LUMBAR VERTEBRAE

Indications
• Ankylosing spondylitis (inflammation of spine and large joints)
• Fractures
• Herniated nucleus pulposus (HNP) (herniated lumbar disk)
• Lordosis
• Metastases
• Scoliosis
• Spina bifida
• Spondylolisthesis (condition in which a bone slips forward onto the bone
below it)
• Spondylolysis (defect in the pars interarticularis of the vertebral arch)
• Constant lower back pain
RADIATION PROTECTION
• Proper patient positioning.
• Collimate the primary beam optimally to the size of the cassette.
• Proper patient instruction to avoid over exposure through repeated
procedures.
• Provision of gonadal shields.
• Instruct attendants to wait from outside.
• Make sure the door is closed during exposure.
• Remember to put on a lead apron during exposure.
ANATOMY
• Lumbar Vertebrae
• The largest individual vertebrae are the five lumbar vertebrae.
• These vertebrae are the strongest in the vertebral column because
the load of body weight increases toward the inferior end of the
column. For this reason, the cartilaginous disks between the inferior
lumbar vertebrae are common sites for injury and pathologic
processes.
LATERAL AND SUPERIOR
PERSPECTIVES
• Patients typically have five lumbar vertebrae located just inferior to
the 12 thoracic vertebrae. Fig. 9-1 illustrates the lateral perspective of
a typical lumbar vertebra. Lumbar vertebral bodies are larger in
comparison with thoracic and cervical vertebral bodies. The most
inferior body, L5, is the largest. The transverse processes are fairly
small, whereas the posteriorly projecting spinous process is bulky and
blunt. The palpable lower tip of each lumbar spinous process lies at
the level of the intervertebral disk space inferior to each vertebral
body.
POSTERIOR AND ANTERIOR PERSPEC
TIVES
• Fig. 9-3 demonstrates the general appearance of a lumbar vertebra as
seen from the anterior and posterior perspectives. Anteroposterior
(AP) or posteroanterior (PA) radiographic projections of the lumbar
spine demonstrate the spinous processes superimposed on the
vertebral bodies. The transverse processes are demonstrated
protruding laterally beyond the edges of the vertebral body.
INTERVERTEBRAL FORAMINA
• Intervertebral foramina are spaces or openings between pedicles
when two vertebrae are stacked on each other. Along the upper
surface of each pedicle is a half-moon–shaped area called the
superior vertebral notch and along the lower surface of each pedicle
is another half-moon–shaped area called the inferior vertebral notch.
When vertebrae are stacked, the superior and inferior vertebral
notches line up, and the two half-moon–shaped areas form a single
opening, the intervertebral foramina.
• Therefore, between every two vertebrae are two intervertebral
foramina, one on each side, through which important spinal nerves
and blood vessels pass. The intervertebral foramina in the lumbar
region are demonstrated best on a lateral radiographic image.
• Zygapophyseal Joints Each typical vertebra has four articular processes
that project from the area of the junction of the pedicles and laminae.
The processes that project upward are called the superior articular
processes and the processes that project downward are the inferior
articular processes. The term facet (fas- t) sometimes is used
interchangeably with the term zygapophyseal joint; the facet is actually
only the articulating surface instead of the entire superior or inferior
articular process. Fig. 9-1 shows the relative positions of the superior
and inferior lumbar articular processes from the lateral perspective.
• The zygapophyseal joints form an angle open from 30° to 50° to the
midsagittal plane, as shown in Fig. 9-2. The upper or proximal lumbar
vertebrae are nearer the 50° angle and the lower or distal lumbar
vertebrae are nearer 30°. Radiographic demonstration of the
zygapophyseal joints is achieved by rotating the patient’s body an
average of 45°.
• The laminae form a bridge between the transverse processes, lateral
masses, and spinous process (Fig. 9-2). The portion of each lamina
between the superior and inferior articular processes is the pars
interarticularis. The pars interarticularis is demonstrated
radiographically on the oblique lumbar image.
PATIENT PREPARATION
Identify the patient by name.
Create a rapport.
Take a brief history of the patient
Explain the procedure to the patient.
Seek consent from the patient.
Remove radio-opaque objects if any
Set the machine and position the patient
Technical Factors (AP ,PA)
• Minimum SID is 40 inches (102 cm).
• IR size—35 × 43 cm (14 × 17 inches), lengthwise, or 30 × 35 cm (11 ×
14 inches)
• Grid
• Analog—75 to 85 kV range
• Digital systems—85 to 95 kV range

