MINIMUM  CERVICAL  STUDY

The minimum study of the cervical spine consists of three views:

1.    AP Lower Cervical Tilt-up

CR through the thyroid cartilage, with a cephalad tube angulation of 15°.  Tip chin up slightly to ensure visualization of C3. This separate view is necessary for two main reasons:  

Legal Requirement

This is not because of statute (RCW) or administrative rule (WAC); instead, it is because of case law.  Numerous examples of expert testimony have confirmed the general understanding that any x-ray study always requires viewing via at least perpendicular planes whenever possible.  Standard x-ray positioning atlases have, for decades, presented the fact that the routine minimum study of the cervical spine consists of three views:  AP, APOM, and neutral lateral.  It therefore presents legal liability to omit any of the standard minimum views.

Visualization of all Necessary Structures

There are some very useful things that can be detected on an AP tilt-up view, structures which cannot be seen properly on the other views, such as:

Uncovertebral joints (joints of Luschka)

In accident cases subtle degenerative changes often appear at this site first.  It is important to show in a new injury case what the status of these delicate joints is at the time of injury, so that subtle degenerative changes which ensue over time can be detected and compared

Tracheal air shadow deviation caused by soft tissue swelling or mass

Identification of the left-or-right sidedness of facet degenerative changes, which are superimposed on top of each other from the lateral perspective

Identification of the left-or-right sidedness of articular pillar fracture or deformity, which is also superimposed from the lateral perspective

Scoliosis or individual segmental tilting and/or rotation

Cervical ribs

Cross-triangulation of structures visualized from the lateral perspective, which is a classic radiologic interpretation principle

2.    APOM

Line up the lower border of the upper central incisors with the base of the skull on a true horizontal plane and place the CR through the center of the wide open mouth.  Collimate tightly, approximately 3x5".  Make sure that there is no patient rotation or lateral flexion; otherwise, comments relative to atlas or axis misalignment are irrelevant.

3.    Neutral Lateral

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.

 

An A-P 7x17 or 14x17 cervicothoracic projection is not a recommended view.

Separate tilt-up and APOM views are necessary in order to see all structures, as described above.

One single A-P view of the cervical and thoracic spine does not allow for the necessary differing tube angles to accommodate for the lordosis and kyphosis; therefore, interspaces are not adequately visualized from the A-P perspective.

The differing centimeter measurement of the cervical and thoracic regions frequently results in these films showing overexposure in the cervical spine and underexposure in the thoracic spine, although selective filtration at the tube could improve this tendency.

Exposure of the thoracic spine from the A-P perspective requires the production of a lateral thoracic projection in addition to a lateral cervical projection; otherwise, the legal minimum of two views at right angles to each other is not accomplished.

Specific Analytical Views (Nasium, Vertex)

If the treating doctor wishes to utilize specialty views, they should be produced in addition to the three standard views, so as to accomplish showing the anatomical part to best advantage and to meet the legal minimum requirement.  Even though the nasium view is taken from the front, it does not provide an adequate view of the cervical vertebrae from the frontal perspective, and so the AP tilt-up view is especially important.  In some cases it may be possible to omit the APOM view, if the C1/C2 anatomy is well visualized on the nasium view.

Billing

According to current CPT, a 2 or 3 view-view cervical study is to be billed as 72040 at a charge which provides a fair compensation for the three views