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FULL SPINE RADIOGRAPHY
The
full spine study consists of five views:
1.
APFS 14x36 or 7x36
 | This
view may be taken with the patient's mouth open or the patient's mouth
closed.
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2.
Additional cervical projection 8x10
| If the
APFS is produced with closed mouth, an additional APOM is required.
If the APFS film is produced with open mouth, an additional lower
cervical tilt-up (15°
cephalad tube angulation) view is required.
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3.
Neutral lateral cervical 8x10
| Have
the nose-to-ear line horizontal and make sure that there is no patient
rotation or lateral flexion. Collimate
just behind the eyes so that a small portion of the hard palate will show on
the finished film to indicate a true neutral positioning; otherwise,
comments about the cervical lordosis have no relevance.
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4.
Lateral thoracic 14x17 or 7x17
5.
Lateral lumbar 14x17 or 7x17
Justification
| Symptomatic,
historical, and/or clinical exam justification must be present
in all three spinal regions and must be indicated in the chart notes.
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| Since
the clinical choice by the physician to produce an APFS radiograph indicates
that there is indeed clinical justification in all three regions of the
spine, the legal minimum requirement of two views at right angles to each
other necessitates the production of lateral projections of each spinal
region.
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Filtration
| Compensating
(wedge) filtration at the tube is vital in order to produce a good quality
full spine film by attenuating the primary beam before it reaches the
patient, thereby accommodating for the small cervical and the much denser
and larger lumbar region.
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| Split
or gradient screens which alter the amount of fluorescence from the screen
onto the film after the radiation has passed through the patient, are
outdated and must be avoided, as this causes even the smallest regions to be
exposed to radiation factors chosen to accommodate the largest region of the
spine.
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Not
all patients are candidates for full spine radiography:
| All
regions of the film should be of diagnostic quality. Many facilities should narrow their parameters as to who is
an appropriate candidate for a full spine study.
Sectional views are often more appropriate for good diagnostic
quality.
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| It is
virtually impossible to produce an excellent APFS film on a patient who
exceeds 34 cm A-P abdomen measurement, and even this requires excellent
compensating filtration. Yochum
and Rowe (Essentials of Skeletal Radiology) state that "patients with
an A-P measurement greater than 28 cm should not be subjected to a
single APFS projection."
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| Beyond
a consideration of thickness is the problem of discrepancy between
the largest centimeter measurement of the patient and his smallest cm
measurement.
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| APFS
views are not suitable for unstable, antalgic, or hyperkyphotic patients.
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Gonad
shielding
| Gonad
shielding should be utilized on all male patients with child-bearing
potential. Contact or shadow
shielding or collimation may be utilized.
Such will never interfere with diagnostic yield if the male patient
is gowned, having removed all clothing, including underwear.
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| Gonad
shielding is not typically utilized on initial studies of female patients,
since it significantly interferes with diagnostic yield.
Gonad shielding should be utilized on females for lateral and spot
projections. It should also be
used when possible on serial (follow-up) studies.
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A
lateral full spine 14x36 film is not a recommended view
| Current
compensating filtration systems at the tube do not allow for the production
of a good quality lateral full spine radiograph in which all regions of the
film are of diagnostic quality. |
| Separate
sectionals should be produced with every AP full spine, and this applies
even for scoliosis studies. |
| In
scoliosis studies, interspaces must be well visualized in order to rule out
anomalies, and good visualization of all interspaces is rare on a lateral
full spine due to projectional distortion. |
| Sagittal
curves can be visualized on sectionals.
Sagittal alignment of the entire spine can be accomplished as a
physical exam procedure via plumbline.
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Final Analysis
| The use of full spine x-rays has evolved over
the last couple decades so that it is indicated chiefly for the evaluation
of scoliosis. The use of full
spine x-rays for general imaging and for pure analysis of mechanical
alignment (that is, for uses other than scoliosis evaluation) is outdated. |
| Including the entire spine on film carries
with it diagnostic liability for all regions included within the field of
view. When all
structures cannot be adequately visualized, a patient could be harmed by a
failure to detect some sort of pathology. |
| Since statistically few other doctors are now
utilizing full spine x-rays (for anything other than scoliosis), there is no
longer widespread peer support for their use if something should go
awry.
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