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VERTEBRAL COLUMN

TOPOGRAPHIC LANDMARKS 2.) Kyphosis


1.) Cervical Region  Exaggerated thoracic curvature
 C1 – mastoid tip  Humpback or hunchback
 C2-C3 – gonion  Increase anterior concavity or posterior
 C5 – thyroid cartilage convexity
 C7 – vertebral prominens 3.) Scoliosis
2.) Thoracic Region  Lateral curvature
 T1 – 2 in. superior to sternal notch  S-shaped
 T2-T3 – manubrial notch/superior margin of 4.) Gibbus
scapula/suprasternal notch  Posterior angulation of the spine
 T4-T5 – sternal angle
 T7 – inferior angle of scapula PATHOLOGY
 T9-T10 – xiphoid process/ensiform 1.) Clay Shoveler’s Fx
 T10 – xiphoid tip  Avulsion fx of the spinous process in the
3.) Lumbar Region lower cervical & upper thoracic region
 L3 – lower costal margin 2.) Compression Fx
 L3-L4 – level of umbilicus  Fx that causes compaction of bone & a
 L4 – most superior aspect of iliac crest decrease in length or width
4.) Sacrum & Pelvic Region 3.) Hangman’s Fx
 S1 – ASIS  Fx of the anterior arch of C2 due to
 Coccyx – pubic symphysis & greater hyperextension
trochanter 4.) Jefferson’s Fx
 Comminuted fx of the ring of C1
SPINAL CURVATURES 5.) Herniated Nucleus Pulposus
1.) Cervical & Lumbar Curve  Rupture or prolapsed of the nucleus
 Convex anteriorly & concave posteriorly pulposus into the spinal canal
 Secondary/compensatory curve: develop 6.) Kyphosis
after birth  Abnormally increased convexity in the
 Cervical: when baby starts holding the head thoracic curvature
 Lumbar: when baby learns to walk 7.) Lordosis
2.) Thoracic & Pelvic Curve  Abnormally increased concavity of the
cervical & lumbar spine
 Convex posterior & concave anteriorly
8.) Osteopetrosis
 Primary curve: present at birth
 Increased density of atypically soft bone
9.) Osteoporosis
ABNORMAL CURVATURES
1.) Lordosis  Loss of bone density
 Exaggerated lumbar curvature 10.) Scheuerrmann’s Disease
 Adolescent kyphosis
 Swayback
 Kyphosis with onset in adolescence
 Increase anterior convexity or posterior
concavity
VERTEBRAL COLUMN

11.) Scoliosis ER: Alternative projection when a patient cannot be


 Lateral deviation of the spine with possible adjusted in the open-mouth position
vertebral rotation
12.) Spina Bifida B.) DENS
 Failure of the posterior encasement of the
spinal cord to close FUCHS METHOD
13.) Spondylolisthesis AP PROJECTION
 Forward displacement of a vertebra over a PP: Supine; chin extended; chin tip & mastoid tip ┴
lower vertebra, usually L5-S1 to IR; MSP ┴ to IR
14.) Spondylolysis RP: Distal to chin tip
 Separation of the pars interarticularis CR: ┴
15.) Odontoid Fx SS: Dens w/in foramen magnum
 Disruption of the arches of C1 ER: Recommended when upper half of dens is not
16.) Teardrop Burst Fx clearly shown in open-mouth position
 Comminuted vertebral body with triangular
fragments avulsed from anteroposterior KASABACH METHOD
border caused by compression with AP AXIAL OBLIQUE PROJECTION
hyperflexion in the cervical region R & L head rotations
17.) Transitional Vertebra PP: Supine; head rotated 40-45o; IOML ┴
RP: Midway b/n outer canthus & EAM
 It occurs when the vertebra takes on a
CR: 10-15o caudad
characteristic of the adjacent region of the
SS: Dens
spine
ER: Recommended in conjuction with AP & lateral
18.) Chance Fx
projections
 Fx through the vertebral body caused by
hyperflexion force
C. ATLAS (C1) & AXIS (C2)
19.) Whiplash Injury
 Damage to the ligaments, vertebrae or spinal
ALBERS-SCHONBERG & GEORGE
cord caused by sudden jerking back of the
METHOD
head & neck
AP “OPEN-MOUTH" PROJECTION
PP: Supine; MSP ┴; open mouth as wide as
A.) ATLANTO-OCCIPITAL JOINTS
possible;
RP: Midpoint of open mouth
AP OBLIQUE PROJECTION
CR: ┴
R & L head rotations
SS: Atlas & axis
PP: Supine; head rotated 45-60o away from side of
interest; IOML ┴ to IR
LATERAL PROJECTION
RP: 1 in. anterior to the EAM
PP: Supine (dorsal decubitus); IR vertical; MSP //
CR: ┴
to IR; MSP ┴ to table; neck slightly extended
SS: Atlanto-occipital joints b/n orbit & ramus of
(mandibular rami does not overlap atlas or axis)
mandible
RP: 1 in. distal to mastoid tip
 Dens is well demonstrated
CR: ┴
VERTEBRAL COLUMN

