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Merrill's Ch 8

SJC Zerbe Procedures Semester 2 Unit 2

Oh man....Yes!
Functions of the vertebral column Encloses and protects the spinal cord Supports the trunk Supports the skull Provides attachment muscles of back and ribs.
The vertebral column is held together by: ligaments
In childhood the vertebral column consists of how many bones 33 Cervical Thoracic Lumbar Sacrum (separated/5 sacral segments) Coccyx (separated/ 3-5 segments usually 4)
True or movable vertebrae consist of: Cervical Thoracic lumbar
False or fixed vertebrae: Sacrum coccyx
4 anterior/posterior curves of the spine: Lordotic - Cervical & Lumbar – convexed anteriorly Kyphotic – thoracic and pelvic – concaved anteriorly
Lumbosacral angle: Obtuse angle formed by the junction of the lumbar and pelvic curves Steeper curve for females
Primary curves: Present at birth Thoracic and Pelvic
Secondary or compensatory curves: Develop after birth Cervical and Lumbar
Cervical curve develops at what stage of life: Usually 3 to 4 months old Infant begins to hold head up
Lumbar curve develops at what stage of life: 1 to 1 ½ years of age When child begins to walk
A slight lateral curvature is sometimes present in the thoracic region and is considered normal: which way will it curve? To the right in a right handed person To the left in a left handed person
Two main parts of a Typical vertebra Body – anterior mass Vertebral arch – ring-like portion enclosing the vertebral foramen
Vertebral canal Formed by the stacked vertebral foramina of the vertebral arches
Intervertebral disks: Separates the vertebral bodies and form ¼ of the length of the spine
Nucleus Pulposis Central mass of the intervertebral disks
Anulus fibrosus Fibrocartilaginous disk that surrounds the nucleus pulposis
The vertebral arch of the typical vertebra is formed by: 2 pedicles 2 laminae 2 transverse processes 1 spinous process
Pedicles Short, thick processes that project posteriorly from the superior and lateral parts of the posterior surface of the vertebral body.
Vertebral notches Concaved Notches in the superior and inferior surfaces of the pedicles
Intervertebral foramen Opening for the transmission of spinal nerves and blood vessels. Formed by the vertebral notches (superior of one and inferior of another)
Lamina Flat, broad projections extending posteriorly and medially from the pedicles
Transverse Processes Processes that project laterally at the junction of the laminae and the pedicles
Spinous process Process that projects posteriorly and inferiorly from the junction of the laminae Posterior midline
Articular Processes 2 superior and 2 inferior process arising from the junction of the pedicles and laminae
Superior articular process Superior portion of the articular process Has an articular facet on the posterior surface for articulation of the inferior articular process of the vertebra above
Inferior articular process Inferior portion of the articular process Has articular facet on the anterior surface for articulation with the superior articular process of the vertebrae below
Zygapophyseal joints Joint formed by the superior and inferior articular processes of adjacent vertebra
Which vertebra are considered typical cervical vertebra? C3-C6 C7 has the typical structures with the exception of the vertebral prominens
What is the Atlas? C1
What is the Axis? C2
Describe the Atlas Ringlike short spinous process Anterior arch Posterior arch 2 lateral masses2 transverse processes
How do the transverse processes of the atlas differ from the rest of the cervical vertebra? Longer than the others. They projects laterally and slightly inferiorly from the lateral masses
Where are the articular processes of C1? On the lateral masses. Superior is horizontal, large and concaved to receive the occipital condyles Inferior articulates with the superior articular process of C2
What is the atlantal ligament? Extends across the ring of the atlas dividing into anterior and posterior portions. Holds dens anteriorly
What is the Dens Odontoid Process Strong Conical process extending superiorly into the anterior portion of the of the atlas Serves as body or pivot of atlas
Superior articular process of C2 On each side of the dens Articulate with the inferior articular processes of the Atlas
Vertebral Prominens 7th cervical vertebra Similar to typical cervical vertebra except it has a long prominent spinous process the projects almost horizontally. Palpable land mark Level with C7/T1 Interspace
Transverse processes of typical cervical vertebra Arise from the body and arch Short/wide Have transverse foramina for arties and veins
The spinous processes of the typical cervical vertebra Short Double pointed (Bifid) Directed posteriorly and slightly inferiorly Tip is at the level of the interspace below from the body they arise from
Articular Pillars (Cervical spine) Short thick columns formed by the junction of the superior and inferior articular process where the pedicles and laminae unite
Zygapophyseal Joints of C2-C7 Articulation of superior and inferior process Between the articular pillars Lie at right angles to the midsagittal plane Demonstrated on a lateral projection
Cervical Intervertebral foramen Formed by the superior and inferior notches Directed anteriorly at a 45 degree angle from the MSP and 15 degrees inferiorly Demonstrated on AP or PA Oblique Projection of the cervical spine.
