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94
CHAPTER 5
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IMAGING PROCEDURES
Evaluation Criteria
• Vertebral column visualized from C7–L1
• No rotation as evident by symmetrical sternoclavicu-
lar notches
Demonstrates
• Entire T-spine, intervertebral joint spaces, and spi-
nous and transverse processes visualized
• Posterior ribs and costovertebral articulations
Demonstrates
• Dens through the foramen magnum free of superim-
position of mandible
• Demonstration of the superior portion of the dens
when not well seen on the AP open mouth projection
• Pathology including but not limited to: fractures of
C1 and C2
Posteroanterior Dens (Judd) Projection
Positioning Criteria
• Place patient PA against the upright Bucky or prone
on the table; gonadal shielding used
• Place an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR in the Bucky
• Adjust patient so that the MML is perpendicular to
the IR with no rotation of the head; central ray can be
angled as needed to be parallel to MML
• Central ray is directed parallel to the MML at MSP
and 1⬙ (2.5 cm) inferoposterior to mastoid tips through
midoccipital bone
• Four-sided collimation appropriate for anatomy
• Minimum SID: 40⬙ (100 cm)
• Exposure is made on suspended respiration
Evaluation Criteria
• Symmetrical appearance of mandibular arch over
foramen magnum
• Dens in foramen magnum
Demonstrates
• Dens through the foramen magnum free of superim-
position of mandible
• Demonstration of the superior portion of the dens
when not well seen on the AP open mouth projection
• Pathology including but not limited to: fractures of
C1 and C2
Thoracic Spine
Anteroposterior Thoracic Spine
Positioning Criteria
• Place the patient AP against the Bucky; if supine, flex
knees and hips to reduce thoracic curvature; gonadal
shielding used
• Place a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in the Bucky
lengthwise centered to central ray
• Utilize anode heel effect to create a more uniform density
• Central ray directed to T6–T7, 3⬙ to 4⬙ (7.5 to 10 cm)
below jugular notch, and MSP
• Minimum SID: 40⬙ (100 cm)
• Collimate on lateral margins to about 5⬙ to 6⬙ (12.5 to
15 cm)
• Exposure taken on full expiration
FIGURE 5-14
95
CHAPTER 5
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IMAGING PROCEDURES
Scoliosis Series
Anteroposterior/Posteroanterior Scoliosis
Series (Ferguson Method)
Two-view series
Positioning Criteria
• Patient is positioned standing or seated in the AP or
PA position with arms at sides against the upright
Bucky; PA is preferred to reduce gonadal dose
• Place a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) or 14⬙ ⫻ 36⬙ (35 ⫻
90 cm) IR in the Bucky; place bottom of IR 1⬙ to 2⬙ (2.5
to 5 cm) below iliac crests
• Central ray directed perpendicular to MSP and cen-
tered to IR
• Utilize a compensating filter to create a uniform den-
sity on the image
• Collimate to area of interest
• SID 40⬙ to 60⬙ (100 to 150 cm); use longer SID if using
a 14⬙ ⫻ 36⬙ (35 ⫻ 90 cm) IR
• Exposure taken on full expiration
• For second image, positioning and centering is same;
add a 3⬙ to 4⬙ (7.5 to 10 cm) block under the foot or
hip if seated on the convex side of the curve
Evaluation Criteria
• All thoracic and lumbar vertebrae should be visualized
• A minimum of 1⬙ (2.5 cm) of iliac crest should be seen
Demonstrates
• Entire thoracic and lumbar spine in a true AP or PA
projection
• Pathology including but not limited to: scoliosis, dif-
ferentiating primary versus compensatory curve
• Pathology including but not limited to: compression
fractures, scoliosis
Lateral Thoracic Spine
Positioning Criteria
• Place the patient in a left lateral position with arms bent
and one on top of the other anteriorly against the Bucky;
if recumbent, flex knees and hips to create a wider base
