Radiographic Positioning of the Lumbar Spine and Abdomen

A-P Lumbar

PREPARE THE ROOM
Cassette:	black, 14" x 17", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	80 kVp, large focal spot
Measure:	through central ray
Filter/shield:	gonad; place bottom of Velcro belt at greater trochanter of femurs.
This should place the bottom of the belt at the symphysis pubis.
	Female use Cu heart, bottom of heart at bottom of belt. Directly above the symphysis pubis.
	Male - use Pb triangle, top of triangle at bottom of belt directly below the symphysis pubis.

PREPARE THE PATIENT
An enema will significantly improve visualization in the pelvic bowl. It should be
administered immediately before the radiographic examination.

Position:	Patient is fully gowned with no jewelry (ask about belly button ring),
bra, metal fasteners on underwear, etc.
Patient is standing (preferred) or supine (especially if large) with midsagittal plane centered to bucky.
Standing comfortably with weight evenly distributed on both feet.
Arms hanging comfortably at side.
Central ray:	1" superior to iliac crests in midline. Top of film at xiphoid process.
Collimation:	Open to full cassette vertically, side-to-side to include TP's (about to the edge of the cross).
Marker:	R or L.

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Hold still,
don't move" - expose.
	Expose on suspended respiration.

EVALUATION CRITERIA: A-P Lumbar
	T11  through the sacrum should be clearly seen.
	SI joints should be equidistant from the spine, spinous processes should be in midline of vertebral bodies, and R and L transverse processes should be about equal in length, all indicating no rotation.
	The lateral margin should include the psoas muscle shadow.
	Optimum exposure should demonstrate both bone and soft tissue density.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

Radiographic Positioning #5822	                         20	                                           last updated; May, 99
Radiographic Positioning of the Lumbar Spine and Abdomen

Lateral Lumbar

PREPARE THE ROOM
Cassette:	black, 14" x 17", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	90 kVp, large focal spot
Measure:	at the level of the ASIS
Filter/shield:	gonad; Nolan system, use lateral lumbar shield (half circle) at level of ASIS

PREPARE THE PATIENT
An enema will significantly improve visualization in the pelvic bowl. It should be administered immediately before the radiographic examination.

Position:	Patient is fully gowned with no jewelry (ask about belly button ring),
bra, metal fasteners on underwear, etc.
Patient is standing (preferred) or supine (especially if large) with midcoronal plane centered to bucky, and left side closest to the bucky.
(If patient is scoliotic place convexity to film side).
Standing comfortably with weight evenly distributed on both feet.
Arms folded on chest, elevate elbows.
Central ray:	Horizontal portion 1" superior to iliac crests in coronal plane, vertical portion of CR approximately through the greater trochanter of the femur.
Collimation:	Open to full cassette vertically, front-to-back to include SP's.
Marker:	L (or R).

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Hold still, don't move” expose.
•	Expose on suspended respiration.

EVALUATION CRITERIA: Lateral Lumbar
	T11 through the sacrum should be clearly seen in lateral profile and centered to the film.
	The lumbar intervertebral foramina should be visualized.
	Optimum exposure should demonstrate both cortical and trabecular bone densities of the vertebral bodies.
	Lumbar spinous processes should be visualized.
	Patient identification and L (or R) marker should be clearly visible without blocking anatomy.

Radiographic Positioning #5822	          21                                  	last updated: May, 99
Radiographic Positioning of the Lumbar Spine and Abdomen

Ferguson's A-P L5/S1 Spot Shot

PREPARE THE ROOM
Cassette:	black, 10" x 12", crosswise (wide, flash up)
Tube:	40" FFD, 35 tube tilt (approx.), lower tube to 33" from bucky.
	To be precise, measure the actual angle on the lateral L/S and use this.
	Subtract 100 if performing radiograph supine.
	when the tube tilt is 20 or greater, move the tube 1" closer to the film
	for every 5 of tube tilt.
Technique:	80 kVp, large focal spot
Measure:	through central ray at the appropriate angle.
	Approximately 2X mAs from A-P lumbar.
Filter/shield:	gonad for males, lay lead vinyl across the groin. For females can't use shielding

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry (ask about belly button ring),
bra, metal fasteners on underwear, etc.
Patient is supine (preferred) or standing with midsagittal plane centered to table, place arms at side or folded upon chest.
Can place foam block under knees and pillow under head to make patient more comfortable.
Central ray:	Passes 1" below the transverse plane connecting the ASIS at appropriate angle, center the cassette to the central ray.
Collimation:	Open to cross both vertically and laterally (approx. 6" square).
Marker:	R or L.

