CERVICAL & THORACIC SPINE :

RADIOGRAPHIC POSITIONING
 Objectives
At the end of this lecture students will be able to:

1. State the indications for cervical n thoracic spine X-Ray.

2. Prepare the equipments needed for cervical n thoracic
spine X-Ray.
3. Perform the cervical n thoracic spine X-Ray.
4. Evaluate the radiographs of cervical n thoracic spine X-
Ray.
5. Understand the danger of mishandling of cervical spine by
careful handling of patients.
6. Appreciate the importance of cervical n thoracic spine X-
Ray. in correct diagnosis by producing high quality images.

2
CERVICAL RADIOGRAPHIC
POSITIONING
PART 1 : RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
CERVICAL RADIOGRAPHIC
POSITIONING
PART II : RADIOGRAPHIC POSITIONING
TOPOGRAPHIC LANDMARKS
 EAM
 Mastoids Tips = C1
 2.5cm below EAM = C1
 Gonion = C3
 Thyroid cartilage = C4-C5
 Vertebra Prominence = C7 / Body T1
 Jugular Notch = T2-T3
 Sternal Angle = T4-T5
 8-10cm inferior to jugular notch = T7
 Xiphoid = T9-T10
 Surface Markings
EAM

Mastoid tips

Thyroid cartilage

Vertebral prominence

13
POSITIONING
CONSIDERATIONS
 100 /150 – 172cm SID.
 Small focal spot
 Shielding of radiosensitive areas
 Medium to high kVp (70-95)
 Breathing technique
 Proper Pt - IR alignment
 PATHOLOGIC INDICATIONS
 Clay shoveler’s #  Herniated Nucleus
 Compression # Pulpolus (HNP)
 Hangmsn’s #  Kyphosis
 Jefferson #  Lordosis
 Odontoid #  Scoliosis
 Teardrop Burst #  Scheuermann’s
 Facet – unilateral Disease
subluxations and  Spondylitis
bilateral locks  Ankylosing Spondylitis
CERVICAL SPINE ROUTINE
 AP Open Mouth
 AP Axial
 Bilateral Oblique (PA or AP)
 Lateral
 Swimmer’s Lateral (if needed)
CERVICAL SPINE – AP OPEN
MOUTH PROJECTION
 AP open mouth for C1-C2
 Erect or supine
 Technical & Positioning Factors
◦ 18X24cm, lengthwise
◦ Grid, 70-80kVp
◦ 100cm SID
◦ Align MSP to CR and centerline of table and film
◦ Mouth open as possible
◦ No rotation of head of thorax
◦ Adjust neck flexion as needed. The line from upper incisors
to mastoid tips must be perpendicular to film or table-top.
◦ CR through center of mouth
◦ Collimate carefully to C1-C2 region.
CERVICAL SPINE – AP OPEN
MOUTH PROJECTION
CERVICAL SPINE – AP OPEN MOUTH
PROJECTION : EVALUATION CRITERIA
 Atlas, axis and dens seen in entirety
 CI-2 zygapophyseal joint spaces open
 Upper incisors superimposing base of
skull.
 No rotation – equal distance from lateral
masses and or transverse process of C1
to condyles of mandible.
 Optimal exposure factors.
CERVICAL SPINE – AP OPEN MOUTH
PROJECTION : EVALUATION CRITERIA
CERVICAL SPINE – AP OPEN MOUTH
PROJECTION : EVALUATION CRITERIA
CERVICAL SPINE – AP AXIAL
PROJECTION
 Erect or supine
 Technical & Positioning Factors
◦ 18X24cm, lengthwise
◦ Adjust head so the plane from the tip of mandible
to base of skull is parallel to angled CR
◦ CR angled 15° – 20° cephalad
◦ CR at lower margin of thyroid cartilage (C5-C6)
◦ Collimate closely to region of cervical vertebrae
