3. Introduction
The vertebral column is commonly called the spine ,backbone
or spinal column ,is a complex succession of many bones.
It is a part of axial skeleton.
It provides a flexible supporting column of the trunk , head and
upper body to lower limbs.
The vertebral column houses the spinal canal, a cavity that
encloses and protects the spinal cord.
The vertebral column is composed of 33 bones which are given
below.
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5. Landmark of spines
T1 =25% of the time it is the most prominent, it does not rotate
as much as C7 when the head turns.(just below of cervical
vertebra)
T2-T3 =sternal or jugular notch
T3-T4 =sternal angle
T7 = inferior angle of scapula
T9-T10 =Xyphoid process
L3-L4 =umbilicus
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6. Some Terminology
Lordosis:
The term lordosis ,meaning bent backward describes the normal
anterio-concavity of the cervical and lumber spine.
Kyphosis:
The meaning of kyphosis is described as abnormal or exaggerated
thoracic “Hump back "curvature with and increased convexity.
Scoliosis:
Abnormal of exaggerated in lateral curvature is called scoliosis.
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7. Anatomy of T-Spine
• The thoracic spine is the longest region of the spine, and by some
measures it is also the most complex.
• Connecting with the cervical spine above and the lumbar spine below,
the thoracic spine runs from the base of the neck down to the abdomen.
• It is the only spinal region attached to the rib cage.
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8. Contd..
• Consists of body, pedicle, lamina, spinous process, transverse process
and superior & inferior articular processes.
• Bodies of vertebrae increases in size fromT1 to T12
• The superior thoracic body resembles with the cervical body & inferior
with the lumbar body.
• They are distinguished by the presence of facets on the sides of the
bodies for articulation with the heads of the ribs, and facets on the
transverse processes of all, except the eleventh and twelfth, for
articulation with the tubercles of the ribs.
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10. Indications
• Any cases of Trauma
• Fracture
• Dislocation
• Foreign body
• Kyphosis
• Subluxation
• Tumor
• Osteoarthritis
• osteoporosis etc.
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11. Basic projections
For Trauma patient on Trolley:-
• Lateral supine with HB (basic)
• AP supine (basic)
Non traumatic pathology:-
• Lateral (basic )
• Supine (basic)
• Ap view erect/supine
• Lateral erect/lying lateral
• AP OR PA Oblique
Projection RAO and LAO or
RPO and LPO Upright and
recumbent positions.
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12. Ap view supine
• Patient is supine, in the middle of the table
• A low pillow under the knee and ankle joint
for the patient comfort
• Cassette is placed under the table in Bucky
• Make exposure on arrested inspiration. This
will cause the diaphragm to move down
over the upper lumbar vertebra, thus
reducing the chance of a large density
difference appearing on the image from
superimposition of the lungs.
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13. CENTERING RAY
• Centered in the midline mid-way
between the cricoid cartilage &the
xiphoid process of the sternum,
approximately 2.5cm below the sternum
angle. (T7)
ESSIANTAL IMAGE CRITERIA
• The image should be include the vertebra
from (C7-L1)
• The image density should be sufficient to
demonstrate bony detail for the upper as
well as the thoracic lower vertebrae.
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14. LATERAL VIEW OF THORAIC SPINE
• The patient should be in lateral decubitus position on x-ray table,
although the this projection can also be done in erect
• The arm should be raised over the head
• The upper edge of the cassette should be at least 40cm in length
positioned 3-4cm above the spinous process of C7.
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15. CENTERING RAY
• Center ray should be right angle of the axis of the thoracic vertebra.
This may required a caudal angulation.
• Centre 5 cm anterior to the spinous process of T6/7. This is usually
found just below the inferior angle of the scapula(assuming the arms
are raised), which is easily palpable.(clear)
ESSIANTAL IMAGE CRITERIA
• Upper two or three vertebra may not be visual due to super imposed by
shoulder.
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16. Contd..
The posterior ribs should be superimposed, thus
indicating that the patient is not rotate too far
backward or forward
There should be clearly visualization of whole
spine(T1-T12)
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17. AP OR PA OBLIQUE PROJECTION RAO and LAO or
RPO and LPO Upright and recumbent positions
• The thoracic zygapophyseal joints are examined using PA oblique
projections .
• Place the patient, standing or sitting upright, in a lateral position before
a vertical grid.
