What makes this a great neutral upright lateral is that all vertebrae from the base of the skull to the 1st thoracic vertebrae are clearly seen. The contour of the vertebral bodies and posterior quadrilateral architecture are well demonstrated. Each superior and inferior articular facet is distinct and the facet faces are easy to interpret. Good subject contrast and detail is seen especially the contour lines that are important to diagnosing injury. The structures that are demonstrated here are: sella turcica and sphenoid sinus, seven cervical vertebrae and T1 and T2, and great soft tissue detail like the perivertebral fat stripe.

This view demonstrates passive flexion of the cervical spine. The main purpose for this view is to evaluate the forward range of motion of cervical spine and function of the apophyseal joints. The white arrows point to the apophyseal joints. They appear to maintain their proper articulation limits. None have slipped forward into the groove on the facet face and become locked. A yellow arrow points to the cervicothoracic junction, which is stable. The contours of the superior and inferior articular processes are well demonstrated for interpretation. The radiographic technique optimally displays all structures meeting the diagnostic criteria.

This is an extension view of the cervical spine. Notice the spacing of the vertebral bodies demonstrating the stability of the symphysis joints. These joints are formed by the annulus fibrosus of their intervertebral disc. Sometimes we get so caught up in evaluating the apophyseal joints that the joints formed by the intervertebral disc get overlooked. Both the flexion and the extension views demonstrate the relationship of these joints. It is the extension view of the cervical spine that best demonstrates the backwards range of motion and spacing of the symphyses joints? Two areas of the column are observed for widening. One is at the disk spaces and the other is the interspinous space between adjacent vertebrae. Both the flexion and extension views are important in delineating these areas of concern.

This view is an upright lateral in the neutral position. A HALO device immobilizes this patient. The neutral position is commonly requested to assess interval changes expected in the healing process. The imaging specialist never removes the brace. Flexion and extension is contraindicated while wearing a HALO device. The lateral view is usually requested along with an AP view as part of the sequence of images corresponding to the patient's history of fracture. Notice that the injury is at the level of the first cervical vertebra. There is good radiographic contrast, bone detail and penetration. It is important to penetrate the vertebrae since follow-up studies must be of sufficient density to be compared. In time as healing occurs the neurosurgeon may accompany the patient to direct the imaging protocol. Flexion and extension views with the Halo device removed require medical supervision.

This is an excellent upright neutral lateral radiograph for several reasons, which are worthy of mention. It is a true lateral meaning that the mandibular angles are superimposed, as are all apophyseal joints. All cervical vertebrae are demonstrated with good visualization of the contour of the vertebral bodies, posterior quadrilateral bone architecture, and bone detail throughout. The purpose of this view is to evaluate the stability of the surgical fixation. In order to evaluate it the vertebrae above and below the fixation must be completely imaged. The fixation supports vertebrae C5, C6, and C7. Because we can see the apophyseal joints and body of T1 the diagnostic criteria are met. However, a more penetrated look at C7/T1 would be the mark of a true professional since the entire vertebra below the fixation device should be completely visualized. Using lower contrast to display the bony elements would improve the visualization of the first thoracic vertebra.

1. Structures to be visualized are from the occiput to T1 in neutral, flexion, and extension.
2. Flexion and extension views of a trauma patient should be performed only after a radiologist has cleared the horizontal beam lateral and a clinical physician has given neurological clearance.
3. Flexion view should be a passive motion to demonstrate forward motion of the spine and interspinous spaces.
4. Extension view is also passive demonstrating backward range of motion and spine and intervertebral joints.
5. Tight collimation and a good radiographic technique to allow for visualization of:
1. Apophyseal joints of the cervical and first thoracic vertebrae in flexion and extension views.
2. Bony detail of the posterior quadrilateral architecture of the vertebrae.
3. Three longitudinal contour lines and contour of each vertebral body.

This is a PA oblique view with the patient positioned in RAO. The CR is angled 15-degrees caudal to open the intervertebral joints. Notice that the intervertebral joints are not opened well. This is because this person is not positioned at a true 45 degrees from the sagittal plane. When positioned correctly the spinous and transverse processes will be superimposed. The problem here is the positioning of the patient not the tube angle. Notice that the upper cervical vertebrae are almost presented in the AP plane. Only the head is turned to 45 degrees. It is important to distinguish between improper tube angle and improper positioning of the patient, or both. The mandible should not overlay the upper spine. Extend the chin to better demonstrate the atlas, axis, posterior arch, and foramen of C2/C3. The IOML should be parallel to the floor; the interpupillary line should be perpendicular to the image receptor.

This is a relatively good radiograph that unfortunately will need to be repeated. The six required intervertebral foramina and vertebrae C7 through T1 are not entirely demonstrated. The visualized foramina are opened well enough for interpretation. The exit route of spinal nerves between C1 and C2 is not demonstrated. The part must be accurately positioned for oblique views, especially the PA views. Commonly the skull or mandible obstructs the spine when the positioning is not correct. To correct this the technologist should align the mid-sagittal plane to the image receptor and align the IOML parallel to the floor. The interpupillary line should be perpendicular to the image receptor and parallel to the floor. These changes will place the head in a true lateral better demonstrating the occiput, C1 and C2. The second point is that better collimation could have been applied in keeping with ALARA, and to improve subject contrast.

This is a near perfectly positioned oblique of the cervical spine. Notice that all of the intervertebral foramina are demonstrated as well as the posterior arch of C1. Notice how the spinous processes are superimposed on the transverse processes. The slight rotation of the mandibular condyles can be corrected by aligning the interpupillary line perpendicular to the image receptor. Even though this is a well-positioned radiograph the exposure is inadequate for interpretation. To correct for the under penetration seen here, increase the kVp at least 15%. Because there is slight motion present on the radiograph it might be a good idea to increase the mA and decrease the time of exposure once a compensatory technique is calculated.

This is a repeated view of the radiograph we have just evaluated (#55) using more kVp. By increasing the kVp 15% better penetration of the bone is seen. The contours of the pedicles that form the intervertebral foramen are well visualized. The articular pillars are also noted. Notice the alignment of the spinous processes and transverse processes posterior to the foramina. Increasing the mA, but maintaining the same mAs also reduced motion. The interpupillary line alignment is not remediated.

This appears to be a reasonably good radiograph; however, it is not a diagnostically acceptable radiograph. The posterior arch of C1 and six intervertebral foramina below it are seen. But of course there are several things that could have been done to make it a better radiograph. It looks like the technologist had the patient hold on to an I.V pole or the upright bucky to maintain balance. This has caused the raised arm to cast a shadow over the spine (yellow arrow). Note the position of the clavicle (white arrow) of the raised arm. To provide balance and stability during upright imaging some patients need to be seated and the arm brought parallel to the floor if holding an I.V. pole.

There are several improvements in the positioning that could be made. Mainly, the three indicees that align the patient for the oblique view is not met. Again we see the mandible obscuring the first and second vertebrae. The interpupillary line is not perpendicular to the image receptor and the infraorbitomeatal line is not parallel to the floor. Raising the chin and using the positioning lines will help improve this radiograph. Additionally, the patient is leaning towards the right shoulder obscuring the lower cervical vertebrae. Straighten the patient more upright and relax their shoulders down. The mid-sagittal plane should be aligned so that it is parallel to the image receptor. Note that the spinous processes are not superimposed on the transverse processes indicating the body is not rotated enough towards the midline.

1. Six open foramina below the posterior arch.
2. The articular pillars clearly.
3. The exposure adequately to penetrate the bone to provide good subject contrast and detail.