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European Commission

RADIATION PROTECTION 118

Referral guidelinesfor imaging

ISBN 92-828-9454-1

OFFICE FOR OFFICIAL PUBLICATIONSOF THE EUROPEAN COMMUNITIES

L-2985 Luxembourg

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Abstract

The newly revised medical exposuredirective (97/43/Euratom) lays down thegeneral principles of radiation protectionof individuals in relation to medicalexposure. Member States had totranspose it into national legislationuntil 13 May 2000. Article 6(2) of thedirective requires Member States toensure that recommendat ionsconcerning referral criteria for medicalexposure are available to the prescribersof medical exposure.

This booklet sets out referral guidelinesthat can be used by health professionalsqualified to refer patients for imaging,in order to ensure that all examinationsare well justified and optimised.

This booklet has evolved from thatpreviously published by the UK RoyalCollege of Radiologists in 1998 and isentitled: Making the best use of adepartment of clinical radiology:guidelines for doctors. These referralguidelines have been adapted by expertsrepresenting European radiology andnuclear medicine, in conjunction withthe UK Royal College of Radiologists,and may now be adopted as modelsfor the Member States.

These referral guidelines are not bindingon Member States, and form part of anumber of technical guides drawn upto facilitate implementation of themedical exposure directive. Localvariations may be required accordingto healthcare practice and provision.

Continued use of recommendations ofthis kind should improve clinical practiceand lead to a reduction in the numberof referrals for investigation andconsequently to a reduction inassociated medical radiation exposure.

Radiation Protection 118

Referral guidelines for imaging

Adapted by experts representingEuropean radiology and nuclear

medicine

In conjunction with the UK Royal College of Radiologists

Co-ordinated bythe European Commission

European CommissionDirectorate-General for the Environment

2000

A great deal of additional information on theEuropean Union is available on the Internet.

It can be accessed through the Europa server(http://europa.eu.int).

Cataloguing data can be found at the end of thispublication.

Luxembourg: Office for Official Publications ofthe European Communities, 2001

ISBN 92-828-9454-1

© European Communities, 2001

Reproduction is authorised provided the source isacknowledged.

Printed in Italy

PRINTED ON WHITE CHLORINE-FREE PAPER

Any views expressed in this document do notnecessarily reflect the views of the EuropeanCommission. Neither the European Commissionnor any person acting on behalf of theCommission is responsible for the use whichmight be made of the following information.

Preface

These referral guidelines for imaging have evolvedfrom the booklet ‘Making the best use of adepartment of clinical radiology: guidelines fordoctors’, which was published by the UK RoyalCollege of Radiologists in 1998 (1). They have beenadapted by various expert groups from severalcountries and comments have also been gathered fromradiological societies and nuclear medicine societiesof Member States through the European Associationfor Radiology and Nuclear Medicine. The EuropeanCommission co-ordinated this process. The referralguidelines may now be adopted as models for theMember States, even though it is recognised thatfurther local adaptation may be needed according tovarying health care practice and provision. The nextedition of the guidelines will be prepared by theRoyal College of Radiologists (Chairman of theworking party: Professor Gillian Needham,Aberdeen), in conjunction with the EuropeanCommission and the various expert bodies within theEuropean Community. They will be even moreevidence-based and take into account European aswell as UK practice.

The EU Council Directive 1997/43/Euratom (2)declared that Member States shall promote theestablishment and use of diagnostic reference levels forradiological examinations and guidance thereof. Thesereferral guidelines can be used for the above purposes.

This publication would not have been possiblewithout the work of a sub-committee which met threetimes in 1999:

Professor Dr W Becker, Nuclear Medicine, Göttingen, DE

Professor Angelika Bischof Delaloye, President,European Association of Nuclear Medicine,Lausanne, CH

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Dr Vittorio Ciani, European Commission, Directorate-General for Environment, Brussels, B

Professor Adrian K Dixon, Royal College ofRadiologists, Cambridge, UK

Mr Steve Ebdon-Jackson, Department of Health,London, UK

Dr Keith Harding, Nuclear Medicine, Birmingham,UK

Dr Elisabeth Marshall-Depommier, Paris, F

Professor Iain McCall, President, UEMS RadiologySection, Oswestry, UK

Professor Gillian Needham, Royal College ofRadiologists, Aberdeen, UK

Professor Hans Ringertz, European Association ofRadiology, Stockholm, S

Dr Bruno Silberman, Hon. General Secretary, UEMS,Paris, F

Dr Diederik Teunen, European Commission,Directorate-General for Environment, Brussels, B

Dr Ciska Zuur, Ministry of Housing, Spatial Planningand the Environment, The Hague, NL

We owe them all a lot of thanks.

P Armstrong Prof Hans Ringertz,President President (1999), Royal College European Associationof Radiologists of Radiology,London, UK Stockholm, SE

Prof. Angelika Bischof Delaloye,President (1999),European Associationof Nuclear MedicineLausanne, CH

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ContentsForeword to the fourth edition (1998) of theRoyal College of Radiologists (RCR)guidelines (1)..................................................... 7

Introduction ....................................................... 11

Why are guidelines and referral criterianeeded?........................................................ 11

What advice is available? ........................... 12

What images are taken?.............................. 14

For whom are the guidelines designed? ..... 14

Using the guidelines.................................... 14

Pregnancy and protection of the foetus ............ 16

Optimising radiation dose ................................. 18

Typical effective doses from diagnosticmedical exposures in the 1990s.................. 19

Communications with a department of clinicalradiology............................................................ 22

Technique-based imaging.................................. 23

Computed tomography (CT)....................... 23

Interventional radiology (includingangiography and minimal access therapy) ... 24

Magnetic resonance imaging (MRI)........... 25

Nuclear medicine (NM) .................................... 27

Nuclear medicine therapy ........................... 28

Ultrasound (US) ................................................ 29

Glossary............................................................. 31

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Clinical problems, investigations,recommendations and comments ...................... 32

A. Head (including ENT problems)........... 32

B. Neck....................................................... 37

C. The spine ............................................... 40

D. Musculoskeletal system......................... 45

E. Cardiovascular system........................... 53

F. Thoracic system..................................... 57

G. Gastrointestinal system ......................... 60

H. Urological, adrenal and genito-urinarysystems .................................................. 73

I. Obstetrics and gynaecology .................. 77

J. Breast disease ........................................ 80

K. Trauma................................................... 84

L. Cancer.................................................... 99

M. Paediatrics.............................................. 110

Selected bibliography........................................ 121

Appendix ........................................................... 124

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Foreword to the fourthedition (1998) of the RoyalCollege of Radiologists(RCR) guidelines (1)

This booklet has been prepared to help referringclinicians make the best use of a department ofclinical radiology. Continued use of recommendationsof this kind leads to a reduction in the number ofreferrals for investigation and also to a reduction inmedical radiation exposure (3–7). Nevertheless theprimary objective of this booklet is to improveclinical practice. Such recommendations work best ifthey are used in conjunction with clinico-radiologicaldialogue and as part of the audit process. They areintended to be used by both hospital doctors (allgrades) and primary care physicians. The editor(Adrian Dixon, Cambridge) has been assisted by theother members of the working party: Dr JohnBradshaw (Bristol), Dr Michael Brindle (President ofthe Royal College of Radiologists, King’s Lynn), thelate Dr Claire Dicks-Mireaux (London), Dr RayGodwin (Bury St Edmunds), Dr Adrian Manhire(Chairman of the RCR audit sub-committee,Nottingham), Dr Gillian Needham (Aberdeen), DrDonald Shaw (London), Mr Chris Squire (RCRclinical audit advisor), Dr Iain Watt (Bristol) andProfessor J Weir (Dean of the Faculty of Radiology,Aberdeen). Mr Barry Wall from the NationalRadiological Protection Board (NRPB) has againkindly provided data regarding radiation doses for avariety of investigations.

Since the third edition there has been yet furtheradvance within magnetic resonance imaging (MRI),and this is reflected in the recommendations. Thisedition also includes recommendations for some ofthe new niche roles for ultrasound (US), computed

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tomography (CT) and nuclear medicine (NM),including positron emission tomography (PET). Thesystem based approach introduced in 1995 has beenretained; most feedback has suggested that this formatwas more useful than the previous arrangement.

Once again we have indicated whether the statementsincluded within the booklet are based on rigorousscientific evidence. In line with UK National HealthService Executive policy on the development ofclinical guidelines (8), we have adopted the followingclassification:

(A) randomised controlled trials (RCTs), meta-analyses, systematic reviews; or

(B) robust experimental or observational studies; or

(C) other evidence where the advice relies on expertopinion and has the endorsement of respectedauthorities.

Interestingly, such grading systems have now becomequite commonplace in many aspects of health care,now that ‘evidence-based medicine’ has becomeaccepted practice (9–10). Review of the evidence hasbeen very time consuming. The working party is verygrateful to Dr Rachael Harrison who did much of theinitial data trawl as part of the REALM projectfunded by the Royal College of Radiologists (RCR).Subsequent literature searches have been performedby individual members of the working party and byvarious members of specialist imaging groups whohave provided very useful data.

Around 85 000 copies of the third edition (1995) ofthe booklet have been distributed and the contentshave, at various times, been commended by theNational Health Service Executive (NHSE) (8,11), theUK chief medical officers and the Audit Commission(12). It is of note that they have been adopted byseveral purchasers, many of whom now link the use

of the RCR’s recommendations to contracts withdepartments of clinical radiology. They have beenadopted in the private sector and adopted andtranslated by the radiological societies of othercountries. The recommendations are also extensivelyused as a standard for audit studies (13). A number offorward-looking hospitals have obtained electronicversions of these recommendations which can beincorporated into hospital information systems. Thisfourth edition has already been endorsed by theAcademy of Medical Royal Colleges and beenapproved by the Guidelines Appraisal Unit at StGeorge’s Hospital, London, in the United Kingdom.

With such serious implications now attached to theserecommendations, the working party has been fullyaware of the importance of getting it ‘as right asreasonably achievable’. We believe that this fourthedition, which has been produced following wideconsultation (see Appendix), represents a currentreasonable view of how departments of clinicalradiology should be used for some of the morecommon clinical problems. There will, undoubtedly,be some unpopular decisions; we have occasionallyreceived diametrically opposite advice. However, thisis probably inevitable in one of the most rapidlydeveloping specialties within medicine.

We hope that this fourth edition will prove useful andtrust that we will continue to receive advice andreferenced comments so that the development ofthese recommendations can continue. The nextedition of the RCR guidelines is planned for 2002.

Adrian K Dixon on behalf of the RCR guidelinesworking party

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Introduction

Why are guidelines and referral criterianeeded?A useful investigation is one in which the result —positive or negative — will alter management or addconfidence to the clinician’s diagnosis. A significantnumber of radiological investigations do not fulfilthese aims and may add unnecessarily to patientirradiation (14). The chief causes of the wasteful useof radiology are:

(1) Repeating investigations which have alreadybeen done: e.g. at another hospital, in anoutpatient department, or in the accident andemergency department.HAS IT BEEN DONE ALREADY? Everyattempt should be made to get previous films.Transfer of digital data through electronic linksmay assist in this respect in future years.

(2) Investigation when results are unlikely toaffect patient management: because theanticipated ‘positive’ finding is usuallyirrelevant, e.g. degenerative spinal disease (as‘normal’ as grey hairs from early middle age) orbecause a positive finding is so unlikely.DO I NEED IT?

(3) Investigating too often: i.e. before the diseasecould have progressed or resolved or before theresults could influence treatment. DO I NEED ITNOW?

(4) Doing the wrong investigation. Imagingtechniques are developing rapidly. It is oftenhelpful to discuss an investigation with aspecialist in clinical radiology or nuclearmedicine before it is requested. IS THIS THEBEST INVESTIGATION?

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(5) Failing to provide appropriate clinicalinformation and questions that the imaginginvestigation should answer. Deficiencies heremay lead to the wrong technique being used (e.g.the omission of an essential view). HAVE IEXPLAINED THE PROBLEM?

(6) Over-investigating. Some clinicians tend to relyon investigations more than others. Somepatients take comfort in being investigated.ARE TOO MANY INVESTIGATIONS BEINGPERFORMED?

What advice is available?In some clinical situations firm guidelines have beenestablished. Guidelines are:

systematically developed statements to assistpractitioner and patient decisions aboutappropriate health care for specific clinicalcircumstances... (Field & Lohr 1992, 15).

Just as the term implies, a guideline is not a rigidconstraint on clinical practice, but a concept of goodpractice against which the needs of the individualpatient can be considered. So while there have to begood reasons for ignoring them they are not absoluterules. No set of recommendations will commanduniversal support and you should discuss anyproblems with your radiologists.

The preparation of guidelines has become something ofa science, with numerous papers emerging within theevolving guidelines discipline. In particular, expertshave provided detailed methodology as to howguidelines should be developed, produced andappraised (8, 15–21). Using such methodology, thedevelopment of a single scientifically robust guidelinerepresents a major piece of academic endeavour. Forthe 280 clinical problems in this booklet, suchexpenditure of time and resources is somewhatimpractical. Nevertheless much of the philosophy of themethodology for the preparation of guidelines has been

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followed during the preparation of theserecommendations. In particular there has been extensiveliterature review with key references analysed. TheRoyal College of Radiologists holds an archive ofreferences upon which statements within the text arebased. Every opportunity has been given to workers inother disciplines and those representing patients to putforward their views. Many groups have beenencouraged to comment on points of fact, local policies,etc. In particular appropriate specialty imaging groupshave provided active support. There has been extensivedialogue with other professional groups, includingpatients’ representatives and all the royal colleges,culminating in endorsement by the Academy ofMedical Royal Colleges (see Appendix). Indeed one ofthe strongest features of these recommendations is thatthey have been reviewed and modified during thedevelopment of four editions since 1989.

Another concurrent development has been theproduction of ‘appropriateness criteria’ by theAmerican College of Radiologists (22). Rather thanpronouncing on what is perceived to be the optimalinvestigation, the ACR lists all possible investigationsand awards an appropriateness score (out of 10).These have been developed using a modified Delphitechnique with consensus reached amongst experts.The RCR has kept a watching brief on this interestingdevelopment and has incorporated some of the ACRconclusions.

Throughout the booklet the strength of the evidence(8) for the various statements is indicated by:

(A) randomised controlled trials (RCTs), meta-analyses, systematic reviews; or

(B) robust experimental or observational studies; or

(C) other evidence where the advice relies on expertopinion and has the endorsement of respectedauthorities.

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In some clinical situations (e.g. the role of US innormal pregnancy) there are conflicting data within alarge body of excellent scientific reports. Thus nofirm recommendations are given and the evidence isclassified as C. It should also be noted that there arevery few randomised trials comparing differentradiological diagnostic procedures – they are difficultto perform and ethical approval may be denied.

What images are taken?All imaging departments should have protocols foreach common clinical situation. Therefore no definiterecommendations are given about this aspect. Sufficeit to say that all examinations should be optimised toobtain maximum information with the minimum ofradiation. It is important to be aware of this as thepatient may not get what the referring clinicianexpects.

For whom are the guidelines designed?These guidelines are intended to be used by all healthprofessionals entitled to refer patients for imaging. Inthe hospital setting they are likely to be of most useto newly qualified doctors and many hospitals give acopy to each newly appointed junior doctor tostimulate good practice.

The range of investigations available to differenthealth professionals must be determined inconsultation with local specialists in radiology andnuclear medicine, bearing in mind the availableresources. The recommendations are also of value tothose interested in audit of a department’s referralpattern and workload (13).

Using the guidelinesThis booklet tends to highlight areas of difficulty orcontroversy. The pages are mostly composed of fourcolumns: the first sets the clinical situation forrequesting an examination; the next lists somepossible imaging techniques (and the band of

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radiation exposure involved); the third gives therecommendation (and the grade of availableevidence) on whether or not the investigation isappropriate; and the fourth provides explanatorycomments.

The recommendations used are:

(1) Indicated. This shows the investigation(s) mostlikely to contribute to clinical diagnosis andmanagement. This may differ from theinvestigation requested by the clinician: e.g. USrather than venography for deep vein thrombosis.

(2) Specialised investigation. These are complex orexpensive investigations which will usually beperformed only for doctors who have therelevant clinical expertise to evaluate the clinicalfindings and act on the imaging results. Theyusually justify individual discussion with aspecialist in radiology or nuclear medicine.

(3) Not indicated initially. This includes situationswhere experience shows that the clinical problemusually resolves with time; we therefore suggestdeferring the study for three to six weeks andonly performing it then if symptoms continue.Shoulder pain is a typical example.

(4) Not indicated routinely. This emphasises thatwhile no recommendation is absolute, the requestwill only be carried out if a clinician givescogent arguments for it. An example of such ajustification would be plain radiography in apatient with backache in whom there wereclinical findings to suggest something more thana degenerative disease (e.g.? Osteoporoticvertebral fracture).

(5) Not indicated. Examinations in this group arethose where the supposed rationale for theinvestigation is untenable (e.g. intravenousurogram (IVU) for hypertension).

Pregnancy and protectionof the foetus

• Irradiation of a foetus should be avoidedwhenever possible (23–25). This includessituations where pregnancy is not suspected bythe woman herself. The prime responsibility foridentifying such patients lies with the referringclinician.

• Women of reproductive age presenting for anexamination in which the primary beamirradiates directly, or by scatter, the pelvic area(essentially any ionising irradiation between thediaphragm and the knees), or for a procedureinvolving radioactive isotopes, should be askedwhether they are or may be pregnant. If thepatient cannot exclude the possibility ofpregnancy, she should be asked if her period isoverdue.

• If there is no possibility of pregnancy theexamination can proceed, but if the patient isdefinitely, or probably, pregnant (i.e. menstrualperiod overdue) the justification for the proposedexamination should be reviewed by theradiologist and the referring clinician, with adecision taken on whether to defer theinvestigation until after delivery or until the nextmenstrual period has occurred. However, aprocedure of clinical benefit to the mother mayalso be of indirect benefit to her unborn childand a delay in an essential procedure until laterin pregnancy may increase the risk to the foetusas well as to the mother.

• If pregnancy cannot be excluded, but themenstrual period is NOT overdue and theprocedure gives a relatively low dose to theuterus the examination may proceed. However, if

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the examination gives relatively high doses (inmost departments, the common examinations inthis category will probably be abdominal andpelvic CT, IVUs, fluoroscopy and NM studies),there will be discussion in line with locallyagreed recommendations.

• In all cases, if the radiologist and referringclinician agree that irradiation of the pregnant orpossibly pregnant uterus is clinically justified,this decision should be recorded. The radiologistmust then ensure that exposure is limited to theminimum required to acquire the necessaryinformation.

• If it becomes obvious that a foetus has beeninadvertently exposed, despite the abovemeasures, the small risk to the foetus of theexposure is unlikely to justify, even at the higherdoses, the greater risks of invasive fetaldiagnostic procedures (e.g. amniocentesis) orthose of a termination of the pregnancy. Whensuch inadvertent exposure has occurred, anindividual risk assessment should be made by aradiation physicist and the results discussed withthe patient.

• The RCR has recently co-authored (with theNRPB and the College of Radiographers) aguidance booklet on the protection of the foetusduring the diagnostic investigation of its mother(25).

