Chapter 19: Special Radiographic Procedures

Which of the following is generally true for knee arthrography?

a. A common nontrauma clinical indication is a Baker's cyst.

b. A minimum of 20 mL of positive contrast media is introduced into joint.

c. During fluoroscopy, views are taken of each meniscus with the knee rotated 30°

between exposures.

d. The amount of aspirated joint (synovial) fluid should equal the amount of injected

contrast media.

a. A common nontrauma clinical indication is a Baker's cyst.

Pg. 729: An example of a nontraumatic pathologic process for which arthrography is indicated is Baker cyst, which communicates with the joint capsule in the popliteal area.

What imaging modality is most frequently used to study the soft tissue structures of the

temporomandibular joint?

a. Computed tomography (CT)

b. Magnetic resonance imaging (MRI)

c. Conventional radiography

d. Ultrasound

b. Magnetic resonance imaging (MRI)

Which of the following instruments is not required during a knee arthrogram?

a. Sterile gauze

b. 10-mL syringe

c. 20-gauge needle

d. Arthroscope

d. Arthroscope

uArthrogram tray

uPrep sponge

uFenestrated drape

uSyringes

uFlexible connector

uNeedles

During an arthrogram, why is the knee flexed following injection of contrast media

before imaging?

a. To reduce the viscosity of the contrast media

b. To force the contrast media outside of the joint if there is a tear

c. To coat the soft tissue structures with contrast media

d. None of the above; the knee should not be flexed during an arthrogram after

injection of contrast media.

c. To coat the soft tissue structures with contrast media

pg.729 When all fluid has been aspirated, the contrast agent or agents are injected into the joint. With the contrast agent injected, the knee is gently flexed, which produces a thin, even coating of the soft tissue structures with the positive medium.

A common fluoroscopy routine for knee arthrography is:

a. nine views of each meniscus rotated 20° between exposures.

b. nine views total of each knee rotated 20° between exposures.

c. six views each of lateral and medial menisci rotated 20° between exposures.

d. horizontal beam projections, six exposures per knee.

a. nine views of each meniscus rotated 20° between exposures.

Pg. 730: During fluoroscopy, the radiologist usually take a series of closely collimated views of each meniscus, rotating the leg approximately 20 degree between exposures. Te result is nine spot images of each meniscus, which demonstrates the meniscus in profile throughout its diameter.

Which of the following is not an indication for knee arthrography?

a. Injury or tears to rotator cuff

b. Evaluate for Baker's cyst

c. Injury or tears to collateral or cruciate ligaments

d. Injury or tears to menisci

a. Injury or tears to rotator cuff

pg. 729

Knee arthrography is indicated when tears of the joint capsule, menisci, or ligaments are suspected. The knee is subject to considerable stress, especially during sports activities, and many of the pathologic processes that occur in the knee are due to trauma.

An example of a nontraumatic pathologic process for which arthrography is indicated is Baker cyst, which communicates with the joint capsule in the popliteal area.

Pg . 731

Arthrography of the shoulder uses single-contrast or double-contrast injection to demonstrate the joint capsule, rotator cuff (formed by conjoined tendons of four major shoulder muscles), long tendon of the biceps muscle, and articular cartilage (Fig. 19.11).

What size needle is used to introduce the contrast media during a shoulder arthrogram?

a. 2 inches, 16 gauge

b. 1 1/2 inches, 18 gauge

c. 2 inches, 25 gauge

d. 2 3/4- to 3 1/2-inch spinal needle

d. 2 3/4- to 3 1/2-inch spinal needle

Pg.731

NEEDLE PLACEMENT AND INJECTION PROCESS

The injection site, directly over the joint, is prepared as in any arthrographic procedure (Fig. 19.12). After the area has been anes-thetized, the physician uses fluoroscopy to guide the needle into the joint space. Because the joint is quite deep, a spinal needle (2¾ to 3½ inches [~7 to 9 cm]) must be used.

