X-Ray-Positioning

SPINE

Dr. Fritsch
 Cervical Spine Series
• Minimal Series – 5 views
– Neutral Lateral
– APOM
– APL5
– LAO or RPO Oblique
– RAO or LPO Oblique

• Additional Views:
– Flexion & Extension Lateral
– Swimmers View
Cervical Spine
Series
Cervical Spine – Neutral Lateral
• Neutral Lateral Cervical Spine
– Structures Demonstrated
• all 7 cervical vertebra, and the soft tissues of the neck
– Film:
• 10x12 film placed vertically; blocker ↓, marker ↓
– FFD: 72″
– kVp Range: 70 – 90
– Measurement:
• taken at the level of C5 in the sagittal plane
– Patient Position:
• patient should be placed perpendicular to the bucky with their shoulder
resting against it, and with their head in a neutral posture.
– Central Ray:
• centered at the sternocleidomastoid with the upper outline of the cross-
hairs adjacent to the mandibular angle
– Collimation:
– set so that the light falls directly posterior to the orbits
horizontally and so that light shines above the skull vertically
– Special Instructions:
• film taken on suspended inspiration
Cervical Spine – Neutral Lateral
Cervical Spine – Neutral Lateral
 Cervical Spine - APOM
• Anterior-Posterior Open Mouth (APOM)
– Structures Demonstrated: C1/C2
– Film: top portion of 7x17 film or single small film; blocker ↑, marker ↑
– FFD: 40″
– kVp Range: 70-80
– Tube Tilt: None
– Measurement: chin to occiput sagittal plane
– Patient Position:
• patient positioned with mouth open, place thumbs on posterior
occiput and inferior molars; level thumbs are optimal for positioning
– Central Ray:
• passes through the patient’s open mouth
– Collimation:
• set such that the light falls directly below the patient’s nose vertically
and shines light on either side of the patient’s mandible horizontally
– Special Instructions: None.
Cervical Spine - APOM
 Cervical Spine – APL5
• Anterior Posterior Lower Cervical Spine – APL5
– Structures Demonstrated:
• lower 5 cervical vertebra, cervicothoracic junction, soft tissues of the
neck and the lung apices
– Film: 10x12 blocker ↑, marker ↑
– FFD: 40″; tube set at 37″ due to tube tilt
– kVp Range 70-80
– Tube Tilt: 150 cephalad
– Measurement: taken at the level of C5 in the sagittal plane
– Patient Position:
• patient standing with chin slightly elevated; inferior border of mandible
about level
– Central Ray:
• centered just below the thyroid cartilage at the sagittal midline
– Collimation:
• set such that the light falls below the lower lip vertically and so there is
light on either side of the patient‘s neck horizontally
– Special Instructions: film taken on suspended inspiration
Cervical Spine – APL5
Cervical Spine – APL5
 Cervical Spine – Anterior Oblique
• Anterior Cervical Oblique
– Structures Demonstrated:
• film taken to view the entire cervical spine, particularly the intervertebral
foramina (IVF). The right anterior oblique (RAO) demonstrates the right
IVF, while the LAO demonstrates the left IVF.
– Film: 10x12 film placed vertically; blocker ↑, marker ↑
– FFD: 40″; tube set at 37″ due to tube tilt
– kVp Range: 80
– Tube Tilt: 150 caudad
– Measurement: taken at the level of C5 in the sagittal plane
– Patient Position:
• patient positioned with shoulders 450 to film (bucky) and the sagittal plane
of the head parallel to the film (bucky)
– Central Ray:
• set at the level of C4 –C5
– Collimation: Light behind orbit, light vertically above ear.
– Special Instructions: film taken with suspended inspiration
Cervical Spine – Anterior Oblique
Cervical Spine – Anterior Oblique
Cervical Spine – Posterior Oblique
• Posterior Cervical Oblique
– Structures Demostrated:
• entire cervical spine, particularly the intervertebral foramina (IVF). The
right posterior oblique (RPO) demonstrates the left IVF, while the LPO
demonstrates the right IVF.
– Film: 10x12 film placed vertically; blocker ↑, marker ↑
– FFD: 40″; tube set at 37″ due to tube tilt
– kVp Range: 80
– Tube Tilt: 150 cephalad
– Measurement:
• taken at the level of C5 in the sagittal plane
– Patient Position:
– patient positioned with shoulders 450 to film (bucky) and the
sagittal plane of the head parallel to the film (bucky)
– Central Ray:
• set at the level of C4 –C5
– Collimation:
• Light behind orbit, light vertically above ear.
– Special Instructions:
• film taken with suspended inspiration
Cervical Spine – Posterior Oblique
Cervical Spine – Flexion Lateral
• Flexion Lateral Cervical Spine
– Structures Demonstrated:
• base of the occiput through the 7 cervical vertebra
– Film: 10x12 film placed vertical; blocker ↓, marker ↓
– FFD: 72″
– kVp Range: 70-80
– Measurement:
• taken at the level of C5 in the sagittal plane
– Patient Position:
• set like the neutral lateral view initially, then move the patient into
maximum flexion with their chin tucked
– Central Ray:
• set as with the neutral lateral prior to moving the patient into flexion
– Collimation:
• set to film size and be sure to exclude the orbits
– Special Instructions:
• film taken on suspended inspiration
Cervical Spine – Flexion Lateral
 Cervical Spine – Flexion Lateral
Flexion