SS: Atlas & axis; atlanto-occipital joints  Hyperflexion: head drop forward; draw
Pancoast, Pendergrass & Schaeffer chin as close as possible to the chest
Recommendation:  Hyperextension: chin elevated as much as
 Head rotated slightly possible
 Rationale: to prevent superimposition of RP: C4
laminae & atlas CR: Horizontal
SS: IV disks & zygapophyseal joints
D.) CERVICAL VERTERBRAE SS in Hyperflexion:
 C1-C7
AP AXIAL PROJECTION  Elevated & widely separated spinous
PP: Supine/upright; chin extended; occlusal plane processes
┴ to IR (prevents superimposition of mandible & SS in Hyperextension:
midcervical vertebrae)  C1-C7
RP: C4  Depressed spinous processes
CR: 15-20o cephalad ER:
SS: C3-T2  For functional studies (motility) of cervical
 Interpediculate spaces vertebrae
 IV disk spaces  To demonstrate normal AP movement or
 Superimposed transverse & articular absence of movement
processes
ER: Used to demonstrate the presence or absence of AP AXIAL OBLIQUE PROJECTION
cervical ribs Barsony & Koppenstein: described this projection
PP: Supine or upright (more comfortable);
GRANDY METHOD RPO/LPO; body rotated 45o; chin
LATERAL PROJECTION protruded/elevated
PP: Seated/upright; patient in true lateral position; RP: C4
shoulder rotated posteriorly or anteriorly (round CR: 15-20o cephalad
shouldered); chin slightly elevated (prevents SS: Intervertebral foramina & pedicles (farthest
superimposition of mandibular rami & spine); MSP from IR)
// to IR Boylston Suggestion:
RP: C4  Functional studies in oblique projection
CR: Horizontal  Rationale: to demonstrate fx of articular
SS: C1-C7 process dislocation/subluxation
 Articular pillars
 Zygapophyseal joints (C3-C7) PA AXIAL OBLIQUE PROJECTION
 Spinous processes PP: Prone or upright (more comfortable);
RAO/LAO; body rotated 45o; shoulder rested
LATERAL PROJECTION against IR; chin protruded/elevated
Hyperflexion & Hyperextension RP: C4
PP: Seated/upright; patient in true lateral position; CR: 15-20o caudad
MSP // to IR
VERTEBRAL COLUMN

