Procedures - Spine

for a lateral c-spine what is visualized?

zygophophyseal joints

for the c-spine obliques (RPO/LPO), what is visualized?

intervertebral foramina (side closest to IR)

what is the degree of rotation for an oblique C-spine?

45º

What is visualized in a LPO/RPO oblique T-spine?

z joints (side closest to IR)

what is the degree of rotation for an oblique t-spine?

70º

what is visualized in a lateral t-spine?

IVF

what is visualized in an oblique l-spine?

z joints (side closest to IR)wha

what is the degree of rotation for an oblique l-spine?

45º

what is visualized in a lateral l-spine

IVF

What landmark is at C1?

mastoid tip

What landmark is at C2–C3?

angle of mandible

What landmark is at C3–C4?

hyoid bone

What landmark is at C4–C5?

thyroid cartilage

What landmark is at C5?

lower margin of thyroid cartilage

What landmark is at T1?

2.5 cm (1 in) above jugular notch

what landmark is at C7?

vertebral prominence (spinous process)

What landmark is at T2–T3?

jugular notch

What landmark is at T4–T5?

sternal angle

What landmark is at T7?

mid thorax/ Inferior angle of scapula

What landmark is at T9–T10?

xiphoid process

What landmark is at T12?

12th rib level

What landmark is at L2–L3?

lower costal margin

What landmark is at L3?

umbilicus

What landmark is at L4–L5?

iliac crest

What landmark is at S1–S2?

ASIS

What landmark is at the coccyx tip?

~1 inch below = pubic symphysis

What does the AP open-mouth C-spine demonstrate?

The dens (odontoid process), lateral masses of C1, and C1–C2 articulation.

What is the key positioning requirement for an AP open-mouth?

The upper incisors and the base of the skull should be aligned so the dens is not superimposed.

what is the CR/SID/kVp for an AP “open mouth” c-spine?

perp to IR through center of open mouth (to C1-C2)

SID 40in (100cm)

kVp 70-85

what is the alternative view for dens is pt is unable to open mouth?

AP (Fuchs) or PA (Judd)

AP Fuchs Method Dens view (Cspine) positioning

supine or erect

MSP aligned to centerline

elevate chin until MML is near perp to IR (cephalic angle may be needed)C

CR/SID/kVp for AP Fuchs/PA Judd method (Dens)

parallel to MML

1in (2.5cm) inferoposterior to mastoid tips and angles of mandible

SID 40in (100 cm)

kVp 70-85

AP “open mouth” c-spine anatomy visualized

dens (odontoid process) and vertebral body of C2, lateral masses and transverse processes of C1, and C1-C2 atlantoaxial joints

upper incisors and base of skull superimposed; entire dens demonstrated within foramen magnum

PA (Judd) c-spine positioning

pt supine or erect

MSP aligned to centerline

elevate chin until MML is perp to IR (chin resting against tabletop)

PA (Judd)/AP (Fuchs) Dens method anatomy visualized

dens (odontoid process) within foramen magnum

tip of mandible not superimposed over dens; symmetric appearance of mandible

What is the CR for an AP axial cervical spine?

15–20° cephalad, entering at C4 (inferior margin of thyroid cartilage)

SID/kVp for AP axial Cspine

40in (100cm)

kvp 70-85

AP Axial C-spine positioning

supine or erect; center MSP to CR

raise pt’s chin slightly (as needed) so CR angle superimposes the mentum of mandible over base of the skull (prevent mandible from superimposing C1-C2)

AP axial C-spine anatomy demonstrated

C3-T2 vertebral bodies and IVF joints

IVF joints open and spinous processes equidistant to midline

What do PA (LPO/RPO) axial oblique C-spine images demonstrate?

The intervertebral foramina closest to the IR.

What is the CR for a PA axial oblique C-spine?

CR 15-20º cephalad, entering C4

LPO/RPO c-spine positioning

pt erect (preferred), rotated 45º

raise chin slightly, looking straight ahead (turn head slightly towards IR to prevent superimposing C1 by ramus of mandible)

anterior obliques result in less thyroid dose

true

SID/kVp for oblique c-spine

40in (100cm)

kVp 70-85

What is the CR for anterior axial oblique C-spine?