Thoracic Vertebral Bodies heart shaped or triangular, Increase in size from 1 to 12 Superior resemble cervical bodies Inferior resemble lumbar bodies
Typical thoracic vertebra T3-T9 Bodies are triangular and deeper posteriorly than anteriorly Posterior bodies have concaved surface Have costal facets for head of ribs (costovertebral joints) Demifacets or whole facets on Thoracic bodies
Transverse processes of thoracic vertebrae Project obliquely, laterally, posteriorly Has facet for articulation with rib tubercle (not 11/12) – costotransverse joints
Thoracic spinous processes 5 to 9 project inferiorly sharply and overlap (Less vertical above and below 5-9) 5th-9th spinous process corresponds in position to the interspace below the vertebrae from origination
Zygapophyseal joints of Thoracic vertebrae: (not T12/L1) Angle anteriorly 15 to 20 degrees and form angle of 70-75 degrees to the MSP Demonstrated on AP/PA oblique
Thoracic Intervertebral Foramen Perpendicular to the MSP Demonstrated on Lateral Projection
Why do the arms need to be raised to right angles from the body for a lateral projection of the thoracic spine To elevate the ribs above the intervertebral foramen
Lumbar vertebral bodies Bean-shaped Increase in size form 1st to 5th
Spinous processes of lumbar vertebra Large, thick, blunt and directed posteriorly at almost horizontal plane Tips align with interspace below from which it arises
Mammillary process Smooth rounded projection on the back of each superior articular process on Lumbar vertebra
Accessory process (spine) Process at the back of the root of the transverse process on lumbar vertebra
Pars Interarticularis Part of the lamina of the lumbar vertebrae between the superior and inferior articular processes
Zygapophyseal Joints of the Lumbar Vertebra Form an angle of 30 to 60 (~ 45) degrees to the MSP Angle increases from L1-L5 Demonstrating lumbar zygapophyseal joints radiographically 45 degree AP Oblique projection demonstrates most average patients 25% L1-2 seen on AP Some L4/5 seen on lateral
Intervertebral Foramen of the lumbar spine Situated at right angles to the MSP (except for 5th, turns anteriorly) Demonstrated on lateral projection
How does the first sacral segment differ from the others? Resembles lumbar vertebra Contains sacral base and sacral promontory Has superior articular process to form zygapophyseal joint with L5
Atlantooccipital Joint Ellipsoidal/freely movable Junction of atlas and occipital condyles
Antlantoaxial Joint Dens and atlas- pivot/freely movable Lateral masses of C1 and Axis – gliding/freely movable
Intervertebral Joints Cartilaginous/symphysis /slightly movable
Zygapophyseal Joints Gliding/freely movable
Costovertebral Joints Gliding/freely movable Head of the rib and facets of the vertebral bodies
Costotransverse Joints Gliding/Freely movable Facets on transverse processes and tubercles of ribs 1-10
Ankylosing spondylitis Rheumatoid arthritis variant involving the sacroiliac joints and spine
Clay Shoveler's Fracture Avulsion fracture of the spinous process in the lower cervical and upper thoracic region
Compression Fracture Fracture that causes compaction of bone and a decrease in length or width
Hangman's Fracture Fracture of the anterior arch of C2 owing to hyperextension
Jefferson Fracture Comminuted fracture of the ring of C1
Herniated nucleus pulposus Rupture or prolapse of the nucleus pulposus into the spinal canal
Kyphosis Abnormally increased convexity in the thoracic curvature
Lordosis Abnormally increased concavity of the cervical and lumbar spine
Scheuermann Disease Adolescent kyphosis Kyphosis with onset in adolescence
Spondylolisthesis Forward displacement of a vertebra over a lower vertebra, usually L5-S1
Spondylolysis Breaking down of the vertebra at the pars interaticularis leading to spondylothisthesis
The vertebral column articulates with the hip bone at the: sacroiliac joint
How many vertebrae make up the vertebral column? 33
How many vertebrae are there in the sacrum? 5
When viewed from the side, the vertebral column presents how many curves? 4
Which of the following vertebral areas have a lordotic curve? ---
1) cervical 
2) thoracic
 3) lumbar 1) cervical
 2) thoracic
 3) lumbar---- 1 and 3
An abnormal increase in the curve of the thoracic spine is termed: kyphosis
An abnormally increased curve of the lumbar spine is termed: lordosis
