The SKULL

Technique

Denise Ogilvie
January 2011
 Learning Objectives
• Demonstrate a knowledge of surface anatomy
of the head
• Demonstrate a knowledge of anatomy,
pathology and physiology of the skull.
• Be able to position a patient's head to produce
routine skull views
• Demonstrate an ability to recognise normal and
abnormal radiographic appearances of the skull.
• Know the planes and points of the skull that are
necessary for positioning
 Learning Objectives
• Explain technical evaluation (critique) and
image evaluation (pathology) of the skull
• Understand and be able to identify and use
equipment required to x-ray a head
 Planes and Points of the Skull
• Midsagittal Plane – vertical plane dividing the
skull into 2 symmetrical halves
• Interorbital (Interpupillary) Line – line between
the centre of the orbits
• Infraorbital Line – a line between the inferior
bony margins of the orbits
BASELINE
• Orbito-meatal baseline (OMBL) or Radiographic
Baseline- from outer canthus of eye to centre of
EAM
 Planes and Points of the Skull
• Infraorbitomeatal baseline-IOMBL-inferior orbital
margin to EAM-[Frankfort Plane]
• Nasion (Naso frontal Articulations) – junction of
nasal and frontal bones
• Glabella – approximately 1cm above the nasion
between the supra-orbital ridges
• EAM
• Acanthion – under nose
• Occipital Protuberance
• Auricular Line – vertical line through EAM
Planes and Points of the Skull
Planes and Points of the Skull
 Skull Series
• There are 2 main series to consider. The choice
of a series will depend on the clinical information.
• Trauma Series: PA or AP
• Townes
• Lateral Horizontal Beam
• Neurological PA 20
• Series: Lateral
• Townes
• SMV (Basal)
 Neurological Skull Series
PA 20
• Patient prone or erect
• Use erect, table bucky 20°

or stationary grid
• 24 x 30 IR portrait
• Patient’s chin down
slightly so base line at
90° to IR – forehead,
nose
• Midsagittal plane 90° to
IR
 Neurological Skull Series
• Angle tube 20° caudad
centering through the
nasion
20°
 Neurological Skull Series
• Show entire skull
• No rotation-lateral border of orbits
equidistant both side
• Petrous ridge in lower 1/3 of orbits
 Neurological Skull Series
Townes
• Patient supine or erect
• 24 x 30cm IR portrait
• Median sagittal plane
vertical and baseline
perpendicular to IR(chin
down)
• Centre to the hairline (he
he) or 6cm above the
nasion 30° caudal so central
ray passes through EAMs
 Neurological Skull Series
• Place the top of the IR
level with the top of the
head. This does not
necessarily correspond
with the Central ray. If
you don’t do this you
may chop off the top of
the skull
 Neurological Skull Series
 No rotation - petrous
bones symmetrical
and equal distance
from the lateral
border of the skull to
the foramen magnum
 Dorsum sellae and
posterior clinoid
process should be
seen in foramen
magnum
 Neurological Skull Series
Lateral
• Done erect,, supine (hori ray)
or prone
• 24 x 30cm IR landscape
• Facing erect bucky or lying
prone, turn head to either
side, raising shoulder and
supporting body
• Generally side of interest
closest to film
 Neurological Skull Series
• Guide head into true
lateral by having one
hand controlling
mandible and other
hand on upper parietal
region.
• Midsagittal plane
parallel to IR and
interpupillary line
perpendicular to IR
 Neurological Skull
Series
• Centre with straight
tube 5cm superior to
the EAM or midway
between glabella and
occipital protuberance
• Due to different body
types and states you
may have to alter and
support the patient in
different ways
 Neurological Skull Series
• Entire skull shown
• Superimposed rami of
mandible
• Orbital roofs
superimposed
• EAM’s superimposed
• Mastoids superimposed
• TMJ’s superimposed
 Neurological Skull
Series
SMV-submento-vertical
(Basal)
 Patient lies supine with a
pillow under shoulders
 Head tilted backwoods so
vertex of skull on table
top so the
Infraorbitomeatal
Baseline [IOMBL]parallel
to table top
 Median sagittal plane
Neurological Skull
Series
SMV - Erect
 Patient sitting in chair,
back to bucky ,small
distance forward, head
tilted back so vertex
against bucky
 Easier to perform
 IOMBaseline parallel to IR
if possible
 Centre between angles of
mandible through the
EAMs perpendicular to
the IOMBL
 Neurological Skull Series
• Mandibular condyles
equidistant to lateral
border of skull
• Symphysis Menti
superimposed over
anterior frontal bone
• No rotation
• Sufficiently penetrated to
see structures within
petrous bones
 Trauma Skull Series
AP
• Patient supine or back
to erect bucky
• 24 x 30cm IR portrait
• Same as PA view with
some magnification of
orbits
• Base line 90° to IR tube
straight center to
nasion
 Trauma Skull Series
• No rotation
• Petrous bones seen
filling orbits
• See more frontal skull
than 20 angulation
 Trauma Skull Series
PA
• This is same patient
positioning as PA 20
• Baseline 90°
• Centre to nasion with a
straight tube
• Less magnification of
orbits than AP
 Trauma Skull Series
• Petrous bone seen
through orbits
• No rotation

• Seeing more of frontal

bone
 Trauma Skull Series
Lateral Horizontal Ray
• Patient supine
• Elevate patient’s head on
small sponge
• Turn tube to horizontal
position
• 24 x 30cm IR with
stationary grid place to
side of patient and
supported with sponge or
other support
 Trauma Skull Series
• Centre with straight
tube 5cm superior to
EAM.
• Must do in trauma
cases to show any fluid
levels which may
indicate # or brain
damage involving
ventricles-leaking spinal
fluid
 References
• Ballinger, PW ,Merril’s Atlas of Radiographic
Positions & Radiologic Procedures, 10th edn
Vol 2
• Lecture Notes-Jane Shepherd
• Nowak, HP 2006, Radiographic Positioning
and Related Anatomy,1st edn