X-RAY OF THE COCCYX | AP AXIAL PROJECTION

When performing x-ray examination of the coccyx in ap axial projection, pathology and fractures of coccyx is demonstrated.

Note: The urinary bladder should be emptied before the procedure begins. Also patient may require to take a cleaning enema as ordered by the doctor to remove fecal material and gas in the colon.

Technical Factors:

  • Image receptor size - 24 x 30 cm or 10 x 12 inches film used. Lengthwise
  • Moving or stationary grid
  • 75 to 80 kV range or 85 to 90 kV but mAs is reduced.
  • mAs for 80 kV is 15 and 90 kV is 8.

Use of Shielding:

x ray coccyx
AP Coccyx 10° Caudad
  • For male patient use of gonadal shielding.
  • Ovarian shielding for females
  • Use of shielding in females is not possible without obscuring the area being examined.

Patient and Part Positioning:

  • Patient is in supine position, provide pillow for head support and legs are extended, with support under knees for patient comfort.
  • Midsagital plane is align to table or grid.
  • Ensure that the pelvis is not rotated.

Central Ray, Collimation and Respiration:

  • Angulate centeral rat 10° caudad towards the feet, to enter 2 inches in the upper symphysis pubis.
  • Image receptor is align to center ray.
  • SID of 40 inches used.
  • The four side of area of interest is well collimated.
  • Suspend breathing on expiration.

Notes: Increase central angle to 15° caudad if the curvature of the anterior coccyx is greater. palpation or as evidence on the lateral.
This may also be done in prone position if necessary to patient condition, in 10° cephalad angle.
Center central ray to coccyx by localizing the greater trochanter.

Radiographic Criteria | X-ray of Coccyx:


coccyx radiograph with labelAnatomy and Structure Shwown:

  • Coccyx free of self-superimposition and superimposition of symphysis pubis.

Patient Positioning:

  • Correct coccyx and central ray alignment demonstrate coccyx free of superimposition and projected superior to pubis.
  • Coccygeal segments should appear open on radiograph, if not they may be fused, or an increase on central ray angulation. (the greater the curvature of the coccyx, the greater is the angulation needed).
  • Coccyx should appear equal distant from lateral walls of the pelvic opening, this is an indication of correct positioning and no patient rotation.

Collimation, Central Ray and Exposure Factors:

  • The coccyx should be in the middle of collimated field or in the radiograph.
  • Optimal density and contrast demonstrate the coccyx.
  • Sharp bony margins indication of no motion.

SHOULDER X-RAY INTERNAL ROTATION - HERMODSSONS METHOD

Hermodsson's Method is an x-ray examination on shoulder view in internal rotation. The patient is in supine position with the humerus is horizontal to the table. The arm is adducted to side of the patient the humerus is internally rotated by 45° with forearm lies accross the anterior trunk. Central ray is angled 15° toward the feet and centered over the humeral head.

SACRUM X-RAY AP AXIAL PROJECTION

X-ray examination of the sacrum taken in AP axial projection, the Pathology and disease of sacrum is demonstrated.

Note: The urinary bladder should be emptied before this procedure begins. Also desirable is to have the lower colon free of gas and fecal material which may require a cleaning enema, as ordered by a doctor.

Technical Factors:

  • Cassette size - 24 x 30 cm or 10 x 12 inches, lengthwise
  • Moving or stationary grid
  • 75 to 80 kV range, mAs 15 (85 to 90 kV and reduction to mAs 8)

Shielding:

  • Use gonadal shielding for males. Ovarian shielding o females is not possible without obscuring area of interest.

Positioning of Patient:

sacrum xray
Sacrum Ap Axial
  • Align mid-sagittal plane to CR and midline of table or gird.
  • Ensure no rotation of pelvis exist.

Central Ray:

  • CR angled 15° cephalad, to enter 2 inches or 5 cm superior to pubic symphysis.
  • IR centered to projected CR
  • SID is 40 inches (100 cm)

Collimation:

  • Close four-sided collimation to area of interest.

Respiration:

  • Suspend respiration on expiration.

sacrum radiograph ap axialNote:Radiologic Technologist may require to increase centeal ray angle to 20° cephalad for patients with an apparent greater posterior curvature or hit of the sacrum and pelvis.

The sacrum of the female patients is usually shorter and wider than the males sacrum ( a consideration in close four- sided collimation.)

This sacral x-ray can also be performed in patient prone position with an angulation of 15° caudad necessary to patient condition.

Sacral X-ray Radiographic Criteria:

In Sacral x-ray structure shown should be a nonforeshorted AP projection of sacrum,the Sacroilliac joint and Lumbar 5 to Sacral 1 junction.
If proper patient position indicating no rotation of pelvis, the lower part of the sacrum should be centered in the pelvic opening.
Foreshortening and the pubis and sacral foramina should not be superimposed for correct alignment of sacrum and the central ray.

