Additional Procedures

What are some of the additional procedures that you might be doing?

• arthrography

• hysterosalpingogram

• myelography

• sialography

• orthorentgenoraphy

• bone densitometry

• conventional tomography

What is arthrography?

Contrast media study of synovial joints and related soft tissue structures

What are the two most common arthrography procedures done?

• shoulders and knees

• TMJs used to be done frequently too

What has greatly reduced the need for arthrography?

MRI (however, still a useful way to see the soft tissue structures located near joints)

What must you have from the patient with any study involving the injection of a contrast medium?

Signed consent form

What are the pathological indication for arthrography?

• due to some type of trauma (tears of menisci or ligaments)

• non-trauma would be a baker’s cyst in the knee

What is the only contraindication for arthrography?

If the patient is allergic to the iodine-based contrast or to the local anethetics

What is the technologists responsibilities for arthrography?

• explaining the procedure to the patient

• getting the consent form signed

• room prep (fluoro is working, tray set up)

• have contrast ready for radiologist (single or double)

• assist radiologist

• after films- sometimes

What are the common joints studies for arthrography?

• hip

• knee

• ankle

• shoulder

• elbow

• wrist

• TMJ

Knee arthrography

• assesses knee joint and associated soft-tissue structures

• joint capsule, menisci, and ligaments

What are the indications for knee arthrography?

• tears in joint capsule

• tears or degeneration of menisci

• ligament injury

What are the contraindications for knee arthrography?

Hypersensitivity to iodine or local anesthetics

What is included in the arthrogram tray?

• prep sponge

• fenestrated drape

• syringes

• flexible connector

• needles

What are the steps of needle placement and injection for arthrography?

1. site prepared

2. skin anesthetized (numbbed)

3. fluid aspirated (not always needed)

4. contrast media instilled

5. needle removed and knee bandaged

6. knee exercised (helps disperse contrast)

How many ccs of positive and negative contrast are needed for arthrography?

5 cc of positive, 80-100 cc of negative

What does shoulder arthrography demonstrate?

Soft-tissue structures

How much positive and negative contrast is used for shoulder arthrography?

10-12 cc positive, 10-12 cc negative

What is needed for the needle placement for shoulder arthrography?

Fluoroscopic guidance

What is the positioning sequence for the shoulder arthrogram?

• scout AP projection

• internal and external rotation

• glenoid cavity (AP oblique)

• inferosuperior axiolateral or

• interubercular groove

What is a hysterosalpingography (HSG)?

Radiographic demonstration of the female reproductive tract with a contrast medium

What does the hysterosalpingography (HSG) demonstrate?

The uterus and the fallopian tubes (degree of openness) of the female reproductive system

What are the pathological indications for hysterosalpingography?

• infertility

• demonstrates any intrauterine pathology (lesions)

• to evaluate the fallopian tubes after a tubal ligation or reconstructive surgery has been done

What are the contraindications for hysterosalpingography?

Pregnancy, acute pelvic inflammatory disease and active uterine bleeding

Approximately how much contrast is injected for a hysterosalpingography?

10 ccs of a positive contrast

What are the technologists responsibilities for a hysterosalpingography?

• explaining the procedure to the patient

• consent form

• room prep (fluoro and tray set up)

• have contrast ready for the OB/rad

• assist the OB/rad with running the equipment and moving the pt

How would you know that a hysterosalpingography (HSG) is abnormal?

Contrast doesn’t spill out to ends of fallopian tubes

What is 1 pointing to?

Fundus

What is 2 pointing to?

Corpus (body)

What is 3 pointing to?

Isthmus

What is 4 pointing to?

Cervix (neck)

What else should you grab for the HSG kit that it usually doesn’t come with?

Separate cervical catheter/HSG catheter and a pad/feminine hygiene product for after exam

What type of procedure is this tray used for?

Hysterosalpingography

What should you see in your image for the HSG?

• pelvic ring centered

• cannula/catheter visible within cervix

• opacified uterine cavity and tubes visible

• contrast medium seen in peritoneum

What is myelography?

A radiographic stick of the spinal cord and its nerve root branches with a contrast medium

What has greatly reduced the number of myelograms done?

MRI and CT

True or false: for myelography sometimes the patient is admitted for the study and may leave later that same day

True

What are the pathological indications for myelography?

When a pt’s symptoms indicate the presence of a lesion, a herniated nucleus pulpous (most common reason), tumors, cysts, and bone fragments (trauma)

What are the contraindications for myelography?

• blood in the cerebrospinal fluid

• arachnoiditis

• increased intracranial pressure

• recent lumbar puncture (within 2 weeks)

What are the technologists responsibilities for myelography?

• explain the procedure to the patient, and consent signed

• room prep- trays, IRs, shoulder and foot harness, large pillow or sponge

• get contrast ready for doctor (make sure it’s the right one)

• assist doctor during procedure (moving pt, getting supplies, changing spot films, collecting CSF- mark vials as they come out)

• after films- shoot throughs and erect

• transport to CT

Why is knowing the needle placement for myelograms important?

The doctor may want the patient on their side, prone, or even sitting up

If your patient is prone for a myelogram what else do you need?

Sponge under their belly

How are the exams done for the myelogram?

• explain procedure to pt

• tell pt table will be moving during exam, including being angled to help move contrast through spine

• scout of lateral lumbar

• radiologist will perform exam

• some post films done by radiographer

What should you make sure to do with your pt after the myelogram is done?

Keep patients head elevated slightly (30-40 degrees) to avoid contrast media passing into cerebral ventricles

What will happen if contrast media moves upward after a myelogram?

Patient will get a spinal headache/migraine

What are the most common injection sites for myelograms?

L3-L4 and C1-C2

How many ccs are injected for the myelogram and where are they injected into?

