1. Radiographic Technique of Thoracic and Lumber Spine
Yashawant kumar Yadav
B.MIT 1st Year
NAMS BIR Hospital

2. Overview Introduction Anatomy of spines Indications
Recommended projections for T & L spine
Summary
references

3. Introduction
The vertebral column is commonly called the spine ,backbone or spinal column ,is a complex succession of many bones.
It is a part of axial skeleton.
It provides a flexible supporting column of the trunk , head and upper body to lower limbs.
The vertebral column houses the spinal canal, a cavity that encloses and protects the spinal cord.
The vertebral column is composed of 33 bones which are given below.

4. Contd.. Cervical vertebrae=7 Thoracic vertebrae=12 Lumber vertebrae=5
Sacrum vertebrae=5
Coccyx=4

5. Landmark of spines
T1 =25% of the time it is the most prominent, it does not rotate as much as C7 when the head turns.(just below of cervical vertebra)
T2-T3 =sternal or jugular notch
T3-T4 =sternal angle
T = inferior angle of scapula
T9-T10 =Xyphoid process
L3-L4 =umbilicus

6. Some Terminology Lordosis:
The term lordosis ,meaning bent backward describes the normal anterio-concavity of the cervical and lumber spine.
Kyphosis:
The meaning of kyphosis is described as abnormal or exaggerated thoracic “Hump back "curvature with and increased convexity.
Scoliosis:
Abnormal of exaggerated in lateral curvature is called scoliosis.

7. Anatomy of T-Spine
The thoracic spine is the longest region of the spine, and by some measures it is also the most complex.
Connecting with the cervical spine above and the lumbar spine below, the thoracic spine runs from the base of the neck down to the abdomen.
It is the only spinal region attached to the rib cage.

8. Contd..
Consists of body, pedicle, lamina, spinous process, transverse process and superior & inferior articular processes.
Bodies of vertebrae increases in size fromT1 to T12
The superior thoracic body resembles with the cervical body & inferior with the lumbar body.
They are distinguished by the presence of facets on the sides of the bodies for articulation with the heads of the ribs, and facets on the transverse processes of all, except the eleventh and twelfth, for articulation with the tubercles of the ribs.

10. Indications Any cases of Trauma Fracture Dislocation Foreign body
Kyphosis
Subluxation
Tumor
Osteoarthritis
osteoporosis etc.

11. Basic projections Ap view erect/supine Lateral erect/lying lateral
AP OR PA Oblique Projection RAO and LAO or RPO and LPO Upright and recumbent positions.
For Trauma patient on Trolley:-
Lateral supine with HB (basic)
AP supine (basic)
Non traumatic pathology:-
Lateral (basic )
Supine (basic)

12. Ap view supine Patient is supine, in the middle of the table
A low pillow under the knee and ankle joint for the patient comfort
Cassette is placed under the table in Bucky
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.

13. CENTERING RAY ESSIANTAL IMAGE CRITERIA
Centered in the midline mid-way between the cricoid cartilage &the xiphoid process of the sternum, approximately 2.5cm below the sternum angle. (T7)
ESSIANTAL IMAGE CRITERIA
The image should be include the vertebra from (C7-L1)
The image density should be sufficient to demonstrate bony detail for the upper as well as the thoracic lower vertebrae.

14. LATERAL VIEW OF THORAIC SPINE
The patient should be in lateral decubitus position on x-ray table, although the this projection can also be done in erect
The arm should be raised over the head
The upper edge of the cassette should be at least 40cm in length positioned 3-4cm above the spinous process of C7.

15. CENTERING RAY ESSIANTAL IMAGE CRITERIA
Center ray should be right angle of the axis of the thoracic vertebra. This may required 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.(clear)
ESSIANTAL IMAGE CRITERIA
Upper two or three vertebra may not be visual due to super imposed by shoulder.