REF: Textbook of radiographic positioning and related anatomy

 ANTERO-POSTERIOR – BASIC
POSITION OF PATIENT AND CASSETTE
• The patient lies supine on the Bucky table, with the median sagittal
plane coincident with, and at right-angles to, the midline of the table and
Bucky.
• The anterior superior iliac spines should be equidistant from the
tabletop.
• The hips and knees are flexed and the feet are placed with their
plantar aspect on the tabletop to reduce the lumbar arch and bring the
lumbar region of the vertebral column parallel with the cassette.
• The cassette should be large enough to include the lower thoracic
vertebrae and the sacro-iliac joints and is centered at the level of the
lower costal margin.
• The exposure should be made on arrested expiration, as the this will
cause the diaphragm to move superiorly. The air within the lungs would
otherwise cause a large difference in density and poor contrast between
the upper and lower lumbar vertebrae.
 DIRECTION AND CENTERING OF THE X-RAY
BEAM

• Direct the central ray towards the midline at the level of the lower
costal margin (L3).
 ESSENTIAL IMAGE CHARACTERISTICS

• The image should include from T12 down, to include all of the sacro-
iliac joints.
• Rotation can be assessed by ensuring that the sacro-iliac joints are
equidistant from the spine.
• The exposure used should produce a density such that bony detail can
be discerned throughout the region of interest.
RADIOLOGICAL CONSIDERATIONS
• The presence of intact pedicles is an important sign in excluding
metastatic disease. Pedicles are more difficult to see on an
underexposed or rotated film.
 COMMON FAULTS AND REMEDIES

• The most common fault is to miss some or all of the sacroiliac joint.
An additional projection of the sacro-iliac joints should be performed.
NOTE

• For relatively fit patients, this projection can be performed with the
patient in the postero-anterior position. This allows better visualization
of the disc spaces and sacro-iliac joints, as the concavity of the lumbar
lordosis faces the tube so the diverging beam passes directly through
these structures. Although the magnification is increased, this does not
seriously affect image quality.
 LATERAL – BASIC
POSITION OF PATIENT AND CASSETTE
• The patient lies on either side on the Bucky table. If there is any degree of scoliosis,
then the most appropriate lateral position will be such that the concavity of the curve is
towards the X-ray tube.
• The arms should be raised and resting on the pillow in front of the patient’s head. The
knees and hips are flexed for stability.
• The coronal plane running through the center of the spine should coincide with, and be
perpendicular to, the midline of the Bucky.
• Non-opaque pads may be placed under the waist and knees, as necessary, to bring the
vertebral column parallel to the film.
• The cassette is centered at the level of the lower costal margin.
• The exposure should be made on arrested expiration.
• This projection can also be undertaken erect with the patient standing or sitting.
DIRECTION AND CENTRING OF THE X-RAY BEAM