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Optimising radiation dose

The use of radiological investigations is an acceptedpart of medical practice, justified in terms of clearclinical benefits to the patient which should faroutweigh the small radiation risks. However, evensmall radiation doses are not entirely without risk. Asmall fraction of the genetic mutations and malignantdiseases occurring in the population can be attributedto natural background radiation. Diagnostic medicalexposures, being the major source of man-maderadiation exposure of the population, add about onesixth to the population dose from backgroundradiation.

The 1997 EU directive (2) requires all concerned toreduce unnecessary exposure of patients to radiation.Responsible organisations and individuals usingionising radiation must comply with these regulations.One important way of reducing the radiation dose isto avoid undertaking investigations unnecessarily(especially repeat examinations).

The effective dose for a radiological investigation isthe weighted sum of the doses to a number of bodytissues, where the weighting factor for each tissuedepends upon its relative sensitivity to radiationinduced cancer or severe hereditary effects. It thusprovides a single dose estimate related to the totalradiation risk, no matter how the radiation dose isdistributed around the body.

Typical effective doses for some common diagnosticradiology range over a factor of about 1 000 from theequivalent of a day or two of natural backgroundradiation (0.02 mSv for a chest radiograph) to 4.5years (eg, for computed tomography of the abdomen).However, there is substantial variation in thebackground radiation between and within countries.The doses for conventional x-ray examinations arebased on results compiled by the NRPB from patient

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Typical effective doses from diagnosticmedical exposures in the 1990s

Diagnostic procedure Typical Equivalent Approximateeffective No. of equivalent

dose chest period of(mSv) x-rays natural

backgroundradiation (1)

X-ray examinations:

Limbs and joints(except hip) <0.01 <0.5 <1.5 days

Chest (single PA film) 0.02 1 3 days

Skull 0.07 3.5 11 days

Thoracic spine 0.7 35 4 months

Lumbar spine 1.3 65 7 months

Hip 0.3 15 7 weeks

Pelvis 0.7 35 4 months

Abdomen 1.0 50 6 months

IVU 2.5 125 14 months

Barium swallow 1.5 75 8 months

Barium meal 3 150 16 months

Barium follow through 3 150 16 months

Barium enema 7 350 3.2 years

CT head 2.3 115 1 year

CT chest 8 400 3.6 years

CT abdomen or pelvis 10 500 4.5 years

Radionuclide studies:

Lung ventilation (Xe-133) 0.3 15 7 weeks

Lung perfusion (Tc-99m) 1 50 6 months

Kidney (Tc-99m) 1 50 6 months

Thyroid (Tc-99m) 1 50 6 months

Bone (Tc-99m) 4 200 1.8 years

Dynamic cardiac (Tc-99m) 6 300 2.7 years

PET head (F-18 FDG) 5 250 2.3 years

(1) UK average background radiation = 2.2 mSv per year: regionalaverages range from 1.5 to 7.5 mSv per year.

With advice from Wall, B. National Radiological Protection Board.

dose measurements made in 380 hospitals throughoutthe UK from 1990 to 1995. They are mostly lowerthan those given in earlier editions of this bookletwhich were based on data from the early 1980s,indicating a gratifying trend towards improved patientprotection. The doses for CT examinations andradionuclide studies are based on national surveysconducted by the NRPB and BNMS and are unlikelyto have changed significantly since then.

Low-dose examinations of the limbs and chest are themost common radiological investigations butrelatively infrequent high-dose examinations such asbody CT and barium studies make the majorcontribution to the collective population dose. Thedoses from some CT examinations are particularlyhigh, show no sign of decreasing and the use of CT isstill rising. CT now probably contributes almost halfof the collective dose from all x-ray examinations. Itis thus particularly important that requests for CT arethoroughly justified and that techniques are adoptedwhich minimise dose while retaining essentialdiagnostic information. Indeed some authoritiesestimate the additional lifetime risk of fatal cancer foran abdominal CT examination in an adult is around 1in 2 000 (compared with the risk for a chest x-ray at1 in a million) (26). However, this is a small excessrisk compared with the very high overall risk ofcancer (nearly 1 in 3) and is usually more than offsetby the benefit gained from the CT examination.

In these referral guidelines the doses have beengrouped into broad bands to help the referrerunderstand the order of magnitude of radiation doseof the various investigations.

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TABLE Classification of the typicaleffective doses of ionisingradiation from common imagingprocedures

Class Typical effective ExamplesDose (mSv)

0 0 US, MRI

I <1 CXR, limb XR, pelvisXR

II* 1–5 IVU, lumbar spine XR,NM (e.g. skeletalscintigram), CT head &neck

III 5–10 CT chest and abdomen,NM (e.g. cardiac)

IV >10 Some NM studies (e.g.PET)

* The average annual background dose in most parts of Europe fallsin Band II.

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Communications with adepartment of clinicalradiology

Referral for an imaging examination is generallyregarded as a request for an opinion from a specialistin radiology or nuclear medicine. The outcome of thisrequest for opinion should be presented in the form ofa report to assist in the management of a clinicalproblem.

Request forms should be completed accurately andlegibly in order to avoid any misinterpretation. Youshould state clearly the reasons for the request andgive sufficient clinical details to enable the imagingspecialist to understand the particular diagnostic orclinical problems that you are attempting to resolveby radiological investigation.

In some cases the best investigation for resolving theproblem may be an alternative imaging examination.

If you are in doubt as to whether an investigation isrequired or which investigation is best, you shouldconsult with an appropriate specialist in radiology ornuclear medicine. Indeed imaging departments arealways pleased to discuss investigations withreferring doctors. Regular clinico-radiologicalmeetings provide a useful format for such discussionand are considered good practice (27).

While it should be noted that these recommendationshave been widely endorsed, it is recognised that afew departments will adapt them according to localcircumstances and policies.

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Technique-based imaging

Computed tomography (CT)CT is now quite widely available throughout Europe.Furthermore there have been recent importantadvances due to the development of spiral andmultislice CT which allows breath-hold volume dataacquisition. Such advances have opened up newdiagnostic opportunities, such as the use of spiral CTin the diagnosis of pulmonary embolism. Neverthelessdifferent hospitals will have their own policies aboutaccepting CT requests. It is worth remembering thatCT is a relatively expensive study and imparts a highx-irradiation dose. Thus it is always worth consideringalternatives, especially in view of the increasing roleof MRI. Indeed the UK National RadiologicalProtection Board have published several generalrecommendations with regard to CT in Protection ofthe patient in x-ray computed tomography (26), someextracts from which are reproduced here:

In view of the potential high doses CT should onlybe carried out after proper clinical justification byan experienced radiologist. Examinations onchildren require a higher level of justification, sincesuch patients are at greater risk from radiation.

When clinically appropriate, the alternative use ofsafer non-ionising techniques (US and MRI) or oflow dose x-ray techniques should be considered.

CT should not be carried out on the abdomen orpelvis of pregnant patients without sound clinicalreasons and particular attention to low-dosetechniques.

Care should always be taken to minimise exposureto the eyes, particularly for patients likely toundergo multiple examinations.

As for all radiological requests, any CT referralwhich falls outside established guidelines should bediscussed with a radiologist. Because of the need to

minimise the extent of the examination (and therebythe cost and radiation dose), it is helpful if theclinical notes and previous imaging investigations areavailable for review at the time of CT.

A few further points:

• CT remains the optimal investigation for manyclinical problems within the chest and abdomen,despite the radiation risks.

• CT is still widely used for intracranial problems,especially CVA and trauma.

• CT remains a simple method of staging manymalignant diseases (e.g. lymphoma) and inmonitoring the response to therapy.

• CT provides valuable pre-operative informationabout complex masses and is widely used forpost-operative complications.

• CT allows accurate guidance for drainageprocedures, biopsies and anaesthetic nerveblocks.

• CT has an important role in trauma.

• CT images may be degraded by prostheses,fixation devices, etc.

• CT provides better anatomical detail in obesepatients than US. In thinner patients andchildren, US should be used wherever possible.

• CT of the abdomen imparts a radiation doseequivalent to about 500 CXRs.

Interventional radiology (includingangiography and minimal accesstherapy)

This area of radiology is currently undergoing rapidexpansion. While all departments of clinical radiologyhave been undertaking angiography and associated

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procedures (e.g. angioplasty) for many years, severalnew techniques have emerged recently. Most abscessesin the abdomen are now treated by percutaneousdrainage procedures using radiological guidance.Likewise the majority of liver biopsies are nowperformed by radiologists (using US guidance). Lymphnode biopsies are routine in most US and CT units.

New technology is rapidly widening the range ofinterventional radiology yet further. Theseinnovations include:

• percutaneous diskectomy for lumbar diskherniation (often using CT control);

• percutaneous insertion of grafts for abdominalaortic aneurysms;

• various techniques to treat inoperable hepaticlesions (e.g. laser ablation under imagingcontrol);

• interventional MRI with ‘real-time’ imaging toallow monitoring of therapeutic manoeuvres.

These examples of recent innovations require closecollaboration with clinical colleagues. The precisearrangements vary considerably according to localexpertise and availability of equipment. There iscontinuing discussion at national level about the bestarrangement for these interventional procedures.Inevitably requests for all such procedures involvedetailed discussion between various specialists.

Magnetic resonance imaging (MRI)

There has been a substantial recent increase in thenumber of MRI systems across Europe. Accordinglythere are numerous recommendations for the use ofMRI. Indeed, with the recent technical advances andincreasing experience, the role of MRI continues toexpand and the limiting factor for further expansionis now often financial.

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Because MRI does not use ionising radiation, MRIshould be preferred where both CT and MRI wouldprovide similar information and when both areavailable. However MRI is in danger of beingsubjected to inappropriate demands which may leadto long waiting times. Thus, all requests for MRIshould be agreed with a radiologist.

A few further points:

• MRI usually provides more information than CTabout intracranial, head and neck, spinal andmusculoskeletal disorders because of highcontrast sensitivity and multiplanar imagingcapability. This helps to establish the diagnosisand institute appropriate management withgreater confidence. It is increasingly being usedin oncology.

• Major recent advances include: breast andcardiac MR imaging; angiographic andinterventional techniques; MRCP and other fluid-sensitive MR techniques; functional MR imagingof the brain. However, many of these techniquesawait full evaluation.

• MRI is not approved during the first trimester ofpregnancy. However it may well prove to besafer than some of the alternative options.Discuss all imaging in pregnancy with theradiology department.

• There are some definite contraindications to theuse of MRI: metallic foreign bodies (FBs) in theorbits, aneurysm clips, pacemakers, cochlearimplants, etc. Furthermore MRI will givereduced image quality close to prostheses, etc.The full list of contraindications is provided inseveral textbooks and monographs. Anyuncertainty about contraindications should bediscussed with the imaging department well inadvance.

Nuclear medicine (NM)

In EU countries NM is an independent specialty, theuse of unsealed sources of radionuclides for diagnosisand therapy being restricted to NM specialists. Insome countries other specialists, usually radiologists,can also provide NM services. Whatever the localarrangements, an experienced specialist will beavailable to discuss the appropriate NM techniques ina given clinical situation. They will also be able toadvise on which particular NM investigation shouldbe used. Accordingly referring clinicians shouldindicate the precise clinical problem requiringinvestigation, because this will determine whichradionuclide (or alternative) investigation is used.

Despite some misconceptions, the radiation dosesimparted by most NM techniques comparefavourably with those of many other imaginginvestigations which are regarded as ‘safe’. As shownin the chart displayed in the section on minimisingradiation dose, the effective dose associated withmost routine NM studies is considerably less thanthat for abdominal CT.

There is particular value in the functional data whichcan be provided by NM techniques. At a basic level,NM can determine whether a distended renal pelvisshown by US is merely due to a capacious collectingsystem, or caused by an obstructing lesion. The sameinvestigation can provide data on the percentage ofoverall renal function provided by each kidney. Morecomplex studies can indicate the ejection fraction ofthe left ventricle or the distribution of blood flow tothe cerebral cortex.

PET has recently made large strides and there is agradual increase in its availability. Because of theshort-lived nature of the key radionuclides (theglucose analogue F-18 fluorodeoxyglucose, FDG, iswidely used), PET can only be offered close to a

27

28

cyclotron and radionuclide pharmacy. However, thedevelopment of double-headed gamma cameras withmodified PET capabilities is a significant advancewhich should increase availability; it is currently thefocus of much research. Because PET can identifysmall foci of viable tumours, it offers exceptionalopportunities in the staging of various cancers (e.g.bronchus) and in cancer follow-up (e.g. lymphoma),where other imaging techniques may be unable todistinguish between residual fibrotic masses andactive disease. PET can also provide unique dataabout brain metabolism and myocardial viability andthere are several research units studying theseaspects. Over the next few years there will be anincreasing uptake of PET into clinical practice and itspotential use is flagged for certain clinical problemsin the ensuing recommendations.

Nuclear medicine therapyAlthough not considered further in these referralguidelines, it is worth considering the important roleof NM in the treatment of both benign and malignantdisease. The thyroid gland is still the most importanttarget but the field is rapidly expanding. Otherindications include neuroendocrine tumours, painfulskeletal metastases, some arthropathies,polycythaemia, malignant effusions. NM treatmentoptions are being investigated in theleukaemias/lymphomas and some liver tumours.

29

Ultrasound (US)Since the previous edition of these guidelines, mostdepartments of clinical radiology have experienced alarge increase in referrals for US examinations.During this period US equipment and expertise haveadvanced and the scope of referrals (Colour Doppler,Power Doppler, transvaginal (TV) gynaecologicalwork, etc.) has widened. These trends are to bewelcomed because US does not employ ionisingradiation. However there is scant evidence that theincrease in US has been accompanied by muchreduction in referrals for other radiologicalinvestigations and a consequent reduction in totalradiation dose to the public.

In fact, the rising US workload has developed whilethe demand for other radiological investigations hasalso continued to increase. The one notable exceptionis the IVU which is required much less often since theadvent of US. However, because US is non-invasive,the total number of patients investigated withuroradiological problems has increased. Departmentsof clinical radiology have developed different localpolicies for dealing with the increasing US workload.

The actual acquisition of US images has to beundertaken by an experienced operator; even such anoperator may not be able to gain perfect images inevery patient. For example US can be difficult andunsatisfactory in obese patients. Furthermore thedistribution of bowel gas may mask certain features.Nevertheless the cheap, quick, reliable and non-invasive nature of US make it an excellent initialinvestigation for a wide range of clinical referrals.Accordingly US has been recommended as theappropriate investigation wherever possible.

Because US avoids ionising radiation and is relativelyinexpensive, it is often recommended where moreexpensive studies (e.g. CT) cannot be justified or

resources are limited. Conversely, it is difficult torefuse a request for US on grounds of invasiveness orexpense. There is thus a danger of US departmentsbeing overloaded with requests which may be on themargins of appropriateness. Accordingly, referringclinicians still have a duty to consider carefullywhether each request for US is justified and whetherthe result (e.g. the presence of gallstones) will affectmanagement (see Introduction, why are guidelinesneeded?).

30

31

GLOSSARY

ABBREVIATION DEFINITION

XR Plain radiography one or morefilms

CXR Chest radiograph

AXR Abdominal radiograph

US Ultrasound

Skeletal survey A series of XRs to show thepresence and extent of involvedskeleton

Mammogram Breast radiography

Ba swallow/ meal/FT Barium swallow/ meal/followthrough

Small bowel enema Detailed Barium study vianasoduodenal intubation

Ba enema Barium enema

IVU Intravenous urogram

CT Computed tomography

CTA CT angiography

HRCT High resolution CT

NM Nuclear medicine

SPECT Single photon emissiontomography

MRI Magnetic resonance imaging

MRA MR angiography

MRCP Magnetic resonance cholangiopancreatography

DSA Digital subtraction angiography

ERCP Endoscopic retrograde cholangiopancreatography

PET Positron emission tomography

A.

Hea

d (

incl

ud

ing

ENT

pro

ble

ms)

Con

geni

tal

diso

rder

s M

RI

(0)

Indi

cate

d (C

)D

efin

itive

exa

m f

or a

ll m

alfo

rmat

ions

and

avo

ids

x-ir

radi

atio

n. 3

D C

Tm

ay b

e ne

eded

for

bon

e

(for

chi

ldre

n se

ean

omal

ies.

Sed

atio

n us

ually

req

uire

d fo

r yo

ung

Se

ctio

n M

)A

1ch

ildre

n. C

onsi

der

US

in n

eona

tes.

Cer

ebro

vasc

ular

acc

iden

t C

T(I

I)In

dica

ted

(C)

CT

adeq

uate

ly a

sses

ses

mos

t ca

ses

and

(CV

A);

str

oke

show

s ha

emor

rhag

e.

MR

I (0

) an

dSp

ecia

lised

M

RI

and

NM

mor

e se

nsiti

ve t

han

CT

in e

arly

N

M (

II)

inve

stig

atio

n (B

)in

farc

tion

and

for

post

erio

r fo

ssa

lesi

ons.

US

caro

tids

(0)

Not

ind

icat

ed

Exc

eptio

ns f

or:

(a)

thos

e w

ith f

ull

reco

very

in

who

m

rout

inel

y (C

)ca

rotid

sur

gery

is

cont

empl

ated

. (b)

an

evol

ving

CV

AA

2w

here

dis

sect

ion

or e

mbo

lus

susp

ecte

d.

Tra

nsie

nt i

scha

emic

U

S ca

roti

ds (

0)In

dica

ted

(B)

If d

oubt

abo

ut d

iagn

osis

or

surg

ery

cont

empl

ated

. at

tack

(T

IA)

Muc

h de

pend

s on

loc

al p

olic

y an

d av

aila

ble

expe

rtis

e.

US

(with

Col

our

Dop

pler

) pr

ovid

es f

unct

iona

l da

ta

abou

t bi

furc

atio

n di

seas

e. A

ngio

grap

hy, M

RA

and

CTA

are

mor

e ex

pens

ive

alte

rnat

ives

to

show

the

(s

ee a

lso

B5)

A3

vess

els.

MR

I an

d N

M c

an b

e us

ed t

o sh

ow f

unct

ion.

32

A. HeadC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Dem

yelin

atin

g an

d ot

her

MR

I (0

)In

dica

ted

(A)

MR

I m

uch

mor

e se

nsiti

ve t

han

CT

for

dem

yelin

atin

gw

hite

mat

ter

dise

ase

dise

ase.

But

MR

I m

ay s

till

be n

egat

ive

in u

p to

25

%of

tho

se w

ith e

stab

lishe

d m

ultip

le s

cler

osis

. MR

I al

sosu

peri

or t

o C

Tin

del

inea

ting

exte

nt a

nd l

ocat

ion

of

A4

othe

r w

hite

-mat

ter

dise

ase.

Spac

e-oc

cupy

ing

CT

(II)

or

Indi

cate

d (B

)M

RI

mor

e se

nsiti

ve f

or e

arly

tum

ours

, in

reso

lvin

g le

sion

(SO

L)

MR

I (0

)ex

act

posi

tion

(use

ful

for

surg

ery)

and

for

pos

teri

or

foss

a le

sion

s. M

RI

may

mis

s ca

lcif

icat

ion.

CT

mor

ew

idel

y av

aila

ble;

and

oft

en s

uffi

cien

t in

sup

rate

ntor

ial

lesi

ons

and

subd

ural

hae

mat

omas

. MR

I su

peri

or i

n th

epo

ster

ior

foss

a an

d fo

r va

scul

ar l

esio

ns. N

M m

ay b

eus

eful

in

cert

ain

circ

umst

ance

s —

tum

our

viab

ility

A

5po

st-t

hera

py, e

spec

ially

pos

t-ra

diot

hera

py.

