Image Evaluation:AP Axial C-Spine

Alexa GergelRADS-216

HIPAA Compliance•This image is HIPAA compliant.

•This image does not violate patient confidentiality.

Marker and Patient ID•A correct post-

processed RT anatomical side marker is visible in the image. In addition, a technologist identifier should be included.

•The annotated RT side marker is placed correctly in the image.

Marker and Patient ID• There are no markers

superimposing pertinent anatomy.

• Additional markers that are necessary for this image include an up or down arrow indicating the position of the patient. This patient was likely supine, and would require a down arrow. This was not used in the original image.

Marker and Patient ID•The image is

displayed correctly based on marker placement.

Radiation Hygiene• There must be at

least three sides of beam restriction on an image.

• The beam restriction demonstrated on this image is acceptable because 4 sides of collimation appear to be demonstrated.

Radiation Hygiene

• Beam restriction is the primary source of gonadal shielding. At least 3 sides of beam restriction are necessary, and one of those needs to be on the side closest to the gonads for adequate gonadal shielding. In addition, a gonadal shield must be provided if the gonads are within 5 cm of the primary beam and shielding will not obstruct any anatomy of interest.

Radiation Hygiene

• There is evidence indicating appropriate use of shielding. There is adequate beam restriction on the side closest to the gonads.

• In addition, a shield would not obstruct any anatomy of interest, and should be used.

Routine Positions/Projections• A routine Cervical Spine study will include:

AP Axial (15˚ to 20˚ cephalad angulation)(Supine or Erect)

Lateral(Right or Left)(Erect or Supine)

AP Axial 45˚ Oblique(LPO)

AP Axial 45˚ Oblique(RPO)

Completeness of Position/Projection

•This image does comply with one of the routine positions/projections—the AP axial position/projection.

•All anatomical parts are not correctly visualized.

Artifact Identification

• There are preventable physical artifacts visible in the image.

• There are body parts that are superimposed that should not be. The mandible is superimposed over the upper cervical vertebra.

Artifact Identification•Hospital

paraphernalia is visible in the image. The patient appears to be wearing a cervical collar which is shown in the image.

Artifact Identification•Patient

clothing/belongings are visible in the image. The patient’s bra is shown at the bottom of the image.

•There does not appear to be any indwelling artifacts/foreign bodies visible in the image.

Artifact Identification•Excess fog is not

visible or degrading overall image quality.

•There does not appear to be any CR/DR artifacts visible in the image.

Image Sharpness

• “Gross” voluntary motion does not appear to be visible in the image.

• Excessive quantum mottle (or image noise) does not appear to be visible in the image.

• There does not appear to be evidence of double (or previous/ghosted) exposure visible in the image.

Image Sharpness

•Grid lines, grid artifact, &/or grid cut-off are expected because a reciprocating or stationary grid would likely be used, but do not appear to be visible in the image because a high frequency grid may have been used

Image Sharpness• Size distortion does not

appear to be greater than expected—there is some degree of distortion expected because the object being imaged is three-dimensional.

• Shape distortion does not appear to be caused by poor CR/IR/Part Alignment

Accurate Part Positioning• The part is not completely

aligned to the longitudinal axis and the image media.

• The part is not accurately centered to the image media. It should be centered at the level of C4.

• The CR does not appear to be centered within 1 cm of the anatomical part.

C6

c4

Accurate Part Positioning• The CR does appear to be

adequately aligned with the image media.

• The CR’s alignment does conform to an accepted IR exposure recognition template/field—4 sides of collimation.

Accurate Part PositioningPositioning Criteria for AP Axial C-Spine according to Merrill’s Atlas:• Place the patient in the supine or

upright position with the back against the IR holder.

• Center MSP of patient’s body to the midline of the table or vertical grid device.

• Extend the chin enough so that the occlusal plane is perpendicular to the tabletop—preventing superimposition of the mandible and mid-cervical vertebrae.

• Center the IR at the level of C4• Adjust the head so that the MSP is

in straight alignment and perpendicular to the IR.

• Suspend respiration• CR directed through C4 at an angle of

15 to 20 degrees cephalad• Adjust collimation 10 in. lengthwise an

1 inch beyond the skin shadow on the sides

Accurate Part PositioningEvaluation Criteria for AP Axial C-Spine according to Merrill’s atlas:• Evidence of proper

collimation• Area from superior portion of

C3 to T2 and surrounding soft tissue

• Shadows of the mandible and occiput superimposed over the atlas and most of the axis

• Open intervertebral disk spaces

• Spinous processes equidistant to the pedicles and aligned with the midline of the cervical bodies

• Mandibular angles and mastoid processes equidistant to the vertebrae

Accurate Part Positioning

•Based on the previous criteria, the anatomical part is not correctly positioned.

Judicious Exposure Technique•The most radiolucent

structure is air within the trachea. This is visible in the image.

•The most radiopaque structure in the image is bony cortex of the mandible. This is seen in the image.

Judicious Exposure Technique

• This image demonstrates long-scale contrast (window width).

• This image displays adequate brightness (window level) and would likely demonstrate an EI level within normal range.

Accept/Reject?This image does not meet minimum established standards and should be rejected.• Required corrections for this

image:• Include a “down” arrow indicate

patient position• The technologist should use their

own marker with their ID• Center CR and IR to C4 to include

C3 through T2 in the image• Raise mandible if possible in

order to demonstrate C3• If the image only displays up to

T2, the bra artifact will not be shown

• Align part to longitudinal axis of the IR

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References:Frank, E. D., Long, B. W., Smith, B. J., & Merrill, V. (2012). Merrill's atlas of radiographic positioning & procedures. St. Louis, MO: Elsevier/Mosby.

McQuillen-Martensen, K. (2011). Radiographic image analysis. St. Louis, MO: Saunders/Elsevier.

• http://www.wikiradiography.net/page/Odontoid-lateral+mass+Asymmetry image link

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