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1. Welcome to the the Spine eLearning module “Foundations; Spinal Image Reading & Radiation Safety.” After completing this module you should be able to identify, and distinguish between, common types of Radiographic Images including Plain X-rays, X-Ray Myelograms, CT, CT Myelograms, and MRI. You should also be able to practice common sense radiation safety.Welcome to the the Spine eLearning module “Foundations; Spinal Image Reading & Radiation Safety.” After completing this module you should be able to identify, and distinguish between, common types of Radiographic Images including Plain X-rays, X-Ray Myelograms, CT, CT Myelograms, and MRI. You should also be able to practice common sense radiation safety.

2. Welcome to the Spine eLearning module “Foundations; Spinal Image Reading & Radiation Safety.” After completing this module you should be able to identify, and distinguish between, common types of Radiographic Images including Plain X-rays, X-Ray Myelograms, CT, CT Myelograms, and MRI. You should also be able to practice common sense radiation safety.Welcome to the Spine eLearning module “Foundations; Spinal Image Reading & Radiation Safety.” After completing this module you should be able to identify, and distinguish between, common types of Radiographic Images including Plain X-rays, X-Ray Myelograms, CT, CT Myelograms, and MRI. You should also be able to practice common sense radiation safety.

3. Types of Radiological Imaging X-Ray. Plain radiographs, or “plain x-rays,” are photographic “negative” images. X-Ray. Plain radiographs, or “plain x-rays,” are photographic “negative” images. They are created by beaming a type of ionizing radiation (x-rays) through an object onto a photographic film or plate. The radiation is absorbed by denser matter which is displayed as a white shadow on the image. The radiation passes through the less dense matter and exposes the underlying film, turning it black.X-Ray. Plain radiographs, or “plain x-rays,” are photographic “negative” images. They are created by beaming a type of ionizing radiation (x-rays) through an object onto a photographic film or plate. The radiation is absorbed by denser matter which is displayed as a white shadow on the image. The radiation passes through the less dense matter and exposes the underlying film, turning it black.

4. X-Ray A “plain x-ray” is a two-dimensional representation of a three-dimensional object. A “plain x-ray” is a two-dimensional representation of a three-dimensional object. This means that “x-rays” are good for general diagnosis, but they are prone to distortions of distances and angles. A “plain x-ray” is a two-dimensional representation of a three-dimensional object. This means that “x-rays” are good for general diagnosis, but they are prone to distortions of distances and angles.

5. Shadows and Light It is very important to remember that an x-ray image is just shadows and light. Like this diagram of a flashlight shining past a potted plant, x-rays create shadows of denser matter on a photo-sensitive film or plate. The resulting image is prone to distortions and exaggerations of distances and angles; objects closer to the x-ray source will make larger shadows than objects which are closer to the film.It is very important to remember that an x-ray image is just shadows and light. Like this diagram of a flashlight shining past a potted plant, x-rays create shadows of denser matter on a photo-sensitive film or plate. The resulting image is prone to distortions and exaggerations of distances and angles; objects closer to the x-ray source will make larger shadows than objects which are closer to the film.

6. Shadows and Light In this example, we see a lateral x-ray image of a teenager’s low-back and pelvis. If you look carefully, you can see that one iliac crest looks like it is much larger than the other . . . (continued on the next slide). In this example, we see a lateral x-ray image of a teenager’s low-back and pelvis. If you look carefully, you can see that one iliac crest looks like it is much larger than the other . . . (continued on the next slide).

7. Shadows and Light This is due to the fact that one iliac crest is closer to the x-ray source (the larger one), and the other is closer to the film (the smaller one). This is due to the fact that one iliac crest is closer to the x-ray source (the larger one), and the other is closer to the film (the smaller one).

8. Shadows and Light This is due to the fact that one iliac crest is closer to the x-ray source (the larger one), and the other is closer to the film (the smaller one). This is due to the fact that one iliac crest is closer to the x-ray source (the larger one), and the other is closer to the film (the smaller one).

