“THE VERTEBAL COLUMN”

CERVICAL SPINE
THORACIC SPINE
LUMBAR SPINE
SACRUM
COCCYX

-K.P.BACILES,RRT
ATLANTO-OCCIPITAL ARTICULATIONS
AP OBLIQUE PROJECTION
R AND L HEAD ROTATIONS

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM)

POSITION OF PATIENT:
•PLACE THE PATIENT IN THE SUPINE POSITION.
• CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF
THE GRID, AND ADJUST THE SHOULDERS TO LIE IN THE SAME
HORIZONTAL PLANE.
• PLACE A SUPPORT UNDER THE PATIENT'S KNEES FOR COMFORT.
POSITION OF PART:

• PLACE THE IR IN THE BUCKY TRAY, AND ADJUST THE

PATIENT'S HEAD SO THAT THE MIDPOINT OF THE IR IS 1
INCH (2.5 CM) LATERAL TO THE MIDSAGITTAL PLANE OF
THE HEAD AT THE LEVEL OF THE EXTERNAL ACOUSTIC
MEATUS (EAM).
• ROTATE THE HEAD 45 TO 60 DEGREES AWAY FROM THE
SIDE BEING EXAMINED
• ADJUST THE FLEXION OF THE NECK TO PLACE THE
INFRAORBITOMEATAL LINE (IOML) PERPENDICULAR TO
THE IR. • SHIELD GONADS.
• RESPIRATION: SUSPENDED.
CENTRAL RAY:

• PERPENDICULAR TO
THE MIDPOINT OF THE IR.
IT ENTERS 1 INCH (2.5
CM) ANTERIOR TO THE
EAM AND EMERGES AT
THE ATLANTO-OCCIPITAL
ARTICULATION.
STRUCTURES SHOWN:

THE RESULTING IMAGE SHOWS AN

AP OBLIQUE PROJECTION OF THE
ATLANTO-OCCIPITAL ARTICULATION,
WITH THE JOINT BEING SHOWN
BETWEEN THE ORBIT AND THE RAMUS
OF THE MANDIBLE.
BOTH SIDES SHOULD BE EXAMINED
FOR COMPARISON. THE DENS OF
THE AXIS IS ALSO WELL
DEMONSTRATED IN THIS POSITION.
THEREFORE IT CAN BE USED FOR THIS
PURPOSE WHEN A PATIENT CANNOT
BE ADJUSTED IN THE OPENMOUTH
POSITION.
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

• OPEN ATLANTO-OCCIPITAL
ARTICULATION
• DENS
ATLANTO-OCCIPITAL ARTICULATIONS
PA PROJECTION

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM)

POSITION OF PATIENT:
•PLACE THE PATIENT IN THE PRONE POSITION.
• CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF
THE GRID.
• IF THE PATIENT IS THIN, PLACE A SMALL, FIRM PILLOW UNDER THE
CHEST TO RELIEVE STRAIN IN HOLDING THE POSITION.
• FLEX THE PATIENT'S ELBOWS, PLACE THE ARMS IN A COMFORTABLE
POSITION, AND ADJUST THE SHOULDERS TO LIE IN THE SAME
HORIZONTAL PLANE.
POSITION OF PART:

•REST THE PATIENT'S FOREHEAD AND NOSE ON THE

TABLE, AND ADJUST THE HEAD SO THAT THE
MIDSAGITTAL PLANE IS PERPENDICULAR TO THE MIDLINE
OF THE GRID
•ADJUST THE FLEXION OF THE NECK TO PLACE THE
ORBITOMEATAL LINE (OML) PERPENDICULAR TO THE
PLANE OF THE IR; CENTER THE IR AT OR SLIGHTLY BELOW
THE LEVEL OF THE INFRAORBITAL MARGINS.
•SHIELD GONADS.
•RESPIRATION: SUSPEND.
CENTRAL RAY:

• PERPENDICULAR TO
THE MIDPOINT OF THE IR.
IT ENTERS THE BACK OF
THE NECK ON THE
MIDSAGITTAL PLANE
AND EXITS AT THE LEVEL
OF THE INFRAORBITAL
MARGINS.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS A PA
PROJECTION OF THE
ATLANTO-OCCIPITAL
JOINTS PROJECTED
THROUGH THE
MAXILLARY SINUSES
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

•OPEN BILATERAL ATLANTO-OCCIPITAL

ARTICULATIONS
• MANDIBULAR CONDYLE EQUIDISTANT
FROM THE MIDLINE
DENS
AP PROJECTION
FUCHS METHOD

FUCHS HAS RECOMMENDED THE AP PROJECTION

FOR DEMONSTRATION OF THE DENS WHEN IT UPPER
HALF IS NOT CLEARLY SHOWN IN THE OPEN-MOUTH
POSITION.
THIS PATIENT POSITION MUST NOT BE ATTEMPTED IF
FRACTURE OR DEGENERATIVE DISEASE OF THE
UPPER CERVICAL REGION IS SUSPECTED.
DENS
AP PROJECTION
FUCHS METHOD

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM)

POSITION OF PATIENT:
•PLACE THE PATIENT IN THE SUPINE POSITION.
• CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF THE
GRID.
• PLACE THE ARMS ALONG THE SIDES OF THE BODY, AND ADJUST THE
SHOULDER TO LIE IN THE SAME HORIZONTAL PLANE.
• PLACE A SUPPORT UNDER THE PATIENT'S KNEES FOR COMFORT.
POSITION OF PART:

•PLACE THE IR IN THE BUCKY TRAY, AND CENTER THE IR

TO THE LEVEL OF THE TIPS OF THE MASTOID PROCESSES.
•EXTEND THE CHIN UNTIL THE TIP OF THE CHIN AND THE
TIP OF THE MASTOID PROCESS ARE VERTICAL.
•ADJUST THE HEAD SO THAT THE MID SAGITTAL PLANE IS
PERPENDICULAR TO THE PLANE OF THE GRID.

•SHIELD GONADS.

•RESPIRATION: SUSPEND.
CENTRAL RAY:

•PERPENDICULAR TO
THE MIDPOINT OF THE
IR; IT ENTERS THE NECK
ON THE MIDSAGITTAL
PLANE JUST DISTAL TO
THE TIP OF THE CHIN.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS AN AP
PROJECTION OF THE
DENS LYING WITHIN
THE CIRCULAR
FORAMEN MAGNUM
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

•ENTIRE DENS WITHIN THE FORAMEN

MAGNUM
•SYMMETRY OF THE MANDIBLE, CRANIUM,
AND VERTEBRAE, INDICATING NO
ROTATION OF THE HEAD OR NECK
ATLAS AND AXIS
AP PROJECTION
OPEN MOUTH

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM)

POSITION OF PATIENT:
•PLACE THE PATIENT IN THE SUPINE POSITION.
• CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF THE
GRID.
• PLACE THE PATIENT' ARMS ALONG THE SIDES OF THE BODY, AND
ADJUST THE SHOULDERS TO LIE IN THE SAME HORIZONTAL PLANE.
• PLACE A SUPPORT UNDER THE PATIENT'S KNEES FOR COMFORT.
POSITION OF PART:

• PLACE THE IR IN THE BUCKY TRAY, AND CENTER THE IR

AT THE LEVEL OF THE AXIS.
• ADJUST THE PATIENT'S HEAD SO THAT THE MIDSAGITTAL
PLANE IS PERPENDICULAR TO THE PLANE OF THE TABLE
• SELECT THE EXPOSURE FACTORS, AND MOVE THE X-
RAY TUBE INTO POSITION SO THAT ANY MINOR CHANGE
CAN BE MADE QUICKLY AFTER THE FINAL ADJUSTMENT
OF THE PATIENT'S HEAD. ALTHOUGH THIS POSITION IS
NOT EASY TO HOLD, THE PATIENT IS USUALLY ABLE TO
COOPERATE FULLY UNLESS HE OR SHE IS KEPT IN THE
FINAL STRAINED POSITION TOO LONG.
POSITION OF PART:

•HAVE THE PATIENT OPEN THE MOUTH A WIDE AS POSSIBLE,

AND THEN ADJUST THE HEAD SO THAT A LINE FROM THE
LOWER EDGE OF THE UPPER INCISORS TO THE TIP OF THE
MASTOID PROCESS (OCCLUSAL PLANE) IS PERPENDICULAR TO
THE IR.

A SMALL SUPPORT UNDER THE BACK OF THE HEAD MAY BE

NEEDED TO FACILITATE OPENING OF THE MOUTH WHILE
PROPER ALIGNMENT OF THE UPPER INCISORS AND MASTOID
TIPS IS MAINTAINED.

• SHIELD GONADS.
POSITION OF PART:

•RESPIRATION: INSTRUCT THE PATIENT TO KEEP

THE MOUTH WIDE OPEN AND TO SOFTLY
PHONATE HAH" DURING THE EXPOSURE.
THIS WILL PLACE THE TONGUE IN THE FLOOR OF
THE MOUTH SO THAT IT IS NOT PROJECTED ON
THE ATLAS AND AXIS AND WILL PREVENT
MOVEMENT OF THE MANDIBLE.
CENTRAL RAY:

•PERPENDICULAR TO
THE CENTER OF THE IR
AND ENTERING THE
MIDPOINT OF THE
OPEN MOUTH
STRUCTURES SHOWN:

THE RESULTING IMAGE

DEMONSTRATES AN AP
PROJECTION OF THE
ATLAS AND AXIS
THROUGH THE OPEN
MOUTH
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

•DENS, ATLAS, AXIS, AND ARTICULATIONS BETWEEN THE FIRST

AND SECOND CERVICAL VERTEBRAE
• ENTIRE ARTICULAR SURFACE OF THE ATLAS AND AXIS (TO
CHECK FOR LATERAL DISPLACEMENT)
• SUPERIMPOSED OCCLUSAL PLANE OF THE UPPER CENTRAL
INCISORS AND THE BASE OF THE SKULL
• WIDE-OPEN MOUTH
• SHADOW OF THE TONGUE NOT PROJECTED OVER THE ATLAS
AND AXIS
• MANDIBULAR RAMI EQUIDISTANT FROM DENS
ATLAS AND DENS
PA PROJECTION
JUDD METHOD

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM)

POSITION OF PATIENT:
•PLACE THE PATIENT IN THE PRONE POSITION.
•CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF THE
GRID.
•FLEX THE PATIENT' ELBOWS, PLACE THE ARM IN A COMFORTABLE
POSITION, AND ADJUST THE SHOULDERS TO LIE IN THE SAME HORIZONTAL
PLANE.
POSITION OF PART:

•HAVE THE PATIENT EXTEND THE NECK AND REST THE CHIN ON
THE TABLE.
• PLACE THE IR IN THE BUCKY TRAY, AND ADJUST THE IR SO
THAT THE MIDPOINT IS CENTERED TO THE THROAT AT THE LEVEL
OF THE UPPER MARGIN OF THE THYROID CARTILAGE.
•ADJUST THE HEAD SO THAT THE CHIN AND MASTOID TIPS ARE
VERTICAL OR THE OML IS APPROXIMATELY 37 DEGREES TO THE
PLANE OF THE IR.
• ADJUST THE MIDSAGITTAL PLANE TO BE PERPENDICULAR TO
THE TABLE.
• SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

•PERPENDICULAR TO
THE MIDPOINT OF THE
IR. IT ENTERS ON THE
MIDSAGITTAL PLANE
JUST DISTAL TO THE
LEVEL OF THE MASTOID
TIPS.
STRUCTURES SHOWN:

THE RESULTING IMAGE

DEMONSTRATES A PA
PROJECTION OF THE
DENS AND ATLAS AS
SEEN THROUGH THE
FORAMEN MAGNUM
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

•ENTIRE DENS WITHIN FORAMEN MAGNUM

•ANTERIOR AND POSTERIOR ARCHES OF
ATLAS
•NO ROTATION OF HEAD OR NECK
DENS
AP AXIAL OBLIQUE PROJECTION
KASABACH METHOD
R OR L HEAD ROTATION

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM)

NOTE: THE HEAD OF A PATIENT WHO HAS A POSSIBLE

FRACTURE OR DEGENERATIVE DI EASE MU T NOT BE
ROTATED.
KASABACH RECOMMENDED THAT THE ENTIRE BODY,
RATHER THAN ONLY THE HEAD. BE ROTATED.
DENS
AP AXIAL OBLIQUE PROJECTION
KASABACH METHOD
R OR L HEAD ROTATION

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM)

POSITION OF PATIENT:
•PLACE THE PATIENT IN THE SUPINE POSITION.
•CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF
THE GRID.
•PLACE THE ARMS ALONG THE SIDES OF THE BODY, AND ADJUST THE
SHOULDERS TO LIE IN THE SAME HORIZONTAL PLANE.
•PLACE A SUPPORT UNDER THE PATIENT'S KNEES FOR COMFORT
POSITION OF PART:

•PLACE THE IR IN THE BUCKY TRAY, AND CENTER THE IR

TO THE MIDSAGITTAL PLANE AT THE LEVEL OF THE
MASTOID TIP.
•ROTATE THE HEAD EITHER RIGHT OR LEFT
APPROXIMATELY 40 TO 45 DEGREES. ADJUST THE HEAD
SO THAT THE IOML IS PERPENDICULAR TO THE PLANE OF
THE TABLE
•FOR RIGHT-ANGLE IMAGES OF THE DENS, MAKE ONE
EXPOSURE WITH THE HEAD TURNED TO THE RIGHT AND
ONE EXPOSURE WITH THE HEAD TURNED TO THE LEFT.
•SHIELD GONADS. •RESPIRATION: SUSPEND.
CENTRAL RAY:

ANGLED 10 TO 15
DEGREE CAUDAD.
CENTER TO A POINT
MIDWAY BETWEEN THE
OUTER CANTHUS AND
THE EAM.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS AN AP AXIAL
OBLIQUE PROJECTION
OF THE DENS AND WAS
RECOMMENDED BY
KASABACH' FOR USE IN
CONJUNCTION WITH THE
AP AND LATERAL
PROJECTIONS
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

•THE RADIOGRAPH SHOULD CLEARLY

DEMONSTRATE THE DENS.
ATLAS AND AXIS
LATERAL PROJECTION
R OR LEFT POSITION

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM)

POSITION OF PATIENT:

•PLACE THE PATIENT IN THE SUPINE POSITION.