15-20º caudad, entering c4

RAO/LAO c-spine positioning

pt erect (preferred), rotated 45º

raise chin slightly, looking straight ahead (turn head slightly towards IR to prevent superimposing C1 by ramus of mandible)

Which foramina are demonstrated on RAO?

RAO → right foramina (downside/closest to IR).

Which foramina are demonstrated on LAO?

LAO → left foramina (downside/closest to IR).

Which foramina are demonstrated on RPO?

Left intervertebral foramina — side farthest from the IR.

Which foramina are demonstrated on LPO?

Right intervertebral foramina — side farthest from the IR.

anatomy visualized on oblique cspine

IVF open (uniformly) and pedicles

What is the CR for a lateral C-spine?

perp horizontally to C4, approximately at the level of the upper thyroid cartilage.

lateral c-spine positioning

erect (sitting or standing)

top of IR about 1-2in above EAM

depress both shoulders evenly

elevate pts chin slightly

lateral cspine SID/kVp

60-72in (150-180cm)'

kVp 70-85

when do you expose on a lateral c-spine

end of full expiration

when is a swimmer’s lateral c-spine done?

Demonstrates C5–T3 when shoulders cannot be depressed enough to see C7-T1 on a routine lateral C-spine

swimmer’s lateral cspine positioning

erect (preferred), sitting or standing

place pt arm and shoulder closest to IR up, flexing elbow and resting forearm on head (support)

arm/shoulder farthest from IR down and rotate slightly posterior (humeral head posterior to vertebrae)

SID/kVp swimmer’s lateral (cpsine)

60-72in (150-180cm)

kVp 75-95

CR for swimmer’s lateral cpsine

perp centered to T1 (about 1in (2.5cm) above jugular notch)

optional* 3-5 caudad to separate two shoulders (pt w limited flexibility)

anatomy demonstrated in swimmer’s lateral c-spine

vertebral bodies and intervertebral disk spaces from C5-T3 (minimum) demonstrated

separation of humeral heads from Cspine; vertebral bodies in lateral perspective

lateral — hyperflexion/extension (cspine) positioning

pt erect (preferred) in true lateral position; cspine aligned to CR

relax and depress shoulders as much as possible (weights may be used)

hyperflexion: depress chin to touch chest (if possible)

hyperextension: elevate chin as far as is comfortable

SID/kVp lateral — hyperflexion/extension (cspine)

SID 60-72in (150-180cm)

kVp 70-85

CR lateral — hyperflexion/extension (cspine)

perp to C4 (upper margin of thyroid cartilage)

respiration lateral — hyperflexion/extension (cspine)

expose on full expiration

anatomy visualized lateral — hyperflexion/extension (cspine)

c1-c7 range of motion and ligament stability

hyperflexion = spinous processes separated

hyperextension = spinous processes in close proximity

why/when would you do a c-spine cross table lateral (horizontal beam)?

to evaluate acute neck trauma and rule out fractures, dislocations, or subluxations without moving or manipulating the patient’s head and neck

pt has suspected or known fx

c-spine lateral (horizontal beam) positioning

pt supine

SID 60-72in (150-180cm)

CR perp to C4 (upper thyroid cartilage)

top of IR approx 1-2in (3-5cm) above EAM

AP t-spine positioning

pt supine (MSP aligned to table or IR); flex hips and knees to reduce lordotic curvature

top of IR at least 1.5in (3cm) above shoulder

AP t-spine — CR, SID, kVp

perp to center of IR (level of T7) (3-4in below jugular notch)

SID 40in (100cm)

kVp 75-90

respiration for AP t-spine

expose on expiration (uniform density)

anatomy demonstrated AP tspine

12 thoracic bodies, intervertebral joint spaces, and spinous/transverse processes

SC joints equidistant from midline

what can be placed down on a lateral t-spine to reduce scatter to IR

lead mat placed posterior to pt

what technique (breathing) instructions are used for lateral tspine

orthostatic

low mA w long exposure time (minimum 2-3secs); pt taking shallow breaths

expose on full inspiration

why is an orthostatic breathing technique done in a lateral tspine?