9. Fluoroscopy Fluoroscopy (“C-arm,” or “fluoro”) is a technique for obtaining ‘live’ x-ray images. This technology uses x-ray radiation and TV technology to create electronic x-ray images. Like “plain x-ray,” “Fluoro” is prone to distortions. This technology uses x-ray radiation and TV technology to create electronic x-ray images. Like “plain x-ray,” “Fluoro” is prone to distortions.

10. Fluoroscopy “Fluoro” works by sending x-ray radiation from a focused source through the patient into an image intensifier. The images are then displayed on a TV-style monitor.“Fluoro” works by sending x-ray radiation from a focused source through the patient into an image intensifier. The images are then displayed on a TV-style monitor.

11. Computer Assisted Tomography (‘CT,’ or ‘CAT Scans’) is an advanced x-ray technology. These images are created by a sophisticated computer with an array of x-ray sensors that are capable of taking 100s or 1000s of images of a single patient at many angles. These images are then analyzed and reconfigured to display images that would be impossible for “plain x-ray.” Computer Tomography

12. Like “plain x-ray” & “fluoro,” CT images are “negatives” which display light shadows of dense matter. CT is a great tool for viewing bony structures and dense objects. Computer Tomography

13. Computer Tomography CT images are computer generated two-dimensional images of a two-dimensional “slice.” They are very accurate representations of actual angles and distances. CT images are computer generated two-dimensional images of a two-dimensional “slice.” They are very accurate representations of actual angles and distances. CT is especially useful in showing the details of bony fractures. CT images are computer generated two-dimensional images of a two-dimensional “slice.” They are very accurate representations of actual angles and distances. CT is especially useful in showing the details of bony fractures.

14. Myelograms X-rays, Fluoros and CTs are best-suited for viewing dense, bony tissue. Sometimes it is helpful to visualize fluid-filled structures -- especially the dura mater. This can be done by injecting radio-opaque dyes into these structures just prior to imaging. X-rays, Fluoros and CTs are best-suited for viewing dense, bony tissue. Sometimes it is helpful to visualize fluid-filled structures -- especially the spinal cord & dura. This can be done by injecting radio-opaque dyes into these structures just prior to imaging. X-rays, Fluoros and CTs are best-suited for viewing dense, bony tissue. Sometimes it is helpful to visualize fluid-filled structures -- especially the spinal cord & dura. This can be done by injecting radio-opaque dyes into these structures just prior to imaging.

15. Myelograms A myelogram can show where neural structures are being pinched. A myelogram can show where neural structures are being pinched like in this lateral CT myelogram of a image an L1 burst fracture. You can see the bright white of the cerebral spinal fluid forming the shape of the dura mater – inside the white shape of cerebral spinal fluid you can see the darker stripe of the spinal cord and conus medularis. The obvious pathology demonstrated here is a burst fracture with displaced fragments in the spinal canal compressing the dura and the spinal cord. A myelogram can show where neural structures are being pinched like in this lateral CT myelogram of a image an L1 burst fracture. You can see the bright white of the cerebral spinal fluid forming the shape of the dura mater – inside the white shape of cerebral spinal fluid you can see the darker stripe of the spinal cord and conus medularis. The obvious pathology demonstrated here is a burst fracture with displaced fragments in the spinal canal compressing the dura and the spinal cord.

16. Discograms Radio-opaque dye can also be injected into the disc space. This helps to visualize the disc and locate the source of pain. Radio-opaque dye can also be injected into the disc space. This helps to visualize the disc and locate a potential source of pain. This is controversial, but some surgeons believe it can help to identify pain generating pathologies that would not otherwise be identified.Radio-opaque dye can also be injected into the disc space. This helps to visualize the disc and locate a potential source of pain. This is controversial, but some surgeons believe it can help to identify pain generating pathologies that would not otherwise be identified.

17. Angiograms Radio-opaque dye can be injected into arteries or veins. This helps to visualize the vascular structures. Radio-opaque dye can be injected into arteries or veins. This helps to visualize the vascular structures.Radio-opaque dye can be injected into arteries or veins. This helps to visualize the vascular structures.

