19] Special Radiographic Procedures ‘This chapter discusses those additional diagnostic imaging procedures that are less common in most radiology depart- ments. Arthtograms, biliary duct procedures, myelograms, long bone measurements, skeletal surveys, and conventional tomegrams dre largely being replaced with other imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRD, However, in some departments, these procedures are still being performed in sufficient hnombers that technologists must be familiar with them so that they can perform them when requested Tre anatomy for these procedures has been studied in previous chapters; therefore, this chapter covers only the pro- ‘cedures themselves and the related positioning. The exception to this is the anatomy of the female reproductive organs 2s deseribed in the section on hysterosalpingography, (CHAPTER OBJECTIVES: Alter you have successfully completed the activities of this chapter, you will be able to: ARTHROGRAPHY 1. Identify the purpose, clinical indications, patient preparation, equipment, general procedure, routines related to knee arthrography: \ positioning 2. Identify the purpose, clinical indications, patient preparation, equipment, general procedure, and positioning and imaging sequence related to shoulder arthrography. BILIARY PROCEDURES 1. Describe the purpose, clinical indications, patient preparation, equipment, general procedure, and positioning and imaging sequence for the postoperative (T-1ube or delayed) cholangiography, 2, Describe the purpose, clinical indications, patient preparation, equipment, general procedure, and the positioning and imaging sequence for an endoscopic retrograde cholangiopancreatography (ERCP), HYSTEROSALPINGOGRAPHY 1. Identify specific aspects of the female reproductive system, 2. Identify the purpose, clinical indications, patient preparation, equipment, general procedure, and the positioning routines related to hysterosalpingography, MYELOGRAPHY, 1. Identify the purpose, clinical indications, contrsindications, equipment, and general procedure related 10 myelography. 2, Identify positioning routines performed for humbar, thoracie, and cervical myelography, 456 C19 Spee Raographic Precedres ‘epg ©2021 Ba re es iaMEASUREMENT (HIP 1. Define long bone measurement and the purpose of this procedure. 2. Identify the speci positioning and procedure for lower limb long bone measurements, ‘SKELETAL SURVEY (BONE SURVEY) Define skeletal survey and the purpose of this procedure. Identify the specific positioning and procedure for a skeletal survey. CONVENTIONAL TOMOGRAPHY Define the specific terms associated with conventional tomography. 2, Identify she controls and variables that are common features on conventional tomographic units __3, Identify the three influencing and controlling factors related to tomographic blur Demonstrate the principles and controlling factors of conventional tomography in laboratory exercises. 5. Define digital tomosynthesis and the purpose of this imaging tecbnique. LEARNING EXERCISES ‘The following review exercises should be completed only after careful study of the associated pages in the textbock as indicated by each exercise, Answers to each review exercise are provided at the end of this workbook. REVIEW EXERCISE A: Arthrography (see textbook pp. 718-721) 1. Which classification of joints are stadied with athrograpy? 2. Cher than conventional radiography of synovial joins (e.g, arthrography), which imaging procedure is preferred by physicians for staying synovial joints? st 5. List the three common forms of knee injury that may requlse arthrography. A B. 4, Give an example of nontraumatic pathology of the knee joint indicating arthrography. 5. What are the evo primary contraindications for arthrography of any joint? 6. True/False: An arthrogram must be approached as a sterile procedure. Proper skin prep and sterility must be maintained 1, ‘True/False: Afler the contrast medium is introduced into the knee joint, the knee must not be flexed or exercised. 8, What is the normal appearance of synovial fluid? 457 oops © 2001 ta be. Moe ene hale 19. Spoil RasiograpleProvoures o9. List the two types of contrast media used for a knee arthrogram, A. B. the two routine projections for conventional radiographic projections used for knee arthrography. A B 11, 8, On average, how many exposures are taken of each meniscus during fluoroscopy of the knee? B, How many degrees of rotation of the leg are used between exposures? 12, What four aspects of shoulder anatomy are demonstrated with shoulder arthrography? A, ©. B Dd. 13, What is the general name for the conjoined tendons of the four major shoulder muscles? 14, What type of needle is commonly used for shoulder arthrograms? 15. List three clinical indications for a shoulder arthrogram. A 3 c 16. List the six projections frequently taken during a shoulder arthrogram. A D. B, E. ©. F REVIEW EXERCISE B: Biliary Procodures (see textbook pp. 722-723) |. Postoperative (T-tube) cholangiograms are usually performed to detect A. Pancreatitis C. Liver eyst B. Biliary stones D. Infected gallbladder 2. Thue/False: A surgeon usually performs Tube cholangiography during a colectomy. 