• PLACE THE ARMS ALONG THE SIDES OF THE BODY, AND ADJUST THE
SHOULDERS TO LIE IN THE SAME HORIZONTAL PLANE.
• PLACE A SPONGE OR PAD UNDER THE PATIENT'S HEAD UNLESS
TRAUMATIC INJURY HAS BEEN SUSTAINED, IN WHICH CASE THE NECK
SHOULD NOT BE MOVED.
POSITION OF PART:

•WITH THE IR IN THE VERTICAL POSITION AND IN CONTACT

WITH THE UPPER NECK, CENTER IR AT THE LEVEL OF THE
ATLANTOAXIAL ARTICULATION 1 INCH DISTAL TO THE TIP OF
THE MASTOID PROCESS.
•ADJUST THE IR SO THAT IT IS PARALLEL WITH THE MIDSAGITTAL
PLANE OF THE NECK, AND THEN SUPPORT THE IR IN POSITION.
•EXTEND THE NECK SLIGHTLY SO THAT THE SHADOW OF THE
MANDIBULAR RAMI DOES NOT OVERLAP THAT OF THE SPINE.
•ADJUST THE HEAD SO THAT THE MIDSAGITTAL PLANE IS
PERPENDICULAR TO THE TABLE.

• SHIELD GONADS. • RESPIRATION: SUSPEND.

CENTRAL RAY:

PERPENDICULAR TO A
POINT 1 INCH (2.5 CM)
DISTAL TO THE
ADJACENT MASTOID TIP.
A GRID AND CLOSE
COLLIMATION SHOULD
BE USED TO MINIMIZE
SECONDARY
RADIATION.
STRUCTURES SHOWN:

THE RESULTING IMAGE

DEMONSTRATES A LATERAL
PROJECTION OF THE ATLAS AND
AXIS .
THE ATLANTO-OCCIPITAL
ARTICULATIONS ARE ALSO
DEMONSTRATED BECAUSE OF THE
SHORT OBJECT-TO-IMAGE RECEPTOR
DISTANCE (OID), BETTER DEFINITION
IS OBTAINED WITH THIS TECHNIQUE
THAN WITH THE CUSTOMARY
METHOD OF PERFORMING THE
LATERAL EXAMINATION OF THE
CERVICAL VERTEBRAE USING A 72-
INCH ( 183-CM) SID
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

•UPPER CERVICAL VERTEBRAE

•SUPERIMPOSED LAMINAE OF THE AXIS AND
SUPERIMPOSED POSTERIOR ARCHES OF THE ATLAS
•NECK EXTENDED SO THE MANDIBULAR RAMI DOES
NOT OVERLAP THE AXIS OR ATLAS
•NEARLY SUPERIMPOSED RAMI OF THE MANDIBLE
CERVICAL VERTEBRAE
AP PROJECTION

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM) LENGTHWISE

POSITION OF PATIENT:
PLACE THE PATIENT IN THE SUPINE OR UPRIGHT POSITION WITH THE BACK
AGAINST THE IR HOLDER.
•ADJUST THE PATIENT'S SHOULDERS TO LIE IN THE SAME HORIZONTAL
PLANE TO PREVENT ROTATION.
POSITION OF PART:

• CENTER THE MIDSAGITTAL PLANE OF THE PATIENT'S BODY TO THE

MIDLINE OF THE TABLE OR VERTICAL GRID DEVICE.
• EXTEND THE CHIN ENOUGH SO THAT THE OCCLUSAL PLANE IS
PERPENDICULAR TO THE TABLETOP. THIS PREVENTS SUPERIMPOSITION
OF THE MANDIBLE AND MIDCERVICAL VERTEBRAE.
• CENTER THE IR AT THE LEVEL OF C4.
•ADJUST THE HEAD SO THAT THE MIDSAGITTAL PLANE IS IN STRAIGHT
ALIGNMENT AND PERPENDICULAR TO THE IR.
• PROVIDE SUPPORT FOR THE HEAD OF ANY PATIENT WHO HAS A
PRONOUNCED LORDOTIC CURVATURE. THIS SUPPORT HELPS
COMPENSATE FOR THE CURVATURE AND REDUCE IMAGE DISTORTION.
• SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

DIRECTED THROUGH C4
AT AN ANGLE OF 15 TO
20 DEGREES CEPHALAD.
THE CENTRAL RAY
ENTERS AT OR SLIGHTLY
INFERIOR TO THE MOST
PROMINENT POINT OF
THE THYROID
CARTILAGE.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOW THE LOWER FIVE
CERVICAL BODIES AND
THE UPPER TWO OR THREE
THORACIC BODIES , THE
INTERPEDICULATE SPACE ,
THE SUPERIMPOSED
TRANSVERSE AND
ARTICULAR PROCESSES,
AND THE INTERVERTEBRAL
DISK SPACES
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

•AREA FROM SUPERIOR PORTION OF C3 TO T2 AND

SURROUNDING SOFT TISSUE
•SHADOWS OF THE MANDIBLE AND OCCIPUT
SUPERIMPOSED OVER THE ATLAS AND MOST OF THE AXIS
•OPEN INTERVERTEBRAL DISK SPACES
•SPINOUS PROCESSES EQUIDISTANT TO THE PEDICLES
•MANDIBULAR ANGLES EQUIDISTANT TO THE VERTEBRAE
CERVICAL VERTEBRAE
LATERAL PROJECTION
R OR L POSITION

IMAGE RECEPTOR: 8 X 10 INCH (18 X 24 CM) LENGTHWISE

SID: A 60- TO 72-INCH (152- TO 1 83- CM) SID IS

RECOMMENDED BECAUSE OF THE INCREASED
OID.
A LONGER DISTANCE HELPS DEMONSTRATE C7.
CERVICAL VERTEBRAE
LATERAL PROJECTION
R OR L POSITION

POSITION OF PATIENT:
PLACE THE PATIENT IN A TRUE LATERAL POSITION, EITHER SEATED OR
STANDING, BEFORE A VERTICAL GRID DEVICE. THE LONG AXIS OF THE
CERVICAL VERTEBRAE SHOULD BE PARALLEL TO THE PLANE OF THE IR.
• HAVE THE PATIENT SIT OR STAND STRAIGHT, AND ADJUST THE HEIGHT
OF THE IR SO THAT IT IS CENTERED AT THE LEVEL OF C4. THE TOP OF THE IR
WILL BE ABOUT 1 -INCH (2.5 CM) ABOVE THE EAM.
POSITION OF PART:

•CENTER THE CORONAL PLANE THAT PASSES

THROUGH THE MASTOID TIPS TO THE MIDLINE OF
THE IR.
•MOVE THE PATIENT CLOSE ENOUGH TO THE
VERTICAL GRID DEVICE TO PERMIT THE ADJACENT
SHOULDER TO REST AGAINST THE DEVICE FOR
SUPPORT.

(THIS PROJECTION MAY BE PERFORMED WITHOUT

THE USE OF A GRID.)
POSITION OF PART:

•ROTATE THE SHOULDERS ANTERIORLY OR

POSTERIORLY ACCORDING TO THE NATURAL
KYPHOSIS OF THE BACK: IF THE PATIENT IS ROUND
SHOULDERED, ROTATE THE SHOULDER ANTERIORLY;
OTHERWISE, ROTATE THEM POSTERIORLY.
•ADJUST THE SHOULDERS TO LIE IN THE SAME
HORIZONTAL PLANE, DEPRESS THEM AS MUCH AS
POSSIBLE, AND IMMOBILIZE THEM BY ATTACHING
ONE SMALL SANDBAG TO EACH WRIST.
THE SANDBAGS SHOULD BE OF EQUAL WEIGHT.
POSITION OF PART:

•BE CAREFUL TO ENSURE THAT THE PATIENT DOES NOT ELEVATE

THE SHOULDER.
•ELEVATE THE CHIN SLIGHTLY, OR HAVE THE PATIENT
PROTRUDE THE MANDIBLE TO PREVENT SUPERIMPOSITION OF
THE MANDIBULAR RAMI AND THE SPINE. AT THE SAME TIME
AND WITH THE MIDSAGITTAL PLANE OF THE HEAD VERTICAL,
ASK THE PATIENT TO LOOK STEADILY AT ONE SPOT ON THE
WALL. THIS HELP MAINTAIN THE POSITION OF THE HEAD.
•SHIELD GONADS.
• RESPIRATION: SUSPEND RESPIRATION AT THE END OF FULL
EXPIRATION TO OBTAIN MAXIMUM DEPRESSION OF THE
SHOULDERS.
CENTRAL RAY:

HORIZONTAL AND
PERPENDICULAR TO C4.
WITH SUCH CENTERING,
THE MAGNIFIED OUTLINE
OF THE SHOULDER
FARTHEST FROM THE IR IS
BE PROJECTED BELOW
THE LOWER CERVICAL
VERTEBRAE.
STRUCTURES SHOWN:

THE RESULTING IMAGE

DEMONSTRATES A LATERAL
PROJECTION OF THE CERVICAL
BODIES AND THEIR INTERSPACES,
THE ARTICULAR PILLARS, THE
LOWER FIVE ZYGAPOPHYSEAL
JOINTS, AND THE SPINOUS
PROCESSES.
DEPENDING ON HOW WELL THE
SHOULDER CAN BE DEPRESSED,
A GOOD LATERAL PROJECTION
MUST INCLUDE C7; SOMETIMES TI
AND T2 CAN ALSO BE SEEN.
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

•ALL SEVEN CERVICAL VERTEBRAE AND AT LEAST ONE THIRD OF THE

T1. (OTHERWISE A SEPARATE RADIOGRAPH OF THE
CERVICOTHORACIC REGION IS RECOMMENDED.)
•NECK EXTENDED SO THAT MANDIBULAR RAMI ARE NOT
OVERLAPPING THE ATLAS OR AXIS.
•SUPERIMPOSED OR NEARLY SUPERIMPOSED RAMI OF THE MANDIBLE.
•NO ROTATION OR TILT OF THE CERVICAL SPINE INDICATED BY
SUPERIMPOSED OPEN ZYGAPOPHYSEAL JOINTS.
•C4 IN THE CENTER OF THE RADIOGRAPH.
•BONE AND SOFT TISSUE DETAIL.
CERVICAL VERTEBRAE
LATERAL PROJECTION
R OR L POSITION
HYPERFLEXION AND HYPEREXTENSION

NOTE: THIS PROCEDURE MUST NOT BE ATTEMPTED UNTIL

CERVICAL SPINE PATHOLOGY OR FRACTURE HAS BEEN
RULED OUT.
CERVICAL VERTEBRAE
LATERAL PROJECTION
R OR L POSITION
HYPERFLEXION AND HYPEREXTENSION

IMAGE RECEPTOR: 11 X 14 INCH LENGTHWISE

SID: A 60- TO 72-INCH (152- TO 1 83-CM) SID IS RECOMMENDED BECAUSE OF

THE INCREASED OID. A LONGER DISTANCE HELPS DEMONSTRATE C7.
CERVICAL VERTEBRAE
LATERAL PROJECTION
R OR L POSITION
HYPERFLEXION AND HYPEREXTENSION

POSITION OF PATIENT:
•PLACE THE PATIENT IN A TRUE LATERAL POSITION, EITHER
SEATED OR STANDING, BEFORE A VERTICAL GRID DEVICE.
•HAVE THE PATIENT SIT OR STAND STRAIGHT, AND ADJUST THE
HEIGHT OF THE IR SO THAT IT IS CENTERED AT THE LEVEL OF C4.
THE TOP OF THE IR WILL BE ABOUT 2-INCHES (5 CM) ABOVE THE
EAM.
POSITION OF PART:

•MOVE THE PATIENT CLOSE ENOUGH TO THE

VERTICAL GRID DEVICE TO PERMIT THE
ADJACENT SHOULDER TO REST AGAINST THE
GRID FOR SUPPORT. KEEP THE MIDSAGITTAL
PLANE OF THE PATIENT'S HEAD AND NECK
PARALLEL WITH THE PLANE OF THE IR.

•ALTERNATIVELY, PERFORM THE PROJECTION

WITHOUT USING A GRID.
POSITION OF PART:

•MOVE THE PATIENT CLOSE ENOUGH TO THE

VERTICAL GRID DEVICE TO PERMIT THE
ADJACENT SHOULDER TO REST AGAINST THE
GRID FOR SUPPORT. KEEP THE MIDSAGITTAL
PLANE OF THE PATIENT'S HEAD AND NECK
PARALLEL WITH THE PLANE OF THE IR.

•ALTERNATIVELY, PERFORM THE PROJECTION

WITHOUT USING A GRID.
CENTRAL RAY:

HORIZONTAL AND PERPENDICULAR

TO C4.

HYPERFLEXION:
ASK THE PATIENT TO DROP THE HEAD
FORWARD AND THEN DRAW THE
CHIN AS CLOSE AS POSSIBLE TO THE
CHEST SO THAT THE CERVICAL
VERTEBRAE ARE PLACED IN A
POSITION OF HYPERFLEXION
(FORCED FLEXION) FOR THE FIRST
EXPOSURE
CENTRAL RAY:

HORIZONTAL AND
PERPENDICULAR TO C4.