Hea

dach

e: a

cute

, sev

ere

CT

(II)

Indi

cate

d (B

)C

Tpr

ovid

es a

dequ

ate

data

in

mos

t ca

ses

of

suba

rach

noid

and

oth

er i

ntra

cran

ial

haem

orrh

age

and

asso

ciat

ed h

ydro

ceph

alus

. NB

:Ane

gativ

e C

Tdo

es n

ot

excl

ude

SAH

and

whe

re s

uspe

cted

lum

bar

punc

ture

sh

ould

fol

low

, ass

umin

g no

con

trai

ndic

atio

ns(e

.g. o

bstr

uctiv

e hy

droc

epha

lus)

. Lum

bar

punc

ture

m

ay a

lso

be n

eede

d to

exc

lude

men

ingi

tis.

MR

I (0

) or

Sp

ecia

lised

M

RI

bette

r th

an C

Tfo

r in

flam

mat

ory

caus

es. N

M m

ayN

M (

II)

inve

stig

atio

n (C

)be

the

mos

t se

nsiti

ve i

nves

tigat

ion

for

ence

phal

itis

and

can

prov

ide

evid

ence

of

circ

ulat

ion

dera

ngem

ent

in

A6

mig

rain

e.

33

A. Head

Hea

dach

e: c

hron

ic

XR

sku

ll, s

inus

, N

ot i

ndic

ated

R

adio

grap

hy o

f lit

tle u

se i

n th

e ab

senc

e of

foc

al

C s

pine

(I)

rout

inel

y (B

)si

gns/

sym

ptom

s. S

ee A

13 b

elow

.

(for

chi

ldre

nC

T(I

I) o

rN

ot i

ndic

ated

So

me

exce

ptio

ns f

or s

peci

alis

ts o

r if

evi

denc

e of

rai

sed

see

Sect

ion

M)

A7

MR

I (0

)ro

utin

ely

(B)

intr

acra

nial

pre

ssur

e, p

oste

rior

fos

sa o

r ot

her

sign

s.

Pitu

itary

and

M

RI

(0)

Spec

ialis

edD

emon

stra

tion

of m

icro

aden

omas

may

not

be

help

ful

juxt

a-se

llar

prob

lem

sin

vest

igat

ion

(B)

for

man

agem

ent.

CT

if M

RI

not

avai

labl

e. U

rgen

t re

ferr

al w

hen

visi

on d

eter

iora

ting.

Som

e ce

ntre

s us

e sp

ecif

ic N

M a

gent

s.

SXR

(I)

Not

ind

icat

ed

Patie

nts

who

req

uire

inv

estig

atio

n ne

ed M

RI

or C

T.A

8ro

utin

ely

(C)

Post

erio

r fo

ssa

sign

sM

RI

(0)

Indi

cate

d (A

)M

RI

muc

h be

tter

than

CT.

CT

imag

es o

ften

deg

rade

d A

9by

bea

m h

arde

ning

art

efac

ts.

Hyd

roce

phal

us

CT

(II)

Indi

cate

d (B

)C

Tad

equa

te f

or m

ost

case

s; M

RI

som

etim

es

nece

ssar

y an

d m

ay b

e m

ore

appr

opri

ate

in c

hild

ren.

U

S fi

rst

choi

ce f

or i

nfan

ts. N

M u

sed

in s

ome

cent

res,

(for

chi

ldre

n se

ees

peci

ally

for

shu

nt f

unct

ion.

Sect

ion

M)

A10

XR

Indi

cate

d (C

)X

R c

an d

emon

stra

te w

hole

val

ve s

yste

m.

34

A. HeadC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Mid

dle

or i

nner

-ear

C

T(I

I)Sp

ecia

lised

E

valu

atio

n of

the

se s

ympt

oms

requ

ires

EN

T,sy

mpt

oms

(inc

ludi

ng

inve

stig

atio

n (B

)ne

urol

ogic

al o

r ne

uros

urgi

cal

expe

rtis

e.ve

rtig

o)A

11

Sens

orin

eura

l de

afne

ss

MR

I (0

)Sp

ecia

lised

M

RI

muc

h be

tter

than

CT,

esp

ecia

lly f

or a

cous

tic

(for

chi

ldre

n se

ein

vest

igat

ion

(B)

neur

omas

. For

dea

fnes

s in

chi

ldre

n se

e M

4.Se

ctio

n M

)A

12

Sinu

s di

seas

e Si

nus

XR

(I)

Not

ind

icat

edT

hick

ened

muc

osa

is a

non

-spe

cifi

c fi

ndin

g an

d m

ay

rout

inel

y (B

)oc

cur

in a

sym

ptom

atic

pat

ient

s.

CT

(II)

Spec

ialis

ed

CT

is m

ore

rew

ardi

ng a

nd p

rovi

des

uniq

ue

inve

stig

atio

n (B

)in

form

atio

n ab

out

ostia

l an

atom

y. L

ow d

ose

tech

niqu

ede

sira

ble.

Ind

icat

ed w

hen

max

imal

med

ical

tre

atm

ent

(for

chi

ldre

n se

eha

s fa

iled,

whe

n co

mpl

icat

ions

ari

se o

r if

mal

igna

ncy

Sect

ion

M)

A13

susp

ecte

d.

Dem

entia

and

mem

ory

SXR

(I)

Not

ind

icat

ed

Con

side

r in

vest

igat

ion

if c

linic

al c

ours

e un

usua

l or

in

diso

rder

s, f

irst

ons

et

rout

inel

y (B

)yo

unge

r pa

tient

. ps

ycho

sis

CT

(II)

or

Spec

ialis

ed

CT

and

SPE

CT

a go

od c

ombi

natio

n fo

r A

lzhe

imer

’s

MR

I (0

) or

in

vest

igat

ion

(B)

dise

ase.

MR

I be

tter

for

stru

ctur

al c

hang

es a

nd

NM

(II

I)as

sess

men

t of

‘no

rmal

pre

ssur

e hy

droc

epha

lus’

. PE

Tan

d SP

EC

Tre

adily

pro

vide

fun

ctio

nal

data

. C

ereb

ral

bloo

d fl

ow s

tudi

es m

ay d

iffe

rent

iate

A

14A

lzhe

imer

’s f

rom

oth

er f

orm

s of

dem

entia

.

35

A. Head

Orb

ital

lesi

ons

CT

(II)

or

Spec

ialis

ed

CT

prov

ides

bet

ter

anat

omic

al d

etai

l, pa

rtic

ular

ly o

f M

RI

(0)

inve

stig

atio

n (B

)bo

ny s

truc

ture

s (e

.g. n

asol

acri

mal

duc

t). M

RI

avoi

ds

radi

atio

n do

se t

o le

ns (

but

cont

rain

dica

ted

whe

n fe

rrom

agne

tic F

B s

uspe

cted

). C

onsi

der

US

for

A15

intr

a-oc

ular

les

ions

.

Orb

itsX

R o

rbit

s (I

)In

dica

ted

(B)

Esp

ecia

lly f

or t

hose

who

hav

e w

orke

d w

ith m

etal

lic

Met

allic

FB

(be

fore

MR

I)m

ater

ials

, pow

er t

ools

, etc

. Som

e ce

ntre

s us

e C

T.

A16

(see

Tra

uma

Sect

ion

K f

or a

cute

inj

ury.

Vis

ual

dist

urba

nces

SXR

(I)

Not

ind

icat

ed

Plai

n X

Rs

rare

ly c

ontr

ibut

ory.

Spe

cial

ists

may

req

uire

A17

rout

inel

y (C

)C

Tor

MR

I.

Epi

leps

y (a

dult)

SX

R (

I)N

ot i

ndic

ated

E

valu

atio

n re

quir

es s

peci

alis

t ex

pert

ise.

Lat

e on

set

rout

inel

y (B

)se

izur

es s

houl

d no

rmal

ly b

e in

vest

igat

ed b

ut i

mag

ing

may

be

unne

cess

ary

if c

lear

ly a

lcoh

ol-r

elat

ed.

CT

(II)

, MR

ISp

ecia

lised

Pa

rtia

l/foc

al s

eizu

res

may

req

uire

det

aile

d ev

alua

tion

(0)

or N

M (

III)

inve

stig

atio

n (B

)if

sur

gery

is

bein

g co

nsid

ered

. Ict

al S

PEC

Tm

axim

ises

lik

elih

ood

of l

ocal

isin

g fo

cus.

Int

eric

tal

func

tiona

l (f

or c

hild

ren

see

imag

ing

also

im

port

ant.

Muc

h de

pend

s on

loc

al p

olic

ySe

ctio

n M

)A

18w

hich

will

det

erm

ine

com

bina

tions

of

proc

edur

es.

36

A. HeadC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

B.

Nec

k (f

or

the

spin

e se

e Se

ctio

ns

C [

Th

e sp

ine]

an

d K

[Tr

aum

a])

Soft

tis

sues

Thy

roid

nod

ules

US

(0)

and

Indi

cate

d (B

)D

emon

stra

tes

mor

phol

ogy;

allo

ws

guid

ed a

spir

atio

nan

d en

larg

emen

tN

M (

I)fo

r cy

tolo

gy o

r bi

opsy

for

his

tolo

gy. S

ome

clin

icia

ns

will

pro

ceed

to

aspi

ratio

n w

ith n

o im

agin

g.

B1

Con

tem

pora

ry C

XR

nee

ded

to s

how

tra

chea

.

Thy

roto

xico

sis

NM

(I)

, US

(0)

Indi

cate

d (B

)C

an d

iffe

rent

iate

bet

wee

n G

rave

s’di

seas

e, t

oxic

no

dula

r go

itre

and

suba

cute

thy

roid

itis.

Pro

vide

s fu

nctio

nal

info

rmat

ion

abou

t no

dule

s. A

lso

usef

ul i

n B

2th

yroi

ditis

.

Ect

opic

thy

roid

tis

sue

NM

(I)

Indi

cate

d (C

)N

M e

xcel

lent

for

sm

all

ecto

pic

rest

s of

thy

roid

tis

sue.

(e.g

. lin

gual

thy

roid

)In

gen

eral

ised

thy

roid

enl

arge

men

t or

mul

tinod

ular

goitr

e U

S re

adily

sho

ws

retr

oste

rnal

ext

ensi

on;

real

time

stud

ies

show

eff

ect

of n

eck

exte

nsio

n, e

tc.

CT

/MR

I ne

eded

to

dem

onst

rate

ful

l re

tros

tern

al e

xten

tB

3an

d tr

ache

al c

ompr

omis

e.

Hyp

erpa

rath

yroi

dism

Imag

ing

Spec

ialis

edSe

ek a

dvic

e. D

iagn

osis

mad

e on

clin

ical

/bio

chem

ical

inve

stig

atio

n (C

)gr

ound

s. I

mag

ing

can

assi

st i

n pr

e-op

erat

ive

loca

lisat

ion

but

may

not

be

need

ed b

y ex

peri

ence

dsu

rgeo

ns. M

uch

depe

nds

on l

ocal

pol

icy

and

avai

labl

ete

chno

logy

and

exp

ertis

e. U

S, N

M, C

Tan

d M

RI

all

B4

accu

rate

in

the

un-o

pera

ted

neck

.

37

B. Neck

Asy

mpt

omat

ic c

arot

idU

S ca

roti

ds (

0)N

ot i

ndic

ated

Sign

ific

ant

inte

rnal

car

otid

art

ery

lesi

ons

are

rare

lybr

uit

B5

rout

inel

y (B

)fo

und.

Swal

low

ed o

r in

hale

dSe

e T

raum

a K

30.

fore

ign

body

(FB

)B

6

Mas

s of

unk

now

n or

igin

US

(0)

Indi

cate

d (C

)U

S fi

rst-

line

inve

stig

atio

n w

hich

can

als

o di

rect

biop

sy. M

RI

or C

Tus

ually

onl

y if

rec

omm

ende

d af

ter

B7

radi

olog

ical

or

spec

ialis

t cl

inic

al o

pini

on.

Saliv

ary

obst

ruct

ion

US

(0)

orIn

dica

ted

(C)

For

inte

rmitt

ent,

food

rel

ated

sw

ellin

g. M

Rsi

alog

ram

(II

)si

alog

raph

y m

ay b

e pr

efer

red

in s

ome

cent

res.

XR

Not

ind

icat

edE

xcep

t in

cal

culu

s in

flo

or o

f m

outh

, whe

re X

R m

ayB

8ro

utin

ely

(C)

be a

ll th

at i

s re

quir

ed.

Saliv

ary

mas

sU

S (0

)In

dica

ted

(B)

US

extr

emel

y se

nsiti

ve a

nd, d

epen

dent

on

loca

lex

pert

ise,

sho

uld

be f

irst

-lin

e in

vest

igat

ion.

MR

Iex

celle

nt f

or e

xten

sive

or

recu

rren

t di

seas

e. C

Tno

w o

fB

9lim

ited

use.

No

indi

catio

n fo

r C

Tsi

alog

raph

y.

Dry

mou

th —

con

nect

ive

US

(0)

orSp

ecia

lised

Not

com

mon

ly r

equi

red.

Sia

logr

am m

ay b

e di

agno

stic

tissu

e di

seas

esi

alog

ram

(II

)in

vest

igat

ion

(C)

but

NM

pro

vide

s be

tter

func

tiona

l as

sess

men

t. M

RB

10or

NM

(II

)si

alog

raph

y al

so u

sed

here

.

38

B. NeckC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Tem

poro

-man

dibu

lar

join

tX

R (

I)Sp

ecia

lised

Rad

iogr

aphs

will

dem

onst

rate

bon

y ab

norm

aliti

es, b

utdy

sfun

ctio

nin

vest

igat

ion

(B)

are

norm

al i

n gr

eat

maj

ority

, as

prob

lem

s ar

e us

ually

rela

ted

to a

rtic

ular

dis

k dy

sfun

ctio

n.

MR

I (0

) or

Spec

ialis

edFo

llow

ing

failu

re o

f co

nser

vativ

e tr

eatm

ent

whe

nar

thro

grap

hy (

II)

inve

stig

atio

n (B

)in

tern

al d

eran

gem

ent

susp

ecte

d. A

rthr

ogra

phy

offe

rs a

B11

true

dyn

amic

dem

onst

ratio

n.

39

B. Neck

C.

Th

e sp

ine

Gen

eral

(fo

r tr

aum

a se

e Se

ctio

n K

)C

onge

nita

l di

sord

ers

XR

(I)

Spec

ialis

ede.

g. F

ull-

leng

th s

tand

ing

radi

ogra

ph f

or s

colio

sis.

See

inve

stig

atio

n (C

)Se

ctio

n M

for

bac

k pa

in (

M10

).

MR

I (0

)Sp

ecia

lised

MR

I de

fine

s al

l sp

inal

mal

form

atio

ns a

nd e

xclu

des

inve

stig

atio

n (B

)as

soci

ated

the

cal

abno

rmal

ity. C

Tm

ay b

e re

quir

ed t

o(f

or c

hild

ren

delin

eate

bon

y de

tail,

but

rem

embe

r la

rge

radi

atio

nse

e Se

ctio

n M

)C

1bu

rden

.

Mye

lopa

thy:

tum

ours

,M

RI

(0)

Indi

cate

d (B

)M

RI

clea

r fi

rst

choi

ce f

or a

ll sp

inal

cor

d le

sion

s an

din

flam

mat

ion,

inf

ectio

n,to

eva

luat

e co

rd c

ompr

essi

on. C

Tm

ay b

e ne

eded

if

infa

rctio

n, e

tc.

bette

r bo

ny d

etai

l is

req

uire

d. M

yelo

grap

hy o

nly

ifM

RI

is u

nava

ilabl

e or

im

poss

ible

. NM

stil

l w

idel

yus

ed t

o sc

reen

for

met

asta

ses

and

for

iden

tifyi

ng f

ocal

C2

skel

etal

les

ions

(su

ch a

s os

teoi

d os

teom

a).

40

C. The spineC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Cer

vica

l sp

ine

Poss

ible

atla

nto-

axia

lX

R (

I)In

dica

ted

(C)

Asi

ngle

lat

eral

cer

vica

l sp

ine

XR

with

the

pat

ient

in

subl

uxat

ion

supe

rvis

ed c

omfo

rtab

le f

lexi

on s

houl

d re

veal

any

sign

ific

ant

subl

uxat

ion

in p

atie

nts

with

rhe

umat

oid

arth

ritis

, Dow

n’s

Synd

rom

e, e

tc. M

RI

(fle

xion

/ext

ensi

on)

show

s ef

fect

on

cord

whe

n X

RC

3po

sitiv

e or

neu

rolo

gica

l si

gns

pres

ent.

Nec

k pa

in, B

rach

algi

a,X

R (

I)N

ot i

ndic

ated

Deg

ener

ativ

e ch

ange

s be

gin

in e

arly

mid

dle-

age

and

dege

nera

tive

chan

gero

utin

ely

(B)

are

ofte

n un

rela

ted

to s

ympt

oms

whi

ch a

re u

sual

ly d

ueto

dis

k/lig

amen

tous

cha

nges

und

etec

tabl

e on

pla

in X

R.

MR

I in

crea

sing

ly b

eing

use

d, e

spec

ially

whe

nbr

acha

lgia

is

pres

ent.

MR

I (0

)Sp

ecia

lised

Con

side

r M

RI

and

spec

ialis

t re

ferr

al w

hen

pain

inve

stig

atio

n (B

)af

fect

ing

lifes

tyle

or

whe

n th

ere

are

neur

olog

ical

sign

s. M

yelo

grap

hy (

with

CT

) m

ay o

ccas

iona

lly b

ere

quir

ed t

o pr

ovid

e fu

rthe

r de

linea

tion

or w

hen

MR

I is

C4

unav

aila

ble

or i

mpo

ssib

le.

41

C. The spine

Th

ora

cic

spin

ePa

in w

ithou

t tr

aum

a:X

R (

I)N

ot i

ndic

ated

Deg

ener

ativ

e ch

ange

s ar

e in

vari

able

fro

m m

iddl

e-ag

ede

gene

rativ

e di

seas

ero

utin

ely

(B)

onw

ards

. Exa

min

atio

n ra

rely

use

ful

in t

he a

bsen

ce o

fne

urol

ogic

al s

igns

or

poin

ters

to

met

asta

ses

orin

fect

ion.

Con

side

r m

ore

urge

nt r

efer

ral

in e

lder

lypa

tient

s w

ith s

udde

n pa

in t

o sh

ow o

steo

poro

ticco

llaps

e or

oth

er f

orm

s of

bon

e de

stru

ctio

n. C

onsi

der

NM

for

pos

sibl

e m

etas

tatic

les

ions

.

MR

I (0

)Sp

ecia

lised

MR

I m

ay b

e in

dica

ted

if l

ocal

pai

n pe

rsis

ts, d

iffi

cult

C5

inve

stig

atio

n (B

)to

man

age

or i

f th

ere

are

long

tra

ct s

igns

.

