referral criteria for planar x-ray & fluoroscopic ... · osteomyelitis primary bone tumour...

Referral Criteria for planar x-ray & fluoroscopic (including

theatres) examinations

Radiology Department

Document Control

Reference No: HEYRAD14 First published: July 2012

Version: 2 Current Version Published:

June 2019

Lead Director & IRMER Practitioner:

Drs Byass & Goldstone

Review Date: June 2022

Document Managed by Name:

Trevor Parker Ratification Committee: Plain Film and Fluoroscopy Operational Group

Document Managed by Title:

Clinical governance Radiographer

Date EIA Completed: N/A

Consultation Process

Section Managers, Lead Radiographers, MPE, Radiologists via RMT

Key words (to aid intranet searching)

Target Audience

All staff Clinical Staff Only Non-Clinical Staff Only

Managers Nursing Staff Only Medical Staff Only

Version Control

Date Version Author Revision description

June 2019 2 Craig Moore & Trevor Parker

Referral criteria taken out of HEYRAD12 to produce this stand-alone document

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1 INTRODUCTION This document is written to ensure that departmental process conforms with the Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER 2017).

2 PURPOSE This document ensures the Radiology Department is compliant with regulation 6(5a) of the Ionising Radiation (Medical Exposure) Regulations 2017. It provides advice for referrers of patients for planar x-ray and fluoroscopic procedures to the Radiology Department at Hull University Teaching Hospitals.

3 SCOPE These procedures apply to all IRMER Referrers who request planar x-ray and fluoroscopic medical exposures.

4 DUTIES It is a legal requirement that the IRMER Referrer includes sufficient clinical details in the request to allow the radiation exposure to be justified and authorised by the Radiology IRMER Practitioner/Operator. The request must therefore conform to the criteria below. The IRMER Operator cannot legally perform x-ray procedures if the IRMER Referrer’s request does not conform to the criteria in this document, or if the patient and IRMER Referrer cannot be identified. Incomplete requests will be returned to the IRMER Referrer. If the request is part of a research project/clinical trial, this must be clearly indicated

on the request.

Typical radiation doses

The following referral criteria include an approximate level of patient radiation dose,

described in the table below.

Symbol Typical effective dose in mSv

Lifetime additional risk of cancer induction per

exam

˂1 Less than 1 in 20,000

1-5 1 in 20,00 to 1 in 4,000

5 - 10 1 in 4,000 to 1 in 2,000

>10 Greater than 1 in 2,000

Plain Film Referral Criteria Examination Plain Film Referral Criteria Relative Dose

Chest

Acute chest pain/central chest pain

Aortic dissection

Acute abdominal symptoms

Chronic stable angina

Pneumothorax

Sternal fracture

Pericarditis

Pleural effusion

Routine pre-operative (only on patients over 60 with significant cardiorespiratory symptoms)

Valvular cardiac disease

Pulmonary embolus

Lung cancer/metastases/pleural tumour

Pneumonia/chest infection

Pneumonia/chest infection follow up

Haemoptysis

Heart disease

Heart failure

Interstitial lung disease

Myocarditis

Hypertension

Acute exacerbation of asthma

Chronic Obstructive Pulmonary Disease

Surgical insertion or removal of device

NG tube check

Cervical rib

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Examination Plain Film Referral Criteria Relative Dose

Sternum

Abnormal isotope bone scan

Infection

Malignancy

Trauma

Abdomen

Acute abdominal pain

Obstruction

Perforation

Blunt trauma

Stab injury

Acute inflammatory bowel disease

Acute pancreatitis

Swallowed sharp or poisonous foreign body

Faecal impaction

Post-operative patient, not improving

Palpable abdominal or pelvic mass

Pre-MRI for patients who lack capacity, to eliminate pain relieving pumps/ baclofen pumps/ spinal stimulators, and renal stents being insitu.

