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84
CHAPTER 5
|
IMAGING PROCEDURES
Under fluoroscopy, a cannula is inserted into the
common bile duct or the pancreatic duct. Retrograde
injection of contrast media into the ducts is followed
by fluoroscopy. The technologist on occasion may be
asked to perform AP/PA or oblique images of the right
upper quadrant postprocedure for documentation.
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
Endoscopic retrograde cholangiopancreatography (or
ERCP) is performed to view the biliary and pancreatic
ducts. The procedure can be diagnostic or therapeutic
in nature. This procedure is performed by the gastroen-
terologist assisted by a team including the technologist.
85
CHAPTER 5
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IMAGING PROCEDURES
Lateral Projection
Positioning Criteria
• Patient placed in the true left lateral position
• Place a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in the
table Bucky aligned with central ray
• Central ray is directed perpendicular to a point 2⬙
(5 cm) superior and posterior to pubic symphysis
Evaluation Criteria
• Urinary bladder free of superimposition
Demonstrates
• Entire bladder free from superimposition
• Visualization of posterolateral aspect of bladder and
vesicoureteral junction
• Pathology including but not limited to: cystitis,
obstruction, vesicoureteral reflux, and calculi
Cystourethrography
Anteroposterior Voiding
Cystourethrogram, Female
Positioning Criteria
• Patient is placed supine on the table or upright against
the Bucky
• Place a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in the
Bucky
• Central ray is directed perpendicular to pubic sym-
physis and MSP
Evaluation Criteria
• Contrast-filled urethra and bladder
Demonstrates
• Urethra seen inferior to bladder
• Functional study of the urinary bladder and urethra
• Pathology including but not limited to: urinary reten-
tion, vesicoureteral reflux
Right Posterior Oblique 30-Degree Voiding
Cystourethrogram, Male
Positioning Criteria
• Patient is placed in a 30-degree RPO on the table or
against the upright Bucky
• Superimpose urethra over soft tissue of right thigh
UROLOGICAL STUDIES
All urological studies utilize an AP abdomen as a scout
projection.
Cystography
Anteroposterior Projection
Positioning Criteria
• Patient is placed in the supine position with legs fully
extended
• Place a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in table
Bucky
• Central ray is directed 10 degrees to 15 degrees cau-
dal at 2⬙ (5 cm) superior to pubic symphysis and MSP
Evaluation Criteria
• Entire bladder visualized superior to the pubic
symphysis
Demonstrates
• Entire bladder free from superimposition
• Pathology including but not limited to: cystitis,
obstruction, vesicoureteral reflux, and calculi
Left Posterior Oblique/Right Posterior
Oblique 60-Degree Projection
Positioning Criteria
• Patient placed in a 60-degree posterior oblique posi-
tion on the table Bucky; keep patient’s legs fully
extended to not obscure the bladder
• Place a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in the
table Bucky
• Central ray is directed perpendicular to 2⬙ (5 cm)
superior to the symphysis pubis and 2⬙ (5 cm)
medial to the up ASIS
Evaluation Criteria
• Urinary bladder free of superimposition
Demonstrates
• Entire bladder free from superimposition
• Visualization of posterolateral aspect of bladder and
vesicoureteral junction
• Pathology including but not limited to: cystitis,
obstruction, vesicoureteral reflux, and calculi
86
CHAPTER 5
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IMAGING PROCEDURES
Demonstrates
• Scout view of abdomen
• Outline of liver, spleen, and kidneys
• Air-filled stomach and bowel
• Psoas muscle on asthenic patients
• Symphysis pubis for bladder region
• Pathologies including but not limited to: obstruction,
choleliths, renal calculi
Right and Left Posterior Oblique
30 Degrees
Positioning Criteria
• Patient is supine with legs extended
• Patient is rotated 30 degrees toward the right or left
side; elevated knee is bent slightly for stability and
elevated arm is crossed over upper chest
• Place a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in the table Bucky
• Central ray directed perpendicular to the level of iliac
crest and 1⬙ to 2⬙ (2.5 to 5 cm) off MSP toward the
up side
• Exposure is made on full expiration
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Entire abdomen included from kidneys to bladder
• Elevated kidney is parallel to IR and in view
• Down ureter is free from superimposition from spine
Demonstrates
• Elevated kidney in profile/parallel to the IR
• Down ureter is filled with contrast and free from
superimposition
• Pathology including but not limited to: infections,
trauma, obstruction, renal calculi
Posteroanterior Postvoid
Positioning Criteria
• Patient prone on the table; gonadal shield for male
patients; breast shield for females
• Place 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in Bucky aligned
with iliac crest at midpoint of receptor
• Central ray directed perpendicular to midpoint of IR
and MSP
• Place a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in the
Bucky
• Central ray is directed perpendicular to pubic sym-
physis and 2⬙ (5 cm) medial to up ASIS
Evaluation Criteria
• Contrast-filled urethra and bladder
Demonstrates
• Urethra seen inferior to bladder
• Functional study of the urinary bladder and urethra
• Pathology including but not limited to: urinary reten-
tion, vesicoureteral reflux
Intravenous Urography
All images are taken at timed intervals from the start
of contrast injection. Images at each time interval may
vary by department protocol. If performing a hyperten-
sive urogram, images are taken at 1, 2, and 3 minutes
with additional radiographs at similar short intervals to
assess this pathology appropriately.