3. Which two blood chemistry values must be checked before a postoperative (T-tube) cholangiogram? A B. 468 (Crap Speci Radiographic Procedures apy © 2001 Ces ne Ap ere9, to. REVIEW EXERCISE 1 4 ‘Why are the contrast media for a T-tube cholangiogram occasionally diluted before injection? ‘True/Palse: Bile is sterile, and standard precautions do not apply when handling it Situation: A T-tube cholangiogram image demonstrates the biliary ducts superimposed over the spine. The patient is in an anteroposterior (AP) position, Which position would remove the ducts from the spine’? Postoperative (T-tube) cholangiograms are generally performed Which of the following procedures might be performed during a postoperative (T-tube) cholangiogram? A, Removal of the gallbladder C. Removal of a biliary stone B. Removal of a liver cyst D. Catheterization of the hepatic portal vein A. A radiographic procedure of examining the biliary and main pancreatic ducts is called a(n) (Weite out the full term.) B. What initials are commonly used as an abbreviation for this procedure? C. What type of special endoscope is ‘ommonly used for this procedure? __ D. Which member of the health care team usually performs this procedure? E. Why should a patient remain NPO at least | hour after this procedure? ‘Which condition of the pancreas may contraindicate an ERCP? Hysterosalpingography (see textbook pp. 724-726) The bysteroselpingogrami (HSG) isa radiographic study of the and “The uteri sited between the posteriorly and the anteriorly List the four divisions ofthe uterus. A B c D. ‘The largest division of the uterus is the 459 ert 202 oer es se hip 19. spect RasographiePosedues5. The distal aspect of the uterus extending to the vagina is the 6, List the three layers of tissue that form the uterus (from the innermost to the outermost layer), A B c 7. Which of the following terms is not an aspect of the uterine tube? A. Commu C. Isthmus B, Ampolla D. Infndibulum 8. True/False: Fentilization of the oyun oceurs in the uterine tube. 9, TruelFalse: The distal portion of the uterine tube opens into the petitoneal cavity 10, Which of the following terms is used to describe the “degre of openness” ofthe uterine tube? A. Stenosis ©. Atresia B. Patency D. Gauge 11. The most common pathologic indication for the HSG is, 12, Inaddition to the answer for question 11, what are two other clinical indications for HSG? i : B 13. List the three common types of lesions that can be demonstrated during an HSG. A, B c 14. The contrast mnediuin preferred by most radiologists for an HSG is A. Water-soluble, iodinated C. Oxygen B. Oil-hased, iodinated D. Nitrogen 15, What device might be needed to aid the insertion and fixation of the cannula or catheter during the HSG? 16. To help facilitate the flow of contrast media into the uterine eavity, in which position is the patient placed following the injection of contrast media? 480 Chant 18. Special Radiographic Procedures yh 201 ase ne. ee an17. In addition to the supine position, what two other positions may be imaged to adequately visualize the pertinent anatomy for an HSG? A B 18, Where is the central ray (CR) centered for radiographic projections taken during an HSG using a 10- x 12-inch (25- x 30-cm) image receptor (IR)? ‘A. At level of anterior superior iliac spine C. Miae crest B. Symphysis pubis D, 2 inches (5 cm) superior to the symphysis pub's REVIEW EXERCISE D: Myclography (see textbook pp. 727-730) |. Myclography is a radiographic study of the: A B. 2. List the four common lesions or clinical indications demonstrated during myelography A c Bee D, ee 3. Of the four clinical indications just mentioned, which is the most common for myelography’ 4, TrueiFalse: Myelography of the cervical and thoracic spinal regions is most common. 5. List the four common contraindications for myelography A c B, D. 6, To reduce patient anxiety, a sedative is usually administered hour(s) before the procedure, 7. What type of radiographic table must be used for myelography? 8. Into which spinal space is the contrast mediuin introduced during myelography? 9, List the two common puncture sites for contrast media injection during myelography. A B. 10, Which of the puncture sites from question 9 is preferred’) 461 Caan © 202 Boi. he se ‘ups 19. Speen Radiographic Procedures|, What is the patient's general body position for each of the following punctures? (Note: There may be more than ne acceptable answer for each.) A. Lumbar B. Cervical 12, Why i large positioning block placed under the abdomen for a lumbar puncture in the prone position? 3. Which type of contrast medium is most commonly used for myelography? 14. The contrast medium in question 13 provides good radiopacity up to after jection, 4. 