CERVICAL SPINE – AP AXIAL
PROJECTION
CERVICAL SPINE – AP AXIAL
PROJECTION : EVALUATION CRITERIA
 C3 –T1 region demonstrated
 No rotation
 Intervertebral disk spaces open
 Base of skull will superimpose C1-C2
 Optimal exposure factors.
CERVICAL SPINE – AP AXIAL
PROJECTION : EVALUATION CRITERIA
CERVICAL SPINE – AP AXIAL
PROJECTION : EVALUATION CRITERIA
CERVICAL SPINE – ANTERIOR &
POSTERIOR OBLIQUE
 Erect or supine
 Technical & Positioning Factors
◦ 18X24cm, lengthwise
◦ Grid, 70-80kVp
◦ 150cm SID
◦ Align MSP to CR and centerline of table and film
◦ Rotate body and head 45°
◦ (RAO & LAO) ANT OBLIQUE : 15°-20° caudad to
C4
◦ (RPO & LPO)POST OBLIQUE : 15°-20° cephalad
to C4
CERVICAL SPINE –OBLIQUE
CERVICAL SPINE – PA @ AP
OBLIQUE - EVALUATION CRITERIA
 C1- C7 intervertebral foramina are open
and clearly seen.
 Cervical pedicles well demonstrated
 Base of skull not superimposed over C1
 Optimal exposure factors.
CERVICAL SPINE – PA @ AP
OBLIQUE - EVALUATION CRITERIA
CERVICAL SPINE – PA @ AP
OBLIQUE - EVALUATION CRITERIA
CERVICAL SPINE – LATERAL
POSITION (NON-TRAUMA)
Technical & Positioning Factors
 24X30cm lengthwise.
 70 – 80kVp
 150-180cm SID
 Relax n drop shoulders.
 Extend chin slightly
 CR perpendicular to C4-5 (thyroid
cartilage)
 Full expiration.
CERVICAL SPINE – LATERAL
POSITION (NON-TRAUMA)
CERVICAL SPINE – LATERAL POSITION
(NON-TRAUMA) – EVALUATION CRITERIA
 C1 – C7 demonstrated
 Rami of mandible not superimposed over
C1-2
 No rotation of head
 Optimal exposure factors.
CERVICAL SPINE – LATERAL POSITION
(NON-TRAUMA) – EVALUATION CRITERIA
CERVICAL SPINE – LATERAL POSITION
(NON-TRAUMA) – EVALUATION CRITERIA
CERVICAL SPINE – FLEXION AND
HYPEREXTENSION LATERAL POSITION.
 True lateral, depress shoulder
 Flexion: flex chin to chest
 Hyperextension : Draw head up and back
as far as possible.
CERVICAL SPINE – FLEXION AND
HYPEREXTENSION LATERAL POSITION.
CERVICAL SPINE – FLEXION AND
HYPEREXTENSION LATERAL POSITION. –
EVALUATION CRITERIA
 C1-C7 visualized (C4-5 should be
centered to collimation field)
 No rotation
 Flexion : spinous process well separated
 Hyperextension : spinous processes in
close proximity.
 Optimal exposure factors.
CERVICAL SPINE – FLEXION AND
HYPEREXTENSION LATERAL POSITION. –
EVALUATION CRITERIA
CERVICAL SPINE – FLEXION AND
HYPEREXTENSION LATERAL POSITION. –
EVALUATION CRITERIA
 CERVICAL SPINE – CERVICOTHOTACIC
(SWIMMERR’S) LATERAL POSITION
 Cervicothoracic (swimmer’s) is performed when the lateral
positions fails to demonstrate C7-T1.
 24X30cm , lengthwise
 150cm SID
 Maintain thorax in true lateral position as much as possible.
 Align midcoronal plane to CR.
 Separate shoulders without compromising lateral position. (
elevate arm and shoulder closet to film, and depress
opposite shoulder and arm bringing slightly anterior
without rotating body.)
 CR to level T1
 Full expiration.
CERVICAL SPINE – CERVICOTHOTACIC
(SWIMMERR’S) LATERAL POSITION
CERVICAL SPINE – CERVICOTHOTACIC
(SWIMMER’S) LATERAL POSITION