Anteroposterior Abdomen Projection,
Scout and Series
Positioning Criteria
• Patient supine with legs fully extended; gonadal
shield for male patients; breast shield for females
• Place 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in Bucky aligned
with iliac crest at midpoint of receptor
• Central ray directed perpendicular to midpoint of IR
and MSP
• Collimate to all sides to include all pertinent anatomy
• Place appropriate side marker in light field at lower
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
• Image taken on full expiration
Evaluation Criteria
• Anatomy from kidneys to bladder is visualized
• No evidence of rotation
• Iliac wings and obturators (if visible) are symmetrical
• Spinous processes centered on vertebrae; transverse
processes equidistant to vertebrae
87
CHAPTER 5
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IMAGING PROCEDURES
Projection can be performed using a perpendicular cen-
tral ray with same centering. This is referred to as a
nephrogram when taken within 60 seconds of contrast
injection.
Anteroposterior Uretic Compression
Uretic compression may be applied prior to contrast
injection to allow for imaging of the proximal urinary
system. Positioning and centering is the same as for the
AP abdomen.
Retrograde Pyelography
Procedure is a nonfunctional study of the urinary system
performed in the surgical suite. Under sterile conditions,
the urologist places a catheter directly into the patient’s
renal pelvis. This is followed by contrast injection, and
• Collimate to all sides to include all pertinent anatomy
• Place appropriate side marker in light field at lower
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
• Image taken on full expiration
Evaluation Criteria
• Anatomy from kidneys to bladder is visualized
• No evidence of rotation
• Iliac wings and obturators (if visible) are symmetrical
• Spinous processes centered on vertebrae; transverse
processes equidistant to vertebrae
Demonstrates
• Residual contrast present in the urinary system
• Outline of liver, spleen, kidneys
• Air-filled stomach and bowel
• Psoas muscle on asthenic patients
• Symphysis pubis for bladder region
• Pathologies including but not limited to: obstruction,
choleliths, renal calculi
The above projection can be performed in the upright
position against the wall Bucky. All centering is the
same. The erect position will also demonstrate neph-
roptosis, benign prostatic hyperplasia, and prolapse of
bladder.
Nephrotomography
Positioning Criteria
• Patient supine with legs fully extended; gonadal
shield for all patients
• Place 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR crosswise in Bucky
• Central ray directed perpendicular to a point midway
between xiphoid and iliac crest (angle of the ribs
and MSP)
• Collimate to all sides to include all pertinent anatomy
• Measure patient thickness to indicate appropriate
slice with tomography
If the patient thickness is measured including a mat
on the table, use thickness minus 2 divided by
3 for the first slice
If measuring the patient with no mat, use thickness
divided by 3 for the first slice
• Place appropriate side marker within light field at
lower lateral aspect of IR; include marker for cm
• Tomography exposure angle typically 10 degrees or
less to minimize number of slices necessary to image
entire kidneys
• Minimum SID: 40⬙ (100 cm)
• Image taken on full expiration
FIGURE 5-7
Evaluation Criteria
• Renal parenchyma of kidneys
• No evidence of rotation
• Spinous processes centered on vertebrae; transverse
processes equidistant to vertebrae
Demonstrates
• Contrast-filled kidneys unobstructed
• Pathologies including but not limited to: renal cysts,
adrenal masses, calculi, obstructions
88
CHAPTER 5
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IMAGING PROCEDURES
• Wait for instruction for urologist on completion of
injection to expose
• Patient should be instructed to suspend respiration
on expiration
Evaluation Criteria
• AP projection of abdomen
• Contrast present in kidney injected
• No rotation, symmetrical transverse processes and
iliac wings
Demonstrates
• Pyelogram: renal pelvis and contrast-filled major and
minor calyces, presence of catheter
• Ureterogram: ureter filled with contrast
• Pathology including but not limited to: renal calculi
and obstructions
images are taken via a special cystoscopic-radiographic
table, mobile unit, or C-arm. AP abdomen scout image
is taken after catheter placement for positioning and
technique. Contrast is injected, and the AP pyelogram
is taken immediately. Following this projection, the
urologist may remove the catheter(s) from the renal
pelvis and place directly in the ureter. Again, contrast
is injected into one or both ureters, and a ureterogram
is taken.
