Dr Mohamed El Safwany, MD.
1
Intended Learning Outcome
The student should be able to recognize
technological principles of radiographic dorsal and
lumbosacral spine imaging.
2
TECHNICAL ASPECTS
A moving or a stationary grid must be used.
Relatively high kV is used, range is (80 - 95) KVp,
(95 -100) kVp for lateral L/S) to reduces patient’s dose.
All part supports and pads mentioned are radiolucent.
The anode heel-effect must be observed, with anode at the head side (a wedge-filter
or graduated screens can be used instead) to produce overall uniform spine density.
Radiosensitive areas must be well covered by shields.
Collimation must be strictly applied in all projections to improve image contrast and reduce
patient’s dose and amount of scatter.
3
AP thoracic (dorsal) spine
B
AP thoracic (dorsal spine): For #s and pathology (compression,
kyphosis, and subluxation).
Patient supine with head under anode side to observe the heeleffect, both knees and hips flexed and arms stretched by the side.
Exposure at end of arrested expiration to reduce volume
of air in thorax for more uniform density of whole dorsal vertebrae.
MSP: 90 to the film, MCP: parallel to film (no rotation).
Film: HD 35x43 cm, lengthwise.
CP: T7 ( 3 – 5 cm below the sternal angle, or 8 – 10 cm below
jugular notch) as for the PA chest.
CR: 90 Vertically to the thoracic spine
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
4
Lateral thoracic (dorsal) spine
B
Lateral thoracic spine: For pathology (compression, kyphosis,
or suluxation).
Patient in a lateral recumbent, both knees flexed and arms
stretched at right angles, waist supported, anode heel-effect
should be well observed. Exposure at end of arrested
expiration, or during quiet breathing using low mA and long
exposure time (3 - 4 s) to diffuse the lung and ribs shadows.
A lead blocker sheet near patient’s back helps stop scatter
rays from reaching the film, thus improves image quality.
MSP: parallel, MCP: 90.
Film: HD 35x43 cm
CP: T7 ( 3 - 5 cm below the sternal angle, or 8 – 10 cm
below jugular notch).
CR: 90 Vertically to the thoracic spine
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
5
PAO (or APO) thoracic spine
B
Zygapophyseal joints of the thoracic spine.
Patient in a lateral recumbent or in lateral erect, body rotated 20
from true lateral, arm nearest couch must be down, arm nearest
tube must be up and forward. Exposure at end of suspended
full expiration.
Film: HD 35x43 cm
CP: T7 ( 5 cm below the sternal angle, 8 – 10 cm below jugular
notch).
CR: 90 V/H to film center.
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
6
AP lumbar spine
B
AP five lumbar vertebral bodies and intervertebral spaces,
spinous and transverse processes, S.I. joints and sacrum.
For #s, pathology (scoliosis and neoplastic processes of
the thoracic spine).
Patient supine or erect, knees flexed with soles of feet on
the couch top, arms at the sides or on the chest, exam can
be done in the erect position, a compression band is used
which will greatly improve contras, exposure must be
during a quiet breathing at low mA and long exposure time
to diffuse colonic gas shadows. Exposure at end of full
expiration.
Film: HD 35x43 cm
CP: Large film (35x43) cm: L4 – L5 (level of iliac crest).
Small film (30x24) cm: L3 (level of lower costal
margins).
CR: 90 V/H to film center.
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
7
Lateral Lumbar Spine
B
Lateral lumbar vertebral bodies, spinous processes, L5 –
S1
junction, and sacrum. Rules-out compression # of lumbar
bodies.
Patient in a lateral recumbent, knees flexed, support
between knees and ankles, pad under the waist,).
Exposure at end of arrested expiration.
Film: HD 35x43 cm
CP: Large film: L4 – L5 (level of iliac crest).
Small film: L3 (level f lower costal margins).
CR: 90 V to center of film
NB/ Lateral for trauma can be done with patient in (supine
decubitus), with same CP and horizontal beam.
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
8
Lateral lumbosacral spine (L5 – S1)
B
For lat L5 – S1 joint space, and for spondylolisthesis or other
pathologies of L4 to L5, or L5 to S1
Patient in a lateral recumbent, the knees flexed, support
between knees and the ankles, pad under the waist, rubber
sheet behind the lumbar region.
Film: HD 18x24 cm
CP: 4 cm below iliac crest, 4 cm anterior to the posterior
surface of the body.
CR: 90 V to film center (with sufficient waist support), 8
caudal for waist (with no support).
NB/ Close collimation is necessary because of the high amount of
secondary radiation produced in this view.
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
9
AO lumbar spine
B
For zygoapophyseal joints.
Patient semidupine (or semi-prone), body then rotated 45,
knee flexed, lower back supported with pads.
Film: HD 30x35 cm
CP: Level of 3 – 4 cm above level of iliac crest.
CR: 90 to film center
NB/
Semi-supine: 45 RPO (for R downside zygo. joints).
Semi-prone : 45 LAO (for L downside zygo. joints).
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
10
AP axial sacrum
B
AP sacrum (not foreshortened), S.I. joints, and L5 – S1
junction.
Patient supine, legs extended, support under the knees.
Exposure during arrested expiration.
Film: HD 24x30 cm
CP: Midway between level of the symphysis pubis and
ASIS.
CR: 15 cephalad.
NB/ For lateral sacrum: Patient in true lateral recumbent, CR 90
vertically 5 cm anterior to posterior sacral surface at level of
ASIS.
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
11
AP axial coccyx
B
For pathology of the coccyx. Urinary bladder should be
Emptied before this examination Cleansing enema must
Also be done to clean the colon of fecal material.
