lumbar spine - radiographic technique

what are the clinical indications for lumbar spine x-ray

—Wedge fracture

—Burst fracture

—Chance fracture

—Scoliosis/kyphosis

—Spondylosis

—Ankylosing spondylitis

—Spondylolisis

—Spondylolisthesis

—Spondyloptosis

—Spina bifida Occulta

—Loss of curvature

—# sacrum

—Dislocation of Sacro-iliac joints

what should not be an indication for lumbar spine

Prolapsed intervertebral disc (PID) should not be an indication for lumbar spine – it should be MRI

what are the radiation protection measures for lumbar spine examinations

—Identification check

—Careful technique to avoid repeat examination

—Gonad protection applied wherever practicable

—Efficient collimation

—Application of the 28 day rule where appropriate

—Consider an alternative imaging modality eg. Ultrasound

Radiographic anatomy of lumbar vertebrae - lateral

lumbar AP xray labelled

radiographic anatomy of lumbar vertebra

what’s the radiographic technique for lumbar AP

—Patient supine with head resting on pillow and arms relaxed to the patient’s side

—Long axis of patient co-incident with midline of the table

—Anterior superior iliac spines (ASIS) equidistant to table top ensuring no rotation.

—MSP of patient 90 degrees to table top.

—Direct vertical central ray 90 degrees to level of lower costal margin in the  midline

•Ensure alignment of patient to image receptor

•Expose on arrested respiration using 100cm SID

how do you reduce lumbar curvature

whats the image criteria for AP lumbar

—Correct name and aspect marker

—Correct area of interest to include T12 superiorly. Proximal 2/3 of sacrum and entirety of sacro-iliac joints inferiorly. Soft tissues lateral to lumbar spine (to exclude renal pathology)

—Correct positioning to include

• —Vertebral bodies to co-incident with midline of image receptor.

• —Spinous processes central to vertebral bodies

• —Evidence of intervertebral joint space

• —Equal proportion of transverse process projected laterally from either side of vertebral bodies

—No artefacts

—Evidence of collimation

—Need for repeats or further views

—Correct exposure factors

Evidence of pathology

what would you consider when assessing the AP lumbar spine for pathology

—Cortical outlines of the vertebrae should be intact and trabecular pattern comparable between each of the vertebrae

—Size of vertebral bodies increases progressively from L1-L5

—Interspinous distance should be approximately equal throughout the lumbar spine indicating no widening or loss of joint space

—Spinous processes should be centralised throughout the lumbar spine indicating no disruption of the vertebral alignment.

—Inter- pedicular distance should be virtually equal throughout the lumbar spine indicating no disruption of the vertebral bodies.

—Pedicles and transverse processes should be symmetrical throughout lumbar spine indicating no disruption of the vertebral alignment.

—No evidence of abnormal soft tissue outlines, which would  indicate para-vertebral swelling.

lateral L spine labelled xray

what’s the radiographic technique for lateral L spine

—From supine position patient rolls onto affected side(posterior aspect of the patient facing radiographer)

—Unless the patient has scoliosis

—Elbows flexed and patients arms resting anteriorly.

—Patients shoulders and hips adjusted so they are in the same plane  allowing the MSP is to be parallel to the table top

—The long axis of the spine co-incident with midline of the image receptor.

—Knees and ankles flexed to aid stability

—Direct vertical central ray at 90 degrees to a point 7.5cm anterior to spinous process at level of lower costal margin using 100cm SID.

—Lead-rubber sheet may be placed posterior to the lumbar region to improve the improve the image quality by absorbing scattered radiation.

•The image should be taken on arrested expiration.

how does lead rubber improve image quality

how does inspiration and expiration affecr diaphragm positioning

decision on which lateral depending on curvature in scoliosis patients

lateral l spine image criteria

—Correct name and aspect marker

—Correct area of interest to include

•      T12 superiorly.

•      Proximal 2/3 of sacrum inferiorly.

•      Soft tissues anteriorly and posteriorly

•      following the curvature of the spine. 

—Correct positioning to include

• —Vertebral bodies to co-incident with midline of image receptor.

• —Superimposition of anterior posterior superior and inferior borders of vertebral bodies

• —Evidence of intervertebral joint space

• —Intervertebral foramina superimposed

—No artefacts

—Evidence of collimation

—Need for repeats or further views

—Correct exposure factors

—Evidence of pathology

lateral l spine image assessment

—Vertebral cortical outlines should be intact and trabecular pattern comparable throughout the vertebrae

—Size of vertebral bodies increases progressively from L1-L5

—Interspinous distance should be equal throughout the lumbar spine indicating no widening or loss of joint space

—Spinous processes should be aligned and not foreshortened throughout.

