Radiographic Positioning Of Skull And Vertebra PDF

RADIOGRAPHIC POSITIONING SKULL AND VERTEBRA FGBREYES, RRT, CVT, MSRT  MORPHOLOGY The morphology, or variations in how these attachments evolved tells us much about the particular animal's adaptations to their environment. (exceptions include O...

RADIOGRAPHIC POSITIONING SKULL AND VERTEBRA FGBREYES, RRT, CVT, MSRT  MORPHOLOGY The morphology, or variations in how these attachments evolved tells us much about the particular animal's adaptations to their environment. (exceptions include Old World primates such as humans, in which the middle ear cavity is Canis latrans auditory bulla enclosed within the temporal bone but not within a bulla). SKULL MORPHOLOGY MESOCEPHALIC Average head 15 cm between parietal eminences 19 cm from the frontal eminence to inion 23 cm from vertex to chin. Temporal base or petrous pyramid forms an angle of 45° to 47° to the MSP. SKULL MORPHOLOGY BRACHYCEPHALIC Short from front to back Broad from side to side Shallow from vertex to base Petrous pyramid forms an angle greater than 47° (approximately 54°) to the MSP. The width is 80% or greater than the length SKULL MORPHOLOGY DOLICOCEPHALIC Head is long from front to back Narrow from side to side Deep from vertex to base. Petrous pyramid form an angle less than 47° (approximately 40°) to the MSP The width is less than 75% of the length. CRANIAL TOPOGRAPHY SURFACE LANDMARKS Midsagittal Plane or Median Plane (MSP) Symmetrically divides the body into left and right halves. Interpupillary Line or Interorbital Line (IPL) Connecting the pupils or outer canthi of the eyes Supraorbital Groove (SOG) Slight depression above each eyebrow. Corresponds to the anterior fossa of the cranial vault. Supraorbital Margin (SOM) Superior rim of each orbit. CRANIAL TOPOGRAPHY SURFACE LANDMARKS Pinna or Auricle Large flap of cartilage at the external portion of the ear Tragus Small flap cartilaginous flap covering the ear. Top of the Ear Attachment (TEA) Superior attachment of the auricle Same level of petrous ridge Canthi/Canthus Junction of the upper and lower eyelids CRANIAL TOPOGRAPHY SURFACE LANDMARKS Gonion/Angle of the Mandible The lower posterior angle on each side of the jaw or mandible Mental Point The midpoint of this triangular area of the chin as it appears from the front. Glabellomeatal Line (GML) It is a line between the glabella and EAM Orbitomeatal Line (OML) Frequently used positioning line located between outer canthus and the EAM. Also called the RADIOGRAPHIC BASE LINE. CRANIAL TOPOGRAPHY SURFACE LANDMARKS Infraorbitomeatal Line (IOML) Reids base line - often used as the imaging reference line in brain CT scanning Line of Frankfurt - a line extending from the most inferior point of the orbital margin to the left tragion. Anthropological base line - passes from the infraorbital point to the upper border of the EAM (also known as the Frankforterline) Base line of the cranium It is a line which connects the infra-orbital point to the EAM CRANIAL TOPOGRAPHY SURFACE LANDMARKS Infraorbitomeatal Line (IOML) Reids base line - often used as the imaging reference line in brain CT scanning Line of Frankfurt - a line extending from the most inferior point of the orbital margin to the left tragion. Anthropological base line - passes from the infraorbital point to the upper border of the EAM (also known as the Frankforterline) Base line of the cranium It is a line which connects the infra-orbital point to the EAM CRANIAL TOPOGRAPHY SURFACE LANDMARKS OML AND GML There is an approximate 8° average angle difference between the OML and GML OML AND IOML There is an average difference of 7° exists between the angles of the OML and IOML IOML AND AML There is an average difference of 15° exists between the angles of the IOML and AML CRANIAL TOPOGRAPHY SURFACE LANDMARKS Acanthiomeatal Line (AML) It is a line between the acanthion and EAM Interpupillary Line (IPL) It joins the center of the two orbits or pupils Mentomeatal Line (MML) It is a line between the mental point (mandible) and EAM. CRANIAL TOPOGRAPHY SURFACE LANDMARKS Lips to Meatal Line (LML) It is a line between the junctions of the lips to the EAM. Glabelloalveolar Line Connects the glabella to a point at the anterior