HYPEREXTENSION:
•ASK THE PATIENT TO ELEVATE
THE CHIN A MUCH AS POSSIBLE
SO THAT THE CERVICAL
VERTEBRAE ARE PLACED IN A
POSITION OF HYPEREXTENSION
(FORCED EXTENSION) FOR THE
SECOND EXPOSURE
STRUCTURES SHOWN:

THE RESULTING IMAGES

SHOW THE MOTILITY OF THE
CERVICAL SPINE WHEN
HYPERFLEXED AND
HYPEREXTENDED THE
INTERVERTEBRAL DISKS AND
THE ZYGAPOPHYSEAL JOINTS
ARE ALSO SHOWN.
STRUCTURES SHOWN:

THE RESULTING IMAGES

SHOW THE MOTILITY OF THE
CERVICAL SPINE WHEN
HYPERFLEXED AND
HYPEREXTENDED THE
INTERVERTEBRAL DISKS AND
THE ZYGAPOPHYSEAL JOINTS
ARE ALSO SHOWN.
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

HYPERFLEXION:
•BODY OF THE MANDIBLE ALMOST VERTICAL FOR
HYPERFTEXION IN THE NORMAL PATIENT
•ALL SEVEN SPINOUS PROCESSES

HYPEREXTENSION
•BODY OF THE MANDIBLE ALMOST HORIZONTAL IN THE
NORMAL PATIENT
•ALL SEVEN CERVICAL VERTEBRAE IN TRUE LATERAL POSITION
CERVICAL INTERVERTEBRAL FORAMINA
AP AXIAL OBLIQUE PROJECTION
RPO OR LPO POSITION

IMAGE RECEPTOR: 8X10 LENGTHWISE

POSITION OF PATIENT:
•PLACE THE PATIENT IN A SUPINE OR UPRIGHT POSITION FACING
THE X-RAY TUBE. THE UPRIGHT POSITION (STANDING OR SEATED)
IS PREFERABLE FOR THE PATIENT'S COMFORT AND MAKES IT
EASIER TO POSITION THE PATIENT.
POSITION OF PART:

•ADJUST THE BODY (INCLUDING THE HEAD) AT

A 45-DEGREE ANGLE, AND CENTER THE
CERVICAL SPINE TO THE MIDLINE OF THE IR.

•CENTER THE IR TO THE THIRD CERVICAL BODY

1 INCH SUPERIOR TO THE MOST PROMINENT
POINT OF THE THYROID CARTILAGE TO
COMPENSATE FOR THE CEPHALIC
ANGULATION OF THE CENTRAL RAY.
POSITION OF PART:

•UPRIGHT POSITION

•ASK THE PATIENT TO SIT OR STAND STRAIGHT WITHOUT STRAIN

AND TO REST THE ADJACENT SHOULDER FIRMLY AGAIN T THE
VERTICAL GRID DEVICE FOR SUPPORT.
•ENSURE THAT THE DEGREE OF BODY ROTATION IS 45
DEGREES.
•WHILE THE PATIENT LOOK STRAIGHT AHEAD, ELEVATE AND, IF
NEEDED, PROTRUDE THE CHIN SO THAT THE MANDIBLE DOES
NOT OVERLAP THE SPINE. TURNING THE CHIN TO THE SIDE
CAUSES SLIGHT ROTATION OF THE SUPERIOR VERTEBRAE AND
SHOULD BE AVOIDED.
POSITION OF PART:

•SEMISUPINE POSITION

•ROTATE THE PATIENT'S HEAD AND BODY APPROXIMATELY 45 DEGREES.

•CENTER THE CERVICAL SPINE TO THE MIDLINE OF THE GRID.
•PLACE SUITABLE SUPPORT UNDER THE LOWER THORAX AND THE ELEVATED HIP.
•PLACE A SUPPORT UNDER THE PATIENT'S HEAD, AND ADJUST IT 0 THAT THE
CERVICAL COLUMN IS HORIZONTAL.
•CHECK AND ADJUST THE 45-DEGREE BODY ROTATION.
•ELEVATE THE PATIENT' CHIN AND PROTRUDE THE JAW AS FOR THE UPRIGHT
STUDY. TURNING THE CHIN TO THE IDE CAUSES SLIGHT ROTATION OF THE
UPERIOR VERTEBRAE AND SHOULD BE AVOIDED.
•SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

DIRECTED TO C4 AT A
CEPHALAD ANGLE OF 15 TO
20 DEGREES SO THAT THE
CENTRAL RAY COINCIDES
WITH THE ANGLE OF THE
FORAMINA
CENTRAL RAY:

DIRECTED TO C4 AT A
CEPHALAD ANGLE OF 15 TO
20 DEGREES SO THAT THE
CENTRAL RAY COINCIDES
WITH THE ANGLE OF THE
FORAMINA
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS THE INTERVERTEBRAL
FORAMINA AND PEDICLES
FARTHEST FROM THE IR AND
AN OBLIQUE PROJECTION
OF THE BODIES AND OTHER
PARTS OF THE CERVICAL
VERTEBRAE
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

OPEN INTERVERTEBRAL FORAMINA FARTHEST FROM THE IR, FROM

C2-C3 TO C7-TI
•OPEN INTERVERTEBRAL DISK SPACES
•UNIFORM SIZE AND CONTOUR OF THE FORAMINA
•ELEVATED CHIN THAT DOES NOT OVERLAP THE ATLAS AND AXIS
•OCCIPITAL BONE NOT OVERLAPPING THE AXIS
•CI-C7 AND T1
CERVICAL INTERVERTEBRAL FORAMINA
PA AXIAL OBLIQUE PROJECTION
RAO OR LAO POSITION

IMAGE RECEPTOR: 8X10 LENGTHWISE

SID: A 60- TO 72-INCH ( 152- TO 183- CM) SID IS

RECOMMENDED BECAUSE OF THE INCREASED
OID.
CERVICAL INTERVERTEBRAL FORAMINA
PA AXIAL OBLIQUE PROJECTION
RAO OR LAO POSITION

IMAGE RECEPTOR: 8X10 LENGTHWISE

POSITION OF PATIENT:
•POSITION OF PATIENT
• PLACE THE PATIENT PRONE OR UPRIGHT WITH THE BACK TOWARD THE
X-RAY TUBE. FOR THE PATIENT'S COMFORT AND ACCURATE ADJUSTMENT
OF THE PART, THE STANDING OR SEATEDUPRIGHT POSITION IS PREFERRED.
POSITION OF PART:

•UPRIGHT POSITION, ASK THE PATIENT TO SIT OR

STAND STRAIGHT WITH ARMS BY SIDE AND REST
SHOULDER AGAINST THE GRID DEVICE.
ROTATE THE PATIENT'S ENTIRE BODY TO A 45-
DEGREE ANGLE TO PLACE THE FORAMINA
OPENINGS PARALLEL WITH THE IR. CENTER THE
CERVICAL SPINE TO THE MIDLINE OF THE GRID
DEVICE
POSITION OF PART:

•SEMIPRONE POSITION, PLACE THE PATIENT'S BODY AT AN

ANGLE OF 45-DEGREES AND THE CERVICAL SPINE CENTERED TO
THE MIDLINE OF THE GRID. HAVE THE PATIENT USE THE FOREARM
AND FLEXED KNEE OF THE ELEVATED IDE TO SUPPORT THE BODY
AND MAINTAIN THE POSITION. PLACE A SUITABLE SUPPORT
UNDER THE PATIENT'S HEAD TO PLACE THE LONG AXIS OF THE
CERVICAL COLUMN PARALLEL WITH THE IR.
• TO AL LOW FOR THE CAUDAL ANGULATION OF THE CENTRAL
RAY, CENTER THE IR AT THE LEVEL OF C5 1 INCH CAUDAL TO THE
MOST PROMINENT POINT OF THE THYROID CARTILAGE.
POSITION OF PART:
•ADJUST THE POSITION OF THE PATIENT'S HEAD SO THAT THE
MIDSAGITTAL PLANE IS ALIGNED WITH THE PLANE OF THE
SPINE.
•ELEVATE AND PROTRUDE THE PATIENT'S CHIN JUST ENOUGH
TO PREVENT SUPERIMPOSITION OF THE MANDIBLE WITH THE
UPPER CERVICAL VERTEBRAE. TURNING THE CHIN TO THE SIDE
CAUSES ROTATION OF THE SUPERIOR VERTEBRAE AND SHOULD
BE AVOIDED. (THE CHIN WILL HAVE TO BE TURNED SLIGHTLY
FOR THE SEMI PRONE POSITION.)
SHIELD GONADS AND HAVE RESPIRATION SUSPENDED.
CENTRAL RAY:

DIRECTED TO C4 AT AN
ANGLE OF 15 TO 20
DEGREES CAUDAD SO THAT
IT COINCIDE WITH THE
ANGLE OF THE FORAMINA
CENTRAL RAY:

DIRECTED TO C4 AT AN
ANGLE OF 15 TO 20
DEGREES CAUDAD SO THAT
IT COINCIDE WITH THE
ANGLE OF THE FORAMINA
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS THE INTERVERTEBRAL
FORAMINA AND PEDICLES
CLOSEST TO THE IR AND AN
OBLIQUE PROJECTION OF
THE BODIES AND OTHER
PART OF THE CERVICAL
COLUMN
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

OPEN INTERVERTEBRAL FORAMINA CLOSEST TO THE IR, FROM

THE FIRST AND SECOND CERVICAL VERTEBRAE TO THE
SEVENTH CERVICAL AND FIRST THORACIC VERTEBRAE
•OPEN INTERVERTEBRAL DISK SPACES
•ELEVATED CHIN AND PROTRUDED JAW SO THE ANGLE OF
THE MANDIBLE DOES NOT OVERLAP THE FIRST AND SECOND
CERVICAL VERTEBRAE
•OCCIPITAL BONE NOT OVERLAPPING THE AXIS
•ALL SEVEN CERVICAL AND THE FIRST THORACIC VERTEBRAE
CERVICAL INTERVERTEBRAL FORAMINA
AP PROJECTION
OTTONELLO METHOD

WITH THE OTTONELLO METHOD THE MANDIBULAR

SHADOW IS BLURRED OR EVEN OBLITERATED BY HAVING
THE PATIENT PERFORM AN EVEN CHEWING MOTION OF
THE MANDIBLE DURING THE EXPOSURE.
THE PATIENT'S HEAD MUST BE RIGIDLY IMMOBILIZED TO
PREVENT MOVEMENT OF THE VERTEBRAE. THE EXPOSURE
TIME MUST BE LONG ENOUGH TO COVER SEVERAL
COMPLETE EXCURSIONS OF THE MANDIBLE.
CERVICAL INTERVERTEBRAL FORAMINA
AP PROJECTION
OTTONELLO METHOD

IMAGE RECEPTOR: 8X10 LENGTHWISE

POSITION OF PATIENT:
PLACE THE PATIENT IN THE SUPINE POSITION.
•CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF
THE GRID.
•PLACE THE PATIENT'S ARMS ALONG THE SIDES OF THE BODY, AND
ADJUST THE SHOULDERS TO LIE IN THE SAME HORIZONTAL PLANE.
•PLACE A SUPPORT UNDER THE KNEES FOR THE PATIENT'S COMFORT. .
POSITION OF PART:
•ADJUST THE PATIENT'S HEAD SO THAT THE MIDSAGITTAL PLANE IS
ALIGNED WITH THE LOWER BODY AND IS PERPENDICULAR TO THE
TABLE.
• ELEVATE THE PATIENT'S CHIN ENOUGH TO PLACE THE OCCLUSAL
SURFACE OF THE UPPER INCISORS AND THE MASTOID TIP IN THE SAME
VERTICAL PLANE.
•IMMOBILIZE THE HEAD, AND HAVE THE PATIENT PRACTICE OPENING
AND CLOSING THE MOUTH UNTIL THE MANDIBLE CAN BE MOVED
SMOOTHLY WITHOUT STRIKING THE TEETH TOGETHER.
•PLACE THE IR IN A BUCKY TRAY, AND CENTER THE IR AT THE LEVEL OF
C4.
•TO BLUR THE MANDIBLE, USE AN EXPOSURE TECHNIQUE WITH A LOW
MILLIAMPERAGE (MA) AND LONG EXPOSURE TIME (MINIMUM OF 1
SECOND).
• SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

PERPENDICULAR TO C4. THE

CENTRAL RAY ENTER AT THE
MOST PROMINENT POINT OF
THE THYROID CARTILAGE.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS AN AP
PROJECTION OF THE
ENTIRE CERVICAL
COLUMN, WITH THE
MANDIBLE BLURRED IF
NOT OBLITERATED
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

ALL SEVEN CERVICAL VERTEBRAE

• BLURRED MANDIBLE WITH RESULTANT

VISUALIZATION OF THE UNDERLYING ATLAS
AND AXIS
CERVICAL AND UPPER THORACIC VERTEBRAE
VERTEBRAL ARCH (PILLARS)
AP AXIAL PROJECTION

NOTE: THE PROCEDURE MUST NOT BE ATTEMPTED UNTIL

CERVICAL SPINE PATHOLOGY OR FRACTURE HAS BEEN
RULED OUT.

THE VERTEBRAL ARCH PROJECTIONS, SOMETIMES REFERRED TO A PILLAR OR

LATERAL MASS PROJECTIONS, ARE USED TO DEMONSTRATE THE POSTERIOR
ELEMENTS OF THE CERVICAL VERTEBRAE, THE UPPER THREE OR FOUR THORACIC
VERTEBRAE, THE ARTICULAR PROCESSES AND THEIR FACETS, THE LAMINAE, AND
THE SPINOUS PROCESSES .
CERVICAL AND UPPER THORACIC VERTEBRAE
VERTEBRAL ARCH (PILLARS)
AP AXIAL PROJECTION

IMAGE RECEPTOR: 8X10 LENGTHWISE

POSITION OF PATIENT:
ADJUST THE PATIENT IN THE SUPINE POSITION WITH THE MIDSAGITTAL
PLANE OF THE BODY CENTERED TO THE MIDLINE OF THE GRID.
•DEPRESS THE PATIENT'S SHOULDERS, AND ADJUST THEM TO LIE IN
THE SAME HORIZONTAL PLANE.
POSITION OF PART:

•WITH THE MIDSAGITTAL PLANE OF THE HEAD

PERPENDICULAR TO THE TABLE, HYPEREXTEND THE
PATIENT'S NECK. THE SUCCESS OF THIS PROJECTION
DEPEND ON THIS HYPEREXTENSION
•IF THE PATIENT CANNOT TOLERATE
HYPEREXTENSION WITHOUT UNDUE DISCOMFORT,
THE OBLIQUE PROJECTION DESCRIBED IN THE NEXT
SECTION IS RECOMMENDED.
•SHIELD GONADS. • RESPIRATION: SU PEND.
CENTRAL RAY:

DIRECTED TO C7 AT AN
AVERAGE ANGLE OF 25
DEGREES CAUDAD (RANGE:
20 TO 30 DEGREES).

