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Legal Requirement
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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.
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Visualization of
all Necessary Structures
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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:
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Uncovertebral
joints (joints of Luschka)
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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
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Tracheal
air shadow deviation caused by soft tissue swelling or mass
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Identification
of the left-or-right sidedness of facet degenerative changes,
which are superimposed on top of each other from the lateral
perspective
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Identification
of the left-or-right sidedness of articular pillar fracture or
deformity, which is also superimposed from the lateral
perspective
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Scoliosis
or individual segmental tilting and/or rotation
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Cervical
ribs
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Cross-triangulation
of structures visualized from the lateral perspective, which
is a classic radiologic interpretation principle |
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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.
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