aspect of the alveolar process of the maxilla. Auricular Line It is perpendicular to the anthropological base line and passes through the EAM CRANIAL TOPOGRAPHY SURFACE LANDMARKS SKULL AP PROJECTION OML perpendicular to the IR CR perpendicular to nasion. Best demonstrate the frontal and parietal bones. Petrous pyramid fills the orbit SKULL PA AXIAL PROJECTION CADWELL’S METHOD Prone Forehead and nose OML is perpendicular to IR MSP is perpendicular to midline of the table. CR 15° caudad to nasion Best demonstrate alveolar ridge fractures. General survey examination of the cranium. Petrous pyramid in the lower 1/3 of the orbits SKULL PA AXIAL PROJECTION CADWELL’S METHOD MODIFICATION CALDWELL’S METHOD 23° caudad to nasion. Glabellomeatal Line (GML) perpendicular to IR 20° to 25° caudad to mid-orbit Demonstrate superior orbital fissures 25° - 30° Caudad Demonstrate rotundum foramina Petrous pyramid projected below the inferior orbital margin. SKULL PA AXIAL PROJECTION TOWNE’S/GRASHEY METHOD MODIFICATION OML perpendicular to film plane (chin depressed) IOML perpendicular to film plane (Patient unable to flex their neck). CENTRAL RAY: 1. 30° caudad to OML perpendicular to IR 2. 37° caudad to IOML perpendicular to IR 3. 40° - 60° caudad Foramen magnum and jugular foramina 2.5 in.(6 cm) above glabella Best demonstrate the occipital bone Posterior clinoid process within the shadow of the foramen magnum. Excessive angulation of CR projects the posterior C1 arch in the foramen magnum. Under angulation of the CR projects the dorsum sella above foramen the magnum. SKULL PA AXIAL PROJECTION TOWNE’S/GRASHEY METHOD MODIFICATION SKULL PA AXIAL PROJECTION HAAS METHOD Prone position Forehead and nose OML perpendicular to IR CR 25° cephalad to 1.5 in. inferior to the inion and exiting 1.5 in. above nasion. Also called Reverse Towne’s projection For hypersthenic or kyphotic, obese and other patients who cannot be adjusted for AP axial projection. Best demonstrate the occipital bone with magnification SKULL PA AXIAL PROJECTION HAAS METHOD SKULL LATERAL MSP is parallel to IR IPL is perpendicular to IR IOML perpendicular to front edge of the cassette. CR perpendicular to 2 inches above EAM Best demonstrate the parietal bones. Sella tursica and clivus are demonstrated in profile. SKULL LATERAL Crosstable or Shoot- Through Lateral Projection demonstrating traumatic sphenoid effusion which is an indication of a basal skull fracture. SVM (SUBMENTOVERTIAL) - FULL BASAL PROJECTION / SCHULLER METHOD Head resting on vertex MSP is perpendicular to IR IOML is parallel to IR. CR to ¾ inch (2 cm) anterior to level of EAMs Best demonstrate the base of the skull Demonstrate the basilar portion of the occipital bone. Mandibular condyles anterior to petrous pyramids. VERTICOSUBMENTO- FULL BASAL PROJECTION / SCHULLER METHOD Distorted and magnified image of the midbase due to increase OID and angulation of CR. Useful for studies of anterior cranial base and sphenoid sinuses. Best projection for foramen ovale and spinosum. Alternative projection for SMV projection. Mandibular condyles anterior to petrous pyramids. AXIOLATERAL - LYSHOLM METHOD Head in lateral position. CR 30°-35° caudad exit at a point 1 inch (2.5 cm) distal to the lower EAM Alternative projection for SMV projection for patient who cannot extend their neck. Oblique position of the lateral base of the cranium closest to the IR. SELLA TURSICA - LATERAL PROJECTIONS Sella Tursica Turkish Saddle Posterior Clinoid Process Small extensions superior to the dorsum sellae. Dorsum Sellae Back of the saddle Posterior wall of sella tursica. Clivus Shallow depression just posterior to the base of the dorsum sellae. Forms a base of support for the pons portion of the brain. SELLA TURSICA - PA AXIAL PROJECTION - HAAS METHOD 1) 25° cephalad to 1.5 inches Reverse Towne’s projection inferior to the inion and exiting 1.5 inches above 25° cephalad nasion Dorsum sellae and posterior clinoid processes projected within the 2) 10° cephalad shadow of the foramen magnum. This is an alternative 10° cephalad projection for demonstrating Dorsum sellae is projected above the dorsum sella, posterior the foramen magnum. clinoid, foramen magnum and petrous ridge. PARANASAL SINUSES PARANASAL