Chapter 9 Lumbar Spine, Sacrum, and Coccyx
69. Which aspect of the Scottie dog is the superior articular process? A) A B) B C) C D) D E) E
E) E
72. Which labeled structure in the figure is the superior articular process? A) A B) B C) C D) D E) E
E) E
66. Where is the CR centered for posterior oblique projections of the SI joints? A) 1 inch (2.5 cm) medial to upside ASIS B) 2 inches (5 cm) medial to upside ASIS C) Centered at upside ASIS D) 1 inch (2.5 cm) medial and inferior to upside ASIS
A) 1 inch (2.5 cm) medial to upside ASIS pg. 352: CR is directed 1" medial to the upside ASIS
35. What type of CR angulation is required for an AP axial projection of the coccyx? A) 10° caudad B) 15° cephalad C) 10° cephalad D) Perpendicular to the cassette
A) 10° caudad pg. 348: angle CR 10° caudad
70. Which aspect of the Scottie dog is the transverse process? A) A B) B C) C D) D
A) A
75. Which labeled structure is the spinous process? A) A B) B C) C D) D E) E
A) A
21. Where is the central ray (CR) centered for an AP projection of the lumbar spine with a 14 x 17-inch (35 x 43-cm) IR? A) At the iliac crest B) At the ASIS C) 1 to 1.5 inches (2.5 to 3 cm) above the iliac crest D) At the lower costal margin
A) At the iliac crest pg. 337: Larger IR (14 x 17) - direct CR to level of iliac crest. This larger IR will include lumbar vertebrae, sacrum, and possibly coccyx.
8. What is the term for the superior aspect of the coccyx? A) Base B) Apex C) Superior margin D) Sacrococcygeal junction
A) Base pg. 328: the distal pointed tip of the coccyx is termed the apex, whereas the broader superior portion is termed the base.
48. A radiograph of an AP projection of the lumbar spine on an average-size patient reveals that the psoas major muscles and transverse processes are not visible. The following analog factors were used for this projection: automatic exposure control (AEC) with center ionization chamber, 95 kV, 40-inch (102-cm) SID, grid, and 14 x 17-inch (35 x 43-cm) image receptor. Which of the following modifications will be most effective in demonstrating these structures? A) Decrease the kV. B) Activate all three ionization chambers. C) Decrease the mAs. D) Increase the kV.
A) Decrease the kV pg. 337: analog kV range = 75 to 85
67. A radiograph of a left posterior oblique (LPO) projection of the lumbar spine reveals that the downside pedicle is projected too far posterior on the vertebral body. What specific positioning error is present on this radiograph? A) Excessive rotation of the spine B) Insufficient rotation of the spine C) Tilt of the spine D) Incorrect CR placement
A) Excessive rotation of the spine pg. 338: accurate patient rotation is indicated by open zygapophyseal joints and the pedicle (eye of Scottie dog) between the midline and lateral aspect of the vertebral border. If the pedicle is demonstrated closer to the midline of the vertebral border and less of the pedicle is seen, this indicates over-rotation. If the pedicle is demonstrated laterally on the vertebral body border with more of the lamina (body of Scottie dog) demonstrated, this indicates under-rotation.
51. A patient comes to radiology for a follow-up study of the lumbar spine. The patient had a spinal fusion performed at the L3-4 level 4 months earlier. Which of the following would best demonstrate the degree of movement at the fusion site? A) Lateral hyperextension and hyperflexion projections B) Ferguson method C) AP and lateral erect projections D) Right and left 45° oblique projections
A) Lateral hyperextension and hyperflexion projections pg. 346: clinical indications - assessment of mobility at a spinal fusion site.
7. Which one of the following structures of the sacrum is considered to be the most posterior? A) Median sacral crest B) Promontory C) Superior articular processes D) Spinous processes
A) Median sacral crest pg. 327: the median sacral crest is formed by fused spinous processes (see fig. 9.5).
54. A geriatric patient comes to radiology for a lumbar spine series. She has severe kyphosis of the thoracolumbar spine. Which one of the following modifications should be applied to this patient? A) Perform all positions erect. B) Perform all positions recumbent, include flexion and extension projections. C) Include the entire spine for all projections regardless of what was ordered by the physician. D) Use high (90 kV) for all projections.
