravity on the scoliosis spine
To measure Cobb angle - measurement to assess the degree of curvature

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26
Q

Side-bending APs

A

To assess the degree of flexibility in the scoliosis spine with the patient bending to the L and R, and give an indication of the level of spinal fusion.

Performed with horizontal beam
Tend to image Lumbar and Thoracic spine separately as apposed to one whole image.

27
Q

Thoracic Spine: T1-T12 Standard Projections

A

AP

LATERAL (turned)

Additional Projections

Lateral (HBL)

28
Q

Thoracic spine Common specific indications

A

Trauma
Pain ?osteoporotic collapse
? Bone primary/hot spot
? Osteomyelitis
? Arthropathy
Orthopaedic follow up

29
Q

T-SPINE - AP PROJECTION PATIENT POSITION:

A

Patient supine with legs straight

M-S plane in midline at right angles to the cassette

Upper edge of IR at level just below
prominence of thyroid cartilage

Patient’s head on pillow, arms by side

Shoulders equidistant from IR

ASIS equidistant from tabletop

30
Q

T-SPINE - AP PROJECTION CENTRING POINT

A

Central ray vertical to the image receptor
Midline at level 5cm below sternal notch (T7)/ midway between xiphisternum and sternal notch
Ensure tube locked/aligned with bucky.

31
Q

T-SPINE – AP PROJECTION Essential Image Characteristics

A

Bony cortex and trabeculae visualised - kVp

C7 – L1 demonstrated

Intervertebral disk spaces demonstrated

Spinous process should be central within vertebral bodies (no rotation).

32
Q

T-SPINE - LATERAL PATIENT POSITION

A

Lay patient on table in the lateral position
M-S plane parallel and middle of axilla coincident with midline of table or vertical IR
Arms raised and folded over head
Vertebral column parallel to cassette
Shoulders superimposed
ASIS superimposed

33
Q

T-SPINE - LATERAL CENTRING POINT

A

Central ray vertical to the image receptor
3 – 4” below suprasternal notch (T7)
Perpendicular to mid-axillary line
Expose on arrested inspiration, in practice this is the armpit

34
Q

T-SPINE – LATERAL

A

Bony cortex and trabeculae seen - kVp
Intervertebral disk spaces demonstrated.
Intervertebral foramina superimposed
Bodies of T3-T12 demonstrated.

35
Q

Thoracic Spine - Considerations

A

Different range of densities overlying TSP = different attenuations of the XR beam\
Upper TSP superimposed by air filled trachea

Lower TSP superimposed by denser heart + liver

Thinner AP at top, thicker at bottom

Ribs superimpose TSP lateral

Difficult to demonstrate whole AP TSP in one projection

36
Q

Thoracic Spine - SOLUTIONS

A

High KVp – demonstrates TSpine in useful density range

Filters to even out densities (not often used these days)

Anode heel effect – anode cranially ensures higher intensity of XR beam directed at the larger/denser lower end of the T-Spine

Gentle breathing blurs out ribs (not often used due to longer exposure time/increased dose and risk of unsharpness of spine).

These are quite dated techniques now. The advanced software removes the need for filters and breathing exposures.
Correct positioning technique, use of grids and correct use of AEC are essential!

37
Q

C-Spine injury prevalence

A

The most common mechanism of injury is accidental falls

Followed by motor vehicle/transport injuries.

A common site of injury is the atlantoaxial region

the most commonly injured levels in the subaxial cervical spine are C6 and C7.

1/3 of injuries identified are considered clinically insignificant.

Despite surprising number of clinically minor injuries, 55% of spinal cord injuries occur in the cervical spine region.

38
Q

CERVICAL SPINE specific clinical indications

A

Trauma
Unconscious patient (Unsure of injury if fallen)
? Ankylosing spondylitis
? Bone primary/hot spot
? Osteomyelitis
? RA
Pain and radiculopathy

39
Q

C-SPINE – Anteroposterior (AP) PATIENT POSITION

A

Patient erect/supine with posterior aspect of head and shoulders against IR

M-S plane in midline at right angles to the IR

Depress/relax the shoulders

Elevate patient’s chin so that symphysis menti and occiput are superimposed

40
Q

C-SPINE – Anteroposterior (AP) CENTRING POINT

A

Centre vertical central ray to sternal notch – then angle central ray
Cranially to the thyroid cartilage (5-15º)

41
Q

C-SPINE - AP IMAGE CRITERIA
C3 – T1

A

Bifid spinous process of C3
2. Superimposed articular processes
3. Uncinate processes
4. Air filled trachea
5. Transverse process of C7
6. Transverse process of T1
7. 1st rib
8. Clavicle

42
Q

C- Spine Essential Image Characteristics

A

The image must demonstrate the third cervical vertebra down to the cervical-thoracic junction.

Lateral collimation to soft tissue margins.

