Vertebral Column - PDF

HOLY INFANT COLLEGE OF TACLOBAN CITY, INC Benigno Aquino Ave., Youngfield, Tacloban City Tel. # (53) 832-2455; Email Address: [email protected] Owned and Administered by the Religious Sisters of Mercy (RSM) COLLEGE OF RADIOLOGIC TECHNOLOGY R...

HOLY INFANT COLLEGE OF TACLOBAN CITY, INC Benigno Aquino Ave., Youngfield, Tacloban City Tel. # (53) 832-2455; Email Address: [email protected] Owned and Administered by the Religious Sisters of Mercy (RSM) COLLEGE OF RADIOLOGIC TECHNOLOGY RADIOGRAPHIC RT 112 : POSITIONING & RADIOLOGIC PROCEDURES 1 Prepared by: MR. ALLYSON Q. FLORENDO, RRT Lecturer, College of Radiologic Technology VERTEBRAL COLUMN FUNCTIONS OF VERTEBRAL COLUMN: E n c l o s e s a n d p r o t e c t s t h e s p i n a l c o r d Acts as a support for the trunk Supports the skull superiorly Provides for attachment for the deep muscles of the back and ribs laterally ANATOMY CERVICAL & THORACIC SPINE  VERTEBRAL COLUMN: FIVE DIVISIONS The vertebral column is composed of small segments of bone called vertebrae. Disks of fibrocartilage are interposed between the vertebrae and act as cushions. The vertebral column is held together by ligaments, and it is jointed and curved so that it has considerable flexibility and resilience.  VERTEBRAL COLUMN: FIVE DIVISIONS In early life, the vertebral column usually consists of 33 small, irregularly shaped bones. 7 Cervical 12 Thoracic 5 Lumbar Sacral vertebrae Coccygeal vertebrae  NORMAL SPINAL CURVATURES The 24 vertebral Segments in the upper three regions remain distinct throughout life and are termed the true or movable vertebrae. The pelvic segments in the two lower regions are called false or fixed vertebrae because of the change they undergo in adults. The sacral segment usually fused into one bone called the sacrum, and the coccygeal segment , referred to as the coccyx also fuse into one bone.  NORMAL SPINAL CURVATURES The thoracic and pelvic curves are called primary curves because they are present at birth. The cervical and lumbar curves are called secondary or compensatory curves because they develop after birth.  LORDOSIS AND KYPHOSIS (ABNORMAL CURVATURES) Any abnormal increase in the anterior concavity (or posterior convexity) of the thoracic curve is termed kyphosis. Any abnormal increase in the anterior convexity (or posterior concavity) of the lumbar or cervical curve is termed lordosis.  SCOLIOSIS (ABNORMAL LATERAL CURVATURES) TYPICAL VERTEBRA TYPICAL VERTEBRAL ANATOMY  TYPICAL VERTEBRA (ARTICULAR PROCESSES)  ZYGAPOPHYSEAL JOINTS & INTERVERTEBRAL FORAMINA Superior and inferior vertebral notches form intervertebral foramina  INTERVERTEBRAL DISK (SAGITTAL VIEW OF VERTEBRAE)  CERVICAL VERTEBRAE (7 VERTEBRAE)  C3-C6 are typical cervical vertebrae  TYPICAL CERVICAL VERTEBRAE (C3-C6) ❑ 3 unique characteristic ▪ Bifid (double- pointed) spinous process ▪ Articular pillar ▪ 3 foramina ▪ Right and left transverse foramina and the vertebral foramen. INTERVERTEBRAL FORAMINA ATLAS  ATLAS & AXIS ATLAS & AXIS AXIS AP OPEN MOUTH PROJECTION  THORACIC CHARACTERISTICS  Distinctive features: Rib articulations (facets and demifacets) Caudally pointed spinous processes  THORACIC CHARACTERISTICS The body of the first thoracic vertebra presents a whole costal facet near its superior border for articulation with the head of the first rib and presents a demifacet (half facet) on its inferior border for articulation with the head of the second rib. The bodies of the second through eighth thoracic vertebrae contain demifacets both superiorly and inferiorly. The ninth thoracic vertebrae has only a superior demifacet. Finally, the tenth, eleventh, and twelfth thoracic vertebral bodies have a single whole facet at the superior margin for articulation with the eleventh and twelfth ribs.  