Lumber Spine and Pelvis Radiography

8/6/2019 Lumber Spine and Pelvis Radiography

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Moderator:-

Mr. Lalit Kumar Gupta (Tutor)Deptt. of Radio-Diagnosis & Imaging

PGIMER, Chandigarh

Presented By:-RUNISHA

B.Sc. Med. Tech. (X-ray) 2nd Year

Deptt. of Radio-Diagnosis & Imaging

PGIMER, Chandigarh


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Vertebral column forms the central axis of theskeleton and is centered in the mid sagittal planeof the posterior part of the trunk.

It is made up of small segments of bone with fibro

cartilaginous discs interposed to act as a cushion.Its functions are :

It encloses and protects the spinal cord

It supports the trunk , skull and provides

attachment to the ribs laterally.

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The Vertebral column normally consists of 33small , irregular bones called vertebrae. The

vertebrae are divided in to five groups andnamed accordingly to the regions they occupy.

The upper sevenvertebrae occupy the region ofthe neck and termed cervical vertebrae.

The succeeding twelve bones lie in the dorsalportion of the thorax called the thoracic

vertebrae.

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The fivevertebraeoccupy the region of

loin or lumbus, arecalled lumbarvertebrae.

The next five are termedsacralvertebrae and the

vertebrae in theterminal group which

vary from three to five innumber are calledcoccygealvertebrae.

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Curvature of Vertebral Column: - At birth, themajority of the vertebral column is curved, with its

concavity facing forward as the development occurs &as the child starts to lift his head & begins to walkadditional curvature develops within the spine inresponse to these activities. According to growing age,

vertebral column has respectively two curvatures thatare termed as:

Primary curvature &

Secondary curvature.

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Primary Curvature: - The whole

of the vertebral column of the

body attains a single concave

curvature during the foetal &

infant life which is the primary

curvature. They are Thoracic &

Sacro-coccygeal.

Secondary Curvature: - At thesame time after birth and with

the growing age, the vertebral

column then again undergoes

two secondary curvatures. Bothof these curvatures are convex in

nature & are located in the

Cervical& Lumbarregions of

the body..


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1. X-ray Unit.

2. HF Generator.

3. Grid.

4. Vertical & table bucky.5. Cassette.

6. Separator

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The radiography of spine can be carried out by using anOrdinary Bucky Table Unit. It has Ceiling Suspension(Mounted) with telescopic arm & multi directionalmovement.

The x-ray tube is a bifocal tube with a 0.6 mm and 1.2mm focus.

The tube column also has motorized vertical momentsand the focus to film distance can be varied from 70 to

130cm.

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Desirable: -1. High mA in b/w 300mA 800mA.

2. High kV 40kV 150kV

3. AEC.

4. APR.

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HF GENERATOR:

It should be 6O 80 KW.

GRID: -

It must be used when kVp is higher than 70 kVp in

spine radiography to reduce the scatter radiation &for better image quality.

It should be 8:1 or 10:1.

VERTICAL BUCKYOR TABLE: -

It should be floating type with motorizedmovement in all direction. For easy pt. setup.

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The radiological technologist must have to know:Indication of special projection.

Must be quick in making decision.

T

he proper knowledge to provide quality of pt.care in emergency cases.

The better image quality should be producedwith min. exposure & to min. discomfort to the

pt. in the min. time period.Ensure any cassettes, grids, lead rubber

protection, foam pads etc. you may require areclean.

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Check form is fully completed & signed.Check pregnancy question if required.Take special care with details from,

elderly, handicapped, deaf, blind, veryyoung, individuals with poor English etc.Review any previous reports & films.Confirm details of patient and

examination.

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Anatomy:-

There are five lumbarvertebrae, of which the first fourare typical, and the fifth is atypical.

Alumbar vertebra is identified by:-

(a) Its large size and(b) By the absence of costal facets on the body.

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Features of typical Lumbar Vertebra:-

a) The body is large, and is wider from side to side.

b) The vertebral foramen is triangular in shape and islarger than in the thoracic region.

c) The pedicles are short, thick and broad.

d) The lamina are short and strong.

e) The transverse processes are thin and tapering, andare directed laterally and slightly backwards.

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Features of atypical 5th Lumbar Vertebra:-

a) The body is the largest of all lumbar vertebrae.

b) The transverse processes are thick, short andpyramidal in shape.

c) The distant between the inferior articular processes isequal or more than the distance between the superior

articular processes.

d) The spine is small, short and rounded at the tip.

e) The pedicles are directed backwards and laterally.

