Cervical Spine X-ray Search Pattern

1. Check the patient history, exam indication, and prior images.

2. Check the adequacy and technique.

1. • Are C1-C7 all present on lateral view?

   • Is the atlanto-axial / craniocervical junction visible?

   • Assess soft tissue neck adequacy. 

   • Is the study a true lateral (do the mandibles overlap closely)?

3. Assess for hardware.

4. Check bone mineralization and morphology.

• Is there demineralization or sclerosis?

• Are there 7 cervical vertebrae?

• Are cervical ribs present? Are there any segmentation anomalies?

• Are the vertebrae normal in shape?

• Are there any diseases of bony fusion (DISH/OPLL/ankylosing spondylitis)?

5. Examine the frontal view.

• Examine the ribs > uncovertebral joints and facets > spinous processes (spacing/alignment) > R and L spinal lines (for alignment) > remaining bones (mandible, skull base, paranasal sinuses) > nasal and pharyngeal soft tissues > lungs/pleura (especially for pneumothorax or lung nodules).

6. Examine the lateral view.

• Check alignment/instability (assess the atlanto-dental interval > assess the basion-dens interval > assess the atlantoaxial interval > assess the anterior, posterior, spinolaminar, and interspinous lines> as necessary, assess the Chamberlain, McGregor, or McRae lines (for basilar invagination).

• Assess for fracture and discopathy (check vertebral heights and disc heights > check for disruption of any usually confluently ossified ligaments or syndesmophytes).

• Look for degenerative changes.

• Look for osseous spinal canal encroachment (obvious neuroforaminal narrowing might be seen, though is better assessed on oblique views).

• Look for osseous erosions.

• Look at other incidentally imaged osseous structures (if the sella is imaged, assess for expansion > assess the sinuses > look to see if there are calcified stylohyoid ligaments typical in Eagle's syndrome).

• Assess the soft tissues (look at the nasopharynx and adenoid tissue > assess for airway narrowing > assess the epiglottis (thickening or thumb sign) > check the trachea (narrowing, or foreign bodies) > look along the course of the air column, piriform sinuses, and vallecula for asymmetry/mass lesion > check the prevertebral soft tissues (are they less than half a vertebral body to the level of C4, and no more than a full vertebral body in width after that?).

• Assess the visualized lungs (look for opacities, masses, nodules > look for lucencies, such as a pneumothorax or cystic lesion).

7. Examine the oblique views.

• Look for neuroforaminal encroachment.

• Be aware that additional regions of the lungs, pleura, and mediastinum may be present.

• The additional views may help problem solve potential findings in the nasopharynx or elsewhere in the aerodigestive tract. 

8. Examine the flexion and extension views (if obtained).

• Look for changes in the atlanto-dental interval.

• Look for subluxation of the vertebral body heights relative to one another (>3mm change between views is often considered abnormal.

• Be wary of newly seen anatomy at the edges of the image, if there is a significant difference in positioning.

9. Perform final checks and proofread the report.

Search patterns created by Dr. Long H. Tu (1)

Lumbar Spine X-ray Search Pattern

1. Check the patient history, exam indication, and prior images.

2. Check the adequacy and technique.

1. • Is the whole lumbar spine visible on both views?

   • Are any parts of the posterior soft tissues excluded?

   • Is there special concern for L5-S1 or sacrococcygeal pathology? 

3. Assess for hardware.

4. Check bone mineralization and morphology.

• Is there demineralization or sclerosis?

• Are there 5 lumbar-type vertebrae without ribs?

• Look for segmentation anomalies. Is there a transitional vertebrae at the lumbosacral junction?

• Are the vertebrae normal in shape?

• Are there any diseases of bony fusion (DISH/OPLL/ankylosing spondylitis)?

5. Examine the lateral view.

• Examine alignment (check the anterior, posterior, spinolaminar, and interspinous lines > assess the spaces between the inter-spinous processes > assess for spondylosis and spondylolisthesis (look carefully at L5-S1 and L4-L5 for these) > assess for lordosis, kyphosis, and abnormal straightening).