THORACIC CHARACTERISTICS T 10 TO L 2 RIB ARTICULATIONS  COSTOVERTEBRAL & COSTOTRANSVERSE JOINTS (RIBS 1-10) The costovertebral joint in the thoracic spine is the juncture at which the head of a rib articulates with the vertebral body of a thoracic vertebra. The costotransverse joint is the juncture at which the neck and tubercle of a given rib are united with the transverse process of its corresponding thoracic vertebra. TYPICAL THORACIC VERTEBRAE (SUPERIOR & LATERAL VIEW) TYPICAL THORACIC VERTEBRA (LATERAL OBLIQUE VIEW) TYPICAL THORACIC VERTEBRAE (ZYGAPOPHYSEAL JOINTS & INTERVERTEBRAL FORAMINA) RADIOGRAPHIC ANATOMY REVIEW AP AXIAL PROJECTION  ANATOMY REVIEW: LATERAL CERVICAL SPINE  ANATOMY REVIEW: OBLIQUE CERVICAL SPINE POSITION ANATOMY REVIEW: AP THORACIC SPINE  ANATOMY REVIEW: LATERAL THORACIC SPINE ZYGAPOPHYSEAL JOINTS (LEFT LATERAL) RIGHT INTERVERTEBRAL FORAMINA (LPO) ZYGAPOPHYSEAL JOINTS 70°-75° LPO (20°-25° FROM LATERAL) INTERVERTEBRAL FORAMINA LATERAL VIEW OF THORACIC SPINE  POSITION-ANATOMY DEMONSTRATED INTERVERTEBRAL ZYGAPOPHYSEAL FORAMINA JOINTS 45° oblique Cervical (upside, posterior Lateral oblique) 70° oblique Thoracic Lateral (upside, posterior oblique) 30-60° oblique Lumbar Lateral (downside, posterior oblique) CERVICAL SPINE TOPOGRAPHIC LANDMARKS T-SPINE TOPOGRAPHIC LANDMARKS  TOPOGRAPHIC LANDMARK QUIZ  TOPOGRAPHIC LANDMARK QUIZ TERMINOLOGY & PATHOLOGY  PATHOLOGY 1. Clay Shoveler’s fracture- avulsion fracture of the spinous process in the lower cervical & upper thoracic region. 2. Compression fracture- fracture that causes compaction of bone & a decrease in length or width. 3. Hangman’s fracture- fracture of the anterior arch of C2 due to hyperextension. 4. Jefferson’s fracture- comminuted fracture of the ring of C1. 5. Herniated Nucleus Pulposus- rupture or prolapsed of the nucleus pulposus into the spinal canal. 6. Kyphosis- abnormally increased convexity in the thoracic curvature. 7. Lordosis- abnormally increased concavity of the cervical & lumbar spine. 8. Osteopetrosis- increased density of atypically soft bone.  PATHOLOGY 9. Osteoporosis- loss of bone density 10. Scheuerrmann’s Disease- adolescent kyphosis or; a Kyphosis with onset in adolescence. 11. Scoliosis- lateral deviation of the spine with possible vertebral rotation. 12. Spina Bifida- failure of the posterior encasement of the spinal cord to close. 13. Spondylolisthesis- forward displacement of a vertebra over a lower vertebra, usually L5-S1.  PATHOLOGY 14. Spondylolysis- separation of the pars interarticularis. 15. Odontoid fracture- disruption of the arches of C1. 16. Teardrop Burst fracture- comminuted vertebral body with triangular fragments avulsed from anteroposterior border caused by compression with hyperflexion in the cervical region. 17. Transitional Vertebra- it occurs when the vertebra takes on a characteristic of the adjacent region of the spine. 18. Chance fracture- fracture through the vertebral body caused by hyperflexion force. 19. Whiplash Injury- damage to the ligaments, vertebrae or spinal cord caused by sudden jerking back of the head & neck.  The cervical spine series consists of a set of X-rays used to examine the bony structures of the cervical spine. While CT scans have largely taken over this role, the cervical spine series remains a crucial radiographic examination, especially in trauma cases, and it is important for all radiographers to be familiar with it.  STANDARD PROJECTIONS AP – Anteroposterior projection of the cervical spine demonstrating the vertebral bodies and intervertebral spaces LATERAL – Zygapophyseal joints – Soft tissue structures around the c-spine – Spinous processes – Anterior-posterior relationship of the vertebral bodies  ODONTOID – Also known as a 'peg' projection it demonstrates the C1 (atlas) and C2 (axis)  AP OBLIQUE – Demonstrates the intervertebral foramina of the side positioned farther from the image receptor. PA OBLIQUE – Demonstrated the intervertebral foramina of the side positioned closer to the image receptor.  