Which of the following projections would NOT be commonly performed during a

shoulder arthrogram?

a. Anteroposterior external/internal rotation projections

b. Scapular Y projection

c. Glenoid fossa projection

d. Transaxillary projection

b. Scapular Y projection

Pg. 731

A suggested imaging sequence can include scout AP projections, with internal and external rotation as stan-dard, and a glenoid fossa, transaxillary, or intertubercular

What is the most common clinical indication for a postoperative (T-tube)

cholangiogram?

a. Jaundice

b. Pancreatitis

c. Chronic cholecystitis

d. Residual calculi

d. Residual calculi

Pg. 732

PURPOSE

Postoperative cholangiography, also termed T-tube or delayed cholan-giography, is usually performed in the radiology department after a cholecystectomy. The surgeon may be concerned about residual stones

The patient must be NPO ____ hours (minimum) before a postoperative (T-tube)

cholangiogram.

a. 4

b. 6

c. 8

d. 12

c. 8

Pg. 732

The patient should be placed in a hospital gown and should be kept NPO (nothing by mouth) for at least 8 hours before the procedure.

The majority of ERCP procedures are performed by a:

a. radiologist.

b. radiologic technologist.

c. gastroenterologist.

d. surgeon.

c. gastroenterologist.

Pg. 733

For diagnostic purposes, the ERCP procedure generally includes endoscopic insertion of the catheter or injection cannula into the common bile duct or main pancreatic duct under fluoroscopic control, followed by retrograde injection (backward or reverse direc-tion) of contrast media into the biliary ducts. The procedure is usually performed by a gastroenterologist, who is assisted by a team that comprises the technologist, one or more nurses, and perhaps a

Which of the following conditions is often a contraindication for an ERCP?

a. Pseudocyst

b. Biliary stenosis

c. Hepatitis

d. Cirrhosis

a. Pseudocyst

Pg733

Primary contraindications to ERCP include hypersensitivity to iodinated contrast medium, acute infection of the biliary system, possible pseudocyst of the pancreas, and elevated creatinine or BUN levels.

Which of the four divisions of the uterus is the largest?

a. Fundus

b. Corpus (body)

c. Isthmus

d. Cervix

b. Corpus (body)

Pg. 734

The corpus (body) is the larger central component of the uterine tissue

The uterine (fallopian) tubes are approximately ____ cm in length.

a. 3 to 4

b. 6 to 8

c. 10 to 12

d. 15 to 18

c. 10 to 12

pg. 734

The uterine (fallopian) tubes communicate with the uterine cavity from a superior lateral aspect between the body and fundus. This region of the uterus is referred to as the cornu. The uterine tubes are approximately 4 to 43 inches (10 to 12 cm) in length and fl to 4mm in diameter.

Which of the four segments of the uterine tube communicates with the uterine cavity?

a. Interstitial

b. Isthmus

c. Ampulla

d. Infundibulum

a. Interstitial

Pg. 734

The proximal portion of the tube, the interstitial segment, communicates with the uterine cavity.

The fingerlike extensions termed fimbriae connect to which part of the uterine tube?

a. Interstitial

b. Isthmus

c. Ampulla

d. Infundibulum

d. Infundibulum

Pg. 734

The most distal end, the infundibulum, contains fin-gerlike extensions termed fimbriae, one of which is attached to each ovary. (4)

Which part of the uterine tube opens into the peritoneal cavity?

a. Isthmus

b. Interstitial

c. Infundibulum

d. None of the above

c. Infundibulum

Pg. 734.

The distal infundibulum portion of the uterine tubes containing

the fimbriae opens into the peritoneal cavity.

The purpose of the hysterosalpingography is to demonstrate the:

a. interior of the cervix, uterus, uterine tubes, and ovaries.

b. interior of the uterus for neoplasms or other abnormalities.

c. uterine cavity and the patency of the uterine tubes.

d. degree of openness of the cornu between the uterus and uterine tubes.

c. uterine cavity and the patency of the uterine tubes.

Pg. 734

HSG is the radiographic demonstration of the female reproductive tract with a contrast agent. The radiographic procedure best demonstrates the uterine cavity and the patency (degree of open-/ ness) of the uterine tubes.

Which of the following is a contraindication to hysterosalpingography?

a. Pregnancy

b. Active uterine bleeding

c. Pelvic inflammatory disease

d. All of the above

d. All of the above

Pg. 735

Pregnancy is a contraindication to HSG. To avoid the possibility the patient may be pregnant, the examination is typically performed 7 to 10 days after the onset of menstruation.

Other contraindications include acute pelvic inflammatory dis-

ease and active uterine bleeding.