20 minaies ©. I hour B. 30 minutes D. 8hours 15. What dosage range of contrast medium is usually injected for myelography? A. 8t0 10mL © 90015 mL B, 20 t0 30 mL. D. Approximately | mL 16, Indicate the correct sequence of events for a myelogram by numbering the following steps in order (from 1 Through 8). A. Introxhice needle into subarachnoid space __B. Collect cerebrospinal uid and send 0 laboratory ©. Take overhead radiographic images 1D. Explain procedure tothe patient E, Introduce contrast medium F. Have patient sign informed consent form 6. Take fluoroscopic images H. Prepare patient's skin for puncture 17, Which position is performed to demonstrate the region of C7 during a cervical myelogram? 18. Why should the patient's head and neck remain hyperextended during cervical myelography? 19. True/False: Generally, AP supine, posteroanterior prone, or horizontal beam lateral projections are not taken ‘during thoracie spine myelography. 462 (isl ¥8. Special Reiogaphie Procedures Capris © 2021 Ea bs. ene20, Complete the following for suggested routine projections (following fluoroscopy and spot filming) forthe different levels of the spine, Projection/Position Level of CR 1. Cervical region 2. Thoracic region 3. Lumbar region 21. True/False: Myelography has been largely replaced by MRI and CT: 22. How is the contrast medium removed from the body after myelography? REVIEW EXERCISE E: Hip-to-Ankle Long Bone Measurement (see textbook p. 731) 1, What is the major reason hip-to-ankle long bone measurement studies are conducted? 2. If surgery is indicated, how might long bone measurement imaging help with planning? 3. What is the recommended source-image receptor distance for long bone measurement studies of hip-to-ankle? 4, What radiographic tools may be used to promote even x-ray absorption from hip to ankle with long bone ‘measurements? 5, How far apart should the lateral malleoli be with the patient standing for Tong bone measurement images? 6, Whar is the angle and placement of the central ray for hip-to-ankle long bone measurement images? REVIEW EXERCISE Radiographic Skeletal Survey (Bone Survey) (see textbook p. 731) 1, What is a skeletal survey? 2. What are some indications for a skeletal survey? 3. Which of the following is not consideved part of the appendicular skeleton? A, Homeri C. Hands B, Thorax D. Lower Legs 463 Cet ©2021 eve is eee, hate 19. Spacia Radiographic Procedures4, Which of the following is considered part af the axial skeleton? ‘A. Forearms C. Feet B. Femurs D, Lumbosacral spine 5, True/False: Radiographic skeletal surveys may be performed as the initial imaging procedure 6, True/False: Radiographic skeletal surveys may be performed following a positive finding on radionuclide bone REVIEW EXERCISE G: Conventional Tomography and Digital Tomosynthesis (see textbook pp. 792-734) 1. Define each of the following terms with short, concise answers. A, Tomograph B. Fulcrum (©. Fulerum tevey D. Object (Focal) plane Bc Sectional thickness coerce eee errr cree era eee ree err era ee eee ete F. Exposure angle (exposure amplitude) G. “Thick ent” H. Blur 2. Which locks on the x-ray tube must be opened or unlocked during linear tomography’? 3. True/False: The Bucky tray lock must be securely locked before a tomographic exposure. 4, True/False: Anatomy at the fulcram level becomes blurred and difficult to see on a radiograph, 5. List four common adjustments or features found on the tomographic control panel A B, D. 6, Thue/False: Objects closer to the objective plane will experience maximum blurring, 7. Briefly describe the tomographic blurring principle. (Why, or how, does blurring occur for some objects whereas others remain in sharp focus?) 464 Cher 19. Speci Raiographs Procaras rt © 202 i eos Ne8, List the four factors that determine the amount of blurring. A B. c D, 9, True/Palse: As the exposure angle decreases, slice thickness also decreases (becomes thinner) 10, True/Palse: As the distance from the IR increases, object blurring increases. 11. To gain maximum blurring of the body of the stermum during tomography, it should be placed ow ube movement A. Pacalle C. Diagonally B. Perpendicular D. ataS® angle 12. Which of the following exposure angles would produce the least amount of blurring outside of the objective plane? A cs B20 D. 40° 13, Which of the following exposure angles would produce the greatest amount of blurring outside of the objecive plane? A 10° as B. 8° D. 20° 14, What exposure angle is recommended for a large structure or a thick cut? 15, True/False: Blurring is a desired outcome of tomography. 16, A tomographic principle in which the enatomie structure moves but the IR/tube remain stetionary is called (Hint: Found in Chapter 8 in text.) 17. What is the minimum exposure time required to produce a breathing lateral projection of the thoracie spine? (Review Chapter 8 in text.) A. I second €. 4 seconds B. 2 seconds D. 6 seconds 465, yt © 2121 Bor gs ean alr 10. Special RaoaraphicPocetres18, What is digital tomosynthesis (DTS)? 19, What is the main advantage of DTS over conventional tomography? 