Patient supine, legs extended, support under the knees
Film: HD 24x30 cm
CP: 5 cm superior to the symphysis pubis.
CR: 10 caudad.
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
12
Lateral coccyx
B
For pathology of the coccyx. (urinary bladder and the
colon should be emptied before examination from their
contents. Cleansing enema is used for the colon.
Patient in a lateral recumbent, knees flexed, support
under the waist
Film: HD 18x24 cm
CP: 5 cm distal to level of ASIS, and 5 cm anterior to
posterior surface of sacrum and coccyx.
CR: 90 V to film center.
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
13
TABLE 4 (Exposure Factors)
PROJECTION
kVp
mAs
AP Thoracic Spine
90
7
Lateral Thoracic Spine
80
50
AO Thoracic Spine
80
26
AP Lumbar Spine
80
15
AP Axial Lumbosacral Spine Joint (L5 – S1)
80
20
Lateral Lumbosacral Spine Joint (L5 – S1)
100
50
Lateral Lumbar Spine
90
65
AO Lumbar Spine
85
15
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
14
TABLE 4 (Exposure Factors)
PROJECTION
kVp
mAs
AP Axial Sacrum
80
15
AP Axial Coccyx
80
15
Lateral Coccyx
90
55
Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa
15
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TECHNICAL ASPECTS
In all cervical spine views, a moving or a stationary grid must be used
Optimal exposure is required to show soft tissue as well as proper bone
density of the entire cervical spine. A small focus improves image detail.
Collimation must strictly be applied in all projections.
Exposure on fully suspended expiration.
17
AP Cervical spine (C1 – C2) Open Mouth
B
To show pathology involving C1 and C2 (dens).
Patient supine (AP) or erect, chin elevated, the
head adjusted so that with the mouth is open, a
line from lower margin of upper incisors to the
mastoid tips is 90 to couch. Mouth should be
wide open during exposure. Grid is not essential
for this view.
Film: HD 18x24 cm.
CP: Center of open mouth.
CR: 90 to film center. A wooden block must be
used to hold the mouth open.
18
AP Axial Cervical (C3 – T3)
B
To show pathology of the mid and lower
cervical spine (C3 – T3).
Patient supine (AP) or erect, a line from the
occlusal plane to the mastoid tips must be 90
to the couch.
Film: HD 24x30 cm. A grid is not necessary
for this view.
CP: Level of lower margin of the thyroid
cartilage
to pass through C5 – C6 (
CR: 15- 20 cephalad.
19
PAO Cervical spine
B
Intervertebral foramina and pedicles. AOs are preferred
because of reduced thyroid doses.
Patient erect, arms at sides, body and head rotated 45,
chin extended.
Film: HD 18x24 cm.
CP: Level of upper the margin of thyroid cartilage to
pass through C4.
CR: 15- 20 caudad.
20
Lateral Cervical spine
B
For pathology involving vertebral bodies, the
intervertebral spaces, spinous processes, and
zygoapophyseal joints .
Patient in erect lateral (stand or sit), shoulder
depressed (with equal weights), forward, and against
vertical film, cassette top margin 5 cm above EAM.
Film: HD 24x30 cm.
CP: Level of upper margin of thyroid cartilage to
pass
through C4 – C5.
CR: 90 to film center, FFD 150 cm.
.
21
Lateral Cervical spine (trauma case)
B
To show pathology in cervical spine (#s and
subluxations).
Patient in supine on a stretcher or on couch.
Film: HD 24x30 cm.
CP: 2.5 cm above level of upper margin of
thyroid cartilage, to pass through C4.
CR: Horizontally 90 to film center.
22
Lateral Cervical (Hyperflexion and hyperextension)
S
Functional study the dynamics (motion/ lack of motion) of the
cervical vertebrae, to rule-out a ‘whiplash’ injury.
Patient sits or stands in the erect lateral, shoulders depressed
(weights may be used), neck hyper-flexed (chin touches the
chest) or hyperextended (head leaned back), as required.
Film: HD 24x30 cm.
CP: Level of upper margin of thyroid cartilage to (C4 – C5).
CR: Horizontally 90 to film (FFD: 180 cm).
23
AP ACROMIOCLAVICULAR JOINTS (ACJs)
B
For #s/ joint separation. Done with /without stress weights
(8 – 10 pounds, 10 – 15 for large adult patients), cassette
crosswise.
Patient erect, back of shoulders against film, 2 films taken in
the same position (one with the weights, other without), film
2” above shoulders, 35x43 film.
CP: Midpoint between clavicles.
CR: 90 horizontal to film center.
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TABLE 2 (Exposure Factors)
PROJECTION
kVp
mAs
AP Cervical (C1 – C2, Dens), Judd Method
75
15
AP Cervical (C1 – C2), ‘Open-Mouth Technique’
75
15
AP Cervical (C1 Ring), ‘Wagging Jaw Technique’
75
15
AP Axial (C3 – C7)
75
10
APO Cervical
75
10
Lateral Cervical (trauma case)
75
28
Lateral Cervical (hyperflexion/ hyperextension)
75
28
Cervicothoracic Lateral (C4 – T3), ‘Swimmer’s View’
80
120
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TABLE 2 (Exposure Factors)
PROJECTION
kVp
mAs
Lateral Cervical
75
28
AP Axial Cervical (Vertebral Arch – Pillars)
75
12
AP/ AP Axial clavicle
70
8
ACJs (Bilateral)
65
20
AP Scapula
75
7
Lateral Scapula
75
13
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Assignment
• Two students
will be
selected for
assignment
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Suggested Readings
• Clark’s
Radiographic
technology
28
Question
• Describe
radiographic
principles of
lumbosacral
spine
radiogram?
29
• Thank You
30