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● Lumbar: when baby learns to walk

TOPOGRAPHIC LANDMARKS
1.) Cervical Region 2.) Thoracic & Pelvic Curve
● C1 – mastoid tip ● Convex posterior & concave anteriorly

● C2-C3 – gonion ● Primary curve: present at birth

● C5 – thyroid cartilage

● C7 – vertebral prominens
2.) Thoracic Region
● T1 – 2 in. superior to sternal notch

● T2-T3 – manubrial notch/superior margin of

scapula/suprasternal notch ABNORMAL CURVATURES
1.) Lordosis
● T4-T5 – sternal angle
● Exaggerated lumbar curvature
● T7 – inferior angle of scapula
● Swayback
● T9-T10 – xiphoid process/ensiform
● Increase anterior convexity or posterior
● T10 – xiphoid tip concavity
3.) Lumbar Region
2.) Kyphosis
● L3 – lower costal margin
● Exaggerated thoracic curvature
● L3-L4 – level of umbilicus
● Humpback or hunchback
● L4 – most superior aspect of iliac crest
● Increase anterior concavity or posterior
4.) Sacrum & Pelvic Region
convexity
● S1 – ASIS 3.) Scoliosis
● Coccyx – pubic symphysis & greater ● Lateral curvature
trochanter ● S-shaped
SPINAL CURVATURES 4.) Gibbus
1.) Cervical & Lumbar Curve ● Posterior angulation of the spine
● Convex anteriorly & concave posteriorly

● Secondary/compensatory curve: develop

after birth
● Cervical: when baby starts holding the head
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● Increased density of atypically soft bone

9.) Osteoporosis
● Loss of bone density
10.) Scheuerrmann’s Disease
● Adolescent kyphosis

● Kyphosis with onset in adolescence

11.) Scoliosis
● Lateral deviation of the spine with possible
vertebral rotation
12.) Spina Bifida
● Failure of the posterior encasement of the
PATHOLOGY spinal cord to close
1.) Clay Shoveler’s Fx 13.) Spondylolisthesis
● Avulsion fx of the spinous process in the ● Forward displacement of a vertebra over a
lower cervical & upper thoracic region lower vertebra, usually L5-S1
2.) Compression Fx 14.) Spondylolysis
● Fx that causes compaction of bone & a ● Separation of the pars interarticularis
decrease in length or width
3.) Hangman’s Fx 15.) Odontoid Fx
● Fx of the anterior arch of C2 due to ● Disruption of the arches of C1
hyperextension 16.) Teardrop Burst Fx
4.) Jefferson’s Fx
● Comminuted vertebral body with triangular
● Comminuted fx of the ring of C1
fragments avulsed from anteroposterior
5.) Herniated Nucleus Pulposus border caused by compression with
● Rupture or prolapsed of the nucleus hyperflexion in the cervical region
pulposus into the spinal canal 17.) Transitional Vertebra
6.) Kyphosis ● It occurs when the vertebra takes on a
● Abnormally increased convexity in the characteristic of the adjacent region of the
thoracic curvature spine
7.) Lordosis 18.) Chance Fx

● Abnormally increased concavity of the ● Fx through the vertebral body caused by

cervical & lumbar spine hyperflexion force

8.) Osteopetrosis 19.) Whiplash Injury
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PP: Supine; chin extended; chin tip & mastoid tip ┴

● Damage to the ligaments, vertebrae or spinal
to IR; MSP ┴ to IR
cord caused by sudden jerking back of the RP: Distal to chin tip
head & neck CR: ┴
SS: Dens w/in foramen magnum
ER: Recommended when upper half of dens is not
clearly shown in open-mouth position

KASABACH METHOD
AP AXIAL OBLIQUE PROJECTION
R & L head rotations
PP: Supine; head rotated 40-45o; IOML ┴
RP: Midway b/n outer canthus & EAM
CR: 10-15o caudad
SS: Dens
ER: Recommended in conjuction with AP & lateral
projections

