Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5830_Библиотеки_им_академика_М_И_Перельмана.pdf
Once the image has been generated the near gain and depth controls can be adjusted to enhance the defi nition of the muscle and
fascial layers, and to ensure that these superfi cial structures fi ll
approximately 40-50% of the display. The medial to lateral placement of the probe can be manipulated so that both the anterior
medial border (linea semilunaris) and the lateral reach of TrA are
within the fi eld of view. Although inward probe pressure may
maximize the fi eld of view one must consider that this will distort
the depth of the lateral abdominal wall muscles. Alternatively,
adequate use of ultrasound gel increases the area of contact and
minimizes the need for this pressure.
THE MIDLINE ABDOMINAL FASCIA
Instrumentation:
Imaging of the midline abdominal fascia and linea alba is com-
monly achieved with a 5 MHz curved (convex) or 7.5 linear array
probe with the ultrasound unit set in B mode (van Uchelen
et al 2001, Whittaker 2004b).
Patient position:
In an attempt to standardize the technique and to facilitate access
to the abdomen, a supine, crook-lying position in which the hips
are relaxed, and legs supported by a bolster is suggested. The
abdomen should be exposed from the xyphoid to below the
umbilicus (preferably to the symphysis pubis).
THE MIDLINE ABDOMINAL FASCIA
31
Figure 2.4 Ultrasound probe placement for USI of the midline abdominal fascia.
32
2 Image generation
Probe placement:
The ultrasound probe is placed transversely across the midline of
the abdomen at the level of interest (Fig. 2.4). The angle of the
probe is manipulated (as near vertical as possible) until there is
a clear transverse image of the two heads of RA as they meet
in the midline (linea alba), as well as the external oblique (EO)
and TrA fascia (Fig. 2.5a, b). In this application, the marker
on the ultrasound probe should be orientated to patient left.
LEFT
RA
a
EO Fascia
TrA Fascia
M
RA
RIGHT
M
RARA
b
Figure 2.5 USI of the midline abdominal fascia. a. Transverse ultrasound image
of midline abdominal fascia (above the umbilicus). b. Labelled outline.
M = midline (linea alba), RA = rectus abdominis, EO = external oblique,
TrA = transversus abdominis.
LUMBAR MULTIFIDUS – SAGITTAL APPLICATION
Once the image has been generated, the depth control can be
adjusted to ensure that the muscle layers fi ll approximately 40-50%
of the screen, while the medial to lateral placement of the probe
can be manipulated so that the linea alba is positioned in the
middle of the screen. Delineation of the RA can be challenging.
Both lowering the general gain of the ultrasound unit (allowing
for the borders of the muscles to become more evident) and asking
the patient to lift their head and shoulders off of the bed (producing a contraction and corresponding architectural change within
the muscle) can be helpful. Although inward probe pressure may
maximize the fi eld of view, one must consider that this will distort
the depth of RA. Alternatively, adequate use of ultrasound gel
increases the area of contact and minimizes the need for this
pressure.
LUMBAR MULTIFIDUS – SAGITTAL APPLICATION
Instrumentation:
Sagittal imaging of the lumbar multifi dus is commonly achieved
with either a 7 MHz linear array (Hides et al 1995a) or a 5 MHz
curved (convex) array probe (Coldron et al 2003, Whittaker
2004b, Stokes et al 2005) with the ultrasound unit set in B
mode.
Patient position:
In an attempt to standardize the technique and to optimize feed-
back for the patient from the ultrasound screen, the suggested
position is side-lying with the hips and knees comfortably fl exed
and the lumbar spine positioned in neutral (Coldron et al 2003).
If there is large discrepancy between the hip and waist circum-
ference, a folded towel or pillow should be placed at the waist
angle in an attempt to prevent side fl exion of the region. The
trunk should be exposed so that the abdomen, lower rib cage
and vertebral column from the mid-thoracic spine to the sacrum
are visible. It is important to consider that this position is used
for standardization purposes and is not always the optimal posi-
tion for assessment or training purposes.
