Additional Procedures (FINAL)

Hysterosalpingogram

The radiographic demonstration of the female reproductive tract

» Demonstrates uterine cavity and patency of uterine tubes

Indications

~ infertility: functional or structural defects

~ intrauterine pathology (ultrasound)

• endometrial polyps

• uterine fibroids

• intrauterine adhesions

~ Evaluate uterine tube after tubal ligation or

reconstructive surgery

» Contraindications

~ pregnancy

~ acute pelvic inflammatory disease (PID)

~ uterine bleeding

Hysterosalpingogram Prep

»Typically scheduled 7-10 days after onset of menstruation

»Bowel preparation

»Mild pain reliever before exam to relieve cramping

»Empty bladder

»Informed consent

»Performed in an R and F room that has ability for Trendelenburg position

»Gynecologic stirrups

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Equipment

»Sterile gloves

»Sterile tray

»Sterile towels

»Speculum

»Tenaculum

»Head lamp

»Privacy screen

Contrast:

The most commonly preferred contrast is

positive, nonionic, and water soluble

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Placement

»Patient is supine in lithotomy

position

»Catheter is placed into cervix

and balloon inflated to prevent

contrast from flowing out of

uterine cavity

»Contrast is injected slowly and

observed traveling through

uterus, fallopian tubes, and

spillage into peritoneal cavity

Hysterosalpingogram Imaging Routine

»AP (scout/post-contrast): CR 2” superior to the symphysis pubis

»LPO and RPO positions as requested

Swallowing Dysfunction Study (Modified Barium Swallow (MBS))

» Designed to:

~ Examine the A&P of the oral cavity and pharynx during deglutition

~ Identify disorders in movement patterns of oropharyngeal structures

~ Define treatment strategies that will eliminate aspiration and/or increase

swallowing efficiency

» Exam coordinated with a licensed

Speech Language Pathologist (SLP)

~ Patient must have been evaluated by SLP before exam

» Procedure done under fluoroscopy to evaluate difficulty swallowing (dysphagia)

Swallowing Dysfunction Study (Modified Barium Swallow (MBS)) Prep

» Varibar contrast in various

consistencies

~ Thick

~ Thin

~ Nectar

~ Honey

~ Pudding

» Cookies, crackers, diced fruit

» Paste or Barium Tablet

» Patient is given food of at least 3

different consistencies (liquid, paste

or puddinglike, and something

requiring mastication)

» Small amounts used (~1, 3, 5, 10 ml)

Technologist Role

Prepare room (tilt x-ray table to

upright position, set fluoro

console, arrange contrast and

any food)

▪ Help to position patient - either

in chair or standing upright

▪ Assist SLP and radiologist

▪ Clean up room

SLP Role

▪ Initial evaluation at bedside

▪ Administer contrast

▪ Evaluate patient

▪ Report findings in concert with

radiologist

Radiologist Role

▪ operate radiographic

equipment

▪ Document fluoro time and

report findings in concert with

SLP

▪ Video record study

Orthoroentgenography

»straight or right-angle radiography

»Performed to determine the length of long bones

»routine radiographs cannot be used for accurate measurements due

to magnification and elongation

»Comparative exam

»A ruler is taped into place on the table top

»The CR is centered directly over each joint space

»A Bell-Thompson ruler is placed under or next to the long bones

»A Bucky should be used for all exposures

»Make sure extremities are fully extended

»Make sure to use R and L markers

»Gonadal shielding can be used

»tube and Bucky are moved

Upper limb measurement

AP shoulder

»Direct the CR to midshoulder joint

AP elbow

»Direct the CR to midelbow joint

AP wrist

»Direct the CR to midwrist joint

Lower limb measurement

AP hip

»Direct the CR to a level 3/4” above symphysis pubis

AP knee

»Direct the CR to a level 3/4” below apex of patella

AP ankle

»Direct the CR to level of ankle joint

Bone Age

»Single PA view of the LT hand to include the wrist and distal forearm

»Performed on children to determine normal v. abnormal “relative age” or “degree of maturation” of skeleton

»Radiologist compares radiograph against a standard of children of same chronological age

~ Greulich and Pyle (developed in the 1950s)

Soft Tissue/ Foreign Body

»Images with decreased technique to demonstrate the soft tissue structures

»Neck is most common soft tissue exam when no foreign body is suspected (see Upper Airway pg. 100)

»2 views at opposing 90-degree angles to show precise location (some exceptions)

»Technique may be reduced depending on system (DR/CR issues) and foreign material (glass v. wood v.

metal)

Bone Survey

Images of skeleton to

confirm presence of

certain pathologies (e.g.

multiple myeloma-cancer

of plasma cells)

Per radiologist protocol;

normally includes AP and

Lateral views of all long

bones, entire spine, skull,

and pelvis

Arthrography

»Contrast-media study of synovial

joints and related soft tissue

»Joints include the hip, knee, ankle,

shoulder, elbow, wrist, and TMJs

»Knee and shoulder are the most

common arthrograms

»MRI is most frequently used to

study the soft tissue structures of

the knee and shoulder

»MRI is also used in conjunction

with arthrography of the shoulder

and knee

Major Structures of the Knee (6)