SINUSES Large air-filled cavities Should be radiographed in erect/upright position. To demonstrate the presence of air-fluid level. To differentiate between shadows caused by fluid and those caused by other pathologic conditions. Patient must be in erect at least 5 minutes before taking the examination. FEMS Frontal Sinuses - Frontal (cranial) bone Ethmoid - Ethmoid (cranial) bone Maxillary Sinuses - Maxillary (facial) bone Sphenoid - Sphenoid (cranial) bone PARANASAL SINUSES (PNS) - LATERAL PROJECTIONS CR 15° caudad to nasion Best projection to demonstrate the frontal sinuses and anterior ethmoidal sinuses. Petrous ridge are projected into lower 1/3 of the orbits. PARANASAL SINUSES (PNS) -WATERS METHOD Patient head is resting on CR directed to acanthion. chin. Best demonstrate the maxillary MML is perpendicular to IR sinuses above the petrous ridge. OML forms an angle of 37° Useful projection for demonstrating the foramen with the plane of the film. rotundum. Tip of the nose ¾ inch Petrous pyramids below the from the image receptor. maxillary sinuses. Demonstrate any retention cyst and possible nasal deviation PARANASAL SINUSES (PNS) -WATERS METHOD Any step deformity in the lines would indicate a fracture of that particular facial bone. PARANASAL SINUSES (PNS) -CALDWELL’S METHOD CR 15° caudad to nasion Best projection to demonstrate the frontal sinuses and anterior ethmoidal sinuses. Petrous ridge are projected into lower 1/3 of the orbits. Caldwell view showing radiographic features of frontal sinus: Scalloping of the superior border, septa, and supraorbital cells PARANASAL SINUSES (PNS) -CALDWELL’S METHOD VS. WATERS METHOD PARANASAL SINUSES (PNS) - PARIETOACANTHIAL TRANS-ORAL PROJECTION OPEN MOUTH WATERS Demonstrate the sphenoid Indications sinuses through the open It can be used to assess for mouth. facial fractures, as well as for acute sinusitis. The open mouth projection removes the upper teeth from direct superimposition of the sphenoid. This is an angled PA radiograph of the skull, with the patient gazing slightly upwards. PARANASAL SINUSES (PNS) - PARIETOACANTHIAL TRANS-ORAL PROJECTION PIERRE METHOD Head resting on nose and chin Instruct the patient to phonate “ah” softly during exposure. Direct CR at 30° caudad to MSP (a line extending from the sella tursica to the center of the open mouth) Demonstrate an axial image of the sphenoid sinuses projected through the open mouth. PARANASAL SINUSES (PNS) - SUVMENTOVERTICO PROJECTION CR perpendicular between the angles of the mandible. Best demonstrate a basal projection of the sphenoid, ethmoid and maxillary sinuses. FACIAL BONES - LATERAL PROJECTIONS Zygoma is centered to MLT CR perpendicular to mid- zygoma (midway between outer canthus and EAM) Useful for demonstrating depressed fractures of the frontal sinus. Superimposed mandibular rami, orbital roof FACIAL BONES - WATERS PROJECTION Demonstrate an axial image of the facial bones. Best single projection for demonstrating the entire facial bone. Petrous ridge below the maxillary sinus. Useful for demonstrating fractures of the orbit and fractures of the nasal wings. FACIAL BONES - MODIFIED WATERS PROJECTION Prone position Demonstrates facial Patient head is resting on bones with less axial chin and nose. angulation. LML is perpendicular to Petrous ridges are projected into table lower-half of the maxillary sinuses. OML forms an angle of Best demonstrates a 55° with the film. more direct view of the CR Perpendicular to orbital rim as compared acanthion with Waters projection. FACIAL BONES - AP AXIAL PROJECTION REVERSE WATERS PROJECTION Patient in supine position. IOML is perpendicular to IR 30° Cephalad – CR will enter the face or slightly below the lips and exits 2 nches above the inion. CR must be parallel to MML. Demonstrate an axial position of the superior facial bone (similar to waters projection), although the structures are magnified. NASAL BONE LATERAL PROJECTION - (SOFT TISSUE LATERAL) CR perpendicular to 1⁄2 inch inferior to nasion Best position to demonstrate non- displaced linear fractures of the nasal bone. Soft tissue structure of the nose. Nasal bones Nasofrontal suture Anterior nasal spine NASAL BONE SUPEROINFERIOR TANGENTIAL (AXIAL) PROJECTION Patient