SPINES
Lateral Thoracic/Dorsal Spine Image # 50
File # 06
Critique: Excellent example of applied breathing technique. Note the blurring effect manifest
in the ribs and lung markings (almost non-existent), which is the fundamental idea underlying
the breathing technique. Note also that the image displays excellent positioning, centering and
collimation. Also, remember that in order to achieve an appropriate breathing technique, one
must utilize a minimum of two (2) seconds exposure time. Finally, the radiograph is 50%
overexposed in the mid to lower T-spine region. Compare to page 443 - 444, Vol I.
AP Lumbar Spine Image # 51
File# 06
Critique: Appropriately positioned and centered (for a 14 x 17 film) AP lumbar spine. While
some collimation is always desirable, this film displays too much collimation, as indicated by the
lack of proper film identification. In addition, low back pain is often due to referral from one’s
flank, which is indicative, when correlated with other diagnostic tests, of renal calculi. Because
of this common finding/association, this film may be deemed unsatisfactory in some medical
institutions due to too much collimation, which may have clipped a renal shadow bearing a
radiopaque stone. A paradox? Well, can you state with absolutely certainty that a film with 1 - 1
½ “ less collimation on both sides of this film would have produced an image with an
appreciable amount of decreased contrast? Let me answer the question for you by saying NO,
and neither could anyone else discern an appreciable difference in contrast. Finally, the
radiograph is 50% underexposed.
See page 451 - Vol I.
Lateral L-5,S-1 Interspace Image # 73 File # 06
Critique: Note that the L-5, S-1 interspace is closed. Why? Is it due to patient anomaly?
Perhaps the radiographer failed to properly assess the level of the spine relative to being parallel
to the plane of the table. If so, then the radiographer either angled the CR when it was not
required, or failed to angle the CR when it was required. The solution to this problem is to
always check for spine alignment with the tabletop (i.e.,parallel). Question: is the film and CR
off-center to L5,S-1 ? If so, did the Law of Tangents play a role in the final appearance of this
image? Compare to pages 454 - 455 - Vol. I.
Lateral L-5,S-1 Interspace Image # 60 File # 06
Critique: A properly positioned and centered L-5,S-1 Interspace. Note: the image is 50-75%
underexposed. Compare to page 454 - 455 - Vol. I.
Page 1
AP Thoracic/Dorsal Spine Image # 63 File # 06
Critique: Note that the top of the film is not one inch above the shoulders, which is evidenced
by T-12 being only marginally demonstrated, i.e., the film is not centered correctly. Note also
that although collimation was employed, the image exhibits scatter manifestation in the upper
thorax. Although the image is 75% overexposed for the upper thoracic region, the technique is
adequate for the lower area. A real dilemma regarding what to do? Well if the image is to be
repeated, a smaller cassette (8 x 10) with a reduction in technical factors (75%) would be
recommended for the upper thoracic, and the film shown here would demonstrate, as it does,
lower thoracic spine. On the other hand, why not consider the “anode heel effect” when
performing AP T-spines, which may avoid the dilemma altogether!
Compare to page 440 - 441 - Vol. I.
AP Lumbar Spine Image # 69 File # 06
Critique: When employing a 14 x 17, one should center the cassette to the iliac crests. In this
image, the centering is above the iliac crests, which is why one sees too much of the T-spine.
Also, the patient’s spine appears to be crooker/curved with convexity to the left side beginning at
 L-2. Is the curved appearance of the spine due to patient scoliosis or improper patient
placement/alignment? Also, the image is 30-50% underexposed in the lower lumbar region.
Compare to page 451, Vol. I.
Lateral Lumbar Spine Image # 66
File # 006
Critique: This image demonstrates patient motion as evidenced by the double-image effect as
seen in the posterior aspect of the lumbar bodies and the lumbar posterior elements (lamina,
pedicle, superior and inferior articulating processes). Otherwise, the image is correctly
positioned and possesses the correct exposure factors. However, the semicircular ring at the top
of the page indicates that the patient’s brassiere was not removed. In some cases, this could
present a problem. Setting endowment aside, one should remove the brassiere as it often
obstructs anatomy in the AP position. Compare to page 452 - 453, Vol. I.
Lateral Lumbar Spine Image # 68 File # 06
Critique: The film is far off-center longitudinally, especially since a 14 x 17 was utilized. Due to
off-centering, note that the vertebral spaces of L 2 and 1 are closed. Another Law of Tangents
problem? Could this closure be mistaken for a patient anomaly? Could the closure be due to
the spine not being parallel to the table? Note also that the inferior portion of the body of
L - 3, 2, and 1 is not superimposed due to off-centering of the anatomy. Also, the “slick”
radiographer in his/her desire to over collimate, managed to clip the identification marker. Is
this sort of error a potential medical-legal problem? One can only wonder at how much
contrast improvement was realized versus the medical-legal entanglement potential. Oh well.