SS: Intervertebral foramina & pedicles (closest to VERTEBRAL ARCH/PILLAR/LATERAL


IR) MASS PROJECTION
AP AXIAL OBLIQUE PROJECTION
OTTONELLO/CHEWING/WAGGING JAW R & L head rotations
METHOD PP: Supine; head rotated 45-50o (C2-C7 articular
AP PROJECTION processes) or 60-70o (C6-T4 articular processes);
PP: Supine; MSP ┴ to IR; chin elevated; upper turn jaw away from side of interest;
incisors & mastoid tips ┴ to IR; mandible in RP: C7
chewing motion during exposure CR: 35o caudad; 30-40o caudad (ranges)
RP: C4 SS: Vertebral arch structures
CR: ┴ ER: Used to demonstrate vertebral arches when the
SS: Entire cervical column patient cannot hyperextend head for AP/PA axial
ER: To blurred the mandibular shadow to projection
demonstrate all cervical vertebrae
TWINNING & PAWLOW METHOD
VERTEBRAL ARCH/PILLAR/LATERAL SWIMMER’S TECHNIQUE
MASS PROJECTION LATERAL PROJECTION
AP AXIAL PROJECTION PP: Humeral head moved anteriorly or posteriorly;
PP: Supine; shoulder depressed; MSP ┴ to IR; depress shoulder away from IR; MSP // to IR;
neck hyperextended; breathing technque
RP: C7  Lateral recumbent (Pawlow): head
CR: 25o caudad; 20-30o caudad (range) elevated on patient’s arm;
SS: Vertebral arch structures  Upright (Twinning): arm closes to IR
 Superior & inferior articular processes extended; elbow flexed; forearm rested on
(pillars) head
 Zygapophyseal joints b/n articular RP: C7-T1 interspace
processes CR: ┴ (shoulder well depressed); 3-5o caudad
 Upper three of thoracic vertebrae (can’t be depressed sufficiently)
 Laminae SS: Cervicothoracic region (C7-T1)
 Spinous processes ER: Performed when shoulder superimposition
ER: Useful for demonstrating the cervicothoracic obscures C7 on a lateral cervical spine projection
spinous processes in patients with whiplash injury Monda Recommendation:
 CR 5-15o cephalad
VERTEBRAL ARCH/PILLAR/LATERAL  To better demonstrate IV disk spaces
MASS PROJECTION
PA AXIAL PROJECTION E.) THORACIC VERTEBRAE
PP: Prone; head rested against IR; neck fully
extended; MSP ┴ to IR AP PROJECTION
RP: C7 PP: Supine/upright; MSP ┴ to IR; hips & knees
CR: 40o cephalad; 35-45o cephalad (range) flexed (to reduce kyphosis); place support under
SS: Vertebral arch structures knees
VERTEBRAL COLUMN

RP: T7 (b/n jugular notch & xiphoid process) F.) LUMBAR-LUMBOSACRAL VERTEBRAE
CR: ┴
SS: T1-T12 AP PROJECTION
 IV disk spaces PP: Supine/upright; elbow flexed; hands on upper
 Transverse processes chest
 Costovertebral articulation  Hips & knees flexed
o Reduces lumbar lordosis
LATERAL PROJECTION o Places back in contact w/ table
PP: Lateral recumbent or upright (Oppenheimer); o Reduces distortion of vertebral
left side against the table (places heart closer to IR) bodies
MSP // to IR; hips & knees flexed; arms at right o Better delineation of IV disk
angle to body (to elevate ribs enough); place RP: L4 (for lumbosacral); L3 (for lumbar spine
support under lower thoracic spine only)
RP: T7 CR: ┴
CR: ┴ (w/ support); 10-15o cephalad (w/o support); SS: Lumbar bodies
10o (female) or 15o (male)  IV disk spaces
SS: T1-T12  Interpediculate spaces
 IV disk spaces  Laminae
 Intervertebral foramina  Spinous & transverse processes
 Lower spinous processes  Sacrum, coccyx & pelvic bones (larger IR)