for patient to maintain position; gonadal shielding used
• Provide support of patient’s waist to ensure entire
T-spine is parallel with IR; patients with broad shoul-
ders will require support in the lower thoracic region;
patients with large hips may require support in the
upper thoracic region
• Place a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in the Bucky
lengthwise centered to central ray
• Central ray directed to T6–T7, 3⬙ to 4⬙ (7.5 to 10 cm)
below jugular notch and the long axis of the T-spine
• Minimum SID: 40⬙ (100 cm)
• Collimate on lateral margins to about 5⬙ to 6⬙ (12.5
to 15 cm); additional lead shielding should also be
placed posterior to the spine out of the field of view
to absorb scatter
• Exposure taken on full expiration or utilize a breathing
technique to blur lungs and ribs overlying vertebrae
Evaluation Criteria
• Vertebral column visualized from T1–L1 (T1–T3 not
well visualized)
• No rotation as evident by superimposed posterior
aspects of vertebrae
Demonstrates
• Entire T-spine seen
• Open intervertebral foramina and intervertebral joint
spaces
• Pathology including but not limited to: compression
fractures, kyphosis, subluxation
96
CHAPTER 5
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IMAGING PROCEDURES
Evaluation Criteria
• Entire lumbar spine seen
• No patient rotation as indicated by: symmetrical
transverse processes, spinous processes centered
on vertebrae
Demonstrates
• Lumbar vertebrae, intervertebral joints, transverse
processes, sacroiliac (SI) joints
Lumbar Spine
Anteroposterior Projection
Positioning Criteria
• Patient is placed supine on the table with knees flexed
to reduce lordotic curve of the spine; gonadal shielding
• Utilize a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR lengthwise
centered to the central ray
• Central ray directed to the iliac crest and MSP
• Minimum SID: 40⬙ (100 cm)
• Collimate on all four sides
• Exposure taken on full expiration
FIGURE 5-15
97
CHAPTER 5
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IMAGING PROCEDURES
12th left rib
Transverse process L1
L1 spinous process
L2 pedicles
L3 vertebral body
L3–L4 intervertebral joint space
Sacrum
FIGURE 5-16
• Pathology including but not limited to: fractures,
scoliosis, Marie-Strümpell disease
Projection can also be performed in the PA and erect
positions with same centering.
If desired, smaller IR (11⬙ ⫻ 14⬙ [27.5 to 35 cm]) can
be used; centering needs to be adjusted to 2⬙ (5 cm)
superior to iliac crest.
Lateral Projection
Positioning Criteria
• Place patient in a left lateral position on the table
with the knees bent and the arms flexed and placed
anterior to the body; gonadal shielding
• Utilize a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR lengthwise in the
Bucky aligned with the central ray
• Central ray is directed perpendicular to iliac crest
and midcoronal plane
• Minimum SID: 40⬙ (100 cm)
• Collimate on all four sides
• Exposure taken on full expiration
Evaluation Criteria
• Entire lumbar spine seen
• No patient rotation as indicated by: symmetrical
transverse processes, spinous processes centered on
vertebrae
Demonstrates
• Lumbar vertebrae, intervertebral joints, transverse
processes, SI joints
FIGURE 5-17
• Pathology including but not limited to: fractures,
scoliosis, Marie-Strümpell disease, spondylolisthesis,
spondylolysis, spinal fusion
Projection can also be performed in the PA and erect
positions with same centering.
If desired, smaller IR (11⬙ ⫻ 14⬙ [27.5 to 35 cm]) can
be used; centering needs to be adjusted to 2⬙ (5 cm)
superior to iliac crest.
Lateral hyperflexion and hyperextension can also
be performed. Patients are instructed to keep pelvis
still and bend forward (hyperflexion) or backward
( hyperextension) as much as possible. Centering for
these projections is 2⬙ (5 cm) above iliac crest.