in prone position or upright seated on chair. CR center to nasion and parallel to GAL Primarily used to demonstrate medial or lateral displacements of fragments in fractures. Demonstrates mid to distal nasal bones in a tangential perspective. ZYGOMA - SUBMENTOVERTICO PROJECTION CR perpendicular to IOML to a point midway between zygoma 1 1⁄2 - 2 inches inferior to mandibular symphysis Also known as the TEA CUP OR JUGHANDLER’S VIEW Demonstrate the lateral margins of the zygomatic arches free of superimposition ZYGOMA TANGENTIAL POSITION: OBLIQUE INFEROSUPERIOR PROJECTION Patient in SMV position Slightly oblique Rotate head/MSP 15° tangential image of toward side being one zygomatic arch examined, then tilt chin free of 15° toward side of interest superimposition. CR Perpendicular to Useful with patients IOML and center to who have depressed zygomatic area of interest fractures or flat approximately 1 1⁄2 inches cheekbones. posterior to outer canthus ZYGOMA TANGENTIAL POSITION: OBLIQUE INFEROSUPERIOR PROJECTION ZYGOMA - MODIFIED FUCHS METHOD CR - 35° caudad and Patient in prone position enters the most prominent Rest cheek of the point of the zygoma affected side on table farthest from film. Oblique position of the AML perpendicular to IR uppermost zygomatic arch Rotate head so that free of superimposition. MSP forms 45° then tilt Lateral portion of maxillary head 15° (rotation and sinus is also well demonstrated. tilt ensure that CR will be Unilateral zygomatic tangent to the lateral arch free from overlying surface of the skull. structures. ZYGOMA - MODIFIED TOWNE’S METHOD 30° caudad to OML perpendicular to IR 37° caudad to IOML perpendicular to IR 1 inch (2.5cm) above glabella Shows the symmetric view of both zygoma ZYGOMA - ZYGOMA MAY METHOD Single zygomatic arch Patient in prone position, free of superimposition. neck extended. CR perpendicular to Rest chin on table IOML to 1 1⁄2 inches Rotate head away from posterior to outer the side being examined so that MSP canthus. forms 15° then tilt head Best projection for 15°. patients who have IOML as nearly parallel to depressed fractures or IR flat cheekbones. ZYGOMA - ZYGOMA MAY METHOD MASTOID AND TEMPORAL BONE AP AXIAL PROJECTION TOWNE’S/GRASHEY METHOD 30° caudad - OML perpendicular to IR 37° caudad - IOML perpendicular to IR 2.5 inches (6 cm) above glabella Demonstrate the petrosas above the base of the skull. ORIGINAL LAW METHOD DOUBLE TUBE ANGULATION METHOD Head in lateral position. 15° caudad and 15° anteriorly to 2 inches posterior and 2 inches superior to the uppermost EAM ORIGINAL LAW METHOD Adjust head until MSP This position forms a 15° angle in demonstrates the relation to the table. 15° caudad to 2 inches mastoid air cells and posterior and 2 inches internal auditory canal superior to the uppermost of the side closest to IR EAM Demonstrates an Superimposed internal axiolateral perspective of acoustic meatus (IAM) mastoid air cells closest and external acoustic to film. meatus (EAM). MODIFIED LAW STENVERS POSTERIOR PROFILE POSITION Head resting on forehead, nose and zygoma Downside or closest to IR petrous bone in profile. 12° cephalad enters 3-4 inches posterior and 1 1⁄2 inferior to upside EAM and exits 1 inch anterior do downside EAM MSP forms an angle of 45° in relation to table. ARCELIN ANTERIOR PROFILE PROJECTION MSP forms an angle of 45° in relation to table. 10° caudad to 1 inch and anterior and 3⁄4 inch superior to elevated EAM. Reverse Stenvers projection. Upside or farthest from IR petrous bone in profile. Useful with children and adults who cannot be placed in prone position. LYSHOLM 30-35° caudad to dependent EAM closest to IR Also referred as the Runstrom II method -Recommended for pt who cannot extend their head enough for a satisfatory SMV. HENSCHEN 15° caudad To dependent EAM closest to IR Demonstration of tumours of acoustic nerve. SCHULLERS 25° caudad to dependent EAM closest to IR Demonstrate the pneumatic structure of the mastoid process ss: Cranial base Sphenoidal sinuses SMV CR perpendicular to OML centered to sagittal plane of the throat at the level of the EAMs. The goal of this projection is to project the long axis of the EAMs, tympanic cavities and the osseus part of the auditory (Eustachian) tubes immediately behind the mandibular condyles. Demonstrate the organ of hearing within the petrosa. HICKY METHOD Tilt vertical grid device down 15° Mastoid process below MSP forms a 55° angle in the shadow of the relation to the table. occipital bone. Perpendicular to anterior border of the mastoid Demonstrate a tangential process at the junction of image of the mastoid the auricle and head about 1 inch superior to process free of the palpable tip of superimposition by mastoid process 15° caudad instead of adjacent bony structures. tilting the IR. HICKY METHOD LOW BEER METHOD Head in lateral position Demonstrate an image similar to Stenvers method 33° anteriorly and 10° cephalad to 1 1⁄2 inch anterior to EAM closest to IR ZANELLI METHOD Patient in lateral position MSP forms an angle of 30° open caudally to IR. Perpendicular to IR, Distal to the uppermost mandibular angle farthest from the film at TMJ closest to f Axiolateral images of the TMJ are demonstrated in the open and closed mouth positions This method uses part angulation instead of central ray angulation ORBITS PARIETO-ORBITAL OBLIQUE POSITION RHESE METHOD Prone position Rest the ZYGOMA, NOSE and CHIN to the table. AML perpendicular to the plane of the film. MSP forms an angle 53° with the plane of the film. Demonstrate the OPTIC FORAMEN at the LOWER OUTER QUADRANT. Also known as the threepoint landing method. ALEXANDER METHOD Patient in supine position. Place IR under occiput on a 15° cranially inclined sponge. Demonstrate the OPTIC FORAMEN at the LOWER OUTER QUADRANT. AML perpendicular to the plane of the film. MSP forms an angle 40° with the plane of the film. MODIFIED PARIETOACANTHIAL MODIFIED WATERS Prone position CHIN and NOSE resting on the table LML is perpendicular to IR OML forms an angle of 55° with the IR. CR perpendicular to acanthion. Best demonstrates the orbital floor. Best projection for visualizing BLOWOUT Fracture Provides a more direct view of the entire orbital rims than with Waters projection. Also known as the Shallow Waters. PETROUS RIDGE projected into LOWER HALF of the MAXILLARY SINUS, below the Infraorbital margin. ORBITS FOREIGH BODY LOCALIZATION VOGT BONE-FREE POSITIONS Made on standard periapical or occlusal size dental film. PARALLAX MOTION METHOD Modified Waters Lateral projection 1st exposure 1st exposure is patient is instructed made looking to look to the cephalad extreme right 2nd exposure 2nd exposure looking caudad extremely looking to the left PFEIFFER-COMBERG METHOD A leaded contact lens is placed directly over the cornea, and intraorbital and intraocular The contact lens embedded around the periphery 4 lead markers spaced at 90° intervals. The apparatus designed comprises: Contact lens localization device Pedestal type of film holde MANDIBLE PA PROJECTION Forehead and nose Rami and lateral portion of the body. CR perpendicular to tip of nose. Chin and nose Frontal view of the body. For the mentum of the mandible. CR perpendicular to glabella For general survey of the Demonstrates condylar process mandible CR perpendicular to lips MANDIBLE PA AXIAL PROJECTION Forehead and nose Mandibular Body Mandibular Rami CR 20°-25° cephalad to exit at acanthion. Well visualized elongated view of the head of the mandibular condyles Chin and nose Mandibular Body TMJ 30° cephalad between TMJs Mandibular body and TMJs MANDIBLE AXIOLATERAL PROJECTION 1. Head in true lateral position 25° cephalad to pass RAMUS directly through the 2. 10° to 15° rotation mandibular region of GENERAL SURVEY interest. 3. 30° rotation The goal of this projection BODY is place the desired portion 4. 