• Assess for fracture and discopathy (check vertebral heights and disc heights > check for disruption of any usually confluently ossified ligaments or syndesmophytes > if the sacrum and coccyx are imaged, assess them for fractures).

• Look for degenerative changes (look at the disc spaces, facets, as well as between any closely spaced spinous process).

• Look for osseous spinal and neuroforaminal encroachment.

• Look for osseous erosions (look for other signs of erosive/inflammatory arthritides).

• Assess for focal bone lesions (these may be lucent or sclerotic, and difficult to detect on radiograph).

• Assess the soft tissues and visualized thorax (examine the limited view of the abdomen as you would on a dedicated view > look especially for any large calcified abdominal aortic aneurysm).

6. Examine the frontal view.

• Assess the spine (look for scoliosis > look for formational anomalies including dysraphisms > look at the spinous processes and posterior elements > look for loss of pedicles > look at the transverse processes of the vertebrae (fractures and other lesions here are easy to miss).

• Assess the sacroiliac joints (look for widening, erosion, ankyloses, and degenerative change).

• Assess any other visualized parts of the boney pelvis (trace the iloischial and iliopectineal lines > examine the sacrum > trace each sacral foramina > examine the pelvic ring > look at any imaged hips).

• Look for loss or displacement of fat planes overlying musculature along the pelvis side (this can indicate blood or other fluid in the pelvis). 

• Look at any other imaged osseous structures, such as ribs or incidental upper extremities.

• Look at any incidentally imaged visceral structures (lung bases > bowel gas pattern > examine the distribution of abdominopelvic viscera for abnormal air or calcification).

7. Perform final checks and proofread the report.

Search patterns created by Dr. Long H. Tu (1)

Thoracic Spine X-ray Search Pattern

1. Check the patient history, exam indication, and prior images.

2. Check the adequacy and limitations of the study.

1. • Do you see the whole thoracic spine?

   • If the upper thoracic spine cannot be evaluated properly due to overlapping structures, do not hesitate to recommend a CT.

   • Are any parts of the posterior soft tissues excluded?

3. Assess for hardware.

4. Check bone mineralization and morphology.

• Is there demineralization or sclerosis?

• Are there 12 rib-bearing vertebrae? 

• Are there cervical ribs? Diminutive 12th ribs?

• Look for segmentation anomalies.

• Are any vertebrae abnormal in shape?

• Are there any diseases of bony fusion such as DISH/OPLL/ankylosing spondylitis?

5. Examine the lateral view.

• Assess alignment (chest the anterior, posterior, spinolaminar, and interspinous lines > assess the spaces between the inter-spinous processes > assess for listhesis > assess for scoliosis, lordosis/kyphosis, abnormal straightening).

• Assess for fracture and discopathy (check vertebral heights and disc heights > check for disruption of any usually confluently ossified ligaments or syndesmophytes > in pediatric patients, look for evidence of Scheuermann's disease).

• Look for degenerative changes.

• Look for osseous spinal and neuroforaminal encroachment.

• Look for osseous erosions (look for other signs of erosive/inflammatory arthritides).

• Assess for focal bone lesions (these may be lucent or sclerotic, and difficult to detect on radiograph).

• Examine the clavicles, scapula, ribs, and any other imaged osseous structures.

• Look at the incidentally imaged visceral chest as you would a lateral chest radiograph.

• Look at the soft tissues of the chest wall, lower neck, and upper abdomen.

6. Examine the frontal view.

• Assess the bones in the usual fashion (assess for scoliosis > look for segmentation and formation anomalies, especially in children > look for loss of pedicles).

• Check the right and left spinal lines.

• Examine the imaged visceral chest as you would a chest radiograph. Be wary of incidental pulmonary nodules / masses.

• Look at the soft tissues of the chest wall, lower neck, and upper abdomen.

7. Perform final checks and proofread the report.

Search patterns created by Dr. Long H. Tu (1)