Compare to page 452 - 453 - Vol I.
AP Lumbar Spine Image # 81 File # 06
Critique: Note carefully that the size of this film is a 10 x 17. Are you familiar with this size?
Neither am I. So, someone simply cut a 14 x 17 down to a 10 x 17. Did this maneuver improve
contrast. If you think so, please enroll in RAD 101 for remedial assistance. Also, where is the
R/L identification marker? Probably not an important concern - right! Oh well, other than the
fact that the crests are not centered to the center of the film, the image is very good. I suppose
one could cut the top of the film off and correct the off-centering problem!
Compare to page 452 - 453, Vol. I.
Lateral Lumbar Spine Image # 67 File # 06
Critique: Film not centered to crest. L-5,S-1, and the L-5 - 4 interspace is closed. Is the closure
due to failure to support the spine with a sponge necessary to place the spine parallel with plane
of table? Note minimal collimation, which is good. Otherwise, the image is technically correct.
Compare to page 452, 453, Vol. I.
RPO Lumbar Spine Image # 56 File # 06
Critique: I suppose an 11 x 14 was used because the patient is 7' 4" - right? Had we used a 10 x
12, which should satisfy the vertebral requirements for a 7'4" basketball star, the bottom of the
film would have been at the ASIS. In this image, notice that the “scottie dogs” at L-5 and 4
appear normal, from 4 upward, the “dog” appears to progressively lose some of his/her
anatomy. Reason: patient is torqued in the upper thorax region, but is correctly rotated in the
lower lumbar region. This is a common positioning error, i.e., forgetting that the lower end is
indeed connected to the upper end (of what?). Remember: roll the patient as you would a
wooden log, keeping the thorax in line with the lumbar area. Technical factors should be
increased by 50%. Otherwise, the vertebra are centered longitudinally.
Compare to pages 456, 457 - Vol. I.
RPO Lumbar Spine Image # 57 File # 06
Critique: Although this image is off-centered longitudinally, and the patient is slightly torqued,
the image does show that placing the bottom of the cassette at the ASIS will, and does, include
all of the lumbar vertebrae and more on a 10 x 12! Technically, the film is 50-75% overexposed.
Compare to 456, 457, - Vol. I.
AP Thoracic Spine (7 x 17)
Image # 64 File # 06
Critique: Even if we could have found the thoracic spine and placed it in the center of the film,
would the collimation to the size of the film appreciably improved the radiographic contrast. By
the way, is this film hanging/presented/oriented on the view box according to proper
radiographic procedure? How do you know? Compare to page 440 - 441, Vol. I.
Page 1
Swimmers Position (Lateral C-7, T-1, 2, 3)
Image # 61 File # 06
Critique: One can only imagine that the radiographer was concerned that he/she might miss
these small in number and size vertebra (11 x 14 - Image A). Perhaps she/he was not sure of
where the vertebra in question were located, or perhaps additional learning is in order! If the
technical factors had been correct in the T-1, 2 & 3 area (75% underexposure), the image would
have been OK, technically speaking. However, the lower arm should not be superimposed over
the C and T spine area. On a lab practical, any cassette larger than an 8 x 10 will bring you a lot
of grief. Compare to page 438 - 439, Vol. I .
Swimmers Position (Lateral C-7, T-1, 2, 3)
Image # 59 File # 06
Critique: One can only imagine that the radiographer was concerned that he/she might miss
these small in number and size vertebra (11 x 14 - Image B). Perhaps she/he was not sure of
where the vertebra in question were located, or perhaps additional learning is in order! If the
technical factors had been correct in the T-1, 2 & 3 area (75% underexposure), the image would
have been OK, technically speaking. However, the lower arm should not be superimposed over
the C and T spine area. Also, the independent arm (side up) could have been moved down a bit
more. On a lab practical, any cassette larger than an 8 x 10 will bring you a lot of grief.
Compare to page 439 - Vol. I .
