Lumbar/ Lumbosacral Vertebrae Study

AP Projection

1. Patient in supine position;
2. Flex at the level of the elbows and rest the hands in upper chest;
3. Aligned the midsagital plane;
4. Flex the knees to reduce lumbar lordosis.

Central ray perpendicular to the middle of L3 and iliac crest (lumbosacral study) or at the level of L3 (lumbar study).

Respiration: Suspended at the end of expiration.

Evaluation Criteria:

• Visualization of T12 to S1or to the end of sacrum;
• Intervertebral joints open;
• No rotation: symmetry of the vertebrae with spinous process at the center of the bodies;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Lateral Projection

1.  Patient in a lateral recumbent position;
2. Flex the knees and overlap both of them;
3. Flex at the level of the elbows with the hands at the side of the head.

Central ray perpendicular ,to the middle of L3 and iliac crest (lumbosacral study) or at the level of L3 (lumbar study), at the midcoronal plane.

Respiration: Suspended at the end of expiration.

Evaluation Criteria:

• Visualization of T12 to S1 or to the end of sacrum;
• Disk spaces open;
• Posterior margins of vertebrae superimposed;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

PA Oblique Projection

1. Patient in prone position;
2. Rotation the body 45º approximately;
3. Support this position with the forearm and with the knee flexed;

Central ray perpendicular at the level L3, 5cm lateral to the elevate side.

Respiration: Suspended at the end of expiration.

Evaluation Criteria:

• Visualization from lower thoracic vertebrae to sacrum;
• Good visualization of scotty dog;
• L3 in the center of the image;
• Iliac crest of the side in the table it is almost in profile position;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Lateral Projection- Hyperflexion and Hyperextension

1. Patient in lateral recumbent position;

                  a) Hyperflexion: lean forward as much as possible;
                  b) Hyperextension: lean backward as much as possible.

Central ray perpendicular to L3.

Respiration: Suspended.

Evaluation Criteria:

• No rotation: posterior margins of vertebrae superimposed;
• Spinal Fusion in the center of image;
• Visualization of T12 to S1;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Thoracic vertebrae

AP Projection

1.  Patient in supine position;
2. Upper limbs extend along the side of the body;
3. Aligned the midsagital plane;
4. Flex the knees.

Central ray perpendicular to the middle of the sternum.

Respiration: Suspended.

Evaluation Criteria:

• Visualization of the all 12 thoracic vertebrae;
• No rotation;
• Spinous process centered and aligned;
• Thoracic vertebrae in the center of the image;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Lateral Projection

1.  Patient in a lateral recumbent position;
2. Flex the knees and overlap both of them;
3. Flex at the level of the elbows with the hands at the side of the head.

Central ray perpendicular to T7.

Respiration: Suspended at the end of the inspiration.

Evaluation Criteria:

• Visualization of the thoracic vertebral totally;
• The thoracic vertebrae in the center of the image;
• No rotation;
• Ribs overlapped;
• Disk spaces open;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Cervicothoracic Region Study

Lateral Projection

1. Patient in upright position and then in a lateral position;
2. Elevate the arm close to the vertical table and rest the hand on the patient´s head;
3. The other arm it is extended along the body.

Central ray perpendicular to space C7-T1.

Respiration: Suspended.

Evaluation Criteria:

• No rotation;
• Shoulders free overlapped from each other;
• Visualization C5 to T4;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Cervical Vertebrae Study

AP Axial Projection

1. Patient in upright or supine position;
2. Extend the chin slightly;

Central ray angled 15º-20º cephalad to C4.

Respiration:Suspended.

Evaluation Criteria:

• Disk spaces open;
• No rotation;
• Spinous process equidistant to the pedicles;
• Visualization of C3 to T1 in the center of the image;
• Superimposed of the mandible and occiput over the atlas and axis;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Lateral Projection

1. Patient in upright or seated position;
2. Place in a true lateral position;
3. Elevate the chin slightly.

Central ray perpendicular and horizontal to C4.

Respiration: Suspended at the end of the expiration.

Evaluation Criteria:

• Visualization of the all seven cervical vertebrae and T1;
• No overlapping of mandible to the atlas or axis;
• Spine in the center of the image;
• No rotation: zygapophysical joints overlapped;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Lateral Projection- Hyperflexion and hyperextension

1. Patient in a true lateral position;

• Hyperflexion: Draw the chin as much as possible to the chest;
• Hyperextension: Elevate the chin as much as possible.

Central ray perpendicular and horizontal to C4

Respiration: Suspended.   

     Hiperflexion

Hiperextension

Evaluation Criteria:

• No rotation;
• Cervical vertebrae in profile position;
• Visualization of C1 to C7;
• In Hyperflexion the body of mandible it is almost in vertical position;
• In Hyperextension the body of mandible it is almost in horizontal position;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Hiperflexion

Hiperextension

AP Axial Projection

1. Patient in upright position;
2. Body rotation at 45º.

Central ray angled 15-20º cephalad to C4.

Respiration: Suspended.

Evaluation Criteria:

• Visualization of C1 to T1;
• Intervertebral foramina open;
• Disk spaces open;
• Occipital and mandible not overlapping to the atlas or axis;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue). 

Atlas and Axis Study

AP Projection

1. Patient in supine position;
2. Open the mouth so that the line from the lower edge of the upper incisors to the tip of the mastoid process.

Central ray perpendicular to the middle of the mouth.

Respiration: pronation of the word ah during the exposure.

