Blair Radiology Exam Examination Packet

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Cecilia Brown
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Blair Radiology Exam Examination Packet This packet is made of up five sections: Examiner s Instructions, Applicant Requirements, Analysis Rubric, Overall Result and Comments and Exam Form.

1 Blair Radiology Exam Examination Packet This packet is made of up five sections: Examiner s Instructions, Applicant Requirements, Analysis Rubric, Overall Result and Comments and Exam Form. The Exam Form is the last two pages and it conforms to the Rubric. EXAMINER S INSTRUCTIONS 1. Examiner #1: Print out this whole packet, best is in a two- sided format. Be sure to print out as many exam forms (pages 7 & 8) as you have x- ray sets to examine. 2. Both Examiners: a. Fill out the exam forms while looking at the x- ray sets, totalling the points for each set, each set is worth 100 points. b. For the Instructor Radiology Exam make sure the sets are consecutive. c. Use the Analysis Rubric as your guide, it has fuller explanations than the Exam form. d. Notes on grading: i. Scoring 100 points on a set means it is an absolutely perfect set, with absolutely no room for improvement in technique, nor analysis. Remember that the applicant is sending their BEST sets or consecutive sets of films. ii. A set fails entirely if it is missing one of the required views. If you have time it would be good to analyze the views present as feedback for the applicant. iii. Absence of a MANDATORY requirement causes the whole view (not set) to fail. It would be good to analyse the film anyway, for feedback purposes, but if the film is worth 30 points as a whole (such as in the case of the BP) then ALL 30 POINTS are lost. iv. Digital Films: Digital films may not show collimation nor does each image show the identification card. Make sure the bony structures fill an adequate portion of the image and that the necessary identifying information is included with the set as part of the digital file. e. A flat lateral is not part of the essential Blair Series and so is not graded. If one is sent in it would still be good to give feedback. 3. Take the total number of points from each set and enter them on the Overall Results and Comments page along with any overall observations. a. Proficiency: Each set must pass with a 70% or greater. All sets must receive a passing grade from each examiner. If a set doesn t pass the applicant may substitute another set within 90 days to avoid another $50 application fee and the resubmittal of another 5 sets. b. Instructor: Each set must pass with an 80% or greater. All sets must receive a passing grade from each examiner. If up to three sets do not pass the applicant may submit the next consecutive set (up to three) within a 90 day period to avoid another $300 application fee and the resubmittal of another 20 consecutive sets. c. Faculty: Each set must pass with an 80% or greater. All sets must receive a passing grade from each examiner. If a set doesn t pass the applicant may substitute another set within 90 days to avoid another $50 application fee and the resubmittal of another 5 sets. 4. On completion Examiner #1 will send the films and paperwork to Examiner #2. 5. Examiner #2 on completion will: a. Note the final recommendation for each set as a Pass or Fail on the Results page. b. Send the Overall Results and Comments page and Exam Forms to the Chair of the Technique and Instruction Committee c. Return the films and copies of the Exam Forms and Overall Results and Comments page to the applicant. 6. Be willing to discuss your findings with the applicant. For which you may want to keep copies of the Exam Forms and Overall Results and Comments page for yourself.

