Special Procedures and Pedi Flashcards
Greek word “arthron” means
“joint”
Arthrography is:
radiologic examination of the synovial joints and related soft tissue structures that employs contrast media.
___ or ____ exams may be used in place of, or in addition to, arthograms.
CT or MRI
Joints commonly examined via arthrography:
Hip Knee Ankle Shoulder Elbow Wrist Most common: shoulder and knee
Knee arthrography does what?
Assess knee joint and associated soft tissue structures (joint capsule, menisci, and ligaments.)
Knee joint and associated soft tissue structures are visualized by introducing:
contrast into joint capsule.
Clinical indications for knee arthrography include:
tears in joint capsule
tears or degeneration of menisci
ligament injury
Contraindications for knee arthrography include:
Hypersensitivity to iodine-based contrast media or local anesthetics.
An example of a NONTRAUMATIC pathologic indicating arthrography is a:
Baker’s cyst, which communicates with the joint capsule in the popliteal area.
Patient prep for knee arthrography:
No dietary prep
Procedure explained
Advise of complications
Signed informed consent form.
Imaging equipment used for knee arthrography:
Fluoroscopy and spot imaging
Patient restraining device (provides medial or lateral stress)
Conventional radiography capability.
Accessory equipment for knee arthrography:
Arthrogram tray (Includes items needed for contrast injection and preparation of injection site.) Prep sponge Fenestrated drape Syringes Flexible connector Needles with local anesthetics Sterile gloves Razor Contrast media Bandaid
Types of contrast media needed for knee arthrography:
Radiolucent (room air)
Radiopaque (idonated)
Double contrast: (5 mL of positive and 80-100mL of negative CO2 or air.)
Seven steps to needle placement and injection for knee arthrography:
- Site prepared according to sterile technique.
- Retropatellar, lateral, anterieor, or medial approach (site of injection is the site preferred by physician)
- Skin anesthetized.
- Fluid aspirated (discarded or sent to lab)
- Contrast media instilled
- Needle removed.
- Knee exercised to produce thin, even coating of sift tissue structures with positive medium.
Knee stressed during fluoroscopy with use of:
compression band.
What should be worn during fluoro?
lead gloves and apron.
Closely collimated views of what should be seen during fluoro imaging of a knee arthrogram?
each meniscus.
What degree of rotation of the knee should be seen between each exposure?
20 degrees.
A 20º rotation of the knee between each exposure results in:
9 spot images of each meniscus, which demonstrates the meniscus in profile throughout its diameter.
Conventional “overhead” projections for knee orthography shows:
entire articular capsule outlined in proper AP and lateral positions with optimal exposure factors and the correct markers visible.
What is often performed following a conventional arthrography?
CT
What is the purpose of shoulder arthrography?
To demonstrate the joint capsule, rotator cuff, long tendon of biceps and articular cartilage.
Does a shoulder arthrography use single or double contrast injection?
Either
Clinical indications for shoulder arthrography:
Chronic pain
General weakness
Tears in rotator cuff
What is the name for the tendons that surround the shoulder joint?
Rotator cuff.
The rotator cuff is actually:
a group of four muscles and their tendons that wraps around the front, back and top of the shoulder joint.
The ends of the rotator cuff muscles form:
tendons that attach to the humerus. It is the tendinous portion that is usually involved in a rotator cuff tear.
Imaging equipment used for shoulder arthrography:
Radiographic/fluoro room
Contrast injection under fluoroscopic control
Conventional imaging done with overhead x-ray tube.
Accessory equipment used for shoulder arthrography:
Standard arthrogram tray
Spinal needle
Specific accessory equipment need of particular physicians.
Type of contrast media used for shoulder arthrography:
Single contrast procedure: 10-12 mL of positive contrast media.
Dual-contrast procedure: 3-4 mL of positive contrast media and 10-12 mL of negative contrast media (i.e., room air)
Would single or double contrast procedure best demonstrate inferior portion of rotator cuff when images are obtained with pt in upright position?
Double
Shoulder arthrography needle placement:
- Injection site prepped according to sterile procedures.
- Area anesthetized, needle guided fluoroscopically into joint space.
- Deep joint requires use of 2 and 3/4 to 3 and 1/2 inch spinal needle.
- Small amount of contrast injected to see if bursa penetrated.
- After all contrast instilled, imaging begins.
Positioning and imaging sequence for shoulder arthrography:
Routines vary.
- Physician manipulates patient under fluoro taking spot images eliminating need for conventional radiographers.
- Radiographer takes conventional images (upright and/or supine) after fluoro.
Suggested positioning routine for shoulder arthrography:
Scout AP
Internal and external rotation
Glenoid fossa (AP oblique)
Transaxillary OR Intertubercular groove (Fisk modification.)