L5–S1 Spot Projection
Positioning Criteria
• Place patient in a left lateral position on the table
with the knees bent and the arms flexed and placed
anterior to the body; gonadal shielding
• Utilize an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR lengthwise in the
Bucky aligned with the central ray
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IMAGING PROCEDURES
• Utilize an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR crosswise aligned
with the central ray
• Central ray directed 30 degrees cephalic for male and
35 degrees cephalic for female patients, entering at
the level of ASIS and MSP
• Collimate on all four sides as appropriate for anatomy
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on suspended respiration
Evaluation Criteria
• L5–S1 joint space is open and centered in the colli-
mated field
• SI joints are symmetrical from spine
Demonstrates
• Open L5–S1 junction
• SI joints are open
• This projection can be performed PA using a caudal
angle centered slightly above iliac crest; PA projec-
tion increases OID and decreases gonadal dose
Anteroposterior/Posteroanterior Right
and Left Bending
Positioning Criteria
• Patient can be placed in the AP or PA position, erect
or recumbent; gonadal shielding
• Utilize a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR with the bottom
placed 2⬙ (5 cm) below iliac crest
• Central ray is directed perpendicular to IR and mid-
line of patient
• Instruct patient to lean from waist holding pelvis still;
two images are taken: right and left
• Collimate to size of IR and crosswise as appropriate
for anatomy
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on full expiration
Evaluation Criteria
• Lumbar vertebrae visualized in lateral flexion
• No rotation of pelvis
• L5 to iliac crests visualized
Demonstrates
• Range of motion of the lumbar spine
• Central ray is directed perpendicular to 1½⬙ (4 cm)
inferior to iliac crest and 2⬙ (5 cm) posterior to ASIS
• Central ray can be angled 5 degrees to 8 degrees cau-
dal to be parallel to the interiliac line (imaginary line
between iliac crests)
• Minimum SID: 40⬙ (100 cm)
• Collimate on all four sides
• Exposure taken on full expiration
Evaluation Criteria
• L5–S1 seen free of superimposition
• No patient rotation as indicated by open joint space
Demonstrates
• L5–S1 intervertebral joint
• Pathology including but not limited to: fractures,
spondylolysis, spondylolisthesis
Lumbar Spine Obliques
Positioning Criteria
Obliques can be performed in either the AP or PA posi-
tion. Both obliques must be performed.
• Patient is placed in a 45-degree oblique either recum-
bent or erect; gonadal shielding
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR placed lengthwise
aligned with central ray
• Central ray is perpendicular to 2⬙ (5 cm) above iliac
crest and 2⬙ (5 cm) medial to ASIS
• Minimum SID: 40⬙ (100 cm)
• Collimate on all four sides to area of interest
• Exposure taken on full expiration
Evaluation Criteria
• L1–L5 vertebrae are seen
• Presence of “scotty dog”
• Spine down center of image and straight
Demonstrates
• RPO/LAO: left zygapophyseal joints
• LPO/RAO: right zygapophyseal joints
• Pathology including but not limited to: defects in pars
interarticularis (spondylolysis)
Anteroposterior L5–S1, 30 Degrees to
35 Degrees Cephalic
Positioning Criteria
• Patient is placed recumbent in the supine position
with knees bent to reduce lordosis of lumbar spine;
gonadal shielding
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CHAPTER 5
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IMAGING PROCEDURES
B
C
Left superior articular
process
Spinous process right
Right superior
articular process
Right inferior
articular process
Lamina
Left inferior
articular process
Pedicle
A
FIGURE 5-18
100
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IMAGING PROCEDURES
• Utilize an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR lengthwise in the
Bucky aligned with the central ray
• Central ray angulation of 10 degrees caudal to enter
2⬙ (5 cm) superior to pubic symphysis
• Collimation on all four sides
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on full expiration
Evaluation Criteria
• Coccyx centered in pelvic inlet and centered on image
• Coccyx seen superior to pubic symphysis
Demonstrates
• AP projection of the coccyx
• Pathologies associated with the coccyx
Lateral Sacrum and Coccyx
It is recommended to perform a combined lateral of this
anatomy to reduce gonadal dose.
