What is the best radiographic study to obtain a full‑length standing image of the entire spine?

Best X-ray Order for Full Spine Imaging

For a full-length standing image of the entire spine, order anteroposterior (AP) and lateral views of the cervical, thoracic, and lumbar spine, specifying "complete spine" or "whole spine" in the order to ensure all regions are included. 1

Essential Components of the Order

• Request AP and lateral views of all three regions (cervical, thoracic, and lumbar spine) as recommended by the American College of Radiology 1
• Explicitly state "complete spine" or "whole spine" in your order to prevent incomplete imaging 1
• Specify standing position when evaluating spinal alignment or deformity, as full-length standing lateral radiographs are necessary for accurate sagittal parameter assessment and cannot be reliably replaced by supine films 2, 3

Views to Include and Exclude

• Do NOT order oblique views – they contribute minimal diagnostic information while significantly increasing radiation exposure 4, 1
• Consider adding a swimmer's lateral view only if visualization of the cervicothoracic junction (C7-T1) is clinically necessary 1
• For lumbar spine specifically, use posteroanterior (PA) projection instead of AP when possible, as this reduces effective radiation dose by 41% with no loss of image quality 5

Critical Information to Provide

Include relevant clinical information in your order to guide the radiologist's interpretation 1:

• Specific symptoms (location of pain, neurologic deficits)
• Clinical indication (trauma, deformity assessment, infection concern, tumor surveillance)
• Any red-flag features (fever, weight loss, progressive neurologic deficit, bowel/bladder dysfunction)

When Full Spine X-ray May NOT Be Appropriate

Consider targeted imaging or alternative modalities in these scenarios:

• For suspected trauma: CT is superior to radiographs, with 94-100% sensitivity versus 49-82% for plain films in detecting fractures 1. In obtunded blunt trauma patients, CT of the entire spine should be performed rather than plain radiographs 4

• For soft tissue pathology: MRI is preferred when suspecting disc disease, marrow edema, intraspinal masses, infection (discitis/osteomyelitis), or neoplasm 4, 1, 6. MRI has high sensitivity and specificity for detecting syringomyelia, transverse myelitis, and primary neural axis tumors 4, 6

• For pediatric back pain with red flags: If clinical presentation suggests serious soft tissue pathology (infection, tumor, myelitis), obtain MRI initially rather than starting with radiographs 4

• For non-contiguous spine fractures: When one fracture is identified, there is a 16% incidence of additional non-contiguous fractures, warranting full spine evaluation 4

Common Pitfalls to Avoid

• Failing to specify all three regions (cervical, thoracic, lumbar) results in incomplete imaging 1
• Ordering unnecessary oblique views increases radiation without diagnostic benefit 4, 1
• Not providing adequate clinical context leads to suboptimal radiologist interpretation 1
• Relying solely on plain films when advanced imaging is indicated – negative radiographs do not exclude all pathology, particularly soft tissue injuries, ligamentous instability, or early infection 4, 1
• Using supine films when standing films are needed – sagittal parameters differ significantly between positions and standing films cannot be reliably predicted from supine imaging 2

Radiation Considerations

• Collimate to the area of clinical concern when appropriate to reduce unnecessary radiation exposure 1
• Consider whether targeted regional imaging (e.g., lumbar spine only) would suffice rather than complete spine imaging 4, 1
• Use PA projection for lumbar spine to reduce effective dose by 41% compared to AP 5