An abnormal lateral curvature of the spine is termed: scoliosis
The articulations between the articular processes of the vertebral arches are called the: zygapophyseal joints
Spinal nerves and blood vessels exit the spinal column through the: intervertebral foramina
Which vertebral process projects posteriorly from the junction of the laminae? Spinous process
The condition in which an intervertebral disk "slips" and protrudes into the vertebral canal is called: herniated nucleus pulposus (HNP)
The "vertebra prominens" is the name given to the: 7th cervical vertebra
The openings in the cervical vertebrae for the transmission of the vertebral artery and vein are called the: transverse foramen
The intervertebral foramina of the cervical spine open: 45º anteriorly and 15º inferiorly
The zygapophyseal joints of the cervical spine are clearly demonstrated on which projection? lateral
How many thoracic vertebrae have a small concave facet on the transverse process, for articulation with the tubercle of a rib? 10
The zygapophyseal joints of the thoracic spine form an angle of how many degrees with the midsagittal plane 70º-75º
The intervertebral foramina of the thoracic spine are clearly demonstrated on which projection? lateral
The condition of the LUMBAR spine in which there is anterior displacement of one vertebra over another is termed: spondylolisthesis
Where should the center of the IR be positioned for the "open mouth" AP projection of the atlas and axis second cervical vertebra
For which projection is the patient instructed to softly phonate "ah" during the exposure? AP "open mouth" atlas and axis This will place the tongue in the floor of the mouth so that it is not superimposing the atlas and axis
Where is the CR directed for an "open mouth" AP projection of the atlas and axis? perpendicular through the open mouth
Which of the following methods is used to demonstrate the dens within the foramen magnum? Fuchs
Where is the center of the IR positioned for the AP projection of the dens, Fuchs method? tip of the mastoid process
What is the CR angulation for the AP projection of the dens, Fuchs method?
Which of the following is placed perpendicular to the tabletop for the AP axial cervical vertebrae? a line drawn from the lower edge of the upper incisors to the tip of the mastoid process
Where is the IR centered for an AP axial cervical spine? fourth cervical vertebra
The CR angle for an AP axial cervical vertebrae is: 15º-20º cephalad
The SID for a lateral cervical spine must be a minimum of how many inches? 60-72 inches
The respiration phase for a lateral cervical spine is: Suspended on full expiration
The Grandy method is _______projection of the ______: lateral projection of the cervical vertebrae
Where is the CR centered for a hyperflexion or hyperextension lateral cervical spine? fourth cervical vertebra
The intervertebral foramina of the cervical spine are demonstrated on which projections? AP Axial Oblique (RPO and LPO Or the PA Axial Oblique (RAO and LAO)
What is the CR angle for the AP axial oblique projection of the cervical intervertebral foramina? 15º-20º cephalad
Which intervertebral foramina are demonstrated on an AP axial oblique projection of the cervical spine those farthest from the IR
What is the recommended SID for the AP axial oblique projection of the cervical spine? 60-72 inches
How much is the body rotated for a PA axial oblique projection of the cervical intervertebral foramina? 45º
What is the name of the most anterior portion of a thoracic vertebra? Body
The brain and the spinal cord make up which part of the nervous system? Central
The natural curvature of the lumbar spine is classified as what type? Concave (posteriorly)
Which vertebrae have demifacets for the articulation of ribs? Thoracic vertebrae articulate w/the ribs at the facets on the posterolateral margin of the bodies. Some are demi and some are full: T1 has whole and demi, T2-T8 have two demi, T9 has one demi superiorly, and T10 –T12 have Whole facets superiorly only
What is another name for the first cervical vertebrae? Atlas
The Atlas sits on its Axis: C1 is the Atlas and C2 is the Axis making up a pivot or trochoid joint. The process (odontoid) of C2 fits into the ring of C1 for articulation
Which position/projection is necessary to demonstrate the intervertebral foramina of the cervical spine? 45 degree oblique with a 15 degree tube angle (Cephalic for RPO/LPO & Caudal for RAO /LAO