A) Perform all positions erect. pg. 334: patients with severe kyphosis may be more comfortable if positioned for images in the erect position.
33. A key advantage of a posteroanterior (PA) projection taken during a pediatric scoliosis study as compared with the AP projection is that it reduces: A) breast and thyroid dose by 90%. B) female ovarian dose by 25% to 30%. C) breast dose by 15% to 20%. D) breast and thyroid dose by 150%.
A) breast and thyroid dose by 90%. pg. 342: a PA is highly recommended because of the significantly reduced dose to radio-sensitive areas such as the female breast & thyroid gland. Studies have shown that this projection results in approximately 90% reduction in dosage to the breasts.
37. A destructive type of lesion with irregular margins and increased density is an indication of possible: A) osteoblastic type of metastases. B) osteolytic of type metastases. C) spondylolisthesis. D) spondylolysis.
A) osteoblastic type of metastases. pg. 335: osteoblastic metastases - proliferative bony lesions of increased density
4. The anterior projecting bony process of the sacrum that forms part of the inlet of the true pelvis is the: A) promontory of the sacrum B) body of S1 C) apex of coccyx D) sacral foramina.
A) promontory of the sacrum pg. 327: the anterior ridge of the body of the first sacral segment helps form the posterior wall of the inlet of the true pelvis and is termed the promontory.
Fig. 9.3 Lumbar vertebra-posterior and anterior view.
A) spinous process B) inferior articular process C) pars interarticularis D) transverse process E) superior articular process
Fig. 9.15 & 9.16 The "Scottie dog", oblique lumbar spine.
A) transverse process B) pedicle C) pars interarticularis (neck) D) inferior articular process E) superior articular process F) zygapophyseal joint
32. The second projection for the Ferguson method of the scoliosis series requires that the concave side of the curve be built up 3 to 4 inches (8 to 10 cm) by placing blocks beneath the patient's foot. A. True B. False
A. False pg. 344: for the second image, place a block under the foot on the convex side of the curve.
15. T/F: A female is more likely to suffer a fracture of the coccyx due to a backward, sitting type of fall than a male. A. True B. False
A. True pg. 328: the most common injury associated with the coccyx results from a direct blow to the lower vertebral column when a person is in a sitting position ... because of the shape of the female pelvis and the more vertical orientation of the coccyx, a female patient is more likely to experience a fracture of the coccyx, than a male patient.
29. T/F: Bone densitometry produces very little skin dose to the patient. A. True B. False
A. True pg. 335: Bone densitometry is accurate within 1% and the radiation skin does is very low.
30. T/F: Conventional radiography does not detect bone loss from conditions such as osteoporosis until bone mass has been reduced at least 30%. A. True B. False
A. True pg. 335: Conventional radiography dose not detect loss of bone until bone mass has been reduced by at least 30%.
28. T/F: MRI (magnetic resonance imaging) is superior to CT (computed tomography) for evaluation of spinal cord and intervertebral disks. A. True B. False
A. True pg. 335: MRI is superior for the evaluation of soft tissue structures of the lumbar spine (ex. spinal cord, intervertebral disk spaces.)
23. T/F: If the waist is supported properly, an average-size patient does not require any CR angulation for the lateral lumbar spine projection. A. True B. False
A. True pg. 339
24. T/F: If the patient has scoliosis, the convexity of the spine should be down toward the image receptor for the lateral spine projection. A. True B. False
A. True pg. 339: if the patient has lateral curvature (scoliosis) of the spine ... the patient should be placed in whichever lateral position places the convexity of the spine down to open the intervertebral joint spaces.
30. The AP and lateral projections for a pediatric scoliosis study should include the entire lumbar and thoracic spine. A. True B. False
A. True pg. 342: anatomy demonstrated - thoracic & lumbar vertebrae, including 1-2" of iliac crests.
59. T/F: The pelvis must remain stationary for the AP right and left bending projections of the scoliosis series. A. True B. False
A. True pg. 345: the pelvis must remain as stationary as possible during positioning. The pelvis acts like a fulcrum during changes in position.