HYPEREXTENDSION AND HYPERFLEXION LATERAL POSITION | SPINAL FUSION SERIES

Pathology Demonstration:

  • Projection is used to asses mobility at a spinal fusion side.
  • Two images are taken with the patient in the lateral position, - one in hyperflexion and hyperextended.
    Right and left bending positions also are generally part of a spinal fusion series and are the same as for the scoliosis series.
spinal fusion series hyperflexion
Hyperflexion Position

Technical Factors:

  • Film size - 35 x 43 cm (14 x 17 inches)
  • Stationary or moving grid.
  • 85 to 95 kV range, and put lead mat behind patient if recumbent.
  • Extension and flexion markers.
  • mAs 50

Shielding:

  • Place lead contact shield over gonads without obscuring area of interest.

Patient Position:
Hyperextension spinal fusion
Hyperextension Position

  • Position patient in lateral recumbent position, with pillow for head and support between knees. (see notes if patient is in erect position.)
  • Place lower edge of IR 1 to 2 inches, below the iliac crest.

Part Position:

  • The midcoronal plane is align in the center of the grid.

Hyperflexion Positioning:

  • Using pelvis as fulcrum (pivot point), let patient to assume fetal position (bending forward) and draw legs up as far as possible.

Hyperextension Positioning:

  • Using pelvis as fulcrum, ask patient to move torso and legs posteriorly as far as possible to hyperextend long axis of body.
  • Ensure that no rotation of thorax or pelvis exists.

Central Ray:

  • Direct CR perpendicular to IR.
  • Center CR to site of fusion if known or to center of IR.
  • SID is 40 inches.

Spinal fusion series hyperflexion
Hyperflexion lateral

Collimation:

  • Four - sided collimation to area of interest.

Respiration:

  • Suspend breathing on expiration.

Notes: Projection also may be done with patient standing erect or sitting on a stool, first leaning
forward as far as possible, gripping the stool legs, then leaning backward as far as possible, gripping the back of the stool to maintain this position.
The pelvis must remain as stationary as possible during positioning. The pelvis acts as a fulcrum (pivot point) during changes in position.

Radiographic Criteria Spinal Fusion Series:

Structure Shown:

Spinal Fusion series hyperextension radiograph
Hyperextension
  • A lateral view of the lumbar vertebrae in hyperflexion and hyperextension.

Position:

  • True lateral position of patient is indicated by superimposed posterior vertebrae bodies.

Collimation and CR:

  • Vertebral column and contrast clearly demonstrate lumbar vertebrae and intervertebral joint spaces.
  • Sharp bony margins indicate no motion.

RIGHT OR LEFT BENDING SCOLIOSIS SERIES | SPINAL FUSION SERIES : AP OR PA

Pathology Demonstrated:

  • The range of motion of the vertebral column is assessed.

Technical Factor:

  • Cassette size is 35 x 43 cm (14 x 17 inches), lengthwise, or 35 x 92 cm or 14 x 56 inches film.
  • Moving or stationary grid.
  • Erect markers for erect patient position.
  • Use of compensating filters to help obtain a more uniform density along the vertebral column.
  • kV 80
  • mAs 15

Shielding:

Right and left bending scoliosis x ray
AP Right Bending
  • Place lead shielding over gonads without obscuring area being examine.

Patient Position:

  • Patient can erect or lying (recumbent) as an AP or PA with its arm on side.

Part Position:

  • Midsagittal plane is align or centered to cassette or table.
  • Ensure no rotation of pelvis area and torso if possible.
  • The lower part of cassette must be 1 to 2 inches below iliac crest.
  • With the pelvis acts as a fulcrum, ask patient to bend laterally, as far as possible to either side.
  • If patient is in lying position, move both the upper torso and the legs to achieve maximum lateral flexion.
  • Repeat above steps when doing opposite side.

Central Ray:

  • CR perpendicular, and directed to center of cassette or image receptor.
  • SID of 40 to 60 inches, and longer SID for larger film used (35 x 90 cm) to acquire adequate collimation.

Collimation:

  • Four- sided collimation to near borders of image receptor, and donot cut any portion of vertebrae column.

Respiration:

  • Suspend respiration on expiration.

Note: The pelvis must remain as stationary as possible during positioning, Pelvis acts as fulcrum (pivot point) during changes in position.
Radiograph may be done as PA projection if taken erect, to significantly reduce exposure to radiation-sensitive organs.

Radiographic Criteria | Right or Left Bending Scoliosis Series | Spinal Fusion Series


Structure Shown:

  • An AP or PA projection of the thoracic and lumbar spine, with the patient in lateral position; minimum of 2.5 cm of the iliac crests is visible on the image.

