This is an inadequate radiograph of the thoracic spine although all thoracic vertebrae (T1-T12) are seen on this AP view. For trauma imaging, C7 and L1 must be entirely demonstrated to evaluate potential dislocation at the cervical and lumbar junctions. As for the radiograph technique, it is adequate for the upper vertebrae but the lower thoracic vertebrae are poorly penetrated. This is because the exposure favors high contrast rather than low contrast and good penetration. To correct for this you should use the anode-heel-effect or a wedge filter to even out the density difference between the upper and lower thoracic spine. When using anode-heel-effect place the thicker part under the cathode end of the anode. This will provide a greater number of photons with greater energy to that area. Using the 50/15 rule to create a radiograph with a slightly lower contrast is recommended to make this an optimal film.

Perhaps the single most important reason to repeat all or a portion of this radiograph is the omission of some of the upper thoracic vertebrae (T1 and T2). The diagnostic criteria require the visualization of all thoracic vertebrae and for trauma imaging to include the 7th cervical and 1st lumbar vertebrae. On this radiograph, the first thoracic vertebra is partially clipped. To correct the omission this radiograph must be repeated. The patient should be better centered along the long axis and the CR passing approximately through T6. A low contrast image is preferred over the high contrast study seen here. Using low kVp to image the thoracic spine is not a good practice. Poor penetration of the lower vertebral bodies like what is seen here results. So change this exposure technique to reflect more penetration and more gray tones, but do not sacrifice subject detail.

No, this radiograph does not meet the diagnostic criteria for the AP thoracic spine view. The reasons why this is not a good radiograph is that the required anatomy is not entirely demonstrated, and the subject contrast is inadequate for diagnosis. The subject contrast throughout the image is not adequate. See how “washed out” the detail is from T1 through T5. Remember, that bone trabecular pattern should be seen. Subject detail is simply inadequate for this to be considered a good radiograph. This film should be repeated using technical factors that improve contrast. Use better centering of the part and the collimation used will prove to be adequate. The amount of kyphotic curvature seen in the upper spine may not be a factor the technologist can control. But you can try to have the patient bend their knees and flatten the spine into the tabletop.

Some good points about this radiograph are that the technologist used a low contrast exposure technique to provide uniform contrast over the entire thoracic spine. From C7 through L1 is well demonstrated in good bone detail. The vertebral bodies are adequately visualized for evaluation of their height, contour, cortices, and trabecular pattern. Alignment of the spine along the mid-sagittal line could have been better because this patient is on a spine board. It is permitted to align the patient using the support board as long as spine precautions are followed. This requires moving the board only not the patient. Supporting the cervical spine while aligning the patient is also required. Otherwise, this is a good radiograph. The patient is slightly rotated to the left. When there is rotation of the part, the side with the smallest distance from the pedicle to spinous process is farthest from the image receptor. In this case it is the right shoulder that should be rotated back towards the film. Because of the chest tube and intubation, the positioning seen here is acceptable and no direct adjustment of the patient should be attempted.

A history of trauma mandates the horizontal beam lateral projection is made. Though the upper vertebrae are not well demonstrated this radiograph is adequate for interpretation. A separate lateral, which can be a Swimmer’s view or shoot through lateral for the upper portion of the spine, is needed to complete the diagnostic criteria. Any additional view must include from C7 through T4. The subject contrast seen here is adequate for diagnosis but could have been better if tighter collimation had been used. Tight collimation will reduce the amount of scatter radiation produced and will ultimately result is less image fog and higher contrast. The CR should passes slightly more posterior to the subject; this will demonstrate the spinous processes and posterior portion of the thorax. Otherwise this is a good radiograph and does not need to be repeated for the above-mentioned observations.

The attenuation of the beam by the tabletop along the posterior margin suggests this is a horizontal beam lateral view. It is an inadequate radiograph for completing clearance of the thoracic spine. The main reason is that it does not include the entire thoracic spine. Adding a second lateral view demonstrating the lower thoracic spine overlapping what is seen here would be acceptable. A Swimmer’s view will still be needed to optimally visualize the cervicothoracic junction and the first three thoracic vertebrae. There is a significant amount of graininess on this radiograph, which diminishes subject contrast. Increasing the mAs and using a long breathing technique (3-4 seconds) or even suspending breathing will help improve subject contrast. Overall, it is a good radiograph that when put with additional images will be useful for interpretation.