• Direct the central ray at right-angles to the line of spinous processes

and towards a point 7.5 cm anterior to the third lumbar spinous
process at the level of the lower costal margin.
Incorrect – vertebral column not
parallel with table
ESSENTIAL IMAGE
CHARACTERISTICS
• The image should include T12 downwards, to include the lumbar
sacral junction.
• Ideally, the projection will produce a clear view through the center of
the intervertebral disc space, with individual vertebral endplates
superimposed.
• The cortices at the posterior and anterior margins of the vertebral
body should also be superimposed.
• The imaging factors selected must produce an image density
sufficient for diagnosis from T12 to L5/S1, including the spinous
processes.
 RADIOLOGICAL CONSIDERATIONS
• The presence of intact pedicles is an important sign in
excluding metastatic disease. Pedicles are more difficult to see
on an underexposed or rotated film.
• Transitional vertebrae are common at the lumbosacral
junction and can make counting the level of an abnormality
difficult. A sacralized L5 has a shape similar to S1, with large
transverse processes, and is partially incorporated into the
upper sacrum. The converse is lumbarization of S1, in which
the body and appendages of S1 resemble L5 and the sacro-
iliac joints are often reduced in height.
• These anomalies may cause errors in counting the
level of an abnormality, in which case the twelfth rib
and thoracic vertebra must be seen clearly to enable
counting down from above. This is of particular
importance when plain images are used to confirm
the level of an abnormality detected on other imaging
modalities, e.g. MRI.
 COMMON FAULTS AND REMEDIES
• High-contrast images will result in an insufficient or high image
density over areas of high or low patient density, i.e. the spinous
processes and L5/S1. A high kVp or the use of other wide-latitude
techniques is recommended.
• The spinous processes can easily be excluded from the image as a
result of overzealous collimation.
• Poor superimposition of the anterior and posterior margins of the
vertebral bodies is an indication that the patient was rolled too far
forward or backward during the initial positioning (i.e. mean sagittal
plane not parallel to cassette).
• Failure to demonstrate a clear intervertebral disc space
usually results as a consequence of the spine not being
perfectly parallel with the cassette or is due to scoliosis
or other patient pathology.
 NOTE

• A piece of lead rubber or other attenuator

placed behind the patient will reduce scatter
incident on the film. This will improve overall
image quality as well as reduce the chance of
automatic exposure control error.
LATERAL HORIZONTAL BEAM

• A patient with a suspected fracture to the lumbar

vertebrae should not be moved from the casualty
trolley without medical supervision. Similarly, the
patient should not be moved into the lateral
decubitus position in these circumstances. This will
necessitate the use of a horizontal beam technique in
order to obtain the second projection required for a
complete examination.
Technical Factors
• Minimum SID is 40 inches (102 cm).
• IR size—35 × 43 cm (14 × 17 inches), or 30 × 35 cm (11 × 14 inches),
lengthwise
• Grid
• Analog—80 to 90 kV range
• Digital systems—90 to 100 kV range
• Lead mat on tabletop behind patient
POSITION OF PATIENT AND
CASSETTE
• The trauma trolley is placed adjacent to the vertical Bucky.
• Adjust the position of the trolley so that the lower costal margin of
the patient coincides with the vertical central line of the Bucky and the
median sagittal plane is parallel to the cassette.
• The Bucky should be raised or lowered such that the patient’s mid-
coronal plane is coincident with the midline of the cassette within the
Bucky, along its long axis.
• If possible, the arms should be raised above the head.
DIRECTION AND CENTERING OF THE X-RAY BEAM

• Direct the horizontal central ray parallel to a line

joining the anterior superior iliac spines and towards a
point 7.5 cm anterior to the third lumbar spinous
process at the level of the lower costal margin.
ESSENTIAL IMAGE
CHARACTERISTICS
• The image should include T12 downwards, to include the lumbar sacral junction.
• Ideally, the projection will produce a clear view through the center of the
intervertebral disc space, with individual vertebral endplates superimposed.
• The cortices at the posterior and anterior margins of the vertebral body should
also be superimposed.
• The imaging factors selected must produce an image density sufficient for
diagnosis from T12 to L5/S1, including the spinous processes.
• Extreme care must be taken if using the automatic exposure control. The
chamber selected must be directly in line with the vertebrae, otherwise an
incorrect exposure will result.
• If a manual exposure is selected, them a higher exposure will be required than
with a supine lateral. This is due to the effect of gravity on the internal organs,
causing them to lie either side of the spine.
LATERAL FLEXION AND EXTENSION