Scoliosis series spinal fusion series
AP Right Bending

Position:

  • Thoracic and lumbar vertebrae should be demonstrated in lateral flexion (bending to the left and right)
  • Rotation of pelvis or thorax may be seen because scoliosis often is accompanied by rotation of involved vetebrae.

Collimation and Central Ray:

  • Vertebral column should be in the middle of the image or collimated field.

Exposure Criteria:

  • Optimal density and contrast help to clearly demonstrate the lumbar and thoracic vertebrae.
  • A compensating filters may be useful for obtaining uniform density along the vertebral column.
  • Sharp bony margins indicate no motion.

FERGUSON METHOD (PA / AP PROJECTION) | SCOLIOSIS SERIES

Pathology Demonstrated on Perguson Method

  • This method demonstrates different deforming primarily curve from compensatory curve.
  • Two images must be done in performing this method. The standard is in patient in erect AP or PA and the one is with foot or hip on the convex side of the elevated curve.

Technical Factors:

  • Cassette size 35 x 43cm or 14 x 17 inches, put in lengthwise,
  • 35 x 92 cm or 14 x 36 inches may also be used if available.
  • Moving or stationary grid
  • Erect marker
  • Compensating filters for uniformity of image and density along vertebral area.
  • SID 60 inches or 152 cm
  • kV 90
  • mAs 25
Perguson method
PA Projection without elevation

Use of Shielding:

  • Place lead shielding over gonads without obscuring the area being expose, breast shield for young female patients.


Patient Position:

  • Position patient, either seated or erect, and arms on side.
  • For 2nd image, put block under the patients foot or in hips if the patient is seated on the curve side so that the patient can barely maintain position without assistance.
  • If 3 to 4 inches block is available place it under the patients buttocks if patient is seated and under its foot if standing.

Part Position:

  • Mid-sagittal plane and cassette must be aligned with patient arms on side.
  • No rotation of torso or pelvis as possible.
  • A minimum of 1-2 inches of cassette below the iliac crest.

Central Ray:

  • Centeral ray is directed to and perpendicular to center of cassette.
  • SID is 40 to 60 inches, if IR is longer, longer SID is required to obtain adequate collimation if a 14 x 36 inches film is used.

Collimation:

  • Collimate on four sided area of interest.

Respiration:

  • Suspend respiration on expiration.

Note: compression band is not required on this method. For 2nd image, place block support under the patient foot on curve side unassisted.
PA projection should be done for radiographs, to reduce patient exposure to rediation sensitive area like thyroid and breast.

Radiographic Criteria | Ferguson Method


Structure Shown:

Ferguson method radiograph
PA projection WITH HIP ELEVATED
  • All thoracic and lumbar vertebrae should be demonstrated.
  • A minimum of 1 inch of iliac crest should be included on the image.

Proper Positioning:

  • Thoracic and lumbar vertebrae should be demonstrated in as true a AP or PA projection as possible.

Collimation and CR:

  • Vertebral column should be in the center of the image or in collimation field.

Exposure Criteria:

  • Optimal density and contrast will clearly demonstrate the lumbar and thoracic vertebrae.
  • A compensating filter may be useful for obtaining uniform density along the vertebral column.
  • Sharp bony margins indicate no motion.

LATERAL POSITON PATIENT ERECT | SCOLIOSIS SERIES

Structure Shown in erct lateral scoliosis series:

  • Spondylolisthesis degree of kyphosis, or lordosis.

Technical Factors:

  • Cassette size 35 x 43 cm (14 x 17 inches), lenghtwise or 35 x 90 cm (14 x 36 inches film if patient is taller.
  • Stationary or moving grid.
  • Erect marker
  • Use of compensating filters to help obtain a more uniform density along the vertebral column.
  • 90 to 100 kV range
  • Technique and dose at 60 inches
  • mAs 50

lateral scoliosis
Lateral projection using 35 x 90 cm or 14 x 36 inch IR

Shielding:

  • Place contact shield or shadow shield over gonads without obscuring area of interest, Use breast shield for younger female patients.

Patient Position:

  • Position patient in erect lateral position with arms elevated, or if unsteady, grasping a support in front. The convex side of the curve is positioned against the cassette.

Part Position:

  • Place pelvis and torso in as true a lateral position as possible.
  • Ensure midcoronal plane is align to body and center of cassette.
  • Lower margin of cassette should be 1 to 2 inches below the iliac crest. Determine by cassette size used and patient size.


Central Ray:

  • Central ray perpendicular, directed to midpoint of cassette.
  • Source to image distance of 40 to 60 inches or 100 to 150 cm; longer SID required in larger image receptor to obtain required collimation.

Collimation:

  • Four side of cassette must be collimated to avoid cut-off of area of interest. Use lateral collimation cautiously to prevent vertebral column cutoff.

