March 09, 2009

Radiography: The Importance of Position and Technique
By Leonard Berlin, MD, FACR
Radiology Today
Vol. 10 No. 5 P. 22

Editor’s Note: Leonard Berlin, MD, FACR, is a professor of radiology at Rush University Medical College and the chairman of the department of radiology at Rush North Shore Medical Center in Skokie, Ill. He began writing on risk management and malpractice issues in a series of articles in the American Journal of Roentgenology. Those articles became the basis for his well-known book Malpractice Issues in Radiology. This Risk Management & Malpractice Defense column is drawn from that book. This article was originally published before PACS was widely deployed, but most of the advice remains relevant in a digital environment.

The new edition of Malpractice Issues in Radiology is available from the American Roentgen Ray Society (

The Cases
Case 1. A 55-year-old woman was referred for radiologic examination of the chest because of hemoptysis. Posteroanterior radiographic findings were interpreted as normal by the radiologist (Fig. 1A). The patient returned 2 years later, again complaining of hemoptysis. Another chest radiograph was obtained, and findings were again reported as normal by the radiologist (Fig. 1B). Approximately 1 year later, the patient was seen by another physician and referred to a different facility for chest radiography. On that examination, a radiologist reported a mass in the left mid lung field (Fig. 1C). A biopsy disclosed squamous cell carcinoma. The patient died approximately 1 year later.

Case 2. A 52-year-old man was admitted to a hospital’s emergency department after having fallen down a stairway while inebriated. After physical examination, the man underwent cross-table lateral cervical spine radiography (Fig. 2A). Radiographic findings were interpreted by the radiologist as negative for fracture or dislocation, although the radiologist noted that the study was “limited” in that only the first four cervical vertebrae were visualized. The patient was admitted to the hospital for observation. The next day, his attending physician noted that the patient complained of neck pain and spasms, although no apparent motor weakness was found. The next day, more than 36 hours after the first radiologic examination, the attending physician ordered a full cervical spine series. The same radiologist then reported “arthritic changes” and found no fracture or dislocation. The radiologist failed to note that the spine was not visualized below the body of C6 on the lateral radiographic view (Fig. 2B).

The patient was discharged with a clinical diagnosis of cervical sprain. Several days later, because of increasing pain and progressive neurologic symptoms, the patient was admitted to another hospital, where radiologic examination disclosed a C6-C7 subluxation with fractures of both vertebrae. A cervical fusion was performed, but the patient became permanently quadriplegic.

Malpractice Issues
Case 1. A malpractice lawsuit was filed against the radiologist, claiming that missing the cancer on radiographs deprived the patient of a chance for cure. During pretrial discovery proceedings, expert radiologists for both the plaintiff and the defendant testified that the patient’s tumor should have been diagnosed on the earlier radiographs, but that the tumor was not adequately visualized because the chest radiographs were overexposed. The expert radiologists testified that the lesion would have been easy to see had a bright light been used, but the defendant radiologist testified that he had interpreted the radiograph on a standard-illumination viewbox. The malpractice lawsuit was settled on behalf of the defendant radiologist for a payment of $290,000.

Case 2. A malpractice lawsuit was filed against the radiologist and the hospital, alleging that failure to promptly establish the correct diagnosis of a cervical spine fracture-dislocation caused spinal cord damage and delayed corrective surgery that would have prevented quadriplegia. During pretrial discovery proceedings, expert witnesses for both the plaintiff and the defendants testified that the cervical spine radiographs fell below acceptable standards in that the C6-T1 area was not properly visualized and that the defendant radiologist was negligent in interpreting the findings as essentially normal without mentioning the lack of full visualization in his reports. The case was settled before trial for $1 million, a payment shared by the radiologist and the hospital.

The common thread linking both cases is the substandard quality of the radiologic examinations. In the first case, the radiographs were overexposed; in the second case, the patient was not positioned properly for visualizing the C6-T1 vertebrae. A radiologist’s accuracy can be no greater than the quality of radiographs presented for interpretation. Although technologists may physically perform the examinations, the radiologist who interprets the radiographs is responsible for determining whether the examination is adequate, and the radiologist bears the ultimate legal liability for an inadequate radiograph that fails to show an abnormality.