The chin should be superimposed over the occipital bone

43
Q

C-spine top tips

A

3rd cervical vertebra obscured by mandible- Mandible not superimposed over occiput - chin not raised enough

3rd cervical vertebra obscured by occiput- Mandible not superimposed over occiput - chin raised too much

Top part of C-Spine ‘shooting off’ the top of the image receptor- Remember to align image receptor after angling the x-ray tube

44
Q

C-SPINE - LATERAL Patient position

A

Patient stands with the affected side against the erect chest stand. Feet slightly apart.

M-S plane parallel to the IR

Chin slightly raised preventing the angle of the mandible from being superimposed over bodies of the upper cervical vertebrae

Ask patient to depress shoulders

45
Q

C-SPINE - LATERAL Centering point

A

Central ray horizontal to the image receptor (SID = 180)

Centre at level of C4 (2.5cm behind, 5cm below angle of mandible)

46
Q

C spine- essential image characteristics

A
  • Entire cervical spine and upper part of T1 should be included (C7-T1 joint space).
  • Mandible or occipital bone should not obscure any part of the upper vertebra.
  • Angles of the mandible and the lateral portions of the floor of the posterior cranial fossa should be superimposed.
  • Soft tissues of the neck should be included.
47
Q

Air-Gap technique:

A

Gap between C-spine & IR

Reduces amount of scatter reaching the IR – improving image quality without need for a grid.

Removing need for a grid means exposure factors and therefore dose can be reduced.

Increased SID with air-gap can counteract magnification

Increased SID can prevent geometric unsharpness.

48
Q

C- spine lateral top tips

A

Vertebral bodies not superimposed- MSP not parallel Rotation of neck

Mandible superimposed over anterior borders of vertebral bodies- Chin not raised enough

T1 not demonstrated- Superimposition of shoulders; Inadequate penetration

49
Q

C-SPINE – PEG VIEW (AP C1-C2 PROJECTION) PATIENT POSITION

A
  • Patient erect/supine with posterior aspect of head and shoulders against IR
  • M-S plane in midline at right angles to the IR
  • Neck extended so that the inferior border of the upper incisors are superimposed on the occiput (an imaginary line joining the tip of the mastoid and the inferior border of the upper incisors is at right angles to the IR)
  • Immediately prior to exposure ask patient to open mouth as wide as possible.
50
Q

C-SPINE – PEG VIEW (AP C1-C2 PROJECTION) entering point and collimation

A

CENTRING POINT
Central ray vertical to the image receptor
Level of lower border of incisors (through open mouth)

COLLIMATION
SUP: Upper C1
INF: Body C3
LAT: Transverse process

51
Q

C-SPINE - AP PEG/C1-C2 PROJECTION: image criteria

A

Upper teeth and occiput superimposed

Odontoid peg and articulation demonstrated through open mouth

NO ROTATION (can mimic misalignment of lateral masses) Ensure symmetry of lateral masses

52
Q

C-SPINE- ADDITIONAL PROJECTIONS

A

Anterior/posterior obliques
Horizontal Beam Lateral
Lateral extension
Lateral flexion
Lateral C7/T1 (Swimmers View)

53
Q

Anteroposterior oblique

A

Demonstrate intervertebral foramina for size, shape and any impingement

54
Q

Horizontal beam lateral

A

Trauma patients – avoid moving the patient and exacerbating their injury

55
Q

Lateral flexion & lateral extension

A

To assess range of movement for cervical spondylosis
To assess stability of spine
To assess atlanto-axial joint for RA patients prior to intubation for anaesthetic.

56
Q

‘Swimmers’ Lateral C7 – T1 projection

A

To demonstrate C7/T1 junction & alignment when unable to do so with a routine lateral

57
Q

Terminology

A

Spondylo –
Spondylitis
Spondylosis
Spondylolysis
Spondylolisthesis

Retrolisthesis

58
Q

Spondylitis

A

Inflammation of the vertebrae

Ankylosing Spondylitis:
a painful, progressive, rheumatic disease
mainly affects the spine
can also affect other joints, tendons and ligaments.
Bamboo spine

59
Q

Spondylosis

A

General term for degenerative changes due to OA (Osteoarthritis)

Can affect cervical, thoracic and lumbar regions

Bony spurs

Osteophytes at the anterior, lateral, and less commonly, posterior aspects of the superior and inferior margins of vertebralbodies

60
Q

Spondylolysis

A

Defect of the pars interarticularis

Stress injury common in young athletes

61
Q

Spondylolisthesis

A

Anterior displacement of vertebra or vertebral column

Most common in L4/L5 and L5/S1

Graded 1-4

Retrolisthesis is displacement posteriorly in the opposite direction

62
Q

Spinal variations - Kyphosis

A

Anterior curvature of the thoracic spine

63
Q
A

Application of imaging (7 decks)

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