• Lateral projections in flexion and extension

may be requested to demonstrate mobility
and stability of the lumbar vertebrae.
 POSITION OF PATIENT AND
CASSETTE
• This projection may be performed supine, but it is most commonly performed erect
with the patient seated on a stool with either side against the vertical Bucky.
• A seated position is preferred, since apparent flexion and extension of the lumbar
region is less likely to be due to movement of the hip joints when using the erect
position.
• The dorsal surface of the trunk should be at right-angles to the cassette and the
vertebral column parallel to the cassette.
• For the first exposure the patient leans forward, flexing the lumbar region as far as
possible, and grips the front of the seat to assist in maintaining the position.
• For the second exposure the patient then leans backward, extending the lumbar
region as far as possible, and grips the back of the seat or another support placed
behind the patient.
• The cassette is centered at the level of the lower costal margin, and the exposure is
made on arrested expiration.
DIRECTION AND CENTERING OF THE X-RAY BEAM

• Direct the central ray at right-angles to the film and

towards a point 7.5 cm anterior to the third lumbar
spinous process at the level of the lower costal margin.
ESSENTIAL IMAGE
CHARACTERISTICS
• The image should include T12 downwards, to include the lumbar
sacral junction.
• Ideally, the projection will produce a clear view through the center of
the intervertebral disc space, with individual vertebral endplates
superimposed.
• The cortices at the posterior and anterior margins of the vertebral
body should also be superimposed.
• The imaging factors selected must produce an image density
sufficient for diagnosis from T12 to L5/S1, including the spinous
processes.
All of the area of interest must be included on both projections.
COMMON FAULTS AND REMEDIES
• Extreme care must be taken if using the automatic exposure control.
The chamber selected must be directly in line with the vertebrae,
otherwise an incorrect exposure will result.
• If a manual exposure is selected, a higher exposure will be required
than with a supine lateral. This is due to the effect of gravity on the
internal organs, causing them to lie either side of the spine.
• A short exposure time is desirable, as it is difficult for the patient to
remain stable.
RIGHT OR LEFT POSTERIOR OBLIQUE

• These projections demonstrate the pars interarticularis

and the apophyseal joints on the side nearest the
cassette. Both sides are taken for comparison.
Technical Factors

• Minimum SID is 40 inches (102 cm).

• IR size—two each 30 × 35 cm (11 × 14 inches), or 24 × 30 cm (10 × 12
inches), lengthwise
• Grid
• Analog—75 to 85 kV range
• Digital systems—85 to 95 kV range
POSITION OF PATIENT AND
CASSETTE
• The patient is positioned supine on the Bucky table and is then
rotated 45 degrees to the right and left sides in turn. The patient’s arms
are raised, with the hands resting on the pillow.
• The hips and knees are flexed and the patient is supported with a 45-
degree foam pad placed under the trunk on the raised side.
• The cassette is centered at the lower costal margin.
DIRECTION AND CENTRING OF THE X-RAY BEAM
• Direct the vertical central ray towards the midclavicular line on the
raised side at the level of the lower costal margin.
ESSENTIAL IMAGE
CHARACTERISTICS
• The degree of obliquity should be such that the posterior elements of
the vertebra are aligned in such as way as to show the classic ‘Scottie
dog’ appearance (see diagram).
RADIOLOGICAL CONSIDERATIONS
• A defect in the pars interarticularis can be congenital or due to
trauma. It is a weakness in the mechanism that prevents one vertebra
slipping forward on the one below (spondylolisthesis) and can be a
cause of back pain. If bilateral, a spondylolisthesis is more likely. The
defect appears as a ‘collar’ on the ‘Scottie dog’, hence the importance
of demonstrating the ‘dog’.
COMMON FAULTS AND REMEDIES

• A common error is to centre too medially, thus excluding the

posterior elements of the vertebrae from the image.
LUMBOSACRAL JUNCTION
-LATERAL
• Technical Factors
• Minimum SID is 40 inches (102 cm).
• IR size—18 × 24 cm (8 × 10 inches), lengthwise
• Grid
• Analog—85 to 95 kV range
• Digital systems—90 to 100 kV range
• Lead mat on tabletop behind patient
 LUMBO-SACRAL JUNCTION

