AP Axial C-Spine Image Evaluation-Alexa Gergel

1. Image Evaluation:
AP Axial C-Spine
Alexa Gergel
RADS-216

2. HIPAA
Compliance
• This image is
HIPAA compliant.
• This image does not
violate patient
confidentiality.

3. 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.

4. 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.

5. Marker and
Patient ID
• The image is displayed
correctly based on
marker placement.

6. 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.

7. 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.

8. 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.

9. 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)

10. 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.

11. 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.

12. Artifact
Identification
• Hospital
paraphernalia is
visible in the image.
The patient appears to
be wearing a cervical
collar which is shown
in the image.

13. 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.

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. 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.

20. Accurate Part Positioning
Positioning 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

21. Accurate Part
Positioning
Evaluation 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

22. Accurate Part
Positioning
• Based on the previous
criteria, the
anatomical part is
not correctly
positioned.

23. 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.

24. 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.

25. 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
123

26. 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
• https://hfu-
my.sharepoint.com/personal/mness_holyfamily_edu/_layouts/15/onedrive.as
px#id=%2Fpersonal%2Fmness%5Fholyfamily%5Fedu%2FDocuments%2FMast
er%2FRADS%2D216%20Images%2FMerrills%5FImages%2F8%5FVertebral%5
FColumn%2F8F45%2Ejpg&FolderCTID=0x0120003CB7C277C84FB54094226
CA9570F27D4&AjaxDelta=1&isStartPlt1=1461707900435&parent=%2Fpersona
l%2Fmness%5Fholyfamily%5Fedu%2FDocuments%2FMaster%2FRADS%2D21
6%20Images%2FMerrills%5FImages%2F8%5FVertebral%5FColumn