C. ATLAS (C1) & AXIS (C2)

ALBERS-SCHONBERG & GEORGE

METHOD
AP “OPEN-MOUTH" PROJECTION
PP: Supine; MSP ┴; open mouth as wide as
A.) ATLANTO-OCCIPITAL JOINTS possible;
RP: Midpoint of open mouth
AP OBLIQUE PROJECTION CR: ┴
R & L head rotations SS: Atlas & axis
PP: Supine; head rotated 45-60o away from side of
interest; IOML ┴ to IR LATERAL PROJECTION
RP: 1 in. anterior to the EAM PP: Supine (dorsal decubitus); IR vertical; MSP //
CR: ┴ to IR; MSP ┴ to table; neck slightly extended
SS: Atlanto-occipital joints b/n orbit & ramus of (mandibular rami does not overlap atlas or axis)
mandible RP: 1 in. distal to mastoid tip
CR: ┴
● Dens is well demonstrated SS: Atlas & axis; atlanto-occipital joints
ER: Alternative projection when a patient cannot be Pancoast, Pendergrass & Schaeffer
adjusted in the open-mouth position Recommendation:
● Head rotated slightly
B.) DENS
● Rationale: to prevent superimposition of
FUCHS METHOD
laminae & atlas
AP PROJECTION
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● Hyperextension: chin elevated as much as

D.) CERVICAL VERTERBRAE
possible
AP AXIAL PROJECTION RP: C4
PP: Supine/upright; chin extended; occlusal plane CR: Horizontal
┴ to IR (prevents superimposition of mandible & SS: IV disks & zygapophyseal joints
midcervical vertebrae) SS in Hyperflexion:
RP: C4
● C1-C7
CR: 15-20o cephalad
SS: C3-T2
● Elevated & widely separated spinous
● Interpediculate spaces
processes
● IV disk spaces SS in Hyperextension:
● C1-C7
● Superimposed transverse & articular
processes ● Depressed spinous processes
ER: Used to demonstrate the presence or absence of ER:
cervical ribs
● For functional studies (motility) of cervical
vertebrae
● To demonstrate normal AP movement or
GRANDY METHOD absence of movement
LATERAL PROJECTION
PP: Seated/upright; patient in true lateral position;
shoulder rotated posteriorly or anteriorly (round
shouldered); chin slightly elevated (prevents
superimposition of mandibular rami & spine);
MSP // to IR AP AXIAL OBLIQUE PROJECTION
RP: C4 Barsony & Koppenstein: described this projection
CR: Horizontal PP: Supine or upright (more comfortable);
SS: C1-C7 RPO/LPO; body rotated 45o; chin
● Articular pillars protruded/elevated
RP: C4
● Zygapophyseal joints (C3-C7) CR: 15-20o cephalad
SS: Intervertebral foramina & pedicles (farthest
● Spinous processes from IR)
Boylston Suggestion:

LATERAL PROJECTION ● Functional studies in oblique projection

Hyperflexion & Hyperextension
PP: Seated/upright; patient in true lateral position; ● Rationale: to demonstrate fx of articular
MSP // to IR process dislocation/subluxation
● Hyperflexion: head drop forward; draw
PA AXIAL OBLIQUE PROJECTION
chin as close as possible to the chest PP: Prone or upright (more comfortable);
RAO/LAO; body rotated 45o; shoulder rested
against IR; chin protruded/elevated
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RP: C4 VERTEBRAL ARCH/PILLAR/LATERAL