Anteroposterior Pyelogram/Anteroposterior
Ureterogram
Positioning Criteria
• Patient is on the surgical table in the supine position;
breast shield when possible for female patients
• Place a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR beneath the patient
• Centering is at iliac crest and MSP
FIGURE 5-8
89
CHAPTER 5
|
IMAGING PROCEDURES
• Pathology including but not limited to: cervical ribs,
clay shoveler’s fracture, compression fractures, and
herniated nucleus pulposus
Anteroposterior Open Mouth
Positioning Criteria
• Patient placed AP erect (or supine) against the Bucky;
gonadal shielding used
• Place an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR in the Bucky and
center to central ray
• Central ray directed to canthus of lips and MSP
• Instruct patient to open mouth; adjust baseline of
mastoid tip and lower margin of upper teeth to be
perpendicular to receptor
• Collimate on all four sides
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
• Suspended respiration
Evaluation Criteria
• Unobstructed view of the dens
Demonstrates
• Entire C2 vertebra and lateral masses of C1 free of
superimposition
SPINE AND PELVIS
Cervical Spine
Anteroposterior Angled Cephalad
Cervical Spine
Positioning Criteria
• Patient placed AP erect (or supine) against the Bucky;
gonadal shielding used
• Central ray angled 15 degrees to 20 degrees cephalic
• Place an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR in the Bucky and
center to central ray
• Central ray directed at C3–C4 and MSP
• Collimate on all four sides
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
• Suspended respiration
Evaluation Criteria
• No rotation of spine
• Entire cervical spine is included
• No evidence of motion
Demonstrates
• Presence of cervical ribs
• Medial/lateral alignment of cervical spine
FIGURE 5-9
90
CHAPTER 5
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IMAGING PROCEDURES
This projection can also be performed with hyper-
flexion and hyperextension. Instruct patient to flex or
extend as much as tolerated. These views are done to
assess vertebral mobility status after trauma or surgical
fusion.
Cross-Table Lateral
Positioning Criteria
• Place patient in a true lateral position against the
Bucky, typically left lateral; gonadal shielding used
• Place an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) or 10⬙ ⫻ 12⬙ (25 ⫻
30 cm) IR with top of IR aligned with top of ear sup-
ported vertically against shoulder of patient centered
to the central ray; no grid is necessary because of use
of air-gap technique
• Central ray directed horizontally to C3–C4 and aligned
with EAM
• Instruct patient to relax shoulders by reaching
toward feet; traction on arms can be done by a quali-
fied physician
• Collimate on all sides
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 72⬙ (180 cm) to offset large OID and
decrease magnification
• Take image on full expiration
Evaluation Criteria
• Cervical spine visualized in its entirety
• No superimposition of gonion over upper cervical
• No evidence of rotation
• Pathology including but not limited to: odontoid
fractures, Jefferson fracture, pathologies associated
with C1–C2
Lateral Cervical Spine
Positioning Criteria
• Place patient in a true lateral position against the
Bucky, typically left lateral; gonadal shielding used
• Place an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR in the Bucky with
top of IR aligned with top of ear
• Central ray directed to C3–C4 and aligned with EAM
• Instruct patient to slightly elevate chin and relax
shoulders; 5- to 10-pound weights can be used if pa-
tient can tolerate
• Collimate on all sides
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 72⬙ (180 cm)
• Take image on full expiration
Evaluation Criteria
• Cervical spine visualized in its entirety
• No superimposition of gonion over upper cervical
• No evidence of rotation
Demonstrates
• C1–C7
• Zygapophyseal joints of cervical spine
• Spinous process
• Intervertebral disc spaces
• Vertebral body alignment
• Pathology including but not limited to: spondylolysis,
osteoarthritis, subluxation
FIGURE 5-10
91
CHAPTER 5
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IMAGING PROCEDURES
Ear
Sella turcica
Sphenoid sinus
Nasopharynx
C1 anterior arch (tubercle)