45° rotation of the mandible parallel with SYMPHYSIS MENTI the IR. MANDIBLE AXIOLATERAL PROJECTION MANDIBLE SUBMENTOVERTEX PROJECTION Head resting on vertex Perpendicular to IOML to a point midway between angles of mandible (1 ½ - 2 inches inferior to mandibular symphysis) Demonstrate the mandibular condyles anterior to pars petrosa Demonstrate the HORSE-SHOE SHAPED mandible bone MANDIBLE PANORAMIC TOMOGRAPHY Adjust chin rest until IOML is parallel with the floor. Occlusal plane will decline by 10° from posterior to anterior. Demonstrate a single frontal projection of the teeth, mandible, nasal fossa, zygomatic arches, and maxilla. STYLOID PROCESS FUCHS METHOD CENTRAL RAY: Angle the top of the grid Perpendicular to head and device 13° downward directed through MSP and toward the patient. parallel with a line extending AML perpendicular to IR through the EAMs. Instruct patient to hold If necessary modify this the mouth open during the projection by angling the CR exposure to prevent the 13° caudad instead of tilting coronoid process of the the IR. mandible from Demonstrate the styloid superimposing the styloid process of the temporal bone process. within the maxillary sinus. STYLOID PROCESS FUCHS METHOD STYLOID PROCESS PA AXIAL PROJECTION CAHOON METHOD Forehead and nose resting on table Demonstrates the styloid process within or above the maxillary sinus. CR 25° cephalad to Nasion STYLOID PROCESS AP OBLIQUE PROJECTION WIGBY-TAYLOR METHOD Patient supine Patient hold his mouth open for exposure to Rotate the head 12° move the coronoid from perpendicular processes of the toward the side being mandible inferiorly Demonstrate an examined Occlusal oblique projection of the plane of upper teeth styloid process overlying perpendicular to plane the soft tissue of the neck. of IR. CR 8° cephalad to ¼ Rest the head on the inch distal to the tip of occiput. the mastoid process STYLOID PROCESS AP OBLIQUE PROJECTION WIGBY-TAYLOR METHOD STYLOID PROCESS AXIOLATERAL OBLIQUE PROJECTION FUCHS METHOD Head in lateral position. CR 10° cephalad and 10° anteriorly to EAM closest to film Demonstrate a lateral image of the styloid process projected into the space superior to the mandibular notch. JUGULAR FORAMINA SUBMENTOVERTICO AXIAL PROJECTION KEMP HARPER METHOD CENTRAL RAY: 20° caudad to 1 inch distal to mandibular symphysis Increased central ray 5- 10° caudad for patient who have prominent mandible. Demonstrate the jugular foramina projected near or level of the angles of the mandible. SUBMENTOVERTICO AXIAL PROJECTION ERASO MODIFICATION OML forms an angle of 25° to plane of IR. Perpendicularly directed to 2 inches distal to mandibular symphysis Not as demanding position as compared with Kemp Harper method. Demonstrate the jugular foramina projected near or level of the angles of the mandible HYPOGLOSSAL CANAL AXIOLATERAL OBLIQUE PROJECTION / MILLER METHOD ANTERIOR PROFILE Used to delineate the hypoglossal canal in a patient with a hypoglossal (12th cranial) nerve tumor. 12° caudad to 1 inch directly anterior and ½ inch inferior to level of EAM. Patient in supine position MSP 45° away from side being examined VERTABRAL COLUMN ANATOMY CERVICAL VERTEBRA INTERVERTEBRAL FORAMINA Directed anteriorly at a 45° angle from the MSP and 15° inferior angle to the horizontal plane of the body. ZYGAPOPHYSEAL JOINT Forms 90° angle to the MSP ATLANTO-OCCIPITAL AP OBLIQUE PROJECTIONS Rotate head 45-60 degrees from the side being examined. CR perpendicular to 1 inch anterior to EAM Demonstrate atlantooccipital articulation between the orbit and the ramus of the mandible. ATLANTO-OCCIPITAL KASABACH METHOD 1st exposure the head is rotated 40-45 degrees to the right away from the side being examined. 2nd exposure the head is rotated the head 40 – 45 degrees to the left away from the side being examined. CR 10-15 degrees caudad to a point midway between the outer canthus and the EAM Demonstrate an AP axial oblique projection of the dens. FUCH METHOD Patient in Supine position. MML perpendicular to table CR parallel to MML, directed to inferior tip of mandible. Best demonstrate the odontoid process within the foramen magnum. This is an alternative projection for the dens when the upper half is not shown on the open-mouth projection. JUDD METHOD Patient in Prone position. OML forms an angle of 37° to plane of IR MML perpendicular to table CR parallel to MML, directed to inferior tip of mandible. Best demonstrate the odontoid process within the foramen magnum. This is an alternative projection for the dens when the upper half is not shown on the open-mouth projection. C1 AND C2 AP OPEN-MOUTH PROJECTION CR Perpendicular to the center of the open-mouth 30 inch (70 cm.) SID is often used to increase the field of view of the odontoid area. Lower margin of upper incisor to the mastoid tip is perpendicular to base of the skull. Best demonstrate