63. T/F: The LPO position for sacroiliac joints will best demonstrate the right joint. A. True B. False
A. True pg. 352: LPO for right SI joint, RPO for left joint
26. What CR angulation should be used for an AP axial projection of the L5-S1 joint space on a male patient? A) 20° cephalad B) 30° cephalad C) 35° caudad D) 40° to 45° cephalad
B) 30° cephalad pg. 341: Male patient = 30° cephalad female patient = 35° cephalad
22. An average of ____ segment(s) make up the adult coccyx. A) 1 B) 4 C) 5 D) 3
B) 4 pg. 328: three to five coccygeal segments (an average of 4) fuse in the adult to form a single coccyx.
3. The zygapophyseal joints of the upper lumbar vertebrae are ____ in relationship to the midsagittal plane. A) 30° B) 50° C) 45° D) 90°
B) 50° pg. 326: the upper (proximal) lumbar vertebrae are nearer the 50° angle.
52. A young female patient comes to radiology for a scoliosis study. The patient has had this series performed frequently. How much will the breast dose be decreased if a PA rather than an AP projection is taken? A) 15% B) 90% C) 35% D) It will not make a significant difference with good collimation.
B) 90% pg. 342: a PA is highly recommended because of the significantly reduced dose to radio-sensitive areas such as the female breast & thyroid gland. Studies have shown that this projection results in approximately 90% reduction in dosage to the breasts.
39. Which of the following is a condition of unknown cause in which calcification of bony ridges between vertebrae occurs, creating a lack of mobility with a "bamboo" appearance? A) Scheuermann disease B) Ankylosing spondylitis C) Spondylolisthesis D) Osteoblastic type of metastases
B) Ankylosing spondylitis pg. 335: Ankylosing spondylitis - an inflammatory condition that usually begins in the SI joints and progresses up the vertebral column. The spine may become completely rigid as the intervertebral and costovertebral joints fuse. It is most common in men in their 30's. pg. 336: vertebral column becoming fused, appearance of a piece of bamboo, anterior longitudinal ligaments calcifying.
71. Which aspect of the Scottie dog is the pedicle? A) A B) B C) C D) D
B) B
74. Which labeled structure is the inferior articular process? A) A B) B C) C D) D E) E
B) B
17. The anterior oblique (RAO/LAO) positions of the lumbar spine will demonstrate the zygapophyseal joints closest to the image receptor. A. True B. False
B. False pg. 331: an anterior oblique visualizes the upside joints (i.e. the joints farthest from the IR)
53. A patient comes in with a possible compression fracture of L3. Which one of the following positioning routines would best demonstrate the body of L3 and the intervertebral joint spaces above and below it? A) Collimated R and L posterior oblique and AP projections B) Collimated PA and lateral projections C) Erect AP and lateral projections D) Collimated LPO and RPO positions
B) Collimated PA and lateral projections pg. 336: AP & lateral lumbar spine pg. 337: PA places the intervertebral spaces more closely parallel to the diverging rays.
46. A radiograph of an AP axial coccyx reveals that the symphysis pubis is superimposed over the distal end of the coccyx. Which of the following modifications will correct this problem during the repeat exposure? A) Decrease the CR angulation. B) Increase the CR angulation. C) Slightly oblique the patient. D) Ask the patient to empty her bladder.
B) Increase the CR angulation. pg. 348: technologist may have to increase the CR angle to 15° caudad with a greater anterior curvature of the coccyx.
20. Which of the following should be done to reduce scatter radiation from reaching the image receptor for the lateral lumbar, sacrum, and coccyx projections? A) Use a lower kV. B) Place a lead mat on the tabletop behind the patient. C) Increase the source image receptor distance (SID) to 44 inches (113 cm). D) Use a smaller image receptor.
B) Place a lead mat on the tabletop behind the patient. pg. 334: close collimation and placing a tabletop lead mat improves image quality by reducing scatter and secondary exposure to the highly sensitive digital image receptors.
12. What type of joint movement occurs with the zygapophyseal joints? A) Ginglymus B) Plane C) Ellipsoidal D) Trochoidal
B) Plane pg. 330: They are diarthrodial, or freely movable, with plane (gliding) type joint movement.