FUCHS METHOD LATERAL PROJECTION


AP OBLIQUE PROJECTION PP: Lateral recumbent or upright; affected side
PP: Supine/upright; RPO/LPO; body rotated 20o against IR; hips & knees flexed; MCP ┴ to IR;
posteriorly; MCP 70o from IR place support under lower thorax (places spine in
RP: T7 true horizontal position)
CR: ┴ RP: L4 (for lumbosacral); L3 (for lumbar spine
SS: Zygapophyseal/apophyseal joints (farthest from only)
IR) CR: ┴ (w/ support); 5-8o caudad (w/o support); 5o
(male) or 8o (female)
OPPENHEIMER METHOD SS: Intervertebral foramina of L1-L4 only; L5
PA OBLIQUE PROJECTION intervertebral foramina (Oblique Projection)
PP: Prone/upright; RAO/LAO; body rotated 20o
anteriorly; MCP 70o from IR F.) L5-S1 LUMBOSCRAL JUNCTION
RP: T7
CR: ┴ LATERAL PROJECTION
SS: Zygapophyseal/apophyseal joints (closest to IR) PP: Lateral recumbent or upright; affected side
against IR; hips & knees flexed; MCP ┴ to IR;
place support under lower thorax (places spine in
true horizontal position)
VERTEBRAL COLUMN

RP: 2 in. posterior to ASIS & 1.5 in. inferior to iliac H.) LUMBOSACRAL JOINTS & SACRAL
crest JOINTS
CR: ┴ (w/ support); 5-8o caudad (w/o support); 5o
(male) or 8o (female) FERGUSON METHOD
SS: Lumbosacral junction AP AXIAL PROJECTION
PP: Supine; lower limb extended; thigh abducted;
G.) ZYGAPOPHYSEAL JOINTS RP: 1.5 in. superior to pubic symphysis
CR: 45o cephalad (Ferguson); 30-35o cephalad; 30o
AP OBLIQUE PROJECTION (male) or 35o (female);
PP: Semisupine/upright; RPO/LPO; body rotated SS: Lumbosacral joint; symmetric sacroiliac joints
45o or 60o (L5-S1 zygapophyseal joints & articular Meese Recommendation:
processes);  PP: Prone (places sacroiliac joints nearly //
RP: to CR)
Lumbar region: 2 in. medial to elevated ASIS &  RP: 2 in. distal to L5 (level of ASISs)
1.5 in. superior to iliac crest (L3)  CR: ┴
5th zygapophyseal joint: 2 in. medial to elevated
ASIS & midway b/n iliac crest & ASIS FERGUSON METHOD
CR: ┴ PA AXIAL PROJECTION
SS: Zygapophyseal/apophyseal joints (closest to IR) PP: Prone
 Scottie dog RP: L4
o Superior articular process (ear) CR: 35o caudad
o Transverse process (nose) SS: Lumbosacral joint; symmetric sacroiliac joints
o Pedicle (eye)
o Part interarticularis (neck) I.) SACROILIAC JOINTS
o Lamina (body)
o Inferior articular process (foot) AP OBLIQUE PROJECTION
Note: PP: Semisupine; RPO/LPO; body rotated 25-30o
 Majority (L3-S1) of zygapophyseal joints RP: 1 in. medial to elevated ASIS
(45o body rotation) CR: ┴
 L1-L2 & L2-L3 (AP; 25% only) SS: Sacroiliac joint (farthest from IR)
 L4-L5 & L5-S1 (LATERAL; small %age)
AP AXIAL OBLIQUE PROJECTION
PA OBLIQUE PROJECTION PP: Semisupine; RPO/LPO; body rotated 25-30o
PP: Semiprone/upright; RAO/LAO; body rotated RP: 1 in. distal to elevated ASIS
45o or 60o (L5-S1 zygapophyseal joints & articular CR: 20-25o cephalad
processes) SS: Sacroiliac joint (farthest from IR)
RP: 1.5 in. superior to iliac crest & 2 in. lateral to
palpable spinous process PA OBLIQUE PROJECTION
CR: ┴ PP: Semiprone; RAO/LAO; body rotated 25-30o
SS: Zygapophyseal/apophyseal joints (farthest from RP: 1 in. medial to elevated ASIS
IR) CR: ┴
 Scottie dog SS: Sacroiliac joint (closest to IR)
VERTEBRAL COLUMN