18. Magnetic Resonance Imaging Magnetic Resonance Imaging (MRI) does not use x-rays. It uses powerful magnets, radio antennae, and advanced computers. The magnets are so strong that they cause the protons of Hydrogen atoms within water molecules to temporarily line-up. The radio antennae then detect the minute signals of these protons as they fall back into their original positions. Magnetic Resonance Imaging (MRI) does not use x-rays. It uses powerful magnets, radio antennae, and advanced computers. The magnets are so strong that they cause the protons of Hydrogen atoms within water molecules to temporarily line-up. The radio antennae then detect the minute signals of these protons as they fall back into their original positions.

19. MR images represent the Hydrogen protons present in tissue (water, fat, etc). Magnetic Resonance Imaging MR images represent the Hydrogen present in tissue (water, fat, etc). Cortical Bone has very little water & no fat, so it has a magnetic resonance very different from that of soft tissue, blood, or CSF. Air also has very little water, so it will sometimes look similar cortical bone in an MRI study. MR images represent the Hydrogen present in tissue (water, fat, etc). Cortical Bone has very little water & no fat, so it has a magnetic resonance very different from that of soft tissue, blood, or CSF. Air also has very little water, so it will sometimes look similar cortical bone in an MRI study.

20. Magnetic Resonance Imaging MRI can be weighted to highlight different tissues and structures within the same anatomy. The most common “weighting” is T1 & T2. T2 is especially useful in spine surgery – it highlights the hydrogen in water as bright white, so it shows the cerebral spinal fluid inside the dura mater and the water inside a healthy intervertebral disc very clearly. You can use this phrase to help you remember – “T2 H2O.” MRI can be weighted to highlight different tissues and structures within the same anatomy. The most common “weighting” is T1 & T2. T2 is especially useful in spine surgery – it highlights the hydrogen in water as bright white, so it shows the cerebral spinal fluid inside the dura mater and the water inside a healthy intervertebral disc very clearly. You can use this phrase to help you remember – “T2 H2O.”

21. Magnetic Resonance Imaging MR Images, like CT images, are computer generated two-dimensional representations of a two-dimensional “slice.” They are very accurate and they can display precise sagittal images and axial images (which are impossible to obtain with “plain x-ray”). MR Images, like CT images, are computer generated two-dimensional representations of a two-dimensional “slice.” They are very accurate and they can display precise sagittal images and axial images (which are impossible to obtain with “plain x-ray”).

22. MR Imaging is not compatible with certain metal alloys (those containing Iron). The presence of these metals will distort or obscure the image because the metal reacts strongly to magnetic fields. Stainless Steel is not MRI compatible, Titanium & Aluminum are MRI compatible. Magnetic Resonance Imaging

23. CT vs. MRI Distinguishing CT & MR images can be difficult be cause they both give axial and sagittal “reconstructions” or “slices.” It may be helpful to remember that CT images give detailed view of dense, bony tissue while MRI is better suited to viewing soft tissues like muscle, nerve structure, ligaments, tendons, intervertebral discs and organs. The two images on the screen are both axial reconstructions of the lower lumbar spine (probably L3 or L4). CT images – like the one on the left, are often stark with only white and two or three shades of gray. MR Images, like the one one the right, often show an almost infinite range of tones form bright white to dark black. Distinguishing CT & MR images can be difficult be cause they both give axial and sagittal “reconstructions” or “slices.” It may be helpful to remember that CT images give detailed view of dense, bony tissue while MRI is better suited to viewing soft tissues like muscle, nerve structure, ligaments, tendons, intervertebral discs and organs. The two images on the screen are both axial reconstructions of the lower lumbar spine (probably L3 or L4). CT images – like the one on the left, are often stark with only white and two or three shades of gray. MR Images, like the one one the right, often show an almost infinite range of tones form bright white to dark black.

24. Planes of the Body There are 3 imaginary planes that are used to help describe anatomy. There are 3 imaginary planes that are used to help describe anatomy. Understanding these planes is essential to understanding spine images.There are 3 imaginary planes that are used to help describe anatomy. Understanding these planes is essential to understanding spine images.

