This document discusses the evaluation of a lateral lumbar spine radiograph. It finds that the image is generally of diagnostic quality, with the vertebrae and disk spaces visible. However, it notes that beam restriction could be improved by including a fourth side, and the patient positioning could be adjusted by bringing them slightly back towards the radiographer. With some minor changes to positioning and technique, the image would meet full acceptance criteria. Overall, the evaluator would accept this image but aims to provide feedback to improve future images.

1. Oral Presentation #10
Nicole Blankenhorn

2. • The image is HIPAA compliant as it does not display any
information that violates HIPAA compliancy
Is the image HIPAA compliant?

3. • There is no anatomical side
marker visible on the image
• There is no marker visible
that indicates whether a
marker was used
• Cannot determine whether a
marker was placed beside
the anatomical part prior to
or following the exposure
Marker & Patient ID

4. • NOW the anatomical marker
correctly marks the side being
imaged
• The marker does not superimpose
over pertinent anatomy
• There are no additional markers
needed/ used for this image
• Upright (or a weight-bearing)
marker could be used if patient
imaged in that position
• Based on marker placement, the
image is correctly displayed
• “if a patient’s left side is positioned
closer to IR for a lateral lumbar
vertebrae projection, place an L
marker on the IR”

5. • Proper beam restriction requires
the presence of at least three
sides of collimation on the image
• There are no sides of beam
restriction present
• Does not mean that BR was not used
• There does not appear to be
evidence to prove primary
shielding (closest to gonads) was
used
• For male patients, gonadal shielding can
be employed
• Gonadal shielding must be
provided if gonads are within 5 cm
of primary beam
Radiation Hygiene

6. Routine Radiographic Projections Performed:
• AP (or PA)
• 45 ̊Obliques
• AP Obliques
• RPO/LPO
• PA Obliques
• RAO/LAO
• Lateral (R or L)
• Lateral L5-S1 “Spot”
Other Projections May Include:
• Erect (Weight-Bearing)
• “With bending”
• Flexion
• Extension
*can be done upright/supine*
• AP/PA Axial – Ferguson Method
• Cross Table Lateral “Shoot thru”
Lateral

7. Ferguson Method
Flexion
Extension
AP Obliques (typically done)
Projections
differ based on
institutional/
departmental
protocol

8. • This image does comply w/routine
position(s)/projection(s)
• Routine Projection
• Left Lateral Projection
• All anatomical parts correctly visualized

9. Artifact Identification
• There appears to be no
preventable physical artifacts
visible
• Gas patterns
• Soft tissue folds
• There appears to be no body
parts superimposed that should
not be
• There appears to be no hospital
paraphernalia visible
• no patient clothing/belongings
visible
• There appears to be no
indwelling artifacts/foreign bodies
visible

10. Artifact Identification/ Image Sharpness
• There does not appear to be excess fog that
could degrade overall image contrast/visibility
of recorded detail & there are no visible
CR/DR artifacts
• There appears to be no “gross” voluntary
motion visible
• There is no excessive quantum mottle (or
image noise) visible
• There is no evidence of a double exposure
• There are no grid lines, grid artifact &/or grid
cut-off
• Grids should be used when:
• Body parts measure more than 10cm in thickness
• Whenever applied kVp is > 70 to 80 (some
sources >60)
• Merrill’s recommends a 16:1 grid
NB

11. Image Sharpness
• Size distortion does not appear
greater than expected
• The CR should enter
perpendicular to the level of the
crest of the ilium (L4)
• Off-centering appears to be less than 1
cm, causing minimal shape distortion

12. Accurate Part Positioning
• The part is adequately aligned to the
longitudinal axis of the imaging
media
• The part is slightly off-centered to the
image media
• Patient should have been moved down
slightly, back JUST A BIT (very minimal)
• The CR does appear to be centered
less than 1 cm of anatomical part
• The CR adequately aligned with the
imaging media
• The CR’s alignment does conform to
an accepted IR exposure field
recognition template/field
• Collimation not visible

13. A Note About Lumbar Spines…
• Sometimes the center of the vertebral column may sag,
due to lateral flexion, or may be straight but tilted at an
angle with the IR
• Occurs in patients with broad shoulders & narrow hips (and vice
versa)
• Slight sagging is acceptable, as it will better align the
disk spaces with the beam, but excessive sagging will
distort vertebral bodies and close disc spaces
 THIS is why a radiolucent sponge is placed
superior to the crest on some patients!