The preferred contrast medium for hysterosalpingography is:

a. positive, ionic, oil based.

b. positive, nonionic, water soluble.

c. negative carbon dioxide gas.

d. thin barium sulfate.

b. positive, nonionic, water soluble.

Pg. 735

Contrast Media

Radiopaque (positive) iodinated contrast media is used for an HSG.

Water-soluble iodinated contrast medium is preferred.

Imaging for a hysterosalpingography includes centering of the CR and image receptor

(IR) to:

a. 4 inches (10 cm) superior to the symphysis pubis.

b. the symphysis pubis.

c. the level of the ASIS.

d. 2 inches (5 cm) superior to the symphysis pubis.

d. 2 inches (5 cm) superior to the symphysis pubis.

Pg. 736

A radiographic AP scout image may be obtained with a 10 × 12-inch (24 x 30-cm) recommended field size. The central ray (CR) and IR are centered to a point 2 inches (5 cm) superior to the symphysis pubis.

Which of the following is NOT a valid radiographic criterion for

hysterosalpingography?

a. Cannula or balloon catheter should be seen within the cervix.

b. Ovaries should be opacified and well demonstrated.

c. Contrast medium should be seen within the peritoneum.

d. The pelvic ring should be centered within the collimation field.

b. Ovaries should be opacified and well demonstrated.

Pg. 736

EVALUATION CRITERIA

• The pelvic ring as seen on an AP projection should be centered within the collimation field.

• The cannula or balloon catheter should be seen within the cervix.

• An opacified uterine cavity and uterine tubes are seen centered to the IR (see Fig. 19.27).

• Contrast medium is seen within the peritoneum if one or both uterine tubes are patent.

• Optimal image receptor exposure and contrast to demonstrate anatomy and contrast medium.

• Ror L marker should be visualized without superimposition of anatomy.

Where is the contrast media instilled during a myelogram?

a. Subarachnoid space

b. Epidural space

c. Subdural space

d. Spinal cord

a. Subarachnoid space

Pg, 737

A myelogram (mi-e-lo-gram) is a radiographic study of the spinal cord and its nerve root branches that uses a contrast medium.

The spinal cord and nerve roots are outlined by injection of a contrast agent into the subarachnoid space of the spinal canal.

What is the most common clinical indication for a myelogram?

a. Benign tumors

b. Malignant tumors

c. Herniated nucleus pulposus

d. Increased intracranial pressure

c. Herniated nucleus pulposus

pg. 737

. The lesions most commonly demonstrated by myelography include herniated nucleus pulpo-sus, which is the most common clinical indication for myelog-raphy; cancerous or benign tumors; cysts; and (in the case of trauma) possible bone fragments.

Myelography is often contraindicated if a lumbar puncture has been performed within

the previous:

a. 2 weeks.

b. 3 weeks.

c. 30 days.

d. 6 months.

a. 2 weeks.

Pg. 737

• Recent lumbar puncture (within two weeks of the current procedure) : Performing myelography on a patient who has had a recent lumbar puncture may result in extravasation of the contrast medium outside the subarachnoid space through the hole left by the previous puncture.

Which of the following is a contraindication for myelography?

a. Arachnoiditis

b. Blood in the CSF

c. Increased intracranial pressure

d. All of the above

d. All of the above

Pg. 737

Contraindications

The following are contraindications to myelography:

• Blood in the cerebrospinal fluid (CSF): The presence of blood in the CSF indicates probable irritation within the spinal canal, which can be aggravated by the contrast medium.

• Arachnoiditis (inflammation of the arachnoid membrane):
  Myelography is contraindicated in the case of arachnoiditis because the contrast medium may increase the severity of the inflammation.

• Increased intracranial pressure: In cases of elevated intracranial pressure, tapping of the subarachnoid space with needle insertion may cause severe complications to the patient as the pressure equalizes between the areas of brain and spinal cord.
  Recent lumbar puncture (within 2 weeks of the current pro-

What is the most common injection site for a myelogram?

a. C1-2

b. T12

c. L4-5

d. L3-4

d. L3-4

Pg. 738

Introduction of contrast media for myelography is accomplished via puncture of the subarachnoid space. Generally, two locations are used as puncture sites: the lumbar (L3-L4) and cervical (C1-C2) areas (Fig. 19.30). Of these two locations, the lumbar area is safer and easier on the patient and is used most often for the procedure.