Extension
Cervical Spine – Extension Lateral
• Cervical Extension Lateral
– Structures Demostrated:
• base of the occiput through the 7 cervical vertebra
– Film: 10x12 film placed vertical; blocker ↓, marker ↓
– FFD: 72″
– kVp Range: 70-80
– Measurement:
• taken at the level of C5 in the sagittal plane
– Patient Position:
• set like the neutral lateral view initially, then move the patient into
maximum extension with their chin elevated
– Central Ray:
• set as with the neutral lateral prior to moving the patient into extension
– Collimation:
• set to film size and be sure to exclude the orbits
– Special Instructions:
• film taken on suspended inspiration
Cervical Spine – Extension Lateral
Cervical Spine – Extension Lateral

Flexion

Extension
 Cervical Spine – Swimmers View
• Swimmer’s View
– Structures Demonstrated:
• view the cervicothoracic junction, C6/C7 – T3/T4
– Film:
• 10x12 film placed vertically; blocker ↓, marker ↓
– FFD: 40″
– kVp: 90
– Measurement:
• taken in the sagittal plane from the middle trapezius to the contra-lateral
axilla
– Patient Position:
• patient positioned in posterior oblique fashion with the shoulders at a100
– 200 angle; patient reaches forward and up with the arm nearest the
bucky, and down and back with the arm nearest the tube
– Central Ray:
• enters at the level of the mid trap.
– Collimation:
• set to film size
– Special Instructions:
• film taken on suspended inspiration
Thoracic Spine Series

• Minimal Series – 2 views

– AP Thoracic
– Lateral Thoracic
Thoracic Spine – Anterior Posterior
• AP Thoracic
– Structures Demonstrated:
• film taken to view the entire thoracic spine and posterior rib heads
– Film: 7x17 film placed vertically; blocker ↓, marker ↓
– FFD: 40″
– kVp: 80
– Measurement:
• taken in the sagittal plane at the level of T6
– Patient Position:
• patient supine sagittal plane parallel to the bucky
– Central Ray:
• sagittal midline, midway between the episternal notch and xiphoid
process; ie. the nipple line
– Collimation:
• set to film size
– Special Instructions:
• film taken on suspended inspiration
Thoracic Spine – Anterior Posterior
Thoracic Spine – Anterior Posterior
 Thoracic Spine – Lateral View
• Lateral Thoracic
– Structures Demonstrated:
• film taken to view the entire thoracic spine
– Film: 14x17 film placed vertically; blocker ↑, marker ↑
– FFD: 40″
– kVp: 90
– Measurement: Perpendicular to T-6
– Patient Position:
• patient in a left lateral , recumbent position
– Central Ray: set at the nipple line
– Collimation:
• collimate to a 7x17
– Special Instructions:
• film taken on suspended inspiration
Thoracic Spine – Lateral View
 Lumbar Series
• Minimal Lumbar Series
– AP Lumbar
– Lateral Lumbar
– AP &/or Lateral Lumbosacral Spot