THE CENTRAL RAY ENTERS THE

NECK IN THE REGION OF THE
THYROID CARTILAGE.
STRUCTURES SHOWN:

THE RESULTING IMAGE

DEMONSTRATES THE
POSTERIOR PORTION OF
THE CERVICAL AND
UPPER THORACIC
VERTEBRAE, INCLUDING
THE ARTICULAR AND
SPINOUS PROCESSES
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

VERTEBRAL ARCH STRUCTURES, ESPECIALLY THE

SUPERIOR AND INFERIOR ARTICULATING
PROCESSES (PILLARS), WITHOUT OVERLAPPING OF
THE VERTEBRAL BODIES AND TRANSVERSE
PROCESSES
•ARTICULAR PROCESSES
•OPEN ZYGAPOPHYSEAL JOINTS BETWEEN THE
ARTICULAR PROCESSES
CERVICAL AND UPPER THORACIC VERTEBRAE
VERTEBRAL ARCH (PILLARS)
AP AXIAL OBLIQUE PROJECTION
R AND L HEAD ROTATIONS

THESE RADIOGRAPHIC PROJECTIONS ARE USED TO

DEMONSTRATE THE VERTEBRAL ARCHES OR PILLARS
WHEN THE PATIENT CANNOT HYPEREXTEND THE HEAD
FOR THE AP OR PA AXIAL PROJECTION.
BOTH SIDES ARE EXAMINED FOR COMPARISON.
CERVICAL AND UPPER THORACIC VERTEBRAE
VERTEBRAL ARCH (PILLARS)
AP AXIAL OBLIQUE PROJECTION
R AND L HEAD ROTATIONS

IMAGE RECEPTOR: 8X10 LENGTHWISE

POSITION OF PATIENT:
PLACE THE PATIENT IN THE SUPINE POSITION.
POSITION OF PART:

•ROTATE THE PATIENT'S HEAD 45 TO 50 DEGREES,

TURNING THE JAW AWAY FROM THE SIDE OF INTEREST. A
45- TO 50-DEGREE ROTATION OF THE HEAD USUALLY
DEMONSTRATES THE ARTICULAR PROCESSES OF C2-C7
AND T1. A ROTATION OF AS MUCH AS 60 TO 70
DEGREES IS SOMETIMES REQUIRED TO DEMONSTRATE
THE PROCESSES OF C6 AND T1-T4
•POSITION THE IR SO THAT THE TOP EDGE IS AT THE LEVEL
OF THE MASTOID TIP.
•SHIELD GONADS •RESPIRATION: SUSPEND.
CENTRAL RAY:

DIRECTED TO EXIT THE

SPINOUS PROCESS OF C7 AT
AN AVERAGE ANGLE OF 35
DEGREE CAUDAD (RANGE:
30 TO 40 DEGREES)
STRUCTURES SHOWN:

THE RESULTING
PROJECTION SHOWS THE
POSTERIOR ARCH AND
PILLARS OF THE
CERVICAL AND UPPER
THORACIC VERTEBRAE
WITH OPEN
ZYGAPOPHYSEAL
ARTICULATION
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

VERTEBRAL ARCH STRUCTURE , ESPECIALLY THE

SUPERIOR AND INFERIOR ARTICULAR PROCESSES,
FREE OF OVERLAP OF THE VERTEBRAL BODIES AND
TRANSVERSE PROCESSES
•ARTICULAR PROCESSES AND FACETS ON THE SIDE
OF INTEREST
•OPEN JOINTS BETWEEN THE ARTICULAR FACETS
ON THE SIDE OF INTEREST
CERVICAL AND UPPER THORACIC
VERTEBRAE
VERTEBRAL ARCH (PILLARS)
PA AXIAL OBLIQUE PROJECTION
R AND L HEAD ROTATIONS

IMAGE RECEPTOR: 8X10 LENGTHWISE

POSITION OF PATIENT:

•UNLESS CONTRAINDICATED, PLACE THE PATIENT IN THE

PRONE POSITION. FOR INJURED PATIENTS, THE PRONE
POSITION SEEMS TO BE MORE COMFORTABLE THAN THE
SUPINE POSITION.
•CENTER THE MIDSAGITTAL PLANE OF THE PATIENT'
BODY TO THE MIDLINE OF THE GRID.
•WHEN THE PATIENT IS THIN, PLACE A PILLOW UNDER
THE CHEST TO OBVIATE ACCENTUATION OF THE
CERVICAL CURVE.
•DEPRESS THE PATIENT'S SHOULDER AND ADJUST THEM
TO LIE IN THE SAME HORIZONTAL PLANE.
POSITION OF PART:

•REST THE PATIENT' HEAD ON ONE CHEEK, TURNING THE

JAW AWAY FROM THE SIDE OF INTEREST. ADJUST THE
HEAD SO THAT THE MIDSAGITTAL PLANE IS AT AN ANGLE
OF 45 DEGREES.
•TO DEMONSTRATE THE C2-C5, FLEX THE PATIENT'S NECK
SOMEWHAT TO REDUCE THE CERVICAL CURVE.
•TO DEMONSTRATE C5-C7 AND T1-T4, ADJUST THE
PATIENT'S HEAD IN MODERATE EXTENSION. POSITION THE
IR SO THAT ITS BOTTOM EDGE IS AT THE LEVEL OF THE TIP
OF THE C7 SPINOUS PROCESS
• SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

DIRECTED TO C7 AT AN
AVERAGE ANGLE OF 35
DEGREES CEPHALAD
(RANGE: 30 TO 40 DEGREES)
AND EXITING AT THE LEVEL
OF THE MANDIBULAR
SYMPHYSIS
STRUCTURES SHOWN:

THE RESULTING
PROJECTION SHOWS THE
POSTERIOR ARCH AND
PILLARS OF THE
CERVICAL AND UPPER
THORACIC VERTEBRAE
WITH OPEN
ZYGAPOPHYSEAL
ARTICULATION
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

VERTEBRAL ARCH STRUCTURE , ESPECIALLY THE

SUPERIOR AND INFERIOR ARTICULAR PROCESSES,
FREE OF OVERLAP OF THE VERTEBRAL BODIES AND
TRANSVERSE PROCESSES
•ARTICULAR PROCESSES AND FACETS ON THE SIDE
OF INTEREST
•OPEN JOINTS BETWEEN THE ARTICULAR FACETS
ON THE SIDE OF INTEREST
CERVICO-THORACIC REGION
LATERAL PROJECTION
R OR L POSITION
UPRIGHT

THIS PROJECTION IS OFTEN CALLED THE "SWIMMER'S LATERAL"

PROJECTION.

IMAGE RECEPTOR: 10X12 LENGTHWISE

POSITION OF PATIENT:
•PLACE THE PATIENT IN A LATERAL POSITION, EITHER SEATED OR
STANDING, AGAINST A VERTICAL GRID DEVICE.
POSITION OF PART:

•CENTER THE MIDCORONAL PLANE OF THE BODY TO

THE MIDLINE OF THE GRID.

•MOVE THE PATIENT CLOSE ENOUGH TO THE GRID

DEVICE SO THAT THE SHOULDER CAN REST FIRMLY
AGAINST THE GRID FOR SUPPORT.

•ELEVATE THE ARM THAT IS ADJACENT TO THE VERTICAL

GRID DEVICE TO A VERTICAL POSITION, FLEX THE
ELBOW, AND REST THE FOREARM ON THE PATIENT'S
HEAD.
POSITION OF PART:

•ADJUST THE HEIGHT OF THE IR SO THAT IT IS CENTERED

AT THE LEVEL OF C7 -T1, WHICH WILL BE AT THE LEVEL OF
THE VERTEBRAL PROMINENCE POSTERIORLY.
•ADJUST THE PATIENT'S HEAD AND BODY INTO A TRUE
LATERAL POSITION, WITH THE MIDSAGITTAL PLANE
PARALLEL TO THE PLANE OF THE IR
•DEPRESS THE PATIENT‘S SHOULDER THAT IS FARTHEST
FROM THE IR AS MUCH A POSSIBLE, AND MOVE THIS
SHOULDER ANTERIORLY. THEN MOVE THE SHOULDER
CLOSEST TO THE IR POSTERIORLY.
POSITION OF PART:

THE GOAL IS TO HAVE ONE SHOULDER PLACED SLIGHTLY

ANTERIOR AND THE OTHER SLIGHTLY POSTERIOR, WITH
SIMULTANEOUS ELEVATION OF ONE SHOULDER AND DEPRESSION
OF THE OPPOSITE ONE. THIS SHOULDER PLACEMENT IS SUFFICIENT
TO PREVENT THE HUMERAL HEADS FROM BEING SUPERIMPOSED
OVER THE VERTEBRAE.
•SHIELD GONADS. • RESPIRATION: SUSPEND.
•IF THE PATIENT CAN COOPERATE AND CAN BE IMMOBILIZED, A
LONG EXPOSURE TIME (LOW MAA) SHOULD BE USED WHILE THE
PATIENT TAKE SHALLOW BREATH . SHALLOW BREATHING BLUR THE
LUNG ANATOMY.
CENTRAL RAY:

DIRECTED TO THE INTER-DISK SPACE

OF C7 AND T1
1. PERPENDICULAR IF THE
SHOULDER IS WELL DEPRESSED
OR
2. AT A CAUDAL ANGLE OF 5
DEGREE IF THE SHOULDER
CANNOT BE WELL DEPRESSED.
COLLIMATION SHOULD BE VERY
CLOSE TO REDUCE SCATTERED
RADIATION AND IMPROVE
CONTRAST.
STRUCTURES SHOWN:

THE RESULTING IMAGE

DEMONSTRATES A
LATERAL PROJECTION
OF THE LOWER
CERVICAL AND UPPER
THORACIC VERTEBRAE
BETWEEN THE TWO
SHOULDERS
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

LATERAL VERTEBRAE, NOT APPRECIABLY

ROTATED
•SHOULDERS SEPARATED FROM EACH OTHER
•AREA FROM APPROXIMATELY C5 TO T4
•X-RAY PENETRATION OF THE SHOULDER
REGION
CERVICO-THORACIC REGION
LATERAL PROJECTION
PAWLOW METHOD METHOD
R OR L POSITION
RECUMBENT

THIS PROJECTION IS ALSO CALLED THE " SWIMMER' LATERAL"

PROJECTION IT IS MOST OFTEN PERFORMED WITH EITHER A LATERAL
CERVICAL OR LATERAL THORACIC PROJECTION WHEN THE SHOULDERS
SUPERIMPOSE THE VERTEBRAE IN THE AREA OF INTEREST.
CERVICO-THORACIC REGION
LATERAL PROJECTION
PAWLOW METHOD AND MODIFIED PAWLOW METHOD
R OR L POSITION
RECUMBENT

IMAGE RECEPTOR: 10X12 LENGTHWISE

POSITION OF PATIENT:
•PLACE THE PATIENT IN A LATERAL RECUMBENT POSITION,
WITH THE HEAD ELEVATED ON THE PATIENT' ARM, SANDBAGS,
OR A SMALL, FIRM PILLOW.
POSITION OF PART:

•CENTER THE MIDCORONAL PLANE OF THE

PATIENT'S BODY TO THE MIDLINE OF THE GRID.
•ADJUST THE SUPPORT UNDER THE PATIENT'S HEAD,
AND PLACE ANOTHER SUPPORT UNDER THE LOWER
THORAX SO THAT THE LONG AXIS OF THE
CERVICOTHORACIC VERTEBRAE IS HORIZONTAL.

•GRASP THE ARM ON WHICH THE PATIENT IS LYING,

AND EXTEND IT ABOVE THE HEAD. MOVE THE
HUMERAL HEAD POSTERIORLY.
POSITION OF PART:

•PLACE THE TOP ARM AT THE PATIENT'S SIDE, AND

IMMOBILIZE IT BY HAVING THE PATIENT GRAB THE
POSTERIOR THIGH. MOVE THE HUMERAL HEAD
POSTERIORLY.
•ADJUST THE BODY INTO A TRUE LATERAL POSITION
•CENTER THE IR AT THE LEVEL OF THE INTERDISK SPACE
OF C7-T1 WHICH IS LOCATED 2 INCHES (5 CM) ABOVE
THE JUGULAR NOTCH.

• SHIELD GONADS. • RESPIRATION: SU PEND.

CENTRAL RAY:

DIRECTED TO THE
INTER-DISK OF C7 AND
T1 AT AN ANGLE OF 3
TO 5 DEGREE
CAUDAD.
STRUCTURES SHOWN:

THE RESULTING IMAGE

HOW A LATERAL
PROJECTION OF THE
CERVICOTHORACIC
VERTEBRAE BETWEEN
THE SHOULDERS
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

LATERAL VERTEBRAE NOT APPRECIABLY ROTATED

•SHOULDERS SEPARATED FROM EACH OTHER •
AREA FROM APPROXIMATELY C5-T4

•X-RAY PENETRATION OF THE SHOULDER REGION

THORACIC VERTEBRAE
AP PROJECTION

IMAGE RECEPTOR: 14X17 LENGTHWISE

POSITION OF PATIENT:
•PLACE THE PATIENT IN THE SUPINE OR UPRIGHT
POSITION.
• PLACE THE PATIENT'S ARMS ALONG THE SIDES OF
THE BODY, AND ADJUST THE SHOULDER TO LIE IN
THE SAME HORIZONTAL PLANE.
POSITION OF PART:

CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE

MIDLINE OF THE GRID.

FOR THE SUPINE POSITION, TO REDUCE KYPHOSIS FLEX THE

PATIENT'S HIPS AND KNEES TO PLACE THIGHS IN VERTICAL
POSITION.

IMMOBILIZE THE FEET WITH SANDBAGS

IF THE PATIENT'S LIMBS CANNOT BE FLEXED, SUPPORT THE

KNEES TO RELIEVE STRAIN.
POSITION OF PART:

FOR THE UPRIGHT POSITION, HAVE THE PATIENT STAND SO THE PATIENT'
WEIGHT IS EQUALLY DISTRIBUTED ON THE FEET TO PREVENT ROTATION
OF THE VERTEBRAL COLUMN.