20, True/False: The data acquired during DTS may acquire as many as 60 images in a single linear sweep. LABORATORY EXERCISES The following exercises involve two procedures for which supplies and equipment are most commonly available to students, Exercise A: Hip-to-Ankle Long Bone Measurement 1. Using a lower limb radiographic phantorn (if available), produce fong bone measurement radiographs of the following Unilateral lower limb (AP projection of hip, knee, and ankle on one IR with a correctly placed Bell- ‘Thompson ruler) ——— Bilateral lower limbs (AP projections of hips, knees, and ankles on one IR with correctly placed Bell- ‘Thompson ruler) Exercise B: Conventional Tomography | ‘This part of the learning exercise needs to be performed in an energized radiographic room equipped with a lineartype i tomographic unit. Check off the following steps as they are completed. Step 1. Equipment setup: Sct up the necessary tomographic equipment, including the adjustable fulcrum level attachment Connected fo the tube and to the Bucky. Ensure the Bucky tray locks are released (as well as the tube angle and tube distance locks), allowing the tube and the Bucky tray to move freely. Step 2. Preparation of phantom for experiments: Design a series of experiments to demonstrate the tomographie blurring principle and the effect of the four controlling and influencing factors on blurring. ‘Commercial tomographic phantoms are available with various lead numbers or other metallic devices placed at specific levels within the phantom. If these are not readily avsilable, one can easily be made With paper clips in combination with a wire mesh or other flat metallic objects placed in horizontal layers in three different books or in three different layers within the same book. The shape or the configuration Of the metallic objects can be varied in each layer so that the various levels can be differentiated on the radiograph, Step 3. Determine exposure factors: Determine approximate exposure factors 10 visualize the metalli ‘objects as placed in the books and stacked on the radiographic table. Start with an approximate upper Jimb exposure technique. Make a test exposure. Set the factors on the control panel of the tomographic unit as needed. 468 haver19. Special Radioraphic Proceaures Cyt © 200 eve. A ie aneOPTIONAL EXPERIMENTS TO DEMONSTRATE TOMOGRAPHIC PRINCIPLES AND VARIABLES Using your knowledge and understanding of tomographic blurring pr perform exercises as needed to demonstrate the following: Experiment A: Orientation of Body Part to Tube Travel—Demonstrate that those objects parallel to the direction of tube movement create “streaks” and are not as effectively blurred as when they are perpendicular to the tube movement. This can be readily shown by changing the longitudinal direction of the metallic objects (e.g., paper clips) 50 that the levels above and below the focal plane will be at some angle or completely perpendicular to the direction of the tube travel. This should demonstvate increased blurring of the objects above and below the focal plane. Experiment B: Influencing and Controlling Factors for Tomographic Blurring—Design experiments to demonstrate how each of the four factors or variables in the following list influences or controls the amount of blurring. For these types of experiments, remember to change only one factor ata time, keeping all other factors constant icipies as studied in this chapter, design and Factor 1—Object-focal plane distance Demonstrate that those objects farther from the focal plane have greater movement on the IR and therefore have increased blurring when compared to those closer to the focal plane. This can be done by first taking temographs with the objects above and below those in the Focal plane. Compare these with tomographs taken when the objects above and below are placed at increased disiances from the Tocal plane. You should be able to demonstrate markedly increased blurring on the second set of tomographs. Factor 2—Exposure angle or amplitude By changing the exposure angle, demonstrate that an increase in exposure angle with greater tube travel increases the blurring, resulting in a thinner focal plane, Likewise, a decrease in exposure angle with less tube travel decreases the movemnent of the objects above and below the focal plane, creating less blurring and a thicker section remaining in focus Remember the amplitude or speed of tube movement must also increase as the exposure angle is increased so that the exposure continues throughout the full are of tube travel, ___.. Factor 3—Object-image receptor distance (1D) ‘Demonstrate that as the distance of the objects from the IR is increased, greater blurring occur. Sponge blocks can be placed betvieen objects (e.g., books or phantom) and the table to increase the OID, (This demonstrates why the upside or side away from the TR on a tomogram of a lateral temporomandibular joint or ofa Iateral of inner ear structures should be examined rather than the downside.) 