—Symmetry and alignment of intervertebral foramina throughout.

—No evidence of abnormal soft tissue outlines, indicating para-vertebral swelling

L5-S1 Junction radiographic technique

—From supine position patient rolls on to affected side

  (posterior aspect of the patient facing radiographer)

—Elbows flexed and patients arms resting anteriorly.

—Patients shoulders and hips adjusted so they are in the same plane

    allowing the MSP is to be parallel to the tabletop

—The long axis of the spine co-incident with midline of the image receptor.

—Knees and ankles flexed to aid stability.

—Direct vertical central ray at 90 degrees to a point 5cm anterior to spinous process of L5 using 100cm SID.

—Lead-rubber sheet may be placed posterior to the patient to  improve the improve the image quality by absorbing scattered radiation.

—The image should be taken on arrested expiration.

Image criteria for L5-S1 Junction

Correct area of interest to include

     L4 superiorly.

     Proximal 2/3 of sacrum inferiorly.

     Soft tissues anteriorly and posteriorly

     following the curvature of the sacrum

 Correct positioning to include

—Vertebral bodies and sacrum to co-incident with midline of image receptor.

—Superimposition of anterior posterior superior and inferior borders of vertebral bodies and sacrum

—Evidence of intervertebral joint space L4/L5 and L5/S1

—Intervertebral foramina superimposed L4/L5 and L5/S1

image assessment for L5-S1 junction

—Vertebral cortical outlines should be intact and trabecular pattern comparable throughout the L4/5 and sacrum

—Size of sacrum decreases progressively from S1-S5

—No widening or loss of joint space L4/5 and L5S1

—Spinous processes of L4 and L5 should be aligned and not foreshortened.

—Symmetry and alignment of intervertebral foramina L4/5 and L5S1 .

—No evidence of abnormal soft tissue outlines, indicating par-vertebral swelling

what is the radiographic technique for lateral sacrum

—From supine position patient  rolls on to affected side (posterior aspect of the patient facing radiographer)

—Elbows flexed and patients arms resting anteriorly.

—Patients shoulders and hips  adjusted

    so they are in the same plane allowing the MSP is to be parallel to the tabletop

—The long axis of the spine co-incident with midline of the image receptor.

—Knees and ankles flexed to aid stability.

—Direct vertical central ray at 90 degrees to a point midway between the PSIS and the sacro-coccygeal junction using 100cm SID.

—Lead-rubber sheet may be placed posterior to the patient to

     improve the improve the image quality by absorbing scattered radiation.

—The image should be taken on arrested expiration.

whats the image criteria for lateral sacrum

Correct area of interest to include

     L5 superiorly.

     Coccyx inferiorly.

     Soft tissues anteriorly and posteriorly

     following the curvature of the sacrum

 Correct positioning to include

—Sacrum co-incident with midline of image receptor.

—Superimposition of anterior posterior superior and inferior borders of sacrum

—Evidence of intervertebral joint space L5/S1

—Intervertebral foramina superimposed L5/S1

what is the radiographic technique for PA sacro-iliac joints

—Patient prone with head resting on pillow and arms placed to either side of head or relaxed to the patient’s side

—Long axis of patient co-incident with midline of the table top.

—Posterior superior iliac spines (PSIS) equidistant to table top ensuring no rotation.

—MSP of patient 90 degrees to table top.

—Direct central ray 10 - 15 ̊caudally to the level of the PSIS in the  midline

•Ensure alignment of patient to image receptor

•Expose on arrested respiration using 100cm SID

PA sacro-iliac joints image criteria

—Correct area of interest L5 superiorly. proximal 2/3 of sacrum inferiorly.

  Medial 1/3 of iliac bones laterally

—Correct positioning to include

• —Sacrum co-incident with midline of image receptor.

• —Superimposition of anterior posterior superior and inferior borders of sacrum.

• —Sacral foramina equal in size and shape

what’s the image assessment for sacrum and SI Joints

—Remember ABCD

—Vertebral cortical outlines should be intact and trabecular pattern comparable throughout sacrum

—Size of sacrum decreases progressively from S1-S5

—No widening or loss of joint space throughout sacrum or SI joint

—Symmetry and alignment of sacral foramina

—No evidence of abnormal soft tissue outlines, indicating para-vertebral swelling