IF THE PATIENT'S LOWER LIMBS ARE OF UNEQUAL LENGTH, PLACE

SUPPORT OF CORRECT HEIGHT UNDER THE FOOT OF THE SHORTER
SIDE.

PLACE THE SUPERIOR EDGE OF THE IR ½ TO 2 INCHES (3.8 TO 5 CM)

ABOVE THE SHOULDER ON AN AVERAGE PATIENT. THIS WILL POSITION
THE IR SO T7 WILL APPEAR NEAR THE CENTER OF THE IMAGE AND ALL
THE THORACIC VERTEBRAE WILL BE SHOWN.
POSITION OF PART:

SHIELD GONADS

RESPIRATION: THE PATIENT MAY BE

ALLOWED TO TAKE SHALLOW BREATHS
DURING THE EXPOSURE OR RESPIRATION IS
SUSPENDED AT THE END OF FULL
EXPIRATION.
CENTRAL RAY:

PERPENDICULAR TO THE IR.

THE CENTER OF THE CENTRAL
RAY SHOULD BE
APPROXIMATELY HALFWAY
BETWEEN THE JUGULAR
NOTCH AND THE XYPHOID
PROCESS

COLLIMATE CLOSELY TO THE

SPINE
STRUCTURES SHOWN:

THE RESULTING IMAGE

HOW AN AP PROJECTION
OF THE THORACIC BODIES
INTERVERTEBRAL DISK
SPACES, TRANSVERSE
PROCESSES,
COSTOVERTEBRAL
ARTICULATION, AND
SURROUNDING
STRUCTURES
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

ALL 12 VERTEBRAE
•WIDE LATITUDE OF EXPOSURE (OR TWO RADIOGRAPH
CAN BE TAKEN FOR THE UPPER AND LOWER
VERTEBRAE).
•X-RAY BEAM COLLIMATED TO THE THORACIC SPINE
•SPINOUS PROCESSES AT THE MIDLINE OF THE PATIENT
•VERTEBRAL COLUMN ALLIGNED TO THE MIDDLE OF THE
RADIOGRAPH
THORACIC VERTEBRAE
LATERAL PROJECTION
R OR L POSITION

IMAGE RECEPTOR: 14X17 LENGTHWISE

POSITION OF PATIENT:
•PLACE THE PATIENT IN THE LATERAL POSITION
•IF POSSIBLE, USE THE LEFT LATERAL POSITION TO PLACE THE HEART CLOSER TO
THE IR WHICH MINIMIZES OVERLAPPING OF THE VERTEBRAE BY THE HEART.
•HAVE THE PATIENT DRESSED IN AN OPEN BACKED GOWN SO THAT THE
VERTEBRAL COLUMN CAN BE EXPOSED FOR ADJUSTMENT OF THE POSITION.
POSITION OF PART: (ASSUMING SUPINE)

•PLACE A FIRM PILLOW UNDER THE PATIENT'S HEAD TO

KEEP THE LONG AXIS OF THE VERTEBRAL COLUMN
HORIZONTAL.
•FLEX THE PATIENT'S HIP AND KNEES TO A
COMFORTABLE POSITION.
•PLACE THE SUPERIOR EDGE OF THE IR ½ TO 2 INCHES
ABOVE THE RELAXED SHOULDERS. CENTER THE
POSTERIOR HALF OF THE THORAX TO THE MIDLINE OF
THE GRID AND AT THE LEVEL OF T7.
T7 WILL BE AT THE INFERIOR ANGLE OF THE SCAPULAE.
POSITION OF PART: (ASSUMING SUPINE)

•RESPIRATION: THE EXPOSURE CAN BE MADE WITH THE

PATIENT BREATHING NORMALLY TO OBLITERATE OR
DIFFUSE THE VASCULAR MARKINGS AND RIBS OR AT
THE END OF EXPIRATION.
CENTRAL RAY:

PERPENDICULAR TO THE
CENTER OF THE IR AT THE
LEVEL OF T7 (INFERIOR
ANGLES OF THE SCAPULAE).
THE CENTRAL RAY ENTERS
THE POSTERIOR HALF OF THE
THORAX.
CENTRAL RAY:

PERPENDICULAR TO THE
CENTER OF THE IR AT THE
LEVEL OF T7 (INFERIOR
ANGLES OF THE SCAPULAE).
THE CENTRAL RAY ENTERS
THE POSTERIOR HALF OF THE
THORAX.
CENTRAL RAY:

AN AVERAGE ANGLE OF
10 DEGREES CEPHALAD IS
SUFFICIENT IN MOST
FEMALE PATIENTS; AN
AVERAGE ANGLE OF 15
DEGREE IS SATISFACTORY
IN MOST MALE PATIENTS
BECAUSE OF THEIR
GREATER SHOULDER
WIDTH
STRUCTURES SHOWN:

THE RESULTING IMAGE IS A

LATERAL PROJECTION OF
THE THORACIC BODIES
THAT DEMONSTRATE THEIR
INTERSPACES, THE
INTERVERTEBRAL
FORAMINA, AND THE
LOWER SPINOUS
PROCESSES.
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

VERTEBRAE CLEARLY SEEN THROUGH RIB AND LUNG SHADOW .

•TWELVE THORACIC VERTEBRAE CENTERED ON THE IMAGE
RECEPTOR. SUPERIMPOSITION OF THE SHOULDERS ON THE UPPER
VERTEBRAE MAY CAUSE UNDEREXPOSURE IN THIS AREA. THE NUMBER
OF VERTEBRAE VISUALIZED DEPEND ON THE SIZE AND SHAPE OF THE
PATIENT. T1-T3 WILL NOT BE WELL VISUALIZED.
•RIBS SUPERIMPOSED POSTERIORLY TO INDICATE THAT THE PATIENT
WAS NOT ROTATED.
•OPEN INTERVERTEBRAL DISK SPACES.
WIDE LATITUDE OF EXPOSURE.
•X-RAY BEAM TIGHTLY COLLIMATED TO REDUCE SCATTER RADIATION.
ZYGAPOPHYSEAL JOINTS
AP OR PA OBLIQUE PROJECTION
RAO AND LAO OR RPO AND LPO
UPRIGHT AND RECUMBENT POSITIONS

THE AP OBLIQUE DEMONSTRATE THE JOINTS FARTHEST

FROM THE IR, AND THE PA OBLIQUES DEMONSTRATE
THE JOINTS CLOSEST TO THE IR.
ZYGAPOPHYSEAL JOINTS
RAO AND LAO OR RPO AND LPO
UPRIGHT AND RECUMBENT POSITIONS

IMAGE RECEPTOR: 14X17 LENGTHWISE

POSITION OF PATIENT: (UPRIGHT)

•PLACE THE PATIENT’S STANDING OR SITTING
UPRIGHT, IN A LATERAL POSITION BEFORE A
VERTICAL GRID.
POSITION OF PART: (UPRIGHT)

•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.

•CENTER THE PATIENT'S VERTEBRAL COLUMN TO THE

MIDLINE OF THE GRID, AND HAVE THE PATIENT REST THE
ADJACENT SHOULDER FIRMLY AGAINST IT FOR SUPPORT.
ADJUST THE HEIGHT OF THE IR IS ½ TO 2 INCHES ABOVE
THE SHOULDERS TO CENTER THE IR TO T7.
POSITION OF PART:

•FOR THE PA OBLIQUE, FLEX THE ELBOW OF THE ARM

ADJACENT TO THE GRID AND REST THE HAND ON THE
HIP. FOR THE AP OBLIQUE, THE ARM ADJACENT TO THE
GRID IS BROUGHT FORWARD TO AVOID
SUPERIMPOSING THE HUMERUS ON THE UPPER
THORACIC VERTEBRAE.
•FOR THE PA OBLIQUE, HAVE THE PATIENT GRASP THE
SIDE OF THE GRID DEVICE WITH THE OUTER HAND.

FOR THE AP OBLIQUE, HAVE THE PATIENT PLACE THE

OUTER HAND ON THE HIP.
POSITION OF PART:

•ADJUST THE PATIENT'S SHOULDER TO LIE IN THE

SAME HORIZONTAL PLANE.
•HAVE THE PATIENT STAND STRAIGHT TO PLACE THE
LONG AXIS OF THE VERTEBRAL COLUMN PARALLEL
WITH THE IR.
•THE WEIGHT OF THE PATIENT'S BODY MUST BE
EQUALLY DISTRIBUTED ON THE FEET, AND THE HEAD
MUST NOT BE TURNED LATERALLY.
•SHIELD GONADS. • RESPIRATION: SUSPEND THE
END OF EXPIRATION.
CENTRAL RAY:

PERPENDICULAR TO
THE IR EXITING OR
ENTERING THE LEVEL
OF T1
CENTRAL RAY:

PERPENDICULAR TO
THE IR EXITING OR
ENTERING THE LEVEL
OF T1
ZYGAPOPHYSEAL JOINTS
RAO AND LAO OR RPO AND LPO
UPRIGHT AND RECUMBENT POSITIONS

IMAGE RECEPTOR: 14X17 LENGTHWISE

POSITION OF PATIENT: (RECUMBENT)

•PLACE THE PATIENT IN A LATERAL RECUMBENT POSITION.
•ELEVATE THE HEAD ON A FIRM PILLOW SO THAT ITS MID
SAGITTAL PLANE IS CONTINUOUS WITH THAT OF THE VERTEBRAL
COLUMN.
•FLEX THE PATIENT'S HIPS AND KNEES TO A COMFORTABLE
POSITION.
POSITION OF PART: (RECUMBENT)

•FOR ANTERIOR (PA OBLIQUE) ROTATION, PLACE THE

LOWER ARM BEHIND THE BACK AND THE UPPER ARM
FORWARD WITH THE HAND ON THE TABLE FOR
SUPPORT
•FOR POSTERIOR (AP OBLIQUE) ROTATION, ADJUST
THE LOWER ARM AT RIGHT ANGLES TO THE LONG AXIS
OF THE BODY, FLEX THE ELBOW, AND PLACE THE HAND
UNDER OR BESIDE THE HEAD. PLACE THE UPPER ARM
POSTERIORLY AND SUPPORT IT
POSITION OF PART: (RECUMBENT)

•ROTATE THE BODY SLIGHTLY, EITHER ANTERIORLY OR

POSTERIORLY 20 DEGREES, SO THAT THE CORONAL PLANE
FORMS AN ANGLE OF 70 DEGREES WITH THE HORIZONTAL.
•CENTER THE VERTEBRAL COLUMN TO THE MIDLINE OF THE
GRID.
•CENTER THE IR ½ TO 2 INCHES ABOVE THE SHOULDERS TO
CENTER IT AT THE LEVEL OF T1.
•IF NEEDED, APPLY A COMPRESSION BAND ACROSS THE HIPS,
BUT BE CAREFUL NOT TO CHANGE THE POSITION.

•SHIELD GONADS.• RESPIRATION: SUSPEND AT THE END OF

EXPIRATION.
CENTRAL RAY:

PERPENDICULAR TO
THE IR EXITING OR
ENTERING THE LEVEL
OF T1
CENTRAL RAY:

PERPENDICULAR TO
THE IR EXITING OR
ENTERING THE LEVEL
OF T1
STRUCTURES SHOWN:

THE RESULTING
IMAGES SHOW
OBLIQUE PROJECTION
OF THE
ZYGAPOPHYSEAL
JOINTS
STRUCTURES SHOWN:

THE RESULTING
IMAGES SHOW
OBLIQUE PROJECTION
OF THE
ZYGAPOPHYSEAL
JOINTS
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY
DEMONSTRATED:

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

LUMBAR-LUMBOSACRAL VERTEBRAE
AP PROJECTION (PA OPTIONAL)

IMAGE RECEPTOR: 14X17 LENGTHWISE

POSITION OF PATIENT:
•EXAMINE THE LUMBAR OR LUMBOSACRAL
SPINE WITH THE PATIENT RECUMBENT.
POSITION OF PART:

•CENTER THE MIDSAGITTAL PLANE OF THE

PATIENT'S BODY TO THE MIDLINE OF THE GRID.
•ADJUST THE PATIENT'S SHOULDERS AND HIPS
TO LIE IN THE SAME HORIZONTAL PLANE.
•FLEX THE PATIENT'S ELBOWS AND PLACE THE
HANDS ON THE UPPER CHEST 0 THAT THE
FOREARMS DO NOT LIE WITHIN THE EXPOSURE
FIELD.
POSITION OF PART:

•A RADIOLUCENT SUPPORT UNDER THE LOWER PELVIC SIDE

CAN BE USED TO REDUCE ROTATION WHEN NECESSARY.
•REDUCE LUMBAR LORDOSIS BY FLEXING THE PATIENT'S HIP
AND KNEES ENOUGH TO PLACE THE BACK IN FIRM CONTACT
WITH TABLE
•FOR DEMONSTRATION OF THE LUMBAR SPINE AND SACRUM,
CENTER THE 35X43 CM IR AT THE LEVEL OF THE ILIAC CREST
(L4). CAREFULLY PALPATE THE CREST OF THE ILIUM. IT IS
POSSIBLE TO BE MISLED BY THE CONTOUR OF THE HEAVY
MUSCLES AND FATTY TISSUE LYING ABOVE THE BONE.
POSITION OF PART:

FOR DEMONSTRATION OF THE LUMBAR SPINE ONLY,

CENTER THE 30X35 CM 1 ½ INCH (3.8 CM) ABOVE THE
ILIAC CREST (L3).