How are CT and MRI used in conjunction with conventional fluoroscopy during shoulder arthrography?
Fluoro guidance of needle, injection of contrast media, joint manipulation to demonstrate contrast agent is in area of interest, pt transferred to CT or MRI with no “overhead” imaging performed.
The two biliary duct procedures are:
T-tube, or delayed, cholangiography
Endoscopic retrograde cholangiopancreatography (ERCP)
Purpose of Post operative (T-tube or delayed) cholangiography:
Performed if surgeon has concerns about residual stones in biliary ducts that went unsuspected during cholecystectomy.
What is done during a post operative (t-tube or delayed) cholangiography?
A t-tube shaped catheter is placed in CBD during cholecystectomy. The catheter extends to outside of body. This is done in the radiology department.
Clinical indications for Post operative cholangiography:
Residual caluli- t-tube enables radiologist to locate stones and remove the through a specialized catheter.
Strictures- Narrowing of biliary ducts demonstrated during operative cholangiogram may warrant further investigation.
Contraindications for post operative cholangiography:
Hypersensitivity to iodinated contrast media
Acute infection of biliary system.
Elevated creatinine or BUN levels.
Patient prep for post operative cholangiography:
Clear explanation of procedure.
Careful clinical history.
NPO for at least 8 hours prior to exam.
Tube is clamped off the day before the procedure, as a preventative measure against air bubbles entering duct where it might simulate cholesterol stones.
Imaging equipment used for Post operative cholangiography:
Fluoroscopy for injection
Post fluoro images “overheads” may be required.
Accessory equipment for post operative cholangiography:
Various size syringes and adaptors
Emesis basins
Gloves
Sterile drapes
Contrast media used during post operative cholangiography:
Water soluble iodinated contrast medium, possibly diluted.
Injection process during post operative cholangiography:
- Unclamp t-tube and drain off excess bile following standard precautions.
- Syringe with adaptor is attached to t-tube.
- Contrast injected under fluoro guidance.
- Spot images.
- Residual stones, if detected, removed.
Responsibilities of tech during t-tube cholangiography:
- Prepare fluoro suite.
- Set up exam tray.
- Select and prepare contrast media.
- Take scout images.
- Provide protective aprons.
- Monitor the pt during procedure.
- Follow standard precautions when handling bile.
- Take conventional radiographs (if requested).
Inspection of any cavity using an endoscope:
Endoscopy
An instrument that allows illumination of internal lining of organ and projects image onto video monitor.
Endoscope.
What type of scope is commonly used for ERCP?
Duodenoscope.
What is an ERCP?
Endoscopic Retrograde Cholgangiopancreatography. Endoscopic inspection, cannulation, and injection of the biliary ducts with the use of a duodenoscope.
What is the purpose of an ERCP?
To examine biliary and main pancreatic ducts. It can be a diagnostic or therapeutic procedure.
Pathologic indications for an ERCP:
Residual calculi (gastroenterologist may be able to remove stones in biliary ducts.) and strictures (narrowing of biliary ducts warranting further investigation.)
Contraindications for ERCP:
Hypersensitivity to iodinated contrast medium.
Acute infection of biliary system.
Possible pseudocysts of pancreas (Injecting contrast into a pseudocyst may lead to a rupture).
Elevated creatinine and/or BUN levels.
Patient prep for ERCP:
NPO 8 hours prior to exam.
NPO at least 1 hour after exam (to prevent aspiration)
Clear explanation of procedure.
Major equipment for ERCP:
Fluoro for placement of catheter into biliary ducts and injection of contrast.
Images may be obtained after fluoro procedure.
Accessory equipment for ERCP:
Various size syringes Syringe adaptors Emesis basin Gloves Sterile drapes
Contrast media for ERCP:
Iodinated, water soluble contrast media, possibly diluted.
Injection process for ERCP:
- Endoscope introduced through mouth and passed through until it reaches the hepatopancreatic ampulla.
- Catheter is inserted into CBD and contrast agent is injected.
- Fluoro and spot images obtained.
HSG is:
Hysterosalpingography: radiographic examination of the uterus and uterine (fallopian) tubes after the injection of contrast medium.
Four parts of the uterus:
Fundus
Body
Isthmus
Cervix
Fundus of the uterus is:
rounded most superior portion of the uterus.
The body of the uterus is:
the larger central component of the uterus.
The isthmus of the uterus is?
Where the uterus joins the cervix. The constricted area between the body of the uterus and the cervix at the internal os.
The cervix of the uterus is:
the distal cylindric portion of the uterus the projects into the vagina.