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Hold still,
don't move" - expose.
	Expose on suspended respiration.

EVALUATION CRITERIA: Ferguson's A-P L5/Sl Spot Shot
	L5/S1 joint space should be clearly seen and in center of exposure field and film.
	S1 joints should be equidistant from spine, spinous processes should be in midline of vertebral bodies, R and L transverse processes should be about equal in length, all indicating no rotation.
	Optimum exposure should demonstrate both bone and soft tissue densities.
	Patient identification and R or L marker should be clearly visible without blocking anatomy.

Radiographic Positioning #5822	           22	                                     last updated: May, 99
Radiographic Positioning of the Lumbar Spine and Abdomen

R or L Posterior Oblique

PREPARE THE ROOM
Cassette:	black, 11" x 14", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	80 kVp, large focal spot
Measure:	through central ray
Filter/shield:	gonad (Pb vinyl or ½ apron)

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry (ask about belly button ring),
bra, metal fasteners on underwear, etc.
Patient is supine (preferred) or standing at 45 angle with foam wedge block supporting shoulder and pelvis that are off the table. Place arms across chest out of collimated field.
LPO has left side closest to film and RPO has right side closest.
Central ray:	1" above level of iliac crest passing through vertebral bodies (about 2" medial to ASIS).
Collimation:	Open to full cassette vertically, side-to-side to area of interest.
Marker:	RPO or LPO preferred. Place marker in front of the spine.
R or L with 2 rules to follow.
	Right means right and left means left.
	Mark the side closest to the film.

EXPOSURE
Patient directions: "Take a deep breath in, blow it all the way out. Hold still,
don't move" - expose.

EVALUATION CRITERIA: R or L Posterior Oblique
	The spinal column from T11 to S1 should be clearly seen and in the midline of the film.
	"Scotty dogs" (zygapophyseal joints, TP's, pedicles, pars interarticularis and lamina of side closest to the film) should be seen on all five L/S vertebra.
	The pedicles ("eye" of the dog) should be seen in the middle of the vertebral body.
	Optimum exposure should demonstrate both bone and soft tissue densities.
	Patient identification and R or L marker should be clearly visible without blocking anatomy.

NOTE:	R and L Anterior oblique visualize side farther away from film but show greater structural detail because the lumbar lordosis compliments the diverging x-ray beam.
For anterior oblique views place marker behind spine.

Radiographic Positioning #5822          	23                                	last updated: May, 99
Radiographic Positioning of the Lumbar Spine and Abdomen

L5/S1 Spot Shot Lateral

PREPARE THE ROOM
Cassette:	black, 8" x 10", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	90 kVp, large focal spot
Measure:	through central ray
Filter/shield:	gonad; Nolan system, use lateral lumbar shield (half circle) at level of ASIS

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry (ask about belly button ring), bra, metal fasteners on underwear, etc.
Patient is recumbent (preferred) or standing with midcoronal plane centered to bucky, and left side closest to the bucky.
Arms folded on chest.
Central ray:	1 "inferior to iliac crests in coronal plane. Middle of the film should be approximately through the greater trochanter of the femur.
Collimation:	Six inch by six inch collimation area.
Marker:	L

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Hold still,
don't move" - expose.
	Expose on suspended respiration.

EVALUATION CRITERIA: L5/Sl Spot Shot Lateral
	L4 through the sacrum should be clearly seen in lateral profile and centered to the film.
	The purpose of this view is to show L5/Sl disc space in lateral projection.
	The lumbar intervertebral foramina at L5/S1 should be visualized.
	Optimum exposure should demonstrate both cortical and trabecular bone densities of the vertebral bodies, and the lumbar spinous processes.
	Patient identification and L marker should be clearly visible without blocking anatomy.