• Extra Views
– Posterior or Anterior Obliques
 Lumbar Spine – AP
• AP Lumbosacral
– Structures Demonstrated:
• Lumbar bodies, transverse processes, and the intervertebral
disk spaces.
– Film: 7x17 film placed vertically; blocker ↓, marker ↓
– FFD: 40″
– kVp: 80
– Measurement:
• taken in the sagittal plane at the level of L3-L4
– Patient Position:
• patient in a true AP position
– Central Ray: set at sagittal midline at the level of L3-L4
– Collimation: to film size.
– Special Instructions: film taken on suspended expiration
Lumbar Spine – AP

NO BELT!!
Lumbar Spine – AP
 Lumbar Spine – Lateral
• Lateral Lumbosacral
– Structures Demonstrated:
• The lateral aspect of the intervertebral disk spaces.
– Film:
– 7x17 film placed vertically; blocker ↑, marker ↑
– FFD: 40″
– kVp: 90
– Measurement:
• taken in the coronal plane at the level of L3-L4.
– Patient Position:
• Patient is recumbent on the left side.
– Central Ray:
• set at the level of L3 –L4
– Collimation: to film size
Lumbar Spine – Lateral
Lumbar Spine – Lateral
 Lumbar Spine – AP Spot
• AP Lumbosacral (Angulated) Spot
– Structures Demonstrated:
• to view L5/S1 articulation and the SI joints
– Film:
• 10x12 film placed horizontally; blocker ↓, marker ↓
– FFD: 40″; tube set at 35″ due to tube tilt
– kVp: 80
– Tube Tilt: 250 cephalad
– Measurement:
• taken in the sagittal plane at midline, between the level of the ASIS
and pubic symphysis
– Patient Position: patient is supinated.
– Central Ray:
• set at the sagittal midline, halfway between the level of the ASIS and
the pubic symphysis
– Collimation:
• set to film size
Lumbar Spine – AP Spot
Lumbar Spine – AP Spot
 Lumbar Spine – Lateral Spot
• Lateral Lumbosacral (L5/S1) Spot
– Structures Demonstrated:
• to view the L4/L5 and L5/S1 articulations
– Film: 10x12 film placed vertically; blocker ↓, marker ↓
– FFD: 40″
– kVp: 90
– Measurement:
• taken in the coronal plane at a level 2″ below the iliac crests
– Patient Position: Left lateral recumbent position.
– Central Ray: set 2″ below iliac crests between the ASIS and PSIS
– Collimation: Collimate to L5-S1
Lumbar Spine – Lateral Spot
Lumbar Spine – Lateral Spot
 Lumbar Spine – Anterior Oblique
• Anterior Oblique (RAO/LAO)
– Structures Demonstrated:
• film taken to view L1 – S1, especially the pars inter-articularis. Recall that
RAO demonstrates the left “pars interarticularis” and the LAO demonstrates
the right “pars interarticularis”
– Film: 14x17 film placed vertically; blocker ↓, marker ↓
– FFD: 40″
– kVp: 80
– Measurement:
• taken in the coronal plane 1″ above the iliac crests, at about the level of L3
– Patient Position:
• patient positioned 450 obliquely to the bucky with the front of the patient
against the bucky
– Central Ray:
• set 1″ above the iliac crests and 1 ½″ off the sagittal midline towards the
high side
– Collimation:
• set to film size
– Special Instructions:
• film taken on suspended expiration
Lumbar Spine – Anterior Oblique
Lumbar Spine – Posterior Oblique
• Posterior Oblique (RPO/LPO)
– Structures Demonstrated:
• to view L1 – S1, especially the pars inter-articularis. Recall that RPO
demonstrates the right “pars” and the LPO demonstrates the left “pars”
– Film: 14x17 film placed vertically; blocker ↓, marker ↓
– FFD: 40”
– kVp: 80
– Measurement:
• taken in the coronal plane 1″ above the iliac crests, at about the level of
L3
– Patient Position:
• patient positioned 450 obliquely to the bucky with the back of the patient
against the bucky
– Central Ray:
• set 1″ above the iliac crests and 1 ½″ off the sagittal midline towards the
high side
– Collimation: set to film size
– Special Instructions:
• film taken on suspended expiration
Lumbar Spine – Posterior Oblique
 Oblique Pneumonic
• CLAPS
• C & A see S
– Cervical & Anterior see Same side (IVF)

• L & P see S
– Lumbar & Posterior see Same side (pars, scotty
dog)