Probe placement:
The ultrasound probe is placed in a sagittal orientation immedi-
ately lateral to the spinous process (over the articular pillar) of
the level of interest. To visualize multifi dus the probe is angled
slightly medial, aiming towards the sulcus between the trans-
verse and spinous processes (Fig. 2.6). The marker on the
probe (indicating the left side of the screen) is orientated towards
the patient’s head, and the angle of the probe is manipulated
until a clear sagittal view of the lumbar multifi dus, sacrum and
articular processes of L5–S1, L4-5 and L3-4 is achieved (Fig.
2.7a, b).
33
34
2 Image generation
CRANIAL CAUDAL
Figure 2.6 Ultrasound probe placement for sagittal USI of the lumbar multifi dus.
Once the image has been generated, the gain and depth controls
can be adjusted to enhance the defi nition of the muscle/bone interface, and to ensure that multifi dus and the spinal column make up
the majority of the image displayed on the screen. The delineation
between the deep and superfi cial fi bres of the lumbar multifi dus is
not as obvious as with the layers of the abdominal muscles. The
deep fi bres of multifi dus are located near the articular pillar and the
superfi cial fi bres are near the top of the screen. A functional delineation becomes more obvious as a contraction is observed.
LUMBAR MULTIFIDUS – TRANSVERSE APPLICATION
Instrumentation:
Transverse imaging of lumbar multifi dus is commonly achieved
with a 5 MHz curved (convex) array probe with the ultrasound
unit set in B mode (Stokes et al 2005) (Fig. 2.8).
Patient position:
The patient can be positioned in either a prone or side-lying position
(Hides et al 1995a, Coldron et al 2003, Stokes et al 2005) for this
imaging application. However, it is important that the posture of
the region is standardized, and that the lumbar spine is positioned
in neutral. If prone is chosen, and an obvious lordosis of the
thoracolumbar or lumbosacral junction exists, a thin pillow should
be placed under the abdomen. The trunk should be exposed so
that the entire region is visible. It is important to consider that
this position is used for standardization purposes and is not always
the optimal position for assessment or training purposes.
CRANIAL
LUMBAR MULTIFIDUS – TRANSVERSE APPLICATION
SC
sMF
35
dMF
L34
a
SC
L34
L45
sMF
dMF
L45
L5S1
L5S1
Probe placement:
b
Figure 2.7 USI of lumbar multifi dus (sagittal). a. Sagittal ultrasound image of
lumbar multifi dus. b. Labelled outline. L34, L45, L5S1 = articular processes,
sMF = superfi cial multifi dus, dMF = deep multifi dus, SC = subcutaneous tissue.
CAUDAL
Initially the ultrasound probe is placed longitudinally, as in the sag-
ittal application, to determine the level of interest. Once the level
of interest is identifi ed, the probe is rotated 90° so that it sits
transversely on midline at that vertebral level. In this application,
orientate the marker on the probe to patient right (i.e. keep the
marker facing the right side of the patient). Once the spinous
process of the vertebral level of interest has been identifi ed, the
probe can be translated laterally (to highlight the side of interest)
and its angle manipulated (Fig. 2.8) (slightly anterolateral) until
36
2 Image generation
CRANIAL
Figure 2.8 Ultrasound probe placement for transverse USI of the lumbar
multifi dus.
a clear transverse view of the medial compartment of the lumbar
fascia (multifi dus), the lamina and spinous process is achieved
(Fig. 2.9a, b).
It is diffi cult to delineate the borders (particularly the lateral) of the
medial compartment of the lumbar fascia (which contains the multifi dus muscle). Both lowering the total gain of the ultrasound unit
(so that the borders become more evident) and asking the patient to
perform a gentle lift of the ipsilateral leg (Stokes et al 2005) (producing a contraction and corresponding architectural change which will
clarify the lateral border of multifi dus from longissimus) can be
helpful. Once the borders are identifi ed, the depth control can be
adjusted so that the multifi dus and spinal column make up the
majority of the image displayed on the screen. The transverse view
allows for differentiation between the medial and intermediate compartments of the lumbar fascia and it is generally used to comment
upon symmetry of size and shape, and linear and cross-sectional area
measurements, as well as for needle guidance in the laborator y.