At first glance this radiograph appears to meet the diagnostic criteria; however it is inadequate for complete clearance of the thoracic spine. This is because the upper thoracic spine (C7-T3) is poorly demonstrated. This is a problem area to demonstrate on the lateral view. So we have to look at this area carefully to determine if it meets the diagnostic standard. Adding a Swimmer’s view to our horizontal beam lateral view will allow us to see these upper thoracic vertebrae. Because the apophyseal joints of the thoracic vertebrae are best seen on the oblique views and these are seldom done, we must see the lateral and AP views well. When imaging the spine we are keenly aware that we must demonstrate the apophyseal joint. Therefore, the lateral view must demonstrate all thoracic vertebrae will in order for anatomic relations to be completely evaluated. This radiograph should be kept for evaluation of the lower vertebrae. Because two or three radiographs are usually taken to complete the lateral criteria this radiograph is certainly worth keeping as part of the set.

This Swimmer’s view does show good positioning of the part and required anatomy. However, the exposure technique did not provide good subject contrast and detail, especially through the region of T2 and T3. This view should be repeated. What is interesting here is that the positioning is superb in that the patient is in a true lateral; however, the arms should not be raised above the head. Instead, bring them out 90-degrees to the patient's body. This will reduce the effect of the shoulders attenuating the beam. As a rule of thumb, if the positioning allows for demonstrating the desired anatomy, then the exposure technique can and must visualize it. This poor quality radiograph features many of the issues technologist face daily in imaging the upper thoracic spine, particularly getting the right subject contrast and image detail. Doubling the mAs and have the patient hold their breath during the exposure should improve the subject detail. Rehearse breathing instructions with the patient to make sure they are holding their breath during the exposure or breathing out slowly. Adding a wee bit more collimation and this could be a great projection.

This is a very good lateral radiograph of the thoracic spine. Notice the chosen radiographic technique demonstrates a higher contrast than previous images. The technologist used the 50/15 rule to get good bone detail. A breathing technique is also used to enhance the visualization of the vertebrae by blurring the rib shadows. This required rehearsing with the patient so that a long sustained expiration was achieved. We can appreciate the quality positioning of the patient as well. Of course the upper thoracic vertebrae will still need to be imaged with a shoot through or Swimmer’s view to demonstrate C7 through T4 completing the diagnostic criteria for the lateral view. The lower thoracic vertebral disc spaces are not opened because the posterior median furrow is not parallel to the tabletop. Overall, this is a fine radiograph.

Because this is a trauma survey this radiograph is taken using a horizontally directed x-ray beam. Notice the attenuation of the beam by the tabletop. The zygapophyseal joints of the thoracic vertebrae are best demonstrated with an oblique view. Here they are clearly seen, which indicates the patient is greatly rotated. Poor collimation further diminishes subject detail and is not in keeping with ALARA. Subject density and contrast through the upper thoracic vertebra and cervicothoracic junction is lost. When imaging the thoracic spine it is particularly difficult to achieve good bone detail and deemphasized lung detail. Keeping the beam quality below 90 kVp can improve subject contrast. Tight collimating to the area of interest is essential to producing a good radiograph. The CR must pass through the spine at T6/T7 and not through the lungs. In this scenario, lowering the tube is a must since the posterior image is cut off in part due to poor beam alignment.

When imaging a large patient like this one the technologist must be keenly aware of the effect of scatter radiation on image production. Because there is no effective collimation this image is marred by fog. As a result, there is complete loss of subject detail. Compare this radiograph to radiograph #73 above to what good subject detail is achievable with good collimation and exposure technique. Collimation raises the subject contrast by reducing aberrant scatter that causes image fog. A large field of view like the entire chest seen here, if not collimated will contribute to lowering contrast. Also, the CR should pass through the center of the part of interest. This along with collimation will result in better contrast. Other changes should include adjusting the exposure technique and better centering of the spine to the tube and image receptor. This radiograph was taken for the thoracic spine; therefore, the CR should pass through T7, not the mid thorax, which is the centering point for a chest x-ray.

The upper thoracic spine and cervicothoracic junction is a problematic imaging area. The purpose of the Swimmer’s view is to visualize both of these regions. Attention to the apophyseal joints of C7/T1 and down through T3 is necessary to meet the anatomical criterion. This is different from the Swimmer’s view for the cervical spine in that our image field is adjusted inferiorly demonstrating the thoracic spine. We must also demonstrate the proper vertebral levels with good contrast and subject detail. This requires a good exposure technique and patient cooperation to reduce unnecessary motion. This is a good radiograph because it meets the entire diagnostic criteria. The slight amount of rotation of the part does not require repeating the radiograph.