The uterus is comprised of three layers:
Endometrium
Myometrium
Serosa
The endometrium of the uterus is:
the inner mucosal lining of the uterine cavity. It undergoes cyclic changes called menstural cycle at about 4 week intervals from puberty to menopause.
The middle mucosal lining of the uterus is called:
the myometrium.
The outer layer of the uterus is called:
the serosa.
The region of the uterus where the uterine tubes communicate with the uterus is called:
the cornu.
The uterine tube is divided into 4 parts:
Interstitial segment
Isthmus
Ampulla
Infundibulum
The interstitial segment of the uterine tubes is where and communicates with what?
In the cornu section and communicates with the uterus.
The isthmus of the uterine tube is:
the constricted portion of the uterine tube where it widens into the central segment.
The Ampulla section of the uterine tube is:
The widened central segment that makes up about the lateral 2/3rds of its length.
The infundibulum of the uterine tubes is:
the terminal and lateral portion of the tube. It is flared in appearance, and its where the fimbriae are.
Purpose of HSG:
Demonstrates size, shape, and position of the uterine cavity, potency of the uterine tubes, detects lesions such as polyps, fistulas and neoplasms.
In some cases, an HSG can act therapeutically to reverse infertility by:
dilating and restoring patency to blocked or tortuous uterine tubes.
Clinical indications for HSG:
Infertility assessment
Demonstration of intrauterine pathology.
Evaluation of uterine tubes after tubal ligation or reconstructive surgery.
Contraindications for HSG:
Pregnancy
Pelvic inflammatory disease
Active uterine bleeding.
Pt Prep for HSG:
Proper bowel prep (mild laxative, suppositories, cleansing enema)
Mild pain reliever (alleviates discomfort associated with cramping)
Empty bladder (Prevents displacement of uterus and fallopian tubes.)
Explanation of procedure
Consent form signed.
Physician may perform pelvic exam.
Major equipment used for HSG:
Conventional or digital fluoro.
Tilting table capabilities
If available, stirrups are used to place pt in the Lithotomy position.
Accessory and optional equipment for HSG:
HSG tray Speculum Sterile drapes Cannula or balloon catheter Contrast media (iodinated water soluble preferred) Speculum Tenaculum Cannula
Type of contrast media used for HSG:
Amount depends on physician preference.
Water soluble iodinated: Absorbed easily, does not leave residue, adequate visualization, causes persisting pain when injected.
Oil based contrast media (no longer used): maximum visualization, slow absorption rate, risk of oil embolus which could reach lungs.
Positioning routines for HSG: (radiographic):
Varies with the method of examination.
Fluoro, conventional radiography, or a combo of both may be used.
Positioning routines for HSG: (digital fluoro or conventional imaging.)
Spot cassette or digital fluoro:
Collimated scout image.
Collimated images during injection of contrast media.
After injection, additional image to document spillage of contrast into peritoneum.
Images may be obtained supine, LPO or RPO.
Centering points for HSG when using conventional radiography:
10x12 inch IR is used, CR perpendicular to a point 2 inches superior to the pubic symphysis. Additional images may include RPO and LPO.
Evaluation criteria for HSG:
- Pelvic ring on AP is centered within collimation field.
- Cannula or balloon catheter demonstrated within cervix.
- Contrast medium seen within peritoneum if one or both uterine tubes are patent.
Greek word “myelos” means:
marrow (the spinal cord)
Purpose of myelography:
Radiographic study of spinal cord and its nerve root branches that uses a contrast medium.
Spinal cord ends where?
At the lower border of L1 (at the level of the intervertebral disk between the 1st and 2nd lumbar vertebrae in adults.)
The tapered area where the spinal cord ends is called:
the conus medullaris.
The spinal cord is connected to:
31 pairs of spinal nerves, each arising from two roots at the sides of the spinal cord.
How many of each type of nerve are within the spine?
8 pairs of Cervical nerves 12 pairs of Thoracic nerves 5 pairs of Lumbar nerves 5 pairs of Sacral nerves 1 pair of Coccygeal nerves
Spinal nerves below the termination of the spinal cord extend inferiorly through the vertebral canal. These nerves are called:
Cauda equina.
This space contains cerebrospinal fluid and surrounds both the spinal cord and brain:
subarachnoid space.
The subarachnoid space extends to:
the second sacral segment.
A common lumbar puncture site, for removal of CSF and injection on contrast media is often performed:
between L3 and L4.
The spinal cord ends at what level?
Lower level of L1
What is the widened triangular cavity situated in the lower posterior fossa between the base of the cerebellum and the dorsal surface of the medulla oblongata?
Cisterna magna
Brain and spinal cord coverings:
meninges. Brain and spinal cord are enlaced by 3 protective meninges.