• Rotate the body 20 degrees anterior (PA oblique) or posterior (AP
oblique) so that the coronal plane form an angle of 70 degrees from the
plane of the IR.
• Adjust the patient's shoulder to lie in the same horizontal plane.
• Suspend the end of expiration.
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19. Recumbent position
• Patient is Placed in a lateral recumbent position.
• Patient’s hips and knees is Flex to a comfortable position.
• For anterior (PA oblique) rotation, the lower arm is placed behind the
back and the upper arm forward with the hand on the table for support.
• Rotate the body slightly, either anteriorly or posteriorly 20 degrees, so
that the coronal plane forms an angle of 70 degrees with the horizontal.
• If needed, apply a compression band across the hips, but be careful not
to change the position.
• Suspend at the end of expiration.
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20. Central ray:-
• Center the IR 11/2
to 2 inches (3.8-5 cm) above the shoulders to center it
at the level of T7.
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21. ESSIANTAL IMAGE CRITERIA
• All twelve thoracic vertebrae .
• Zygapophyseal joints closest to the IR
on PA obliques and the joints farthest
from the film on AP obliques .
• Wide exposure latitude.
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22. LUMBAR SPINE(L1-L5)
The lumbar spine consists of moveable
vertebrae numbered L1-L5.
The lumbar spine is designed to be incredibly
strong, protecting the highly sensitive spinal
cord and spinal nerve roots. At the same time, it
is highly flexible, providing for mobility in
many different planes including flexion,
extension, side bending, and rotation.
The first lumbar vertebra is level with the
anterior end of the ninth rib. This level is also
called the important transpyloric plane.
Lumber vertebrae doesn’t have facet .
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25. Basic AP view
Patient position
• Patient lies in supine on table
with the median sagittal plane at
the right angle at the midline of
the table
• The cassette should be large
enough (14x17”) to include the
lower thoracic vertebrae & Sacro-
iliac joint and centered at the
lower costal margin.
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26. Centering point..
• Perpendicular to the IR at the level of
the iliac crests (L4) for a lumbosacral
examination or (3.8 cm) above the iliac
crest (L3) for a lumbar examination.
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27. ESSIANTAL IMAGE CRITERIA
The image should include from the (T12)down, to include all of the
Sacro-iliac joint.
Rotation can be assessed by ensuring that the Sacro- iliac joints are
the equidistant from the spine.
The exposure used should produce a density such that bony detail can
be discerned throughout the region of interest.
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29. LATERAL PROJECTION R or L position
The patient lies on either side on the Bucky table. If there is
any degree of scoliosis, then the most appropriate lateral position
will be such that the concavity of the curve is towards the
X-ray tube.
The arms should be raised and resting on the pillow in front of
the patient’s head. The knees and hips are flexed for stability.
The coronal plane running through the center of the spine
should coincide with, and be perpendicular to, the midline of
the Bucky.
Non-opaque pads may be placed under the waist and knees,
as necessary, to bring the vertebral column parallel to the film.
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30. Contd..
The cassette is centered at the level of the lower costal margin.
The exposure should be made on arrested expiration.
This projection can also be undertaken erect with the patient
standing or sitting.
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31. Direction and centering of the X-ray beam
Direct the central ray at right-angles to the line of spinous
processes and towards a point 7.5 cm anterior to the third lumbar
spinous process at the level of the lower costal margin.
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32. Essential image characteristics
• The image should include T12 downwards, to include the lumbar
sacral junction.
• Ideally, the projection will produce a clear view through the
center of the intervertebral disc space, with individual vertebral
end plates superimposed.
• The cortices at the posterior and anterior margins of the vertebral
body should also be superimposed.
• The imaging factors selected must produce an image density
sufficient for diagnosis from T12 to L5/S1, including the spinous
processes.
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34. AP Oblique Projection RPO and LPO positions
• The patient turns from the supine position
toward the affected side approximately 45
degree to demonstrate the joints closest to the
IR (opposite the thoracic zygapophyseal
joints).
• Adjust the patient's body so that the long axis
of the patient is parallel with the long axis of
the radiographic table.
• Center the patient's spine to the midline of
the grid.
• Suspend at the end of expiration.
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35. Central ray
• Enter 2 inches (5 cm) medial to
the elevated ASIS and 1-1/2
inches (3.8 cm) above the iliac
crest (L3).
• Center the IR to the central ray.
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36. Structures shown
• The resulting image shows an oblique
projection of the lumbar and/or lumbosacral
spine, demonstrating the articular processes
of the side closest to the IR. Both sides are
examined for comparison .
