Vertebral Column

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER ONE

CRT04103 · Radiographic Techniques and Procedures

Study Vertebral Column using the sections below. Use the topic navigation to continue through Radiographic Techniques and Procedures.

RADIOGRAPHIC PROCEDURE OF THE VERTEBRAL COLUMN

USEFUL LANDMARKS

The easily palpated tip of the mastoid process indicates the level of C1.

The spinous process of C7 produces a visible protuberance on the posterior aspect of the inferior part of the neck.
Below this, the spinous process of the thoracic spine can be palpated.
NB: the thoracic spinous processes are directed

steeply downwards, so their palpable tips will be adjacent to the vertebral body below.

The inferior angle of the scapula indicates the level of T7 when the arms are placed by the side.

The sternal notch lies at the junction between T2 and T3.
T4 is indicated by the sternal angle with T9 corresponding to the xiphisternal joint, although the size of this structure is variable.

The lower costal margin indicates L3 and is located easily.

This is a very useful aid to positioning in spinal radiography.

A line joining the most superior parts of the iliac crests indicates the level of L4, whilst the tubercle of the iliac crest discloses the location of L5.
The anterior and posterior

The anterior and posterior iliac spines lie at the level of the second sacral vertebra.

The coccyx can be palpated between the buttocks and lies at the level of the symphysis pubis.

CERVICAL SPINE LATERAL VIEW

Position of patient and cassette
The patient stands or sits with either shoulder against the cassette.
The median sagittal plane should be adjusted such that it is parallel with the cassette.
The head should be flexed or extended such that the angle of the mandible is not superimposed over the upper anterior cervical vertebra or the occipital bone does not obscure the posterior arch of the atlas.

• To aid immobilization, the patient should stand with the feet

slightly apart and with the shoulder resting against the cassette
stand.
In order to demonstrate the lower cervical vertebra, the
shoulders should be depressed,

This can be achieved by asking the patient to relax their shoulders downwards. The process can be aided by asking the patient to hold a weight in each hand (if they are capable) and making the exposure on arrested expiration.

Direction and centering of the X-ray beam

The horizontal central ray is centred to a point vertically below the mastoid process at the level of the prominence of the thyroid cartilage.

Essential image characteristics

The whole of the cervical spine should be included, from the atlanto-occipital joints to the top of the first thoracic vertebra.
The mandible or occipital bone does not obscure any part of

the upper vertebra.

Angles of the mandible and the lateral portions of the floor of the posterior cranial fossa should be superimposed.

Soft tissues of the neck should be included.
The contrast should produce densities sufficient to demonstrate

soft tissue and bony detail.

Position of patient and cassette

The patient is positioned supine on the X-ray table, with the median sagittal plane perpendicular to the tabletop and coincident with the midline of the Bucky.
The upper edge of a cassette, which should be at least 40 cm long for an adult, should be at a level just below the prominence of the thyroid cartilage to ensure that the upper thoracic vertebrae are included.

Vertebral Column

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.

Direction and centering of the X-ray beam

Direct the central ray at right-angles to the cassette and towards a point 2.5 cm below the sternal angle.
Collimate tightly to the spine.

Essential image characteristics

The image should include the vertebrae from C7 to L1.
The image density should be sufficient to demonstrate bony detail for the upper as well as the thoracic lower vertebrae.

LATERAL THORACIC SPINE

Usually undertaken with the patient in the lateral decubitus
position on the X-ray table, although this projection can also be performed erect.
The median sagittal plane should be parallel to the cassette
and the midline of the axilla coincident with the midline of

the table or Bucky.

• The arms should be raised well above the head.

The head can be supported with a pillow, and pads may be placed between the knees for the patient’s comfort.
The upper edge of the cassette should be at least 40 cm in length and and should be positioned 3–4 cm above the spinous process of C7.

Direction and centering of the X-ray beam

The central ray should be at right-angles to the long axis of the thoracic vertebrae. This may require 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.