The three meningial layers of the brain and spinal cord are:
dura mater
arachnoid
pia mater
This layer forms the strong, fibrous covering of the brain and spinal cord, has an inner and outer layer, and are tightly fused together except for spaces that are provided for large venous blood channels called venous sinuses or _____ _____ sinuses.
Dura mater
Exterior to the dura mater, between the dura mater and the inner table of the skull is a potential space termed the
epidural space.
Trauma to the head can cause an _______ hematoma, an accumulation of blood between the skull and dura mater.
Epidural
The middle me nix is termed:
the arachnoid layer. It is an avascular covering and named arachnoid because of its spider’s web arrangement of delicate collagen fibers and some elastic fibers.
Between the dura mater and the arachnoid is a thin _____ space which contains interstitial fluid and various blood vessels.
subdural
The innermost menix and is a thin, transparent connective tissue layer that adheres to the surface of the spinal cord and brain. It contains many blood vessels that supply oxygen and nutrients to the spinal cord.
Pia mater
Between the arachnoid and pia mater is the ________ which contains the CSF.
subarachnoid space.
What provides protection to the spinal cord?
the bony vertebral column, the vertebral ligaments, meninges, and cerebrospinal fluid.
Purpose of a myelography:
Radiographic examination of the spinal cord and its nerve root branches with a contrast medium.
The spinal cord and nerve roots are outlined by injection of a contrast medium into the __________ of the spinal canal.
subarachnoid space
Myelography of which parts of the spine are most common?
Lumbar and cervical.
Clinical indications of myelography:
When pt symptoms indicated the presence of a lesions that may either be present within the spinal canal or may protrude into the canal.
Pathology demonstrated by myelography:
Herniated nucleus pulposis (most common)
Cancerous or benign tumors
Cysts
Trauma (possible bone fragment.)
Contraindications for myelography:
Blood in CSF
Arachnoiditis
Increased cranial pressure
Recent lumbar puncture.
The presence of blood in the CSF indicates:
probably irritation within the spinal canal, which can be aggravated by the contrast.
How would contrast medium affect Arachnoiditis?
it could increase the severity of the inflammation.
In cases of elevated intracranial pressure, tapping of the subarachnoid space with needle insertion may cause:
severe complications to the patient as the reassure equalizes between the area of the brain and spinal cord.
Performing myelography on a patient who has had a recent lumbar puncture may result in:
contrast medium extravasating outside the subarachnoid space through the hole left by the previous puncture.
Pt Prep for myelography:
- Pt may be pre-medicated with a sedative 1 hour prior to exam
- Exam and possible complications explained thoroughly to pt.
- Informed consent is signed by pt.
Major equipment used for myelography:
R/F room
Table with 90 degree/45 degree tilting ability
Shoulder brace
Ankle restraints. Foot rest on for upright.
Image intensifier lock.
Accessory & optional equipment for myelography:
Grid cassettes with holders Myelography tray Sterile gloves Antiseptic solution Appropriate lab reqs Large position sponge or pillow.
Contrast media for myelography:
Best type of contrast medium is one that is miscible with CSF, easily absorbed, non toxic and inert and has good radiopacity. Non-ionic, water-soluble iodine based media primarily used because of relatively low osmolality.
What type of contrast media was used for myelography in the past?
Air or gas and oil-based media.
Contrast used for myelography must be:
approved for intrathecal injections.
During myelography, Absorption of non-ionic water soluble media begins:
about 30 minutes after injection.
How long does non-ionic water soluble contrast media stay in the body during myelography?
Good radiopacity for up to an our after injection.
Hazy effect after 4-5 hours.
Radiographically undetectable after 24 hours.
Dosages of contrast medium during myelography:
Varies with concentration of medium and area of spine under examination. Rages of about 9-15 mL
During myelography exam of cervical area, when pt is prone or in Trendelenburg position, chin must be:
hyperextended to prevent medium from flowing into the cranial region of the subarachnoid space.
Needle placement for myelorgraphy:
Lumbar: L3-L4
Cervical C1-C2 ( Cisterna magna)
Injection process for myelography:
Skin prepped.
Fluoro may be used to facilitate needle placement for lumbar puncture.
CSF sample collected.
Contrast is introduced through a puncture of the subarachnoid space.
Needle removed.
Which location is a safer site for myelography?
L3-L4. The cervical site would be used only if the lumbar site is contraindicated or a pathologic condition indicates complete blockage of vertebral area above lumbar area.
Two body positions used for lumbar puncture:
Prone (with firm pillow or large positioning block placed under abdomen to flex spine.)
Left lateral with spine flexed to widen interspaces.
Cisternal puncture:
Erect C1-C2 level. Prone with head flexed to open interspinous space.