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Lumber spine lies in the abdomen and is superimposedby the gut which has faecal matter so except in traumaand emergency patients this radiograph is not done

without preparation.

1) Patient is prescribed 2 TDS of charcoal and 2 tablets ofthe laxative dulcolex at bed time for prior two days.

2)The patient is asked to come empty stomach on theday of examination.

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Patients referred for radiography may beworried and anxious about the outcome, somepatients, are difficult to handle and may needspecial care, typically the very young,old physically and or mentally infirm,

unconscious or unable to co-operate, Theassistance of a nurse or other competent personmay be required.

It is important to remember the dignity of the

patient, and essential to have clean hands, aclean cassette or bucky stands and cleanimmobilization aids at all times.

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Lower Back Ache (Pain).PIVD.

Trauma e. g. Fracture.

Lordosis.

Scoliosis.

Zygapophyseal Joint.

Vertebral fracture.

Osteoporotic collapse.Butterfly Vertebrae.

Inter-vertebral foramina.

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Spine TB (Potts Disease)

Osteomyelitis.

Osteoporosis.

Osteochondritis

(Schewermans Disease). Hemi vertebrae.

Pagets Disease.

Congenital abnormalities. Tumors: - e.g. Metastases

or Benign, Primary Bone

tumor..


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a) AP View.

b) Lateral View.

ADDITIONALVIEWS:a) AP Obliqueb) PAOblique

c) Lateral-Flexion andE

xtensiond) Lumber Intervertebral Disks

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1)AP VIEW:ForLumber spinePositioning: Patient is made to

lie down in supine position with

mid saggital plane center to thecentre of the table. Legs are flexed at the hip and

knee joint to reduce curvatureof lumbar spine .

Both hands are placed over thechest or below head

Both the anterior superior iliacspines are in the same plane.

C.R: Directed at the mid point ofthe line joining the inferiorcostal margin i.e L3.

Film is centered at the same level.

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ForLumbosacral Spine:

It is taken in the same position

but legs are extended and the filmis centered at the level of iliac crest.

C.R: Directed perpendicular to thefilm at the mid point of the line

joining the anterior superior iliacspines.

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AP VIEW


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ForLumbosacral Junction:

It is taken in the same position

but legs are extended and thefilm is centered at the level ofiliac crest.

C.R: Directed 5-15 degree

towards the head midway atthe level of anterior superioriliac spine.

So it is also called AP Axial

view. Exposure is made on

suspended inspiration.

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AP Axial View


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Area from the lower thoracic vertebrae to the coccyxshould be included.

There should not be an artifact across themidabdomen from the elastic in the patientsunderclothing.

Exposure should penetrate all the vertebral structures. Intervertebral joints should be open and well

visualized.

Sacroiliac joints should be equidistant from the

vertebral column.

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y 2)LATERALVIEW:ForLumberSpine

Positioning: Patient is turnedtowards one side with backtowards the technologist.

The MSP of the pt.s body should be parallel to the x-ray

table top & MCP is centered tothe centre of the table.

Arms are placed over the headand legs are flexed at knee andhip joint.

Aradioparent pad is placedunder lower abdomen to bringthe line joining the spinousprocesses parallel to the film.

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Astrip of lead rubber or separator is place just post. Tothe pt. to prevent scatter radiation reaching to the

film.The cassette is centered in the bucky tray at the level

of the L3 vertebra.

C.R: Directed at the level of lower costal

margin 1 inch anterior to spinousprocess of L3 or midline of axilla up tothe level of inferior costal margin.

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LATERALVIEW:- ForLumboSacral Spine

Position is same as that oflumbar spine.

The cassette is centered in thebucky tray at the level of the

lower costal margin.C.R.: Directed 1 inch below the

highest point of iliac crestand 2 inches anterior to the

joining the spinous process. Exposure is made on

suspended inspiration.

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LATERALVIEW:- ForLumbosacral Junction:

Position is same as that oflumbar spine.

The cassette is centered in thebucky tray at the level of thelower costal margin.

C.R.: Directed at right angle tothe lumbosacral region of thevertebral column at a point 3inch anterior and at the level

of the 5th lumbar spinousprocess.

Exposure is made onsuspended inspiration.