ADDITIONAL PROJECTIONS CERVICOTHORACIC VIEW – Modified lateral projection of the cervical spine to visualize the C 7 / T 1 j u n c t i o n. FLEXION-EXTENSION LATERAL – Specialized projections of the cervical spine often requested to assess for spinal stability. FUCHS VIEW – Non-angled AP radiograph of C1 and C2 it should not be used in a trauma setting.  The thoracic spine series includes two standard X-ray views, along with various additional views based on specific clinical needs. This series is frequently used in cases of trauma, for postoperative imaging, and to assess chronic conditions.  STANDARD PROJECTIONS AP VIEW – Images the entirety of the thoracic spine, which consists of twelve vertebrae. – Intervertebral joints are seen in profile. – Often performed erect unless otherwise indicated. LATERAL VIEW – Intervertebral joints and neural foramen are open, with the superimposition of the posterior spinous processes. – Ideal projection when examining for suspected fractures and dislocations.  MODIFIED TRAUMA PROJECTIONS HORIZONTAL BEAM LATERAL – Visualization of thoracic vertebral bodies, pedicles, and facet joints taken supine – Used in the context of trauma  ADDITIONAL PROJECTIONS FLEXION-EXTENSION VIEW – Functional view used to assess spinal stability. BOLSTER VIEW – Specialized view for scoliosis, often performed under the guidance of an orthopedic surgeon.  The lumbar spine series consists of two standard X-ray views, with additional views taken based on clinical requirements. This series is commonly used in trauma cases, for postoperative assessments, and to evaluate chronic conditions like ankylosing spondylosis.  STANDARD PROJECTIONS PA/AP VIEW – The entire lumbar spine should be visible, with a demonstration of T11/T12 superiorly and the sacrum inferiorly. – Often performed erect unless otherwise indicated. LATERAL VIEW – Visualization of lumbar vertebral bodies, pedicles, and facet joints. – Ideal projection when examining for suspected fractures. – Can be performed erect to assess stable fracture (under a specialist's guidance). MODIFIED TRAUMA PROJECTIONS HORIZONTAL BEAM LATERAL – Visualization of lumbar vertebral bodies, pedicles, and facet joints taken supine. – Used in the context of trauma.  ADDITIONAL PROJECTIONS OBLIQUE VIEW – Used to visualize the articular facets and pars interarticularis of the lumbar spine. FLEXION-EXTENSION VIEW – Functional view used to assess spinal stability. RADIOGRAPHIC POSITIONING  ATLANTO- OCCIPITAL JOINTS  AP OBLIQUE PROJECTION R & L HEAD ROTATIONS PP: – Supine – Head rotated 45-60o away from side of interest; – OML ┴ to IR RP: 1 in. anterior to the EAM CR: ┴ AP OBLIQUE PROJECTION SS: – Atlanto-occipital joints between orbit & ramus of mandible – Dens is well demonstrated ER: – Alternative projection when a patient cannot be adjusted in the open-mouth position  AP OBLIQUE PROJECTION BUETTI RECOMMENDATION PP: – Head is turned 45-50 degrees to one side. – Mouth wide open – The chin is drawn down as much as the open mouth allows RP: Open mouth to the dependent mastoid tip. MOUTH WIDE OPEN CR: Perpendicular C1 & C2  FUCHS METHOD (AP PROJECTION) PP: – Supine – Chin extended – Chin tip & mastoid tip ┴ to IR – MSP ┴ to IR RP: Distal to chin tip CR: ┴ SS: Dens within foramen magnum ER: Recommended when upper half of dens is not clearly shown in open-mouth position  SMITH-ABEL METHOD AP AXIAL PROJECTION PP: – Supine – Patient’s neck slightly extended – Mouth is opened wide – Exposure is made with head passively rotated 10 degrees to side. Rationale: To remove Note: Mouth is opened wide. mandible from area of Disclaimer: No image found. interest.  