Respiration:

  • Suspend respiration on expiration.

Radiographic Criteria in lateral Scoliosis series:

Lateral Using 35 x 90 cm or 14 x 36 inch IR

Structure Shown:

  • Thoracic and lumbar vertebrae are demonstrated in a lateral position.

Position:

  • Thoracic and lumbar vertebrae are in as true a lateral position as possible.
  • Rotation of pelvis and torso are seen because scoliosis generally is accompanied by twisting or rotation of involved vertebrae.

Collimation and CR:

  • Vertebrae column should be in center of collimation field of cassette.
  • A minimum of 1 inch or 2.5 cm of the iliac crest should be included.

Exposure Criteria:

  • Optimal density and contrast demonstrated lumbar vertebrae and thracic verterbrae.
  • A compensation filter is useful for ensuring and even density if a 35 x 90 cm or 14 x 36 inch IR is used.
  • Sharp bony margins indicate no motion.

SCOLIOSIS SERIES X-RAY EXAM IN AP or PA Projection


Pathology Demonstrated when taking scoliosis series in AP or PA:

  • Degree and severity of scoliosis are shown.
  • When taking scoliosis series it is usually taken two AP or PA images for comparison one is in erect position and one is in recumbent patient position.

Technical Factors:

  • Image receptor size is 14 x 17 inches or 35 x 43 cm, cassette is in lengthwise, for taller patients use 35 x 90 cm cassette if available.
  • Moving or stationary grid
  • Compensating filters to obtain a more uniform density along the vertebral column.
  • kV is appropriate for patient size/age, to provide an image of optimal contrast and make patient dose or exposure low.
  • If patient is in erect position use erect makers.
  • SID is 60 inches or 152 cm.
  • If taken in PA use kV 90, mAs 25
  • AP kV 90, mAs 25
Scoliosis series PA projection
PA Projection

Shielding:

  • Shield gonadal region without obscuring area of interest. for younger patients use breast shield. Shadow shield placed on collimator may be used.

Patient Position:

  • The patient position may be erect or recumbent position, and weight evenly distributed on both feet for the erect position.

Part Position:

  • CR and midline of cassette is align to midsagittal plane, with arms at side.
  • Ensure no rotation to torso or pelvis if possible.
  • Scoliosis may result in twisting and rotation of vertebrae, making some rotation unvoidable.
  • Place lower margin of IR a minimum of 1 to 2 inches (3 to 5 cm) below iliac crest. (centering height determined by IR size and or area of scoliosis.

Central Ray:

  • CR perpendicular, directed to midpoint of IR
  • SID of 40 to 60 inches (100 to 150 cm) or longer SID required.
  • with larger IR to obtain required collimation
  •  

Collimation:

  • Collimate on four sides to area of interest. Too narrow a collimation is not recommended on initial image because deformities of adjacent areas of ribs and pelvis also must be evaluated.

Respiration:

  • Suspend breathing on expiration.

Note: A PA rather than an AP projection is recommended because of the significantly reduced dose to radiation-sensitive areas, such as female breast and the thyroid gland. Studies have shown that this projection results in approximately 90% reduction in dosage to the breast.
Scoliosis generally requires repeat examination; over several years for pediatric patients, with emphasis on the need for careful shielding.

Radiographic Criteria in Scoliosis Series AP or PA

Scoliosis

Structure Shown:

  • The lumbar and thoracic vertebrae, as well approximately 2 inches (5cm) of the iliac crest.

Position:

  • Thoracic and lumbar vertebrae are demonstrated in as true an AP projection as possible.
  • Some rotation on pelvis and thorax may be apparent because scoliosis generally is accompanied by twisting or rotation of involved vertebrae.

Collimation and CR:

  • Sufficient density and contrast should demonstrate the thoracic and lumbar vertebrae in their entity.
  • A compensating filter assists in obtaining an even density throughout the length, if a 14 x 36-inch (35 x 90 cm) image receptor is being used.
  • Sharp bony markings indicate no patient motion.

Retrograde Urography - AP Projection

In retrograde urography contrast media or agent are injected to pelvicalyceal system via ureters with the use of catheter. When contrast agent are injected the image improves opacification of the renal collecting system but little physiologic information about the urinary system.


Indications and contraindications on retrograde urography:

Retrograde urography
Patient positioned on table for retrograde urography. modified lithotomy position
Patient who has allergy on iodinated contrast media and have renal insufficiency is indicated for evaluation in retrograde urogram. Because the contrast media is not introduced intravenously, the possible reactions is low.

