Recommended X-ray Views for Thoracic Vertebrae
For thoracic spine imaging, obtain anteroposterior (AP) and lateral radiographs as the minimum standard views, with an additional "swimmer's lateral" view if the upper thoracic region (cervicothoracic junction) is obscured by overlying shoulders. 1
Standard Imaging Protocol
Minimum Required Views
- Anteroposterior (AP) projection: Essential for evaluating alignment, interpedicular distance, and detecting fractures 1
- Lateral projection: Critical for assessing vertebral body height, alignment, spinal canal compromise, and overall sagittal profile 1
Additional View When Needed
- Swimmer's lateral view: This specialized oblique projection should be added when the cervicothoracic junction (upper thoracic spine) is not adequately visualized on the standard lateral view due to shoulder overlap 1
- The swimmer's view is performed with the arm closest to the X-ray beam elevated, though it only successfully visualizes the cervicothoracic junction in approximately 40% of cases 1
Important Clinical Context
Limitations of Plain Radiographs
- Radiographs have significant limitations with reported sensitivity of only 49-62% for detecting thoracic spine fractures compared to CT's 94-100% sensitivity 1
- The clinical significance of fractures missed on radiographs remains uncertain, as many are non-displaced transverse process or minor endplate fractures that don't alter management 1
- Plain films require 30-40% bone destruction before fractures become visible 2
When to Consider CT Instead
- CT is the gold standard for thoracic spine fracture detection and should be strongly considered in high-risk patients (midline tenderness, high-energy mechanism, age >60 years) or unexaminable patients (intoxicated, GCS <15, distracting injury) 1
- For trauma patients already undergoing chest/abdomen/pelvis CT, sagittal and coronal spine reformats from existing data are both effective and radiation-sparing, with 94-99% sensitivity comparable to dedicated spine protocols 1
Role of Advanced Imaging
- MRI should be obtained when there is suspicion of spinal cord injury, posterior ligamentous complex injury, or neurologic deficits, as it influences management in up to 25% of thoracolumbar fracture cases 1
- MRI is superior for detecting soft tissue injuries, epidural hematomas, and cord contusions not visible on radiographs or CT 1
Common Pitfalls to Avoid
- Don't rely solely on radiographs in high-risk trauma patients – the low sensitivity means significant injuries can be missed 1
- Ensure complete visualization of the cervicothoracic junction, as this is a common site for missed injuries when obscured by shoulders 1
- Screen the entire spine when one level is injured, as approximately 20% of spine injuries have a second noncontiguous spinal injury 1