25. Planes of the Body Sagittal Plane (a.k.a. Lateral Plane) Coronal Plane (a.k.a. Frontal Plane) Axial Plane (a.k.a. Transverse Plane) Oblique Sagittal Plane. This plane splits the body, from head to toe, back to front. (a.k.a. Lateral Plane) Coronal Plane. This plane splits the body head to toe, side to side. (a.k.a. Frontal Plane) Axial Plane. This plane slices through the body yielding cross-sectional views. (a.k.a. Transverse Plane) Oblique. Any plane that is not one of the above is oblique. Sagittal Plane. This plane splits the body, from head to toe, back to front. (a.k.a. Lateral Plane) Coronal Plane. This plane splits the body head to toe, side to side. (a.k.a. Frontal Plane) Axial Plane. This plane slices through the body yielding cross-sectional views. (a.k.a. Transverse Plane) Oblique. Any plane that is not one of the above is oblique.

26. Orientation The top of the image represents the ventral side of the patient; the bottom of the image is the dorsal side. The right side of the image is the patient’s left-hand side; the left side of the image is the patient’s right-hand side. The conventional orientation of all axial films is such that the top of the image represents the ventral side of the patient; the bottom of the image is the dorsal side. The right side of the image is the patient’s left-hand side; the left side of the image is the patient’s right-hand side. To better understand axial images, imagine that you are looking at the soles of a patient’s feet while he or she is laying face up on a table.The conventional orientation of all axial films is such that the top of the image represents the ventral side of the patient; the bottom of the image is the dorsal side. The right side of the image is the patient’s left-hand side; the left side of the image is the patient’s right-hand side. To better understand axial images, imagine that you are looking at the soles of a patient’s feet while he or she is laying face up on a table.

27. Imaging Studies MRI and CT images are often presented as a series of multiple images on a single page. These are arranged sequentially to help the physician get a three-dimensional sense of the anatomy. MRI and CT images are often presented as a series of multiple images on a single page. These are arranged sequentially to help the physician get a three-dimensional sense of the anatomy.MRI and CT images are often presented as a series of multiple images on a single page. These are arranged sequentially to help the physician get a three-dimensional sense of the anatomy.

28. Scout Images When images are presented this way there will often be a perpendicular view included to help the physician “navigate” through the images. When images are presented this way there will often be a perpendicular view included to help the physician “navigate” through the images.When images are presented this way there will often be a perpendicular view included to help the physician “navigate” through the images.

29. Developing Technology 3 Dimensional Computer Reconstruction CT MRI Flouro

30. Image Guided Surgery Image Guided Surgery (IGS) uses CT, MR, or even Fluoroscopic imaging to create a virtual patient. High tech cameras , instruments and computers then allow the surgeon to perform very intricate procedures with sub-millimetric precision and high confidence.

31. Imaging Decisions Clinicians need to decide which imaging technologies to use on each patient based on that patient’s needs. Each series of images uses valuable resources (money, time & talent) and it’s very important to use these resources efficiently. Clinicians need to decide which imaging technologies to use on each patient based on that patient’s needs. Each series of images uses valuable resources (money, time & talent) and it’s very important to use these resources efficiently.Clinicians need to decide which imaging technologies to use on each patient based on that patient’s needs. Each series of images uses valuable resources (money, time & talent) and it’s very important to use these resources efficiently.

32. Imaging Decisions: X-rays Plain Radiographs (x-rays) are the most widely available, least expensive images. Plain Radiographs (X-rays) are the most widely available, least expensive images. They can be used to show bony tissues, fractures & dislocations. Sophisticated users can even use these images as clues to more subtle problems. Plain Radiographs (X-rays) are the most widely available, least expensive images. They can be used to show bony tissues, fractures & dislocations. Sophisticated users can even use these images as clues to more subtle problems.

33. Imaging Decisions: X-rays Plain Radiographs (x-rays) are usually the first series of images to be ordered by the physician. Plain Radiographs (X-rays) are usually the first series of images to be ordered -- and then decisions about the need for further imaging can be made based the information provided by the x-rays.Plain Radiographs (X-rays) are usually the first series of images to be ordered -- and then decisions about the need for further imaging can be made based the information provided by the x-rays.