Lum

bar

sp

ine

Chr

onic

bac

k pa

in w

ithX

R (

II)

Not

ind

icat

edD

egen

erat

ive

chan

ges

are

com

mon

and

non

-spe

cifi

c.no

poi

nter

s to

inf

ectio

nro

utin

ely

(C)

Mai

n va

lue

in y

oung

er p

atie

nts

(e.g

. les

s th

an 2

0,or

neo

plas

msp

ondy

lolis

thes

is, a

nkyl

osin

g sp

ondy

litis

, etc

.) o

r in

olde

r pa

tient

s e.

g. >

55.

MR

I (0

) or

CT

Spec

ialis

edIn

cas

es w

here

man

agem

ent

is d

iffi

cult.

Neg

ativ

eC

6(I

I) o

r N

M (

II)

inve

stig

atio

n (C

)fi

ndin

gs m

ay b

e he

lpfu

l.

42

C. The spineC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Bac

k pa

in w

ith p

ossi

ble

Imag

ing

Indi

cate

d (B

)To

geth

er w

ith u

rgen

t sp

ecia

list

refe

rral

; M

RI

is u

sual

lyse

riou

s fe

atur

es s

uch

as:

the

best

inv

estig

atio

n. I

mag

ing

shou

ld n

ot d

elay

•on

set

< 2

0, >

55

yrs

spec

ialis

t re

ferr

al. N

M i

s al

so w

idel

y us

ed f

or p

ossi

ble

•sp

hinc

ter

or g

ait

bone

des

truc

tion,

and

in

case

s of

chr

onic

pai

n or

•sp

hinc

ter

or g

ait

whe

re i

nfec

tion

is s

uspe

cted

.di

stur

banc

e•

sadd

le a

naes

thes

ia•

seve

re o

r pr

ogre

ssiv

em

otor

los

s(‘

NO

RM

AL’

PLA

IN X

R M

AY

BE

FA

LSE

LY•

wid

espr

ead

neur

olog

ical

RE

ASS

UR

ING

).de

fici

t•

prev

ious

car

cino

ma

•sy

stem

atic

ally

unw

ell

•H

IV•

wei

ght

loss

•in

trav

enou

s dr

ug a

buse

•st

eroi

ds•

stru

ctur

al d

efor

mity

•no

n-m

echa

nica

l pa

in

C7

(for

chi

ldre

n se

e Se

ctio

n M

)

43

C. The spine

Acu

te b

ack

pain

: di

skX

R (

II)

Not

ind

icat

edA

cute

bac

k pa

in i

s us

ually

due

to

cond

ition

s w

hich

hern

iatio

n; s

ciat

ica

with

rout

inel

y (C

)ca

nnot

be

diag

nose

d on

pla

in X

R (

oste

opor

otic

no a

dver

se f

eatu

res

colla

pse

an e

xcep

tion)

. ‘N

orm

al’

plai

n X

Rs

may

be

(see

abo

ve).

fals

ely

reas

suri

ng. D

emon

stra

tion

of d

isk

hern

iatio

nre

quir

es M

RI

or C

Tan

d sh

ould

be

cons

ider

edim

med

iate

ly a

fter

fai

led

cons

erva

tive

man

agem

ent.

MR

I (0

) or

CT

Not

ind

icat

edM

RI

gene

rally

pre

ferr

ed (

wid

er f

ield

of

view

, con

us,

(II)

initi

ally

(B

)po

st-o

pera

tive

chan

ges

etc.

) an

d av

oids

x-i

rrad

iatio

n.E

ither

MR

I or

CT

is n

eede

d be

fore

int

erve

ntio

n (e

.g.

epid

ural

inj

ectio

n). M

RI

bette

r th

an C

Tfo

r po

st-

C8

oper

ativ

e pr

oble

ms.

44

C. The spineC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

D.

Mu

scu

losk

elet

al s

yste

mO

steo

mye

litis

XR

(I)

+N

M (

II)

Indi

cate

d (B

)T

he 2

–3 p

hase

ske

leta

l sc

intig

ram

is

mor

e se

nsiti

veor

MR

I (0

)th

an X

R. H

owev

er, f

indi

ngs

are

not

spec

ific

and

furt

her

spec

ialis

ed N

M w

ith a

ltern

ativ

e ag

ents

may

be

need

ed. F

at-s

uppr

esse

d M

RI

is b

ecom

ing

rega

rded

as

the

optim

al i

nves

tigat

ion.

CT

(II)

or

Spec

ialis

edC

Tus

ed t

o id

entif

y se

ques

tra.

Bot

h C

Tan

d U

S ca

nU

S (0

)in

vest

igat

ions

(C

)de

mon

stra

te a

ppro

pria

te s

ite f

or g

uide

d pe

rcut

aneo

usbi

opsy

. US

may

be

help

ful,

espe

cial

ly i

n ch

ildre

n, i

fm

etal

war

e ca

uses

art

efac

ts o

n M

RI/

CT

or i

f N

M n

onD

1sp

ecif

ic d

ue t

o re

cent

sur

gery

.

Prim

ary

bone

tum

our

XR

(I)

Indi

cate

d (B

)X

R m

ay c

hara

cter

ise

the

lesi

on.

MR

I (0

) or

Spec

ialis

edM

RI

usef

ul f

or f

urth

er c

hara

cter

isat

ion

and

nece

ssar

yC

T(I

I)in

vest

igat

ions

(B

)fo

r su

rgic

al s

tagi

ng;

shou

ld b

e pe

rfor

med

bef

ore

any

biop

sy. C

Tca

n sh

ow b

ony

deta

il be

tter

at s

ome

site

s(e

.g. s

pine

) an

d fo

r so

me

smal

l le

sion

s an

d is

nee

ded

if M

RI

unav

aila

ble.

MR

I m

ore

usef

ul f

or a

sses

smen

tof

ext

ent.

CT

ches

t if

CX

R n

egat

ive

to a

sses

spu

lmon

ary

met

asta

ses

for

man

y pr

imar

y m

alig

nant

lesi

ons.

(se

e L

41).

The

se s

tate

men

ts a

pply

to

adul

tsD

2an

d ch

ildre

n.

45

D. Musculoskeletal system

Kno

wn

prim

ary

tum

our.

NM

(II

)In

dica

ted

(B)

NM

rea

dily

ass

esse

s th

e w

hole

ske

leto

n an

d is

muc

hSk

elet

al m

etas

tase

sm

ore

sens

itive

tha

n pl

ain

XR

, tho

ugh

less

spe

cifi

c.L

ocal

ised

XR

s m

ay b

e ne

eded

to

excl

ude

othe

r ca

uses

of i

ncre

ased

act

ivity

, e.g

. deg

ener

ativ

e di

seas

e. I

npr

osta

tic c

ance

r bi

oche

mic

al m

arke

rs (

PSA

) ca

n be

used

to

follo

w u

p pr

ogre

ss o

f sk

elet

al i

nvol

vem

ent.

NM

can

als

o he

lp c

hara

cter

ise

the

lesi

on. (

e.g.

ost

eoid

oste

oma)

and

is

usef

ul i

n fo

llow

-up.

Skel

etal

sur

vey

Not

ind

icat

ed(I

I)ro

utin

ely

(C)

MR

I (0

)Sp

ecia

lised

MR

I m

ore

sens

itive

and

spe

cifi

c th

an N

M, e

spec

ially

inve

stig

atio

n (C

)fo

r m

arro

w-b

ased

les

ions

. How

ever

, fie

ld o

f vi

ew i

sD

3lim

ited.

46

D. Musculoskeletal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Soft

tis

sue

mas

s tu

mou

r,M

RI

(0)

Indi

cate

d (B

)M

RI

bette

r th

an C

Tfo

r ex

clus

ion,

det

ectio

n an

dpo

ssib

le r

ecur

renc

est

agin

g of

sof

t tis

sue

tum

ours

(su

peri

or c

ontr

ast

reso

lutio

n, m

ultip

lana

r ca

pabi

lity,

del

inea

tion

ofne

urov

ascu

lar

bund

le a

nd m

uscl

e/co

mpa

rtm

ent

invo

lvem

ent)

. CT

has

grea

ter

sens

itivi

ty f

orca

lcif

icat

ion.

Inc

reas

ing

inte

rest

in

US

for

som

ean

atom

ical

site

s. M

R a

ccep

ted

as i

nves

tigat

ion

ofch

oice

for

pos

sibl

e re

curr

ence

alth

ough

US

has

itspr

opon

ents

and

can

be

used

for

bio

psy.

Con

side

r N

MD

4(e

.g. P

ET

).

Bon

e pa

inX

R (

I)In

dica

ted

(B)

Loc

al v

iew

of

sym

ptom

atic

are

as o

nly.

NM

(II

) or

Indi

cate

d (B

)W

hen

sym

ptom

s pe

rsis

t an

d pl

ain

XR

s ne

gativ

e.D

5M

RI

(0)

Mye

lom

aSk

elet

al s

urve

yIn

dica

ted

(C)

For

stag

ing

and

iden

tifyi

ng l

esio

ns w

hich

may

ben

efit

(II)

from

rad

ioth

erap

y. S

urve

y ca

n be

ver

y lim

ited

for

follo

w-u

p.

NM

(II

)N

ot i

ndic

ated

Skel

etal

sci

ntig

raph

y is

oft

en n

egat

ive

and

rout

inel

y (B

)un

dere

stim

ates

dis

ease

ext

ent;

cons

ider

bon

e m

arro

wst

udie

s.

MR

I (0

)Sp

ecia

lised

MR

I ve

ry s

ensi

tive,

eve

n lim

ited

to s

pine

, pel

vis

and

inve

stig

atio

n (B

)pr

oxim

al f

emor

a. P

artic

ular

ly u

sefu

l in

non

-sec

reto

rym

yelo

ma

or i

n th

e pr

esen

ce o

f di

ffus

e os

teop

enia

. Can

D6

be u

sed

for

tum

our-

mas

s as

sess

men

t an

d fo

llow

-up.

47

D. Musculoskeletal system

Met

abol

ic b

one

dise

ase

Skel

etal

sur

vey

Not

ind

icat

edB

ioch

emic

al t

ests

usu

ally

suf

fice

. If

need

ed, t

his

(II)

rout

inel

y (C

)sh

ould

be

limite

d (e

.g. h

ands

, CX

R, p

elvi

s an

d la

tera

llu

mba

r sp

ine)

. Bon

e de

nsito

met

ry m

ay b

e ne

eded

.(s

ee D

9).

NM

(II

)In

dica

ted

(C)

Skel

etal

sci

ntig

ram

goo

d fo

r co

mpl

icat

ions

Ost

eom

alac

iaX

R (

0)In

dica

ted

(B)

Loc

alis

ed X

R t

o es

tabl

ish

caus

e of

loc

al p

ain

orD

7eq

uivo

cal

lesi

on o

n N

M.

NM

(II

)Sp

ecia

lised

NM

can

sho

w i

ncre

ased

‘ac

tivity

’an

d so

me

loca

lco

mpl

icat

ions

. Bon

e de

nsito

met

ry m

ay b

e ne

eded

.D

8(s

ee D

9).

Pain

— o

steo

poro

ticX

R (

II)

late

ral

Indi

cate

d (B

)L

ater

al v

iew

s w

ill d

emon

stra

te c

ompr

essi

on f

ract

ures

.co

llaps

eth

orac

ic a

ndN

M o

r M

RI

mor

e us

eful

in

dist

ingu

ishi

ng b

etw

een

lum

bar

spin

ere

cent

and

old

fra

ctur

es a

nd c

an h

elp

excl

ude

path

olog

ical

fra

ctur

es. B

one

dens

itom

etry

(du

al e

nerg

yX

R a

psor

ptio

met

ry (

DE

XA

) or

qua

ntita

tive

CT

)pr

ovid

es o

bjec

tive

mea

sure

men

ts o

f bo

ne m

iner

alco

nten

t; ca

n al

so b

e us

ed f

or m

etab

olic

bon

e di

seas

eD

9(s

ee D

7, D

8).

48

D. Musculoskeletal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Art

hrop

athy

, pre

sent

atio

nX

R (

I) a

ffec

ted

Indi

cate

d (C

)M

ay b

e he

lpfu

l to

det

erm

ine

caus

e al

thou

gh e

rosi

ons

join

tar

e a

rela

tivel

y la

te f

eatu

re.

XR

(I)

Indi

cate

d (C

)In

pat

ient

s w

ith s

uspe

cted

rhe

umat

oid

arth

ritis

, XR

hand

s/fe

etfe

et m

ay s

how

ero

sion

s ev

en w

hen

sym

ptom

atic

hand

(s)

appe

ar n

orm

al.

XR

(II

) m

ulti

ple

Not

ind

icat

edjo

int(

s)ro

utin

ely

(C)

US

(0)

orSp

ecia

lised

All

can

show

acu

te s

ynov

itis.

NM

can

sho

wN

M (

II)

orin

vest

igat

ions

(C

)di

stri

butio

n. M

RI

can

show

art

icul

ar c

artil

age.

D10

MR

I (0

)

Art

hrop

athy

, fol

low

-up

XR

(I)

Not

ind

icat

edX

Rs

need

ed b

y sp

ecia

lists

to

assi

st m

anag

emen

tD

11ro

utin

ely

(C)

deci

sion

s.

Pain

ful

shou

lder

joi

ntX

R (

I)N

ot i

ndic

ated

Deg

ener

ativ

e ch

ange

s in

the

acr

omio

-cla

vicu

lar

join

tsin

itial

ly (

C)

and

rota

tor

cuff

are

com

mon

. Ear

lier

XR

if

soft

tis

sue

D12

calc

ific

atio

n is

exp

ecte

d.

Pain

ful

pros

thes

isX

R (

I)+

NM

(II

)In

dica

ted

(B)

Ano

rmal

NM

stu

dy e

xclu

des

mos

t la

te c

ompl

icat

ions

.Fu

rthe

r sp

ecia

lised

NM

stu

dies

can

hel

p di

stin

guis

hlo

osen

ing

from

inf

ectio

n.

US

(0)

orSp

ecia

lised

Usu

ally

cou

pled

with

asp

irat

ion/

biop

sy/a

rthr

ogra

phy.

fluo

rosc

opy

(II)

inve

stig

atio

n (C

)Su

ch i

nter

vent

ion

whi

ch p

rovi

des

a de

fini

tive

resu

lt is

D13

incr

easi

ngly

bei

ng u

sed.

49

D. Musculoskeletal system

Shou

lder

im

ping

emen

tM

RI

(0)

Spec

ialis

edA

lthou

gh i

mpi

ngem

ent

is a

clin

ical

dia

gnos

is, i

mag

ing

inve

stig

atio

n (B

)is

ind

icat

ed w

hen

surg

ery

is b

eing

con

side

red

and

prec

ise

delin

eatio

n of

ana

tom

y is

req

uire

d. B

utde

gene

rativ

e ch

ange

s al

so c

omm

on i

n th

eas

ympt

omat

ic p

opul

atio

n.

US

(0)

Spec

ialis

edSu

bacr

omia

l an

d ac

rom

iocl

avic

ular

joi

nt i

mpi

ngem

ent

D14

inve

stig

atio

n (B

)ar

e dy

nam

ic p

roce

sses

whi

ch c

an b

e as

sess

ed b

y U

S.

Shou

lder

ins

tabi

lity

CT

Spec

ialis

edG

leno

id l

abru

m a

nd s

ynov

ial

cavi

ty a

re w

ell

arth

rogr

aphy

(II

)in

vest

igat

ion

(B)

delin

eate

d by

bot

h te

chni

ques

. Som

e gr

adie

nt e

cho

MR

tec

hniq

ues

can

show

lab

rum

wel

l w

ithou

tar

thro

grap

hy.

MR

Spec

ialis

edD

15ar

thro

grap

hy (

0)in

vest

igat

ion

(C)

Rot

ator

cuf

f te

arA

rthr

ogra

phy

Spec

ialis

edM

uch

depe

nds

on l

ocal

exp

ertis

e an

d su

rgic

al p

lans

.(I

I) o

r U

S (0

)in

vest

igat

ion

(B)

All

thre

e te

chni

ques

dem

onst

rate

rot

ator

cuf

f te

ars.

D16

or M

RI

(0)

50

D. Musculoskeletal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

SI j

oint

les

ion

XR

SI

join

ts (

II)

Indi

cate

d (B

)M

ay h

elp

in i

nves

tigat

ion

of s

ero-

nega

tive

arth

ropa

thy.

SI j

oint

s us

ually

ade

quat

ely

dem

onst

rate

d on

AP

lum

bar

spin

e.

MR

I (0

) or

Spec

ialis

edM

RI

or N

M o

r C

Tw

hen

plai

n X

Rs

equi

voca

l; M

RI

NM

(II

) or

inve

stig

atio

n (C

)ca

rrie

s no

rad

iatio

n do

se.

D17

CT

(II)

Hip

pai

n: f

ull

mov

emen

tX

R p

elvi

s (I

)N

ot i

ndic

ated

XR

onl

y if

sym

ptom

s an

d si

gns

pers

ist

or c

ompl

exro

utin

ely

(C)

hist

ory

(e.g

. cha

nce

of a

vasc

ular

nec

rosi

s, s

ee D

20)

(for

chi

ldre

n se

eSe

ctio

n M

)D

18N

B:T

his

reco

mm

enda

tion

does

not

app

ly t

o ch

ildre

n.

Hip

pai

n: l

imite

dX

R p

elvi

s (I

)N

ot i

ndic

ated

Sym

ptom

s of

ten

tran

sien

t. X

R i

f hi

p re

plac

emen

tm

ovem

ent

initi

ally

(C

)m

ight

be

cons

ider

ed o

r sy

mpt

oms

pers

ist.

PET

may

be h

elpf

ul, i

f X

R, M

RI

stan

dard

NM

all

norm

al.

(for

chi

ldre

n se

eSe

ctio

n M

)D

19N

B:T

his

reco

mm

enda

tion

does

not

app

ly t

o ch

ildre

n.

Hip

pai

n: a

vasc

ular

XR

Pel

vis

(I)

Indi

cate

d (B

)A

bnor

mal

in

esta

blis

hed

dise

ase.

necr

osis

MR

I (0

)Sp

ecia

lised

MR

I us

eful

whe

n X

R n

orm

al, e

spec

ially

in

high

ris

kin

vest

igat

ion

(B)

patie

nts.

NM

and

CT

can

also

pro

vide

inf

orm

atio

nD

20he

re.

51

D. Musculoskeletal system

Kne

e pa

in:

with

out

XR

(I)

Not

ind

icat

edSy

mpt

oms

freq

uent

ly a

rise

fro

m s

oft

tissu

es a

nd t

hese

lock

ing

or r

estr

ictio

n in

rout

inel

y (C

)w

ill n

ot b

e de

mon

stra

ted

on X

R. O

Ach

ange

sm

ovem

ent

com

mon

. XR

s ne

eded

whe

n co

nsid

erin

g su

rger

y.D

21

Kne

e pa

in:

with

loc

king

,X

R (

I)In

dica

ted

(C)

To i

dent

ify

radi

o-op

aque

loo

se b

odie

s.re

stri

cted

mov

emen

t or

effu

sion

(lo

ose

body

) D22

Kne

e pa

in:

arth

rosc

opy

MR

I (0

)Sp

ecia

lised

MR

I ca

n as

sist

the

man

agem

ent

deci

sion

as

to w

heth

erbe

ing

cons

ider

edin

vest

igat

ion

(B)

or n

ot t

o pr

ocee

d w

ith a

rthr

osco

py. E

ven

in t

hose

patie

nts

with

def

inite

clin

ical

abn

orm

aliti

es,

war

rant

ing

inte

rven

tion,

sur

geon

s fi

nd p

re-o

pera

tive

D23

MR

I he

lpfu

l in

ide

ntif

ying

uns

uspe

cted

les

ions

.