Examination Procedure:

Retrograde urography are done in specialized aseptic room, this combined urologic-radiologic examination is carefully done under aseptic condition by the urologist, assistance of a nurse and radiographer.
The procedure is performed in a specially equipped cystoscopic-radiographic examining room that, because of its collaborative nature, may be located in the urology department or the radiology department.
The nurse is responsible for the preparation of the instruments and the care and draping of the patient.
One of the radiographer responsibilities is to ensure that the overhead parts of the radiographic equipment are free of dust for the protection of the operative field and the sterile layout.
Retrograde urography
Retrograde Urography in AP projection
Radiographer also positions the patient on the cystoscopic table with knee flexed over the stirrups of the adjustable leg supports. (modified lithotomy position) - true lithotomy position requires acute flexion of the hips and knees.
If a general anesthetic is not used, the radiographer explains the breathing procedure to the patient and checks the patient's position table. The kidneys and the full extend of the ureters in patients of average height are included on a 35 x 43 cm IR when the third lumbar vertebra is centered to the grid.
To make the lumbar less curve elevate thigh, if does not reduce put pillow under patient's head and shoulder so that the back is in contact with the table. Most tables used in cystoscopic-radiography are equipped with an adjustable leg rest to permit extension of the patient's legs for certain radiographic studies.
The urologist then performs catherization of the ureters through a ureterocystoscope, which is a cystoscope with an arrangement that aids insertion of the catheters into the vesicoureteral orifices. After the endoscopic examination, the urologist passes a ureteral catheter well into on or both ureters and leaving the catheters in position, usually withdraws the cystoscope.

AP AXIAL L5 TO S1 PROJECTION: LUMBAR SPINE


Pathology Demonstrated:

  • Pathology of L5 to S1 and the sacroiliac joints is demonstrated.

Technical Factors:

  • IR size 18 x 24 cm (8 x 10 inches), crosswise
  • Moving or stationary grid
  • 80 to 85 kV range
  • mAs 20

Shielding:

    Lumbar X ray L5 - S1
  • Shield gonads without obscuring area of interest. Female ovarian shielding obscures a portion of sacroiliac joints.

Patient Position:

  • Patient should be supine, with pillow for head and legs, extended, with support under knees for comfort.

Part Position:

  • Place arms at side or on chest.
  • Align midsagittal plane to CR and midline of table / grid.
  • Ensure that no rotation of torso or pelvis exist.

Central Ray:

  • Angle CR cephalad, 30° for males to 35°for females.
  • CR should enter at the level of the ASIS centered to the midline of the body.
  • Center IR to projected CR.
  • Minimum SID is 40 inches (100 cm)

Collimation:

  • Close four-sided collimation to area of interest.

Respiration:

  • Suspend breathing during exposure.

Note: Angled AP projection opens L5 to S1 joint.
Lateral view of L5-S1 generally provides more information than the AP projection.
This projection may also be performed prone with caudad angle of CR (increase OID.)

Radiographic Criteria on AP AXIAL L5 to S1 LUMBAR SPINE X-RAY:

Structure Shown:

  • L5 to S1 joint space and sacroiliac joints in AP projection.

Position:

    Lumbar X ray L5 - S1
  • Sacroiliac joints demonstrate equal distance from spine, indicating no pelvic rotation.
  • Correct alignment of CR and L5 to S1 is evidenced by an open joint space.

Collimation and CR:

  • L5 to S1 joint demonstrates in the center of a well-collimated field/IR.

Exposure Criteria:

  • Optimal density and contrast demonstrate the L5 to S1 region and sacroiliac joints.
  • Sharp bony margins indicate no motion.

LATERAL L5 TO S1 POSITION IN LUMBAR SPINE

Pathology Demonstrated:

  • Spondylolisthesis involving L4 to L5 or L5 to S1 and other L5 to S1 pathologies is demonstrated.

Technical Factors:

  • IR size - 18 x 24 cm (8 x 10 inches), lengthwise
  • Moving or stationary grid.
  • 95 to 100 kV range
  • Lead mat on tabletop behind patient
  • mAs 50

Shielding:

  • Shield gonads without obscuring area of interest.

Patient Position:

  • Patient should be in the lateral recumbent position, with a pillow for head and knees flexed. Provide support between knees and ankles to better maintain a true lateral position and ensure patient comfort.

Part Position:

  • Align midcoronal plane to CR and midline of table or grid.
  • Flex knees.
  • Place radiolucent support under waist. see note
  • Ensure that pelvis and torso are in true lateral position.

Central Ray:

  • Direct CR perpendicular to image receptor with sufficient waist support or angles 5° to 8° caudad with less support. see note
  • Center CR 1.5 inches or 4 cm inferior to iliac crest and 2 inches 5 cm posterior to ASIS. Center IR to CR.
  • Minimum SID is 40 inches or 100 cm.

Collimation:

  • Close four-sided collimation to area of interest.

