Odontoid X-rays: A Pain in the Peg!

I’m doing a peg x-ray, and have followed the positioning book ‘to the letter’. My image processes…Negative. The occiput is superimposed over the peg.

‘Right. Where’s the positioning book? Ok. Agh, that’s what I did the first time!’ I try again…

Negative. The occiput is still projected over the peg.

A colleague appears, so I ask for their opinion, reposition and x-ray again.


I see the radiation dose adding up, and decide not to acquire any more images.

A Problem

Does this sound familiar? After being in the situation multiple times, eventually I wondered…how can I prevent it? What can I do to ensure that my peg x-rays are perfect first time, every time?

After some thought, the first thing I realised is that it is not always possible to acquire a perfect image of the peg first time. Of course I want to eliminate the need to repeat. Who doesn’t? But that’s a dream, and an unrealistic one at that. As it turns out, I was asking myself a lazy question. Is there really a way of never repeating a peg x-ray again? Is having to repeat a peg x-ray even the issue? No. The issue is that I sometimes have to repeat them 3 or 4 times, and still end up with poor quality images!

Let’s work out why. As far as I can see, there are three common scenarios that result in a repeat peg x-ray.

The Block


The first is when, from the word go, I position the patient poorly. Of course, this yields a substandard image. Whenever I position poorly, there is always a ‘block’. The block could be fatigue, if I’m near the end of a difficult night shift, for example. It may be a patient screaming, or a doctor hovering over my shoulder waiting to see the images. It might be laziness. Whatever the block, it needs to be dealt with. If I found a brick in my path, I’d move it out of the way. If I didn’t, I’d probably trip over it! When x-raying, if I positioned lazily, then I’d need to snap out of it and do it properly. If a patient were screaming at me, then that would be the problem – not my positioning. I’d need to solve this before x-raying. I would count lack of knowledge and/or skill as a block, in which case I’d need to seek help or stop, then get my head in the game, learn, and practice. If I do a peg x-ray without removing all of the blocks, simply, I end up repeating it.

The Brick Wall

Brick Wall

I have tried to remove the blocks, but I can’t, they’re too heavy. What now? The second scenario is when I understand how to position a patient accurately, can’t remove the blocks, thus can’t position ‘by the book’, and am forced to modify my technique. Imagine an intoxicated patient trying to remove their neck immobilisation. Clearly, this is dangerous for the patient, and is going to hinder my ability to acquire an optimal peg x-ray. I try multiple ways of calming them down, but to no effect. I decide to make the best of the situation, modify my technique, and take a peg  x-ray. Fortunately, the patient co-operates by opening their mouth, but the image is undiagnostic. What would you do next?

The Mud

Stuck in The Mud

The third scenario is when I know how to position a patient accurately, and do so. There’s no blocks – easy!! But the image is undiagnostic. I’m stuck in the mud. HOW? I don’t know, is the honest answer. Let’s call it sods law, chance, the fact that every patient and situation is different. Whatever you like. The fact is, it happens, and it can also lead to multiple repeats. It’s a ‘block’ unto itself. What would you do next?

I won’t discuss the block scenario any further, because the solution is obvious – I need remove it! Instead, in the next article in this series, I’ll explore the actions I might take in the brick wall and mud scenarios, and discover why they often result in multiple peg x-rays.

What would you do next?

Question Marks

When you are in the brick wall or mud scenario, what do you do next? Tell me in the comments below…

Comments 3

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