Hal

lux

valg

usX

R (

I)Sp

ecia

lised

For

asse

ssm

ent

befo

re s

urge

ry.

D24

inve

stig

atio

n (C

)

Plan

tar

fasc

iitis

—X

R (

I)N

ot i

ndic

ated

Plan

tar

spur

s ar

e co

mm

on i

ncid

enta

l fi

ndin

gs. T

heca

lcan

eal

spur

rout

inel

y (B

)ca

use

of t

he p

ain

is s

eldo

m d

etec

tabl

e on

XR

. US,

NM

and

MR

I ar

e m

ore

sens

itive

in

show

ing

infl

amm

ator

y ch

ange

but

the

maj

ority

of

patie

nts

can

D25

be m

anag

ed w

ithou

t im

agin

g.

52

D. Musculoskeletal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

E. C

ard

iova

scu

lar

syst

emC

entr

al c

hest

pai

nC

XR

(I)

Indi

cate

d (B

)C

XR

mus

t no

t de

lay

adm

issi

on t

o a

spec

ialis

ed u

nit.

myo

card

ial

infa

rctio

nC

XR

can

ass

ess

hear

t si

ze, p

ulm

onar

y oe

dem

a, e

tc.

and

can

excl

ude

othe

r ca

uses

. Dep

artm

ent

film

pref

erab

le. S

ubse

quen

t im

agin

g in

volv

es s

peci

alis

edin

vest

igat

ions

(N

M, c

oron

ary

angi

ogra

phy,

etc

.) a

ndde

pend

on

loca

l po

licy.

NM

off

ers

myo

card

ial

perf

usio

n an

d ve

ntri

culo

grap

hy d

ata.

Inc

reas

ing

E1

inte

rest

in

MR

I.

Che

st p

ain:

aor

ticC

XR

(I)

Indi

cate

d (B

)M

ainl

y to

exc

lude

oth

er c

ause

s; r

arel

y di

agno

stic

.di

ssec

tion:

acu

te

CT

(III

) or

Indi

cate

d (B

)Se

ek a

dvic

e fr

om l

ocal

rad

iolo

gist

s. M

uch

vari

atio

n.U

S (0

) or

Mod

ern

CT

syst

ems

prov

ide

very

acc

urat

e re

sults

.M

RI

(0)

Oft

en c

oupl

ed w

ith t

rans

-tho

raci

c U

S or

, bet

ter,

tran

s-oe

soph

agea

l U

S. M

RI

prob

ably

the

mos

tac

cura

te a

nd i

ncre

asin

gly

used

, des

pite

log

istic

prob

lem

s an

d co

nstr

aint

s w

ith s

ome

life-

supp

ort

syst

ems.

Ang

iogr

aphy

rar

ely

nece

ssar

y un

less

abo

veE

2ex

amin

atio

ns a

re e

quiv

ocal

.

Aor

tic d

isse

ctio

n: c

hron

icM

RI

(0)

Spec

ialis

edM

RI

best

inv

estig

atio

n to

ass

ess

chan

ge i

nin

vest

igat

ion

(B)

long

itudi

nal

exte

nt. T

rans

-oes

opha

geal

US

and

CT

E3

reco

mm

ende

d.

53

E. Cardiovascular system

Pulm

onar

y em

bolu

sN

M (

II)

orIn

dica

ted

(B)

Inte

rpre

ted

alon

g w

ith c

onte

mpo

rary

CX

R. E

quiv

ocal

CT

(III

)fi

ndin

gs (

e.g.

int

erm

edia

te p

roba

bilit

y) m

ay n

eces

sita

tefu

rthe

r cl

arif

icat

ion.

Som

e ce

ntre

s us

e U

S to

sho

wth

rom

bus

in l

eg v

eins

for

fur

ther

pro

of. A

norm

alpe

rfus

ion

NM

stu

dy e

xclu

des

pulm

onar

y em

bolis

m i

nm

ost

case

s. S

pira

l C

Tus

ed i

ncre

asin

gly

as t

he i

nitia

lte

st, e

spec

ially

in

patie

nts

with

co-

exis

ting

card

iore

spir

ator

y di

seas

e, a

nd a

head

of

pulm

onar

yE

4an

giog

raph

y.

Peri

card

itis

— p

eric

ardi

alC

XR

(I)

Indi

cate

d (B

)M

ay b

e no

rmal

; ef

fusi

on v

olum

e/ef

fect

not

effu

sion

dete

rmin

ed.

US

(0)

Indi

cate

d (B

)E

xtre

mel

y ac

cura

te:

may

be

need

ed u

rgen

tly f

orta

mpo

nade

; ca

n sh

ow b

est

acce

ss f

or d

rain

age.

CT

E5

som

etim

es n

eede

d fo

r ca

lcif

icat

ion,

loc

ulat

ion,

etc

.

Susp

ecte

d va

lvul

arC

XR

(I)

and

Indi

cate

d (B

)U

sed

for

initi

al a

sses

smen

t an

d w

hen

ther

e is

a c

hang

eca

rdia

c di

seas

eca

rdia

c U

S (0

)in

the

clin

ical

pic

ture

.E

6

Clin

ical

det

erio

ratio

nC

ardi

ac U

S (0

)In

dica

ted

(B)

US

may

sho

w r

emed

iabl

e co

mpl

icat

ions

(V

SD,

follo

win

g m

yoca

rdia

lpa

pilla

ry r

uptu

re, a

neur

ysm

, etc

.).

infa

rctio

n E

7

54

E. Cardiovascular systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Follo

w-u

p of

pat

ient

sC

XR

(I)

Not

ind

icat

edO

nly

if s

igns

or

sym

ptom

s ha

ve c

hang

ed, w

hen

with

hea

rt d

isea

se o

rro

utin

ely

(B)

com

pari

son

with

the

CX

R o

btai

ned

at p

rese

ntat

ion

hype

rten

sion

E8

may

be

help

ful.

Abd

omin

al a

ortic

US

(0)

aort

aIn

dica

ted

(A)

Use

ful

in d

iagn

osis

, det

erm

inat

ion

of m

axim

alan

eury

smdi

amet

er a

nd f

ollo

w-u

p. C

Tpr

efer

able

for

sus

pect

edle

ak b

ut s

houl

d no

t de

lay

urge

nt s

urge

ry.

CT

(III

) or

Indi

cate

d (A

)C

Tan

d M

RI

for

rela

tions

hip

to r

enal

ves

sels

and

M

RI

(0)

iliac

s. I

ncre

asin

g de

man

d fo

r de

taile

d an

atom

ical

info

rmat

ion

beca

use

of i

ncre

asin

g co

nsid

erat

ion

E9

for

perc

utan

eous

ste

ntin

g.

Dee

p-ve

in t

hrom

bosi

sU

S (0

) lo

wer

Indi

cate

d (A

)M

ore

sens

itive

with

col

our-

flow

Dop

pler

. Mos

tli

mb

vein

scl

inic

ally

sig

nifi

cant

thr

ombi

are

det

ecte

d. I

ncre

asin

gex

peri

ence

with

US

for

calf

vei

n th

rom

bi. M

ay s

how

othe

r le

sion

s.

Veno

grap

hy (

II)

Not

ind

icat

edE

xten

sive

var

iatio

n ac

cord

ing

to U

S ex

pert

ise

and

E10

rout

inel

y (C

)lo

cal

ther

apeu

tic s

trat

egy.

Isch

aem

ic l

egA

ngio

grap

hySp

ecia

lised

Loc

al p

olic

y ne

eds

to b

e de

term

ined

in

agre

emen

t(I

II)

inve

stig

atio

n (A

)w

ith v

ascu

lar

surg

eons

, esp

ecia

lly w

ith r

egar

d to

ther

apeu

tic i

nter

vent

ions

. US

used

in

som

e ce

ntre

s as

firs

t in

vest

igat

ion.

Spi

ral

CT

and

MR

I ar

e be

ing

E11

deve

lope

d.

55

E. Cardiovascular system

Myo

card

ial

eval

uatio

nN

M (

III)

Indi

cate

d (A

)N

M i

s th

e m

ost

esta

blis

hed

inve

stig

atio

n fo

r as

sess

ing

E12

myo

card

ial

perf

usio

n. C

ardi

ac M

RI

only

ava

ilabl

e in

afe

w c

entr

es.

56

E. Cardiovascular systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

F. T

ho

raci

c sy

stem

Non

-spe

cifi

c ch

est

pain

CX

R (

I)N

ot i

ndic

ated

Con

ditio

ns s

uch

as T

ietz

e’s

dise

ase

show

no

F1

initi

ally

(C

)ab

norm

ality

on

CX

R. M

ain

purp

ose

is r

eass

uran

ce.

Che

st t

raum

aC

XR

(I)

Not

ind

icat

edSh

owin

g a

rib

frac

ture

aft

er m

inor

tra

uma

does

not

rout

inel

y (C

)al

ter

man

agem

ent

F2

(see

Tra

uma

Sect

ion

K).

Pre-

empl

oym

ent

orC

XR

(I)

Not

ind

icat

edN

ot j

ustif

ied

exce

pt i

n a

few

hig

h-ri

sk c

ateg

orie

s (e

.g.

scre

enin

g m

edic

als

at r

isk

imm

igra

nts

with

no

rece

nt C

XR

). S

ome

have

to

be d

one

for

occu

patio

nal

(e.g

. div

ers)

or

emig

ratio

nF

3pu

rpos

es (

UK

cat

egor

y 2)

.

Pre-

oper

ativ

eC

XR

(I)

Not

ind

icat

edE

xcep

tions

bef

ore

card

io-p

ulm

onar

y su

rger

y, l

ikel

yro

utin

ely

(B)

adm

issi

on t

o IT

U, s

uspe

cted

mal

igna

ncy

or p

ossi

ble

TB

. Ana

esth

etis

ts m

ay a

lso

requ

est

CX

Rs

for

dysp

noei

c pa

tient

s, t

hose

with

kno

wn

card

iac

dise

ase

and

the

very

eld

erly

. Man

y pa

tient

s w

ith c

ardi

ore

spir

ator

y di

seas

e ha

ve r

ecen

t C

XR

ava

ilabl

e; a

F4

repe

at C

XR

is

then

not

usu

ally

nee

ded.

Upp

er r

espi

rato

ry-t

ract

C

XR

(I)

Not

ind

icat

edin

fect

ion

F5

rout

inel

y (C

)

Chr

onic

obs

truc

tive

CX

R (

I)N

ot i

ndic

ated

Onl

y if

sig

ns o

r sy

mpt

oms

have

cha

nged

.ai

rway

s di

seas

e or

rout

inel

y (B

)as

thm

a; f

ollo

w-u

pF

6

57

F. Thoracic system

Pneu

mon

ia a

dults

:C

XR

(I)

Indi

cate

d (A

)To

con

firm

cle

arin

g, e

tc. P

oint

less

to

re-e

xam

ine

atfo

llow

-up

less

tha

n 10

-day

int

erva

ls a

s cl

eari

ng c

an b

e sl

ow(f

or c

hild

ren

see

(esp

ecia

lly i

n th

e el

derl

y).

Sect

ion

M)

F7

Pleu

ral

effu

sion

CX

R (

I)In

dica

ted

(B)

Smal

l ef

fusi

on c

an b

e m

isse

d, e

spec

ially

on

a fr

onta

lC

XR

.

US

(0)

Indi

cate

d (B

)To

pro

ve f

luid

con

sist

ency

; to

gui

de a

spir

atio

n. C

Toc

casi

onal

ly n

eede

d fo

r be

tter

loca

lisat

ion,

ass

essm

ent

F8

of s

olid

com

pone

nts,

etc

.

Hae

mop

tysi

sC

XR

(I)

Indi

cate

d (B

)PA

plus

lat

eral

vie

w.

CT

(III

)Sp

ecia

lised

Man

y ce

ntre

s us

e C

Tan

d th

en p

roce

ed t

oin

vest

igat

ion

(B)

bron

chos

copy

; in

crea

sing

use

of

CT

firs

t (s

ee C

ance

rL

7). C

onsi

der

bron

chia

l ar

teri

ogra

phy

in m

assi

veF

9ha

emop

tysi

s.

ITU

/HD

U p

atie

ntC

XR

(I)

Indi

cate

d (B

)A

CX

R i

s m

ost

help

ful

whe

n th

ere

has

been

a c

hang

ein

sym

ptom

s or

ins

ertio

n or

rem

oval

of

a de

vice

. The

valu

e of

the

rou

tine

daily

CX

R i

s be

ing

incr

easi

ngly

F10

ques

tione

d.

58

F. Thoracic systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Occ

ult

lung

dis

ease

CT

(II)

Indi

cate

d (B

)H

igh

reso

lutio

n C

Tca

n sh

ow a

bnor

mal

ities

not

evid

ent

on C

XR

, esp

ecia

lly i

nter

stiti

al d

isea

se.

NM

(II

)Sp

ecia

lised

NM

can

ass

ess

dise

ase

activ

ity (

e.g.

mea

sure

inve

stig

atio

n (B

)pe

rmea

bilit

y in

alv

eolit

is)

and

mon

itor

effe

cts

ofF

11th

erap

y.

59

F. Thoracic system

G.

Gas

tro

inte

stin

al s

yste

mG

astr

oin

test

inal

tra

ctD

iffi

culty

in

swal

low

ing

Ba

swal

low

(II

)In

dica

ted

(B)

Ba

stud

ies

are

still

rec

omm

ende

d be

fore

pos

sibl

een

dosc

opy;

the

y w

ill a

ccur

atel

y lo

calis

e le

sion

s an

dsh

ow t

he d

egre

e of

obs

truc

tion

caus

ed b

y a

stri

ctur

ean

d its

len

gth.

Web

s an

d po

uche

s ar

e w

ell

NM

(I)

Spec

ialis

edde

mon

stra

ted.

Sub

tle s

tric

ture

s m

ay b

e de

mon

stra

ted

inve

stig

atio

n (B

)by

a m

arsh

mal

low

(or

oth

er b

olus

) st

udy.

Det

aile

dfl

uoro

scop

y or

NM

nee

ded

for

mot

ility

dis

orde

rs.

Vid

eo s

wal

low

s fo

r su

spec

ted

phar

ynge

al d

ysfu

nctio

nG

1in

con

junc

tion

with

spe

ech

ther

apis

ts.

Che

st p

ain

— h

iatu

sB

a sw

allo

wN

ot i

ndic

ated

Alth

ough

Ba

swal

low

use

ful

to d

emon

stra

te h

erni

a,he

rnia

or

refl

ux/m

eal

(III

)ro

utin

ely

(C)

refl

ux a

nd t

heir

com

plic

atio

ns, n

ot a

ll su

ch p

atie

nts

need

inv

estig

atio

n. R

eflu

x is

com

mon

and

not

nece

ssar

ily th

e ca

use

of p

ain.

NM

may

be

over

sens

itive

;pH

mon

itori

ng i

s ge

nera

lly r

egar

ded

as t

he ‘

gold

stan

dard

’fo

r ac

id r

eflu

x bu

t gi

ves

no a

nato

mic

alin

form

atio

n. M

etap

lasi

a an

d oe

soph

agiti

s ar

e be

stde

tect

ed b

y en

dosc

opy

whi

ch a

lso

allo

ws

biop

sy.

G2

Incr

easi

ng u

se o

f B

a st

udie

s be

fore

ant

i-re

flux

sur

gery

.

60

G. Gastrointestinal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Oes

opha

geal

per

fora

tion

CX

R (

I)In

dica

ted

(B)

CX

R m

ay b

e su

ffic

ient

, unl

ess

loca

lisat

ion

for

surg

ical

repa

ir i

s pl

anne

d.

Swal

low

(II

)Sp

ecia

lised

Swal

low

sho

uld

be p

erfo

rmed

with

wat

er-s

olub

leG

3in

vest

igat

ion

(B)

non-

ion

ic c

ontr

ast

agen

ts. S

ome

cent

res

use

CT.

Acu

te G

I bl

eedi

ng:

AX

R (

II)

Not

ind

icat

edO

f no

val

ue.

haem

atem

esis

rout

inel

y (B

)

Ba

stud

ies

(II)

Not

ind

icat

edE

ndos

copy

pro

vide

s di

agno

sis

of u

pper

GI

lesi

ons,

rout

inel

y (A

)al

low

s in

ject

ion

of v

aric

es, e

tc. B

a st

udie

s pr

eclu

dean

giog

raph

y.

NM

(II

)Sp

ecia

lised

Aft

er e

ndos

copy

. NM

can

det

ect

blee

ding

rat

es a

s lo

w(r

ed c

ell

stud

y)in

vest

igat

ion

(B)

as 0

.1 m

l/min

; m

ore

sens

itive

tha

n an

giog

raph

y. R

edce

ll st

udy

is m

ost

usef

ul i

n in

term

itten

t bl

eedi

ng.

Ang

iogr

aphy

Spec

ialis

edW

hen

cons

ider

ing

surg

ery

or i

nter

vent

ion

(e.g

.G

4(I

II)

inve

stig

atio

n (B

)em

bolis

atio

n) f

or u

ncon

trol

labl

e bl

eedi

ng.

61

G. Gastrointestinal system

Dys

peps

ia i

n th

e yo

unge

r Im

agin

gN

ot i

ndic

ated

Mos

t pa

tient

s un

der

45 y

rs c

an b

e tr

eate

d w

ithou

tpa

tient

(e.

g. u

nder

45

yrs)

(Ba

mea

l (I

I)/

rout

inel

y (C

)co

mpl

ex i

nves

tigat

ions

and

will

und

ergo

a t

rial

of

End

osco

py (

0))

ther

apy

(ant

i-ul

cer

or r

eflu

x). E

ither

Ba

mea

l or

endo

scop

y fo

r th

ose

who

fai

l to

res

pond

. Oth

er a

larm

feat

ures

poi

ntin

g to

ear

ly i

nves

tigat

ion

incl

ude

unin

tent

iona

l w

eigh

t lo

ss, a

naem

ia, a

nore

xia,

GI

blee

ding

, pai

n re

quir

ing

hosp

italis

atio

n, n

on-s

tero

idan

ti-in

flam

mat

ory

drug

s, v

omiti

ng, n

o im

prov

emen

tfo

llow

ing

trea

tmen

t in

tho

se p

ositi

ve f

or H

elic

obac

ter

G5

pylo

ri.

Dys

peps

ia i

n th

e ol

der

Imag

ing

(Ba

Indi

cate

d (C

)E

ndos

copy

is

ofte

n th

e fi

rst

line

inve

stig

atio

n.pa

tient

(e.

g. o

ver

45 y

rs)

mea

l (I

I)/

How

ever

, Ba

mea

l re

mai

ns a

rea

sona

ble

alte

rnat

ive.

endo

scop

y (0

))T

he a

ltern

ativ

e in

vest

igat

ion

shou

ld b

e co

nsid

ered

whe

neve

r sy

mpt

oms

cont

inue

aft

er n

egat

ive

resu

lt.T

he m

ain

conc

ern

is t

he d

etec

tion

of e

arly

can

cer,

G6

espe

cial

ly s

ubm

ucos

al t

umou

rs.