RPO Lumbar Spine Image # 65 File # 06
Critique: I suppose an 11 x 14 was used because the patient is 7' 4" - right? Had we used a 10 x
12, which should satisfy the vertebral requirements for a 7'4" basketball star, the bottom of the
film would have been at the ASIS. In this image, notice that the “scottie dogs” at L-5 and 4
appear normal, but from 4 upward, the “dog” appears to progressively lose some of his/her
anatomy. Reason: patient is slightly torqued in the upper thorax region, but is correctly rotated in
the lower lumbar region. This is a common positioning error, i.e., forgetting that the lower end is
indeed connected to the upper end (of what?). Remember: roll the patient as you would a
wooden log, keeping the thorax in line with the lumbar area. It is also clear that the patient is off
centered longitudinally. Compare to pages 456, 457, Vol. I.
AP Open Mouth Odontoid Process Image # 74 File # 07
Critique: Image A clearly shows that the central incisors and the mastoid tips are not
superimposed. In this case, the C-spine is flexed too much as evidenced by the placement of the
central incisors below or near the base of the odontoid. Technical factors are fine.
Compare to page 414, 415, Vol. I.
8
AP Open Mouth Odontoid Process Image # 54 File # 07
Critique: Image B clearly shows that the central incisors and the mastoid tips are not
superimposed. In this case, the C-spine is not flexed enough as evidenced by the placement of
the base of the skull below or near the base of the odontoid. Technical factors are fine.
Compare to page 414 - 415, - Vol. I.
AP Open Mouth Odontoid Process Image # 62 File # 07
Critique: Image C clearly shows that the central incisors and the mastoid tips are not
superimposed. In this case, the C-spine is flexed too much as evidenced by the placement of the
central incisors below or near the base of the odontoid. Technical factors are fine. But, a 10 x
12! Compare to pages 414, 415 - Vol. I.
AP Open Mouth Odontoid Process Image # 55 File # 07
Critique: Image D clearly shows that the central incisors and the mastoid tips are not
superimposed. In this case, the C-spine is not flexed enough as evidenced by the placement of
the base of the skull across mid to upper portion of the odontoid process. Pay particular
attention to the vertical line of increased density running vertically through the odontoid process.
The vertical density represents the “spitting space” between the two central incisors. Although
not present in this case, a few patients will present with platybasia wherein the floor of the
skull/posterior fossa surrounds the foramen magnum. In these cases, the odontoid process will
always be partially obscured by the foramen magnum. “Cro-Magnon?” So what to do?
Tomography or perhaps, a few other special projections. Technical factors: 50 - 75%
overexposed. Compare to pages 414 - 415, - Vol. I.
AP Open Mouth Odontoid Process Image # 71 File # 07
Critique: Image E clearly shows that the central incisors and the mastoid tips are not superimposed. In this case, the C-spine is not flexed enough as evidenced by the placement of the
base of the skull below or near the base of the odontoid. Technical factors are fine.
Compare to page 414, 415, - Vol. I.
AP Open Mouth Odontoid Process Image # 53 File # 07
Critique: Image F clearly shows that the central incisors and the mastoid tips are not superimposed. In this case, the C-spine is flexed too much as evidenced by the placement of the
central incisors far below the base of the odontoid. Technical factors are fine.
Compare to pages 414, 415, - Vol. I.
Oblique Cervical Spine Image # 52 File # 07
Critique: Can you tell if the image is an LAO or a RAO? Guess not since the R marker is
absent. Otherwise, note that the intervertebral foramina are open, as they should be (in red), but
C-7 is obscured by the patient’s shoulders not being pressed downward - an important
maneuver that will bring you big dividends on a lab practical. Also note that the vertebrae at C-1
& 2 are somewhat over-obliqued due to patient torque. Technical factors are fine, and would
have been fine for C-7, had the shoulder been positioned down.
Compare to pages 426 - 429 - Vol. I.
LAO Oblique Cervical Spine Image # 72 File # 07
Critique: The intervertebral foramina are open, (in red), but C-7 is partially obscured by the
patient’s shoulders not being pressed downward - an important maneuver that will pay you big
dividends on a lab practical. Also note that the vertebrae at C-1 & 2 are somewhat over-obliqued
due to patient torque. Technical factors are fine, and would have been fine for C-7, had the
shoulder been positioned down. Compare to pages 426 - 429, Vol. I.
Lateral C-Spine Image # 70 File # 07
Critique: “Ain’t “ close collimation a wonderful thing! I suppose C-1 was not important to
visualize in this probable trauma patient. Is C-7 visible? Got to get those shoulders down.
Compare to pages 422 - 425 Vol. I. By the way, the orthopedic appliance was implanted long
before this image was taken, and is intended to complete the C-spine fusion process from a
previous injury or pathological state.