J.) PUBIC SYMPHYSIS SS: Sacrum

CHAMBERLAIN METHOD L.) COCCYX


PA PROJECTION
PP: Upright; standing on two blocks AP/PA AXIAL PROJECTION
 First exposure: remove one blocks; one leg PP: Supine or prone (patient w/ painful
hangs with no muscular resistance injury/destructive disease)
 Second exposure: replace support under RP: 2 in. superior to pubic symphysis (supine);
foot that was hanging; remove the opposite Palpable coccyx (prone)
one; second leg hanging free CR: 10o caudad (supine); 10o cephalad (prone)
RP: Pubic symphysis SS: Coccyx free of superimposition
CR: ┴
SS: Pubic symphysis LATERAL PROJECTION
Chamberlain Recommendations: PP: Lateral recumbent; interiliac plane ┴ to IR;
 For abnormal sacroiliac motion pelvis & shoulder in true lateral position
 Lateral Projection: RP: 3.5 in. posterior & 2 in. inferior to ASIS
o Upright CR: ┴
o Centered to lumbosacral junction SS: Coccyx
 2 PA Projections of Pubic bones:
o Upright M.) LUMBAR INTERVERTEBRAL DISKS
o Weight-bearing on alternate limbs
o To demonstrate pubic symphysis WEIGHT-BEARING METHOD
reaction by a change in the normal PA PROJECTION
relation of pubic bones PP: Upright; patient bending to right & left; lean
directly lateral as far as possible
K.) SACRUM RP: L3
CR: 15-20o caudad
AP/PA AXIAL PROJECTION SS: Lower thoracic & lumbar region
PP: Supine or prone (patient w/ painful ER: Perform for demonstration of the mobility of
injury/destructive disease) intervertebral joints
RP: 2 in. superior to pubic symphysis (supine); Duncan & Hoen Recommendation:
visible sacral curve (prone)  PA projection be used
CR: 15o cephalad (supine); 15o caudad (prone)  Rationale: IV disks more nearly // to CR
SS: Sacrum free of foreshortening

LATERAL PROJECTION  THE END 


PP: Lateral recumbent; interiliac plane ┴ to IR; “BOARD EXAM is a matter of PREPARATION. If
pelvis & shoulder in true lateral position you FAIL to prepare, you PREPARE to fail”
RP: 3.5 in. posterior to ASIS 03/31/14

CR: ┴
VERTEBRAL COLUMN

RULES OF OBLIQUE
Anatomy of
Projection Position/Degrees Structure Shown Central Ray
Interest
LPO – 45o Right IF (side up) 15-20o cephalad
CERVICAL AP Oblique
RPO – 45o Left IF (side up) 15-20o cephalad
(Intervertebral
LAO – 45o Left IF (side down) 15-20o caudad
Foramina) PA Oblique
RAO – 45o Right IF (side down) 15-20o caudad
LPO – 70o Right ZJ (joints up) ┴
THORACIC AP Oblique
RPO – 70o Left ZJ (joints up) ┴
(Zygapophyseal
LAO – 70o Left ZJ (joints down) ┴
Joints) PA Oblique
RAO – 70o Right ZJ (joints down) ┴
LPO – 45o Left ZJ (joints down) ┴
LUMBAR AP Oblique
RPO – 45o Right ZJ (joints down) ┴
(Zygapophyseal
LAO – 45o Right ZJ (joints up) ┴
Joints) PA Oblique
RAO – 45o Left ZJ (joints up) ┴
LPO – 25-30o Right SIJ (joint up) ┴
AP Oblique
SACROILIAC RPO – 25-30o Left SIJ (joint up) ┴
JOINTS LAO – 25-30o Left SIJ (joint down) ┴
PA Oblique
RAO – 25-30o Right SIJ (joint down) ┴
LPO – 45o Left AR (side down) ┴
AP Oblique
RPO – 45o Right AR (side down) ┴
AXILLIARY RIBS
LAO – 45o Right AR (side up) ┴
PA Oblique
RAO – 45o Left AR (side up) ┴

ZYGAPOPHYSEAL INTERVERTEBRAL
ANATOMY
JOINTS FORAMINA
Cervical Lateral Oblique – 45o
Thoracic Oblique – 70o Lateral
Lumbar Oblique – 45o Lateral