Ulc

er f

ollo

w-u

pB

a st

udie

s (I

I)N

ot i

ndic

ated

Scar

ring

pre

clud

es a

ccur

ate

asse

ssm

ent.

End

osco

pyro

utin

ely

(B)

pref

erre

d to

con

firm

com

plet

e he

alin

g an

d to

obt

ain

biop

sies

(e.

g. H

elic

obac

ter

pylo

ri, e

tc.)

whe

re n

eces

sary

.So

me

cent

res

use

NM

stu

dies

(C

arbo

n-14

bre

ath

test

)G

7to

ass

ess

effe

ct o

f tr

eatm

ent

of H

elic

obac

ter

pylo

ri.

62

G. Gastrointestinal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Prev

ious

upp

er G

I su

rger

yW

ater

sol

uble

Indi

cate

d (B

)To

ass

ess

anas

tom

osis

and

tra

nsit

thro

ugh

to s

mal

l(r

ecen

t)co

ntra

st m

ediu

mbo

wel

.G

8st

udy

(II)

Prev

ious

upp

er G

IB

a st

udie

s (I

I)N

ot i

ndic

ated

Gas

tric

rem

nant

bes

t as

sess

ed b

y en

dosc

opy

(gas

triti

s,su

rger

y (o

ld)

rout

inel

y (B

)ul

cera

tion,

rec

urre

nt t

umou

r, et

c.).

Cro

ss-s

ectio

nal

imag

ing

(US,

CT,

etc

.) m

ay b

e ne

eded

to

asse

ssex

tram

ural

dis

ease

. End

osco

pic

US

can

dem

onst

rate

subm

ucos

al r

ecur

renc

e.

NM

(II

)Sp

ecia

lised

NM

can

pro

vide

fun

ctio

nal

data

abo

ut e

mpt

ying

.G

9in

vest

igat

ion

(B)

Inte

stin

al b

lood

los

s,B

a sm

all

bow

elN

ot i

ndic

ated

Onl

y af

ter

uppe

r an

d lo

wer

tra

ct i

mag

ing

(Ba

stud

ies

chro

nic

or r

ecur

rent

stud

y (I

I)in

itial

ly(C

)or

end

osco

py).

NM

(II

) (r

edSp

ecia

lised

Whe

n al

l ot

her

inve

stig

atio

ns a

re n

egat

ive.

cell

or

Mec

kel’s

inve

stig

atio

n (B

)st

udy)

and

/or

G10

angi

ogra

phy

(III

)

Acu

te a

bdom

inal

pai

n —

CX

R (

I) (

erec

t)In

dica

ted

(B)

Dec

ubitu

s A

XR

to

show

fre

e ai

r if

CX

R s

upin

e.pe

rfor

atio

n— o

bstr

uctio

nan

d A

XR

(II

)Su

pine

AX

R u

sual

ly s

uffi

cien

t to

est

ablis

h di

agno

sis

and

poin

t to

an

anat

omic

al l

evel

of

obst

ruct

ion.

CT

(II)

Spec

ialis

edC

onsi

der

erec

t AX

R i

f su

pine

AX

R n

orm

al a

ndIn

vest

igat

ion

(B)

stro

ng c

linic

al s

uspi

cion

of

obst

ruct

ion.

The

re i

sin

crea

sing

use

of

CT

here

– e

.g. t

o es

tabl

ish

site

and

G11

caus

e of

obs

truc

tion.

63

G. Gastrointestinal system

Smal

l bo

wel

Con

tras

t st

udie

sSp

ecia

lised

Stud

ies

with

non

-ion

ic a

gent

s ca

n de

term

ine

both

the

obst

ruct

ion

(II)

or

CT

(III

)in

vest

igat

ion

(B)

site

and

com

plet

enes

s of

obs

truc

tion.

Som

e ce

ntre

s us

eC

Tin

thi

s si

tuat

ion

whi

ch c

an d

eter

min

e le

vel

and

G12

likel

y ca

use.

Smal

l bo

wel

obs

truc

tion:

Smal

l bo

wel

Indi

cate

d (B

)Sm

all

bow

el e

nem

a is

the

exa

min

atio

n of

cho

ice.

chro

nic

or r

ecur

rent

Ba

stud

y (I

I)G

13

Smal

l bo

wel

dis

ease

Ba

smal

l bo

wel

Indi

cate

d (C

)B

a fo

llow

thr

ough

ten

ds t

o gi

ve a

low

er r

adia

tion

dose

susp

ecte

d (e

.g. C

rohn

’sst

udy

(II)

than

sm

all

bow

el e

nem

a. S

ome

cent

res

use

US

and/

ordi

seas

e)C

Tto

ass

ess

bow

el w

all.

NM

(w

hite

cel

lSp

ecia

lised

Lab

elle

d w

hite

cel

l sc

intig

raph

y re

veal

s ac

tivity

and

stud

y) (

III)

inve

stig

atio

n (B

)ex

tent

of

dise

ase.

Com

plem

enta

ry t

o B

a st

udie

s. C

TG

14an

d M

RI

rese

rved

for

com

plic

atio

ns.

64

G. Gastrointestinal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Lar

ge b

owel

tum

our

or

Ba

enem

a (I

II)

Indi

cate

d (B

)N

B:

Dou

ble

cont

rast

Ba

is o

nly

usef

ul i

f th

e bo

wel

is

infl

amm

ator

y bo

wel

prop

erly

pre

pare

d. F

urth

erm

ore

all

patie

nts

shou

lddi

seas

e: p

ain,

ble

edin

g,un

derg

o re

ctal

exa

min

atio

n to

ass

ess

suita

bilit

y fo

r B

ach

ange

in

bow

el h

abit,

enem

a an

d to

exc

lude

a l

ow r

ecta

l tu

mou

r. G

ood

etc.

prac

tice

requ

ires

a s

igm

oido

scop

y be

fore

Ba

enem

a.D

efer

Ba

enem

a fo

r se

ven

days

aft

er f

ull

thic

knes

sbi

opsy

via

a r

igid

sig

moi

dosc

ope.

Bio

psie

s ta

ken

duri

ng f

lexi

ble

sigm

oido

scop

y ar

e us

ually

sup

erfi

cial

and

the

risk

of

subs

eque

nt p

erfo

ratio

n is

low

(id

eally

a48

hou

r de

lay)

. Som

e ce

ntre

s us

e co

lono

scop

yin

itial

ly, r

eser

ving

Ba

enem

a fo

r di

ffic

ult

orin

com

plet

e ex

amin

atio

ns. S

ome

cent

res

use

CT

for

the

frai

l el

derl

y pa

tient

. Alth

ough

the

irr

itabl

e bo

wel

synd

rom

e is

the

mos

t co

mm

on c

ause

of

a ch

ange

in

bow

el h

abit,

Ba

enem

a or

col

onos

copy

is

need

ed t

oG

15ex

clud

e ot

her

caus

es.

Lar

ge b

owel

obs

truc

tion:

Ene

ma

(III

)Sp

ecia

lised

Sing

le c

ontr

ast

(ide

ally

wat

er-s

olub

le c

ontr

ast

acut

ein

vest

igat

ion

(B)

med

ium

) st

udy

can

show

nar

row

ed a

rea

and

excl

ude

‘pse

udo-

obst

ruct

ion’

. Som

e ce

ntre

s us

e C

Tw

hich

can

G16

poin

t to

the

lik

ely

caus

e.

65

G. Gastrointestinal system

Infl

amm

ator

y bo

wel

AX

R (

II)

Indi

cate

d (B

)O

ften

suf

fici

ent

for

eval

uatio

n.di

seas

e of

col

on

NM

(w

hite

cel

lIn

dica

ted

(B)

Lab

elle

d w

hite

cel

l st

udy

best

exa

m —

will

rev

eal

stud

y) (

III)

activ

ity a

nd e

xten

t of

dis

ease

.

Ba

enem

a (I

II)

Not

ind

icat

edB

a en

ema

is d

ange

rous

whe

n to

xic

meg

acol

on p

rese

nt;

rout

inel

y (B

)un

prep

ared

ene

ma

in s

elec

ted

case

s af

ter

disc

ussi

onG

17w

ith r

adio

logi

sts.

Infl

amm

ator

y bo

wel

Ba

enem

a (I

II)

Not

ind

icat

edC

olon

osco

py f

ollo

w-u

p pr

efer

red

to i

dent

ify

dise

ase

of c

olon

:ro

utin

ely

(B)

deve

lopi

ng c

arci

nom

a in

tho

se a

t hi

gh r

isk,

alth

ough

long

-ter

m f

ollo

w-u

pB

a en

ema

is s

till

ofte

n us

ed, p

artic

ular

ly a

fter

com

plex

inte

stin

al s

urge

ry. L

ikew

ise

Ba

enem

a pr

efer

red

for

G18

eval

uatin

g fi

stul

ae e

tc.

Gen

eral

ab

do

min

al p

rob

lem

sA

cute

abd

omen

pai

n;A

XR

(II

) pl

usIn

dica

ted

(B)

Loc

al p

olic

y w

ill d

eter

min

e st

rate

gy. S

upin

e A

XR

(fo

r(w

arra

ntin

g ho

spita

ler

ect

CX

R (

I)ga

s pa

ttern

, etc

.) i

s us

ually

suf

fici

ent.

Ere

ct A

XR

not

adm

issi

on a

nd s

urgi

cal

indi

cate

d ro

utin

ely.

Inc

reas

ing

use

of C

Tas

a ‘

catc

h-co

nsid

erat

ion)

all’

inve

stig

atio

n he

re. U

S w

idel

y us

ed a

s a

G19

prel

imin

ary

surv

ey.

66

G. Gastrointestinal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Palp

able

mas

sA

XR

(II

)N

ot i

ndic

ated

rout

inel

y (C

)

US

(0)

Indi

cate

d (B

)U

S us

ually

sol

ves

the

prob

lem

and

is

very

rel

iabl

e in

thin

pat

ient

s, r

ight

upp

er q

uadr

ant

and

pelv

is.

G20

CT

(III

)In

dica

ted

(A)

CT

is a

n al

tern

ativ

e an

d us

eful

to

excl

ude

a le

sion

;pa

rtic

ular

ly g

ood

in f

at p

atie

nts.

Mal

abso

rbtio

nB

a st

udy

ofN

ot i

ndic

ated

Imag

ing

is n

ot r

equi

red

for

the

diag

nosi

s of

coe

liac

smal

l bo

wel

(II

)ro

utin

ely

(B)

dise

ase

but

may

be

indi

cate

d fo

r je

juna

l di

vert

icul

osis

or w

hen

biop

sy i

s no

rmal

/equ

ivoc

al. C

Tm

ay b

e be

tter

if l

ymph

oma

susp

ecte

d.

NM

(I)

Spec

ialis

edN

umer

ous

NM

inv

estig

atio

ns a

vaila

ble

whi

ch s

houl

din

vest

igat

ion

(B)

esta

blis

h pr

esen

ce o

f m

alab

sorp

tion.

Som

e of

the

se a

reG

21no

n-ra

diol

ogic

al (

e.g.

bre

ath

test

).

App

endi

citis

Imag

ing

Spec

ialis

edW

ide

rang

e of

pol

icy

vary

ing

acco

rdin

gly

to l

ocal

inve

stig

atio

n (C

)av

aila

bilit

y of

equ

ipm

ent

and

expe

rtis

e an

d th

e bo

dyha

bitu

s of

the

pat

ient

.App

endi

citis

is

usua

lly a

clin

ical

dia

gnos

is. I

mag

ing

(e.g

. US

with

gra

ded

com

pres

sion

) ca

n he

lp i

n eq

uivo

cal

case

s or

in

diff

eren

tiatio

n fr

om g

ynae

colo

gica

l le

sion

s. S

o to

o ca

nN

M (

whi

te c

ell

stud

y) a

nd f

ocus

ed a

ppen

dix

CT

(FA

CT

). U

S re

com

men

ded

in c

hild

ren

and

youn

gG

22w

omen

.

67

G. Gastrointestinal system

Con

stip

atio

nA

XR

(II

)N

ot i

ndic

ated

Man

y no

rmal

adu

lts s

how

ext

ensi

ve f

aeca

l m

ater

ial;

rout

inel

y (C

)al

thou

gh t

his

may

be

rela

ted

to p

rolo

nged

tra

nsit

time

it is

im

poss

ible

to

asse

ss s

igni

fica

nce

on A

XR

alo

ne.

(for

chi

ldre

nB

ut A

XR

can

hel

p ce

rtai

n sp

ecia

lists

(e.

g.se

e Se

ctio

n M

)G

23ge

riat

rici

ans)

in

refr

acto

ry c

ases

.

Abd

omin

al s

epsi

s;

US

(0)

or C

TIn

dica

ted

(C)

Seek

rad

iolo

gica

l ad

vice

; m

uch

depe

nds

on l

ocal

pyre

xia

of u

nkno

wn

orig

in(I

II)

or N

M (

III)

avai

labi

lity

and

expe

rtis

e. U

S of

ten

used

fir

st (

spee

d,(P

UO

)co

st)

and

may

be

defi

nitiv

e, p

artic

ular

ly w

hen

ther

ear

e lo

calis

ing

sign

s; e

spec

ially

goo

d fo

rsu

bphr

enic

/sub

hepa

tic s

pace

s an

d pe

lvis

. CT

prob

ably

best

tes

t ov

eral

l: in

fect

ion

and

tum

our

usua

llyid

entif

ied

and

excl

uded

. Als

o al

low

s bi

opsy

of

node

sor

tum

our

and

drai

nage

of

colle

ctio

ns (

espe

cial

lyre

cent

pos

t-op

erat

ive)

. NM

par

ticul

arly

goo

d w

hen

ther

e ar

e no

loc

alis

ing

feat

ures

: la

belle

d W

BC

goo

dfo

r ch

roni

c po

st-o

pera

tive

seps

is;

galli

um w

illac

cum

ulat

e at

site

s of

tum

our

(e.g

. lym

phom

a) a

ndG

24in

fect

ion.

68

G. Gastrointestinal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Live

r, g

allb

lad

der

an

d p

ancr

eas

Hep

atic

met

asta

ses

US

(0)

Indi

cate

d (B

)T

he m

ajor

ity o

f m

etas

tase

s w

ill b

e de

mon

stra

ted

byU

S w

hich

als

o al

low

s bi

opsy

. US

shou

ld b

e th

e in

itial

inve

stig

atio

n bu

t m

etas

tase

s m

ay s

how

the

sam

ere

flec

tivity

as

the

hepa

tic p

aren

chym

a an

d th

us b

eC

T(I

I) o

rSp

ecia

lised

mis

sed.

CT

/MR

I us

ed f

or f

urth

er e

xclu

sion

, whe

re U

SM

RI

(0)

inve

stig

atio

n (B

)eq

uivo

cal

or s

urpr

isin

gly

norm

al a

nd w

here

ful

lst

agin

g is

nee

ded

or h

epat

ic r

esec

tion

is p

lann

ed (

see

also

Can

cer

L13

). R

ecen

t in

tere

st i

n du

al-p

hase

spi

ral

CT.

MR

I be

ing

incr

easi

ngly

use

d he

re. S

ome

rece

ntG

25in

tere

st i

n N

M (

som

atos

tatin

ana

logu

es a

nd P

ET

).

Hep

atic

hae

man

giom

aM

RI

(0)

orIn

dica

ted

(B)

MR

I, C

Tan

d N

M r

elia

bly

show

fur

ther

cha

ract

eris

tic(e

.g. o

n U

S)C

T(I

II)

feat

ures

of

haem

angi

oma

and

man

y ot

her

solit

ary

hepa

tic l

esio

ns.

NM

(re

d ce

llSp

ecia

lised

G26

stud

y) (

III)

inve

stig

atio

n (B

)

Jaun

dice

US

(0)

Indi

cate

d (B

)Se

nsiti

ve f

or b

ile d

uct

dila

tatio

n. B

ut d

ilata

tion

may

be s

ubtle

in

earl

y ob

stru

ctio

n an

d sc

lero

sing

chol

angi

tis. S

how

s ga

llsto

nes

and

mos

t fo

rms

ofhe

patic

dis

ease

. US

also

sho

ws

the

leve

l an

d ca

use

ofan

y ob

stru

ctio

n to

com

mon

bile

duc

t. D

iscu

sssu

bseq

uent

inv

estig

atio

ns (

CT,

ER

CP,

MR

CP,

etc

.)G

27w

ith r

adio

logi

st.

69

G. Gastrointestinal system

Bili

ary

dise

ase,

AX

R (

II)

Not

ind

icat

edPl

ain

XR

s on

ly s

how

abo

ut 1

0%

of

galls

tone

s.(e

.g. g

alls

tone

s)ro

utin

ely

(C)

US

(0)

Indi

cate

d (B

)U

S al

low

s ev

alua

tion

of o

ther

org

ans

too.

Cho

lecy

stog

raph

y is

now

rar

ely

need

ed (

e.g.

poo

rvi

ews

at U

S). C

T/e

ndos

copy

may

be

need

ed f

orfu

rthe

r de

linea

tion.

Inc

reas

ing

inte

rest

in

MR

CP.

NM

(II

)Sp

ecia

lised

Bili

ary

scin

tigra

phy

show

s cy

stic

duc

t ob

stru

ctio

n in

G28

inve

stig

atio

n (B

)ac

ute

chol

ecys

titis

. Als

o us

eful

in

chro

nic

chol

ecys

titis

.

Panc

reat

itis:

acu

teA

XR

(II

)N

ot i

ndic

ated

Unl

ess

diag

nosi

s in

dou

bt;

then

AX

R n

eede

d to

rout

inel

y (C

)ex

clud

e ot

her

caus

es o

f ac

ute

abdo

men

pai

n (s

eeG

19).

Som

e pa

tient

s pr

esen

ting

with

acu

te p

ancr

eatit

isha

ve u

nder

lyin

g ch

roni

c pa

ncre

atiti

s w

hich

may

cau

seca

lcif

icat

ion

evid

ent

on A

XR

.

US

(0)

Indi

cate

d (B

)To

sho

w g

alls

tone

s an

d to

dia

gnos

e an

d fo

llow

pseu

docy

st d

evel

opm

ent,

espe

cial

ly g

ood

in t

hin

patie

nts.

70

G. Gastrointestinal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

CT

(III

) or

Not

ind

icat

edR

eser

ved

for

clin

ical

ly s

ever

e ca

ses

(to

asse

ss e

xten

tM

RI

(0)

rout

inel

y (B

)of

nec

rosi

s), i

n pa

tient

s w

ho d

o no

t im

prov

e on

trea

tmen

t or

if

ther

e is

unc

erta

inty

as

to t

he d

iagn

osis

.C

Tca

n he

lp p

redi

ct m

orbi

dity

and

mor

talit

y. S

ome

cent

res

use

MR

I, e

spec

ially

if

repe

ated

fol

low

-up

G29

likel

y.

Panc

reat

itis:

chr

onic

AX

R (

II)

Indi

cate

d (B

)To

sho

w c

alci

fica

tion.

US

(0)

orIn

dica

ted

(B)

US

may

be

defi

nitiv

e in

thi

n pa

tient

s; C

Tw

ill s

how

CT

(IV

)ca

lcif

icat

ion

to g

ood

effe

ct.

