Scoliosis and spine imaging.

Radiographers understand the importance of getting the most diagnostic information from as few radiographs as possible. And in the world of pediatric scoliosis imaging, pediatric orthopedic surgeons, radiologists and orthotists must obtain more than just spine data from each and every radiograph.

Texas Scottish Rite Hospital for Children (TSRHC) is a pediatric orthopedic hospital in Dallas, Texas. Upon diagnosis of scoliosis in a child, the hospital staff assures the patient and parents that, although scoliosis can be inherited, it is not uncommon, not contagious and usually not painful. TSRHC staff also help patients and parents understand that they did not cause the scoliosis and they could not have prevented its occurrence.

With 7 pediatric orthopedic surgeons at TSRHC requesting more than 12 000 scoliosis films a year, our pediatric radiographers take the time needed to produce excellent radiographs, maximize radiation protection and support patients and parents.

This article is a follow-up to the Directed Reading titled "Spinal Curves and Scoliosis," by Susan M Anderson, MAEd, R.T.(R), in the September/ October issue of Radiologic Technology. I will expand on Anderson's article by discussing the different protocols for imaging babies, children, preteens and teens.

Scoliosis

The most common type of scoliosis is idiopathic scoliosis, which usually occurs in preteen and teen girls. Girls have scoliosis 8 times more often than boys do.

Congenital scoliosis, or early-onset scoliosis, is a frequent reason for imaging the spine of babies and young children. As a rule, children with congenital scoliosis will have missing vertebrae, fused vertebral bodies or a combination of these.

Infants and Young Children

The major directive a radiographer obtains from orthopedic surgeons concerning spine imaging is to have the patient stand with equal weight on both feet (no shoes). Nevertheless, in a pediatric imaging setting, the radiographer must be prepared to image all age groups from newborn to teens, as well as children who may have cerebral palsy, muscular dystrophy, autism, spina bifida, obesity, casts, braces or other physical limitations. Leaded markers (see Box 1), such as right, left, standing, sitting, supine and bending, must clearly reflect how each scoliosis exam was performed. Box 1 Sample Protocol for Markers To Label Spine Films * RIGHT and LEFT. * STANDING, SITTING, SUPINE and CTL. * BENDING and arrow ([??]) for bending films. * Do not use UPRIGHT or ERECT markers; use STANDING or SITTING markers instead. * Annotate patient information as needed.

For babies younger than 1 year, anteroposterior (AP) and lateral images of the entire spine are performed supine with breast/gonadal shielding in place. This should be the only age group in which a routine scoliosis series is performed supine.

Once a toddler can stand, every attempt is made to do a standing AP scoliosis exam with breast/gonadal shields in place and a standing lateral scoliosis exam with 1 breast shield in place. At TSRHC, we do not use gonadal shielding with the lateral spine view because we believe it does not protect the gonads effectively. It can be a challenge to do this study if the toddler cannot cooperate. Sometimes it is easier to manage a small child in the AP and lateral position, and it may require 2 to 3 people to control the child's arms, legs, head and feet (see Box 2). Box 2 Sample Protocol for Scoliosis Series--Other * If the patient cannot stand, do a sitting study with AP/ lateral images. Reproduce how the patient sits naturally in the wheelchair. Do not artificially straighten the patient or spine. * Use breast and gonadal shields as described in Box 3. * For preschool children and older children who cannot follow instructions, the radiographer might be able to manage the patient better in the AP/lateral position. * Supine spine radiographs should be limited to babies younger than 1 year.

As soon as the child can follow instructions (4 to 6 years of age), a radiographer can turn the child around and do the standing scoliosis series posteroanterior (PA) and lateral (see Boxes 3 and 4). To determine which lateral (right or left) to perform, the radiographer must review the AP or PA radiograph. Radiographers should look for a C-curve or an S-curve. For patients with a C-curve in which the apex of the curve is toward the patient's right side, take a right lateral spine image. If the apex of the curve is toward the left, take a left lateral spine image. For patients with an S-curve, look for the apex of the larger curve, then follow the above instructions. Box 3 Sample Protocol for Scoliosis Series--Standing * For cooperative patients, do exam PA/lateral. Patient's skull must be either true AP/PA or lateral. * Spine must be straight with no twisting or slouching. * AP/PA view should include the entire thoracolumbar spine, at least 1 iliac crest/Risser and both femoral heads. The chin should be up to include the lower cervical spine. Use breast and gonadal shields. * Lateral view should include entire spine from C-1 to femoral heads and cervical spine in neutral position. Use 1 breast shield (see Figure 1). * L5-S1 must be seen on both the PA/AP and lateral images. * Send and store AP and PA scoliosis images with an R/L flip because this matches how the physician views a patient's spine. Box 4 Sample Protocol for Arms, Legs and Feet Positioning * Standing PA should include arms down and slightly away from hip joints. Legs and knees should be straight. Feet (no shoes) should be slightly apart, flat on the floor and facing forward. * Standing lateral should include humeri parallel to the floor with elbows bent. Legs and knees should be straight, and feet should be slightly apart, flat on the floor and facing forward. * Note that the arms on lateral view should never be fully extended from the shoulders because this can mimic kyphosis or hyperlordosis. * Sitting AP should include arms down and knees apart to visualize hip joints. * Sitting lateral should include humeri parallel to the floor with elbows bent.

Preteen and Teens

Preteen and teen spine imaging protocols are the same as those for children who can follow instructions. If the female patient is 10 to 17 years old, her parent or legal guardian must complete and sign a pregnancy screening form. Women aged 18 years or older will complete and sign their own pregnancy screening form. Radiographers will then review and sign this form, as well as verbally question the patient about a chance of pregnancy.

When applicable, orthopedic surgeons and orthotic staff will decide whether the spine studies will be done "in brace" or "out of brace." The orthopedist will dictate whether the "in brace" spine studies require the patient to stand (all day brace) or be supine (night brace only). Also, some centers have protocols on how long a patient must be in the brace or out of the brace before the scoliosis series is performed. TSRHC does not have such protocols.

For preteens and teens, the use of breast and gonadal shields continues to be mandatory and every patient must be reminded of the significance of standing tall and straight. Allowing the patient to sag, twist or slouch even 5[degrees] during the spine study can interfere with the physician's treatment plan. Accurate measurements are crucial because physicians must choose the most appropriate treatment from several different options, including taking a "wait and see" approach, having the patient wear a brace or preparing for spine surgery.

Additionally, it is essential that every radiographer in the radiology department follow the same scoliosis series protocol for each age group. To follow the progression of the scoliotic curve, every scoliosis image must be performed in a consistent manner as compared to previous scoliosis images. Children might have follow-up radiographic exams over the course of 5, 10 or 20 years. Thus, the scoliosis series protocol concerning patient positioning, shield placement and patient instructions must be reliable and reproducible.

If a radiographer needs to perform a scoliosis series "off" protocol, the orthopedic surgeon and radiologist must be notified. An easy method would be to annotate this information on the spine radiograph. Some common annotations are "shoes and ankle splints on," "3-cm block under left foot," "patient standing on left tip toes" or "patient wearing a right prosthesis."

Maximizing Diagnostic Information

Pediatric orthopedic surgeons and radiologists positioning, shield placement and patient instructions must be reliable and reproducible.

If a radiographer needs to perform a scoliosis series "off" protocol, the orthopedic surgeon and radiologist must be notified. An easy method would be to annotate this information on the spine radiograph. Some common annotations are "shoes and ankle splints on," "3-cm block under left foot," "patient standing on left tip toes" or "patient wearing a right prosthesis."

Maximizing Diagnostic Information