Special Procedures Flashcards
Arthrography
exam of the synovial joints and related soft tissue structures that employs contrast media
what are joints commonly examined
hip, knee, ankle, shoulder, elbow, wrist
what are the most common arthrogram procedures
shoulder and knee
what are the structures of major interest in knee arthro
joint capsule, menisci, collateral, cruciate and other minor ligaments
Knee Arthro
clinical indications
mostly trauma tears in joint capsule tears or degeneration of menisci ligament injury bakers cyst
Knee Arthro
contraindications
hypersensitivity to iodine based contrast media or local anesthetics
what modality is bakers cyst best seen on?
ultrasound
Knee Arthro
patient prep
no dietary prep
procedure explained
advise of complications
signed informed consent form
Arthrogram tray
prep sponge, drapes, connector, needles, anesthetics, sterile gloves, razor, contrast, bandaid
radiolucent
room air
radiopaque
iodinated
Knee Arthro
what kind of contrast is used and how much
Double contrast study
5mL of positive and 80-100mL of negative (CO2 or air)
Knee Arthro
what type of approaches do physicians use for site of injection
retropatellar, lateral, anterior, or medial
Knee Arthro
fluoro imaging
20 degree rotation between each exposure
results in 9 spot images of each meniscus
Knee Arthro
overhead projections
entire articular capsule outlined
proper AP and Lateral positions
Shoulder Arthro
can be single or double contrast study that demonstrates joint capsule, rotator cuff, long tendon of biceps and articular cartilage
Shoulder Arthro
clinical indications
chronic pain
general weakness
tears in rotator cuff
rotator cuff
a group of four muscles and their tendons that wraps around the front back and top of the shoulder joint
shoulder Arthro
accessory equipment
standard arthro tray
spinal needle
shoulder Arthro
contrast media single contrast study
10-12mL of positive contrast media
NO negative contrast media
shoulder Arthro
contrast media double contrast study
3-4mL of positive contrast media and 10-12mL of negative contrast media
what contrast study for shoulder arthro BEST demonstrates the inferior portion of the rotator cuff
double contrast study with pt. in upright position
shoulder Arthro
suggested positioning routine
scout AP
internal/external rotation
glenoid fossa AKA grashey
transaxillary or fisk modification (intertubercular groove)
what contrast media is used for CT to follow
iodinated water soluble
what contrast media is use for MRI to follow
Gadolinium
Biliary duct procedures
T-tube or dleayed, cholangiography
endoscopic retrograde cholangiopancreatography ERCP
T-tube/delayed purpose
performed if surgeon has concerns about residual stones in biliary ducts that went unsuspected during cholecystectomy
T-tube/delayed procedure
T-tube shaped catheter is placed in common bile duct during cholecystectomy.
the catheter extends to the outside of the body
T-tube is unclamped and drains excess bile into emesis basin
syringe with adapter is attatched to t-tube
iodinated contrast is injected under fluoro
spot images taken and residual stones if detected may be removed
T-tube/delayed clinical indications
residual calculi
strictures (narrowing of biliary duct)
T-tube/delayed contraindications
hypersensitivity to iodinated contrast media
acute infection of biliary system
elevated creatinine or BUN levels
T-tube/delayed patient prep
NPO for at least 8 hrs prior to exam
exam explained
careful clinical history
why is the t-tube clamped off the day prior to the t-tube cholangiogram?
done as a preventative measure against air bubbles entering ducts where it might simulate stones.