2 APPLICANT REQUIREMENTS Once the application has been accepted and approved by the Committee of Technique and Instruction, the applicant should contact two Blair Advanced Instructors, as indicated on the Blair Society website, who are willing to analyze the x- rays. These may be assigned by the Committee Chair. I. Proficiency and Faculty Certifications : Submit five (5) complete sets (not necessarily consecutive) of Blair Upper Cervical X- Ray series to the first of the two selected instructors. All five sets must pass with a 70% or greater from each instructor for Proficiency and 80% for Faculty. II. Primary Instructor Certification : Submit twenty (20) complete and consecutive sets of Blair Upper Cervical X- Ray series to the first of the two selected instructors. Films can be sent in increments of 5, 10 or the full 20. All twenty sets must pass with an 80% or greater from each instructor. III. The submitted x- rays need to be have taken and marked by the applicant. For Faculty Certification only: if x- ray facilities necessary to take Blair films are unavailable, the Certified Blair Advanced Instructor heading the examination will send five full sets of Blair x- rays to be marked and returned by the Faculty applicant. IV. The submitted x- ray sets need to be taken no earlier than 90 days before submission of the application for the Proficiency and Faculty Certifications, within one year for the Instructor Certification. V. At minimum the Blair X- Ray series is made up of an A- P open mouth, base posterior, unilateral or bilateral stereoviews and bilateral protractoviews (stereoviews when necessary). As many retake or supplemental views may be included in each film set as are necessary to obtain readable images of the articular margins of each of the joints in question. VI. The requisite x- ray form to be filled out for each set can be downloaded from the website. A. Listings for C1 to C4 must be marked. B. All angles from C1 to C4 must be marked. C. Contraindications and pathologies should be noted. D. Preferred contact based on listing, angles and anatomy should be recorded. VII. Include two stamped and addressed envelopes one made out to the second Instructor and the other to yourself. VIII. Digital X- Rays: Digitally taken x- rays need to be submitted as.jpegs on a disc exported from your digital x- ray program. Two discs may be burned and sent to each instructor simultaneously. IX. Instructors will evaluate film quality, patient placement and findings. X. Failure to pass one or more sets: A. Proficiency and Faculty: submit a like number of sets within a 90 day period in order to avoid another $50 application fee and the resubmittal of another 5 sets. B. Instructor: submit alike number of sets (up to three) within a 90 day period in order to avoid another $300 application fee and the resubmittal of another 20 sets. The submitted sets must be consecutive to the original 20 sets.

3 Blair Radiology Examination ANALYSIS RUBRIC The only difference between the different levels of certification are the number of x- rays and whether they are consecutive or not. There are some grey areas, but in general a correctly taken and analyzed set will pass. The examiners will send their notes on each set to you after reporting the results to the Technique and Instruction Committee. Generally they are willing and eager to discuss any of their findings. Not all requirements are weighted equally, but you should strive to meet all of them. I. For Each Film: these are critical, if a court of law will not accept your films, neither will we. Before you can be considered proficient in the technique you must demonstrate that you are proficient in taking and reading x-rays. A. (MANDATORY ) Legal Requirements: The label and side markers are imprinted into the image and clear. Legally required information is present and legible. Be careful to accurately mark any stereoviews with the appropriate lead markers. A film that is not legally acceptable is an automatic fail. There may be slightly different requirements in each state, if there is a discrepancy let the examiners know. Digital Films must have this information included with the digital file if it is not actually imprinted on the image. B. (MANDATORY ) Technique factors: combination of contrast and penetration are of diagnostic quality. Thin structures are not too dark. Thicker areas are visible in detail, not too white to see structure. C. Note any contraindications, pathologies or significant abnormalities. D. Collimate on at least three of the four sides. Digital Films may not show collimation, but the bony structures should fill an adequate portion of the image. II. Base Posterior: The Base Posterior is the most important film in the Blair Series. Failure to take and analyze this correctly seriously jeopardizes your ability to get an accurate Atlas listing. A. Image Positioning: 1. Foramen Magnum positioned about 1/4 to 1/3 of the way up from the inferior edge of the film. 2. (Critical) Atlas is visualized between the mandible and the posterior aspect of the skull without significant overlap. 3. (Critical) Head tilt measurement areas (inferior orbit) are visualized. B. Patient Positioning: 1. Sagittal line of the skull is vertical in respect to the film and orbits are horizontally level with the superior aspect of the film. Asymmetry may occasionally be a factor here. 2. (MANDATORY) Head Tilt: a) Parallel lines constructed from like points in the orbital area to the external margin of the skull. b) Length of these lines differs by no more than 1/8 inch (3.2 mm). C. Occipital condyle analysis: 1. (MANDATORY) Lead ear markers are present. 2. (Critical) Baseline: constructed properly from like parts of each of the ear markers. The best practice is measuring from the posterior margin where it corresponds to the posterior margin of the external auditory meatus. 3. Each Convergence Angle (critical but with some margin for interpretation): a) Each Anterior Point One is marked correctly at the juncture of the inferior aspect of the Atlas anterior arch and the respective Atlas lateral mass (the anterior dip of the anterior arch and the lateral mass tubercle). b) Each Posterior Point One is marked correctly at the juncture of the posterior margin of the foramen magnum or anterior margin of the Atlas posterior arch with the postero- medial margin of the respective Atlas lateral mass. c) Line 1-1 is constructed properly between Anterior and Posterior Points One as marked. d) The lateral margin of the each lateral mass outlined properly. e) Lines 1-2 are constructed properly extending laterally from Points One at 90 to Line 1-1 as marked. f) Each Anterior Point Two is marked correctly at the juncture of Anterior Line 1-2 as marked and the lateral margin of the respective lateral mass as marked. g) Each Posterior Point Two is marked correctly at the juncture of Posterior Line 1-2 and the lateral margin of the respective lateral mass as marked. h) The Anterior and Posterior Lines are bisected properly as marked and the longitudinal axis line of each condyle is