Respiration:

  • Suspend breathing

Note: If waist is not supported sufficiently, resulting in sagging of the vertebral column, the CR must be angled 5° to 8° caudad to be parallel to the interiliac plane (imaginary line between iliac crest)
High amounts of secondary or scatter radiation are generated as the result of the part thickness. Close collimation  is essential, along with placement of lead mat on tabletop behind patient. (This is especially important with digital imaging.)

Radiographic Criteria:


Structure Shown:

  • Open L4 to L5 and L5 to S1 joint space.

Proper Patient Position:

  • No rotation of the patient is evidenced by superimposed AP dimensions of greater sciatic notches of posterior pelvis and superimposed posterior borders of the vertebral bodies.
  • Correct alignment of the vertebral column and the IR and CR is indicated by open L4 to L5 and L5 to S1 joint spaces.

Collimation and CR:

  • L5 to S1 joint space in center of closely collimated field / IR.

Exposure Criteria:

  • Optimal contrast and density should clearly demonstrated the L5 to S1 joint space through the superimposed ilia of the pelvis.
  • Sharp bony margins indicate no motion.

LATERAL POSITION: LUMBAR SPINE

Pathology Demonstrated:

  • Fractures on lumbar spine, spondylolisthesis, neoplastic processes, and osteoporosis of lumbar vertebrae are demonstrated.

Technical Factors:

  • Film size - 35 x 43 cm (14 x 17 inches), lengthwise, or 30 x 35 cm (11 x 14 inches)
  • Moving or stationary grid
  • 85 to 95 kV range
  • Lead mat on table behind patient
  • mAs for female is 50
  • mAs for male is 65

Shielding:

  • Shield gonads without obscuring area of interest.

Patient Position:

    lateral lumbar x ray
  • Position patient lateral recumbent, provide pillow for head, knee flexed, with support between knees and ankles to better maintain a true lateral position and ensure patient comfort.

Part Position:

  • Align midcoronal plane to central and midline of x-ray table or grid.
  • Place radiolucent support under waist as needed to place the long axis of the spine near parallel to the table (palpate the spinous processes to determine see note:)
  • Ensure the pelvis and torso are in true lateral position.

Central Ray:

  • Direct central ray perpendicular to long axis of spine.
  • Larger IR (30 x 35cm): Center to level of iliac crest (L4 - L5). This position includes lumbar vertebrae, sacrum, and possibly coccyx.
  • Center image receptor to central ray.
  • Smaller film (30 x 35 cm): Center to L3 at the level of the lower costal margin. (1.5 inches above iliac crest.) This position includes the five lumbar vertebrae. Center IR to CR.
  • SID is 40 inches or 100 cm.

Collimation:

  • Closely collimate on lateral borders. (Light field appears small because of proximity of the patient to the x-ray tube and the divergence of the x-ray beam.)

Respiration:

  • Suspend breathing on expiration.

Note: Although the average male patient (and some female patients requires no CR angle, a patient with a wider pelvis and a narrow thorax may require a 5° to 8° caudad angle even with support. If patient has a lateral curvature (scoliosis) of the spine (as determined by viewing of the spine from the back with the patient in the erect position and with hospital gown open), patient should be place in whichever lateral position places the "sag" or convexity of the spine, down to better open the intervertebral spaces.

Radiographic Criteria:


Structure Shown:

  • Intervertebral foramina L1 to L4, vertebral bodies, intervertebral joints, spinous processes, and L5 to S1 junction are visible.
  • Depending on the image receptor size used, the entire sacrum also may be included.
    lumbar lateral radiograph

Position:

  • Vertebral column is aligned parallel to the IR, as indicated by the following: intervertebral foramina appearing open; intervertebral joint spaces appearing open;
  • No rotation is indicated by superimposed greater sciatic notches and posterior vertebral bodies.

Collimation and CR:

  • The vertebral column should be centered to the collimated field of IR, at the level of L3.

Exposure Criteria:

  • Optimal density and contrast should clearly demonstrated the vertebral bodies and joint spaces.
  • Sharp bony margins indicate no motion.

OBLIQUES PROJECTION | ANTERIOR OR POSTERIOR OBLIQUE : LUMBAR SPINE

Pathology Demonstrated:

  • Detects of the pars interarticularis like spondylolysis are demonstrated.
  • Both right and left obliques obtained.

Technical Factors:

  • Image receptor size - two 30 x 35 cm or (11 x 14 inches), lengthwise or 24 x 30 cm (10 x 12 inches)
  • Moving or stationary grid
  • 75 to 85 kV range (or 85 to 90 kV and reduction of mAs and dose.)
  • mAs 15 for both anterior and posterior oblique

Shielding:

  • Place contact shield over gonads without obscuring area of interest.
RPO lumbar spine x ray
AP Oblique - RPO

Patient Position:

  • Patient should be semisupine (RPO and LPO or semiprone (RAO and LAO)

Part Position:

  • Rotate body 45° to place spinal column directly over midline of table/grid, aligned to CR.
  • Flex knee to stability and comfort.
  • Support lower back and pelvis with radiolucent sponge to maintain position. (This support is strongly recommended to prevent patients from grasping the edge of the table, which may result in their fingers being pinched.)