C1 and C2 free from superimposition Best demonstrate zygapophyseal joint of C1 and C2 Best demonstrate Odontoid and Jefferson’s fractures. CERVICAL VERTEBRA AP AXIAL PROJECTION Occlusal plane perpendicular to the base of the skull. CR 15˚- 20˚ cephalad, to enter at the level of the lower margin of thyroid cartilage to pass through C4. Best demonstrate intervertebral disk space of C3-T2 CERVICAL VERTEBRA UPRIGHT LATERAL PROJECTION Top of cassette about 1-2 inches CR horizontally directed to upper above EAM. margin of thyroid cartilage (C4-C5). Adding 5-to 10 lbs. weights to Best demonstrate cervical each arm may help in pulling zygapophyseal joints. down shoulders. Most cervical injuries are best seen in Long (72 inches or 180 cm) SID lateral projection. compensates for increased OID and provides for less 7 cervical vertebra demonstrated. magnification. CERVICAL VERTEBRA UPRIGHT LATERAL PROJECTION CERVICAL VERTEBRA AP OBLIQUE PROJECTIONS RPO AND LPO POSITIONS Rotate body and head 45° 15˚-20° cephalad toC4 Best demonstrate intervertebral foramina and pedicles farthest from the image receptor CERVICAL VERTEBRA PA OBLIQUE PROJECTIONS RAO AND LAO POSITIONS Rotate body and head 45° 15˚-20° caudad toC4 Best demonstrate intervertebral foramina and pedicles nearest to the image receptor CERVICAL VERTEBRA AP WAGGING JAW PROJECTION OTTONELLO METHOD CR perpendicular to C4 Have the patient open and closed the mouth during exposure to blur out the mandible. Use low mA and long exposure time (minimum of 1 second) Lower margin of upper incisors to base of skull is perpendicular to table. Entire cervical column is demonstrated. CERVICAL VERTEBRA VERTEBRAL ARCH (PILLARS) AP AXIAL PROJECTION Patient in supine position Hyperextend neck 25 caudad to C7 (range20˚- 30˚caudad) Refer as PILLAR OR LATERAL MASS PROJECTIONS. Demonstrate the posterior elements of the cervical vertebra. Demonstrate Pathology involving the posterior vertebral arch (particularly the pillars) of C4 to C7. VERTEBRAL ARCH (PILLARS) AP AXIAL OBLIQUE PROJECTION RIGHT AND LEFT HEAD ROTATIONS CR 35° caudad to spinous Demonstrate the vertebral arches or pillars when process of C7 (Range of CR the patient cannot hyperextend the neck for the 30°-40°) AP or PA axial projection. Rotate the patient’s head 45-50 degrees from the side of interest. 45°-50° rotation demonstrate the articular process of the C2-C7 and T1 60°-70° rotation will demonstrate the processes of C6 and T1- T4 CERVICOTHORACIC SWIMMERS LATERAL TWINNING METHOD Patient in erect position Perpendicular if the shoulder is well depressed 5° caudad if the shoulder is not depressed RP: Interdisk space of C7 and T1 Best projection to demonstrate C7 to T1 when not shown on a cervical lateral projection. Good projection to demonstrate the upper thoracic vertebrae (T1- T4) when not shown on a thoracic lateral projection. Swimmers lateral upright method CERVICOTHORACIC SWIMMERS LATERAL PAWLOW METHOD Patient in a lateral Swimmers lateral recumbent method recumbent position PAWLOW METHOD 3°-5° caudad to the interdisk of C7 and T1 MODIFIED PAWLOW: 5°-15° cephalad This is a good projection when C7 to T1 is not visualized on the lateral cervical spine or when the upper thoracic vertebrae are of special interest on a lateral thoracic spine. CERVICAL SPINE LATERAL PROJECTION HYPERFLEXION AND HYPEREXTENSION CR perpendicular to IR, directed horizontally to C4 Functional study to demonstrate range of motion or lack of motion of cervical vertebrae. Performed to rule out whiplash injuries. Follow up examination after spinal fusion surgery. Spinal curvature Range of spinal motion Ligament stability C1-C7 THORACIC VERTEBRA AP PROJECTION CR perpendicular to IR, directed horizontally to C4 Functional study to demonstrate range of motion or lack of motion of cervical vertebrae. Performed to rule out whiplash injuries. Follow up examination after spinal fusion surgery. THORACIC VERTEBRA LATERAL PROJECTION Patient is allowed to MALE: 15° cephalad continue breathing during FEMALE: 10° cephalad exposure to blur out If vertebral column is not unwanted rib and lung horizontal (support not placed markings overlying the under lower thoracic). thoracic vertebra. Thoracic vertebral bodies in Use at least 2 