Lateral C-Spine Image # 58 File # 07
Critique: More close collimation, but this time the radiographer managed not to clip the
anatomy. C-7 is partially obscured by the patient’s shoulders - a weight-bearing problem or
technical factors? Always note the depiction of the odontoid process (in red outline) on
lateral projections. We often forget the value of the lateral in visualizing the odontoid process
from this perspective. By the way, is this a right or left lateral, or does it matter. Guess not since
the R/L marker is absent. However, we sure did collimate well, didn’t we!
Compare to pages 422 - 429 - Vol. I.
AP Cervical Spine
Image # 14 C & 14D File # 07
Critique: Image # 14 C demonstrates what happens when one fails to angle the CR on an AP Cspine. In image 14C, note how the mandible (Mandibular Symphysis and Body)is superimposed
over the cervical bodies of 5, 4, and 3. By comparison, Image 14D demonstrates a cephalic CR
angle of 15-200 . However, further C-spine extension would have possibly further enhanced the
demonstration of an additional cervical vertebrae in the AP position.
Compare to pages 420 - 421, Vol. I
Page 13
Lateral Cervical Spine
Image # 25 File # 07
Critique: Correctly positioned lateral cervical spine. Note that all vertebrae are demonstrated
and the image is well centered. Note also that the patient is placed in a “halo” traction device,
and the posterior elements at C-5 & 6 have been fused via surgical wires.
Right Sacroiliac Joint (LPO)
Image # 77 File # 08
Critique: The right joint space is opened proximally, with minimal joint closure distally.
Generally: a well positioned image with body obliquity 25 - 300.
Compare with page 443 - Vol. I
AP Sacrum (CR  150 Cephalic)
Image # 86 File # 08
Critique: The CR should enter 2" superior to the symphysis pubis. In this image, the CR entered
higher than the aforementioned site. Also, the sacrum is typically well-accommodated by an 8 x
10. Otherwise, the image clearly demonstrates bi-lateral sacroiliac joints from the supine
recumbent position.
AP Sacrum (CR  150 cephalic)
Critique: Correctly positioned sacrum.
Image # 88
Compare to page 449 - Vol. I.
File # 08
AP Coccyx (CR  100 caudal)
Image # 87 File # 08
Critique: While correct positioning is demonstrated, visibility of the coccyx is obscured by
flatus. Would a cathartic preparation been helpful? Also, the image is overexposed by 50%.
Compare to page 449 - Vol I.
Left Sacroiliac Joint (RPO )
Critique: Insufficient obliquity. Compare to page 443 - Vol. I.
AP Coccyx ( CR  100 caudal)
Critique: Correctly positioned and well-demonstrated coccyx
Compare to page 449 - Vol. I.
Image # 78
File # 08
Image # 82
File # 08
Lateral Coccyx Image # 85 File # 08
Critique: Other than the use of a 10 x 12 film to image a 2" anatomical structure, the image is
excellent. However, a 10 x 12 coccyx on the practical will bring grief. Note also that no lead
strip/sheeting was used on this image. So what do you think about that! A final note. This
patient is one of those individuals whose anatomy is such that the sacrum and coccyx are almost
equally visualized in the lateral position..
Compare to page 451 - Vol. I.
Bi-lateral Sacroiliac Joints
Image # 18 A & 18 B File # 08
Critique: Images A and B demonstrate what can happen when one fails to remember that when
the patient is supine recumbent and a radiographer - like you- desires to radiograph the sacroiliac
joints, it is the side that is up/away from the table, which must be centered to the film ,i.e., it is
the side up in the supine recumbent oblique position that is demonstrated. In this case, Image A1
shows no sacroiliac joint in profile, and Image B1 demonstrates an opened joint space, which
goes to show you there is always an element of luck in most endeavors, especially when the
radiographer uses a 10 x 12. Just imagine the anatomical structures that could have been
visualize if a 14" x 54" bucky system were available! What a S.A. ! Right !
Compare to page 443 - Vol. I.
AP and Lateral Coccyx
Image # 18 C & 18 D File # 08
Critique: Image 18 C (AP coccyx) provides an example of an image wherein the radiographer
either forgot to angle the CR caudally 100, or the angulation was, at best, minimal. The
angulation problem can been seen by observing (1) the shape of the pelvis, which has no
elongation effect, (2) the position of the symphysis is not projected downward, and (3) the
coccygeal segments are partially overlying the symphysis, because the symphysis was not
projected downward. Note the bi-lateral acetabular-ischial epiphysis. The lateral projection
(image18 D) is correctly positioned and well-demonstrates the coccyx. Note the almost 900 turn
near the coccygeal sacral junction. Compare to pages 448, 449 and 451 - Vol.I
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