64. A radiograph of the left sacroiliac joint demonstrates it open and clearly seen. Which of the following positions was performed? A) LPO B) RPO C) RAO D) AP
B) RPO pg. 352: LPO for right SI joint, RPO for left joint
49. A patient comes to radiology for a study of the lumbar spine. The initial radiographs demonstrate potential pathology involving the L5-S1 zygapophyseal joint. Which of the following positions and/or projections would best demonstrate this joint space? A) Lateral L5-S1 position B) Right and left 30° oblique projections C) Right and left 50° oblique projections D) Closely collimated and lateral position of L5-S1 region
B) Right and left 30° oblique projections pg. 338: oblique lumbar spine - rotate the body 45° for general lumbar spine; rotate the body 50° for L1-L2 zygapophyseal joints; rotate the body 30° for L5-S1 zygapophyseal joints.
10. What is the joint classification of the zygapophyseal joints? A) Cartilaginous/amphiarthrodial B) Synovial/diarthrodial C) Fibrous/synarthrodial D) Symphyses/amphiarthrodial
B) Synovial/diarthrodial pg. 330: zygapophyseal joints are classified as synovial joints. These joints are lined with a synovial membrane. They are diarthrodial, or freely movable, with plane (gliding) type joint movement.
41. Sciatic type of pain resulting from a "slipped disk" indicates: A) spondylolisthesis. B) herniated nucleus pulposus. C) ankylosing spondylitis. D) spina bifida.
B) herniated nucleus pulposus pg. 335: HNP - also commonly known as herniated lumbar disk (slipped disk). Occurs most frequently at the L4-L5 levels, causing sciatica.
56. T/F: The use of digital radiography is not recommended for studies of the sacrum and coccyx. A. True B. False
B. False
61. T/F: AEC (automatic exposure control) should not be used for an L5-S1 lateral or a lateral sacrum and coccyx. A. True B. False
B. False
58. T/F: The "nose" of the Scottie dog represents the spinous process of a lumbar vertebra. A. True B. False
B. False pg. 330: One transverse process forms the nose
16. The Scottie dog sign is demonstrated with oblique projections of the thoracic and lumbar spine. A. True B. False
B. False pg. 330: can only see "Scottie dog" in the lumbar vertebrae.
27. T/F: Carefully placed gonadal shielding must always be used on female patients for the AP lumbar spine projection. A. True B. False
B. False pg. 333: gonadal shielding can and should always be used on male patients of reproductive age on coccyx, sacrum, or lumbar spine radiographs. If the area of interest includes the sacrum and/or coccyx, gonadal shielding for females may not be possible without obscuring essential anatomy.
9. T/F: The long axis of the sacrum is generally angled more posteriorly in males than females. A.) True B.) False
B.) False pg. 328: the long axis of the sacrum is angled posteriorly ... this angle is greater in an average woman as compared with an average man.
25. Which of the following statements is NOT true about the lateral L5-S1 projection? A) If the waist is not supported, the CR must be angled 5° to 8° caudad. B) A lead mat should be placed on the tabletop behind the patient, and there should be close collimation to improve image quality. C) A 14 x 17-inch (35 x 43-cm) IR should be used. D) The CR is centered 1.5 inches (3 to 4 cm) inferior to the iliac crest and 2 inches (5 cm) posterior to the ASIS.
C) A 14 x 17-inch (35 x 43-cm) IR should be used. pg. 341: CR perp. to IR with sufficient waist support, or angle the CR 5° to 8° caudad. High amounts of secondary radiation are generated as the result of part thickness Close collimation is essential, along with placement of a lead mat behind the patient. Direct CR 1.5" inferior to the iliac crest and 2" posterior to ASIS. IR size 8" x 10"
65. Radiographs of oblique projections of the SI joints do not clearly demonstrate the inferior/distal aspect of the joints. What can the technologist do to better demonstrate this region? A) Increase rotation of the pelvis. B) Initiate exposure upon expiration. C) Angle CR 15° to 20° cephalad. D) Perform positions erect.
C) Angle CR 15° to 20° cephalad. pg. 352: to demonstrate the inferior or distal part of the joint more clearly, the CR may be angled 15° to 20° cephalad.
6. Which specific aspect of the sacrum articulates with the ilium to form the sacroiliac joint? A) Promontory B) Cornu C) Auricular surface D) Inferior articular processes
C) Auricular surface pg. 327: the sacrum articulates with the ilium of the pelvis at the auricular surface to form the SI joints.