Essential image characteristics

The upper two or three vertebrae may not be demonstrated
due to the superimposition of the shoulders.
Look for the absence of a rib on L1 at the lower border of the
image. This will ensure that T12 has been included within
the field.
The posterior ribs should be superimposed, thus indicating
that the patient was not rotated too far forwards or

backwards.

• The trabecular of the vertebrae should be clearly visible, demonstrating an absence of movement unsharpness.

The image density should be adequate for diagnosis for both the upper and lower thoracic vertebrae.

THE VERTEBRAL COLUMN

1.UNDERLINED ANATOMY

The vertebral column consist of 33 vertebrae 7cervical ,12 thoracic, 5 lumbar ,5 sacral and 4 coccygeal The coccygeal segments in some cases are three fused together and form a triangular bone.

The vertebrae in each region show variation from basic pattern.

Each region demands its own technique to demonstrate it.

When dealing with radiographic technique of the vertebral column, the following terminologies should be remembered;

Kyphosis-abnormal backward bending of the spine
Lordosis -abnormal forward bending of the spine

Scoliosis-abnormal lateral bending of the spine

Vertebral Column

Most of the in the vertebral column need a Bucky or stationary grid except the lateral view of the cervical spine.

Arrested respiration for this examination of ths region is necessary After routine examination of part of the vertebral column, the doctor may request a coned view of particular vertebrae At least three to five vertebrae should be be covered in coned view views

Note;the vertebral column of a child may be shown almost completely on one film.

Vertebral levels

Some useful land marks

Angle of mandible 2-3 CV

Sternal notch 2-3 DV
Sternal angle 4-5 DV
Xiphisternal junction 9-4DV
Lower coastal margin 3-4 LV
Umbilicus 3-4 LV
Iliac crest 4 LV
ASIS 2 sacral

Symphysis pubis-1st piece of coccyx

Radiation protection

With the exception of lumbo-sacral region and sacrum in female patients, it is always possible to protect the gonads from direct radiation by accurate conning and lead rubber placed over the gonad area The ten day rule should be observed for female patients of child bearing age.

demonstration

CERVICAL VERTEBRAE

The cervical spine is convex forwards.

The seven cervical vertebrae show marked differences from each other, particularly the first(atlas)which has an anterior arch instead of vertebral body,into which first the odontoid peg of the second CV (AXIS).

In the AP view, the upper CV is obscured by the jaws and occiput .

But they can be demonstrated if this view is taken with patients mouth open.

Preparation of the patient

Remove dentures, hairpins and neck and ear ornaments..

The patients should undress and given the x -ray gown

Basic views

AP (CV 1-3)

AP ( CV 3-7)

Lateral view

Antero-posterior – first ,second and 3rd

cervical vertebrae (open mouth)

Position of patient and cassette

The patient lies supine on the Bucky table or, if erect positioning is preferred, sits or stands with the posterior aspect of the head and shoulders against the vertical Bucky.

The medial sagittal plane is adjusted to coincide with the midline of the cassette, such that it is at right-angles to the cassette.

The neck is extended, if possible, such that a line joining the tip of the mastoid process and the inferior border of the upper incisors is at right-angles to the cassette. This will superimpose the upper incisors and the occipital bone, thus allowing clear visualization of the area of interest.

The cassette is centered at the level of the mastoid process

Direction and centring of the X-ray beam

Direct the perpendicular central ray along the midline to the center of the open mouth.

If the patient is unable to flex the neck and attain the position described above, then the beam must be angled, typically five to ten degrees cranially or caudally, to superimpose the upper incisors on the occipital bone.

The cassette position will have to be altered slightly to allow the image to be centered after beam angulation.

Antero-posterior third to seventh

vertebrae

Position of patient and cassette

The patient lies supine on the Bucky table or, if erect positioning is preferred, sits or stands with the posterior aspect of the head and shoulders against the vertical Bucky.

The median sagittal plane is adjusted to be at right-angles to the cassette and to coincide with the midline of the table or Bucky.