SMITH-ABEL METHOD AP AXIAL PROJECTION CR: – 35 degrees caudad SS: – Laminae and articular facets of the upper vertebrae ER: – This method is recommended for visualization of the posterolateral elements of the upper vertebra. Note: Mouth is opened wide. No image found.  JUDD METHOD (PA PROJECTION) PP: – Prone – Neck extended – Chin against the table – IR centered to throat (level of upper margin of thyroid cartilage) – OML 37o to IR – MSP ┴ to IR – Chin & mastoid tip ┴ RP: Distal to level of mastoid tips at MSP CR: ┴ SS: Dens and atlas within Contraindication: Patient who has an foramen magnum unhealed fracture who has a degenerative disease or suspected fracture of the upper cervical region.  KASABACH METHOD (AP AXIAL OBLIQUE PROJECTION) R & L head rotations PP: Supine Head rotated 40-45o IOML ┴ RP: Midway between outer canthus & EAM CR: 10-15o caudad SS: Dens ER: Recommended in conjunction with AP & lateral projections  KASABACH METHOD (AP AXIAL OBLIQUE PROJECTION) HERMANN-STENDER Described a position for demonstrating the atlanto-occipital-dens relationship. Same head position as Kasabach Method RP: Between the mastoid processes at the level of the atlanto-occipital joints. CR: Perpendicular ALBERS-SCHONBERG & GEORGE METHOD AP PROJECTION OPEN-MOUTH PP: – Supine – MSP ┴ – Open mouth as wide as possible and phonate “ah” during the exposure. Rationale: This places the tongue in the floor of the mouth so that it will not be projected on the atlas and axis & prevent movement of the mandible. RP: Midpoint of open mouth CR: ┴ ALBERS-SCHONBERG & GEORGE METHOD SS: Atlas & axis through the open mouth Articular surfaces of the atlas and axis – Rationale: To check for lateral displacement. Entire atlas is not demonstrated – If patient has deep head or long mandible ALBERS-SCHONBERG & GEORGE METHOD SID: 30 inches – Rationale: Often used to increase the FOV of the odontoid area. TOMOGRAPHY: Required if the traumatized patient cannot move their head or open the mouth. – Occlusal Plane is a line from the lower edge of the upper incisors to the tip of the mastoid process.  LATERAL PROJECTION R & L POSITION PP: – Supine (dorsal decubitus) – IR vertical – MSP // to IR – MSP ┴ to table – Neck slightly extended (mandibular rami does not overlap atlas or axis) RP: 1 in. distal to mastoid tip (level of atlantoaxial articulation) CR: ┴  LATERAL PROJECTION R & L POSITION SS: – Atlas & axis – Atlanto-occipital joints – Better definition is obtained because of short OID.  LATERAL PROJECTION R & L POSITION PANCOAST, PENDERGRASS & SCHAEFFER RECOMMENDATION Recommended that the head be r o t a t e d s l i g h t l y – Rationale: To prevent superimposition of the laminae and atlas. Recommended a s l i g h t h o r i z o n t a l t i l t of the head – Rationale: For demonstration of the arches of the atlas.  CERVICAL VERTEBRAE  AP AXIAL PROJECTION PP: – Supine/upright – Chin extended – Occlusal plane ┴ to IR Rationale: Prevents superimposition of mandible & midcervical vertebrae RP: C4 CR: 15-20o cephalad  AP AXIAL PROJECTION SS: – C3-T2 – Interpediculate spaces – IV disk spaces – Superimposed transverse & articular processes ER: Used to demonstrate the presence or absence of cervical ribs.  GRANDY METHOD (LATERAL PROJECTION) PP: – Seated or upright – Patient in true lateral position – Shoulder rotated posteriorly or anteriorly (round shouldered) – Chin slightly elevated (prevents superimposition of mandibular rami & spine) – MSP parallel to IR RP: C4 CR: Horizontal  GRANDY METHOD (LATERAL PROJECTION) SS: – C1-C7 – C1-T2 (good lateral projection) – Articular pillars – Lower five zygapophyseal joints (C3-C7) – Spinous processes in profile – Magnified outline of the shoulder farthest from the IR is projected below the lower cervical vertebrae LATERAL PROJECTION HYPERFLEXION & HYPEREXTENSION PP: – Seated or upright – Patient