CERVICAL SPINE – CERVICOTHOTACIC
(SWIMMER’S) LATERAL POSITION –
EVALUATION CRITERIA
 C4 – T3 clearly seen
 Humeral heads separated.
 Vertebral rotation is minimal.
 Optimal exposure factors.
CERVICAL SPINE – CERVICOTHOTACIC
(SWIMMER’S) LATERAL POSITION –
EVALUATION CRITERIA
CERVICAL SPINE – CERVICOTHOTACIC
(SWIMMER’S) LATERAL POSITION –
EVALUATION CRITERIA
ALTERNATIFE PROJECTION FOR DENS –
(FUCH METHOD – AP AND JUDD
METHOD –PA)
 These are two different methods of archieving a similar
result.
 Purpose of these projection is an alternative method to
the AP open mouth for visualizing the dens and other
C1-C2 structures within the foramen magnum.
 18X24cm crosswise.
 70-80kVp
 MML near perpendicular to table top.
 No rotation of the head.
 CR parallel to MML
 AP : CR inferior to tip of mandible.
 PA : CR 2.5 cm inferosuperior to mastoid tips.
ALTERNATIFE PROJECTION FOR DENS –
(FUCH METHOD – AP AND JUDD
METHOD –PA)
ALTERNATIFE PROJECTION FOR DENS –
(FUCH METHOD – AP AND JUDD
METHOD –PA) – EVALUATION CRITERIA
 Dens within foramen magnum
 No rotation evident
 Correct extension of head. (mandible just
superior to foramen magnum.
 Optimal exposure factors
ALTERNATIFE PROJECTION FOR DENS –
(FUCH METHOD – AP AND JUDD
METHOD –PA) – EVALUATION CRITERIA
AP CHEWING OR WAGGING JAW
PROJECTION (OTONELLO METHOD)
 This projection is to demonstrate the entire
cervical spine with one single exposure by
blurring out the mandible over C2-C4
 Extend chin to place upper incisors and base of
skull in same plane
 CR perpendicular to film at C4-C5 level
 Explain to patient to no bite down on teeth
each time but keep continual movement of
lower jaw (mandible)
 Exposure time 3 seconds or longer.
AP CHEWING OR WAGGING JAW
PROJECTION (OTONELLO METHOD)
AP CHEWING OR WAGGING JAW
PROJECTION (OTONELLO METHOD)
AP CHEWING OR WAGGING JAW
PROJECTION (OTONELLO METHOD) –
EVALUATION CRITERIA
 C1-C7 Vertebrae should be
demonstrated(upper incisors should be
just above dens.)
 Adequate blurring of mandible
 No rotation of cranium.
 Optimal exposure factors.
CERVICAL SPINE – AP AXIAL PROJECTION
– VERTEBRAL ARCH (PILLARS)
 24X30, lengthwise
 Supine with arms at side
 MSP plane to CR
 Hyperextend the neck
 No rotation of the head or thorax
 CR angled 20°-30° caudal at level of the
lower margin of the thyroid cartilage.
 SID 100cm
 Suspended respiration.
CERVICAL SPINE – AP AXIAL PROJECTION
– VERTEBRAL ARCH (PILLARS)
CERVICAL SPINE – AP AXIAL PROJECTION
– VERTEBRAL ARCH (PILLARS)
CERVICAL SPINE – AP AXIAL PROJECTION –
VERTEBRAL ARCH (PILLARS)- EVALUATION
CRITERIA
 Posterior elements of mid and distal cervical and
proximal thoracic vertebra
 In particular, the articulations (zygapophyseal joint)
between the lateral masses (or pillars) are open and
well demostrated, along with the laminae and spinous
processes
 No rotation
 Lateral collimation to soft tissue edges of the neck and
proximal and distal borders to margins of IR
 Center of collimation field (CR) at or near C5 vertebra
