Cervical spine trauma at night: collar, cross-table lateral and the request for obliques
At 02:10 a 62-year-old man is brought to casualty after a motorcycle collision. He is conscious and oriented and complains of midline neck pain. The trauma team has applied a rigid cervical collar and he is supine on a backboard. The duty radiographer is alone; the second radiographer is on leave and the CT scanner is occupied by a head-injury case for the next 40 minutes. The casualty officer requests AP and lateral cervical spine views "with the collar removed so the bones are clear". The patient has already vomited once and is retching. His shoulders are thick-set and lie high. A digital radiography unit with a horizontal-beam facility and a fixed 180 cm source-to-image distance is available. The officer also wants both oblique views added "as a routine". The radiographer must decide what can be done safely now and what must wait. No previous imaging is available and the patient cannot turn onto his side.
1. How would you obtain the lateral cervical spine view, and what exposure factors would you start with?
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Positioning. Keep the collar on. The collar is holding a potentially unstable spine in alignment, and removing it on a radiographer's judgement, without the trauma team controlling the head, risks converting a stable injury into a cord injury. The request is not authority to remove it.
Place the image detector vertically behind the neck, supine, with a horizontal beam. Centre at about C4 and collimate tightly from C1 to T1. Ask the patient to pull the shoulders down as far as pain allows; do not rotate or extend the neck. Keep the 180 cm distance to reduce magnification.
Exposure. Start around 70–80 kVp and 20–32 mAs for an average adult on digital. A higher kVp is preferred because it penetrates the shoulders and reduces the need for a repeat, which matters more than a small contrast gain. Do not use a thyroid shield: it would obscure the very region being examined.
Safety. The retching is an aspiration risk. Ask the nurse to suction and monitor the airway; the exposure takes seconds, but the patient must not be left face-up and unobserved.
2. The lateral film shows C1 to C6, but the C7–T1 junction is hidden by the shoulders. The officer asks for the same lateral to be repeated. What do you do?
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Repeating the same projection will produce the same shoulder superimposition; the geometry has not changed, so the repeat adds dose without adding information.
First alternative: swimmer's view. With the trauma team present, one arm is raised above the head while the head and neck remain immobilised, and a horizontal beam is directed at the C7–T1 level with a slight angulation to clear the shoulder. This changes the geometry and often opens the junction.
If that still fails, stop and document. The correct next step is a CT cervical spine, which is both more sensitive for fracture and faster to clear the spine than a series of plain-film attempts. The radiographer should say plainly: "C7–T1 is not shown; a further plain film is unlikely to show it, and CT is the appropriate examination."
Record the limitation in the report and inform the referring officer, so that the incompleteness is a clinical decision rather than an unnoticed gap.
3. How would you respond to the requests to remove the collar and to add both oblique views?
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Collar removal. Decline, politely but clearly. In a trauma patient with midline pain and an uncleared spine, the collar is removed only under the trauma team's control, usually with manual in-line stabilisation, and usually in the CT suite rather than the radiography room. The radiographer's responsibility is to image the patient as immobilised, not to optimise the film by removing a device that is protecting the cord.
Obliques. Oblique cervical views are not part of routine trauma series. They add dose, take time, and are poor at showing the lower cervical spine in a patient with high shoulders. If the concern is a facet or pedicle injury that plain films cannot resolve, CT answers it better. The request should be discussed with the radiologist and the referring officer rather than simply performed "routinely".
The underlying principle is justification: every exposure must have a clinical question it can answer. Neither request meets that test at 02:10 in this patient.