BLADDER/PELVIC FLOOR – SAGITTAL APPLICATION
Instrumentation:
Sagittal imaging of the bladder is commonly achieved with a 5 MHz
curved (convex) array probe with the ultrasound unit set in B
RIGHT
BLADDER/PELVIC FLOOR – SAGITTAL APPLICATION
37
MF
LAMINA
a
MF
LAMINA
SP
SP
Patient position:
b
Figure 2.9 USI of lumbar multifi dus (transverse). a. Transverse ultrasound
image of lumbar multifi dus. b. Labelled outline. SP = spinous process,
MF = multifi dus.
LEFT
mode (O’Sullivan et al 2002, Bø et al 2003, Thompson &
O’Sullivan 2003, Whittaker 2004a, b).
To standardize the technique and to facilitate access to the lower
abdomen, the patient is positioned supine with their legs straight
and the hips relaxed. The patient’s abdomen should be exposed
from the xyphoid to the symphysis pubis. For optimal imaging
the bladder needs to be moderately full. This can be achieved
by asking the patient to void approximately one hour prior to
the assessment, to then drink 500 ml of water, and refrain from
voiding until after the assessment is completed. It is important
38
2 Image generation
Probe placement:
to note that unlike other abdominal ultrasound scans (such as
those associated with more traditional imaging goals) where the
bladder needs to be near full capacity to serve as an acoustic
window, overfi lling in this situation will actually confound the
assessment process by increasing the resting tone of the PFM.
The ultrasound probe is placed in a sagittal orientation along the
midline of the abdomen with the marker on the probe (indicating the left side of the screen) towards the patient’s head. The
probe is then translated inferiorly until it encounters the superior
aspect of the symphysis pubis. At this point the angle of the probe
is manipulated until it is pointing posterior and inferior to the
symphysis pubis (towards the gluteal border of the bladder)
allowing for a clear image of the bladder and the proximal aspect
of its neck (Fig. 2.11a, b). If there is interest in one side of the
pelvic fl oor the probe should be further orientated in a slight
superolateral to inferomedial direction, just lateral to midline
(Fig. 2.10).
Once the image has been generated, the gain and depth controls
can be adjusted to enhance the defi nition of the borders of the
bladder, and to ensure that the bladder and the structures sitting
inferior fi ll approximately 70 % of the screen. Although inward
probe pressure may maximize the fi eld of view, one must consider
that this will distort the shape of the RA and bladder. Alternatively,
Figure 2.10 Ultrasound probe placement for sagittal USI of the bladder.
CRANIAL
a
BLADDER/PELVIC FLOOR – TRANSVERSE APPLICATION
BLADDER
RA
39
BLADDER
VW
b
Figure 2.11 USI of the bladder and pelvic fl oor (sagittal). a. Sagittal ultrasound
image of the bladder. b. Labelled outline. RA = rectus abdominis
the bladder, VW = vaginal wall.
adequate use of ultrasound gel increases the area of contact and
minimizes the need for this pressure.
BLADDER/PELVIC FLOOR – TRANSVERSE APPLICATION
Instrumentation:
Transverse imaging of the bladder is commonly achieved with a
5 MHz curved (convex) array probe with the ultrasound unit set
in B mode (Whittaker 2004a, b, Sherburn et al 2005).
CAUDAL
, BN = neck of
40
2 Image generation
Patient position:
Probe placement:
In an attempt to standardize the technique and to facilitate access
to the lower abdomen, the patient is placed in a supine position
with their hips relaxed and legs supported by a bolster. The
patient’s abdomen should be exposed from the xyphoid to the
symphysis pubis. As with the sagittal application the bladder
needs to be moderately full (300-500 ml).
The ultrasound probe is placed in a transverse orientation, across
the midline of the abdomen, immediately superior to the pubic
symphysis. The angle of the probe is manipulated until it is
approximately 60° from the vertical and aimed towards the
gluteal or posteroinferior region of the bladder (Fig. 2.12). The
marker on the probe (indicating the left side of the display
screen) should be orientated towards the left side of the patient.
The angle of the probe should be adjusted until there is a clear
image of the bladder and the midline pelvic fl oor structures
(urethra, perineal body, rectum etc.) as seen in Fig. 2.13a, b
(Whittaker 2004a).
Once the image has been generated the gain and depth controls
can be adjusted to enhance the defi nition of the borders of the
bladder, and to ensure that the bladder and the structures sitting
inferior fi ll approximately 70 % of the screen. Although inward
Figure 2.12 Ultrasound probe placement for transverse USI of the bladder.