Cervical Spine

Trauma

Fracture follow up

Osteoporotic collapse

Bone pain

Osteomyelitis

Primary bone tumour

Metastases

Myeloma

Metabolic bone disease

Osteomalacia

Arthropathy

Ankylosing Spondylitis

Atlanto-axial subluxation

Neurological deficit


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Thoracic Spine

Trauma and follow-up for vertebral #

Fracture follow up


Bone pain

Osteomyelitis

Primary bone tumour

Metastases

Myeloma


Osteomalacia

Arthropathy




Lumbar Spine

Trauma and follow-up for vertebral #

Fracture follow up


Bone pain

Osteomyelitis

Primary bone tumour

Metastases

Myeloma


Osteomalacia

Arthropathy




Sacrum

Trauma

Fracture follow up


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Sacroiliac joints

? sacroiliitis

? RA

? Uveitis

Coccyx Acute trauma


Pelvis/Hip

Fall /inability to weight bear

? avascular necrosis

? Total Hip Replacement

? bone tumour

? osteomyelitis

? arthropathy

Painful prosthesis


Pagets

Paediatric Pelvis

Irritable hip

Slipped capital femoral epiphysis

Perthes disease

Limping (unknown cause)

Trauma

Fracture follow up

Clicking hips

Development dysplasia of the hip

Hip

Trauma ?fracture

Fracture

Orthopaedic Referral

Complex history

Pain & OA

? bone tumour

? dislocated hip

? avascular necrosis

? osteomyelitis

?arthropathy


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Femur

Trauma

Fracture follow up

Bone tumour

Osteomyelitis

Osteomalacia

Painful prosthesis

Paget’s disease


Myeloma

Intramedullary nailing

Knee

Trauma – non weight bearing

Fracture follow up

Knee pain with locking/restricted movement

Bone tumour

Knee replacement/surgery

Effusion

Loose body

Osteomyelitis

Osteochondritis dessicans

Osteomalacia

Painful prosthesis


Arthropathy

Tibia & Fibula

Trauma – non weight bearing/bony tenderness

Fracture follow up

Knee pain with locking/restricted movement

Bone tumour

Osteomyelitis

Osteomalacia

Painful prosthesis


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Ankle

Trauma – tenderness/soft tissue swelling

Fracture follow up

Bone tumour

Osteomyelitis

Osteomalacia

Painful prosthesis

Ankle replacement/surgery


Foot

Trauma – bony tenderness

Stress fracture

Fracture follow up

Bone tumour

Osteomyelitis

Foot surgery


Calcaneum

Trauma

Stress fracture

Fracture follow up

Osteomyelitis


Shoulder

Trauma

Fracture follow up

Bone tumour

Osteomyelitis

Arthropathy

Painful prosthesis


Soft tissue calcifications (calcific tendonitis)

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Clavicle

Trauma

Fracture follow up

Bone tumour

Osteomyelitis


Acromio-clavicular joint

Trauma/dislocation

Sterno-clavicular joint

Subluxation

Dislocation

Tumour

Scapula

Trauma

Fracture follow up

Bone tumour

Osteomyelitis


Humerus

Trauma

Fracture follow up

Bone tumour

Osteomyelitis

Myeloma

Painful prosthesis


Elbow

Trauma

Fracture follow up

Bone tumour

Osteomyelitis

Arthropathy


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Forearm

? # following trauma

Follow up fracture (supported by RIS/PACS history)

? bone tumour

? osteomyelitis (must be at least

5/6 days after trauma to show/ ap view only)


Radius & Ulna

Trauma

Fracture follow up

Bone tumour

Osteomyelitis


Wrist

Trauma

Fracture follow up

Bone tumour

Osteomyelitis

Arthropathy


Scaphoid

Trauma

Follow up (10-14 days)

Fracture follow up

Bone tumour


Hand

Trauma

Fracture follow up

Bone tumour

Arthropathy

Osteomyelitis


Bone age (DP view of non-dominant hand and wrist)

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Fingers

Trauma/dislocation

Fracture follow up

Arthropathy

Skull

Penetrating injury

Suspected NAI

Hydrocephalus ?shunt function

Following abnormal bone scan as indicated by radiologist

Facial Bones

Orbital Trauma –blunt injury

Middle 1/3 facial injury

Major facial trauma

Max-Fax Request OM15, OM30

Mandible

Trauma/dislocation

Fracture follow up

Osteomyelitis

Bone tumour

Dental assessment (OPT & Cephalostat)

Orbits

? Metallic FB (please read pre MRI protocol)

? Metallic FB or

? removed FB

? Glass FB

IVU

Renal Stone Disease

Analgesic Nephropathy

Medullary Sponge Kidneys

In conjunction with other imaging methods:

Haematuria. These patients need urology referral.

