What is the proper positioning for a cervical spine x-ray (x-ray) lateral view?

Proper Positioning for Cervical Spine X-ray Lateral View

For a cervical spine lateral view x-ray, the patient should be positioned supine with the head and neck in neutral position, arms at sides, with a foam cushion or pillow supporting the head and neck, ensuring visualization from the craniocervical junction to the cervicothoracic junction.

Patient Positioning Requirements

Basic Position

• Patient lies supine on the x-ray table
• Head and neck in neutral position (not flexed or extended)
• Arms placed at sides of the body
• Spine aligned with the body's midline

Head and Neck Support

• Use a foam cushion or pillow to support the head and neck 1
• Ensure the cervical spine is in a neutral position
• Avoid rotation of the head and neck

Field of View Requirements

• Must visualize from the craniocervical junction (occipito-atlantal articulation) to the cervicothoracic junction 1
• Adequate penetration to see all vertebral bony structures and soft tissue relations 1

Technical Considerations

Ensuring Adequate Visualization

• If the cervicothoracic junction is not visible on standard lateral view, a "swimmer's lateral view" may be required 1
• Arm traction may be attempted to better visualize the cervicothoracic junction, though success rates are limited (only 7.7% if C7 is not initially visible) 1
• For patients with stout necks, a 30° oblique from horizontal and 30° cephalad from neutral position may improve visualization of the lower cervical spine 2

Image Quality Factors

• Ensure no rotation of the patient's body or head
• Maintain consistent positioning for follow-up examinations
• Proper penetration is essential to visualize both bony structures and soft tissues

Clinical Significance

Diagnostic Value

• An anatomically and technically adequate lateral view can detect 73.4-89.7% of cervical injuries when interpreted by an expert 1
• However, this view alone will miss approximately 15% of cervical spine injuries 1
• 10-20% of missed injuries result from misinterpretation of suboptimal radiographs 1

Limitations

• Single lateral view is insufficient for complete cervical spine clearance
• The American College of Radiology now recommends CT of the cervical spine without IV contrast as the gold standard for suspected cervical spine injuries (97% detection rate) 3
• In 49% of cases, the cervicothoracic junction cannot be visualized even with arm traction 1

Common Pitfalls to Avoid

• Inadequate visualization of the cervicothoracic junction - where up to 60% of cervical injuries may occur 1
• Poor patient positioning - rotation, excessive adduction or abduction can affect accuracy 1
• Relying solely on lateral view - a three-view series (lateral, AP, and odontoid) is recommended for trauma patients 1
• Inadequate penetration - prevents proper evaluation of bony structures
• Improper alignment - the spine should be parallel to the table

Special Considerations

Pediatric Patients

• Achieving neutral position in children can be challenging
• Studies show only 10% of immobilized children are in true neutral position (0°) 4
• 60% of children show >5° of kyphosis or lordosis despite immobilization efforts 4

Trauma Patients

• For unconscious trauma patients, CT is now preferred over plain radiographs 3
• Lateral plain film sensitivity is only 51.7% for unstable injuries in unconscious intubated patients 1
• Soft tissue signs become unreliable after tracheal or gastric intubation 1

Remember that while proper positioning for lateral cervical spine x-rays remains important, CT has largely supplanted radiographs for assessment of traumatic cervical spine injury due to its significantly higher sensitivity 1, 3.