16. Contd..
The posterior ribs should be superimposed, thus indicating that the patient is not rotate too far backward or forward
There should be clearly visualization of whole spine(T1-T12)

17. AP OR PA OBLIQUE PROJECTION RAO and LAO or RPO and LPO Upright and recumbent positions
The thoracic zygapophyseal joints are examined using PA oblique projections .
Place the patient, standing or sitting upright, in a lateral position before a vertical grid.
Rotate the body 20 degrees anterior (PA oblique) or posterior (AP oblique) so that the coronal plane form an angle of 70 degrees from the plane of the IR.
• Adjust the patient's shoulder to lie in the same horizontal plane.
Suspend the end of expiration.

18. Central ray
• Perpendicular to the IR exiting or entering the level of T7

19. Recumbent position Patient is Placed in a lateral recumbent position.
Patient’s hips and knees is Flex to a comfortable position.
For anterior (PA oblique) rotation, the lower arm is placed behind the back and the upper arm forward with the hand on the table for support.
Rotate the body slightly, either anteriorly or posteriorly 20 degrees, so that the coronal plane forms an angle of 70 degrees with the horizontal.
If needed, apply a compression band across the hips, but be careful not to change the position.
Suspend at the end of expiration.

20. Central ray:-
Center the IR 1 1/2 to 2 inches (3.8-5 cm) above the shoulders to center it at the level of T7.

21. ESSIANTAL IMAGE CRITERIA
All twelve thoracic vertebrae .
Zygapophyseal joints closest to the IR on PA obliques and the joints farthest from the film on AP obliques .
Wide exposure latitude.

22. LUMBAR SPINE(L1-L5)
The lumbar spine consists of moveable vertebrae numbered L1-L5.
The lumbar spine is designed to be incredibly strong, protecting the highly sensitive spinal cord and spinal nerve roots. At the same time, it is highly flexible, providing for mobility in many different planes including flexion, extension, side bending, and rotation.
The first lumbar vertebra is level with the anterior end of the ninth rib. This level is also called the important transpyloric plane.
Lumber vertebrae doesn’t have facet .

23. Indications Low back pain Trauma Fracture Kyphosis Lordosis Scoliosis
Spondylitis
Spondylolysis
Metastases
Subluxation
tumor

25. Basic AP view Patient position
Patient lies in supine on table with the median sagittal plane at the right angle at the midline of the table
The cassette should be large enough (14x17”) to include the lower thoracic vertebrae & Sacro- iliac joint and centered at the lower costal margin.

26. Centering point..
• Perpendicular to the IR at the level of the iliac crests (L4) for a lumbosacral examination or (3.8 cm) above the iliac crest (L3) for a lumbar examination.

27. ESSIANTAL IMAGE CRITERIA
The image should include from the (T12)down, to include all of the Sacro-iliac joint.
Rotation can be assessed by ensuring that the Sacro- iliac joints are the equidistant from the spine.
The exposure used should produce a density such that bony detail can be discerned throughout the region of interest.

29. LATERAL PROJECTION R or L position
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 center 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.

30. Contd..
The cassette is centered 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.

31. Direction and centering 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.

32. Essential image characteristics
The image should include T12 downwards, to include the lumbar sacral junction.
Ideally, the projection will produce a clear view through the center of the intervertebral disc space, with individual vertebral end plates superimposed.
The cortices at the posterior and anterior margins of the vertebral body should also be superimposed.
The imaging factors selected must produce an image density sufficient for diagnosis from T12 to L5/S1, including the spinous processes.

34. AP Oblique Projection RPO and LPO positions
The patient turns from the supine position toward the affected side approximately 45 degree to demonstrate the joints closest to the IR (opposite the thoracic zygapophyseal joints).
Adjust the patient's body so that the long axis of the patient is parallel with the long axis of the radiographic table.
Center the patient's spine to the midline of the grid.
Suspend at the end of expiration.

35. Central ray
Enter 2 inches (5 cm) medial to the elevated ASIS and 1-1/2 inches (3.8 cm) above the iliac crest (L3).
Center the IR to the central ray.

36. Structures shown
The resulting image shows an oblique projection of the lumbar and/or lumbosacral spine, demonstrating the articular processes of the side closest to the IR. Both sides are examined for comparison .
When the body is placed in a 30- to 50degree oblique position then articular processes and the zygapophyseal joints are demonstrated. When the patient has been properly positioned, images of the lumbar vertebrae have the appearance of "Scottie dogs."