During a myelogram performed with the patient prone, why is a positioning block

(bolster) placed under the abdomen for the lumbar puncture?

a. To force the contrast media toward the head

b. For patient comfort

c. To widen the interspinous spaces

d. To prevent reflux of contrast media back into the syringe

c. To widen the interspinous spaces

Pg, 738

For a cisternal puncture, the patient may be seated in an erect position (Fig. 19.32) or prone, with the head flexed to open the interspinous space.

Other than prone, what additional position is recommended for a cisternal puncture?

a. Erect-seated

b. Left lateral decubitus

c. Right lateral decubitus

d. Trendelenburg

a. Erect-seated

Pg, 738

For a cisternal puncture, the patient may be seated in an erect position (Fig. 19.32) or prone, with the head flexed to open the interspinous space.

How is the water-soluble contrast media eliminated following a myelogram?

a. Withdrawn through a needle/syringe

b. Remains in the spinal canal

c. Excreted by the kidneys

d. Excreted by the lungs

c. Excreted by the kidneys

Pg. 737

Water-soluble contrast media provide excellent radiographic visualization of the nerve roots, are easily absorbed into the vascular system, and are excreted by the kidneys.

What is an average dosage of contrast media given during a myelogram?

a. 1 to 2 mL

b. 3 to 4 mL

c. 9 to 15 mL

d. 20 to 24 mL

c. 9 to 15 mL

Pg. 738

The dosage for myelographic contrast media is recommended by the manufacturer and varies with the concentration of the medium used and the area of the spine under examination. Generally, a range of approximately 9 to 15 mL is used.

What is the most common type of contrast media given during a myelogram?

a. Iodinated, oil based

b. Room air

c. Carbon dioxide

d. Nonionic, water soluble

d. Nonionic, water soluble

Pg. 737

None of the currently available commercial contrast media meet all these criteria. In the past, air or gas (radiolucent) and oil-based iodinated (radiopaque) media were used for myelography. However, nonionic, water-soluble, iodine-based media are primarily used at the present time because of their relatively low osmolality (see Chapter 14).

The suggested positioning routine for lumbar myelography is:

a. patient prone: semierect horizontal beam lateral, left and right lateral decubitus (AP

and PA), and PA projection.

b. patient on side: right lateral decubitus (AP) and left lateral decubitus (PA).

c. patient prone: semierect horizontal beam lateral.

d. patient supine: semierect AP and horizontal beam lateral.

c. patient prone: semierect horizontal beam lateral.

Ph. 738

Two body positions generally are used for a lumbar puncture.

The patient may be prone, with a firm pillow or large positioning block placed under the abdomen to flex the spine (Fig. 19.31), or may lie in a left lateral position with the spine flexed.

Why is the supine AP projection rarely taken during a thoracic spine myelogram?

a. Patient discomfort at puncture site

b. Contrast media may leak from puncture site

c. Contrast media tend to pool near the midthoracic region

d. Excessive radiation exposure to anterior chest structures

c. Contrast media tend to pool near the midthoracic region

Pg. 740

NOTE: A supine AP and a horizontal beam lateral are generally not recommended; in the supine position, pooling of contrast medium occurs in the midthoracic region as a result of the usual thoracic curvature.

Which of the following is a suggested conventional positioning routine for cervical

myelography following fluoroscopy and spot imaging?

a. Patient prone: PA lateral, swimmer's lateral, and one lateral decubitus-horizontal

beam

b. Patient on side: right lateral decubitus (AP) and left lateral decubitus (PA)

c. Patient prone: PA horizontal beam and swimmer's lateral of C6 or C7

d. Patient prone: horizontal beam lateral (centered to C4-5) and swimmer's horizontal

beam lateral (centered to C7)

d. Patient prone: horizontal beam lateral (centered to C4-5) and swimmer's horizontal

beam lateral (centered to C7)

Pg. 739

(Figs. 19.37 and 19.38)

• The patient is positioned prone, with the chin extended

• For a right lateral, the right arm is extended along the right side of the body, with that shoulder depressed. The left arm is flexed (i.e., stretched superior to the head)

• The CR is directed to the level of C7.

• The field is collimated to reduce scatter radiation.

• Respiration is suspended during the exposure.
  NOTE: Additional positions may include anterior oblique projections.

The literal definition of orthoroentgenography is:

a. long bone measurement.

b. straight or right angle to radiography.

c. joint radiography.

d. extremity study.

b. straight or right angle to radiography.