CR: 15-20o caudad MASS PROJECTION
SS: Intervertebral foramina & pedicles (closest to PA AXIAL PROJECTION
IR) PP: Prone; head rested against IR; neck fully
extended; MSP ┴ to IR
OTTONELLO/CHEWING/WAGGING JAW RP: C7
METHOD CR: 40o cephalad; 35-45o cephalad (range)
AP PROJECTION SS: Vertebral arch structures
PP: Supine; MSP ┴ to IR; chin elevated; upper
incisors & mastoid tips ┴ to IR; mandible in VERTEBRAL ARCH/PILLAR/LATERAL
chewing motion during exposure MASS PROJECTION
RP: C4 AP AXIAL OBLIQUE PROJECTION
CR: ┴ R & L head rotations
SS: Entire cervical column PP: Supine; head rotated 45-50o (C2-C7 articular
ER: To blurred the mandibular shadow to processes) or 60-70o (C6-T4 articular processes);
demonstrate all cervical vertebrae turn jaw away from side of interest;
RP: C7
CR: 35o caudad; 30-40o caudad (ranges)
SS: Vertebral arch structures
ER: Used to demonstrate vertebral arches when the
patient cannot hyperextend head for AP/PA axial
projection

VERTEBRAL ARCH/PILLAR/LATERAL TWINNING & PAWLOW METHOD

MASS PROJECTION SWIMMER’S TECHNIQUE
AP AXIAL PROJECTION LATERAL PROJECTION
PP: Supine; shoulder depressed; MSP ┴ to IR; PP: Humeral head moved anteriorly or posteriorly;
neck hyperextended; depress shoulder away from IR; MSP // to IR;
RP: C7 breathing technque
CR: 25o caudad; 20-30o caudad (range)
● Lateral recumbent (Pawlow): head
SS: Vertebral arch structures
elevated on patient’s arm;
● Superior & inferior articular processes
(pillars) ● Upright (Twinning): arm closes to IR
extended; elbow flexed; forearm rested on
● Zygapophyseal joints b/n articular
head
processes RP: C7-T1 interspace
● Upper three of thoracic vertebrae CR: ┴ (shoulder well depressed); 3-5o caudad
(can’t be depressed sufficiently)
● Laminae SS: Cervicothoracic region (C7-T1)
ER: Performed when shoulder superimposition
● Spinous processes obscures C7 on a lateral cervical spine projection
Monda Recommendation:
ER: Useful for demonstrating the cervicothoracic
● CR 5-15o cephalad
spinous processes in patients with whiplash injury
● To better demonstrate IV disk spaces
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SS: Zygapophyseal/apophyseal joints (farthest from

E.) THORACIC VERTEBRAE IR)

AP PROJECTION OPPENHEIMER METHOD

PP: Supine/upright; MSP ┴ to IR; hips & knees PA OBLIQUE PROJECTION
flexed (to reduce kyphosis); place support under PP: Prone/upright; RAO/LAO; body rotated 20o
knees anteriorly; MCP 70o from IR
RP: T7
RP: T7 (b/n jugular notch & xiphoid process) CR: ┴
CR: ┴ SS: Zygapophyseal/apophyseal joints (closest to IR)
SS: T1-T12
● IV disk spaces

● Transverse processes

● Costovertebral articulation

F.) LUMBAR-LUMBOSACRAL VERTEBRAE

AP PROJECTION
LATERAL PROJECTION PP: Supine/upright; elbow flexed; hands on upper
PP: Lateral recumbent or upright (Oppenheimer); chest
left side against the table (places heart closer to IR) ● Hips & knees flexed
MSP // to IR; hips & knees flexed; arms at right
angle to body (to elevate ribs enough); place o Reduces lumbar lordosis
support under lower thoracic spine o Places back in contact w/ table
RP: T7 o Reduces distortion of vertebral
CR: ┴ (w/ support); 10-15o cephalad (w/o support);
10o (female) or 15o (male) bodies
SS: T1-T12 o Better delineation of IV disk
RP: L4 (for lumbosacral); L3 (for lumbar spine
● IV disk spaces
only)
CR: ┴
● Intervertebral foramina
SS: Lumbar bodies
● Lower spinous processes ● IV disk spaces

● Interpediculate spaces
FUCHS METHOD
AP OBLIQUE PROJECTION ● Laminae
PP: Supine/upright; RPO/LPO; body rotated 20o
posteriorly; MCP 70o from IR
● Spinous & transverse processes
RP: T7
CR: ┴
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5th zygapophyseal joint: 2 in. medial to elevated