ER

CP

(II)

or

Spec

ialis

edE

RC

Psh

ows

duct

mor

phol

ogy,

but

con

side

rabl

e ri

skG

30M

RC

P(0

)in

vest

igat

ion

(C)

of a

cute

pan

crea

titis

. Hen

ce c

urre

nt i

nter

est

in M

RC

P.

Post

-ope

rativ

e bi

liary

lea

kN

M (

II)

Indi

cate

d (C

)U

S w

ill u

sual

ly h

ave

show

n th

e an

atom

y of

the

colle

ctio

ns, e

tc. N

M s

tudy

(H

IDA

) w

ill s

how

act

ivity

at s

ite o

f le

ak. M

RC

Pal

so u

sed

here

. ER

CP

will

sho

wth

e an

atom

y of

the

lea

k an

d m

ay a

llow

int

erve

ntio

nG

31(e

.g. s

tent

).

Panc

reat

ic t

umou

rU

S (0

)In

dica

ted

(B)

Esp

ecia

lly i

n th

in p

atie

nts

and

for

lesi

ons

in t

he h

ead

CT

(III

)an

d bo

dy. I

ncre

asin

g us

e of

end

osco

pic

and

or M

RI

(0)

lapa

rosc

opic

US.

CT

(or

MR

I) g

ood

in t

he f

atte

rpa

tient

and

whe

re U

S eq

uivo

cal

or w

here

pre

cise

stag

ing

need

ed. E

RC

P/M

RC

Pm

ay a

lso

be i

ndic

ated

.N

M (

eg P

ET

) m

ay h

elp

dist

ingu

ish

carc

inom

a fr

omG

32pa

ncre

atiti

s.

71

G. Gastrointestinal system

Insu

linom

aIm

agin

gSp

ecia

lised

Whe

n bi

oche

mic

al t

ests

are

con

vinc

ing.

MR

Iem

ergi

ng a

s th

e be

st e

xam

inat

ion

alth

ough

art

eria

lph

ase

spir

al C

Tpr

omis

ing.

Mos

t ce

ntre

s se

ek t

wo

posi

tive

inve

stig

atio

ns b

efor

e su

rger

y (o

ut o

fC

T/N

M/M

RI

/ang

iogr

aphy

). E

ndos

copi

c an

d in

tra-

G33

oper

ativ

e U

S al

so u

sefu

l.

72

G. Gastrointestinal systemC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

H.

Uro

logi

cal,

ad

ren

al a

nd

gen

ito

-uri

nar

y sy

stem

s

Hae

mat

uria

mac

ro-

US

(0)

+A

XR

In

dica

ted

(B)

The

re i

s a

wid

e va

riat

ion

in l

ocal

pol

icy.

Im

agin

gor

mic

rosc

opic

(II)

or

IVU

(II

)st

rate

gies

sho

uld

be a

gree

d w

ith t

he l

ocal

neph

rolo

gist

s an

d ur

olog

ists

. In

man

y ce

ntre

sU

S+

AX

R a

re t

he i

nitia

l st

udie

s, b

ut i

f ne

gativ

e, I

VU

is s

till

indi

cate

d in

pat

ient

s w

ith c

ontin

uing

mac

rosc

opic

hae

mat

uria

or

in t

he o

ver

40s

with

mic

rosc

opic

hae

mat

uria

. Con

vers

ely,

pat

ient

s in

who

mIV

U a

nd c

ysto

scop

y ar

e no

rmal

who

con

tinue

to

blee

dsh

ould

und

ergo

US,

as

IVU

can

fai

l to

sho

w a

ren

altu

mou

r an

d U

S w

ill o

ccas

iona

lly d

emon

stra

te a

H1

blad

der

lesi

on n

ot s

een

at c

ysto

scop

y. I

ncre

asin

g us

eof

CT.

Hyp

erte

nsio

n (w

ithou

tIV

U (

II)

Not

ind

icat

edIV

U i

s in

sens

itive

for

ren

al a

rter

y st

enos

is. S

ee H

3.ev

iden

ce o

f re

nal

dise

ase)

rout

inel

y (A

)H

2

Hyp

erte

nsio

n: i

n th

eU

S (0

) ki

dney

sIn

dica

ted

(B)

To a

sses

s re

lativ

e re

nal

size

and

par

ench

ymal

pat

tern

.yo

ung

adul

t or

in

patie

nts

Dop

pler

US

is n

ot s

ensi

tive

enou

gh f

or u

se a

s a

unre

spon

sive

to

med

icat

ion

scre

enin

g to

ol.

NM

(II

)In

dica

ted

(B)

Cap

topr

il re

nogr

aphy

is

an e

stab

lishe

d m

etho

d of

reno

gram

dete

rmin

ing

func

tiona

lly s

igni

fica

ntre

nal

arte

ryst

enos

is.

73

H. Urological systems

Ang

iogr

aphy

Spec

ialis

edTo

sho

w s

teno

sis

if s

urge

ry o

r an

giop

last

y is

(D

SA(I

II),

inve

stig

atio

n (C

)co

nsid

ered

as

a po

ssib

le t

reat

men

t.C

TA(I

II)

orH

3M

RA

(0))

Ren

al f

ailu

reU

S (0

)+

Indi

cate

d (B

)Fo

r re

nal

size

, str

uctu

re, o

bstr

uctio

n, e

tc. N

B:

aA

XR

(II

)no

rmal

US

does

not

exc

lude

obs

truc

tion.

NM

(II

)In

dica

ted

(B)

Whe

n ap

prop

riat

e, r

enog

raph

y ca

n as

sess

ren

alH

4pe

rfus

ion,

fun

ctio

n an

d ob

stru

ctio

n.

Ren

al c

olic

, loi

n pa

inIV

U (

II)

or U

S In

dica

ted

(B)

Imag

ing

shou

ld b

e pe

rfor

med

as

an e

mer

genc

y(0

) an

d A

XR

(II

)ex

amin

atio

n w

hils

t th

e pa

in i

s pr

esen

t, as

rad

iolo

gica

lor

CT

(III

)si

gns

disa

ppea

r ra

pidl

y af

ter

pass

age

of a

sto

ne.

Del

ayed

film

s (u

p to

24

hrs)

may

be

need

ed t

o sh

owth

e si

te o

f ob

stru

ctio

n. A

plai

n A

XR

on

its o

wn

is o

flit

tle v

alue

. Bot

h C

Tan

d U

S ar

e in

crea

sing

ly

bein

g us

ed, e

spec

ially

in

thos

e w

ith c

ontr

aind

icat

ions

H5

to c

ontr

ast

med

ium

.

Ren

al c

alcu

li (i

n th

eU

S (0

)+

Indi

cate

d (C

)A

XR

alo

ne m

ay b

e ap

prop

riat

e fo

llow

-up

for

prev

ious

lyab

senc

e of

acu

te c

olic

)A

XR

(II

)de

mon

stra

ted

calc

uli

afte

r an

unc

ompl

icat

ed a

cute

atta

ck. A

n IV

U m

ay b

e re

quir

ed b

efor

e tr

eatm

ent

tosh

ow a

nato

my.

NM

may

be

need

ed t

o de

term

ine

H6

rela

tive

func

tion.

74

H. Urological systemsC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Ren

al m

ass

US

(0)

Indi

cate

d (B

)U

S is

goo

d at

dis

tingu

ishi

ng b

etw

een

cyst

ic a

nd s

olid

mas

ses.

AX

R (

II)

+N

ot i

ndic

ated

CT

or M

RI

pref

erab

le f

or f

urth

er e

valu

atio

n. N

M m

ayH

7IV

U (

II)

rout

inel

y (C

)be

nee

ded

to d

eter

min

e re

lativ

e fu

nctio

n.

Pros

tatis

mU

S 0)

Indi

cate

d (B

)U

S ca

n al

so a

sses

s up

per

trac

t an

d bl

adde

r vo

lum

esIV

U (

II)

Not

ind

icat

edbe

fore

and

aft

er v

oidi

ng, p

refe

rabl

y w

ith f

low

rat

es. I

tH

8ro

utin

ely

(B)

can

also

sho

w b

ladd

er c

alcu

li.

Pros

tatic

mal

igna

ncy

US

(0)

Spec

ialis

edT

rans

rect

al U

S w

ith g

uide

d bi

opsi

es a

fter

clin

ical

H9

inve

stig

atio

n (B

)ex

amin

atio

n. S

ome

inte

rest

in

MR

I an

d PE

The

re.

Uri

nary

ret

entio

nU

S (0

)In

dica

ted

(C)

US

to e

valu

ate

the

uppe

r tr

acts

(af

ter

cath

eter

isat

ion

IVU

(II

)N

ot i

ndic

ated

and

relie

f of

bla

dder

dis

tens

ion)

, par

ticul

arly

if

urea

H10

rout

inel

y (C

)le

vels

rem

ain

rais

ed.

Scro

tal

mas

s or

pai

nU

S (0

)In

dica

ted

(B)

Allo

ws

diff

eren

tiatio

n of

tes

ticul

ar f

rom

ext

ra-

H11

test

icul

ar l

esio

ns.

Test

icul

ar t

orsi

onU

S (0

)Sp

ecia

lised

Tors

ion

is u

sual

ly a

clin

ical

dia

gnos

is. I

mag

ing

inve

stig

atio

n (C

)in

vest

igat

ions

mus

t no

t de

lay

the

prio

rity

tha

t m

ust

begi

ven

to s

urgi

cal

expl

orat

ion.

Dop

pler

US

can

be u

sed,

whe

n cl

inic

al f

indi

ngs

are

equi

voca

l in

the

pos

tpu

bert

al t

estis

.

NM

(II

)Sp

ecia

lised

NM

tec

hniq

ues

can

assi

st w

ith t

his

diag

nosi

s bu

tH

12in

vest

igat

ion

(C)

prom

pt r

esul

ts e

ssen

tial.

75

H. Urological systems

Uri

nary

tra

ct i

nfec

tion

US

(0)

+N

ot i

ndic

ated

The

maj

ority

do

not

need

inv

estig

atio

n un

less

the

rein

adu

ltsA

XR

(II

) or

rout

inel

y (C

)ar

e re

curr

ent

infe

ctio

ns, r

enal

col

ic o

r fa

ilure

to

IVU

(II

)re

spon

d to

ant

ibio

tics.

Slig

htly

low

er t

hres

hold

to

(for

chi

ldre

n se

ein

vest

igat

e m

ale

patie

nts.

Sect

ion

M)

H13

NB

:T

his

does

not

app

ly t

o ch

ildre

n.

Adr

enal

med

ulla

ryC

T(I

II)

orSp

ecia

lised

Whi

lst

US

may

ide

ntif

y le

sion

s of

thi

s ty

pe, C

Tan

dtu

mou

rsM

RI

(0)

inve

stig

atio

n (B

)M

RI

prov

ide

the

best

ana

tom

ical

del

inea

tion.

Im

agin

gis

rar

ely

indi

cate

d in

the

abs

ence

of

bioc

hem

ical

evid

ence

of

such

tum

ours

.

NM

(II

)Sp

ecia

lised

MIB

G l

ocat

es f

unct

ioni

ng t

umou

rs a

nd i

s pa

rtic

ular

lyH

14in

vest

igat

ion

(B)

usef

ul f

or e

ctop

ic s

ites

and

met

asta

ses.

Adr

enal

cor

tical

les

ions

,C

T(I

II),

NM

Spec

ialis

edL

ocal

adv

ice

on t

he m

ost

appr

opri

ate

exam

inat

ion

Cus

hing

’s a

nd C

onn’

s(I

V)

or M

RI

(0)

inve

stig

atio

n (B

)sh

ould

be

soug

ht. B

oth

CT

and

MR

I ca

n di

ffer

entia

tedi

seas

e an

d sy

ndro

me

betw

een

the

diff

eren

t le

sion

s. N

M c

an d

istin

guis

hbe

twee

n fu

nctio

ning

and

non

-fun

ctio

ning

ade

nom

as.

H15

So t

oo c

an v

ario

us M

RI

tech

niqu

es.

76

H. Urological systemsC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

I. O

bst

etri

cs a

nd

gyn

aeco

logy

NB

:T

rans

vagi

nal

(TV

) U

S eq

uipm

ent

shou

ld b

e av

aila

ble

in a

ll de

part

men

ts p

erfo

rmin

g pe

lvic

US

Scre

enin

g in

pre

gnan

cyU

S (0

)In

dica

ted

(C)

Scre

enin

g U

S ha

s no

t be

en s

how

n to

alte

r pe

rina

tal

mor

talit

y, e

xcep

t w

here

sel

ectiv

e te

rmin

atio

n of

preg

nanc

y is

app

lied

in t

he p

rese

nce

of g

ross

foe

tal

abno

rmal

ity. I

t do

es p

rovi

de u

sefu

l in

form

atio

n ab

out

datin

g an

d m

ultip

le p

regn

anci

es. U

S is

als

o of

pro

ven

valu

e in

ass

essi

ng p

lace

nta

prae

via

and

intr

a-ut

erin

egr

owth

. In

the

spec

ialis

t ca

re o

f hi

gh-r

isk

preg

nanc

ies,

Dop

pler

US

of t

he u

mbi

lical

art

ery

assi

sts

man

agem

ent.

The

re i

s w

ide

vari

atio

n in

the

use

of

I1ob

stet

ric

US

in d

iffe

rent

cou

ntri

es.

Susp

ecte

d pr

egna

ncy

US

(0)

Not

ind

icat

edPr

egna

ncy

test

ing

mos

t ap

prop

riat

e. U

S va

luab

leI2

rout

inel

y (C

)w

here

mol

ar p

regn

ancy

sus

pect

ed.

Susp

ecte

d ec

topi

cU

S (0

)In

dica

ted

(B)

Aft

er p

ositi

ve p

regn

ancy

tes

t. T

VU

S pr

efer

red.

preg

nanc

yI3

Col

our

flow

Dop

pler

inc

reas

es s

ensi

tivity

.

Poss

ible

non

-via

ble

US

(0)

Indi

cate

d (C

)R

epea

t U

S af

ter

a w

eek

may

be

need

ed (

espe

cial

lypr

egna

ncy

whe

n ge

stat

iona

l sa

c <

20

mm

or

crow

n ru

mp

leng

th<

6 m

m).

Pre

gnan

cy t

est

requ

ired

. Whe

re d

oubt

exi

sts

abou

t th

e vi

abili

ty o

f a

preg

nanc

y, d

elay

in

evac

uatio

nI4

of t

he u

teru

s is

ess

entia

l.

77

I. Obstetrics and gynaecology

Susp

ecte

d pe

lvic

mas

sU

S (0

)In

dica

ted

(C)

Com

bina

tion

of t

rans

-abd

omin

al a

nd T

VU

S of

ten

requ

ired

. US

shou

ld c

onfi

rm a

les

ion’

s pr

esen

ce a

ndde

term

ine

likel

y or

gan

of o

rigi

n. S

ee C

ance

r Se

ctio

nL

. MR

I is

the

bes

t se

cond

lin

e in

vest

igat

ion,

alth

ough

I5C

Tst

ill w

idel

y us

ed.

Pelv

ic p

ain,

inc

ludi

ngU

S (0

)In

dica

ted

(C)

Esp

ecia

lly w

hen

clin

ical

exa

min

atio

n di

ffic

ult

orsu

spec

ted

pelv

icim

poss

ible

.in

flam

mat

ory

dise

ase

and

susp

ecte

d en

dom

etri

osis

MR

I (0

)Sp

ecia

lised

Can

be

usef

ul t

o lo

calis

e th

e la

rger

foc

i of

I6in

vest

igat

ion

(B)

endo

met

rios

is.

Los

t IU

CD

US

(0)

Indi

cate

d (C

)

AX

R (

II)

Not

ind

icat

edU

nles

s IU

CD

is

not

seen

in

uter

us o

n U

S.I7

rout

inel

y (C

)

Rec

urre

nt m

isca

rria

ges

US

(0)

Indi

cate

d (C

)W

ill s

how

the

maj

or c

onge

nita

l an

d ac

quir

edpr

oble

ms.

MR

I (0

)Sp

ecia

lised

Supp

lem

ents

US

for

uter

ine

anat

omy.

Som

e ce

ntre

sI8

inve

stig

atio

n (C

)us

e hy

ster

osal

ping

ogra

phy.

78

I. Obstetrics and gynaecologyC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Infe

rtili

tyU

S (0

)In

dica

ted

(C)

For

folli

cle-

trac

king

dur

ing

trea

tmen

t. Fo

r as

sess

men

tof

tub

al p

aten

cy. S

ome

cent

res

use

MR

I an

d/or

I9hy

ster

osal

ping

ogra

phy.

Susp

ecte

d ce

phal

opel

vic

XR

(II

)N

ot i

ndic

ated

The

nee

d fo

r pe

lvim

etry

is

incr

easi

ngly

bei

ngdi

spro

port

ion

Pel

vim

etry

rout

inel

y (B

)qu

estio

ned.

Loc

al p

olic

y sh

ould

be

dete

rmin

ed i

nag

reem

ent

with

obs

tetr

icia

ns. F

urth

erm

ore

MR

I or

CT

MR

I (0

) or

Spec

ialis

edsh

ould

be

used

whe

reve

r po

ssib

le. M

RI

is b

est

as i

tC

T(I

I)in

vest

igat

ion

(C)

avoi

ds x

-irr

adia

tion.

CT

gene

rally

off

ers

a lo

wer

dos

eI1

0th

an s

tand

ard

XR

pel

vim

etry

.

79

I. Obstetrics and gynaecology

J. B

reas

t d

isea

seA

sym

pto

mat

ic p

atie

nts

Bre

ast

scre

enin

gM

amm

ogra

phy

Var

ious

Var

ious

str

ateg

ies

have

bee

n ad

opte

d in

dif

fere

ntJ1

–4(I

)in

dica

tions

coun

trie

s. T

his

topi

c is

not

con

side

red

furt

her.

Fam

ily h

isto

ry o

f br

east

Mam

mog

raph

ySp

ecia

lised

A

t pr

esen

t th

ere

is n

o ev

iden

ce o

f be

nefi

t bu

t th

ere

isca

ncer

(I)

exam

inat

ion

(C)

som

e ev

iden

ce o

f ha

rm. S

cree

ning

sho

uld

only

be

cont

empl

ated

aft

er g

enet

ic r

isk

asse

ssm

ents

and

appr

opri

ate

coun

selli

ng a

s to

the

ris

ks a

nd u

npro

ven

bene

fits

. Con

sens

us a

t th

e m

omen

t is

tha

t sc

reen

ing

shou

ld o

nly

be c

onte

mpl

ated

whe

n th

e lif

etim

e ri

sk o

fbr

east

can

cer

is g

reat

er t

han

2.5

times

ave

rage

. Uni

tssh

ould

col

lect

and

aud

it th

eir

wor

k. T

his

topi

c is

bei

ngri

goro

usly

dis

cuss

ed a

t th

e pr

esen

t tim

e. F

urth

erev

alua

tion

is u

sual

ly o

btai

ned

by U

S, N

M a

nd M

RI

J5ac

cord

ing

to l

ocal

exp

ertis

e an

d av

aila

bilit

y.