The chief disadvantage of CT scanograms as compared with orthoroentgenography is:

a. distortion of joints due to penumbra.

b. artifacts from special ruler placed in gantry.

c. CT involves high cost and specialized equipment.

d. CT produces a poor image of bones.

c. CT involves high cost and specialized equipment.

What is the name of the special ruler used in orthoroentgenography?

a. Long bone ruler

b. Shepard-Logan ruler

c. Bell-Thompson ruler

d. Myer-Smith ruler

c. Bell-Thompson ruler

ppt.

u“Bell-Thompson” ruler with radiopaque markings beside limb

Which of the following factors is most critical when performing

orthoroentgenography?

a. The patient should not move between exposures.

b. Short exposure time techniques must be used.

c. A long source IR distance (SID) must be used for less beam divergence.

d. Both right and left limbs must be examined at the same time for length

comparisons.

a. The patient should not move between exposures.

Which one of the following is not a factor that directly controls or influences the

amount of tomographic blurring?

a. Size of anatomy

b. Tomographic angle

c. Object-IR distance

d. Exposure angle

a. Size of anatomy

The pivot point between the x-ray tube and IR in a tomographic system is termed:

a. amplitude.

b. fulcrum.

c. tube trajectory.

d. objective plane.

b. fulcrum.

The total distance the x-ray tube travels is termed:

a. tomographic angle.

b. fulcrum.

c. objective plane.

d. fulcrum level.

a. tomographic angle.

Objects within the body that are farther from the objective plane have:

a. greater movement.

b. increased blurring.

c. less blurring.

d. both A and B.

d. both A and B.

Which of the following procedures is the most common application of conventional

tomography?'

a. Intravenous urography

b. Long bone studies

c. Sternum studies

d. Vertebral column studies

a. Intravenous urography

Objects within the objective plane will appear:

a. blurred.

b. sharper and in relative focus.

c. as radiolucent densities.

d. as streaks.

b. sharper and in relative focus.

Which of the following exposure angles will produce the thinnest sectional thickness?

a. 10°

b. 20°

c. 30°

d. 40°

d. 40°

Objects within the body above and below the focal plane appear blurred because:

a. they are not placed parallel to the direction of tube travel.

b. their images move from one part of the IR to another as the tube and IR move through their travel during the exposure.

c. they are situated too close to the focal plane.

d. the body part is too large for sufficient penetration of x-rays.

b. their images move from one part of the IR to another as the tube and IR move through their travel during the exposure.

Another term for tomography is:

a. computed tomography.

b. orthoroentgenography.

c. body section radiography.

d. orthostatic radiography.

c. body section radiography.

T/F: Intercondylar fossa projections are often required during a conventional knee

arthrogram.

False

T/F: CT and MRI arthrography has significantly reduced the number of radiographic

arthrograms performed.

True

T/F: An endoscopic retrograde cholangiopancreatography (ERCP) can either be a diagnostic or a therapeutic procedure.

True

Pg. 733

T/F: The technologist must follow standard precautions when handling bile.

True

T/F: The patient must remain NPO (nothing by mouth) a minimum of 8 hours following an

ERCP.

False

Pg. 733

The patient should be placed in a hospital gown and should be kept NPO for a least 8 hours before the procedure

T/F: Arachnoiditis is a clinical indication for a myelogram procedure.

False

Pg. 737

Contradictions

T/F: Most disk pathology of the spine occurs in the cervical and lumbar regions.

True

T/F: long bone measurement of the lower limb requires that the entire lower limb be included on a s single radiograph .

False

T/F: Gonadal shielding cannot be used for long bone measurement of the lower limb for

males or females.

False

A long-leg/lower-limb measurement does not require the entire lower limb to fit on a single radiograph.

• The limb is usually imaged in multiple sections because the entire lower extremity is too long for one IR.

• The images are then joined together (stitched) to make one long image for measurement.

T/F: The wrist should be placed into the pronated PA position for a long bone study of the

upper limb.

False

T/F: Lower limb orthoroentgenograms should be performed nongrid.

False

T/F: Linear tomography is primarily used for studies of the temporal bones.

False

T/F: The primary factor affecting the sectional thickness, as controlled by the operator, is

exposure angle.

True

T/F: More blurring occurs with a shorter exposure angle.

False