73. Which labeled structure is the pars interarticularis? A) A B) B C) C D) D E) E
C) C
57. Which of the following fractures is due to a hyperflexion force injury? A) Compression fx B) Burst fx C) Chance fx D) Metastatic fx
C) Chance fx pg. 335: Chance - results from hyperflexion force that causes fracture through the vertebral body and posterior elements. Patients wearing lap-type seat belts are at risk because these belts act as a fulcrum during sudden deceleration.
47. A radiograph of an AP axial L5-S1 projection reveals that the joint space is not open. The following factors were used on this female patient: 80 kV, 40-inch (102 cm) SID, grid, 35° caudad angle, and CR centered to the ASIS. Which of the following factors needs to be modified to produce a more diagnostic image? A) Increase the CR angulation. B) Decrease the CR angulation. C) Change the direction of the CR angulation. D) Center the CR higher to place it parallel to the joint space.
C) Change the direction of the CR angulation. pg. 341: CR should be angled 35° cephalad
45. A radiograph of an AP axial sacrum reveals that it is foreshortened and the sacral foramina are not clearly seen. The patient was in an AP supine position, and the technologist angled the CR 10° cephalad. What specific positioning error is present on this radiograph? A) Excessive CR angulation B) Rotation of the sacrum C) Insufficient CR angulation D) Wrong direction of the CR angle
C) Insufficient CR angulation pg. 347: CR should be angled 15° cephalad
50. A patient comes to radiology for a study of the lumbar spine. He has a clinical history of spondylolisthesis of L5. Which of the following projections will best demonstrate the severity of this condition? A) 30° oblique projections B) 50° oblique projections C) Lateral L5-S1 projection D) AP axial L5-S1 projection
C) Lateral L5-S1 projection pg. 340: Lateral L5-S1 clinical indications - spondylolisthesis involving L4-L5 or L5-S1.
43. What CR angle should be used for a lateral sacrum/coccyx projection? A) 15° cephalad B) 30° cephalad C) None. CR is perpendicular to the image receptor. D) 10° cephalad
C) None. CR is perpendicular to the image receptor pg. 349: CR is perpendicular to the IR
40. An anterior wedging of vertebrae with a loss of body height but rarely causing neurologic symptoms is called: A) a teardrop burst fracture. B) a chance fracture. C) a compression fracture. D) spondylolysis.
C) a compression fracture pg. 335: compression fracture - the superior and inferior surface of the vertebral body are driven together, producing a wedge-shaped vertebra. This type of fracture rarely causes neurological deficit.
11. The intervertebral joints in the lumbar spine are classified as: A) synovial/diarthrodial. B) fibrous/synarthrodial. C) cartilaginous/amphiarthrodial. D) fibrous/amphiarthrodial.
C) cartilaginous/amphiarthrodial. pg. 330: These joints, which are tightly bound by cartilage, are classified as cartilagenous joints. They are amphiarthrodial (slightly movable) joints of the symphysis subclass.
5. Another term for the sacral horns is the: A) base of the sacrum B) promontory of the sacrum C) cornu of the sacrum D) median sacral crest.
C) cornu of the sacrum pg. 327: the sacral horns (cornua) are small tubercles that represent the inferior articular processes projecting inferiorly from each side of the fifth sacral segment. They project inferiorly and posteriorly to articulate with the corresponding horns (cornua) of the coccyx.
60. For a lateral L5-S1 projection, the CR must be parallel to the: A) midsagittal plane. B) midcoronal plane. C) interiliac line. D) transverse plane.
C) interiliac line pg. 340: CR is perp. to IR with sufficient waist support, or angle the CR 5° to 8° caudad with less support ... the CR must be parallel to the interiliac line.
34. Where is the CR centered for an AP axial projection of the sacrum? A) At the level of the ASIS B) At the level of the symphysis pubis C) 1 to 1 1/2 inches (3 to 4 cm) below the iliac crest D) 2 inches (5 cm) above the symphysis pubis
D) 2 inches (5 cm) above the symphysis pubis pg. 347: direct CR 2" superior to pubic symphysis
62. How much obliquity of the body is required for posterior oblique positions for the sacroiliac joints? A) 45° B) 10° to 15° C) 60° to 70° D) 25° to 30°
D) 25° to 30° pg. 352: rotate the body into a 25° to 30° posterior oblique, with the side of interest elevated.