what contrast media is used for t-tube/delayed
water soluble iodinated contrast media
what endoscope is commonly used for ERCP’s
duodenoscope
ERCP procedure
endoscopic inspection, cannulation and injection of the biliary ducts with the use of a duodenoscope
ERCP purpose
to examine biliary and main pancreatic ducts
can be diagnostic or therapeutic
ERCP therapeutic procedure
removal of choleliths or small lesions
repair stenosis of spincter of oddi or associated ducts
ERCP diagnostic procedure
retrograde injection of contrast into biliary ducts usually performed by gastroenterologist
ERCP pathologic indications
residual calculi
strictures
ERCP contraindications
hypersensitivity to iodinated contrast media
acute infection of biliary system
possible pseudocysts of pancreas
elevated creatinine and/or BUN levels
ERCP patient prep
NPO 8 hrs prior to exam
NPO at least 1 hr after exam to prevent aspiration
explain procedure
ERCP contrast media
iodinated water soluble contrast
ERCP injection process
endoscope introduced through mouth until it reaches hepatopancreatic ampulla
catheter inserted into CBD and contrast injected
HSG
exam of the uterus and fallopian tubes after the injection of contrast
4 parts of uterus
- fundus
- body
- isthmus (where uterus joins the cervix)
- cervix
3 layers of the uterus
- endometrium (inner)
- myometrium (middle)
- serosa (outer)
cornu
the region of the uterus where the uterine tubes communicate with the uterus
uterine tube divided into 4 parts
- interstitial segment
- isthmus
- ampulla
- infundibulum
purpose of and HSG
detects lesions such as polyps, fistulas and neoplasms shows patency of uterine tubes
HSG
clinical indications
infertility assessment
demonstration of intrauterine pathology
pelvic masses, fistulas, congenital defects, spontaneous abortions
evaluation of uterine tubes after tubal ligation or reconstructive surgery
HSG
contraindications
pregnancy
pelvic inflammatory disese
active uterine bleeding
HSG
patient prep
proper bowel prep mild pain reliever empty bladder explain procedure consent form signed
HSG
contrast media
water soluble iodinated absorbed easily no residue in reproductive tract will cause pain *used to use oil based contrast media
HSG
scout image positioning
2 inches above pubic symphysis
additional images may be RPO/LPO
myelography
study of spinal cord and its nerve root branches that uses a contrast medium
a common lumbar puncture site for removal of CSF and injection of contrast is often performed between
L3 and L4
some people do L2/L3 but is risky because Spinal cord ends at lower level of L1
3 layers of meninges
- dura mater (tough mother)
- arachnoid (middle menix)
- pia mater (innermost)
epidural space
potential space between the dura mater and the inner table of the skull
trauma to the head can cause an
epidural hematoma
what is an epidural hematoma
an accumulation of blood between the skull and the dura mater
subdural space
thin space between the dura mater and arachnoid which contains interstitial fluid and various blood vessels
can have a subdural hematoma
subarachnoid space
between the arachnoid and pia mater.
contains CSF
what areas of the spine are most common sites for myelography
lumbar and cervical
myelography
clinical indications
presence of a lesion that may be protruding into canal
myelography
pathology demonstrated
HNP (MRI used)
cancerous or benign tumors (MRI used)
cysts (MRI used)
trauma (CT used)
what is the most common clinical indication for myleography
herniated nucleus pulposus
myelography
contraindications
blood in CSF
arachnoiditis (inflammation of arachnoid menix)
increased cranial pressure
recent lumbar puncture (within 2 weeks of procedure)
myelography
patient prep
pt. may be pre medicated with a sedative 1 hour prior
exam and possible complications explained
informed consent signed
myelography
contrast media
best type is one that is miscible with CSF
easily absorbed, non toxic and inert and has good radiopacity
non ionic water soluble iodine based media is the best
due to low osmalality
approved for intrathecal injections
myelography
contrast media dosage
varies with concentration of medium
range of about 9-15mL
myelography
needle placement
lumbar L3-L4
cervical C1-C2
what is the reason the cervical site would be used over the lumbar site during myelography
only if the lumbar site is contraindicated or a pathologic condition indicates complete blockage of vertebral area above lumbar area
2 body positions used for lumbar puncture
- prone
2. left lateral
cisternal puncture
erect C1-C2 level
prone with head flexed
cervical myelogram positioning
horizontal beam lateral
swimmer’s lateral horizontal beam
additional : anterior obliques
thoracic myelogram positioning
right lateral decubitus
left lateral decubitus
right or left lateral vertical beam
lumbar myelogram positioning
semierect horizontal lateral
horizontal CR to L3
additional: anterior obliques, or PA/AP
orthoroentgenogram
obtain accurate and comparative long bone measurements
orthoroentgenogram
what to do
immobilize extremity
tape ruler to table
no movement of extremity or ruler between exposures
orthoroentgenogram
clinical indications
back pain resulting from leg length difference
developmental anomalies
bone lengthening survey
is it more precise to do orthoroentgenograms bilaterally or unilaterally
unilaterally
orthoroentgenogram
procedure
3 exposures per IR
CR centered to joint
ruler next to limb
what is the ruler called that is used foe orthoroentgenograms
bell thompson ruler
orthoroentgenogram
lower limb measurement includes
AP hip CR centered to head of femur
AP knee CR centered to knee joint
AP ankle CR centered to ankle joint
orthoroentgenogram
upper limb measurement includes
AP shoulder CR centered to shoulder joint hand supinated
AP elbow CR centered to mid elbow joint
AP wrist CR centered to mid wrist
CT long bone measurement
hip to ankle
knees true AP
demonstrates bilateral lower extremity to include iliac crest and calcaneus