● Sacrum, coccyx & pelvic bones (larger IR)
ASIS & midway b/n iliac crest & ASIS
CR: ┴
LATERAL PROJECTION SS: Zygapophyseal/apophyseal joints (closest to IR)
PP: Lateral recumbent or upright; affected side ● Scottie dog
against IR; hips & knees flexed; MCP ┴ to IR;
place support under lower thorax (places spine in o Superior articular process (ear)
true horizontal position) o Transverse process (nose)
RP: L4 (for lumbosacral); L3 (for lumbar spine
o Pedicle (eye)
only)
CR: ┴ (w/ support); 5-8o caudad (w/o support); 5o o Part interarticularis (neck)
(male) or 8o (female) o Lamina (body)
SS: Intervertebral foramina of L1-L4 only; L5 o Inferior articular process (foot)
intervertebral foramina (Oblique Projection) Note:
● Majority (L3-S1) of zygapophyseal joints
(45o body rotation)
● L1-L2 & L2-L3 (AP; 25% only)

● L4-L5 & L5-S1 (LATERAL; small %age)

F.) L5-S1 LUMBOSCRAL JUNCTION

PA OBLIQUE PROJECTION
PP: Semiprone/upright; RAO/LAO; body rotated
LATERAL PROJECTION
45o or 60o (L5-S1 zygapophyseal joints & articular
PP: Lateral recumbent or upright; affected side
processes)
against IR; hips & knees flexed; MCP ┴ to IR;
RP: 1.5 in. superior to iliac crest & 2 in. lateral to
place support under lower thorax (places spine in
palpable spinous process
true horizontal position)
CR: ┴
RP: 2 in. posterior to ASIS & 1.5 in. inferior to iliac
SS: Zygapophyseal/apophyseal joints (farthest from
crest
IR)
CR: ┴ (w/ support); 5-8o caudad (w/o support); 5o
(male) or 8o (female) ● Scottie dog
SS: Lumbosacral junction
H.) LUMBOSACRAL JOINTS & SACRAL
JOINTS
G.) ZYGAPOPHYSEAL JOINTS
FERGUSON METHOD
AP OBLIQUE PROJECTION AP AXIAL PROJECTION
PP: Semisupine/upright; RPO/LPO; body rotated PP: Supine; lower limb extended; thigh abducted;
45o or 60o (L5-S1 zygapophyseal joints & articular RP: 1.5 in. superior to pubic symphysis
processes); CR: 45o cephalad (Ferguson); 30-35o cephalad; 30o
RP: (male) or 35o (female);
Lumbar region: 2 in. medial to elevated ASIS & SS: Lumbosacral joint; symmetric sacroiliac joints
1.5 in. superior to iliac crest (L3) Meese Recommendation:
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● PP: Prone (places sacroiliac joints nearly // ● First exposure: remove one blocks; one leg
to CR) hangs with no muscular resistance
● RP: 2 in. distal to L5 (level of ASISs) ● Second exposure: replace support under
foot that was hanging; remove the opposite
● CR: ┴
one; second leg hanging free
RP: Pubic symphysis
FERGUSON METHOD CR: ┴
PA AXIAL PROJECTION SS: Pubic symphysis
PP: Prone Chamberlain Recommendations:
RP: L4
CR: 35o caudad ● For abnormal sacroiliac motion
SS: Lumbosacral joint; symmetric sacroiliac joints
● Lateral Projection:
o Upright
o Centered to lumbosacral junction
● 2 PA Projections of Pubic bones:
o Upright
o Weight-bearing on alternate limbs
o To demonstrate pubic symphysis
reaction by a change in the normal
I.) SACROILIAC JOINTS relation of pubic bones