14. Note, Continued
• IF patient has SCOLIOSIS, place them in the ERECT
POSITION
• Place patient in a R or L lateral position
• Whichever lateral places the sag (convexity) of the spine
down (better opens intervertebral spaces)
Alignment of CR and
Scoliotic lumbar vertebra

15. Positioning
• IR Size: 14x17 LW
• 40”SID (a 42-46” SID reduces magnification)
Position of Patient
• Use same body position (recumbent or upright)
as for PA/AP projection
• Ensure patient is dressed in an open-backed
gown so spine can be exposed for adjustment of
position
Position of Part
• Ask patient to turn onto affected side & flex
hips/knees to a comfortable position
• Thin patients require pad under dependent hip to
relieve pressure
• Align MCP to midline of grid & ensure that it is
vertical
• With the patients elbows flexed, adjust the
dependent arm at right angles to body
• To prevent rotation, superimpose knees exactly &
place small sponge/sandbag between them
• Place a suitable radiolucent support under lower
thorax & adjust it so that the long axis of the
spine is horizontal
• Collimate to 8x17
• Suspend at the end of respiration

16. Central Ray
• Enters MCP perpendicular to the level of the crest of the
ilium (L4)
• When spine cannot be adjusted so that it is horizontal,
angle the CR caudad so that it is perpendicular to the
long axis
• Degree of angulation depends on angulation of the lumbar
column& breadth of the pelvis
• Typically: 5º for men & 8º for women

17. Improving Radiographic Quality
• The quality of a radiographic image can be improved if a
sheet of leaded rubber is placed on the table behind the
patient
• kVp is increased for lateral projections due to the increased
part thickness
• Lead absorbs scatter
• Scatter decreases radiographic quality
• With AEC, scatter coming from patient can terminate
exposure timer prematurely & create an underexposed
image
• Close collimation necessary

18. Evaluation Criteria
• Area from the lower thoracic
vertebrae to the coccyx
• 12th thoracic vertebra, 1st -5th vertebrae &
L5-S1 intervertebral disk spaces included
in field
• Open intervertebral disk spaces
& intervertebral foramina
• Superimposed posterior margins
of each vertebral body
• Vertebrae aligned down the
middle of the image
• Nearly superimposed crests of
the ilia when the x-ray beam is
not angled
• Spinous processes in profile
• Evidence: proper collimation

19. IMA GE EVA LU ATION
Is the anatomical part correctly positioned? YES
Area from the lower thoracic vertebrae to the coccyx
12th thoracic vertebra, 1st -5th vertebrae & L5-S1
intervertebral disk spaces included in field
 Although included, it is difficult to visualize
L5S1 joint space
Open intervertebral disk spaces & intervertebral
foramina
Superimposed posterior margins of each vertebral
body
Vertebrae aligned down the middle of the image
Nearly superimposed crests of the ilia when the x-ray
beam is not angled
Spinous processes in profile
Evidence: proper collimation

21. Exposure Technique
• The most radiolucent structures are the
patient soft tissue & air/ gas patterns
• The most radiopaque structures are the
bony trabecular markings
• Given that there is no EI value, it is
difficult to determine as to whether the
image is underexposed, overexposed
or adequately exposed
• Upon further observation of the image, I
believe that the image was adequately
exposed & the EI value was likely within
normal range
• Long Scale Contrast
• Shade of grey
• Adequate amount of brightness
 Appears to be sufficient brightness

22. Accept or Reject?
• This image meets the standards for acceptance
criteria
• It is of diagnostic quality
• I would accept this image
• I would change a few things…

23. • Include marker PRIOR
TO the exposure
• Improve BR to having 4
sides- or an acceptable 3
sides!
• Include a leaded strip
behind patient
• Improves contrast
• Ensure that CR enters at
the correct location
• Patient should have been
brought back more toward
the radiographer
• Places spine at center of field,
aligning to longitudinal axis IR

24. References
• Frank,E.D.,Long B.W.,Smith,B.J.,Merrill,V.,& Ballinger,
P.W. (2007). Merrill’s atlas of radiographic positioning &
procedures. St Louis,MO: Mosby/Elsevier
• McQuillen-Martensen (2015). Radiographic Image
Analysis. Vol 4 St. Louis, MO: Elsevier