34. Imaging Decisions: CT If fractures, or other bony defects, are suspected, CT images can provide very detailed information. If fractures, or other bony defects, are suspected, and treatment decisions require very detailed analysis of the problem prior to treatment, CT images can provide very detailed information. But, it can be difficult to get CT images because this requires the patient to be placed inside the machine -- medically unstable patients, children, or uncooperative patients may not be able to tolerate this examination without sedation. If fractures, or other bony defects, are suspected, and treatment decisions require very detailed analysis of the problem prior to treatment, CT images can provide very detailed information. But, it can be difficult to get CT images because this requires the patient to be placed inside the machine -- medically unstable patients, children, or uncooperative patients may not be able to tolerate this examination without sedation.

35. Imaging Decisions: MRI When soft tissue injury is suspected, MRI is usually the imaging technology of choice. When soft tissue injury is suspected, MRI is usually the imaging technology of choice. Then it’s necessary to select among a range of special MRI images, including T1 & T2. But, it can be difficult to get MRI images because it requires the patient to be placed inside a machine -- medically unstable patients, children, or uncooperative patients may not be able to tolerate this examination without sedation. When soft tissue injury is suspected, MRI is usually the imaging technology of choice. Then it’s necessary to select among a range of special MRI images, including T1 & T2. But, it can be difficult to get MRI images because it requires the patient to be placed inside a machine -- medically unstable patients, children, or uncooperative patients may not be able to tolerate this examination without sedation.

36. Imaging Decisions It is often necessary to utilize multiple imaging modalities. X-ray, CT and MRI to get all the information required for treatment. It is often necessary to utilize multiple imaging modalities. X-ray, CT and MRI to get all the information required for treatment especially in complex cases where multiple pathologies may be present.. It is often necessary to utilize multiple imaging modalities. X-ray, CT and MRI to get all the information required for treatment especially in complex cases where multiple pathologies may be present..

37. Common Sense Radiation Safety X-ray, “Fluoro”, and CT imaging techniques use ionizing radiation to create images. Ionizing radiation can be hazardous to living tissue. X-ray, “Fluoro”, and CT imaging techniques use ionizing radiation to create images. Ionizing radiation can be hazardous to living tissue. X-ray, “Fluoro”, and CT imaging techniques use ionizing radiation to create images. Ionizing radiation can be hazardous to living tissue.

38. It’s not hard to exceed recommended limits The National Council on Radiation Protection & Measurement Report … titled "Limitation of Exposure to Ionizing Radiation," recommends that . . . the annual effective dose limit for occupationally exposed personnel 5 rem/year the lens of the eye radiation dose limit … 15 rem/year. the occupational dose limit recommended for exposure of the skin, hands, and feet should be 50 rem/year. In a report titled “Limitation of Exposure to Ionizing Radiation,” The National Council on Radiation Protection & Measurement recommends that …In a report titled “Limitation of Exposure to Ionizing Radiation,” The National Council on Radiation Protection & Measurement recommends that …

39. It’s not hard to exceed recommended limits the annual effective dose limit for occupationally exposed personnel 5 rem/year the lens of the eye radiation dose limit … 15 rem/year. the occupational dose limit recommended for exposure of the skin, hands, and feet should be 50 rem/year. In a report titled “Limitation of Exposure to Ionizing Radiation,” The National Council on Radiation Protection & Measurement recommends that … the annual effective dose limit for occupationally exposed personnel 5 rem/year the lens of the eye radiation dose limit … 15 rem/year. the occupational dose limit recommended for exposure of the skin, hands, and feet should be 50 rem/year. In a report titled “Limitation of Exposure to Ionizing Radiation,” The National Council on Radiation Protection & Measurement recommends that … the annual effective dose limit for occupationally exposed personnel 5 rem/year the lens of the eye radiation dose limit … 15 rem/year. the occupational dose limit recommended for exposure of the skin, hands, and feet should be 50 rem/year.

40. It’s not hard to exceed recommended limits “Based on our findings … the annual occupational dose limits would be exceeded by performing just 34 vertebroplasty procedures per year.” Spine 2003; 28(14):1608-1613 How does this effect you and your customers? A study recently published in the journal “Spine” stated “Based on our findings … the annual occupational dose limits would be exceeded by performing just 34 vertebroplasty procedures per year.”How does this effect you and your customers? A study recently published in the journal “Spine” stated “Based on our findings … the annual occupational dose limits would be exceeded by performing just 34 vertebroplasty procedures per year.”