AP OBLIQUE PROJECTION K.) SACRUM

PP: Semisupine; RPO/LPO; body rotated 25-30o
RP: 1 in. medial to elevated ASIS AP/PA AXIAL PROJECTION
CR: ┴ PP: Supine or prone (patient w/ painful
SS: Sacroiliac joint (farthest from IR) injury/destructive disease)
RP: 2 in. superior to pubic symphysis (supine);
AP AXIAL OBLIQUE PROJECTION visible sacral curve (prone)
PP: Semisupine; RPO/LPO; body rotated 25-30o CR: 15o cephalad (supine); 15o caudad (prone)
RP: 1 in. distal to elevated ASIS SS: Sacrum free of foreshortening
CR: 20-25o cephalad
SS: Sacroiliac joint (farthest from IR) LATERAL PROJECTION
PP: Lateral recumbent; interiliac plane ┴ to IR;
PA OBLIQUE PROJECTION pelvis & shoulder in true lateral position
PP: Semiprone; RAO/LAO; body rotated 25-30o RP: 3.5 in. posterior to ASIS
RP: 1 in. medial to elevated ASIS CR: ┴
CR: ┴ SS: Sacrum
SS: Sacroiliac joint (closest to IR)
J.) PUBIC SYMPHYSIS L.) COCCYX

CHAMBERLAIN METHOD AP/PA AXIAL PROJECTION

PA PROJECTION PP: Supine or prone (patient w/ painful
PP: Upright; standing on two blocks injury/destructive disease)
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RP: 2 in. superior to pubic symphysis (supine); M.) LUMBAR INTERVERTEBRAL DISKS
Palpable coccyx (prone) WEIGHT-BEARING METHOD
CR: 10o caudad (supine); 10o cephalad (prone) PA PROJECTION
SS: Coccyx free of superimposition PP: Upright; patient bending to right & left; lean
directly lateral as far as possible
LATERAL PROJECTION RP: L3
PP: Lateral recumbent; interiliac plane ┴ to IR; CR: 15-20o caudad
pelvis & shoulder in true lateral position SS: Lower thoracic & lumbar region
RP: 3.5 in. posterior & 2 in. inferior to ASIS ER: Perform for demonstration of the mobility of
CR: ┴ intervertebral joints
SS: Coccyx Duncan & Hoen Recommendation:
● PA projection be used

● Rationale: IV disks more nearly // to CR

☺ THE END ☺
“BOARD EXAM is a matter of PREPARATION. If
you FAIL to prepare, you PREPARE to fail”
03/31/14
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RULES OF OBLIQUE

Anatomy of Interest Projection Position/Degrees Structure Shown Central Ray

LPO – 45o Right IF (side up) 15-20o cephalad

CERVICAL AP Oblique
RPO – 45o Left IF (side up) 15-20o cephalad
(Intervertebral
LAO – 45o Left IF (side down) 15-20o caudad
Foramina) PA Oblique
RAO – 45o Right IF (side down) 15-20o caudad

LPO – 70o Right ZJ (joints up) ┴

THORACIC AP Oblique
RPO – 70o Left ZJ (joints up) ┴
(Zygapophyseal
LAO – 70o Left ZJ (joints down) ┴
Joints) PA Oblique
RAO – 70o Right ZJ (joints down) ┴

LPO – 45o Left ZJ (joints down) ┴

LUMBAR AP Oblique
RPO – 45o Right ZJ (joints down) ┴
(Zygapophyseal
LAO – 45o Right ZJ (joints up) ┴
Joints) PA Oblique
RAO – 45o Left ZJ (joints up) ┴

LPO – 25-30o Right SIJ (joint up) ┴

AP Oblique
SACROILIAC RPO – 25-30o Left SIJ (joint up) ┴
JOINTS LAO – 25-30o Left SIJ (joint down) ┴
PA Oblique
RAO – 25-30o Right SIJ (joint down) ┴

LPO – 45o Left AR (side down) ┴

AP Oblique
RPO – 45o Right AR (side down) ┴
AXILLIARY RIBS
LAO – 45o Right AR (side up) ┴
PA Oblique
RAO – 45o Left AR (side up) ┴

ZYGAPOPHYSEAL INTERVERTEBRAL
ANATOMY
JOINTS FORAMINA
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Cervical Lateral Oblique – 45o

Thoracic Oblique – 70o Lateral

Lumbar Oblique – 45o Lateral