This is an AP lumbar spine image of a 30 year old male who presented to the Emergency Department following a football injury in which he was kneed in the lower back/right flank.

The patient underwent a clinical examination and it was decided that a lumbar spine X-ray examination was warranted. Can you see any abnormal findings?

IMAGE 1

There is a fracture of the right transverse process of L3 seen in image 1. There is also a suspicion of a fracture of the right transverse process of L2. Fractures of the transverse processes of the other visualized visualized vertebrae cannot be clearly seen but equally cannot be excluded due to poor definition/overlap of bowel gas. The transverse processes are thin bony structures and are easily obscured by overlying bowel.

Image 1 also demonstrates a few prominent air-filled (but not dilated) loops of small bowel. Some patients who are in pain air swallow, and others in severe pain develop a reflex ileus, either of which tend to obscure bony detail.

IMAGE 2

There was suspicion that this injury was more extensive than the visualised fracture of the transverse process of L3. The AP lumbar spine image was repeated using the same kVp and mAS but using a longer exposure time of 1.6 seconds. The resultant image (2) demonstrates the displaced fractured right transverse process of L3 clearly as well as a similar fracture at L2. I would argue that this technique should be considered in the first instance- in fact it is equally applicable to all thoracic and lumbar spine plain film radiography (AP and lateral). The visualization of the psoas muscle is also improved.

There is a mild scoliosis concave to the right which is likely to be associated with the fractured right transverse processes.

Beware the pitfalls of breathing technique; if the patient is not very compliant, you may end up with movement unsharpness of bony structures as well as soft tissues. The longer the exposure time, the greater the blurring of the soft tissue structures, but also the greater the risk of bony movement unsharpness. In short, you have to pick your patient.

It has been argued that you could miss an important soft tissue finding using the breathing technique. For example, a patient who presents with low back pain may in fact have renal colic and a radio-opaque stone(s) or an aortic aneurysm. It would be reasonable to ask if this situation is any different to performing a breathing technique lateral thoracic spine examination? - wouldn’t an incidental finding of bronchogenic carcinoma be equally important?

Was the repeated AP lumbar spine view warranted? This is a fertile area for debate. If it was known or reasonably expected that the patient would proceed to CT, the repeated view was probably not warranted. As it happens, the patient did eventually proceed to CT and a further fractured right transverse process of L4 was identified. Fractures of the lumbar transverse processes are significantly associated with injuries to the abdominal viscera, variously reported in the literature to be between 20 and 50%. Was the repeated AP lumbar spine unnecessary in retrospect or was it influential in the decision to proceed to CT?

It has been argued that you should finish with one imaging modality before you proceed to the next. This argument has a certain intuitive appeal but lacks sophistication. I would argue that current practice requires requires radiographers to weigh up all of the relevant considerations in these situations. You should have a low threshold for consulting with the referring doctor and/or radiologist. Good radiography is that which is the best yield/risk for that patient, at that time, and for their their likely conditions.