Radiographic Positioning #5822         	24                                	last updated: May, 99
Radiographic Positioning of the Lumbar Spine and Abdomen

Compression Lateral

PREPARE THE ROOM
Cassette:	black, 8" x 10", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	90 kVp, large focal spot
Measure:	through central ray
Filter/shield:	gonad; Nolan system, use sacral shield at level of ASIS

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry (ask about belly button ring),
bra, metal fasteners on underwear, etc.
A 50 pound backpack is placed on patient and patient should then walk for 5 minutes. If pain increases during time, immediately take film.
Patient is standing with midcoronal plane centered to bucky, and left side closest to the bucky (unless scoliotic, then convexity to film side) still wearing backpack.
Patient standing with weight evenly distributed on both feet.
Arms folded on chest.
Central ray:	1 "inferior to iliac crests in coronal plane. Middle of the film should be approximately through the greater trochanter of the femur.
Collimation:	Six inch square area.
Marker:	L (or R).

EXPOSURE
Patient directions; "Take a deep breath in, now blow it all the way out. Hold still, don't move" - expose.
	Expose on suspended respiration.
	Now remove the backpack.

EVALUATION CRITERIA: Compression Lateral
	TI I through the sacrum should be clearly seen in lateral profile and centered to the film.
	The backpack will be seen.
	This view is taken to see if anterolisthesis increases with increases weight bearing.
	The lumbar intervertebral foramina should be visualized.
	Optimum exposure should demonstrate both cortical and trabecular bone densities of the vertebral bodies, and the lumbar spinous processes.
	Patient identification and L marker should be clearly visible without blocking anatomy.

Radiographic Positioning #5822            	25                                	last updated: May, 99
Radiographic Positioning of the Lumbar Spine and Abdomen

Traction Lateral

PREPARE THE ROOM
Cassette:	black, 8" x 10", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	90 kVp, large focal spot
Measure:	through central ray
Filter/shield:	gonad; Nolan system, use lateral lumbar shield (half circle) at level of ASIS

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry (ask about belly button ring),
bra, metal fasteners on underwear, etc.
The patient hangs by their arms from a bar that is suspended over the top of the bucky.
Hang with midcoronal plane centered to bucky, and left side closest to the bucky (unless scoliotic, then convexity to film side). Ideally this will also take place for 5 minutes then expose film while still hanging.
Central ray:	1" inferior to iliac crests in coronal plane. Middle of the film should be approximately through the greater trochanter of the femur.
Collimation:	Six inch square area.
Marker:	L (or R).

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Hold still, don't move" expose.
	Expose on suspended respiration.
•	Now they can stop hanging and stand up.

EVALUATION CRITERIA: Traction Lateral
	T11 through the sacrum should be clearly seen in lateral profile and centered to the film.
	The lumbar intervertebral foramina should be visualized.
	Optimum exposure should demonstrate both cortical and trabecular bone densities of the vertebral bodies, and the lumbar spinous processes.
	Patient identification and L marker should be clearly visible without blocking anatomy.

TRACTION & COMPRESSION LATERAL
	Translation of the spondylolisthetic segment will be compared from the traction to the compression views. If it is greater than 4mm, it is unstable.

Radiographic Positioning #5822         	26                                	last updated: May, 99
Radiographic Positioning of the Lumbar Spine and Abdomen

Kidney, Ureter, Bladder (KUB)

PREPARE THE ROOM
Cassette:	black, 14" x 17", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	70 kVp, large focal spot
Measure:	through central ray
Filter/shield:	gonad
	Female - usually can't be filtered because of obscuring anatomy.
	Male - use Pb triangle

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry (ask about belly button ring),
bra, metal fasteners on underwear, etc.
Patient is supine with knees bent and midsagittal plane centered to table.
If erect KUB is requested to demonstrate air-fluid levels, patient is centered to bucky like in A-P lumbar.
Central ray:	Level with iliac crests (if full vertical collimation will include pubic symphysis).
Collimation:	Open to full cassette vertically, laterally to edge of soft tissues.
Marker:	R just above R iliac crest.

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Hold still,
don't move" - expose.
	Expose on suspended respiration.
	Note: phase of respiration depends on patient height. Small patient suspended expiration, tall patient suspended inspiration.

EVALUATION CRITERIA: KUB
	The lower margin of film should include the superior portion of the arch of the symphysis pubis.
	The upper abdomen should be included visualizing the top of the diaphragm, upper margins of the kidneys as well as the lower portion of the dense liver and the area of the spleen.
	Note: a tall, asthenic person may require 2 radiographs to include both areas listed above.
	No rotation: the vertebral column should be in midline and the iliac wings should be equal in size and shape.
	No motion: should be evidenced by sharp gas bubbles.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

Radiographic Positioning #5822         	27                                	last updated: May, 99