9-15 ccs into the subarachnoid space

Why is L3-L4 a common in section site for the lumbar myelograms?

The conus medullaris is here, where the spinal cord tapers off (not a solid cord)

What procedure is this tray used for?

Myelogram

What is the needle placement and injection process for the myelogram?

1. skin prep

2. lumbar puncture (prone or left lateral position)

3. CSF sample collected

4. contrast medium instilled

5. needle removed

How do you get CSF out of the spinal cord?

Do not suck it out, it must drip out on its own

What color is CSF?

Clear

What type of contrast is used for a myelogram?

Ionic or nonionic, water soluble iodine based

What views do you do for the cervical myelogram?

• transcervical lateral- CR to C5

• swimmers lateral- CR to C7

What views do you do for the lumbar myelogram?

• semi-erect trans abdominal lateral- CR to L3

• possible additional views- anterior obliques, PA/AP

What is sialography?

Radiographic examination of the salivary glands and associated ducts with a contrast medium

What has widely replaced sialography?

MRI and CT

What are the accessory organs of digestion located within and adjacent to the oral cavity?

Teeth and salivary glands

What do the salivary glands do?

Secrete the majority of the saliva found within the oral cavity that helps to dissolve food and facilitate digestion

How do the salivary glands communicate with the mouth?

Via the ducts

What are the three major salivary glands?

• parotid

• submandibular

• sublingual

Parotid salivary gland

Largest

Submandibular salivary gland

Second largest

Sublingual salivary gland

Smallest

What are the other associated ducts?

• parotid duct- AKA Stenson’s duct

• submandibular duct- AKA submaxillary or Wharton’s duct

• ducts of rivinus- 12 small ducts, one or two are larger and are referred to as Bartholin’s ducts

When is an sialography exam done?

• pt’s symptoms indicate a potential pathologic process of the salivary duct or gland

• can include obstruction of the duct by a stone; stricture or tumors located within the duct

• also can be done to look for a possible fistula

What is a fistula?

Abnormal connection or opening between two different parts (not supposed to be connected but is)

What are the contraindications for sialography?

When the patients shows severe inflammation or allergy to the contrast

What are the technologists responsibilities for sialography?

• explain the procedure

• consent form

• pt prep- remove dentures, jewelry

• room prep- tray, fluoro working

• get contrast ready for doctor- only need 1-2 mL

• scout film

• assist the doctor and pt through put the procedure

• after films if needed

What is the purpose of sialogarphy?

To opacify salivary duct and glands to demonstrate potential pathology

What are the indications for a sialogram?

• obstruction of the ducts by calculi, strictures, or tumors

• sialectasia (dilation of a duct)

• possible fistula

What is orthorentgenography- long bone study?

An exam to determine if there are any limb length discrepancies

Who do you usually do orthorentgenography studies on?

Adults or children, but more commonly children

True or false: orthorentgenography can be done for either upper or lower limbs, but more commonly done for lower

True

How do you do orthorentgenography?

You take three images on one film centered on three joints and coned into the particular joint

What are the three joints done for lower limb orthorentgenography?

Hip, knee, and ankle

What are the three joints done for upper limb orthorentgenography?

Shoulder, elbow, and wrist

What is the name of the ruler used for orthorentgenography?

Bell-Thompson, metallic markings

Where do you put the ruler for a long bone study?

Under the patients limb and tape it to the table

What is a more modern way to do a long bone study?

Using image stitching

What are the indication for orthorentgenography?

• back pain due to difference in the length of legs

• developmental anomalies

• epiphysiodesis- surgical procedure to shorten a limb

• bone-lengthening surgery

Epiphysiodesis

Surgical procedure to shorten a limb

What is bone densitometry?

Specialty that uses various method in assessing bone mineral density for diagnosis of osteoporosis

What are the three most commonly used bone denstometery tests?

• dual energy x-ray absorption- DXA

• quantitative computer tomography- QCT

• quantitative ultrasound- QUS

Dual energy x-ray absorptiometry (DXA)

• most common method

• uses both high and low energy range for maximum attenuation differences

• scout image for correct positioning and artifacts

What is a Z-score in bone densitometry?

Compares patient to an average individual same age and sex

What is a T-score in bone densitometry?

Compares person to someone young and healthy

Quantitative computer tomography (QCT)

• provides analysis of attenuation data as individual slices or provides a 3D analysis

• costs more and the patient dose is higher than for other methods

Quantitative ultrasound (QUS)

• non ionizing technique using ultrasound

• peripheral site selections such as the os calcis

• provides quick and simple measurements for screening purposes

What is conventional tomography?

Special type of imaging used to obtain a diagnostic image of a specific layer of tissue or object that is superimposed by other tissues or objects

What are the five types of tube trajectories (way the tube moves over the body) in conventional tomography?

• linear

• elliptical

• circular

• spiral

• hypocyclodial

Fulcrum

Pivot point through which the x-ray tube and IR move

What are the two types of fulcrum levels?

• fixed

• variable

Fixed fulcrum level

Adjust the table height not the fulcrum

Variable fulcrum level

Fulcrum level is moved not the table height

How can you determine you starting fulcrum level?

First take two scout films (AP and lateral) to locate the area of interest, then according to what your scout films show, set your fulcrum level

What are the four influencing and controlling factors which determine the amount of blurring in conventional tomography?

• distance the object is from the objective plane

• exposure angle

• distance the object is from the IR

• tube trajectory

Objects within the body that are (closer or farther) from the focal plane have greater blurring

Farther

True or false: if the arc of the tube movement increases the blurring increases

True

True or false: the straighter the line of the tubes trajectory the less blurring that occurs

True

What are the other conventional tomography methods?

• breathing technique

• pantomography- panorex unit

• digital tomosynthesis