Positioning Criteria
• Patient is placed in the left lateral position on the
table; gonadal shielding without obscuring area of
interest
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in the
Bucky aligned with the central ray
• Central ray directed perpendicular at the level of ASIS
and 3⬙ to 4⬙ (7.5 to 10 cm) posterior
SACRUM AND COCCYX
Anteroposterior Sacrum
Positioning Criteria
• Patient is positioned AP recumbent on the table with
legs slightly elevated; breast shielding for females
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in the
Bucky aligned with the central ray
• Central ray angulation of 15 degrees cephalic to enter
2⬙ (5 cm) superior to pubic symphysis
• Collimation on all four sides
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on full expiration
Evaluation Criteria
• Sacrum centered in pelvic inlet, free of foreshorten-
ing, centered on image
• Symmetrical SI joints
Demonstrates
• AP projection of the sacrum, L5–S1 junction, and SI
joints
• Pathologies associated with the sacrum
Anteroposterior Coccyx
Positioning Criteria
• Patient is positioned AP recumbent on the table with
legs slightly elevated; breast shielding for females
Spina bifida occulta
SI joint
Sacral hiatus
FIGURE 5-19
101
CHAPTER 5
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IMAGING PROCEDURES
• Central ray directed 30 degrees cephalic for male and
35 degrees cephalic for female patients, entering 2⬙
(5 cm) below level of ASIS and MSP
• Collimate on all four sides as appropriate for anatomy
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on suspended respiration
Evaluation Criteria
• L5–S1 joint space is open and centered in the colli-
mated field
• SI joints are symmetrical from spine
Demonstrates
• Open L5–S1 junction
• SI joints are open
This projection can be performed in the PA position
using a caudal angle and centered slightly above iliac
crest. PA projection increases OID and decreases go-
nadal dose.
Sacroiliac Joint Obliques
Obliques can be performed in the AP or PA position.
Both obliques are performed for comparison.
Positioning Criteria
• Patient is recumbent on the table and rotated
25 degrees to 30 degrees; gonadal shielding
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise aligned
to the central ray
• Central ray is perpendicular to a point 1⬙ medial to
up side ASIS for posterior obliques; center to down SI
joint for anterior obliques
• Collimation on all four sides
• Minimum SID: 40⬙ (100 cm)
• Exposure made on full expiration
Evaluation Criteria
• Joint space appears open and is centered on the
image
Demonstrates
• LPO/RAO: right SI joint
• RPO/LAO: left SI joint
• Dislocation or subluxation of the joint
• Collimation on all four sides; use an additional shield
posterior to the patient to absorb scatter
• Minimum SID: 40⬙ (100 cm)
• Exposure made on suspended expiration
Evaluation Criteria
• Sacrum and coccyx seen in entirety
• Posterior margins of pelvis are superimposed, no
rotation
Demonstrates
• Lateral of sacrum and coccyx, L5–S1 joint
• Pathology including but not limited to: anterior/
posterior displacement of fractures
L5-S1
disc space
Sacral
hiatus
Coccyx
FIGURE 5-20
Sacroiliac Joints
Anteroposterior Axial Sacroiliac Joints
Positioning Criteria
• Patient is placed recumbent in the supine position
with knees bent to reduce lordosis of lumbar spine;
gonadal shielding
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise aligned
with the central ray
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CHAPTER 5
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IMAGING PROCEDURES
• Pathology including but not limited to: fractures
including Malgaigne and Duverney, degenerative
disease, bone lesions
Anteroposterior Pelvis Bilateral Frog-Leg
Projection (Modified Cleaves Method)
Projection typically performed on younger patients to
assess congenital hip dysplasia.
Positioning Criteria
• Patient is placed supine on the table with arms at
sides
• Gonadal shielding for both male and female patients
with care to not obscure the hip joints
• Instruct patient to flex knees to 90 degrees, place the
plantar surfaces of the feet together, and abduct the
knees approximately 45 degrees from vertical
• Utilize a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR placed crosswise
in the Bucky, positioned so that the upper edge of the
IR is at iliac crest
• Central ray perpendicular to midpoint of IR, 3⬙
(7.5 cm) inferior to ASIS and MSP
• Collimate on all four sides
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on suspended respiration
Evaluation Criteria
• Entire pelvis is visualized
• Iliac wings are symmetrical
• Obturator foramen are symmetrical and open
Demonstrates
• Entire pelvis and proximal femora
• Femoral head and neck in a lateral position
• Acetabulum and trochanteric areas seen well
• Pathology including but not limited to: congenital hip
dysplasia, degenerative disease, bone lesions
Anteroposterior Axial Pelvis Inlet Projection