in true lateral position – MSP parallel to IR Hyperflexion: – Head drop forward – Draw chin as close as possible to the chest Hyperextension: – Chin elevated as much as possible  LATERAL PROJECTION RP: C4 CR: Horizontal or perpendicular SS: – IV disks & zygapophyseal joints – Mobility of the cervical spine when hyperflexed and hyperextend  LATERAL PROJECTION SS in Hyperflexion: – C1-C7 – All spinous process in profile – Elevated & widely separated spinous processes – Body of mandible almost parallel SS in Hyperextension: – C1-C7 in true lateral position – Depressed spinous processes – Body of mandible almost horizontal  LATERAL PROJECTION ER: – For functional studies (motility) of cervical vertebrae – To demonstrate normal AP movement or absence of movement Note: This procedure must not be attempted until cervical spine pathology or fracture has been ruled out.  AP AXIAL OBLIQUE PROJECTION BARSONY & KOPPENSTEIN described this projection. PP: – Supine or upright (more comfortable) – RPO/LPO – Body rotated 45o – Chin protruded/elevated RP: C4 CR: 15-20o cephalad SS: – C1-T1 intervertebral foramina & pedicles (farthest from IR)  AP AXIAL OBLIQUE PROJECTION Boylston Suggestion: – Suggested AP oblique projection hyperflexion & hyperextension for functional studies in oblique projection. Rationale – To demonstrate fracture of articular process dislocation/subluxation  PA AXIAL OBLIQUE PROJECTION PP: – Prone or upright (more comfortable – RAO/LAO – Body rotated 45o – Shoulder rested against IR – Chin protruded/elevated RP: C4  PA AXIAL OBLIQUE PROJECTION CR: 15-20o caudad SS: – Intervertebral foramina & pedicles (closest to IR)  OTTONELLO/CHEWING/ WAGGING JAW METHOD AP PROJECTION PP: – Supine – MSP ┴ to IR – Chin elevated – Upper incisors & mastoid tips ┴ to IR – Mandible in chewing motion during exposure RP: C4 CR: ┴ OTTONELLO/CHEWING/ WAGGING JAW METHOD SS: – Entire cervical column ER: – To blurred the mandibular shadow to demonstrate all cervical vertebrae  VERTEBRAL ARCH/ PILLARS/LATERAL MASS PROJECTION AP AXIAL PROJECTION PP: – Supine – Shoulder depressed – MSP ┴ to IR – Neck hyperextended RP: C7 CR: – 25o caudad – 20-30o caudad (range)  VERTEBRAL ARCH/ PILLARS/LATERAL MASS PROJECTION SS: – Vertebral arch structures – Superior & inferior articular processes (pillars) – Zygapophyseal joints between articular processes – Upper three of thoracic vertebrae – Laminae – Spinous processes  VERTEBRAL ARCH/ PILLARS/LATERAL MASS PROJECTION ER: – Useful for demonstrating the cervicothoracic spinous processes in patients with whiplash injury.  VERTEBRAL ARCH/ PILLARS/LATERAL MASS PROJECTION PA AXIAL PROJECTION PP: – Prone – Head rested against IR – Neck fully extended – MSP ┴ to IR RP: C7 CR: – 40o cephalad – 35-45o cephalad (range) SS: Vertebral arch structures  VERTEBRAL ARCH/ PILAR/LATERAL MASS PROJECTION AP AXIAL OBLIQUE PROJECTION R & L head rotations PP: – Supine – Head rotated 45-50o (C2-C7 articular processes) or – Head rotated 60-70o (C6-T4 articular processes) – Turn jaw away from side of interest RP: C7 CR: – 35o caudad – 30-40o caudad (ranges)  VERTEBRAL ARCH/ PILAR/LATERAL MASS PROJECTION SS: Vertebral arch structures ER: Used to demonstrate vertebral arches when the patient cannot hyperextend head for AP/PA axial projection PA AXIAL OBLIQUE Reverse the CR (cephalad)  SWIMMER’S TECHNIQUE (LATERAL PROJECITON) PP: – Humeral head moved anteriorly or posteriorly – Depress shoulder away from IR – MSP parallel to IR – Breathing technique Lateral recumbent (Pawlow): – Head elevated on patient’s arm Upright (Twinning): – Arm closes to IR extended – Elbow flexed – Forearm rested on head RP: C7-T1 interspace Respiration Technique: – Suspend or breathing technique if patient can cooperate and can be immobilized Rationale: To blur the lung anatomy  SWIMMER’S TECHNIQUE (LATERAL