 Zygapophyseal joint open, indicating correct CR angle
CERVICAL & THORACIC SPINE :
RADIOGRAPHIC POSITIONING
THORACIC RADIOGRAPHIC
POSITIONING
PART 1 : RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
RADIOGRAPHIC ANATOMY
THORACIC RADIOGRAPHIC
POSITIONING
PART II : RADIOGRAPHIC POSITIONING
THORACIC SPINE – AP
PROJECTION
 35X43cm lengthwise.
 75-85 kVp, grid
 100cm SID
 MSP to CR and midline of table and
cassette.
 Knees flexed (tends to straighten entire
vertebral column).
 CR to T7(8-10cm below jugular notch)
 Expose upon expiration.
THORACIC SPINE – AP
PROJECTION
THORACIC SPINE – AP PROJECTION –
EVALUATION CRITERIA
 C7-L1 demonstrated
 No rotation (sternoclavicular joints equal
distance from spine)
 Vertebral bodies well penetrated.
 Optimal exposure factors.
THORACIC SPINE – AP PROJECTION –
EVALUATION CRITERIA
THORACIC SPINE – AP PROJECTION –
EVALUATION CRITERIA
THORACIC SPINE – LATERAL
POSITION
 35X43cm lengthwise.
 80-90kVp, grid.
 100cm SID
 Support waist, to keep spine from too much sag
but remaining near parallel to film. **some
broad shouldered patients without major
support under waist, the CR can be angled 3°-
5° cephalad to the perpendicular spine.
 CR to T7
 Lead blocker on table top next to patient.
(reduces scatter radiation)
THORACIC SPINE – LATERAL
POSITION cont…
 Midcoronal plane to CR and midline of table
and cassette, knees and hips flexed, true lateral
 Arms in front.
 Ensure no rotation of pelvis or shoulder.
 Close collimation to thoracic vertebra is
important
 Breathing technique: to blur overlying ribs and
lungs detail.
THORACIC SPINE – LATERAL
POSITION
THORACIC SPINE – LATERAL
POSITION – EVALUATION CRITERIA
 T1 to L1 demontrated.
 Intervertebral disk spaces open.
 No rotation (superimposition of
posterior ribs, and vertebral bodies and
posterior ribs in lateral profile.)
 Optimal exposure factors.
THORACIC SPINE – LATERAL
POSITION – EVALUATION CRITERIA
THORACIC SPINE – LATERAL
POSITION – EVALUATION CRITERIA
THORACIC SPINE – OBLIQUE
POSITION (PA OR AP)
 Both Right n Left oblique are taken for
comparison
 Midaxillary plane to CR and to midline of
table.
 Rotate body 20° from lateral to form a
70° oblique position.
 CR perpendicular to T7 (8-10cm below
jugular notch)
 Expose upon expiration.
THORACIC SPINE – OBLIQUE
POSITION (PA OR AP)
THORACIC SPINE – OBLIQUE
POSITION (PA OR AP)
THORACIC SPINE – OBLIQUE
POSITION (PA OR AP)
THORACIC SPINE – OBLIQUE POSITION
(PA OR AP) – EVALUATION CRITERIA
 All twelve thoracic vertebra
demonstrated.
 Zygapophyseal joints open.
 Optimal exposure factors.
THORACIC SPINE – OBLIQUE POSITION
(PA OR AP) – EVALUATION CRITERIA
THORACIC SPINE – OBLIQUE POSITION
(PA OR AP) – EVALUATION CRITERIA
Fracture
 Hangman’s fracture
- hyperextension of neck
- vertebral arch
seperated from body
- Subluxation of C2 and
C3

86
Fracture

87
Dislocation/ subluxation
 Misalignment of spine

88
Herniated Nucleus Pulposus

89
Spondylosis

90
Spondylosis

91