Which of the following positions will best demonstrate the left zygapophyseal joints of the thoracic spine?

Citation, DOI & article data

Citation:

McWilliam, R., Murphy, A. Lumbar spine (oblique view). Reference article, Radiopaedia.org. (accessed on 26 Sep 2022) https://doi.org/10.53347/rID-49730

The lumbar spine oblique view is used to visualize the articular facets and pars interarticularis of the lumbar spine. 

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This view is used most commonly to assess for a pars interarticularis defect, although this has largely been superseded by CT and MRI. Additionally, it is a frequently used view for needle placement in fluoroscopic guided procedures 2, such as transforaminal epidural steroid injections.  

• the radiographs can be performed with the patient in the posteroanterior (PA) erect or supine position
  • PA erect
    •  two radiographs performed with patient at RAO 35-45°  and LAO 35-45°  
  • supine
    •  two radiographs performed with patient at RPO 35-45°  and LPO 35-45°  
• ensure arms are removed from the region of interest 
• using a 45° radiolucent sponge in the supine position will assist the patient in maintaining the correct position, whilst flexing the knees will also provide stability. 

• left and right oblique positions
• expiration (to minimize superimposition of the diaphragm over the upper lumbar spine) 
• centering point
  • PA erect
    • 2.5 cm above the iliac crests and 3 cm lateral from the spinous processes towards the upside. RAO and LAO will demonstrate the facet joints on the upside, for example, the LAO position will show the right facet joints
  • supine
    • 2.5 cm above the iliac crests and 5 cm medial from the ASIS on the upside. RPO and LPO will demonstrate the facet joints on the downside, for example, the RPO position will show the right facet joints 
• collimation
  • superiorly to include the T12/L1 junction 
  • inferior to include the L5/S1 junction 
  • anterior to include the anterior border of the lumbar vertebral bodies 
  • posterior to include all elements of the posterior column, particularly the spinous processes 
• orientation  
  • portrait
• detector size
  • 35 cm x 43 cm 
• exposure
  • 70-80 kVp
  • 60-80 mAs 
• SID
  • 110 cm
• grid
  • yes (ensure the correct grid is selected if using focused grids)

• the entire lumbar spine should be visible from T12/L1 - L5/S1
  • check department protocol before imaging, as focused imaging of the lower lumbar vertebrae may be required 
• a well-positioned oblique lumbar radiograph will demonstrate the scottie dog sign, showing the articular processes and facet joints  
• adequate image penetration and image contrast is evident by clear visualization of lumbar vertebral bodies, with both trabecular and cortical bone demonstrated
• pedicles should be in the central of the vertebral bodies 

• to correct poor positioning consider the location of the pedicles
  • if they are anterior on the vertebral body- rotate the patient more
  • if they are posterior on the vertebral body- rotate the patient less

References

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