PROJECITON) CR: – ┴ (shoulder well depressed) – 3-5o caudad (can’t be depressed sufficiently) SS: – Cervicothoracic region (C7-T1) ER: – Performed when shoulder superimposition obscures C7 on a lateral cervical spine projection – Perform when a lateral projection of the upper thoracic vertebra is needed SWIMMER’S TECHNIQUE (LATERAL PROJECTION) MONDA RECOMMENDATION: – CR: 5-15o cephalad Exam Rationale: To better demonstrate IV disk spaces when the spine is tilted because of broad shouldered or a non-elevated lower spine. NOTE: Proper angle result in CR perpendicular to the long axis of the tilted spine.  THORACIC VERTEBRAE  AP PROJECTION PP: – Supine/upright – MSP ┴ to IR – Hips & knees flexed (to reduce kyphosis) – Place support under knees RP: – T7 (between jugular notch & xiphoid process) CR: ┴ Respiration: – Shallow breathing or suspend at the end full expiration.  AP PROJECTION SS: – T1-T12 – IV disk spaces – Transverse processes – Costovertebral articulation  AP PROJECTION FUCHS SUGGESTION Used the heel effect of the tube Cathode side toward the feet – Rationale: To obtain a more uniform density of the thoracic spine  LATERAL PROJECTION PP: – Lateral recumbent or upright (Oppenheimer) – Left side against the table (places heart closer to IR) MSP parallel to IR – Hips & knees flexed – Arms at right angle to body (to elevate ribs enough) – Place support under lower thoracic spine RP: T7  LATERAL PROJECTION Respiration: Normal breathing – Rationale: To obliterate or diffuse the vascular markings and ribs or at the end of expiration CR: – ┴ (with support) – 10-15o cephalad (without support) – 10o cephalad (female) or 15o cephalad(male) SS: – T1-T12 – IV disk spaces – Intervertebral foramina – Lower spinous processes  FUCHS METHODD (AP OBLIQUE PROJECTION) PP: – Supine/upright – RPO/LPO – Body rotated 20o posteriorly – MCP 70o from IR RP: T7 CR: ┴ SS: – Zygapophyseal or apophyseal joints (farthest from IR) – T12 inferior articular processes (RPO/LPO 45 degrees)  FUCHS METHODD (AP OBLIQUE PROJECTION) Exam Rationale: – Gives an excellent demonstration of the cervicothoracic spinous process – Used when the patient cannot satisfactorily positioned for a direct lateral projection. ACCENTUATED DORSAL KYPHOSIS A greater degree of rotation is required – Rationale: To show the joints at the proximal and distal ends in the region.  OPPENHEIMER METHODD (PA OBLIQUE PROJECTION)  OPPENHEIMER METHODD (PA OBLIQUE PROJECTION) PP: – Prone/upright – RAO/LAO – Body rotated 20o anteriorly – MCP 70o from IR RP: T7 CR: ┴ SS: – Zygapophyseal or apophyseal joints (closest to IR) – T12 inferior articular processes (RAO/LAO 45 degrees)  LUMBAR- LUMBOSACRAL VERTEBRAE  AP/PA PROJECTION PA PROJECTION (OPTIONAL) PP: Supine/upright Elbow flexed Hands on upper chest Hips & knees flexed – Reduces lumbar lordosis – Places back in contact with table – Reduces distortion of vertebral bodies – Better delineation of IV disk RP: – L4 (for lumbosacral) – L3 (for lumbar spine only) CR: ┴  AP PROJECTION SS: – Lumbar bodies – IV disk spaces – Interpediculate spaces – Laminae – Spinous & transverse processes – T11-T12, sacrum, coccyx & pelvic bones (larger IR)  AP PROJECTION PA PROJECTION – Places the IV disk spaces at an angle nearly parallel to the divergence of the beam – Reduces the dose to the patient – Sometimes used for upright studies of lumbar and lumbosacral spine.  LATERAL PROJECTION PP: – Lateral recumbent or upright – Affected side against IR – Hips & knees flexed; MCP ┴ to IR – Place support under lower thorax (places spine in true horizontal position) RP: – L4 (for lumbosacral) – L3 (for lumbar spine only)  LATERAL PROJECTION CR: – ┴ (with support) – 5-8o caudad (without support) – 5o caudad (male) or 8o caudad (female) SS: – Intervertebral foramina of L1-L4 only – L5 intervertebral foramina (Oblique Projection) – Lumbar bodies – IV disk spaces  LATERAL PROJECTION IMPROVING RADIOGRAPHY QUALITY Leaded rubber placed on the table behind the patient – Rationale: To absorb scatter radiation from the patient and table Scatter Radiation – Decrease the quality of the radiograph, blacken the spinous process and prematurely terminate the exposure in AEC.  