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Area from the lower thoracic vertebrae to the coccyx

should be included. Intervertebral disk spaces should be open.

Posterior margins of each vertebral body should besuperimposed.

Vertebrae should be aligned down the middle of theradiograph.

When x-ray beam is not angled, the crests of iliumshould nearly superimpose each other.

Spinous processes should be demonstrated.

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Oblique view done for lumbar canal stenosis i.e.blockage of lumbar canal.

a) AP Oblique (posterior oblique).

b) PAOblique (anterior oblique).

In the RPO view: Lt. Foramina are shown &

In the LPO View: Rt. Foramina are shown.

In the RAO View: Rt. Foramina are shown &

In the LAO View: Lt. Foramina are shown.

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Positioning:This view can be done in both

Upright & Lying-Downposition.

The pt. is made to lie-downin supine position on the x-ray table facing towards the

X-ray tube.T

hen the pt.s body isrotated 45 away from thevertical bucky on each sideto bring the MSP at 45 withthe x-ray table.

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The arm touching the table is

raised and folded over the

head.

The arm of other side is bring

forward and asked to hold the

table.

The hip and knee are flexed ofthe side touching the table and

the pt. is supported with form

pads placed under the trunk

on the raised side.

The cassette is placed &

centered it at the level of the

third lumbar vertebrae.

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LPO


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Area from the lower thoracic vertebrae to the

sacrum should be included. Intervertebral foramina of the farthest side is

visualized.

y When the joint is not well demonstrated and the

pedicle is quite anterior on the vertebral body, thepatient is not obliqued enough.

y When the joint is not well demonstrated and thepedicle is quite posterior on the vertebral body, the

patient is obliqued too much.Vertebral column should be parallel with the

tabletop so the T12-L1 and L1-L2 joint spacesremain open.

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The lower arm is placedalong side.

The upper arm placed

forward with the handtouching to the table.

The cassette is placed &centered at the level of thethird lumber vertebrae.

C.R: Directe the verticalcentral ray towards themidclavicular line on theraised side at the level of

the lower costal margin.

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LAO


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Area from the lower thoracic vertebrae to the sacrumshould be included.

Intervertebral foramina of the nearest side isvisualized.

Vertebral column should be parallel with the tabletopso the T12-L1 and L1-L2 joint spaces remain open.

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Lateral projections in flexion and extension may berequested to demonstrate mobility and stability of thelumbar vertebrae and Intervertebral discs.

Positioning:-

The patient sits on a backless seat with either side

against the vertical Bucky. The sitting position is preferred since apparent flexion

and extension of the lumbar region is less likely to bedue to movement at the hip joints than when using theerect position.

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The dorsal surface of thetrunk should be at rightangles to the film and the

vertebral column parallel tothe film. The patient first leans

forwards, flexing thelumbar region as far aspossible, and grips the frontof the seat to assist inmaintaining the position.

The patient then leans

backwards, extending thelumbar region as far aspossible, and grips the backof the seat. The film iscentered at the level of the

lower costal margin.42

FlexionFlexion

ExtensionExtension


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CR:-Direct the horizontalcentral ray at the right anglesto the film and towards a

point 3 inches anterior to thethird lumbar spinous processat the level of the lower costalmargin.

Evaluation Criteria Flexionand Extensiony Vertebral column should not

be rotated.y Density of the radiographs

must be sufficient tdemonstrate the degree ofmovement when they aresuperimposed.

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FlexionFlexion

ExtensionExtension


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Positioning:-

This examination is made with the patient in thestanding position. PAprojection be used, because inthis direction the divergent rays are more nearlyparallel with the Intervertebral disk space.

With the patient standing before a vertical grid adjustthe height of the cassette so that its midpoint is at thelevel of the third lumbar vertebra. This centering willinclude several of the thoracic interspaces as well as allof the lumbar interspaces.

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Center the mid sagittal planeof the patients body to themidline of the vertical grid

device and adjust the body ina PAposition. Let the armsbang unsupported by thesides.

One radiograph is made withright bending and one withleft bending.

Have the patient lean directlylaterally as far as possiblewithout rotation and withoutlifting his foot. The degree of

leaning must not besupported in position. Respiration is suspended for

the exposure.

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Right Bending


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CR:-Direct the central ray to thethird lumbar vertebra at an angleof15 to 20 degrees cauded or

direct it perpendicular to L3.Structures Shown:-

Two PAbending projections ofthe lower thoracic region and thelumbar region are presented for

the demonstration of themobility of the intervertebraljoints.