Which vertebrae has no body? C1 Atlas
What is the purpose of having the patient flex his knees for an AP projection of the lumbar spine? Better visualization of disk spaces. The lordotic curve of the l-spine distorts the bodies and closes the disk spaces. Flexing the knees removes the curve “opening” the spaces on the image
How much should the patient be obliqued from the lateral position in order to demonstrate the zygapophyseal joints of the thoracic spine? 20 degrees In order to demonstrate the zygapophyseal joints of the thoracic spine the patient is rotated posteriorly from the lateral position 20 degrees. (Rotated 70 degrees from the supine position)
What is the posterior, bony ring of a typical vertebrae called? Vertebral arch
Which of the following positions/projections would be required to demonstrate the mobility of the cervical spine? Lateral Projection in Flexion and extension -performed to demonstrate mobility of the cervical spine and are usually done after a whiplash type injury. They should not be performed until fracture has been ruled out.
Spina bifida is caused by: Posterior laminae failing to unite and enclose the spinal cord
What is the recommended SID for the AP/PA Axial Oblique projections of the C-spine? 72”
Which of the following projections will best demonstrate the transverse processes of the lumbar vertebrae? AP
The manubrial notch is at approximately the same level as the: T2-T3 interspace T5 is at the sternal angle L3 is at the costal margin
The pars interarticularis is represented by what part of the “scotty dog” seen in a correctly positioned oblique lumbar spine? Neck
What position/projection best demonstrates the intervertebral foramina of the lumbar spine? LATERAL The lateral position of the lumbar spine demonstrate the intervertebral foramen, vertebral bodies, and the disk spaces. The RPO and LPO demonstrates the zygapophaseal joints closest to the IR
The apophyseal articulations of the thoracic spine are demonstrated with the Coronal plane 70 degrees to the IR the patient is placed in lateral position and then rotated either 20 degrees anteriorly or posteriorly to put the coronal plane at a 70 degree angle with the IR. APO: the side farthest from the IR, PAO: the side closest
Which position/projections will provide an AP projection of the L5-S1 interspace? Ferguson -Patient AP with 30-35 degree angle cephalad due to the angle of the disk space created by the sacrum. The L5-S1 interspace can be demonstrated in the lateral projection with the lateral L5-S1 spot.
In the posterior oblique of the cervical spine, the intervertebral foramina that are best seen are those: Furthest from the IR. -face up, angle up, side up -face down, angle down, side down
To demonstrate the first two cervical vertebrae in the AP Projection, the patient is positioned so that: A line between the maxillary occlusal plane and the mastoid tip is vertical and the CR is perpendicular through the open mouth If the head is overflexed the teeth will cover the dens, if the head is overextended the base of the skull will cover the dens.
Which of the following will demonstrate the lumbosacral apophyseal articulation? AP Oblique Projection: 30 degree RPO and LPO The L5-S1 articulation forms a 30 degree angle to the MSP; therefor a 30 degree oblique will demonstrate this best. For L1-L4 a 45 degree oblique is utilized to demonstrate the zygapophyseal joints
Which method utilizes a "chewing motion" of the mandible to demonstrate the cervical spine in an AP projection? Ottonello The movement of chewing during exposure blurs out the mandibular shadow. The head must be completely still and the exposure must be long enough to cover several complete excursions of the mandible
What is the CR angulation for the lateral projection of the cervicothoracic region (Swimmers method) when the shoulder can be depressed? Perpendicular to IR. In the “twining” the patient is erect with the dependent arm raised with the shoulder rolled posteriorly. The independent arm is down with the shoulder depressed and rolled anteriorly. If this does not work a 5 degree caudal angle
The CR angulation for the lateral projection of the cervicothoracic region when the shoulders cannot be separated: 3º-5º caudad Ideally, the cathode end of an x-ray tube should be positioned to take advantage of the "heel effect" of the tube.
