THE VERTEBRAL COLUMN

Mr. NICAS CW
 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
 The Vertebral Column
 Vertebrae separated
by intervertebral
discs
 The spine has a
normal curvature
 Each vertebrae is
given a name
according to its
location
 Most of the examination in the vertebral column
need a Bucky or stationary grid except the lateral
view of the cervical spine.
 Arrested respiration for this examination of this
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
 Vertebral levels
• Some useful land marks
1. Angle of mandible 2-3 CV
2. Sternal notch T2-T3
3. Sternal angle T4-T5
4. Xiphisternal junction T9-4
5. Lower coastal margin 3-4 LV
6. Umbilicus 3-4 LV
7. Iliac crest 4 LV
8. ASIS 2 sacral
9. 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.
• Note; the vertebral column of a child may be
shown almost completely on one film.
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.
 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 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
The thoracic spine is concave forward.
There are twelve vertebrae
The upper thoracic vertebrae resemble
the cervical vertebrae the lower thoracic
vertebrae resemble the lumbar vertebrae
The bodies of the thoracic vertebral
increase in size from the upper region to
the lower
 Preparation of the patient
 The patient is undressed to the waist and
given an x ray gown
 Basic views
 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 thoracic-vertebrae
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.
 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 sliightly to
the spine.
 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 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.
 LUMBAR VERTEBRAE
 The lumbar spine is done with a patient lying in
supine position.
 Remembering the anatomy of the lumbar, the
radiographic technique of this area needs
methods of reducing lumbar lordosis
 In lateral view the shoulders and hips are in
contact to the table and bring sag of this region.
 The sag depends on the physique of the patient
 Radiation protection
 The primary beam should be carefully
restricted to the area of interest and gonad
area covered with suitable gonad protector
 Basic views
 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)
Lateral
 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
This region is rarely shown in the
antero- posterior and lateral view of
the lumbar spine
• 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
The region is usually obscured by foecal
matters or gas shadows in the colon.
Laxatives is given whenever possible in
special cases
Tube angulation will depend on the
inclination of the sacrum
 Basic views
 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

The coccyx is often obscured by

bowel’s contents
This should be cleared of gas and
foecal matter
Collimation should be used for this
examination of this region
 Basic views
• 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.
THANK YOU !!