– Lumbar spine does not show sacrum

Sacrum & Coccyx
• Minimal Series:
– AP Sacrum
– AP Coccyx
– Lateral Sacrum
– Lateral Coccyx
 AP Sacrum
• AP Sacrum
– Structure Demonstrated:
• The sacrum will be free from the foreshortening of the sacral curvature.
– Film:
• 10x12 film placed horizontal; blocker ↓, marker ↓
– FFD: 40″; tube set at 37″ due to tube tilt
– kVp: 80
– Tube Tilt: 150 cephalad
– Measurement:
• taken in the sagittal plane, at midline, between the ASIS and the pubic
symphysis
– Patient Position:
• patient is supinated
– Central Ray:
• set at sagittal midline between the level of the ASIS and the pubic symphysis
– Collimation:
• set to film size
AP Sacrum
 Lateral Sacrum
• Lateral Sacrum – film taken to view the sacrum
– Film: 10x12 film placed vertically; blocker ↑, marker ↑
– FFD: 40″
– kVp: 90
– Correction Factor: -2 ½
– Tube Tilt: None
– Measurement: taken in the coronal plane 2″ below the iliac
crests
– Patient Position: patient in true lateral position
– Central Ray: set 2″ below the iliac crests between the ASIS and
PSIS
– Collimation: set to film size
– Special Instructions: film taken on suspended expiration
Lateral Sacrum
 AP Coccyx

• AP Coccyx
– film taken to view the coccyx
– Film: 8x10 film placed vertically;
blocker ↑, marker ↑
– FFD: 40″; tube set at 38″ due to tube
tilt
– kVp: 80
– Tube Tilt: 100 caudad if taken AP, or
100 cephalad if taken PA
– Measurement: taken in the sagittal
plane 2″ above the pubic symphysis
– Patient Position: patient in true AP
position, or PA position
– Central Ray: set at sagittal midline 2″
above the pubic symphysis
– Collimation: set to film size
– Special Instructions: film taken on
suspended expiration
AP Coccyx
 Sacrum & Coccyx

• Lateral Coccyx
– film taken to view the coccyx
– Film: 8x10 film placed vertically; blocker ↑, marker ↑
– FFD: 40″
– kVp: 90
– Tube Tilt: None
– Measurement: taken in coronal plane at the region of the
coccyx, which will be considerably posterior to the middle of
the pelvis. DO NOT use lateral lumbar measurement.
– Patient Position: patient in true lateral position
– Central Ray: set at the level of the coccyx
– Collimation: set to film size
– Special Instructions: film taken on suspended expiration
Lateral Coccyx
 Sacro-Iliac Joints
• Minimal Series:
– R & L Anterior S-I joints
Or
R & L Posterior S-I joints
 Sacro-iliac Joints
• Anterior Sacroiliac Joint :
– Structures Demonstrated:
• film taken to specifically view either the right or left SI joint in its
plane
– Film: 10x12 film placed vertically; blocker ↓, marker ↓
– FFD: 40″; tube set at 37″ due to tube tilt (or 35″ if you use 250 tube
tilt)
– kVp: 80
– Tube Tilt: 100 – 150 cephalad; some texts suggest 250
– Measurement: taken in the sagittal plane at the level of the ASIS
– Patient Position:
• Patient is semisupinated on the table. Oblique the patient 30
degrees.
– Central Ray:
• set 1″ medially from the ASIS of the side you want to view
– Collimation: set to film size
Sacro-iliac Joints - Anterior
 Sacro-iliac Joints - Posterior
• Posterior Sacro-iliac Joints
– Structures Demonstrated:
• film taken to specifically view either the right or left
SI joint in its plane
– Film:
• 10x12 film placed vertically; blocker ↓, marker ↓
– FFD: 40″; tube set at 37″ due to tube tilt (or 35″ if you
use 250 tube tilt)
– kVp: 80
– Tube Tilt:
• 100 – 150 cephalad; some texts suggest 250
– Measurement:
• taken in the sagittal plane at the level of the ASIS
– Patient Position:
• Patient is semipronated. The unaffected side is
elevated 30 degrees from the table.
– Central Ray: set 1″ medially from the PSIS of the side
you want to view
– Collimation: set to film size
Sacro-iliac Joints - Posterior
THE END

X-Ray-Positioning

SPINE

Dr. Fritsch