seconds lateral profile. exposure time. Intervertebral joint spaces Perpendicular to T7 entering Intervertebral foramina the posterior half of the thorax. THORACIC VERTEBRA LATERAL PROJECTION THORACIC VERTEBRA OBLIQUE PROJECTIONS AP AND PA OBLIQUES POSITIONS Rotate the body 20° from Posterior Oblique Position true lateral so that Best demonstrate zygapophyseal joint farthest from the image midcoronal plane forms an receptor. angle of 70° from plane of Anterior Oblique Position the image receptor. Best demonstrate zygapophyseal CR perpendicular to T7. joint closest to image receptor. LUMBAR VERTEBRA AP PROJECTION Patient in supine position with knees flex. CENTRAL RAY 1. Perpendicular at The knees are flexed to the level of the iliac crest for decrease the lordotic curve lumbosacral studies. of the lumbar. 2. Perpendicular to L3 for Lumbar PA PROJECTION: reduce study. patient dose and The erect position may be useful sometimes used for upright to demonstrate the natural studies of the lumbar spine. weight-bearing stance of the It is also the preferred position for patient who spine. has excruciating pain to Demonstrate the lumbar bodies, reduce the physical intervertebral disk spaces. discomfort associated with the examination LUMBAR VERTEBRA AP PROJECTION LUMBAR VERTEBRA LATERAL PROJECTION Flex knees to straighten the Lumbar spine not horizontal to spine and helps open table. intervertebral disk spaces. 1. Male – 5 degrees caudad CENTRAL RAY: 2. Female – 8 degrees caudad Lumbar Spine horizontal to Demonstrate the lumbar bodies, table. intervertebral disk spaces and 1. Perpendicular at the level of transverse process, the iliac crest for lumbosacral Best demonstrate the studies. intervertebral foramina. 2. Perpendicular to L3 for Good projection for Lumbar study. demonstrating compression fractures. LUMBAR VERTEBRA LATERAL PROJECTION LUMBAR VERTEBRA OBLIQUE PROJECTIONS Rotate body 45 degrees. Best demonstrate the scotty dog. 30˚ for L5 to S1. Best demonstrate the A 30° rotation best zygapophyseal joint. demonstrate the lumbosacral processes Neck - Pars Interarticularis A 50˚ oblique from plane of Ear - Superior articular tabletop best visualizes the process zygapophyseal joints at L1 to L2. Eye - Pedicle CR perpendicular to 1-1 ½ Nose - Transverse process inches above iliac crest (L3) Front legs - Inferior articular process Body - Lamina LUMBAR VERTEBRA OBLIQUE PROJECTIONS Posterior Oblique position Anterior Oblique position Best visualize zygapophyseal Best visualize zygapophyseal joint nearest to image receptor. joint farthest to image receptor LATERAL L5 TO S1 FRANCIS METHOD Patient in lateral position, locate both iliac crest Draw an imaginary line between the interiliac plane Adjust CR angulation to be parallel with the interiliac line. 5°-8° caudad to 1 ½ inch inferior to iliac crest and 1 ½ inch anterior to posterior surface of the body. An alternate technique to demonstrate the L5-S1 junction when the spine is not horizontal. GOOD PROJECTION FOR RULING OUT SPONDYLOLISTHESIS. LUMBOSACRAL JUNCTION AND SACROILIAC JOINTS AP AXIAL AND PA AXIAL PROJECTION: CENTRAL RAY: AP AXIAL MALE 30˚cephalad FEMALE 35˚cephalad at the level of the ASIS PA AXIAL MALE 30˚caudad FEMALE 35˚cephalad at the level of the ASIS Demonstrate an open L5- S1 intervertebral disk space. LUMBOSACRAL JUNCTION AND SACROILIAC JOINTS AP AXIAL AND PA AXIAL PROJECTION 5th LUMBAR PA AXIAL OBLIQUE PROJECTION KOVACS METHOD Rotate the pelvis 30 degrees anteriorly from the lateral position. CR 15-30 degrees caudad to superior edge of the upside iliac crest. Best demonstrate the L5 intervertebral foramen SACROILIAC JOINTS AP OBLIQUE PROJECTIONS: SACROILIAC JOINTS AP OBLIQUE PROJECTIONS: SACROILIAC JOINTS PA OBLIQUE PROJECTIONS: PA PROJECTIONS CHAMBERLAIN METHOD SACRUM AND COCCYX AP AND PA AXIAL PROJECTIONS SACRUM AND COCCYX AP AND PA AXIAL PROJECTIONS SACRUM AND COCCYX LATERAL PROJECTIONS SACRAL VERTEBRA CANAL AND SACROILIAC JOINTS AXIAL PROJECTION / NOLKE METHOD LUMBAR INTERVERTEBRAL DISK; WEIGHT BEARING METHOD SCOLIOSIS RADIOGRAPHY PA AND LATERAL PROJECTIONS FERGUNSON METHOD AP PROJECTION; RIGHT AND LEFT BENDING SPINAL FUSION SERIES LATERAL PROJECTION; HYPERFLEXION AND HYPEREXTENSION THANK YOU FOR YOUR KIND ATTENTION!