• SHIELD GONADS.
• RESPIRATION: SUSPEND AT THE END OF EXPIRATION.
CENTRAL RAY:

PERPENDICULAR TO THE
IR AT THE LEVEL OF THE
ILIAC CRESTS (L4) FOR A
LUMBOSACRAL
EXAMINATION OR 1 ½
INCHES (3.8 CM) ABOVE
THE ILIAC CRESTS (L3)
FOR A LUMBAR
EXAMINATION.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS THE LUMBAR
BODIES, INTERVERTEBRAL
DISK SPACES, INTER-
PEDICULATE SPACES,
LAMINAE, AND SPINOUS
AND TRANSVERSE
PROCESSES
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

AREA FROM THE LOWER THORACIC VERTEBRAE TO THE SACRUM

•X-RAY BEAM COLLIMATED TO THE LATERAL MARGIN OF THE PSOAS
MUSCLES
•NO ARTIFACT ACROSS THE MIDABDOMEN FROM ANY ELASTIC IN THE
PATIENT'S UNDERCLOTHING
•X-RAY PENETRATION OF ALL VERTEBRAL STRUCTURES
•OPEN INTERVERTEBRAL JOINTS
•SACROILIAC JOINTS EQUIDISTANT FROM THE VERTEBRAL COLUMN
•SYMMETRIC VERTEBRAE, WITH SPINOUS PROCESSES CENTERED TO
THE BODIES
LUMBAR-LUMBOSACRAL VERTEBRAE
LATERAL PROJECTION
R OR L POSITION

IMAGE RECEPTOR: 14X17 LENGTHWISE

POSITION OF PATIENT:
•FOR THE LATERAL POSITION, USE THE SAME BODY POSITION
(RECUMBENT OR UPRIGHT) AS FOR THE AP OR PA
PROJECTION.
• HAVE THE PATIENT DRESSED IN AN OPEN-BACKED GOWN SO
THAT THE SPINE CAN BE EXPOSED FOR FINAL ADJUSTMENT OF
THE POITION.
POSITION OF PART:

ASK THE PATIENT TO TURN ONTO THE AFFECTED SIDE

AND FLEX HIPS AND KNEES TO A COMFORTABLE
POSITION.
•WHEN EXAMINING A THIN PATIENT, ADJUST A SUITABLE
PAD UNDER THE DEPENDENT HIP TO RELIEVE PRESSURE.
•ALIGN THE MIDCORONAL PLANE OF THE BODY TO THE
MIDLINE OF THE GRID AND ENSURE THAT IT IS VERTICAL.
REMEMBER THAT NO MATTER HOW LARGE THE PATIENT,
THE LONG AXSI OF THE BODY OF THE LUMBAR PINE IS
SITUATED IN THE MIDCORONAL PLANE
POSITION OF PART:

WITH THE PATIENT'S ELBOW FLEXED, ADJUST THE

DEPENDENT ARM AT RIGHT ANGLES TO THE BODY.

•TO PREVENT ROTATION, EXACTLY SUPERIMPOSE THE

KNEES AND PLACE A SMALL SANDBAG BETWEEN THEM.
• PLACE A SUITABLE RADIOLUCENT SUPPORT UNDER THE
LOWER THORAX, AND ADJUST IT SO THAT THE LONG AXIS
OF THE SPINE IS HORIZONTAL THIS IS THE PREFERRED
METHOD OF POSITIONING THE SPINE.
POSITION OF PART:

WHEN USING A 35X43 CM IR, CENTER IT AT THE LEVEL

OF THE CREST OF THE ILIUM (L4).
WITH A 30 X 35 CM IR, CENTER IT 1 ½ INCHES(3.8 CM)
ABOVE THE ILIAC CREST.
• SHIELD GONADS.
• RESPIRATION: SUSPEND AT THE END OF EXPIRATION.
CENTRAL RAY:

PERPENDICULAR TO THE
IR AT THE LEVEL OF THE
ILIAC CRESTS (L4) FOR A
LUMBOSACRAL
EXAMINATION OR 1 ½
INCHES (3.8 CM) ABOVE
THE ILIAC CRESTS (L3)
FOR A LUMBAR
EXAMINATION.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS THE LUMBAR
BODIES AND THEIR
INTERSPACES, THE
SPINOUS PROCESSES,
AND THE LUMBOSACRAL
JUNCTION
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

AREA FROM THE LOWER THORACIC VERTEBRAE TO THE COCCYX USING

A 35 X 43 CM IMAGE RECEPTOR
•AREA FROM THE LOWER THORACIC VERTEBRAE TO THE SACRUM USING
A 30 X 35 CM IMAGE RECEPTOR
•OPEN INTERVERTEBRAL DISK SPACES
•SUPERIMPOSED POSTERIOR MARGINS OF EACH VERTEBRAL BODY
•VERTEBRAE ALIGNED DOWN THE MIDDLE OF THE RADIOGRAPH
•NEARLY SUPERIMPOSED CRESTS OF THE ILIA WHEN THE X-RAY BEAM IS
NOT ANGLED
•SPINOUS PROCESSES
L5-S1 LUMBOSACRAL JUNCTION
LATERAL PROJECTION
R OR L POSITION

IMAGE RECEPTOR: 8X10 LENGTHWISE

POSITION OF PATIENT:
EXAMINE THE L5-S1 LUMBOSACRAL REGION WITH THE
PATIENT IN THE LATERAL RECUMBENT POSITION
POSITION OF PART:

WITH THE PATIENT IN THE RECUMBENT POSITION, ADJUST

THE PILLOW TO PLACE THE MIDSAGITTAL PLANE OF THE
HEAD IN THE SAME PLANE WITH THE SPINE.
•ADJUST THE MIDCORONAL PLANE OF THE BODY
(PASSING THROUGH THE HIP AND SHOULDERS) SO IT IS
PERPENDICULAR TO THE IR.
•FLEX THE PATIENT'S ELBOW, AND ADJUST THE
DEPENDENT ARM IN A POSITION AT RIGHT ANGLES TO
THE BODY
•IF POSSIBLE, FULLY EXTEND THE PATIENT'S HIPS FOR THIS
STUDY.
POSITION OF PART:

AS DESCRIBED FOR THE LATERAL PROJECTION, PLACE

A RADIOLUCENT SUPPORT UNDER THE LOWER THORAX
AND ADJUST IT SO THAT THE LONG AXIS OF THE SPINE
IS HORIZONTAL.
•SUPERIMPOSE THE KNEES EXACTLY, AND PLACE A
SUPPORT BETWEEN THEM.
•SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

CENTER ON A
CORONAL PLANE 2
INCHES (5 CM)
POSTERIOR TO THE ASIS
AND 1 ½ INCHES (3.8
CM) INFERIOR TO THE
ILIAC CREST.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOW A LATERAL
PROJECTION OF THE
LUMBOSACRAL
JUNCTION, THE LOWER
ONE OR TWO LUMBAR
VERTEBRAE, AND THE
UPPER SACRUM
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

OPEN LUMBOSACRAL JOINT

• COLLIMATED X-RAY BEAM THAT INCLUDES ALL OF LS AND THE UPPER
SACRUM
• LUMBOSACRAL JOINT IN THE CENTER OF THE EXPOSURE AREA
• CRESTS OF THE ILIA CLOSELY SUPERIMPOSING EACH OTHER WHEN THE
X-RAY BEAM IS NOT ANGLED
ZYGAPOPHYSEAL JOINTS
AP OBLIQUE PROJECTION
RPO AND LPO POSITIONS
THE ARTICULAR PROCESSE OF THE LUMBAR VERTEBRAE FORM AN ANGLE OF 30 TO 50 DEGREES, AND THOSE
BETWEEN THE LAST LUMBAR VERTEBRA AND THE SACRUM FORM AN ANGLE OF 30 DEGREES TO THE
MIDSAGITTAL PLANE IN THE MAJORITY OF PATIENTS.

IMAGE RECEPTOR: 14 X17 INCHES OR 11X14 INCHES

LENGTHWISE

POSITION OF PATIENT:
WHEN OBLIQUE PROJECTIONS ARE INDICATED, THEY ARE GENERALLY
PERFORMED IMMEDIATELY AFTER THE AP PROJECTION AND IN THE SAME BODY
POSITION (RECUMBENT OR UPRIGHT).
POSITION OF PART:

• HAVE THE PATIENT TURN 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. IN THE OBLIQUE POSITION THE LUMBAR SPINE LIES
IN THE LONGITUDINAL PLANE THAT PASSES 2 INCHES (5
CM) MEDIAL TO THE ELEVATED ASIS.
POSITION OF PART:

• ASK THE PATIENT TO PLACE THE ARMS IN A

COMFORTABLE POSITION. A SUPPORT MAY BE PLACED
UNDER THE ELEVATED SHOULDER, HIP, AND KNEE
•CHECK THE DEGREE OF BODY ROTATION, AND MAKE
ANY NECESSARY ADJUSTMENT . ADJUST AT AN ANGLE OF
45 DEGREES FOR DEMONSTRATION OF THE ARTICULAR
PROCESSES IN THE LUMBAR REGION AND AT AN ANGLE
OF 30 DEGREE FOR DEMONSTRATION OF THE
LUMBOSACRAL PROCESSES .
• SHIELD GONADS. • RESPIRATION: SUSPEND AT THE END
OF EXPIRATION.
CENTRAL RAY:

ENTER 2 INCHES (5
CM) MEDIAL TO THE
ELEVATED ASIS AND 1
½ INCHES (3.8 CM)
ABOVE THE ILIAC
CREST (L3).
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
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

AREA FROM THE LOWER THORACIC VERTEBRAE TO THE SACRUM.

•ZYGAPOPHYSEAL JOINTS CLOSEST TO THE IR OPEN AND UNIFORMLY VISIBLE
THROUGH THE VERTEBRAL BODIES.
WHEN THE JOINT IS NOT WELL DEMONSTRATED AND THE PEDICLE IS
ANTERIOR ON THE VERTEBRAL BODY, THE PATIENT IS NOT ROTATED
ENOUGH.
WHEN THE JOINT IS NOT WELL DEMONSTRATED AND THE PEDICLE IS
POSTERIOR ON THE VERTEBRAL BODY, THE PATIENT IS ROTATED TOO MUCH.
•
VERTEBRAL COLUMN PARALLEL WITH THE TABLETOP SO THAT THE T12-L1 AND L1-
L2 JOINT PACES REMAIN OPEN
ZYGAPOPHYSEAL JOINTS
PA OBLIQUE PROJECTION
RAO AND LAO POSITIONS

IMAGE RECEPTOR: 14 X17 INCHES OR 11X14

INCHES LENGTHWISE

POSITION OF PATIENT:
PLACE THE PATIENT IN ANTERIOR OBLIQUE POSITION OPPOSITE OF
THE AFFECTED SIDE
POSITION OF PART:

•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 SEMIPRONE POSITION AND SUPPORT THE
BODY ON THE FOREARM AND FLEXED KNEE.
•ALIGN THE BODY TO CENTER L3 TO THE MIDLINE
OF THE GRID
POSITION OF PART:

•ADJUST THE DEGREE OF BODY ROTATION TO AN

ANGLE OF 45 DEGREES FOR THE LUMBAR REGION
AND 30 DEGREES FROM THE HORIZONTAL FOR THE
LUMBOSACRAL ZYGAPOPHYSEAL JOINT.
•CENTER THE IR AT THE LEVEL OF L3.
•TO DEMONSTRATE THE LUMBOSACRAL JOINT,
POSITION THE PATIENT AS DESCRIBED ABOVE BUT
CENTER L5.
• SHIELD GONADS. • RESPIRATION: SUSPEND AT THE
END OF EXPIRATION.
CENTRAL RAY:

PERPENDICULAR TO ENTER
THE L3 (1 TO ½ ABOVE THE
CREST OF THE ILIUM). THE
CENTRAL RAY ENTER THE
ELEVATED IDE
APPROXIMATELY 2 INCHES
(5 CM) LATERAL TO THE
PALPABLE SPINOUS
PROCESS
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
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

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.
•VERTEBRAL COLUMN PARALLEL WITH THE TABLETOP SO THAT THE T12-L1
AND L 1-L2 JOINT SPACES REMAIN OPEN.
INTERVERTEBRAL FORAMINA
PA AXIAL OBLIQUE PROJECTION
KOVACS METHOD
RAO AND LAO POSITIONS

IMAGE RECEPTOR: 8X10 INCHES LENGTHWISE

POSITION OF PATIENT:
PLACE THE PATIENT IN THE LATERAL RECUMBENT POSITION LYING
ON THE SIDE BEING EXAMINED.
POSITION OF PART:

• WITH THE PATIENT IN THE LATERAL POSITION, ALIGN THE

BODY SO THAT A PLANE PASSING 1 ½ INCHES
POSTERIOR TO THE MIDCORONAL PLANE IS CENTERED
TO THE MIDLINE.
•HAVE THE PATIENT EXTEND THE UPPER ARM AND
GRASP THE END OF THE RADIOGRAPHIC TABLE TO
MAINTAIN THE THORAX IN THE LATERAL POSITION WHEN
THE PELVIS IS ROTATED.
•KEEPING THE PATIENT'S THORAX EXACTLY LATERAL,
ROTATE THE PELVIS 30 DEGREES ANTERIORLY FROM THE
LATERAL POSITION.
POSITION OF PART:

• PLACE A SANDBAG SUPPORT UNDER THE FLEXED

UPPERMOST KNEE TO PREVENT TOO MUCH ROTATION
OF THE HIPS
• ADJUST THE POSITION OF THE IR SO THAT IT MIDPOINT
COINCIDES WITH THE CENTRAL RAY.
• SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

DIRECTED ALONG A STRAIGHT

LINE EXTENDING FROM THE
SUPERIOR EDGE OF THE CREST
OF THE UPPERMOST ILIUM
THROUGH L5 TO THE INGUINAL
REGION OF THE DEPENDENT
SIDE. DEPENDING ON THE
ALIGNMENT OF THE SPINE, THE
CENTRAL RAY ANGULATION
MAY VARY FROM 15 TO 30
DEGREES CAUDAD.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS THE L5
INTERVERTEBRAL
FORAMEN. BOTH SIDES ARE
EXAMINED FOR
COMPARISON.
THE KOVACS METHOD IS
SHOWN BESIDE THE
LATERAL L5-S1
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

OPEN L5 INTERVERTEBRAL FORAMEN ON THE SIDE CLOSER TO THE IR

•L5 INTERVERTEBRAL FORAMEN IN THE CENTER OF THE RADIOGRAPH

LS JUNCTION AND SI JOINTS
AP OR PA AXIAL PROJECTION

IMAGE RECEPTOR: 8X10 INCHES LENGTHWISE

POSITION OF PATIENT:
FOR THE AP AXIAL PROJECTION OF THE LUMBOSACRAL AND
SACROILIAC JOINTS, POSITION THE PATIENT IN THE SUPINE
POSITION.
POSITION OF PART:

•WITH THE PATIENT SUPINE AND THE

MIDSAGITTAL PLANE CENTERED TO THE GRID,
EXTEND PATIENT' LOWER LIMBS OR ABDUCT THE
THIGH AND ADJUST IN THE VERTICAL POSITION
•ENSURE THAT THE PELVIS IS NOT ROTATED.