L5-S1 LUMBOSACRAL JUNCTION  LATERAL PROJECTION PP: – Lateral recumbent or upright – Affected side against IR – Hips & knees flexed – MCP ┴ to IR – Place support under lower thorax (places spine in true horizontal position) RP: – 2 in. posterior to ASIS & 1.5 in. inferior to iliac crest  LATERAL PROJECTION CR: – ┴ (with support) – 5-8o caudad (without support) – 5o (male) or 8o (female) SS: – Lumbosacral junction  LUMBAR ZYGAPOPHYSEAL JOINTS AP OBLIQUE PROJECTION PP: – Semisupine/upright – RPO/LPO – Body rotated 45o or 60o (L5-S1 zygapophyseal joints & articular processes) RP: – Lumbar region: 2 in. medial to elevated ASIS & 1.5 in. superior to iliac crest (L3) – 5th zygapophyseal joint: 2 in. medial to elevated ASIS & midway between iliac crest & ASIS AP OBLIQUE PROJECTION CR: ┴ SS: – Zygapophyseal/apophyseal joints (closest to IR) – Scottie dog Superior articular process (ear) Transverse process (nose) Pedicle (eye) Pars interarticularis (neck) Lamina (body) Inferior articular process (foot) AP OBLIQUE PROJECTION AP OBLIQUE PROJECTION Note: – 45o Oblique Projection Demonstrate majority (L3-S1) of zygapophyseal joints – AP Projection 25% of L1-L2 & L2-L3 – Lateral Projection Small percentage of L4-L5 & L5-S1 PA OBLIQUE PROJECTION PP: Semiprone / upright RAO/LAO Body rotated 45o or 60o – (L5-S1 zygapophyseal joints & articular processes) RP: – 1.5 in. superior to iliac crest & 2 in. lateral to palpable spinous process CR: ┴ SS: – Zygapophyseal/apophyseal joints (farthest from IR) – Scottie dog FIFTH LUMBAR  KOVACS METHOD (PA AXIAL OBLIQUE PROJECTION) PP: – Lateral recumbent; RAO/LAO – Pelvis rotated 30o anteriorly from lateral – Sandbags under the flexed uppermost knee (prevent too much rotation of the hips) RP: – L5 – Superior edge of the crest (entrance) CR: 15-30o caudad SS: L5 intervertebral foramina LUMBOSACRAL AND SACRAL JOINTS  FERGUSON METHOD (AP AXIAL PROJECTION) PP: – Supine – Lower limb extended – Thigh abducted RP: – 1.5 in. superior to pubic symphysis CR: – 45o cephalad (Ferguson) – 30-35o cephalad 30o (male) or 35o (female);  FERGUSON METHOD (AP AXIAL PROJECTION) SS: – Lumbosacral joint; symmetric sacroiliac joints MEESE RECOMMENDATION: PP: Prone Places sacroiliac joints nearly parallel to CR RP: 2 in. distal to L5 (level of ASISs) CR: ┴  FERGUSON METHOD (PA AXIAL PROJECTION) PP: Prone RP: L4 CR: 35o caudad SS: – Lumbosacral joint – Symmetric sacroiliac joints SACROILIAC JOINTS AP OBLIQUE PROJECTION PP: – Semisupine – RPO/LPO – Body rotated 25-30o RP: 1 in. medial to elevated ASIS CR: ┴ SS: – Sacroiliac joint (farthest from IR) – PA OBLIQUE: Sacroiliac joint closest to IR AP OBLIQUE PROJECTION AP OBLIQUE PROJECTION BROWER & KRANSDORF – Summarized difficulties in imaging the sacroiliac joints. – Rationale: Because of patient positioning & variability  AP AXIAL OBLIQUE PROJECTION PP: – Semisupine – RPO/LPO – Body rotated 25-30o RP: – 1 in. distal to elevated ASIS CR: 20-25o cephalad SS: – Sacroiliac joint (farthest from IR) PA OBLIQUE PROJECTION PP: – Semiprone – RAO/LAO – Body rotated 25-30o RP: – 1 in. medial to elevated ASIS CR: ┴ SS: – Sacroiliac joint (closest to IR) PA OBLIQUE PROJECTION PUBIC SYMPHYSIS  CHAMBERLAIN METHOD (PA PROJECTION) PP: Upright; standing on two blocks First exposure: – Remove one block – One leg hangs with no muscular resistance Second exposure: – Replace support under foot that was hanging – Remove the opposite one – Second leg hanging free RP: Pubic symphysis CR: ┴  