Where should the cathode be placed for an AP thoracic spine? toward the feet “Fat Cat”; due to the anode heel effect the density overall will be similar if the thickest portion is placed under the cathode end of the tube.
Where should the arms be placed for a lateral projection of the thoracic spine? at right angles to the long axis of the body This will aid in elevating the ribs to clear the intervertebral foramina
If support is not placed under the lower thoracic vertebrae for a lateral projection, the central ray may have to be angled. What is the degree of angulation that would be required? 10º-15º cephalad The preferred method is to build the patients spine to a horizontal position; however if this is not possible angle the CR cephalic to be perpendicular to the long axis of the spine. 10 usually for females and 15 for males.
If a lead rubber sheet is not placed on the table when performing a lateral projection of the thoracic spine (if using AEC), the image may be: Underexposed A lead strip behind the patient will absorb scatter which will affect the quality of the image. If using AEC, the scatter will reach the photocell and terminate the exposure prematurely causing it to be underexposed.
Which respiration phase should be used for the lateral projection of the thoracic spine? Breathing Technique or Suspended at expiration The exposure is best done with the patient breathing to obliterate the lungs; if not possible suspended at the end of expiration will give a more uniform density than suspended or inspiration.
The phase of respiration for an AP projection of the lumbar spine is: Suspended at the end of expiration should be used for all of the routine lumbar projections except the L5-S1 lateral spot in which just suspended may be utilized.
Where is the CR directed for an AP lumbosacral spine? iliac crests For the Lumbosacral spine CR should be at the level of the iliac crests on a 14x17LW IR. The CR is 1 ½” above the crest for lumbar spine on a 11x14 LW IR. This is true for the AP and the Lateral projections
Which plane is placed perpendicular to the tabletop and centered to the midline of the grid for a lateral lumbar spine? midcoronal plane No matter how large the patient is, the long axis of the body of the lumbar spine is situated in the midcoronal plane.
If the lumbar spine cannot be adjusted so it is horizontal for the lateral projection, the central ray should be angled: 5º-8º-caudad 
the preferred method is the build the spine into a horizontal position; however if this is not possible then a 5-8 degree caudal angle may be used to place the CR perpendicular to the long axis of the spine. 5 for men and 8 for women
Where should CR location be for Lateral L5/S1? 2" posterior to the ASIS and 1½" below the iliac crest
. CR should be _|_ to the horizontal spine centered to a coronal plane 2” post to the ASIS and 1 ½” inferior to the Iliac Crest. build the spine up; if not possible a 5(men) to 8(women) degree caudal
What is the CR centering point for an AP oblique lumbar spine? 2 inches medial to the elevated ASIS and 1½ inches above the iliac crest
Pelvic Sacral Foramina Four pairs of openings throughout the sacrum for transmission of nerves and blood vessels
Ala of the Sacrum Wing-like masses of the sacrum
Auricular surface of sacrum (Superolateral) surface for articulation with the pelvis
Sacral Apex Inferior portion of the sacrum
Sacral cornu 2 processes that project inferiorly from posterolateral aspect of the last sacral segment to join coccygeal cornu
How are the legs positioned for the AP Axial (sacrum, coccyx, and SI joints) Patient is supine with legs EXTENDED
CR angle and location for AP Axial Sacrum 15 degrees cephalic 2” superior to the pubic symphysis
CR angle and location for AP Axial coccyx? 10 degrees cadual 2” superior to the Pubic Symphysis
CR angle and location for AP Axial L5/S1 (Ferguson Method) 30 (male) to 35 (female) degrees cephalic 1 ½” superior to the pubic symphysis
How can the spine be supported to lateral when the patient has a smaller waist than hips? Place radiolucent support under the waist when in lateral position
What can be done to limit the amount of scatter that reaches the IR when performing the lateral sacrum and coccyx (other than the grid) Lead masking posteriorly on the table
CR location for the lateral sacrum? 3 ½” posterior to ASIS
CR location for lateral coccyx? 3 1/2” Posterior to ASIS and 2” inferior to ASIS
IR size and direction for lateral Sacrum? 10x12 LW
Created by: paigeduh