Recurrent urinary tract infections

Renal tract obstruction

Renal trauma

Post operative – renal tract.

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Sinuses

Referrals from ENT only unless authorised by a radiologist.

? Polyp

Chronic sinusitis

Clinical indication of recurrent sinusitis

? fluid levels

? malignancy

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Fluoroscopy Referral Criteria

Examination Fluoroscopy Referral Criteria Relative Dose

Barium Meal/Swallow

Dyspepsia

Gastric or duodenal ulcer

Globus

Disordered swallowing mechanism

Oesophageal pouch/web

Dysphagia

Oesophageal stricture

Carcinoma

Gastro-oesophageal reflux

Hiatus hernia

Odynophagia

Achalasia

Contrast Enema

Barium Enema clinical indications:

?Inflammatory bowel disease

?Abdominal mass

Change in bowel habit

Bleeding PR

Lower abdominal pain Water soluble contrast enema clinical indications:

?Large bowel obstruction

Post Operative Assessment

? Colonic Fistula or Leak

? malrotation after discussion with Radiologist

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Water Soluble Enema

Any barium swallow criteria with high risk of aspiration

Gastric outlet obstruction

Post-operative assessment

Oesophageal perforation or fistula

Small Bowel Follow Through

Coeliac disease

Crohn’s disease

Obstruction

Intestinal blood loss – chronic or recurrent

Video Fluoroscopy Dysphagia

Sialogram ? Stones in salivary glands/ducts

? stricture

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Pancreatic and biliary malignancy

Choledocholithiasis

Acute or chronic pancreatitis

Pancreatic divisum

Palliative therapies

Dilatation of benign structures

Manometry

Hysterosalpingogram (HSG)

Infertility

Artificial insemination

Cystogram

Recurrent urinary tract infections

Pyelonephritis

Hydronephrosis

Bladder trauma/rupture

Stress incontinence/bladder dysfunction

Vesico-ureteric reflux

Cystocele

Bladder cancer

Bladder polyps

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Percutaneous Transhepatic Cholangiogram (PTC)

Jaundice

Obstruction of bile duct

Hepatic carcinoma

Fluoroscopic Injections Pain relief

Cholecystotomy Empyema of gallbladder

Duodenal, Oesophageal, Colonic or Biliary Stent

Malignant obstruction

Ureteric Stent

Malignant obstruction

Inflammation

Infection

Surgical trauma

Ascitic Drain Refractory ascites secondary to portal hypertension

Palliation of malignant ascites

Respiratory embarrassment

PleurX™ Drain Long term palliation of malignant ascites

Radiologically Inserted Gastrostomy (RIG)

Compromise/disease of the upper GI tract.

Nephrostomy

Urinary tract infection

Urinary tract malignancy

Chemotherapy

Spina Bifida

Biopsy (Liver, Lung, Renal, Omental, Thyroid, Bone or Lymph node)

Collection of pathological/histological samples for analysis

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Chest Drain

Post biopsy

Pneumothorax

Chylothorax

Empyema

Haemothorax

Hydrothorax

Arthrocentesis

Pathological/histological sample collection

Gout

Septic Arthritis

Nasojejunal Tube

Nutrition due to compromise/disease of the upper GI tract

Post RIG insertion

Inferior/Superior Vena Cava Filter

Deep vein thrombosis

Pulmonary embolus

Free floating thrombus in IVC

Prophylaxis pre-surgery

Testicular Embolisation Painful varicocele

Venogram Vein patency

Dacrocystogram Epiphoria

Arthrogram Rotator cuff tear

Evaluation of the glenoid/acetabular labrum

Lumbar (Nerve root block, facet joint injection, SI joint injection)

Lumbosacral pain syndromes (including somatic, neuropathic and visceral origin).

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Cervical (Nerve root block, facet joint injection)

Cervical pain, occipital headache, sympathetic mediated pain

Joint injections Bursa, pain due to arthritis

Proctograms

Anismus,

Tenismus

Difficulty defecating

Obstructed defecation

Faecal incontinence

Prolapse

Anterior or posterior rectocele.

Descending Perennial Syndrome (DPS),

Chronic constipation

Incomplete emptying or capacious rectum

Rectal intussusception

Intra-anal intussusception

External rectal prolapse

Enterocele

Sigmoidocele

Incontinence and solitary rectal ulcer.

Urethorograms Trauma,

Stricture, poor bladder emptying

post-op assessment.