LATERAL
POSITION OF PATIENT AND CASSETTE
• The patient lies on either side on the Bucky table, with the arms raised
and the hands resting on the pillow. The knees and hips are flexed slightly
for stability.
• The dorsal aspect of the trunk should be at right-angles to the cassette.
This can be assessed by palpating the iliac crests or the posterior superior
iliac spines.
• The coronal plane running through the centre of the spine should
coincide with, and be perpendicular to, the midline of the Bucky.
• The cassette is centred at the level of the fifth lumbar spinous process.
• Non-opaque pads may be placed under the waist and knees, as
necessary, to bring the vertebral column parallel to the cassette.
DIRECTION AND CENTRING OF THE X-RAY BEAM
• Direct the central ray at right-angles to the lumbo-sacral region and
towards a point 7.5 cm anterior to the fifth lumbar spinous process.
This is found at the level of the tubercle of the iliac crest or midway
between the level of the upper border of the iliac crest and the anterior
superior iliac spine.
• If the patient has particularly large hips and the spine is not parallel
with the tabletop, then a five-degree caudal angulation may be
required to clear the joint space.
ESSENTIAL IMAGE
CHARACTERISTICS
• The area of interest should include the fifth lumbar vertebra and the
first sacral segment.
• A clear joint space should be demonstrated.
RADIATION PROTECTION
• This projection requires a relatively large exposure so should not be
undertaken as a routine projection. The lateral lumbar spine should be
evaluated and a further projection for the L5/S1 junction considered if
this region is not demonstrated to a diagnostic standard.
 LUMBO-SACRAL JUNCTION

ANTERO-POSTERIOR
• The lumbo-sacral articulation is not always demonstrated well on the
antero-posterior lumbar spine, due to the oblique direction of the
articulation resulting from the lumbar lordosis. This projection may be
requested to specifically demonstrate this articulation.
Technical Factors
• Minimum SID is 40 inches (102 cm).
• IR size—18 × 24 cm (8 × 10 inches), crosswise
• Grid
• Analog: 80 to 85 kV range
• Digital Systems: 90 to 100 kV range
POSITION OF PATIENT AND CASSETTE
• The patient lies supine on the Bucky table, with the median sagittal plane
coincident with, and perpendicular to, the midline of the Bucky.
• The anterior superior iliac spines should be equidistant from the
tabletop.
• The knees can be flexed over a foam pad for comfort and to reduce the
lumbar lordosis.
• The cassette is displaced cranially so that its centre coincides with the
central ray.
DIRECTION AND CENTRING OF THE X-RAY BEAM
• Direct the central ray 10–20 degrees cranially from
the vertical and towards the midline at the level of the
anterior superior iliac spines.
• The degree of angulation of the central ray is normally
greater for females than for males and will be less for
a greater degree of flexion at the hips and knees.
ESSENTIAL IMAGE CHARACTERISTICS
• The image should be collimated to include the fifth lumbar
and first sacral segment.
RIGHT OR LEFT POSTERIOR
OBLIQUE
• These projections demonstrate the pars interarticularis and the
apophyseal joints on the side nearer the film.
POSITION OF PATIENT AND
CASSETTE
• The patient is positioned supine on the Bucky table and is then
rotated to the right and left sides in turn so that the median sagittal
plane is at an angle of approximately 45 degrees to the tabletop.
• The hips and knees are flexed and the patient is supported with 45-
degree foam pads placed under the trunk on the raised side.
• The cassette is displaced cranially at a level to coincide with the
central ray.
ESSENTIAL IMAGE
CHARACTERISTICS
• The posterior elements of L5 should appear in the ‘Scottie dog’
configuration
COMMON FAULTS AND REMEDIES
• A common error is to centre too medially, thus excluding the
posterior elements of the vertebrae from the image.
• 1. Body of vertebra
• 2. Facet joint
• 3. Inferior articular process
• 4. Intervertebral disc
• 5. Intervertebral foramen
• 6. Lamina of vertebral arch
• 7. Pedicle
• 8. Sacroiliac joint
• 9. Spinous process
• 10. Superior articular process
• 11. Transverse process
REFERENCES
• CLARK’S POSITIONING IN RADIOGRAPHY
• TEXTBOOK OF RADIOGRAPHIC POSITIONING AND RELATED ANATOMY,
EIGHTH EDITION
• Radiographic Anatomy and Interpretation of the Musculoskeletal
System Editors Harald Ostensen M.D. Holger Pettersson M.D.