Evaluation Criteria:

• Visualization of the atlas, axis e dens in the center of the mouth;
• Upper central incisors and the base of the skull superimposed;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Sacroiliac Joints Study

AP Projection

1. Patient in supine position;
2. Lower limbs in extension.

Central ray angled 30-35º cephalad to the middle between Anterior Superior Iliac Spine (ASIS) and pubic symphysis.

Respiration: Suspended.

Evaluation Criteria:

• Lower spine in the center of the image and centered with the sacrum;
• Good visualization of the sacroiliac joints and L5;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

AP Oblique Projection

1. Patient start in prone supine position;
2. Elevation from the affected side 25-30º

                              - LPO to demonstrate the right joint;
                              - RPO to demonstrate the left joint.

Central ray perpendicular to the middle between Anterior Superior Iliac Spine (ASIS) and pubic symphysis, of the affected side.

Respiration: Suspended.

Evaluation Criteria:

• Sacroiliac joint open and in the center of the image;
• Iliac crest almost in profile position;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

RPO- Left joint

Acetabulum Study

AP Oblique Projection

1. Patient in supine position;
2. Elevation from the affected side about 45º (situation A) or approximation the affected side and elevation the other side 45º (situation B).

Central ray perpendicular to the middle, between Anterior Superior Iliac Spine (ASIS) and pubic symphysis, of the affected side.

Respiration: Suspended.

Situation A:

• Obturator foramen opened;
• Iliac crest almost in profile;
• Acetabulum in the center of the image;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Situation B:

• Iliac crest unfolded;
• Obturator foramen in oblique position;
• Acetabulum in the center of the image;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Anterior Pelvis Bones Study

Superoinferior axial “Inlet” Projection

1. Patient in supine position;
2. Lower limbs in extension.

Central ray angled 45º caudal to the middle between Anterior Superior Iliac Spine (ASIS) and pubic symphysis.

Respiration: Suspended.

Evaluation Criteria:

• Good visualization of the pelvic;
• Symphysis pubic in axial projection;
• Visualization of the hip joint;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

AP Axial “Outlet” Projection

1. Patient in supine position;
2. Lower limbs in extension.

Central ray angled 45º cephalad to the middle between Anterior Superior Iliac Spine (ASIS) and pubic symphysis.

Respiration: Suspended.

Evaluation Criteria:

• Pubic bones superimposed by the sacrum;
• Symmetry of the obturator foramen;
• Visualization of the hip joint;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Pelvis

AP Projection

1. Patient in supine position;
2. Medially rotation of the  lower limbs about 15º.

Central ray perpendicular  to the middle between Anterior Superior Iliac Spine (ASIS) and pubic symphysis.

Respiration: Suspended.

Evaluation Criteria:

• Visualization of the entire pelvis and proximal femur;
• Lesser trochanter on the medial border;
• Greater trochanter in profile;
• Spine in the center of the image and centered with the center of the sacrum;
• Symmetric of obturator foramina;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Hip Study

 AP Projection

1. Patient in supine position;
2. Medially rotation of the lower limb 15º.

Central ray perpendicular to the femoral neck.

Respiration: Suspended.

Evaluation Criteria:

• Visualization of the hip joint;
• Greater trochanter in profile;
• Visualization of one third of the proximal femur;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Lateral Projection

1.  Patient start in supine position;
2. Rotate slightly the patient from the affected side (30-45º);
3. Flex the affected knee 90º and the other lower limb it is in extension.

Central ray perpendicular to hip joint.

Respiration: Suspended.

 Evaluation Criteria:

• Visualization of one third of the proximal femur;
• Hip joint in the center of the image;
• Femoral neck is overlapped by the greater trochanter;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Femur Study

AP Projection

1. Patient in supine position;
2. Medial rotation of 15º.

Central ray perpendicular to the middle of the femur.

Note: To study the distal femur it is necessary to include the knee joint and in study of proximal femur it is necessary to include the hip joint.

Evaluation Criteria:

• In study of distal femur it is necessary to see no rotation in the knee joint;
• In study of the proximal femur it is necessary to see the lesser trochanter in medial border and greater trochanter in profile;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

                Proximal Fémur

                Distal Fémur

Lateral Projection

1.  Patient turn to the affected side;
2. For the study of distal femur flex the knee 30º;
3. For the study of the proximal femur it is necessary to flex the knee 45º and rotate 5º for the lateral position.

Central ray perpendicular to the middle of the femur.

Proximal Fémur

Distal Fémur

Evaluation Criteria:

• In study of distal femur:
• Patella in profile;
• Patellofemural joint open;
• In study of proximal femur:
• Greater and lesser trochanters not proeminent;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

                                                           Proximal Fémur

Distal Fémur

Patella Study

PA Projection

1. Patient in prone position;
2. Tip of the foot supported in the table (patella parallel with the plane of the IP).

Central ray perpendicular to the middle of the popliteal area.

Evaluation Criteria:

• Patella superimposed by the femur;
• No rotation;
• Visualization of the knee joint;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Lateral projection

1. Patient in the lateral recumbent position;
2. Flex the knee at 30º.

Central ray perpendicular to the middle of pattelofemoral joint.

Evaluation Criteria:

• Knee flexed 0º;
• Patellofemural joint open;
• Patella in profile;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).

Tangential Projection

1. Patient in supine position;
2. Flex the knee at 30º, 60º or 90º;
3. Ask to patient hold the IP.

Central ray angled 15º (knee flexed 30º), 20º (knee flexed 60º) or 25º (knee flexed 90º) cephalic and tangential to the patella.

Evaluation Criteria:

• Patella in profile;
• Patellofemural joint open;
• Appropriate exposure values (visualization of the all bony trabeculation and soft tissue).