The neck is extended (if the patient’s condition will allow) so that the lower part of the jaw is cleared from the upper cervical vertebra.

The cassette is positioned in the Bucky to coincide with the central ray.

The Bucky tray will require some cranial displacement if the tube is angled.

Direction and centring of the X-ray beam

A 5–15-degree cranial angulation is employed, such that the inferior border of the symphysis menti is superimposed over the occipital bone.

The beam is centered in the midline towards a point just below the prominence of the thyroid cartilage through the fifth cervical vertebra.

Axial – upper cervical vertebra

This is a useful projection if the odontoid peg cannot be demonstrated using the open mouth projection. Remember that the neck must not be flexed in acute injuries.

Position of patient and cassette

The patient lies supine on the Bucky table, with the median sagittal plane coincident with the midline of the table and at right-angles to the cassette.

The neck is extended so that that the orbito-meatal baseline is at 45 degrees to the tabletop. The head is then immobilized.

The cassette is displaced cranially so that its centre coincides with the central ray.

Direction and centering of the X-ray beam

The beam is angled 30 degrees cranially from the vertical and the central ray directed towards a point in the midline between the external auditory meatuses.

Lateral erect

Position of patient and cassette

The patient stands or sits with either shoulder against the cassette.

The median sagittal plane should be adjusted such that it is parallel with the cassette.

The head should be flexed or extended such that the angle of the mandible is not superimposed over the upper anterior cervical vertebra or the occipital bone does not obscure the posterior arch of the atlas.

To aid immobilization, the patient should stand with the feet slightly apart and with the shoulder resting against the cassette stand.

In order to demonstrate the lower cervical vertebra, the shoulders should be depressed.

Direction and centring of the X-ray beam

The horizontal central ray is centred to a point vertically below the mastoid process at the level of the prominence of the thyroid cartilage.

Lateral supine

For trauma cases, the patient’s condition usually requires the examination to be performed on a casualty trolley.

The lateral cervical spine projection is taken first, without moving the patient.

Position of patient and cassette

The patient will normally arrive in the supine position.

It is vitally important for the patient to depress the shoulders(assuming no other injuries to the arms).

The cassette can be either supported vertically or placed in the erect cassette holder, with the top of the cassette at the same level as the top of the ear.

Addition view

Right and left posterioroblique – erect

Oblique projections are requested mainly to supplement the basic projections in cases of trauma.

The images demonstrate the intervertebral foramina, the relationship of the facet joints in suspected dislocation or subluxation as well as the vertebral arches.

Oblique projections have also been used with certain pathologies, such as degenerative disease.

Position of patient and cassette

The patient stands or sits with the posterior aspect of their head and shoulders against the vertical Bucky (or cassette if no grid is preferred).

The median sagittal plane of the trunk is rotated through 45 degrees for right and left sides in turn.

The head can be rotated so that the median sagittal plane of the head is parallel to the cassette, thus avoiding superimposition of the mandible on the vertebra.

The cassette is centered at the prominence of the thyroid cartilage.

Direction and centering of the X-ray beam

The beam is angled 15 degrees cranially from the horizontal and the central ray is directed to the middle of the neck on the side nearest the tube.

Cervico-thoracic vertebrae(Lateral swimmers’)

In all trauma radiography, it is imperative that all of the cervical vertebrae and the cervico-thoracic junction are demonstrated.

Position of patient and cassette

This projection is usually carried out with the patient supine/erect on a trauma trolley.

The trolley is positioned adjacent to the vertical Bucky, with the patient’s median sagittal plane parallel with the cassette.

The arm nearest the cassette is folded over the head, with the humerus as close to the trolley top as the patient can manage.

The arm and shoulder nearest the X-ray tube are depressed as far as possible.

The shoulders are now separated vertically.

The Bucky should be raised or lowered, such that the line of the vertebrae should coincide with the middle of the cassette.

This projection can also be undertaken with the patient erect, either standing or sitting or supine.