Cental Ray:

  • Direct CR perpendicular to image receptor.
  • Center to L3 at the level of the lower costal margins (4 cm or 1.5 inches above iliac crest.
  • Center 2 inches or 5 cm medial to upside ASIS.
  • Center IR to central ray.
  • SID is 40 inches or 100 cm.

Collimation:

  • Four-sided collimation to area of interest.

Respiration:

  • Suspend breathing on expiration.

  • Note: A 50° oblique from plane of tabletop best visualizes the zygapophyseal joint at L1 to L2, and 30 degree for L5 to S1.

Radiographic Criteria:


Structure Shown:

AP Oblique Lumbar spine radiograph
AP Oblique - Scottie Dogs
  • Zygapophyseal joints are visible. (RPO and LPO show downside; RAO and LAO show upside.
  • Scottie dogs should be visualized, and zygapophyseal joint should appear open.

Proper Patient Positioning:

  • Correct 45° patient rotation results in the pedicle (the eye of scottie dog) near the center of the vertebral body on the image.
  • The pedicle demonstrated posteriorly on the vertebral body indicates overrotation, and the pedicle demonstrated anteriorly on the vertebral body indicates underrotation.

Collimation and Central Ray:

  • The vertebral column should be in the midline of the collimated field / IR, which is centered to L3.

Exposure Criteria:

  • Optimal density and contrast clearly demonstrate zygapophyseal joint from L1 to L5.
  • Sharp bony margins indicate no motion.

AP or PA Projection in Lumbar Spine X-ray

Pathology Demonstrated:

  • Pathology of the lumbar vertebrae, including fractures, scoliosis, and neoplastic processes, is demonstrated in this projection.

Technical Factor:

  • IR size - 35 x 43 cm (14 x 17 inches), lengthwise, or 30 x 35 cm (11 x 14 inches)
  • Moving or stationary grid
  • 75 to 80 kV range (or 80 to 92 kV and reduce of mAs and dose.)
  • if in AP position at 80 kV mAs is 15
  • if in AP Position at 92 kV mAs is 8
  • and if in PA at 92 kV mAs is 8.

Patient Shielding:

lumbar spine x ray
AP Lumbar Spine
  • Place the gonadal shielding in the gonads area without obscuring the part or area of interest.
  • When using a female ovarian shielding it obscures portions of sacrum and coccyx.

Patient Position:

  • Let patient in supine and slightly flex the knee and put pillow on head for patient comfortability. It may also be done in prone or standing position. see note.

Part Position:

  • Midsagital plane is align to central ray and in the midline of table or bucky.
  • Put arm on chest or at the side.
  • Ensure that no rotation of torso or pelvis exist.

Central Ray:

  • Direct the central ray perpendicular to image receptor to following:
  • If large image receptor used (35 x 43): Center to level of illiac crest between L4-L5 interspace. This large image receptor will include the lumbar vetebrae, sacrum, and possibly coccyx.
  • If smaller image receptor 30 x 35: Center central ray to level of L3, it can be palpated to the local costal margin ( 1 1/2 inches or 4 cm above the iliac crest.) Small image receptor will include primary the five lumbar vertebrae.
  • Minimum SID is 40 inches or 100 cm.

Collimation:

  • Four-sided collimation with superior and inferior borders to near IR margins.


Patient Respiration:

  • Let patient suspend breathing on expiration when exposing.

Note: Partial flexion of knees as shown straighten the spine, which help to open intervertebral disk spaces.
Radiograph may done prone as a PA projection, which places the intervetebral spaces more closely parallel to the diverging rays.
The erect position may be useful for demonstrating the natural weight bearing stance of the spine.

Radiographic Criteria:

Structure Shown:

  • Lumbar vertebral bodies, intervertebral joints, spinous and transverse processes, SI joints, and sacrum are shown.
  • 35 x 43 cm or 14 x 17 inches film. Approximately T11 to the distal sacrum should be included.
  • 30 x 35 cm or 11 x 14 inches film. T12 to S1 should be included.
lumbar spine radiograph

Patient Positon:

  • No patient rotation is indicated by the following:
  • SI joint id equidistant from spinous processes.
  • Spinous processes in midline of vertibral column.
  • R and L transverse processes in equal in length.

Collimation and Central Ray:

  • The vertebral column should be centered to the IR / collimated field, at the approximate level of L3 - L4.
  • Lateral margins of collimated field should include the SI joints and psoas muscles.

Exposure Criteria:

  • Optimal density and contrast should demonstate the lumbar vertebral bodies, intervertebral disk spaces, transverse processes, and psoas muscle.
  • Sharp bony margins indicate no motion.