37. Image Criteria Area from the lower thoracic vertebrae to the sacrum.
• Zygapophyseal joints closest to the IR open and uniformly visible through the vertebral bodies.
Vertebral column parallel with the tabletop so that the T 12-LI and LI- L2 joint paces remain open.

38. PA Oblique Projection RAO and LAO positions
Examine the patient in the upright or recumbent prone position. The recumbent position generally used because it facilitates immobilization.
However, the OID is increased, which can affect resolution.
The joints farthest from the IR are demonstrated with the PA oblique projection (opposite the thoracic zygapophyseal joints).
From the prone position, have the patient turn to a semi-prone position and support the body on the forearm and flexed knee.
Center the IR at the level of L3.
To demonstrate the lumbosacral joint, position the patient as described above but center L5.

39. Central ray
Perpendicular to enter the L3 (1 to ½ inches [2.5 to 3.8 cm] above the crest of the ilium). The central ray enter the elevated ide approximately 2 inches (5 cm) lateral to the palpable spinous process.

40. Structures shown
The resulting image shows an oblique projection of the lumbar or lumbosacral vertebrae, demonstrating the articular processes of the side farther from the IR .
The fifth lumbosacral joint is usually well demonstrated in oblique position.
When the body is placed in a 30- to 50degree oblique position and the lumbar spine is radiographed, the articular processes and zygapophyseal joints are demonstrated .
When the patient has been properly positioned, image of the lumbar vertebrae have the appearance of "Scottie dog .”

42. Evaluation Criteria
Area from the lower thoracic vertebrae to the sacrum.
Zygapophyseal joints farthest from the IR.
When the joint is not well demonstrated and the pedicle is quite anterior on the vertebral body, the patient is not rotated enough.
When the joint is not well demonstrated and the pedicle is quite posterior on the vertebral body, the patient is rotated too much.

43. Lateral Horizontal Beam
Patient’s preparation
The trauma trolley is placed adjacent to the vertical Bucky.
Adjust the position of the trolley so that the lower costal margin of the patient coincides with the vertical central line of the Bucky and the median sagittal plane is parallel to the cassette.
The Bucky should be raised or lowered such that the patient’s mid- coronal plane is coincident with the midline of the cassette within the Bucky, along its long axis.
If possible, the arms should be raised above the head.

45. Direction and centering of the X-ray beam
Direct the horizontal central ray parallel to a line joining the anterior superior iliac spines and towards a point 7.5cm anterior to the third lumbar spinous process at the level of the lower costal margin.
Essential image characteristics
Refer to lateral lumbar spine.
Extreme care must be taken if using the automatic exposure control. The chamber selected must be directly in line with the vertebrae, otherwise an incorrect exposure will result.

46. Contd…
• If a manual exposure is selected, then a higher exposure will be required than with a supine lateral. This is due to the effect of gravity on the internal organs, causing them to lie either side of the spine.

47. Lateral Flexion and Extension
Lateral projections in flexion and extension may be requested to demonstrate mobility and stability of the lumbar vertebrae.
Patient preparation
This projection may be performed supine, but it is most commonly performed erect with the patient seated on a stool with either side against the vertical Bucky.
A seated position is preferred, since apparent flexion and extension of the lumbar region is less likely to be due to movement of the hip joints when using the erect position.

48. • The dorsal surface of the trunk should be at right-angles to the cassette and the vertebral column parallel to the cassette. • For the first exposure the patient leans forward, For the second exposure the patient then leans backward, • The cassette is centered at the level of the lower costal margin, and the exposure is made on arrested expiration.

49. Direction and centering of the X-ray beam
• Direct the central ray at right-angles to the film and towards a point 7.5cm anterior to the third lumbar spinous process at the level of the lower costal margin.
Essential image characteristics
Refer to lateral lumbar spine .
All of the area of interest must be included on both projections.

51. Exposure according to positions of T&L
Thoracic spine mAs KVp AP/oblique Lat Lumber spine AP/oblique Lateral

52. References
Clark’s 13th ed
Merrill's
web

53. Thank you

55. Cricoid cartilages = ? Auto tomography=?