41. Common Sense Radiation SafetyProper shielding is effective! That same study showed that simple shielding precautions could significantly reduce x-ray exposure for surgical personnel.That same study showed that simple shielding precautions could significantly reduce x-ray exposure for surgical personnel.

42. Common Sense Radiation Safety All organs and tissues are sensitive to radiation, but some are particularly vulnerable. Reproductive System Thyroid Fetal Tissue Eyes Genetic Material chromosomes, genes, etc. All organs and tissues are sensitive to radiation, but some are particularly vulnerable – including ... Reproductive System Thyroid Fetal Tissue Eyes Genetic Material chromosomes, genes, etc. All organs and tissues are sensitive to radiation, but some are particularly vulnerable – including ... Reproductive System Thyroid Fetal Tissue Eyes Genetic Material chromosomes, genes, etc.

43. Common Sense Radiation Safety Exposure is determined by three factors. Time. Distance. (Distance x 2 = Exposure x 1/4) Shielding. Exposure is determined by three factors. Time. The less time your are exposed to radiation, the less you exposure will be. Distance. Intensity of radiation decreases exponentially with distance. (Distance x 2 = Exposure x 1/4) Shielding. The more dense material between you and the source, the lower your exposure will be.* Exposure is determined by three factors. Time. The less time your are exposed to radiation, the less you exposure will be. Distance. Intensity of radiation decreases exponentially with distance. (Distance x 2 = Exposure x 1/4) Shielding. The more dense material between you and the source, the lower your exposure will be.*

44. Common Sense Radiation Safety How to protect yourself: leave the room if possible wear lead apron, thyroid collar & protective goggles all in good condition! How can you protect yourself? leave the room if possible wear a lead apron, thyroid collar & protective goggles -- all in good condition! Note the image of the protective glove and the xray of that same glove – the effective of protective equipment can be reduced by neglect and abuse. Think about this the next time you are in the OR -- That ratty old lead apron may not give you much protection, but then again, do you want take the best one and leave the old, ratty one for someone else who absolutely has to stay in the room? If you can, leave the room while xray is in use. How can you protect yourself? leave the room if possible wear a lead apron, thyroid collar & protective goggles -- all in good condition! Note the image of the protective glove and the xray of that same glove – the effective of protective equipment can be reduced by neglect and abuse. Think about this the next time you are in the OR -- That ratty old lead apron may not give you much protection, but then again, do you want take the best one and leave the old, ratty one for someone else who absolutely has to stay in the room? If you can, leave the room while xray is in use.

45. X-ray Safety The use x-rays produce unique hazards in that we cannot use any of our senses to detect the presence of ionizing radiation, We must rely on detection equipment. An unobstructed x-ray beam is very well defined and collimated. At no time should any part of your body enter the x-ray beam path.The use x-rays produce unique hazards in that we cannot use any of our senses to detect the presence of ionizing radiation, We must rely on detection equipment. An unobstructed x-ray beam is very well defined and collimated. At no time should any part of your body enter the x-ray beam path.

46. X-ray Safety Scattering occurs when x-rays strike the target at different angles and all the energy is not absorbed by the target. The x-rays will be diffracted in different directions. All personnel working around fluoroscopes should maintain a distance of six feet from the working table to maintain exposures as low as possible. Remember the inverse square law applies to ionizing radiation for exposure reduction. By doubling the distance form the exposure source your exposure decreases by the square of the distance.Scattering occurs when x-rays strike the target at different angles and all the energy is not absorbed by the target. The x-rays will be diffracted in different directions. All personnel working around fluoroscopes should maintain a distance of six feet from the working table to maintain exposures as low as possible. Remember the inverse square law applies to ionizing radiation for exposure reduction. By doubling the distance form the exposure source your exposure decreases by the square of the distance.

47. Radiation SafetyIs all of this really necessary? Yes! This is a fluoroscope burn! So, is all of this really necessary? Yes, it is. Radiation exposure is cumulative and over-exposure can be serious as this image clearly demonstrates.So, is all of this really necessary? Yes, it is. Radiation exposure is cumulative and over-exposure can be serious as this image clearly demonstrates.

48. Foundation Spinal Image Reading & Radiation Safety