• Patient is placed supine on the table with arms
at sides; gonadal shield for males, breast shield for
females
• Utilize a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR placed crosswise
in the Bucky aligned with central ray
• Central ray angled 40 degrees caudal at the level of
ASIS and MSP
• Collimate on all four sides
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on suspended respiration
PELVIS AND HIP
Anteroposterior Pelvis
Positioning Criteria
• Patient is placed supine on the table with arms at
sides; gonadal shield for males, breast shield for
females
• Instruct patient to separate legs 8⬙ to 10⬙ (20 to
25 cm) and medially rotate the entire lower extremity
15 degrees to 20 degrees; DO NOT DO THIS IF THERE
IS SUSPECTED FRACTURE OR DISLOCATION
• Utilize a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR placed crosswise
in the Bucky, positioned so that the upper edge of the
IR is 1⬙ (2.5 cm) superior to iliac crest
• Central ray perpendicular to midpoint of IR, 2⬙ (5 cm)
inferior to ASIS and MSP
• Collimate on all four sides
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on suspended respiration
Evaluation Criteria
• Entire pelvis is visualized
• Iliac wings are symmetrical
• Obturator foramen are symmetrical and open
Demonstrates
• Entire pelvis and proximal femora
• Femoral necks elongated, greater trochanter in profile
FIGURE 5-21
103
CHAPTER 5
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IMAGING PROCEDURES
• Rotate patient into a 45-degree oblique depending on
what anatomy is of interest
• RPO: Right anterior rim and posterior ilioischial col-
umn and left posterior rim and anterior ilioischial col-
umn are demonstrated
• LPO: Left anterior rim and posterior ilioischial col-
umn and right posterior rim and anterior ilioischial
col umn are demonstrated
• Central ray directed perpendicular
• Up side: 2⬙ (5 cm) distal to up side ASIS
• Down side: 2⬙ (5 cm) distal and 2⬙ (5 cm) medial to
down side ASIS
• Collimate on all four sides
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on suspended expiration
Evaluation Criteria
• Hip joint of interest centered in image
• Four-sided collimation
• Obturator foramen of up side is open and closed on
down side if obliqued correctly
Demonstrates
• Acetabulum with minimal superimposition of struc-
tures and in profile
• Ilioischial column
• Pathology including but not limited to: acetabular
fractures and hip dislocation
Anteroposterior Unilateral Hip Projection
Positioning Criteria
• Patient is supine on the table with arms at the sides;
gonadal shielding
• Place a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in the
Bucky aligned to the central ray
• Central ray is directed perpendicular to the femoral
neck located 1⬙ to 2⬙ (2.5 to 5 cm) medial and 3⬙ to 4⬙
(7.5 to 10 cm) inferior to ASIS
• Instruct patient to internally rotate lower extremity
15 degrees to 20 degrees unless fracture or disloca-
tion is suspected
• Collimate on all four sides
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Greater trochanter, femoral neck and head seen in
profile without foreshortening
• If after joint replacement, entire orthopedic appliance
must be included
• Sufficient internal rotation noted by minimal visual-
ization of lesser trochanter medially
Evaluation Criteria
• Unobstructed view of the pelvic ring
• No rotation of pelvis
• Ischial spines are symmetrical
• Collimation laterally extends to include femoral heads
and acetabula; superiorly includes the iliac wing and
inferiorly includes the symphysis pubis
Demonstrates
• Pelvic inlet (superior aperture) seen free of superim-
position
• Ischial spines
• Pathology including but not limited to: trauma
assessment, posterior displacement, inward or out-
ward rotation of anterior pelvis
Anteroposterior Axial Pelvis Outlet Projection
Positioning Criteria
• Patient is placed supine on the table with arms
at sides; gonadal shield for males; breast shield for
females
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR placed crosswise
in the Bucky aligned with central ray
• Central ray angled 20 degrees to 35 degrees for males,
30 degrees to 45 degrees for females, cephalic at a point
1⬙ to 2⬙ (2.5 to 5 cm) below pubic symphysis and MSP
• Collimate on all four sides
• Minimum SID: 40⬙ (100 cm)
• Exposure taken on suspended respiration
Evaluation Criteria
• Unobstructed view of the pelvic outlet
• No rotation of pelvis
• Obturator and ischia are open and equal in size
• Collimation laterally extends to include femoral
heads and acetabula; superiorly includes body and
superior pubic rami and inferiorly includes the ischial
tuberosities
Demonstrates
• Superior and inferior rami of pubes and body and
ramus of ischium
• Pathology including but not limited to: trauma assess-
ment for fractures and displacement
Anteroposterior Oblique Pelvis:
Judet Method
Positioning Criteria
• Place patient in the supine position on the table;
gonadal shielding