4 drawn correctly. i) The Convergence Angle is measured properly as marked as the angle between the longitudinal axis line of each condyle and a line perpendicular to the Baseline as marked. III. Lateral Flat: this is not a required view for the Blair technique, but if you are going to do it, do it right! A. Image Positioning: The spine is roughly in the center of the film horizontally. The body of C7 is visualized. B. Patient Positioning: Head appears straight and level. No apparent rotation of the whole image. C. Mensuration: 1. Atlas Plane Line is constructed and measured properly. 2. Cervical curve measurement is constructed and measured properly. There are many methods of doing this, they each have their strengths and weaknesses, if you are going to do it pick an appropriate one for the neck being analyzed. IV. A-P Open Mouth: A. Image Positioning: The spine is roughly in the center of the film horizontally. C7 is visualized. C1 is roughly in the center of the film vertically. B. Patient Positioning: 1. The mouth is open. The inferior margins of the superior front teeth are roughly in alignment with inferior margin of the occiput. There is no apparent rotation of the image. 2. ( Critical) The posterior arch is visualized as are the lateral masses, the C2 spinous process and the dens. V. Lateral Stereoviews: only one stereoview is required, but it is strongly advised you do two. If you only do one, then all the joints need to be visualized on that one view or in combination with protractoviews. A. Image Positioning: The spine is roughly in the horizontal center of the film. The head appears level. B. (Critical) Patient Positioning: Patient is rotated enough for bilateral joint separation. Tube declension is enough for bilateral joint separation. C. Stereoview Technique: Tube shift appears to be adequate. Stereo image is clear and lines up (no movement other than tube shift between pictures). ( MANDATORY) Lead stereo markers are imprinted, correct and clear. D. (Critical) Joint Visualization: all zygapophyseal joints are visualized clearly from C2/C3 to C7/T1 bilaterally or in combination with other views. Patient anatomy may make the lower cervicals unclear. E. Joint Analysis: (Critical but with some margin for interpretation) 1. Misaligned vertebrae are correctly identified and analyzed. 2. Joint mensuration: angles are all within range of acceptability for those visualized. VI. Blair Protractoviews: A. Image Positioning: (Critical but with some margin for interpretation and allowance for patient anatomy) 1. Each occipital condyle corresponding to the side of protractoview is horizontally near or slightly to one side of the center of the film and vertically near but slightly below the center of the film. 2. Opposite occipital condyle is visualized. B. (Critical) Patient Positioning: 1. Patient appears to be angled along the appropriate convergence angle. 2. Each atlanto- occipital joint is visualized horizontally through the appropriate maxillary sinus cavity and vertically between the occiput and the hard palate. C. (Critical) Stereoview Technique: Only necessary when the convergence angle runs through a vertically shaped anterior structure as seen on the Base Posterior, typically when the convergence angles are less than 20º or over 40º, but it will depend on the patient. Tube shift appears to be adequate. Stereo image is clear and lines up (no movement other than tube shift between pictures). ( MANDATORY) Lead stereo markers are imprinted, correct and clear. D. Corresponding atlanto- occipital joint analysis. (Critical but with some margin for interpretation and allowance for patient anatomy) 1. Occipital condyle: sharp margins with sharp angles. 2. Juxtapositional analyses are correct as visualized. 3. Occipital slope angles are measured correctly. E. Critical: Opposite atlanto- occipital joints are visualized clearly and the occipital convexity angles are measured correctly using the posterior 1/3rd of the occipital condyle. F. Note prefered side of adjustment based on the angles and other bony structures.