Direction and centering of the X-ray beam

The horizontal central ray is directed to the midline of the Bucky at a level just above the shoulder remote from the cassette.

Thoracic vertebrae

Antero-posterior

lateral

AP Position of patient and cassette

The patient is positioned supine on the X-ray table, with the median sagittal plane perpendicular to the tabletop and coincident with the midline of the Bucky.

The upper edge of a cassette, which should be at least 40 cm long for an adult, should be at a level just below the prominence of the thyroid cartilage to ensure that the upper thoracicvertebrae are included.

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.

Vertebral Column

The radiographer can employ a number of strategies to reduce the high radiographic contrast associated with this region. The use of a relatively high kVp (80 kVp or more) will usually lower the radiographic contrast, thus demonstrating all the vertebrae within the useful density range.

The anode heel effect can also be exploited by positioning the anode cranially and the cathode caudally.

The use of graduated screens, wedge filters placed on the light beam diaphragm or attenuators positioned over the upper thoracic vertebrae have also proved effective in reducing the contrast.

Heel effect

Normally the principle of heel effect is used when examining the thoracic spine i.e…the thicker part is placed to the cathode side while the thinner part is placed toward the anode side.

Lateral

Position of patient and cassette

Usually undertaken with the patient in the lateral decubitus position on the X-ray table, although this projection can also be performed erect.

The median sagittal plane should be parallel to the cassette and the midline of the axilla coincident with the midline of the table or Bucky.

The arms should be raised well above the head.

The head can be supported with a pillow, and pads may be placed between the knees for the patient’s comfort.

The upper edge of the cassette should be at least 40 cm in length and should be positioned 3–4 cm above the spinous process of C7.

Direction and centring of the X-ray beam

The central ray should be at right-angles to the long axis of the thoracic vertebrae. This may require 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.

Lumbar vertebrae

Antero-posterior

Lateral

Position of patient and cassette

The patient lies supine on the Bucky table, with the median sagittal plane coincident with, and at right-angles to, the midline of the table and Bucky.

The anterior superior iliac spines should be equidistant from the tabletop.

The hips and knees are flexed and the feet are placed with their plantar aspect on the tabletop to reduce the lumbar arch and bring the lumbar region of the vertebral column parallel with the cassette.

The cassette should be large enough to include the lower thoracic vertebrae and the sacro-iliac joints and is centred at the level of the lower costal margin. The exposure should be made on arrested expiration, as the diaphragm will cause the diaphragm to move superiorly.

The air within the lungs would otherwise cause a large difference in density and poor contrast between the upper and lower lumbar vertebrae.

Methods of reducing the sag.

Used radiolucent form pads on cotton material to reduce the sag

Direction and centering of the X-ray beam

Direct the central ray towards the midline at the level of the lower costal margin (L3)

Position of patient and cassette

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 centre 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.

The cassette is centred 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

Direction and centring 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.

Lumbo-sacral junction

Lateral

Antero-posterior

Position of patient and cassette

The patient lies on either side on the Bucky table, with the arms raised and the hands resting on the pillow.

The knees and hips are flexed slightly for stability.

The dorsal aspect of the trunk should be at right-angles to the cassette.

This can be assessed by palpating the iliac crests or the posterior superior iliac spines.

The coronal plane running through the centre of the spine should coincide with, and be perpendicular to, the midline of the Bucky.

The cassette is centred at the level of the fifth lumbar spinous process.

Non-opaque pads may be placed under the waist and knees, as necessary, to bring the vertebral column parallel to the cassette.

Direction and centering of the X-ray beam

Direct the central ray at right-angles to the lumbo-sacral region and towards a point 7.5 cm anterior to the fifth lumbar spinous process.

This is found at the level of the tubercle of the iliac crest or midway between the level of the upper border of the iliac crest and the anterior superior iliac spine.