Colostomy Barium Enema

What is Colostomy?

Colostomy is the surgical formation of an artificial or surgical connection between to two portion of the large intestine.
colostomy prepIf a colon has disease, tumor, or inflammatory processes, a section of a large intestine may have been removed or altered. In common cases, because of tumor in the sigmoid colon, or rectum, this part of lower intestine is removed. The terminal end of intestine then is brought to the anterior surface of the abdomen, where an artificial opening is created. This artificial opening is termed a stoma.

In some cases, a temporary colostomy is performed to allow healing of the involved section of large intestine. The involved region is bypassed through the use of colostomy. Once the healing are complete, the two sections of the large intestine are reconnected.
Fecal matter then is discharge from the body via the stoma into the appliance bag that is attached to the skin over the stoma.
Once is healing is complete, an anastomosis (reconnection ) of the two sections of the large intestine is performed surgically. For select patients, the colostomy is permanent because of the amount of large intestine removed or other factors.

Purpose of Colostomy

The purpose of colostomy barium enema is to assess for proper healing, obstruction or leakage or to perform a presurgical evaluation. Sometimes, in addition to the colostomy barium enema, another enema may be given rectally at the same time. This type of study evaluates the terminal large intestine before it is reconnected surgically.


Colostomy Patient Preparation:


If the barium enema is used for nonacute reasons, the patient is asked to irrigate the ostomy before under going the procedure. The patient may be asked to bring an irrigation device and additional appliance bags. The patient should follow the same dietary restriction as are required for the standard barium enema.

Procedure on Colostomy:

Barium sulfate remain the contrast media of choice. A single or double-contrast media procedure may be performed as with any routine barium enema. Iodinated, water-soluble contrast media may be used if indicated. The colostomy barium enema requires that the contrast media take a different route through the stoma. As a result of bowel resection, anatomic structures and landmarks often are altered. The radiologic technologist must observe the anatomy during fluoroscopy to plan for alterations in the positioning routine. Before the resected bowel is reattached (thus eliminating the need for the colostomy), barium may be delivered though both the stoma and the rectum during the procedure to ensure that healing is complete. Finally, the radiologic technologist should have a clean appliance bag available for the postevacuation phase of the study. Some patients are unable to use the restroom.

LEFT ANTERIOR OBLIQUE | BARIUM ENEMA

Pathology Demonstrated:

  • Obstruction, including ileus, volvulus, and intusseception, often are demonstrated, Double-contrast media barium enema is ideal for demonstrating diverticulosis, polyps, and mucosal changes.

Technical Factors:

  • Image receptor size - 35 x 43 cm (14 x 17 inches), lengthwise
  • Moving or stationary grids
  • 100 to 125 kV range single-contrast study
  • 90 to 100 kV range for double-contrast study
  • 80 to 90 kV range for iodinated, water soluble contrast media.
  • mAs 4

Shielding:

  • Place lead shield over gonads only if possible without covering pertinent anatomy.

Patient Position:

  • Patient is semiprone, rotated into a 35° to 45° left anterior oblique, with a pillow for the head.

Part Position:

  • Align MSP along long axis of table, with right and left abdominal margins equidistant from center line of table and CR.
  • Place right arm up on pillow, with left arm down behind patient and right knee partially flexed.
  • Check posterior pelvis and trunk for 35° to 45° rotation.

Central Ray:

  • CR is perpendicular to IR, directed to a point about 1 inch or 2.5 cm to the right of MSP.
  • Center CR and IR to 1 to 2 inches (2.5 to 5 cm) above iliac crest. see note.
  • Center cassette to central ray.
  • Minimum SID is 40 inches (100 cm)

Collimation:

  • Collimate on four sides to outer margins of IR.

Respiration:

  • Suspend respiration and expose on expiration.

Note: Most adult patient requires about 2 inches (5cm) higher centering to include the left colic flexure, which generally cuts off the lower large bowel: then a second image centered 2 to 3 inches (5 to 75 cm) lower is required to include the rectal area.

Radiographic Criteria:

Structure Shown:

  • The left colic flexure should be seen as open without significant superimposition.
  • The decending colon should be well demonstrated.
  • The entire large intestine should be included (see notes)

Position:

  • Spine is parallel to the edge of radiograph (unless scoliosis is present). Ala of right ilium is elongated if visible, whereas the left side is foreshorted and the left colic flexure is seen in profile.

Collimation and CR:

  • Only minimal collimation margins seen on all four sides for adults.
  • CR is centered at level of iliac crest  to include entire left colic flexure.

Exposure Criteria:

  • Appropriate technique should visualize the contrast-filled large intestine without significant overexposure of any portion.
  • Sharp structural margins indicate no motion.

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