This method of examination isused in cases of disk protrusion

to localize the involved joint asshown by limitation of motion atthe site of the lesion in theradiograph.

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Lumber Intervertebral Disk


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Area from the lower thoracic interspaces to all of thesacrum should be included.

Patient should not be rotated in the bending position.

Bending direction must be correctly identified with

appropriate lead markers.

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y The large, C-shaped sacroiliac (SI)joint connects the pelvic bones(the ilia) to the sacrum at the baseof the spine. There are two SI

joints, one on either side of thetailbone. Serving as shockabsorbers for the pelvis and lowback, the SI joints moveconstantly when the body is inmotion, helping to provide

stability and structural support tothe lower part of the body.


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Basicviews:1) AP Oblique (posterior oblique)2) PAOblique (anterior oblique)

ADDITIONALVIEWS:1) AP View2) PAView

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Joint space should be open or have minimal overlap ofthe ilia and sacrum.

Joint should be centered on the radiograph.

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2) PAOBLIQUE:

Positioning: patient is madeto lie in a semi proneposition with side to beexamined close to the film.

Patient is made to rest on hisforearm and knee of theelevated side.

the pt. is supported withform pads placed under theknee.

C.R.: Passing through a point 1inch medial to thedependent anterior superioriliac spine of the side closer

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Joint space closest to thefilm should be open orhave minimal overlap of

the ilia and sacrum.Joint should be centered

on the radiograph.

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RAO


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3)APView:- Supine or erectpositioning may be adopted for

this projection.Positioning: Patient is made to

lie down in supine positionwith mid saggital plane

centre to the center of thetable.

Both hands are placed over

the chest. Both the anterior superior

iliac spines are in the sameplane or equidistance from 55

1010--2525


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T

he Sacrum lies below the 5th

lumbar vertebra.It is made up five sacral vertebra that are fusedtogether.

It is wedged b/w the two hip bones and takespart in forming the pelvis. As a whole the bone

is triangular. It has an upper end or base which articulateswith the 5th lumber vertebra; a lower end orapex which articulates with the coccys; a

convex posterior/dorsal surface; a concaveanterior/pelvic surface and right and lateralsurfaces that articulate with the ilium of thecorresponding side.

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T

he coccyx consists of four rudimentary vertebratefused together.

It has pelvic and dorsal surfaces. The base or upper endhas an oval facet for articulation with the apex of thesacrum. Lateral to the facet there are two cornua that

project upwards and are connected to the cornua ofthe sacrum by ligaments. The first coccygeal vertebrahas rudimentary transverse processes. The remaining

vertebrae are represented by nodules of bone.


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Basicviews:1)AP VIEW: Positioning: same as for

lumbo sacral junction butwithout angulation.

2) LATERALVIEW:

Positioning: same as forlumbar spine lateral viewbut

Smaller size film is used.

Film is placed with itsupper border 1 inch abovethe iliac crest.

C.R.: 1 inch below the upperborder of iliac crest.

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It is overlapped by pubic

symphysisBasicviews:1)APVIEW:Positioning:

Same as lumbosacral APviews with propercollimation. Lower borderof the film is 2 inches belowthe pubic symphysis.

C.R.: directed at a point justabove pubic symphysis with15 degree caudedangulation.

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AP VIEW


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2)LATERALVIEW:

Positioning:

Same as in lumbo-sacralspine lateral view.

Lower border of the film isplaced 1 inch below the endof coccyx.

C.R.: directed at the tip ofcoccyx.

Cones and small collimationis used to view the sharp

image of coccyx.

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LAT View


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Anatomy:-

This is a large irregular bone. It is made up of three parts.These are the ilium superiorly, the pubis anteroinferiorly,and the ischuim posteroinferiorly.

The three parts are joined to each other at a cup shapedhollow, called the acetabulum.

The pubis and ischium are separated by a large ovalopening called the obturator foramen.

The acetabulum articulates with the head of the femur toform the hip joint. The pubic parts of the two hip bones

form the pelvic or hip girdle.

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The bony pelvis is formed by the

two hip bones along with thesacrum and coccyx.

The acetabulum is directedlaterally.