•SHIELD GONADS. • RESPIRATION: SUSPEND.

CENTRAL RAY:

DIRECTED THROUGH THE

LUMBOSACRAL JOINT AT AN
AVERAGE ANGLE OF 30 TO 35
DEGREES CEPHALAD. THE CENTRAL
RAY ENTER ABOUT 1 ½ INCHES
SUPERIOR TO THE PUBIC SYMPHYSIS
ON THE MIDSAGITTAL PLANE

30 DEGREES FOR MALE PATIENTS

35 DEGREES FOR FEMALE PATIENTS
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS THE
LUMBOSACRAL JOINT
AND ASYMMETRIC
IMAGE OF BOTH
SACROILIAC JOINTS
FREE OF
SUPERIMPOSITION
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

LUMBOSACRAL JUNCTION AND SACRUM

•OPEN INTERVERTEBRAL SPACE BETWEEN L5

AND SI

•BOTH SACROILIAC JOINTS ADEQUATELY

PENETRATED
CENTRAL RAY:

DIRECTED THROUGH THE

LUMBOSACRAL JOINT AT AN
AVERAGE ANGLE OF 30 TO 35
DEGREES CAUDAL. THE CENTRAL
RAY ENTERS THE SPINOUS PROCESS
OF L4

30 DEGREES FOR MALE PATIENTS

35 DEGREES FOR FEMALE PATIENTS
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS THE
LUMBOSACRAL JOINT
AND ASYMMETRIC
IMAGE OF BOTH
SACROILIAC JOINTS
FREE OF
SUPERIMPOSITION
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

LUMBOSACRAL JUNCTION AND SACRUM

•OPEN INTERVERTEBRAL SPACE BETWEEN L5

AND SI

•BOTH SACROILIAC JOINTS ADEQUATELY

PENETRATED
SI JOINTS
AP OBLIQUE PROJECTION
RPO AND LPO POSITIONS

IMAGE RECEPTOR: 8X10 INCHES LENGTHWISE

BOTH OBLIQUES ARE USUALLY OBTAINED FOR
COMPARISON.

POSITION OF PATIENT:
PLACE THE PATIENT IN THE SUPINE POSITION, AND
ELEVATE THE HEAD ON A FIRM PILLOW.
POSITION OF PART:

USE THE LPO POSITION TO DEMONSTRATE THE RIGHT

JOINT AND THE RPO POSITION TO SHOW THE LEFT JOINT.
THE SIDE BEING EXAMINED IS FARTHER FROM THE IR.

ELEVATE THE SIDE UNDER EXAMINATION

APPROXIMATELY 25 TO 30 DEGREES, AND SUPPORT THE
SHOULDER, LOWER THORAX, AND UPPER THIGH

ADJUST THE PATIENT'S BODY SO THAT ITS LONG AXIS IS

PARALLEL WITH THE LONG AXIS OF THE RADIOGRAPHIC
TABLE.
POSITION OF PART:

ALLIGN THE BODY SO THAT A SAGITTAL PLANE PASSING 1 INCH

MEDIAL TO THE ASIS OF THE ELEVATED IDE IS CENTERED TO THE
MIDLINE OF THE GRID.

CHECK THE ROTATION AT SEVERAL POINTS ALONG THE BACK.

CENTER THE IR AT THE LEVEL OF THE ASIS.

SHIELD GONADS. COLLIMATING CLOSE TO THE JOINT MAY SHIELD THE

GONADS IN MALE PATIENTS. IT MAY BE DIFFICULT TO USE CONTACT
SHIELDING IN FEMALE PATIENTS.
RESPIRATION: SUSPEND.
CENTRAL RAY:

PERPENDICULAR TO THE CENTER

OF THE IR, ENTERING 1 INCH
MEDIAL TO THE ELEVATED ASIS
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOW THE SACROILIAC
JOINT FARTHEST FROM THE
IR AND AN OBLIQUE
PROJECTION OF THE
ADJACENT STRUCTURES.

BOTH SIDES ARE EXAMINED

FOR COMPARISON
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

LUMBOSACRAL JUNCTION AND SACRUM

•OPEN SACROILIAC JOINT SPACE WITH

MINIMAL OVERLAPPING OF THE ILIUM AND
SACRUM

•JOINT CENTERED ON THE RADIOGRAPH

SI JOINTS
PA OBLIQUE PROJECTION
RAO AND LAO POSITIONS

IMAGE RECEPTOR: 8X10 INCHES LENGTHWISE

BOTH OBLIQUES ARE USUALLY OBTAINED FOR
COMPARISON.

POSITION OF PATIENT:
USE THE RAO POSITION TO DEMONSTRATE THE RIGHT JOINT
AND THE LAO POSITION TO SHOW THE LEFT JOINT. THE SIDE
BEING EXAMINED IS CLOSER TO THE IR.
POSITION OF PART:

ADJUST THE PATIENT BY ROTATING THE SIDE OF INTEREST

TOWARD THE RADIOGRAPHIC TABLE UNTIL A BODY
ROTATION OF 25 TO 30 DEGREES IS ACHIEVED. THE
FOREARM AND FLEXED KNEE USUALLY FURNISH
SUFFICIENT SUPPORT FOR THIS POSITION.

CHECK THE DEGREE OF ROTATION AT SEVERAL POINTS

ALONG THE ANTERIOR SURFACE OF THE PATIENT'S BODY.
O ADJUST THE PATIENT'S BODY SO THAT ITS LONG AXIS
PARALLEL WITH THE LONG AXIS OF THE TABLE.
POSITION OF PART:

CENTER THE BODY SO THAT A POINT 1 INCH MEDIAL

TO THE ASIS CLOSEST TO THE IR IS CENTERED TO THE
GRID

CENTER THE IR AT THE LEVEL OF THE ASIS.

SHIELD GONADS.
RESPIRATION: SUSPEND.
CENTRAL RAY:

PERPENDICULAR TO THE IR AND

CENTERED 1 INCH MEDIAL TO
THE ASIS CLOSEST TO THE IR
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS THE
SACROILIAC JOINT
CLOSEST TO THE IR
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

LUMBOSACRAL JUNCTION AND SACRUM

•OPEN SACROILIAC JOINT SPACE WITH

MINIMAL OVERLAPPING OF THE ILIUM AND
SACRUM

•JOINT CENTERED ON THE RADIOGRAPH

PUBIS SYMPHYSIS
PA PROJECTION
CHAMBERLAIN METHOD FOR ABNORMAL
SACROILIAC MOTION

*TWO PA PROJECTIONS OF THE PUBIC BONE , WITH THE

PATIENT IN THE UPRIGHT POSITION AND WITH WEIGHT-
BEARING ON THE ALTERNATE LIMBS TO DEMONSTRATE
PUBIC SYMPHYSIS REACTION BY A CHANGE IN THE
NORMAL RELATION OF THE PUBIC BONES IN CASES OF
SACROILIAC SLIPPAGE OR RELAXATION.
PUBIS SYMPHYSIS
PA PROJECTION
CHAMBERLAIN METHOD FOR ABNORMAL
SACROILIAC MOTION

IMAGE RECEPTOR: 8X10 INCHES LENGTHWISE FOR

EACH EXPOSURE

POSITION OF PATIENT:
PLACE THE PATIENT UPRIGHT, FACING THE VERTICAL GRID DEVICE
AND STANDING ON THE TWO BLOCKS.
POSITION OF PART:

• CENTER THE MIDSAGITTAL PLANE OF THE BODY TO THE

MIDLINE OF THE GRID, AND ADJUST THE ASIS
EQUIDISTANT FROM THE IR.
• HAVE THE PATIENT GRASP THE SIDE OF THE DEVICE
FOR STEADINESS. HOWEVER, THE DEVICE MUST NOT BE
USED TO SUPPORT THE PATIENT' WEIGHT.
•IF NECESSARY, PLACE A COMPRESSION BAND ACROSS
THE PELVIS TO IMMOBILIZE THE PATIENT BUT NOT TO AID
IN SUPPORTING THE WEIGHT OF THE BODY
POSITION OF PART:

ADJUST THE HEIGHT OF THE GRID, AND CENTER THE IR TO THE

PUBIC SYMPHYSIS.
•FOR THE FIRST EXPOSURE, REMOVE ONE OF THE BLOCK SO
THAT ONE LEG HANG FREE. THE PATIENT SHOULD BE GIVEN
GOOD INSTRUCTIONS ABOUT LETTING THE LEG HANG WITH
NO MUSCULAR RESISTANCE.
•FOR THE SECOND EXPOSURE, REPLACE THE SUPPORT UNDER
THE FOOT THAT WAS HANGING, AND REMOVE THE OPPOSITE
ONE, PERMITTING THE SECOND LEG TO HANG FREE.
CHAMBERLAIN SUGGESTED THAT THE IDENTIFICATION MARKER
BE PLACED ON THE WEIGHT-BEARING SIDE
• SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

PERPENDICULAR AND CENTERED

TO THE PUBIC SYMPHYSIS.

•USE CLOSE COLLIMATION.

STRUCTURES SHOWN:

THE TWO IMAGES HOW PA

PROJECTIONS OF THE PUBIC
SYMPHYSIS.
ABNORMAL MOTION OF THE
SACROILIAC JOINTS IS
DEMONSTRATED BY A
CHANGE IN THE NORMAL
RELATION OF THE PUBIC
BONES TO EACH OTHER
WHEN THE BODY WEIGHT IS
BORNE ON ONE LEG
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

PUBIC SYMPHYSIS IN THE CENTER OF THE

RADIOGRAPH

•NO ROTATION OF THE PATIENT, INDICATED BY

SYMMETRY OF THE PUBIC BONES AND
OBTURATOR FORAMINA
•IDENTIFICATION MARKER PLACED ON THE
WEIGHT-BEARING SIDE
SACRUM AND COCCYX
AP AND PA AXIAL PROJECTIONS

IMAGE RECEPTOR: 10X12 FOR SACRUM AND

8X10 INCHES LENGTHWISE FOR COCCYX

POSITION OF PATIENT:
THE SUPINE POSITION IS MOST OFTEN USED. .
POSITION OF PART:

•WITH THE PATIENT EITHER SUPINE OR PRONE, CENTER THE

MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF THE
TABLE GRID.
• ADJUST THE PATIENT SO THAT BOTH ASIS ARE EQUIDISTANT
FROM THE GRID.
• HAVE THE PATIENT FLEX THE ELBOWS AND PLACE THE ARMS
IN A COMFORTABLE, BILATERALLY SYMMETRIC POSITION.
• WHEN THE SUPINE POSITION IS USED, PLACE A SUPPORT
UNDER THE PATIENT'S KNEES.
•SHIELD GONADS ON MEN. WOMEN CANNOT BE SHIELDED
FOR THIS PROJECTION. • RESPIRATION: SUSPEND.
CENTRAL RAY: SACRUM

SUPINE:
DIRECT THE CENTRAL RAY 15
DEGREE CEPHALAD AND CENTER IT
TO A POINT 2 INCHES SUPERIOR TO
THE PUBIC SYMPHYSIS
PRONE:
,ANGLE THE CENTRAL RAY 15
DEGREES CAUDAD AND CENTER IT
TO THE CLEARLY VISIBLE SACRAL
CURVE.
CENTRAL RAY: COCCYX

SUPINE:
DIRECT THE CENTRAL RAY 10
DEGREE CAUDAD AND CENTER IT
TO A POINT 2 INCHES SUPERIOR TO
THE PUBIC SYMPHYSIS
PRONE:
,ANGLE THE CENTRAL RAY 10
DEGREES CEPHALAD AND CENTER
IT TO THE CLEARLY VISIBLE SACRAL
CURVE.
STRUCTURES SHOWN:

THE RESULTING IMAGE

DEMONSTRATES THE
SACRUM OR COCCYX
FREE OF
SUPERIMPOSITION
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

SACRUM FREE OF FORESHORTENING, WITH THE SACRAL

CURVATURE STRAIGHTENED
•PUBIC BONES NOT OVERLAPPING THE SACRUM

COCCYGEAL SEGMENTS NOT SUPERIMPOSED

• SHORT-SCALE CONTRAST ON THE RADIOGRAPH
• COCCYX CENTERED AND SEEN IN ITS ENTIRETY
• TIGHT COLLIMATION EVIDENT TO IMPROVE THE
VISIBILITY
SACRUM AND COCCYX
LATERAL PROJECTIONS
R OR L POSITION

IMAGE RECEPTOR: 10X12 FOR SACRUM AND 8X10

INCHES LENGTHWISE FOR COCCYX

POSITION OF PATIENT:
ASK THE PATIENT TO TURN ONTO THE INDICATED SIDE AND FLEX THE
HIPS AND KNEES TO A COMFORTABLE POSITION.
POSITION OF PART:

•ADJUST THE ARMS IN A POSITION AT RIGHT

ANGLES TO THE BODY.
•SUPERIMPOSE THE KNEES, AND IF NEEDED, PLACE
POSITIONING SPONGES UNDER AND BETWEEN THE
ANKLES AND BETWEEN THE KNEE . •ADJUST A
SUPPORT UNDER THE BODY TO PLACE THE LONG
AXIS OF THE SPINE HORIZONTAL.
THE INTERILIAC PLANE IS PERPENDICULAR TO THE IR.
POSITION OF PART:

•ADJUST THE PELVIS AND SHOULDERS SO THAT

THE TRUE LATERAL POSITION IS MAINTAINED
•TO PREPARE FOR ACCURATE POSITIONING OF
THE CENTRAL RAY, CENTER THE SACRUM OR
COCCYX TO THE MIDLINE OF THE GRID.
• SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:
SACRUM