C2 dens (odontoid process)
Mandible ramus
Transverse process
C4 vertebral body
Hyoid bone
C5 spinous process
C6 pedicle
C6 lamina
C6–C7 apophyseal joint
C6–C7 intervertebral disc space
Trachea
FIGURE 5-11
Demonstrates
• C1–C7
• Zygapophyseal joints of cervical spine
• Spinous process
• Intervertebral disc spaces
• Vertebral body alignment
• Pathology including but not limited to: clay shovel-
er’s fracture, compression fracture, hangman’s frac-
ture, odontoid fracture, teardrop burst fracture, or
subluxation
Anterior and Posterior Oblique
Cervical Spine
Positioning Criteria
• Patient is rotated 45 degrees, keeping head and neck
aligned and centered to the upright Bucky; gonadal
shielding used
• Place an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR in the Bucky length-
wise and aligned with the central ray
• Anterior obliques: Central ray is angled 15 degrees
caudal, centered to C4 and midline of neck
• Posterior obliques: Central ray is angled 15 degrees
cephalic, centered to C4 and midline of neck
• Instruct patient to slightly elevate chin to reduce su-
perimposition of mandible
• Collimate on all four sides
• SID of 72⬙ (180 cm) to reduce magnification from OID
• Exposure made on suspended expiration
Evaluation Criteria
• Correct rotation and angulation
• Intervertebral spaces and foramina are open
• Pedicles in profile
Demonstrates
• Anterior obliques: intervertebral foramina and pedi-
cle on the side of the patient closest to the IR (e.g.,
RAO: right foramina and pedicles)
• Posterior obliques: intervertebral foramina and ped-
icles on the side of the patient farthest from the IR
(e.g., LPO: right foramina and pedicles)
• Pathology including but not limited to: stenosis
involving the intervertebral foramen
Projections can be performed recumbent with the
patient on the table.
92
CHAPTER 5
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IMAGING PROCEDURES
A
B
Occiput
C1 laminae
C2 spinous process
Left C4–C5 intervertebral
foramen
C5 left pedicle
C5 right pedicle
C6 left pedicle
C6 vertebral body
Left C7–T1 intervertebral
foramen
Trachea
Right 1st rib
Occiput
Mandible ramus
C3 vertebral body
Right intervertebral foramina
Right C5–C6 apophyseal joint
Right C6–C7 intervertebral foramen
C7 right pedicle
C7 left pedicle
FIGURE 5-12
93
CHAPTER 5
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IMAGING PROCEDURES
Demonstrates
• Vertebral bodies and intervertebral disc spaces of
C4–T3 are shown
• Pathology including but not limited to: fractures,
subluxation, osteoarthritis
Anteroposterior Dens (Fuchs) Projection
Positioning Criteria
• Place patient AP against the upright Bucky or supine
on the table; gonadal shielding used
• Place an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR in the Bucky
• Adjust patient so that the mentomeatal line (MML) is
perpendicular to the IR with no rotation of the head;
if patient is status post head and neck trauma, do
not attempt movement: Central ray can be angled as
needed to be parallel to MML
• Central ray is directed parallel to the MML at MSP
and inferior to the tip of mentum
• Four-sided collimation appropriate for anatomy
• Minimum SID: 40⬙ (100 cm)
• Exposure is made on suspended respiration
Evaluation Criteria
• Symmetrical appearance of mandibular arch over
foramen magnum
• Dens in foramen magnum
Lateral Swimmer’s Projection
(Cervicothoracic Lateral)
Performed when C7–T1 is not seen well on routine cer-
vical lateral projection
Positioning Criteria
• Erect is preferred, but can be performed supine
• Elevate patient’s arm and shoulder nearest the IR;
arm and shoulder farthest from IR should be relaxed
and down; gonadal shielding used
• Place 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR in upright Bucky
aligned with central ray
• Central ray perpendicular to T1, level of jugular
notch, and level of vertebra prominens posteriorly; a
3-degree to 5-degree caudal angle can be used on pa-
tients with limited flexibility of the upper extremities
• Minimum SID: 72⬙ (180 cm)
• Exposure taken on full expiration; if patient can
cooperate, a breathing technique can be employed
to improve visibility of the cervicothoracic junction
Evaluation Criteria
• Vertebral rotation should be minimal
• Humeral heads should be separated vertically
FIGURE 5-13