The flat, expanded ilium formsthe upper part of the bone, that

lies above the acetabulum. The obturator foramen lies

below the acetabulum. It isbounded anteriorly by the thinpubis, and posteriorly by thethick and strong ischium.

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a) AP View

b) Lateral View

ADDITIONALVIEWS:

a) PAViewb) Inlet and Outlet Viewc) Posterior Oblique

d) AP- Erect (Subluxation)e) Lilienfeld Method

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1) AP VIEW:


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1)AP VIEW:Positioning: Patient is made to

lie down in supine positionwith mid saggital plane

centre to the center of thetable. Both hands are placed over

the chest. Both the anterior superior

iliac spines are in the sameplane or equidistance fromthe table.

The heel should be separatedand the limbs rotatedmedially.

The film is centered at a levelmid way between theanterior superior iliac spineand the sup. border of thepubis symphysis.

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2)LATERALVIEW:

Positioning: Patient is turned

towards one side with backtowards the technologist.

The MSP of the pt.s body shouldbe parallel to the x-ray table top& MCP is centered to the centre

of the table.

Arms are placed over the headand legs are kept straight withthe help of non opaque pads.

Astrip of lead rubber orseparator is place just post. Tothe pt. to prevent scatterradiation reaching to the film.

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The cassette is placed in thebucky tray 1inch above the

upper border of iliac crest.C.R. Directed perpendicular

to a point centered at the levelof the soft tissue depression

just above the greatertrochanter (app. 2 inch)

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LAT View


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Entire pelvis should be included along with theproximal femurs.

Sacrum and coccyx should be included.

Posterior margin of ilium and ischium should besuperimposed.

Femurs should be superimposed.

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InletView:-

Positioning: It is same aspelvis AP view.

CR:- Direct to the 2 inchdistal to the symphysispubis with the centralray at an angle of 20-35

degree for female and30-45 degree for maletowards feet.

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P t i Obli Vi F


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PosteriorObliqueView:- ForIlium

Positioning:Patient is made to liedown in supine position with midsagittal plane parallel to thelongitudinal axis of the couch.

Then pt. is turned 30 to 40 degreestowards the side being examined sothat the general plane of the ilium isparallel to the film.

The hips and knees are flexed andthe patient supported on nonopaque pads. The film is centered atthe level of the anterior superioriliac spines.

CR:- Directed mid way between theanterior superior iliac spine on theside being examined and the midline of the pelvis with the central rayparallel to the front.

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AP-Erect View:-

Positioning:Patient stands with the posterior aspectagainst the vertical bucky and the arms folded across thethorax.

The anterior superior iliac spines should be equidistance

from the film and the mid sagittal plane should bevertical.

The symphysis pubis should be centered over the verticalcentral line of the bucky and the film centered at the

level of the symphysis pubis.

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Two radiographs may be exposedseparately with the full weight of thebody on each lower limb in turn.

CR:- Direct to the symphysis pubis withthe central ray perpendicular to the film.

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Positioning:-

Place the patient on theradiographic table in aseated-erect position.

Center the mid sagittal

plane of the body to themidline of the table.

Have the patient extend thearms for support, lean

backward 45 or 50 degrees,and then arch the back toplace the pubic arch in avertical position.

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Superior and inferior rami of pubis bone should bemedially superimposed.

There should be no rotation.

Pubic and ischial bones should be centered to the

radiograph. Hip joint should be included.

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The radiological technologist should ensure thatnobody enters in the radiographic examination room

during the exposure of the patient.

The X-ray beam should be well collimated.

At all times, lead apron should be placed over the pt.to save from leakage & scatter radiation.

Careful preparation of the pt. which may reduce therepeat examination.

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Presence of essential staff only, during theradiographic examination.

The person applying the traction must be medicallysupervised & must be wearing a radiation protectivelead rubber apron & gloves.

A good technique with attention to collimation ofbeam will reduce the radiation dose to the BreastTissue & Gonads.

Use of high speed film screen combination.

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With the newer advancements in the field of radiology, advanced modalities like MRI & CT aretaking the place ofSpine Radiography rapidly .

With CT & MRI we can have a 3-D image & thus

the Spine, disk & Spinal cord can be diagnosedprecisely.

While MRI promises to give useful diagnosticinformation without any radiation risks.

But still, Spine Radiography will continue to playits role in Diagnostic Radiology, may be due tolesser radiation hazards than CT or we can say forthe economic reasons .

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Lumber Spine and Pelvis Radiography

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