How to Write an Order for X-ray of the Whole Spine
The proper way to order a whole spine X-ray is to request anteroposterior (AP) and lateral radiographs of the cervical, thoracic, and lumbar spine, with appropriate collimation to the area of interest.
Components of a Complete Spine X-ray Order
- Request anteroposterior (AP) and lateral views of the cervical, thoracic, and lumbar spine 1
- Specify "complete spine" or "whole spine" in the order to ensure all regions are included 1
- Avoid requesting additional oblique views as they contribute little diagnostic information while increasing radiation exposure 1
- For upper thoracic spine visualization that may be obscured by shoulders, include a request for a "swimmer's lateral view" if needed 1
- Include relevant clinical information and the specific diagnostic question in your order 1, 2
Important Considerations
- Collimation to the area of concern may aid in diagnosis while reducing unnecessary radiation exposure 1
- Be aware that a full-spine radiographic examination delivers significant radiation doses to bone marrow (115 mrad to 85% of active marrow), breasts (235-465 mrad), ovaries (165 mrad), and thyroid (700 mrad) 3
- Consider whether targeted imaging of specific symptomatic regions might be more appropriate than whole spine imaging 1
- Remember that radiographs alone may be inadequate for diagnosing certain pathologies, with negative radiographs not excluding all pathology 2
When to Consider Additional or Alternative Imaging
- For suspected spine trauma, CT is more sensitive than radiographs for detecting fractures (94-100% vs 49-82% sensitivity) 1
- MRI is preferred for evaluating soft tissue abnormalities, including disc disease, marrow edema, and intraspinal masses 1
- In cases with clinical "red flags" (neurologic deficit, fever, weight loss, etc.), negative radiographs should prompt further imaging evaluation 2
- For suspected cervical ligament injury, flexion-extension views may be considered, though their utility in acute trauma is limited 4, 5
Common Pitfalls to Avoid
- Ordering unnecessary oblique views that increase radiation exposure without improving diagnostic yield 1
- Failing to specify all regions of the spine needed (cervical, thoracic, lumbar) 1
- Not providing adequate clinical information to guide the radiologist's interpretation 2
- Relying solely on plain radiographs when more advanced imaging may be necessary based on clinical presentation 1, 6