1. Align the mid-sagittal plane (MSP) to the vertically directed central ray (CR) for the AP view.
2. Use close collimation and be sure to include all transverse processes and a portion of the posterior ribs on the AP view. Use close collimation for the lateral view and be sure to use good tube-part-image receptor alignment. The thoracic spine should be centered to the image receptor and the CR should pass through the spine.
3. Radiographic technique must be adequate to evaluate the vertebral bodies for contour and architecture, spinous processes, articular pillars, and trabecular pattern of bone.
4. All of C7 through L1 must be demonstrated on both the AP and lateral views using one or more images to achieve the criterion.

This radiograph meets the diagnostic criteria stated above for routine imaging. It demonstrates all vertebrae from T12 through the sacrum and coccyx making this is a good AP radiograph of the lumbar spine. The well collimation lateral margins include both SI joints and psoas muscles. The degree of collimation enhances subject detail and is in keeping with the practice of ALARA. The radiographic technique well penetrates the vertebral bodies demonstrating them, the articular pillars, apophyseal joints, and spinous processes. This is an excellent radiograph for interpretation. Now a word of caution here is warranted. For trauma imaging the exposure technique would not be considered adequate at the thoracolumbar junction (T12/L1). It is underpenetrated in this area and is not optimal for trauma protocol. So while it is marginally good for routine work it may not pass for trauma imaging.

This is a good horizontal beam lateral view of the lumbar spine. It includes enough of the thoracic spine to evaluate the thoracolumbar junction. Distally from L5/S1 junction through the coccyx is incompletely visualized. The spinous processes and vertebral bodies appear adequately. The collimation is superb for bringing out subject contrast and detail. But the diagnostic criteria are not entirely met with this lateral image. The entire sacrum and coccyx must be included on the spot film to complete the diagnostic standard for this view because it is a trauma survey. Radiographic technique is adequate for visualization of fractures or dislocations in the visualized areas.

This radiograph does not entirely include the both SI joints and the sacrum. A careful evaluation of the right S.I. joint shows that it may be over collimated. Compare its anatomy to the one on the left. Irregularities may be due to fracture or a variant anatomy. Although bone detail is seen it is not optimally presented due to mineral loss. When there is bone loss the radiographic technique should be adjusted to bring out bone detail. Use sufficiently high kVp to penetrate the bone and accent the detail using appropriate mAs. The kVp selected will have the greatest effect on bone loss. Be sure to penetrate the bone well to see the contour of the vertebral bodies, articular pillars, and joint structures. This radiograph should be repeated, or a coned view of the area over the SI joints made.

Yes this image does meet the diagnostic criteria because it offers a more penetrated view of the lumbosacral junction (L5/S1), and the entire sacrum and coccyx. This criterion should be met for all trauma lumbosacral spine clearance surveys. Notice that the pelvis is not rotated, which we can appreciate because of the superimposition of the greater sciatic notches. This is a well-made radiograph on all accounts.

This radiograph is not taken for trauma so the entire sacrum and coccyx does not need to be demonstrated only L5/S1 spot is needed. The required anatomy is demonstrated, but it does not meet the diagnostic criteria. L5/S1 is not centered to the film and to the path of the central ray. The alignment of the pelvis is good evidenced by the superimposition of the greater sciatic notches. A slight angle on the tube of 5-10 degrees caudal would better demonstrate the lumbosacral joint and intervertebral disc space. Placing a sponge just slightly above the iliac crest will help reduce the sagging seen here. While sufficient bone penetration is seen, there is insufficient mAs to provide good bone detail. The image suffers from graininess due to too few photons and lots of scatter caused by the excessively high kVp. Making technique adjustments like slightly decreasing the kVp and increasing the mAs will make this a much better radiograph.

For this radiograph the patient was placed in the lateral recumbent position. Clearly, the patient is not in a true lateral. The obvious discrepancies are the part is not centered, portions of the image are clipped, and metal snaps are present. About 5% of the population have spondylolisthesis secondary to chronic stress fractures, and rare congenital anomalies. These changes must be distinguished from acute changes seen in trauma patients. Good positioning of L5/S1 is required for all imaging of the lumbosacral junction. To meet the diagnostic criteria the part should be centered to include all posterior spine elements. Be sure to always align the posterior median furrow and natal crease using a pillow or sponge. This will align the MSP parallel with the tabletop. Then, a tube angle of 5 degrees caudal will open the lumbosacral junction and demonstrate L5/S1 properly for interpretation. This view should be repeated to correct the poor positioning seen here.