 MCL (medial collateral ligament)

 LCL (lateral collateral ligament)

 ACL (anterior cruciate ligament)

 PCL (posterior cruciate ligament)

 Medial Meniscus

 Lateral Meniscus

Knee Arthrogram

»Informed consent before procedure

»Performed in an R and F room that can perform horizontal beam radiography

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»Scout AP and Lateral

»The radiologist prepares injection site (joint capsule injection via medial, lateral, anterior, or retropatellar approach)

»Synovial fluid is aspirated

»Contrast is administered

»Nine exposures are taken of the meniscus using 20º rotations of the knee

»Lateral or medial stress is applied to better visualize meniscus under fluoro

Shoulder Arthrogram

» Injection site is prepped the same way as for others

» A 2¾” to 3½” spinal needle is needed to reach the deep joint capsule

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Commonly performed scout views for a shoulder arthrogram include:

 AP internal/external rotation

 Glenoid fossa (Grashey),

transaxillary, or bicipital groove

(Fisk) projections

 Upright or Supine

Imaging sequence is then repeated post-contrast

If normal, the patient is instructed to exercise arm and the imaging sequence is repeated

Myelography

The radiography study of the spinal cord and its nerve root branches

• Largely being replaced by MRI or CT

• Some departments perform CT

• Most disk pathology of the spine occurs in the cervical and lumbar region

Contraindications

1. Blood in CSF

2. Arachnoiditis

3. Increased intracranial pressure

4. Recent LP

Post-Procedural Care

» Activity restriction

» Hydration

» Elevation of head

Myelography Prep

Informed consent before procedure

Risk of infection at injection site

Sedative/muscle relaxant for anxious patient

»The radiologist prepares injection site; then inserts the spinal needle.

»CSF fluid is collected

»Contrast is injected into the subarachnoid space

»A bandage is applied to puncture site after needle is removed

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»Contrast is injected into the

subarachnoid space

»L3-4 is the most common

injection site for any myelogram

(cervical, thoracic, or lumbar)

»C1-C2 is used when lumbar area

is contraindicated – pathology or

blockage of vertebral canal

prevents flow of contrast to

thoracic or cervical regions

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Equipment

»Performed in an R and F room that has ability to assume Trendelenburg position

»Shoulder braces

»Footrest

»IR with grids

» Razor

»Basin

»Prep sponges

»Sterile drapes

»Sterile gauze

» 5 ml and 20 ml syringes

» 25- and 22-guage needles

» 18-guage spinal needle

»Vial of local anesthetic

» Three test tubes

»Sterile gloves

»Antiseptic solution

» Lab requisitions – to send with CSF sample to lab

»Positioning wedge

Myelography (Lumbar)

Prone and left lateral positions

» For prone – a positioning block is placed under

the abdomen to widen the interspinous spaces

» For left lateral – the patient flexes spine the to

widen the interspinous spaces

Contrast media

» Single contrast (9-15ml)

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Lumbar region

Scout PA and Lateral at injection site (serves as l-spine scouts)

»Radiologist obtains fluoroscopic images

»Technologist obtains post contrast

~ Semi-upright x-table lateral

Myelography (Cervical)

Prone and upright positions

Neck is flexed to widen the interspinous spaces

Contrast media

» Single contrast (9-15ml)

Myelography (Thoracic)

Scout PA and Lateral at injection site

Scout PA and Lateral of Thoracic spine

Radiologist obtains fluoroscopic images

Technologist obtains post contrast

 Right lateral decubitus

 Left lateral decubitus

 Right or left lateral recumbent

Conus medullaris

The terminal end of the spinal cord (L1-L2, can be T12-L3)

Lumbar, sacral, and coccygeal nerve roots descend from the conus medullaris, which is termed the cauda equina (horse's tail)

Normal platelet count is approximately ____

150-400k

Prothrombin Time (PT): normal time is approximately ____ for liquid portion of blood (plasma) to coagulate

11-13.5 secs

International Normalized Ratio (INR): INR was devised to standardize PT results. Times can vary if patient is on anti-coagulation therapy. Normal should be approximately

0.8 to 1.1

Warfarin: 2-3

Partial Thromboplastin Time (PTT): clotting should occur approximately between _

25-35 secs

Creatinine Value

0.6-1.5 mg/dL

BUN Value

8-25

GFR Ranges

90-60-45-30

III Procedures

» Arthrogram

~ Knee

• AP

• Lateral

~ Shoulder

• AP internal/external rotation

• Glenoid fossa (Grashey), transaxillary, or bicipital groove (Fisk)

» Myelogram

~ Cervical

• PA prone

• X-table Lateral

• X-table Swimmer’s

~ Thoracic

• PA prone

• Right lateral decubitus

• Left lateral decubitus

• Right or left lateral recumbent

~ Lumbar

• Semi-upright x-table lateral

I & II Procedures

» Hysterosalpingogram (pp. 724-726)

» Swallowing Dysfunction Study

» Long bone measurement (pp. 731)

~ Upper limb

~ Lower limb

» Bone survey

» Bone age

» Soft tissue/foreign body