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FULL
SPINE RADIOGRAPHY
The
full spine study consists of five views:
1.
APFS 14x36 or 7x36
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This
view may be taken with the patient's mouth open or the patient's mouth
closed. |
2.
Additional cervical projection 8x10
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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. |
3.
Neutral lateral cervical 8x10
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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
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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. |
Filtration
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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patient, are outdated and must be avoided, as this causes even the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. |
Not
all patients are candidates for full spine radiography:
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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. |
Gonad
shielding
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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
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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. |
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Separate
sectionals should be produced with every AP full spine, and this
applies even for scoliosis studies. |
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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. |
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Sagittal
curves can be visualized on sectionals. Sagittal
alignment of the entire spine can be accomplished as a physical exam
procedure via plumbline. |
Final Analysis
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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. |
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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. |
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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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