Brogdon et al.1 discussed in fine detail the various factors that determine the conspicuousness of a pulmonary parenchymal lesion and how visualization of such a lesion is affected by its size, tissue background, kilovoltage, milliamperage, and characteristics. Although that article and others2,3 recommend the use of a bright light to evaluate questionable dense areas on radiologic images, there is a point beyond which overexposure of film will transform an otherwise visible density into one that cannot be reasonably discerned. Radiologists should familiarize themselves with various authorities and with the American College of Radiology’s Standard for the Performance of Adult Chest Radiography, which sets forth comprehensive technical specifications that should lead to high-quality diagnostic chest radiography.4,5

From a risk management perspective, there is no greater need for meticulous and careful positioning than with patients who suffer cervical spine trauma. The economic costs of caring for a patient who is quadriplegic because of a cervical spine fracture, particularly one who is young with a long life expectancy, generate some of the highest monetary indemnifications in medical malpractice litigation. Missing a fracture or dislocation of the cervical-thoracic spine because proper radiographic views were not obtained is virtually indefensible. Every radiology facility must have a policy in place that calls for additional imaging procedures to accomplish this visualization if routine lateral views fail to properly visualize the lower cervical and upper thoracic segment in patients who present with a history of neck trauma. Rogers6 and Hanafee and Crandall7 believe that in most cases a swimmer’s view will be sufficient for this purpose, although other authors believe that, as an alternative, oblique views are satisfactory.8,9 The point is that the C6-C7-T1 area must be satisfactorily visualized in all cases, either by lateral or special oblique radiographs or by CT.

Summary and Risk Management
Radiologists should interpret only radiographs that are of adequate diagnostic quality from both the technical and positioning points of view. The risk management pointers that follow will help radiologists minimize the likelihood of incurring a medical malpractice lawsuit, maximize the chances for a successful defense if such a suit is filed, and ensure good patient care.

• All radiology facilities should have written policies that describe the imaging views required and the technical factors to be used for all radiographic examinations.

• Technique charts or routine phototimer settings may not always result in ideally exposed radiographs. In cases of overexposure, radiologists must use their best judgment to determine whether a radiograph can be properly interpreted with the use of a bright light. Similar judgment about whether an underexposed film or a view in which the patient has been poorly positioned can be adequately interpreted must also be made by the radiologist. If radiologists decide that the radiographs are interpretable, I encourage them to use phrases such as “Film is somewhat over-(or under-) exposed (or patient positioning is not optimal), but the radiologic examination is still believed to be of reasonable diagnostic quality,” when appropriate. By dictating such phrases into a report at the time of image interpretation, radiologists can help explain and even defend their own judgment should litigation ensue.

• Occasionally, circumstances may prevent technologists from obtaining all required views in a particular radiologic examination. Should radiologists determine that they can interpret such an incomplete study with reasonable accuracy, they may do so, but they should document in their reports the reasons for deviating from established policy.

• If the patient’s physical condition prevents a technologist from completing radiography with all required views or with optimal exposure techniques, the radiologist should make every attempt to encourage the technologist and the patient to perform a complete examination. If a complete examination is not possible, the radiologist should state in the report that the examination was incomplete because of the patient’s condition and should specify which views were not taken or which areas of anatomic interest were not sufficiently visualized. The report should also state that additional or follow-up views need to be obtained when the patient’s condition permits.

• If a radiologist believes that a radiograph cannot be properly interpreted because of poor exposure or positioning, an immediate second radiograph should be requested if the patient is available. If the patient is not available, the radiologist should render an interpretation stating that the study cannot be interpreted, giving the reasons why, and stating that second radiographs have been requested. In such situations, the radiologist should attempt to recall the patient directly or, if that is not possible, to contact the referring physician who can recall the patient. Documentation of the recall or attempted recall should be in the report.

• In the specific instance of cervical spine trauma, radiologists must satisfy themselves that every region from the occiput to the first thoracic vertebra is adequately visualized. Swimmer’s views, oblique views, or CT scans should be obtained if necessary. If the patient’s condition precludes the technologist from obtaining these views and visualizing the C6-T1 area, the radiologist should document this problem in the report, asking for a second, complete radiologic examination when the patient’s condition permits, and should verbally communicate this request to the referring physician. Such communication should also be documented in the report.

— This article appeared in its original form in the American Journal of Roentgenology. It is reprinted here with permission of the American Roentgen Ray Society.

1. Brogdon BG, Kelsey CA, Moseley RD Jr. Factors affecting perception of pulmonary lesions. Radiol Clin North Am. 1983;21(4):633-654.

2. Smith MJ. Error and Variation in Diagnostic Radiology. Springfield, Ill.: C. C. Thomas; 1967: 91-93.

3. Viamonte MJ Jr. Errors in Chest Radiography. New York: Springer-Verlag; 1991: 7.

4. Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Baltimore: Lippincott Williams & Wilkins; 1994: 327, 343-344.

5. American College of Radiology. ACR standard for the performance of adult chest radiography. In: Standards. Reston, Va.: American College of Radiology; 1993.

6. Rogers LF. Radiology of Skeletal Trauma, 2nd ed. New York: Churchill Livingstone; 1992: 451-453.

7. Hanafee W, Crandall P. Trauma of the spine and its contents. Radiol Clin North Am. 1966;4(2):365-382.

8. Murphey MD, Batnitzky S, Bramble JM. Diagnostic imaging of spinal trauma. Radiol Clin North Am. 1989;27(5):855-872.

9. Harris JH Jr, Harris WH, Novelline R. The Radiology of Emergency Medicine, 3rd ed. Baltimore: Williams & Wilkins: 1993: 149-162.