5 Examiner s Overall Results and Comments Applicant: Date Submitted: EXAMINER S COMMENTS Examiner #1: SCORES ID Ex #1 Ex #2 Pass/Fail Set #01 Set #02 Set #03 Set #04 Set #05 Set #06 Signature: Date: Examiner #2: Set #07 Set #08 Set #09 Set #10 Set #11 Set #12 Set #13 Set #14 Set #15 Set #16 Set #17 Signature: Date: Set #18 Set #19 Set #20 COMMITTEE COMMENTS/RECOMMENDATIONS: Jan 31st, 2015 Board Approved Edition

6 (THIS PAGE INTENTIONALLY BLANK) Jan 31st, 2015 Board Approved Edition

7 Applicant: Date: Film Set Identification: Blair Radiology Examination Scoring Sheet I. Base Posterior (30 points): A. Mandatory : The absence of which automatically fails this view and it is worth 0 points: The label is imprinted and clear. Legally required information is present and legible (or digitally available). The side markers are imprinted and legible. Head tilt is marked correctly and the difference is ⅛ inch (3.2 mm) or less. Lead ear markers are present. Technique factors: combination of contrast and penetration are of diagnostic quality. B. (1 pts) Three of four sides show collimation. (Digital Films: bony structures fill an adequate amount of image). C. Image Positioning: 1. (1 pt) Foramen Magnum positioned about 1/4 to 1/3 of the way up from the inferior edge of the film. 2. (3 pts) Atlas is visualized between the mandible and the posterior aspect of the skull. D. Patient Positioning: 1. (1 pt) Sagittal line of the skull is vertical and orbits are horizontally level. E. Occipital condyle analysis: 1. (4 pts) Baseline: constructed properly from like parts of each ear marker. 2. Each Convergence Angle a) (4 pts) Anterior and Posterior Points One are marked correctly. b) (2 pts) Lines 1-1 are constructed properly between Anterior and Posterior Points One as marked. c) (2 pts) Lateral margins of the lateral masses are outlined properly. d) (4 pts) Lines 1-2 are constructed properly as marked. e) (4 pts) Anterior and Posterior Points Two are marked correctly. f) (2 pts) Anterior and Posterior Lines are bisected properly as marked and the longitudinal axis line of the each condyle are drawn correctly. g) (2 pts) Convergence Angles are measured properly as marked. F. Examiner s Notes: II. A-P Open Mouth (5 points): A. Mandatory : The absence of which automatically fails this view and it is worth 0 points: The label is imprinted and clear. Legally required information is present and legible (or digitally available). The side markers are imprinted and legible. Technique factors: combination of contrast and penetration are of diagnostic quality. B. (½ pt) Three of four sides show collimation. (Digital Films: bony structures fill an adequate amount of image). C. Image Positioning: 1. (½ pt) The spine is roughly in the center of the film horizontally. 2. (½ pt) C1 is roughly in the center of the film. D. Patient Positioning: 1. (1 pt) The mouth is open and the front teeth are roughly in alignment with occiput. 2. (½ pt) There is no apparent rotation of the whole image. 3. (1 pt) The posterior arch is visualized. 4. (1 pt) The condyles and spinous process of C2 are visualized. E. Examiner s Notes: III. Lateral Stereoview(s) (10 points): A. Mandatory : The absence of which automatically fails this view and it is worth 0 points: The label is imprinted and clear. Legally required information is present and legible (or digitally available). The side and stereo markers are imprinted and legible. The Left/Right stereo markers are imprinted and visible. Technique factors: combination of contrast and penetration are of diagnostic quality.