The most obvious observation is that the radiograph is made with the patient fully clothed with their pants on. This is not an acceptable imaging standard. The required anatomy is demonstrated; however, the presentation of the anatomy for diagnosis is poor. The radiographic exposure technique is adequate, and the collimation is superb, but the study is obviously rushed. This has led to poor positioning seen at the lumbosacral junction. The arrow shows the iliac wing, which is severly rotated. There is too much rotation of the greater sciatic notch as well. Placing a pillow or sponge between the patient’s knees to align the spine will correct for this. Repeat this radiograph and have the patient properly dress for the study.

It is difficult to know what the technologist was trying to achieve when this radiograph was made. It appears there was some difficulty in locating the lumbosacral junction. To find L5/S1 you should remember that the iliac crest is at the level of L4. This places L5/S1 at approximately 1 inch below this point. The mark was missed in this positioning attempt and as a result there is too much of the lumbar spine demonstrated and too little of the sacrum. The collimation is poor reflecting the uncertainty of the radiographer in accomplishing this radiograph. This radiograph must be repeated using the radiological landmarks for locating L5/S1. The radiographic exposure technique should also be changed so that the part is well penetrated. This is a high contrast film having poor penetration of the lumbosacral junction.

The evaluation of any patient with internal fixation of the spine demands good subject detail, especially in the area of the attachments of the device to bone. The radiograph falls short in displaying bone penetration and detail required at the bone/metal interfaces. This image should be repeated using exposure factors that increase bone density and subject detail. Some of the loss of subject detail seen here is due to breathing motion or involuntary body motion. Reducing this motion will also improve the overall quality of this study. The good points are that the patient is not rotated, and the applied collimation is excellent.

You should quickly notice that this is not an acceptable radiograph for diagnostic interpretation of the lumbosacral spine. It is grossly under penetrated because of the high radiographic contrast chosen by the technologist. Image detail, particularly bone detail, is compromised by the exposure technique. This is an error in thinking because optimal kVp for lumbar imaging requires at least 80 kVp for an adult or higher depending on patient size. It is recommended that 80-90 kVp be used for the AP view, and 85-95 kVp for the lateral view, and 95 kVp for the spot film. The choice for beam quality depends on radiologist preference and the size of each patient. But we can agree that the outcome must be a well-penetrated study. Make sure you have demonstrated good bone detail, the contour of the vertebral bodies, the apophyseal joints, articular pillars, and interspinous spaces very well. Then apply good collimation to include the S.I. joints paying attention to optimal subject contrast.

Occasionally some orthopedic physicians request standing views of the lumbar spine. Always include the SI joints on the AP view and the hip joints on the lateral as part of the diagnostic criteria for the standing views. Both the iliac wings and greater sciatic notches are superimposed properly. This is because the patient’s legs are spread comfortably and the technologist took the time to adjust the patient to a true lateral. The upper part of the lumbar spine is not aligned. We can see the posterior ribs are not superimposed and the spine is tilted as in leaning towards the image receptor. Always align the posterior median furrow parallel to the image receptor. Place position markers anterior to the patient for spine work because patients do have a tendency to slightly rock back and forth and may come to rest in your marker.

I hope your answer to this question is that you would repeat this view. The main problem with this image is the position marker is in the field of interest. This is sufficient reason to repeat the view. This closely collimated part shows good subject contrast and detail. The posterior vertebral elements and apophyseal joints of L5/S1 are well demonstrated. Position better, or open the collimator slightly to include all of S1. In the future if close collimation is used, place the marker well outside the field of view. Scatter radiation will imprint the marker on the film in most cases.

1. The AP view - the lateral margins must include all transverse processes and both sacroiliac (SI) joints. Radiographic technique must be adequate to see the vertebral bodies, articular facets, articular pillars, and spinous processes.
2. All of L1 through L5 (possible L6), the sacrum, and coccyx must be demonstrated on both the AP and lateral views of acute trauma patients, especially if a known fracture is found in the thoracic or cervical region.
3. The MSP must be parallel to the table for vertical beam imaging of the lumbar spine. Adjust the rotation of the spine if necessary using a cushion between the knees and legs.