18. The average degree of rotation required to demonstrate the L3-4 zygapophyseal joints is: A) 50° B) 30° C) 20° to 25° D) 45°
D) 45° pg. 331: A 45° oblique is used for the general lumbar region, but if interest is specifically focused on L1 or L2, the degree of rotation may be increased to 50°. If interest is in the L5-S1 area, rotation may be decreased to 30°.
1. The intervertebral foramina of the lumbar spine are located at an angle of _____ in relation to the midsagittal plane. A) 45° B) 30° to 35° C) 70° to 75° D) 90°
D) 90° pg. 326: see fig 9.2, the interverterbal foramen are situated 90 degrees relative to the MSP
55. A female patient is brought to the emergency department (ED) because of a MVA (motor vehicle accident). Her chief complaint is pain in the lower lumbar region. The ED physician orders a lumbar series. Upon questioning, the technologist learns that the patient is pregnant. The ED physician is made aware of the pregnancy but still wants the lumbar spine series performed. What can the technologist do to minimize dose to the fetus and mother? A) Use higher kV than normal, reduce mAs accordingly. B) Use smallest IR possible. C) Collimate as much as feasible. D) All of the above should be done.
D) All of the above should be done
19. Why should the hips and knees be flexed for an anteroposterior (AP) projection of the lumbar spine? A) For patient comfort B) To reduce the lumbar curvature C) To demonstrate any possible spondylolisthesis D) Both A and B
D) Both A and B pg. 333: AP projections of the lumbar spine are obtained with the knees flexed. Flexing the knees reduces the lumbar curvature (lordosis), bringing the back closer and more parallel to the IR. Flexing the knees allows for greater patient comfort.
38. A fracture through the vertebral body and posterior elements caused by lap seat belts during an auto accident involving sudden deceleration is a ____ fracture. A) compression B) Jefferson C) teardrop burst D) Chance
D) Chance pg. 335: Chance - results from hyperflexion force that causes fracture through the vertebral body and posterior elements. Patients wearing lap-type seat belts are at risk because these belts act as a fulcrum during sudden deceleration.
68. Which aspect of the Scottie dog is the inferior articular process? A) A B) B C) C D) D
D) D
13. Which of the following topographic landmarks corresponds with the L4-5 vertebral level? A) Xiphoid process B) Lower costal margin C) Anterior superior iliac spine (ASIS) D) Iliac crest
D) Iliac crest pg. 332: the iliac crest is at approximately the same level as the junction of the fourth and fifth lumbar vertebrae.
44. A radiograph of a lateral projection of the lumbar spine reveals that the mid- to lower-intervertebral joint spaces are not open. The patient's waist was supported. Which of the following modifications will help open these joint spaces during the repeat exposure? A) Increase the SID for less divergence of the x-ray beam. B) Decrease waist support and/or angle the CR 5° to 8° cephalad. C) Have the patient hold her breath on a deeper inspiration to expand the thorax and straighten the spine. D) Increase waist support and/or angle CR 5° to 8° caudal.
D) Increase waist support and/or angle CR 5° to 8° caudal. pg. 339: a patient with a wider pelvis and narrow thorax may require a 5° to 8° caudad angle even with support.
2. The small section of bone found between the superior and inferior articular processes of the lumbar spine is termed: A) pillar B) transverse processes C) articular facets D) pars interarticularis
D) pars interarticularis pg. 326: the portion of each lamina between the superior and inferior articular processes is the pars interarticularis.
42. An abnormal lateral curvature of the spine is a congenital condition termed: A) spina bifida. B) spondylolisthesis. C) lordosis. D) scoliosis.
D) scoliosis pg. 335: scoliosis - lateral curvature of the vertebral column that usually occurs with some rotation of the vertebrae. Involves both thoracic and lumbar regions.
36. The radiographic appearance on an oblique lumbar spine in which the neck of the Scottie dog appears broken suggests the presence of: A) spondylolisthesis. B) spina bifida. C) compression fracture. D) spondylolysis.
D) spondylolysis. pg. 335: on the oblique projection, the neck of the Scottie dog appears broken. It is most common at L4 & L5.
14. Which one of the following structures is located at the level of the ASIS? a. S1-2 b. Tip of coccyx c. Promontory of sacrum d. L4-5
a. S1-2 pg. 332: the ASIS is approximately the same level as the first or second sacral segment.