PERPENDICULAR AND DIRECTED

TO THE LEVEL OF THE ASSS AND
TO A POINT 3 ½ INCHES
POSTERIOR.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS A LATERAL
PROJECTION OF THE
SACRUM OR COCCYX
CENTRAL RAY:
COCCYX

PERPENDICULAR AND
DIRECTED TOWARD A
POINT 3 ½ INCHES
POSTERIOR TO THE ASIS
AND 2 INCHES
INFERIOR.
STRUCTURES SHOWN:

THE RESULTING IMAGE

SHOWS A LATERAL
PROJECTION OF THE
SACRUM OR COCCYX
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

SACRUM AND COCCYX SEEN CLEARLY WITH SHORT-

SCALE CONTRAST

•USE OF TIGHT COLLIMATION AND A LEAD RUBBER

ABSORBER BEHIND THE SACRUM

• CLOSELY SUPERIMPOSED POSTERIOR MARGIN OF THE

ISCHIA AND ILIA
SACRAL VERTEBRAL CANAL AND SI JOINTS
AXAL PROJECTIONS
NOLKE METHOD

IMAGE RECEPTOR: 8X10 INCHES CROSSWISE

POSITION OF PATIENT:
SEAT THE PATIENT ON THE END OF THE RADIOGRAPHIC TABLE. THE
PATIENT SHOULD IT FAR ENOUGH BACK TO CENTER THE
MIDCORONAL PLANE OF THE BODY TO THE HORIZONTAL AXIS OF
THE BUCKY TRAY
POSITION OF PART:

•ADJUST THE POSITION OF THE PATIENT' BODY SO THAT THE

MIDSAGITTAL PLANE IS PERPENDICULAR TO THE MIDLINE OF
THE GRID.
•HAVE THE PATIENT LEAN FORWARD ENOUGH THAT THE
UPPER, MIDDLE, OR LOWER PORTION OF THE SACRAL
VERTEBRAL CANAL IS VERTICAL.
•BE CERTAIN THAT THE PATIENT IS NOT LEANING LATERALLY.
•HAVE THE PATIENT GRASP THE LEGS OR ANKLES (DEPENDING
ON THE DEGREE OF LEANING) TO MAINTAIN THE POSITION.
•CENTER THE IR TO THE VERTICALLY PLACED PORTION OF THE
SACRUM
• RESPIRATION: SUSPEND.
CENTRAL RAY:

PERPENDICULAR TO
THE IR AND THE LONG
AXIS OF THE SACRUM.

•USE CLOSE
COLLIMATION.
STRUCTURES SHOWN:

THE RESULTANT IMAGE

SHOWS A CROSS SECTION
OF THE UPPER AND LOWER
SACRAL VERTEBRAL
CANAL.

THE SACROILIAC JOINTS

ARE ALSO DEMONSTRATED
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

SACRAL VERTEBRAL CANAL IN THE CENTER OF THE

EXPOSURE AREA

•NO LATERAL ROTATION OF THE PATIENT (SACRAL

AND PELVIC STRUCTURES ARE SYMMETRIC)
LUMBAR INTERVERTEBRAL DISKS
PA PROJECTIONS
WEIGHT BEARING METHOD
R AND L BENDING

IMAGE RECEPTOR: 14X17 INCHES LENGTHWISE

POSITION OF PATIENT:
PERFORM THIS EXAMINATION WITH THE PATIENT IN THE STANDING POSITION.
POSITION OF PART:

WITH THE PATIENT FACING THE VERTEBRAL GRID DEVICE, ADJUST THE
HEIGHT TO BE AT THE LEVEL OF L3

ADJUST THE PATIENT’S PELVIS FOR ROTATION FOR ENSURING THAT THE
ASIS ARE EQUIDISTANT FORM THE IR

CENTER THE MIDSAGITTAL PLANE OF THE PATIENT'S BODY TO THE

MIDLINE OF THE VERTICAL GRID DEVICE

•LET THE PATIENT' ARMS HANG UNSUPPORTED BY THE SIDES.

• MAKE ONE RADIOGRAPH WITH THE PATIENT BENDING TO THE RIGHT
AND ONE WITH THE PATIENT BENDING TO THE LEFT
POSITION OF PART:

HAVE THE PATIENT LEAN DIRECTLY LATERAL AS FAR AS

POSSIBLE WITHOUT ROTATION AND WITHOUT LIFTING THE
FOOT. THE DEGREE OF BENDING MUST NOT BE FORCED,
AND THE PATIENT MUST NOT BE SUPPORTED IN POSITION.

• BE CERTAIN THAT THE MIDSAGITTAL PLANE OF THE

LOWER LUMBAR COLUMN AND SACRUM REMAINS
CENTERED TO THE GRID DEVICE AS THE UPPER PORTION
MOVES LATERALLY.
• SHIELD GONADS. • RESPIRATION: SU PEND.
CENTRAL RAY:

DIRECTED
PERPENDICULAR TO L3
AT AN ANGLE OF 15 TO
20 DEGREE CAUDAD OR
PROJECTED THROUGH
THE L4-L5 OR L5-S1
INTERSPACES,
STRUCTURES SHOWN:

THE RESULTING IMAGES

SHOW BENDING PA
PROJECTIONS OF THE
LOWER THORACIC
REGION AND THE
LUMBAR REGION FOR
DEMONSTRATION OF
THE MOBILITY OF THE
INTERVERTEBRAL JOINTS
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

AREA FROM THE LOWER THORACIC INTERSPACES TO

ALL OF THE SACRUM
• NO ROTATION OF THE PATIENT IN THE BENDING
POSITION
• BENDING DIRECTION CORRECTLY IDENTIFIED ON THE
IMAGE WITH APPROPRIATE LEAD MARKER
THORACOLUMBAR SPINE: SCOLIOSIS
PA PROJECTION
FERGUSON METHOD

IMAGE RECEPTOR: 14X17 INCHES LENGTHWISE

POSITION OF PATIENT:
PERFORM THIS EXAMINATION WITH THE PATIENT IN THE STANDING
POSITION.
POSITION OF PART:

•FOR THE FIRST RADIOGRAPH, ADJUST THE PATIENT

IN A NORMALLY SEATED OR STANDING POSITION
TO CHECK THE SPINAL CURVATURE.
•CENTER THE MIDSAGITTAL PLANE OF THE PATIENT'S
BODY TO THE MIDLINE OF THE GRID. •ALLOW THE
PATIENT' ARMS TO HANG RELAXED AT THE SIDES. IF
THE PATIENT IS SEATED, FLEX THE ELBOWS AND RE T
THE HANDS ON THE LAP
DO NOT SUPPORT THE PATIENT OR USE A
COMPRESSION BAND
POSITION OF PART:

•FOR THE SECOND RADIOGRAPH, ELEVATE THE

PATIENT‘S HIP OR FOOT ON THE CONVEX SIDE OF
THE PRIMARY CURVE APPROXIMATELY 3 OR 4
INCHES BY PLACING A BLOCK, A BOOK, OR
SANDBAGS UNDER THE BUTTOCK OR FOOT
DO NOT SUPPORT THE PATIENT IN THESE POSITIONS.
•DO NOT EMPLOY A COMPRESSION BAND.

•SHIELD GONADS. • RESPIRATION: SUSPEND.

CENTRAL RAY:

PERPENDICULAR TO
THE MIDPOINT OF THE
IR
STRUCTURES SHOWN:

THE RESULTING IMAGE SHOW

PA PROJECTION OF THE
THORACIC AND LUMBAR
VERTEBRAE, WHICH ARE USED
FOR COMPARISON TO
DISTINGUISH THE DEFORMING
OR PRIMARY CURVE FROM
THE COMPENSATORY CURVE
IN PATIENT WITH SCOLIOSIS
STRUCTURES SHOWN:

THE RESULTING IMAGE SHOW

PA PROJECTION OF THE
THORACIC AND LUMBAR
VERTEBRAE, WHICH ARE USED
FOR COMPARISON TO
DISTINGUISH THE DEFORMING
OR PRIMARY CURVE FROM
THE COMPENSATORY CURVE
IN PATIENT WITH SCOLIOSIS
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

THORACIC AND LUMBAR VERTEBRAE TO INCLUDE

ABOUT 1 INCH OF THE ILIAC CREST
•VERTEBRAL COLUMN ALIGNED DOWN THE CENTER
OF THE RADIOGRAPH
•CORRECT IDENTIFICATION MARKER
LUMBAR SPINE: SPINAL FUSION
AP PROJECTION
R AND L BENDING

IMAGE RECEPTOR: 14X17 INCHES LENGTHWISE

POSITION OF PATIENT:
PLACE THE PATIENT IN THE SUPINE POSITION, AND CENTER THE
MIDSAGITTAL PLANE OF THE BODY TO THE MIDLINE OF THE GRID.
POSITION OF PART:

•MAKE THE FIRST RADIOGRAPH WITH MAXIMUM

RIGHT BENDING, AND MAKE THE SECOND
RADIOGRAPH WITH MAXIMUM LEFT BENDING.

•TO OBTAIN EQUAL BENDING FORCE

THROUGHOUT THE SPINE, CROSS THE PATIENT'S LEG
ON THE OPPOSITE SIDE TO BE FLEXED OVER THE
OTHER LEG. FOR EXAMPLE, A RIGHT BENDING
REQUIRES THE LEFT LEG TO BE CROSSED OVER THE
RIGHT.
POSITION OF PART:

•MAKE THE FIRST RADIOGRAPH WITH MAXIMUM RIGHT

BENDING, AND MAKE THE SECOND RADIOGRAPH WITH
MAXIMUM LEFT BENDING.

•MOVE BOTH OF THE PATIENT'S HEELS TOWARD THE SIDE THAT

IS FLEXED. IMMOBILIZE THE HEELS WITH SANDBAGS.
•MOVE THE SHOULDER DIRECTLY LATERAL AS FAR AS POSSIBLE
WITHOUT ROTATING THE PELVIS
•AFTER THE PATIENT IS IN POSITION, APPLY A COMPRESSION
BAND TO PREVENT MOVEMENT.
• SHIELD GONADS. • RESPIRATION: SUSPEND.
CENTRAL RAY:

PERPENDICULAR TO
THE LEVEL OF THE
THIRD LUMBAR
VERTEBRA, 1 TO 1 ½
INCHES ABOVE THE
ILIAC CREST ON THE
MID SAGITTAL PLANE
STRUCTURES SHOWN:

THE RESULTING
IMAGES SHOW AP
PROJECTIONS OF THE
LUMBAR VERTEBRAE,
MADE IN MAXIMUM
RIGHT AND LEFT
LATERAL FLEXION
STRUCTURES SHOWN:

THE RESULTING
IMAGES SHOW AP
PROJECTIONS OF THE
LUMBAR VERTEBRAE,
MADE IN MAXIMUM
RIGHT AND LEFT
LATERAL FLEXION
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

SITE OF THE SPINAL FUSION CENTERED AND

INCLUDING THE SUPERIOR AND INFERIOR VERTEBRAE
•NO ROTATION OF THE PELVIS (SYMMETRIC ILIA)
• BENDING DIRECTION CORRECTLY IDENTIFIED WITH
APPROPRIATE LEAD MARKERS
•SUFFICIENT RADIOGRAPHIC DENSITY TO
DEMONSTRATE THE DEGREE OF MOVEMENT WHEN
VERTEBRAE ARE SUPERIMPOSED
LUMBAR SPINE: SPINAL FUSION
LATERAL PROJECTION
R AND L POSITION
HYPERFLEXION AND HYPEREXTENSION

IMAGE RECEPTOR: 14X17 INCHES LENGTHWISE

POSITION OF PATIENT:
ADJUST THE PATIENT IN A LATERAL RECUMBENT POSITION.
POSITION OF PART:

•FOR THE FIRST RADIOGRAPH, HAVE THE PATIENT LEAN

FORWARD AND DRAW THE THIGH UP TO FORCIBLY FLEX
THE SPINE A MUCH A POSIBLE
•FOR THE SECOND RADIOGRAPH, HAVE THE PATIENT
LEAN THE THORAX BACKWARD AND POSTERIORLY
EXTEND THE THIGHS AND LIMBS AS MUCH AS POSSIBLE
•AFTER THE PATIENT IS IN POSITION, APPLY A
COMPRESSION BAND ACROSS THE PELVIS TO PREVENT
MOVEMENT.
•CENTER THE IR AT THE LEVEL OF THE SPINAL FUSION.
• SHIELD GONADS. • RESPIRATION: SUSPEND
CENTRAL RAY:

PERPENDICULAR TO
THE SPINAL FUSION
AREA OR L3
STRUCTURES SHOWN:

THE RESULTING IMAGES SHOW

TWO LATERAL PROJECTIONS OF
THE SPINE MADE IN
HYPERFLEXION AND
HYPEREXTENSION TO DETERMINE
WHETHER MOTION IS PRESENT IN
THE AREA OF A SPINAL FUSION
OR TO LOCALIZE A HERNIATED
DISK AS SHOWN BY LIMITATION
OF MOTION AT THE SITE OF THE
LESION.
CENTRAL RAY:

PERPENDICULAR TO
THE SPINAL FUSION
AREA OR L3
STRUCTURES SHOWN:

THE RESULTING IMAGES SHOW

TWO LATERAL PROJECTIONS OF
THE SPINE MADE IN
HYPERFLEXION AND
HYPEREXTENSION TO DETERMINE
WHETHER MOTION IS PRESENT IN
THE AREA OF A SPINAL FUSION
OR TO LOCALIZE A HERNIATED
DISK AS SHOWN BY LIMITATION
OF MOTION AT THE SITE OF THE
LESION.
EVALUATION CRITERIA
THE FOLLOWING SHOULD BE CLEARLY DEMONSTRATED:

SITE OF THE SPINAL FUSION IN THE CENTER OF THE

RADIOGRAPH
•NO ROTATION OF THE VERTEBRAL COLUMN
(POSTERIOR MARGINS OF THE VERTEBRAL BODIES ARE
SUPERIMPOSED)
•HYPERFLEXION AND HYPEREXTENSION
IDENTIFICATION MARKERS CORRECTLY USED FOR
EACH RESPECTIVE PROJECTION