2. 1 Dr Mohamed El Safwany, MD.

3. Intended Learning Outcome 2 The student should be able to recognize technological principles of radiographic dorsal and lumbosacral spine imaging.

4. 3 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.

5. 4 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 heel- effect, 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

6. 5 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

7. 6 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

8. 7 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

9. 8 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

10. 9 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

11. 10 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

12. 11 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

13. 12 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

14. 13 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

15. 14 TABLE 4 (Exposure Factors) PROJECTIONkVpmAs AP Thoracic Spine907 Lateral Thoracic Spine8050 AO Thoracic Spine8026 AP Lumbar Spine8015 AP Axial Lumbosacral Spine Joint (L5 – S1)8020 Lateral Lumbosacral Spine Joint (L5 – S1)10050 Lateral Lumbar Spine9065 AO Lumbar Spine8515 Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa

16. 15 TABLE 4 (Exposure Factors) PROJECTIONkVpmAs AP Axial Sacrum8015 AP Axial Coccyx8015 Lateral Coccyx9055 Layout and design by A Musa, Department of Radiological Sciences, Faculty of Applied Medical Sciences, King Saud University, Riyadh, Copyright  2003 A Musa

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18. 17 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.

19. 18 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.

20. 19 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.

21. 20 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.

22. 21 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..

23. 22 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.

24. 23 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).

25. 24 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.

26. 25 TABLE 2 (Exposure Factors) PROJECTIONkVpmAs AP Cervical (C1 – C2, Dens), Judd Method7515 AP Cervical (C1 – C2), ‘Open-Mouth Technique’7515 AP Cervical (C1 Ring), ‘Wagging Jaw Technique’7515 AP Axial (C3 – C7)7510 APO Cervical7510 Lateral Cervical (trauma case)7528 Lateral Cervical (hyperflexion/ hyperextension)7528 Cervicothoracic Lateral (C4 – T3), ‘Swimmer’s View’80120

27. 26 TABLE 2 (Exposure Factors) PROJECTIONkVpmAs Lateral Cervical7528 AP Axial Cervical (Vertebral Arch – Pillars)7512 AP/ AP Axial clavicle708 ACJs (Bilateral)6520 AP Scapula757 Lateral Scapula7513

28. Assignment Two students will be selected for assignment 27

29. Suggested Readings Clark’s Radiographic technology 28

30. Question Describe radiographic principles of lumbosacral spine radiogram? 29

31. Thank You 30