8 Applicant: Date: Film Set Identification: B. (½ pt) Three of four sides show collimation. (Digital Films: bony structures fill an adequate amount of image). C. (½ pt) Image Positioning: The spine is roughly in the horizontal center of the film. The head appears level. D. (1 pt) Patient Positioning: Patient is rotated and tube declined enough for bilateral joint separation. E. (1 pt) Stereoview Technique: Tube shift appears to be adequate. Stereo image is clear and lines up. F. (1 pt) Joint Visualization: all zygapophyseal joints are visualized clearly from C2/C3 to C7/T1 bilaterally or in combination with other views. Patient anatomy may make the lower cervicals unclear. G. Joint Analysis: 1. (3 pts) Misaligned vertebrae are correctly identified and analyzed. 2. (3 pts) Joint mensuration: angles are all within range of acceptability for those visualized. H. Examiner s Notes: IV. Blair Protractoviews (25 points each): A. Mandatory : The absence of which automatically fails this view and it is worth 0 points: Left Right The label is imprinted and clear. Legally required information is present and legible (or digitally available). Left Right The side (and stereo if needed) markers are imprinted and legible. Left Right The lateral margins of the corresponding lateral mass and condyle must be visualized. Left Right Technique factors: combination of contrast and penetration are of diagnostic quality. B. Left Right (1 pt) Three of four sides show collimation. (Digital Films: bony structures fill an adequate amount of image). C. Image Positioning: 1. Left Right (1 pt) Each occipital condyle corresponding to the side of protractoview is horizontally near or slightly to one side of the center of the film and vertically near but slightly below the center of the film. 2. Left Right (1 pt) Opposite occipital condyle is visualized. D. Patient Positioning: 1. Left Right (2 pts) Patient appears to be angled along the appropriate convergence angle. 2. Left Right (2 pts) Each atlanto-occipital joint is visualized horizontally through the appropriate maxillary sinus cavity and vertically between the occiput and the hard palate. Anatomy permitting. E. Stereoview Technique (when necessary, if not necessary assign full points for scoring purposes): 1. Left Right (2 pts) Necessary and done. 2. Left Right (2 pts) Tube shift appears to be adequate. Stereo image is clear and lines up. F. Corresponding atlanto-occipital joint analysis. 1. Left Right (2 pts) Occipital condyle: sharp margins with sharp angles. 2. Left Right (6 pts) Juxtapositional analyses (listings) are correct as visualized. 3. Left Right (2 pts) Occipital slope angles are measured correctly (occiput, not atlas). G. Opposite atlanto-occipital joints 1. Left Right (2 pts) Visualized clearly. 2. Left Right (2 pts) Occipital convexity angles are measured correctly (posterior 1/3rd of occipital condyle). H. Examiner s Notes: V. Set as a whole (5 points): A. (3 pts) Any contraindications, pathologies or significant abnormalities are noted. B. (2 pts) Note prefered side of adjustment based on the angles and other bony structures. VI. Examiner s Overall Impression: Blair Advanced Instructor Signature: Set Total Score: /100

Dr.Noor Hashem Mohammad Lecture (5)

Dr.Noor Hashem Mohammad Lecture (5) 2016-2017 If the mandible is discarded, the anterior part of this aspect of the skull is seen to be formed by the hard palate. The palatal processes of the maxillae