Myelography

Indicated where there is suspicion of pathology affecting the contents of the spinal canal - specifically the spinal cord, cauda equina and spinal nerve roots.

It is mostly indicated when MRI is contraindicated and occasionally as a problem solving investigation supplementary to MRI.

NG Tube

Nutritional support required – difficulties in performing the procedure on ward.

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MCUG Recurrent UTI’s

Poor urine flow,

Vesico-ureteric reflux

Lumbar Puncture

Difficulties in performing the procedure on ward/day unit. o To obtain samples of cerebrospinal fluid (CSF) for diagnostic

purposes. o Measure opening pressure CSF for diagnostic purposes o Therapeutic drainage of CSF where pressure is raised and

clinical symptoms of raised intracranial pressure

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Theatre X-Ray Procedures Referral Criteria Examination Theatre X-Ray Procedures – Referral Criteria Relative Dose

Dynamic Hip Screw Fractured hip/femur

Intramedullary Nailing Fractured femur/tibia

Manipulation under Anaesthetic

To evaluate the position of a fracture during manipulation

Open Reduction Internal/External Fixation (ORIF)(ExFix)

Reduction of fractures Check position of metalwork during operation

Temporary Pacemaker Insertion

Complete/partial heart block Arrhythmia Asystole

Retrograde Pyelogram Ureteric obstruction Filling defects (stones or tumours) Assist with percutaneous access Stent placement Haematuria Trauma Assess duplex systems

Joint Injections e.g. hip Bursa Pain due to Arthritis

Cervical- (medial branch nerve block/facet joint/epidural/stellate ganglion/RF)

Cervical pain, Occipital headache, Sympathetic mediated pain

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Examination Theatre X-Ray Procedures – Referral Criteria Relative Dose

Lumbar-(Spinal Nerve Root Block/medial branch nerve block/Epidural/Facet joint Injection/SI joint/sympathectomy-lumbar, superior hypogastric plexus block, ganglion impar block)/piriformis injection/pudendal nerve block/psoas compartment block/Radiofrequency ablation(RF)

Lumbosacral pain syndromes, thoracic pain syndromes(including somatic, neuropathic and visceral origin)

Thoracic-paravertebral/intercostal nerve block/epidural/sympathectomy/suprascapular nerve block/RF

Lumbosacral pain syndromes, thoracic pain syndromes(including somatic, neuropathic and visceral origin)

Trigeminal Nerve Rhizotomy

Neuralgia

Removal of Metal Work/Foreign Bodies (FBD)

Location of broken screws/plates/foreign bodies/lost swabs

Hickman Line/Portacath insertion/Longline check

Difficulty in positioning of line, e.g. portacath, hickman line, for permanent IV access.

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Examination Theatre X-Ray Procedures – Referral Criteria Relative Dose

On table Angiography – peripheral vascular

Trauma to check vascular flow, angioplasty, graft patency, embolism.

On Table Cholangiogram Query presence of stones in biliary duct.

Sacral Nerve Stimulation Fecal incontinence and overactive bladder

Retrograde pyelogram/ Cystoscopy/ On table Cystogram

Ureteric reflux, ‘STING’ (subureteral transurethral injection) procedure, stones. Disorders of urethra including posterior urethral valves. Position check for stents. Abnormalities of duplex systems.

Stent insertion/ stent removal/ stent change.

Kidney stones/obstruction of the urine flow from the kidney.

Any instrumented spinal surgery (including anterior cervical plates, corpectomy cages, arthroplasty, interspinous distraction devices, vertebroplasty)

To ascertain correct vertebral level prior and during surgery. Deformity correction (ie checking the fracture-dislocation has corrected, or the spondylolisthesis has reduced)

Transsphenoidal Adenomectomy

Removal of tumour from pituitary gland

Radiofrequency Rhizotomy

Trigeminal Neuralgia

ERCP – Endoscopic Retrograde Choledocopancreatogram +/- Stent Insertion

Acute Pancreatitis – If considered Gall stone related Pancreatic trauma Pancreatic ascites Dilated bile ducts on Ultrasound or CT Pancreatic masses or cysts Possible bile duct damage post surgery Chronic abdominal pain

Dilatation e.g. Oesophageal/Stent Ins

Oesophageal Carcinoma Benign strictures Post surgical anastamosis strictures

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