467 at ©2025 Beri ne eg era ‘her 19. Special Racor PoceresSELF-TEST My SCORE = ____% Directions: This self-test should be taken only after completing all of the readings, review exercises, and laboratory activities For a particular section. The purpose of this testis not only to provide a good learning exercise but also to serve a a stiong indicator of what your final evaluation exam will be. Lis strongly suggested that if you do not receive at least 8 90% to 95% grade on this self-test that you review those areas in which you missed questions before going to your instructor for the final evaluation exam for this chapter, |. List the two synovial types of joints most commonly examined with an arthrogram, A B. List the two contraindications for an arthrogram. A B. 3. An indication of a possible Baker cyst st sts the need for an arthrogram procedure for the 4. List the two types of contrast media commonly used for a knee arthrogram. A B 5. What is the purpose of flexing the knee gently after the contrast medium has been injected for an arthrogram procedure? 6, How many exposures are made, and how much is the leg rotated, between each exposure for horizontal beam knee athrograms? A. Number of exposures per meniscus: B. Degrees of rotation between exposures: ‘The term rotator cuff refers to what structures of the shoulder? 8. What type of needle is most often used to introduce contrast media during a shoulder asthrogram? 468 Cis 19 Special Rooraphic Procedures: Sel-Test any ©2021 Ba eet en | i i9. List the overhead projections that may be requested for a shoulder arthrogcam, Scout A Postinjection B. © D. E, E 10. How is the contrast medium instilled into the bitiary ducts during an ERCP? 11. Other than a radiologist, what type of physician often performs ERCP? 12. What is the most common clinical reason for performing a T-tube cholangiogram? 13. Which of the following conditions may contraindicate an ERCP? A. Biliary obstruction C. Jaundice B, Stone in main pancreatic duct D. Pyeudocyst 14, List the four divisions of the uterus, A B, 15. Which of the following is not a tissue layer of the uterus? A. Osseometrium C. Endometrium B. Myometrium D. Serosa 16. True/False: The uterine tubes are connected directly to the ovaties. 17. List the three contraindications for Hysterosalpingography (HSG). A B. ics 18, True/False: An oil-based contrast medium is preferred for the majority of HSG. 19. True/False: Hysterosalpingography can be a therapeutic procedure in comecting certain obstructions within tke uterine tube. 469 xs 2128 Bn, pean ‘hape 19. Space Racograpie Prous: Se Test20. List the four common lesions or conditions diagnosed through a myelogram. eee EEE c B. D. 21. List the four contraindications for a myelogram. A c. B D. 22. The most common clinical indication for a myelogram is: A, Benign tumors CC. Herniated nucleus pulposus (HNP) B. Spinal cysts, D. Bony injury to the spine 23. In which space is the contrast medium injected during a myelogram? 24. Which position will move the contrast media column from the lumbar o the cervical region during a myelogram? A. Fowler C. Trendelenburg B, Left lateral decubitus D. Prone 25. What isthe most common spinal puncture site for a lumbar myelogram? A L314 Clas BOLI42 D. 15-81 26. A cervical puncture is indicated for an upper spinal region myelogram if A The patient has severe lordosis, B, The patient has mild scoliosis, . The patient has HNP of the LA-LS level D. The patient has complete blockage atthe T-spine level 27. The absorption of the water-soluble contrast media into the vascular system of the body begins approximately ‘minutes after injection and is totally undetectable radiographically after hours. 28. Which position is performed during a cervical myelogram to demonstate the C7-T1 region? 29. The formal term for a radiographic study to compare the bilateral lower limbs is, 30. True/False: To measure the length of a long bone properly, the entire lower limb should be included on a single projection, 31 rue/False: Movement of the body part between exposures compromises the long bone study. 32, The/False: Ifa long bone study of both lower limbs is ordered, the use of two metal rulers is recommended with both limbs exposed atthe same time on the same IR. 470 hep 18 Special Reographis Precodure: So Tst th © 2021 Ba ee es33. What is the proper name for the filter used to promote consistent x-ray absorption with long bone measurement images? 34, List several indications for a radiographic skeletal survey, 35. Another term for tomography is 36. Match each of the following tomographic terms with its correct definition. A. Object plane 1, Distortion of objects outside the objective plane ____B. Exposure angle 2. Thickness of the focal plane ©. Tomogram 3. Radiograph produced by a tomographic unit ——_D. Blur 4. The plane in which the target anatomy is clear —_E. Fulerum 5. ‘The pivot point between the tube and the IR F, Sectional thickness 6. The factor that determines slice thickness 31, True/False: Maximum blurring of anatomy is achieved when it is perpendicular to tube travel 38, True/False: The primary factor affecting the sectional thickness, as controlled by the operator, is exposure angle 39, Thue/False: Increased blurring occurs when the object is farther from the IR. 40, True/Palse: More blurring occurs with a shorter exposure angle. Al, Define tomesynthesis an Cait © 20 Boro ne Atego Chote 19. SpeiatRasograhie Procedures Sa-Test a