To blur out overlying ribs and lung markings so the thoracic vertebral bodies, intervertebral spaces, and intervertebral foramina are clearly visible

lateral tspine positioning

pt recumbent (support under head); lateral w knees flexed, arms raised, and elbows flexed

align and center midaxillary plane to midline of table or IR

ensure top of IR at least 1.5in (3cm) above shoulders

CR lateral tspine

perp to center of IR T7 (3-4in (8-10cm)) below jugular notch or 7-8in (18-20cm) below the vertebra prominens)

pt w broad shoulders may require 10-15º cepahlic angle

SID/kVp lateral tspine

40in (100cm)

kVp 80-95

anatomy demonstrated in a lateral tspine

12 thoracic bodies, intervertebral joint spaces, and spinous/transverse processes

intervertebral disk spaces open

AP/PA thoracolumbar positioning x ray

Patient supine (AP) or prone (PA); MSP centered to IR, with no rotation.

AP/PA thoracolumbar spine — CR?

Perpendicular to IR, centered at the T12–L1 junction (thoracolumbar junction).

What anatomy should be demonstrated?

Lower thoracic and upper lumbar vertebrae, including the T11–L2 region and thoracolumbar junction.

What indicates proper AP/PA positioning?

Vertebral bodies and spinous processes are centered and aligned, with minimal rotation.

AP/PA thoracolumbar spine — SID?

40 inches (100 cm)

AP/PA thoracolumbar spine — kVp?

75–85 kVp

PA Scoliosis Series: Ferguson Method positioning

pt erect, standing or seated, spine aligned and centered to midline of table or IR, arms at side

distribute weight evenly on both feet (erect position)

lower margin of IR 1-2in (2.5-5cm) below iliac crest

2nd image: 3-in (8-10cm) block under the foot (or butt if seated) on convex side of curvature so pt can barely maintain position w/o assistance

CR, SID, kVp PA Scoliosis Series: Ferguson Method

perp to center of IR

40-60in (100-150cm); longer SID recommended

75-90 kVpe

expiration for PA Scoliosis Series: Ferguson Method

expose on full expiration

lateral PA Scoliosis Series: Ferguson Method positioning

true lateral position (erect or recumbent as ordered)

spine positioned with the sag or convexity of the spine closest to the IR

lateral PA Scoliosis Series: Ferguson Method: CR, SID, kVp

Perpendicular to the mid-coronal plane or centered to the area of the curve (approx 1 to 2 inches below the iliac crest (or level of L3/thoracolumbar junction).

40 to 72 inches (72in preferred)

80–95 kVp

What anatomy is demonstrated on the lateral Ferguson scoliosis view?

Entire spine, from C7 through sacrum, including the vertebral bodies and intervertebral spaces.

What is evaluated on the lateral scoliosis view?

Spinal curvature, vertebral alignment, and sagittal balance; also helps evaluate kyphosis and lordosis.

What is the Ferguson method used to evaluate?

Scoliosis/spinal curvature and the degree of vertebral rotation/curvature.

What anatomy is demonstrated in the PA Scoliosis Series — Ferguson Method

Entire spine from C7 through sacrum, including the vertebral bodies and intervertebral spaces.

What is evaluated on the PA scoliosis view?

Spinal curvature, vertebral alignment, and vertebral rotation.

AP lspine positioning

pt supine or erect, MSP aligned to midline of table or grid

flex hips/knees (reduce lordotic curvature) (if pt recumbent)

ASIS same distance from table

CR AP lspine (when using 14×17in or 35×43cm cassette) open collimation

perp to IR

CR at level of iliac crest (L4-L5)

larger IR will include lumbar vertebrae, sacrum, and possible coccyx

CR AP/PA lspine (when using 14×17in or 35×43cm cassette) tighter collimation

CR perp to IR

CR to level of L3 (1.5in above iliac crest)

will include 5 lumbar vertebrae

SID, kVp, respiration for AP/PA lspine

40in (100cm)

75-90 kVp

expose at end of expiration

anatomy demonstrated on AP/PA lspine

lumbar vertebral bodies, intervertebral joints, and spinous/transverse processes, SI joints and sacrum

more open collimation = T11 to distal sacrum

tight collimation = T12-S1

symmetry of transverse processes, SI joints, and sacrum

spinous processes midline

open intervertebral joint spaces

lateral lspine positioning

pt recumbent or erect in true lateral position; flex hips and knees, align and center midaxillary plane to centerline

place support under waist (as needed, to place entire spine parallel to tabletop)

provide support between knees (recumbent position)