CHAMBERLAIN METHOD (PA PROJECTION) SS: Pubic symphysis CHAMBERLAIN RECOMMENDATIONS: – For abnormal sacroiliac motion LATERAL PROJECTION: – Upright – Centered to lumbosacral junction 2 PA PROJECTIONS OF PUBIC BONES: – Upright – Weight-bearing on alternate limbs – To demonstrate pubic symphysis reaction by a change in the normal relation of pubic bones SACRUM AP/PA AXIAL PROJECTION PP: Supine or prone (patient with painful injury/destructive disease) RP: 2 in. superior to pubic symphysis (supine) Visible sacral curve (prone) CR: – 15o cephalad (supine) – 15o caudad (prone) SS: – Sacrum free of foreshortening LATERAL PROJECTION PP: – Lateral recumbent – Interiliac plane ┴ to IR – Pelvis & shoulder in true lateral position RP: – 3.5 in. posterior to ASIS CR: ┴ SS: Sacrum COCCYX AP/PA AXIAL PROJECTION PP: – Supine or prone (patient with painful injury or destructive disease) RP: – 2 in. superior to pubic symphysis (supine) – Palpable coccyx (prone) CR: – 10o caudad (supine) – 10o cephalad (prone) SS: – Coccyx free of superimposition  LATERAL PROJECTION PP: – Lateral recumbent – Interiliac plane ┴ to IR – Pelvis & shoulder in true lateral position RP: – 3.5 in. posterior & 2 in. inferior to ASIS CR: ┴ SS: Coccyx SACRAL VERTEBRAL CANAL & SACROILIAC JOINTS  NOLKE METHOD (AXIAL PROJECTION) PP: Seated MCP of body ┴ to horizontal axis of bucky MSP ┴ to midline of the grid Lean forward (to place upper, middle or lower portion of sacral canal vertical) Grasp the legs/ankles RP: Sacrum CR: – ┴ to long axis of sacrum  NOLKE METHOD (AXIAL PROJECTION) SS: Spine slightly flexed: – Lower sacral vertebral canal – Junction of sacrum and coccyx & last lumber vertebra  NOLKE METHOD (AXIAL PROJECTION) SS: Moderate flexion (bending forward): – Cross section of upper & lower sacral vertebral canal – Sacroiliac joints  NOLKE METHOD (AXIAL PROJECTION) SS: Acute flexion (bending forward): – Upper sacral vertebral canal projected into the angle formed by ascending rami of ischial bones just posterior to pubic symphysis – Spinous process of L5 projected across the shadow of the canal  LUMBAR INTERVERTEBRAL DISK  WEIGHT-BEARING METHOD (PA PROJECTION) R & L BENDING PP: – Upright – Patient bending to right & left – Lean directly lateral as far as possible RP: ┴ to L3 CR: 15-20o caudad SS: – Lower thoracic & lumbar region WEIGHT-BEARING METHOD (PA PROJECTION) ER: – Perform for demonstration of the mobility of intervertebral joints – Involvement of the joints (patient with IV disk protrusion)  WEIGHT-BEARING METHOD (PA PROJECTION) DUNCAN & HOEN RECOMMENDATION: – PA projection be used Rationale: – IV disks more nearly parallel to CR  RULES OF OBLIQUE Anatomy of Projection Position/Degrees Structure Shown Central Ray Interest LPO – 45o Right IF (side up) 15-20o cephalad AP Oblique CERVICAL RPO – 45o Left IF (side up) 15-20o cephalad (Intervertebral LAO – 45o Left IF (side down) 15-20o caudad Foramina) PA Oblique RAO – 45o Right IF (side down) 15-20o caudad LPO – 70o Right ZJ (joints up) ┴ THORACIC AP Oblique RPO – 70o Left ZJ (joints up) ┴ (Zygapophyseal LAO – 70o Left ZJ (joints down) ┴ Joints) PA Oblique RAO – 70o Right ZJ (joints down) ┴ LPO – 45o Left ZJ (joints down) ┴ LUMBAR AP Oblique RPO – 45o Right ZJ (joints down) ┴ (Zygapophyseal LAO – 45o Right ZJ (joints up) ┴ Joints) PA Oblique RAO – 45o Left ZJ (joints up) ┴ LPO – 25-30o Right SIJ (joint up) ┴ AP Oblique SACROILIAC RPO – 25-30o Left SIJ (joint up) ┴ JOINTS LAO – 25-30o Left SIJ (joint down) ┴ PA Oblique RAO – 25-30o Right SIJ (joint down) ┴ LPO – 45o Left AR (side down) ┴ AP Oblique RPO – 45o Right AR (side down) ┴ AXILLIARY RIBS LAO – 45o Right AR (side up) ┴ PA Oblique RAO – 45o Left AR (side up) ┴  ZYGAPOPHYSEAL INTERVERTEBRAL ANATOMY JOINTS FORAMINA Cervical Lateral Oblique – 45o Thoracic Oblique – 70o Lateral Lumbar Oblique – 45o Lateral