If the patient has particularly large hips and the spine is not parallel with the tabletop, then a five-degree caudal angulation may be required to clear the joint space

Radiation protection

This projection requires a relatively large exposure so should not be undertaken as a routine projection. The lateral lumbar spine should be evaluated and a further projection for the L5/S1 junction considered if this region is not demonstrated to a diagnostic standard.

Antero-posterior

Position of patient and cassette

The patient lies supine on the Bucky table, with the median sagittal plane coincident with, and perpendicular to, the midline of the Bucky.

The anterior superior iliac spines should be equidistant from the tabletop.
The knees can be flexed over a foam pad for comfort and to reduce the lumbar lordosis.

The cassette is displaced cranially so that its centre coincides with the central ray.

Direction and centring of the X-ray beam

Direct the central ray 10–20 degrees cranially from the vertical and towards the midline at the level of the anterior superior iliac spines.

The degree of angulation of the central ray is normally greater for females than for males and will be less for a greater degree of flexion at the hips and knees.

Sacrum

Antero-posterior/postero-anterior

Lateral

Position of patient and cassette

The patient lies supine or prone on the Bucky table, with the median sagittal plane coincident with, and at right-angles to, the midline of the Bucky.

The anterior superior iliac spines should be equidistant from the tabletop.

If the patient is examined supine (antero-posteriorly), the knees can be flexed over a foam pad for comfort. This will also reduce the pelvic tilt.

The cassette is displaced cranially for antero-posterior projection, or caudally for postero-anterior projections, such that its centre coincides with the angled central ray.

Direction and centering of the X-ray beam

Antero-posterior: direct the central ray 10–25 degrees cranially from the vertical and towards a point midway between the level of the anterior superior iliac spines and the superior border of the symphysis pubis.

The degree of angulation of the central ray is normally greater for females than for males and will be less for a greater degree of flexion at the hips and knees.

Postero-anterior: palpate the position of the sacrum by locating the posterior superior iliac spine and coccyx. Centre to the middle of the sacrum in the midline.

The degree of beam angulation will depend on the pelvic tilt.

Palpate the sacrum and then simply apply a caudal angulation, such that the central ray is perpendicular to the long axis of the sacrum (see photograph opposite).

Lateral

Position of patient and cassette

The patient lies on either side on the Bucky table, with the arms raised and the hands resting on the pillow.

The knees and hips are flexed slightly for stability.
The dorsal aspect of the trunk should be at right-angles to the

cassette.

This can be assessed by palpating the iliac crests or the posterior superior iliac spines.

The coronal plane running through the centre of the spine should coincide with, and be perpendicular to, the midline of the Bucky.

The cassette is centred to coincide with the central ray at the level of the midpoint of the sacrum.

Direction and centering of the X-ray beam

Direct the central ray at right-angles to the long axis of the sacrum and towards a point in the midline of the table at a level midway between the posterior superior iliac spines and the sacro-coccygeal junction.

Coccyx

Antero-posterior

Lateral

Antero-posterior

Position of patient and cassette

The patient lies supine on the Bucky table, with the median sagittal plane coincident with, and at right-angles to, the midline of the Bucky.

The anterior superior iliac spines should be equidistant from the tabletop.
The knees can be flexed over a foam pad for comfort and to reduce the pelvic tilt.

The cassette is displaced caudally so that its centre coincides with the central ray.

Direction and centering of the X-ray beam

Direct the central ray 15 degrees caudally towards a point in the midline 2.5 cm superior to the symphysis pubis.

Lateral

Position of patient and cassette

The patient lies on either side on the Bucky table, with the palpable coccyx in the midline of the Bucky.

The arms are raised, with the hands resting on the pillow. The knees and hips are flexed slightly for stability.

The dorsal aspect of the trunk should be at right-angles to the cassette.

This can be assessed by palpating the iliac crests or the posterior superior iliac spines.

The median sagittal plane should be parallel with the Bucky.

The cassette is centered to coincide with the central ray at the level of the coccyx.

Direction and centering of the X-ray beam

Direct the central ray at right-angles to the long axis of the sacrum and towards the palpable coccyx.