• When the body is placed in a 30- to
50degree oblique position then articular
processes and the zygapophyseal joints are
demonstrated. When the patient has been
properly positioned, images of the lumbar
vertebrae have the appearance of "Scottie
dogs."
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37. Image Criteria
• Area from the lower thoracic
vertebrae to the sacrum.
• Zygapophyseal joints closest to the
IR open and uniformly visible through
the vertebral bodies.
• Vertebral column parallel with the
tabletop so that the T 12-LI and LI-
L2 joint paces remain open.
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38. PA Oblique Projection RAO and LAO positions
• Examine the patient in the upright or recumbent prone position. The
recumbent position generally used because it facilitates immobilization.
• However, the OID is increased, which can affect resolution.
• The joints farthest from the IR are demonstrated with the PA oblique
projection (opposite the thoracic zygapophyseal joints).
• From the prone position, have the patient turn to a semi-prone position
and support the body on the forearm and flexed knee.
• Center the IR at the level of L3.
• To demonstrate the lumbosacral joint, position the patient as described
above but center L5.
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39. Central ray
• Perpendicular to enter the L3 (1
to ½ inches [2.5 to 3.8 cm]
above the crest of the ilium).
The central ray enter the
elevated ide approximately 2
inches (5 cm) lateral to the
palpable spinous process.
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40. Structures shown
• The resulting image shows an oblique projection of the lumbar or
lumbosacral vertebrae, demonstrating the articular processes of the
side farther from the IR .
• The fifth lumbosacral joint is usually well demonstrated in oblique
position.
• When the body is placed in a 30- to 50degree oblique position and
the lumbar spine is radiographed, the articular processes and
zygapophyseal joints are demonstrated .
• When the patient has been properly positioned, image of the
lumbar vertebrae have the appearance of "Scottie dog .”
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42. Evaluation Criteria
• Area from the lower thoracic
vertebrae to the sacrum.
• Zygapophyseal joints farthest from
the IR.
• When the joint is not well
demonstrated and the pedicle is quite
anterior on the vertebral body, the
patient is not rotated enough.
• When the joint is not well
demonstrated and the pedicle is quite
posterior on the vertebral body, the
patient is rotated too much. 42
43. Lateral Horizontal Beam
Patient’s preparation
• The trauma trolley is placed adjacent to the vertical Bucky.
• Adjust the position of the trolley so that the lower costal margin of the
patient coincides with the vertical central line of the Bucky and the
median sagittal plane is parallel to the cassette.
• The Bucky should be raised or lowered such that the patient’s mid-
coronal plane is coincident with the midline of the cassette within the
Bucky, along its long axis.
• If possible, the arms should be raised above the head.
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45. Direction and centering of the X-ray beam
• Direct the horizontal central ray parallel to a line joining the anterior
superior iliac spines and towards a point 7.5cm anterior to the third
lumbar spinous process at the level of the lower costal margin.
Essential image characteristics
• Refer to lateral lumbar spine.
• Extreme care must be taken if using the automatic exposure control.
The chamber selected must be directly in line with the vertebrae,
otherwise an incorrect exposure will result.
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46. Contd…
• If a manual exposure is selected, then a higher exposure will be required than with
a supine lateral. This is due to the effect of gravity on the internal organs, causing
them to lie either side of the spine.
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47. Lateral Flexion and Extension
• Lateral projections in flexion and extension may be requested to
demonstrate mobility and stability of the lumbar vertebrae.
Patient preparation
• This projection may be performed supine, but it is most commonly
performed erect with the patient seated on a stool with either side
against the vertical Bucky.
• A seated position is preferred, since apparent flexion and extension of
the lumbar region is less likely to be due to movement of the hip joints
when using the erect position.
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48. • The dorsal surface of the
trunk should be at right-angles
to the cassette and the
vertebral column parallel to
the cassette.
• For the first exposure the
patient leans forward, For the
second exposure the patient
then leans backward,
• The cassette is centered at
the level of the lower costal
margin, and the exposure is
made on arrested expiration.
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49. Direction and centering of the X-ray beam
• Direct the central ray at right-angles to the
film and towards a point 7.5cm anterior to
the third lumbar spinous process at the level
of the lower costal margin.
Essential image characteristics
• Refer to lateral lumbar spine .
• All of the area of interest must be included
on both projections.
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