Wom

en <

50

yrs

havi

ngM

amm

ogra

phy

Not

ind

icat

edA

met

a-an

alys

is h

as s

how

n w

omen

< 5

0 yr

s w

ho h

ave

or b

eing

con

side

red

for

(I)

rout

inel

y (A

)re

ceiv

ed H

RT

for

> 1

1 yr

s ar

e no

t at

inc

reas

ed r

isk

ofH

RT

brea

st c

ance

r co

mpa

red

to a

pee

r gr

oup.

Wom

en o

nH

RT

50 y

rs a

nd o

ver

can

be a

ppro

pria

tely

mon

itore

dJ6

by b

reas

t sc

reen

ing

prog

ram

mes

.

80

J. Breast diseaseC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Asy

mpt

omat

ic w

omen

Mam

mog

raph

yB

est

cons

ider

ed a

s pa

rt o

f w

hate

ver

natio

nal

brea

stw

ith a

ugm

enta

tion

(I)

scre

enin

g po

licy

appl

ies

(see

J1–

4).

mam

mop

last

yJ7

Sym

pto

mat

ic p

atie

nts

Clin

ical

sus

pici

on o

fM

amm

ogra

phy

Indi

cate

d (B

)R

efer

ral

to a

bre

ast

clin

ic s

houl

d pr

eced

e an

ybr

east

can

cer

(dia

gnos

is)

(I),

radi

olog

ical

inv

estig

atio

n.

US

(0)

Spec

ialis

edM

amm

ogra

phy

±U

S sh

ould

be

used

in

the

cont

ext

ofin

vest

igat

ion

(B)

trip

le a

sses

smen

t —

i.e

. clin

ical

exa

min

atio

n, i

mag

ing

and

cyto

logy

/bio

psy.

Ultr

asou

nd c

an r

eadi

ly d

irec

tbi

opsy

.

NM

(II

I) o

rSp

ecia

lised

NM

or

MR

I so

met

imes

a u

sefu

l ad

junc

t to

tri

ple

J8M

RI

(0)

inve

stig

atio

n (B

)as

sess

men

t of

an

equi

voca

l le

sion

.

Gen

eral

ised

lum

pine

ss,

Mam

mog

raph

yN

ot i

ndic

ated

In t

he a

bsen

ce o

f ot

her

sign

s su

gges

tive

ofge

nera

lised

bre

ast

pain

,(I

) or

US

(0)

rout

inel

y (C

)m

alig

nanc

y, i

mag

ing

is u

nlik

ely

to i

nflu

ence

or t

ende

rnes

s, o

rm

anag

emen

t. Fo

cal,

rath

er t

han

gene

ralis

ed p

ain

may

long

stan

ding

nip

ple

war

rant

inv

estig

atio

n.re

trac

tion

J9

Cyc

lical

mas

talg

iaM

amm

ogra

phy

Not

ind

icat

edIn

the

abs

ence

of

othe

r cl

inic

al s

igns

sug

gest

ive

of(I

)ro

utin

ely

(B)

mal

igna

ncy

and

loca

lised

pai

n, i

nves

tigat

ion

isJ1

0un

likel

y to

inf

luen

ce m

anag

emen

t.

81

J. Breast disease

Aug

men

tatio

nU

S (0

)In

dica

ted

(B)

The

ass

essm

ent

of i

nteg

rity

of

brea

st i

mpl

ants

or

mam

mop

last

yco

inci

dent

mas

ses

requ

ires

spe

cial

ist

skill

s an

dfa

cilit

ies.

MR

I (0

) or

Spec

ialis

edM

RI

is n

ow a

n es

tabl

ishe

d in

vest

igat

ion

for

impl

ant

NM

(II

I)in

vest

igat

ion

(B)

leak

age.

It

can

also

sho

w t

umou

rs.

Scin

timam

mog

raph

y an

d PE

Tal

so h

ave

a ro

le w

hen

J11

othe

r in

vest

igat

ions

are

unh

elpf

ul.

Page

t’s d

isea

se o

f th

eM

amm

ogra

phy

Indi

cate

d (C

)T

he p

reva

lenc

e of

coe

xist

ent

brea

st c

ance

r va

ries

in

nipp

le(I

)pu

blis

hed

stud

ies,

but

its

ass

ocia

tion

is c

lear

and

J12

just

ifie

s sp

ecia

list

refe

rral

.

Bre

ast

infl

amm

atio

nU

S (0

)In

dica

ted

(B)

US

can

dist

ingu

ish

betw

een

an a

bsce

ss r

equi

ring

drai

nage

and

dif

fuse

inf

lam

mat

ion,

and

can

gui

deas

pira

tion

whe

n ap

prop

riat

e. M

amm

ogra

phy

may

be

J13

of v

alue

whe

re m

alig

nanc

y is

pos

sibl

e.

82

J. Breast diseaseC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Bre

ast

canc

erB

reas

t/ax

illa

Spec

ialis

edT

he r

ole

of s

entin

el n

ode

scin

tigra

phy

and

loca

lisat

ion

Stag

ing:

axi

llabr

east

NM

inve

stig

atio

n (C

)is

cur

rent

ly b

eing

eva

luat

ed.

axil

la (

III)

Stag

ing:

gen

eral

NM

ske

leta

lIn

dica

ted

(B)

For

patie

nts

with

a p

rim

ary

tum

our

>2c

m a

nd t

hose

(II)

with

bon

e pa

in.

US

live

r (0

)N

ot r

outin

ely

J14

indi

cate

d (C

)

Bre

ast

canc

erM

amm

ogra

phy

Indi

cate

d (A

)Pr

inci

ples

of

trip

le a

sses

smen

t ap

ply.

For

loc

oreg

iona

lFo

llow

-up

(sur

veill

ance

)(I

)re

curr

ence

, NM

sci

ntim

amm

ogra

phy

and

MR

I ha

ve a

J15

role

.

83

J. Breast disease

K.

Trau

ma

Hea

d:

gen

eral

Hea

d in

jury

:Pr

otoc

ols

for

man

agem

ent

of h

ead

inju

ries

are

con

stan

tly u

nder

rev

iew

and

will

var

y ac

cord

ing

to l

ocal

avai

labi

lity

of C

T, d

ista

nces

inv

olve

d in

tra

nspo

rtat

ion

to n

euro

surg

ical

cen

tres

, etc

. The

rec

omm

enda

tions

give

n he

re m

ay n

eed

to b

e ad

apte

d fo

llow

ing

cons

ulta

tion

with

the

neu

rosu

rgic

al c

entr

e fo

r yo

ur a

rea

in t

helig

ht o

f lo

cal

circ

umst

ance

s an

d po

licie

s.

The

key

man

agem

ent

and

clin

ical

que

stio

ns i

n he

ad i

njur

y ar

e:

Clin

ical

:Is

the

re e

vide

nce

of b

rain

inj

ury?

Is t

here

evi

denc

e of

int

racr

ania

l ha

emor

rhag

e or

rai

sed

intr

acra

nial

pre

ssur

e?Is

the

re c

lini

cal

evid

ence

of

a sk

ull

frac

ture

and

, if

so, i

s it

dep

ress

ed?

Are

oth

er s

yste

ms/

area

s in

volv

ed?

Man

agem

ent:

Doe

s th

e pa

tien

t ne

ed a

dmis

sion

to

hosp

ital

for

obs

erva

tion

?Is

CT

requ

ired

?Is

a n

euro

surg

ical

opi

nion

req

uire

d?

The

se q

uest

ions

und

erlin

e ke

y po

licie

s co

ncer

ning

man

agem

ent

of p

atie

nts.

Dec

isio

ns a

bout

im

agin

g re

quir

emen

tsca

nnot

be

sepa

rate

d fr

om n

on-i

mag

ing

issu

es s

uch

as a

dmis

sion

.

84

K. Trauma

The

usu

al i

ndic

atio

ns f

or a

dmis

sion

inc

lude

: co

nfus

ion

or d

epre

ssed

con

scio

usne

ss;

frac

ture

on

SXR

; ne

urol

ogic

al s

ympt

oms

or s

igns

; se

izur

es;

CSF

or

bloo

d fr

om n

ose

or e

ar;

coag

ulat

ion

diso

rder

s; l

ack

of a

dult

supe

rvis

ion

at h

ome;

pat

ient

dif

ficu

lt to

asse

ss (

non-

acci

dent

al i

njur

y (N

AI)

, dru

gs, a

lcoh

ol, e

tc.)

. If

a de

cisi

on i

s m

ade

to a

dmit

for

obse

rvat

ion,

im

agin

g be

com

es l

ess

urge

nt, a

nd t

he p

atie

nt w

ill b

e be

tter

exam

ined

whe

n so

ber

and

mor

e co

oper

ativ

e. C

Tis

inc

reas

ingl

y be

ing

used

as

the

firs

tin

vest

igat

ion

in t

hose

whe

re t

here

is

a m

ediu

m r

isk

of i

ntra

cran

ial

inju

ry, i

n w

hich

cas

e SX

R i

s us

ually

unn

eces

sary

.D

iffi

culti

es w

ith i

mag

e in

terp

reta

tion

or t

he m

anag

emen

t of

the

pat

ient

may

be

reso

lved

by

refe

rral

s vi

a im

age

tran

sfer

syst

ems

to d

esig

nate

d ne

uros

cien

ce c

entr

es.

Intr

acra

nial

abn

orm

alit

ies

sugg

esti

ng n

eed

for

urge

nt n

euro

surg

ical

man

agem

ent

incl

ude:

Hig

h or

mix

ed a

ttenu

atio

n in

trac

rani

al l

esio

nSh

ift

of m

id-l

ine

stru

ctur

es (

e.g.

thi

rd v

entr

icle

)O

blite

ratio

n of

thi

rd v

entr

icle

Rel

ativ

e di

lata

tion

of a

lat

eral

ven

tric

le(s

)O

blite

ratio

n of

bas

al c

iste

rns

Intr

acra

nial

air

Sub-

arac

hnoi

d or

int

rave

ntri

cula

r ha

emor

rhag

e.

Chi

ldre

nH

ead

inju

ries

are

rel

ativ

ely

com

mon

in

child

ren;

in

the

maj

ority

of

case

s, t

here

is

no s

erio

us i

njur

y: i

mag

ing

and

hosp

italis

atio

n ar

e un

nece

ssar

y. I

f th

ere

is a

his

tory

of

loss

of

cons

ciou

snes

s, n

euro

logi

cal

sign

s or

sym

ptom

s (e

xclu

ding

asi

ngle

vom

it) o

r an

ina

dequ

ate

or i

ncon

sist

ent

hist

ory,

im

agin

g is

req

uire

d. C

Tis

the

sim

ples

t w

ay o

f ex

clud

ing

sign

ific

ant

brai

n in

jury

. If

non-

acci

dent

al i

njur

y is

sus

pect

ed, a

sku

ll SX

R a

s pa

rt o

f a

skel

etal

sur

vey

is r

equi

red.

In

addi

tion,

MR

I of

the

brai

n m

ay b

e re

quir

ed l

ater

to

furt

her

docu

men

t tim

ing

of t

he i

njur

y.

85

K. Trauma

Hea

d:

low

ris

k o

f in

trac

ran

ial

inju

ry•

Fully

ori

enta

ted

SXR

(I)

Not

ind

icat

edT

hese

pat

ient

s ar

e us

ually

sen

t ho

me

with

hea

d in

jury

•N

oam

nesi

aro

utin

ely

(C)

inst

ruct

ions

to

the

care

of

a re

spon

sibl

e ad

ult.

The

y•

No

neur

olog

ical

def

ects

CT

(II)

Not

ind

icat

edm

ay b

e ad

mitt

ed t

o ho

spita

l if

no

such

adu

lt is

•N

ose

riou

s sc

alp

rout

inel

y (C

)av

aila

ble.

lace

ratio

n•

No

haem

atom

aK

1

Hea

d:

med

ium

-ris

k o

f in

trac

ran

ial

inju

ry•

Los

s of

con

scio

usne

ssC

T(I

I) o

rIn

dica

ted

(B)

CT

is i

ncre

asin

gly

bein

g us

ed a

s th

e fi

rst

and

ON

LYor

am

nesi

aSX

R (

I)in

vest

igat

ion

in t

his

grou

p of

pat

ient

s, t

o co

nfid

ently

•V

iole

nt m

echa

nism

sex

clud

e cr

ania

l in

jury

. If

no f

ract

ure

is s

een,

pat

ient

sof

inj

ury

will

usu

ally

be

sent

hom

e w

ith h

ead

inju

ry i

nstr

uctio

ns•

Scal

p br

uise

, sw

ellin

gto

the

car

e of

a r

espo

nsib

le a

dult.

If

no r

espo

nsib

leor

lac

erat

ion

dow

n to

adul

t is

ava

ilabl

e or

if

a fr

actu

re i

s pr

esen

t, th

e pa

tient

bone

or

> 5

cm

will

usu

ally

be

adm

itted

. See

Sec

tion

M (

M13

) fo

r•

Neu

rolo

gica

l sy

mpt

oms

non-

acci

dent

al i

njur

y in

chi

ldre

n. M

RI

of t

he b

rain

or s

igns

(in

clud

ing

is t

he p

refe

rred

inv

estig

atio

n fo

r in

trac

rani

al i

njur

ies

head

ache

, vom

iting

tw

ice

in N

AI,

but

SX

R m

ay s

till

be n

eede

d to

exc

lude

or m

ore,

ret

urn

visi

t)fr

actu

res

mis

sed

on C

T.

86

K. TraumaC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

•In

adeq

uate

his

tory

or

exam

inat

ion

(epi

leps

y/a

lcoh

ol/c

hild

/etc

.)

•C

hild

bel

ow 5

yrs

:su

spec

ted

NA

I, t

ense

font

anel

le, f

all

mor

e th

an60

cm

or

on t

o ha

rdsu

rfac

eK

2

Hea

d:

hig

h r

isk

of

intr

acra

nia

l in

jury

•Su

spec

ted

FB o

rC

T(I

I)In

dica

ted

(B)

The

se p

atie

nts

will

usu

ally

hav

e be

en a

dmitt

ed f

orpe

netr

atin

g in

jury

to

skul

lob

serv

atio

n. I

f th

ere

is a

ny d

elay

in

getti

ng C

Ton

an

•D

isor

ient

ated

or

urge

nt b

asis

, see

k ne

uros

urgi

cal

opin

ion.

depr

esse

d co

nsci

ousn

ess

NB

:C

Tsh

ould

be

avai

labl

e w

ithi

n fo

urho

urs

of•

Foca

l ne

urol

ogic

alad

mis

sion

in

all

pati

ents

wit

h a

skul

l fr

actu

re.

sym

ptom

s or

sig

nsSX

R is

not

req

uire

d be

fore

CT.

In

rhin

orrh

oea/

otor

rhoe

a•

Seiz

ure

NM

can

ide

ntif

y si

te o

f le

akag

e in

chr

onic

pha

se.

•Sk

ull

frac

ture

or

sutu

ral

dias

tasi

s sh

own

on S

XR

•C

SF f

rom

nos

e or

CSF

/bl

ood

from

ear

•U

nsta

ble

syst

emic

sta

tepr

eclu

ding

tra

nsfe

r to

neur

olog

ical

uni

t•

Dia

gnos

is u

ncer

tain

K3

87

K. Trauma

Hea

d:

very

hig

h r

isk

of

intr

acra

nia

l in

jury

•D

eter

iora

ting

CT

(II)

Indi

cate

d (B

)U

RG

EN

TN

EU

RO

SUR

GIC

AL

AN

D A

NA

EST

HE

TIC

cons

ciou

snes

s or

RE

FER

RA

LIN

DIC

AT

ED

, whi

ch s

houl

d no

t be

neur

olog

ical

sig

nsde

laye

d by

im

agin

g.(e

.g. p

upil

chan

ges)

•C

onfu

sion

or

com

aN

B:

CT

shou

ld b

e pe

rfor

med

as

an e

mer

genc

y (s

eepe

rsis

tent

des

pite

K3

abov

e).

resu

scita

tion

•Te

nse

font

anel

le o

rsu

tura

l di

asta

sis

•O

pen

or p

enet

ratin

g in

jury

•D

epre

ssed

or

com

poun

dfr

actu

re•

Frac

ture

of

skul

l ba

se K4

Nas

al t

raum

aSX

R (

I)N

ot i

ndic

ated

Unl

ess

requ

este

d by

a s

peci

alis

t. Po

or c

orre

latio

nX

R f

acia

l bo

nes

rout

inel

y (B

)be

twee

n ra

diol

ogic

al f

indi

ngs

and

pres

ence

of

(I),

XR

nas

alex

tern

al d

efor

mity

. Man

agem

ent

of t

he b

ruis

ed n

ose

bone

s (I

)w

ill d

epen

d on

loc

alpo

licy:

usu

ally

fol

low

-up

at a

nE

NT

or m

axill

o-fa

cial

clin

ic w

ill d

eter

min

e th

e ne

edK

5fo

r X

R.

88

K. TraumaC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Orb

ital

trau

ma:

XR

fac

ial

bone

sIn

dica

ted

(B)

Esp

ecia

lly i

n th

ose

whe

re ‘

blow

-out

’in

jury

pos

sibl

ebl

unt

inju

ry(I

)M

RI

or l

ow d

ose

CT

may

eve

ntua

lly b

e re

quir

ed b

ysp

ecia

lists

, esp

ecia

lly w

hen

XR

s or

clin

ical

sig

nsK

6eq

uivo

cal.

Orb

ital

trau

ma:

XR

orb

its

(I)

Indi

cate

d (C

)W

hen:

(1)

Rad

io-o

paqu

e in

tra-

ocul

ar F

B i

s a

pene

trat

ing

inju

rypo

ssib

ility

(se

e A

16).

(2)

Inv

estig

atio

n re

ques

ted

byop

htha

lmol

ogis

t. (3

) Su

spic

ion

of d

amag

e to

orb

ital

wal

ls.

US

(0)

orSp

ecia

lised

US

or l

ow-d

ose

CT

may

be

requ

ired

; M

RI

K7

CT

(II)

inve

stig

atio

n (B

)co

ntra

indi

cate

d w

ith m

etal

lic F

B (

see

A16

).

Mid

dle

thir

d fa

cial

inj

ury

XR

fac

ial

bone

sIn

dica

ted

(B)

But

pat

ient

coo

pera

tion

esse

ntia

l. A

dvis

able

to

dela

y(I

)X

R i

n un

coop

erat

ive

patie

nts.

In

child

ren,

XR

oft

enun

help

ful.

Low

-dos

e C

TSp

ecia

lised

Dis

cuss

with

max

illof

acia

l su

rgeo

n w

ho m

ay r

equi

reK

8(I

I)in

vest

igat

ion

(B)

low

-dos

e C

Tat

an

earl

y st

age.

Man

dibu

lar

trau

ma

XR

Man

dibl

e (I

)In

dica

ted

(C)

For

non-

trau

mat

ic T

MJ

prob

lem

s se

e B

11.

or o

rtho

pant

omo-

K9

gram

(O

PG

) (I

)

89

K. Trauma

Cer

vica

l sp

ine

Con

scio

us p

atie

nt w

ithX

R C

spi

ne (

I)N

ot i

ndic

ated

In t

hose

who

mee

t al

l of

the

fol

low

ing

crite

ria:

head

and

/or

face

inj

ury

rout

inel

y (B

)(1

) Fu

lly c

onsc

ious

.on

ly(2

) N

ot i

ntox

icat

ed.

(3)

No

abno

rmal

neu

rolo

gica

l fi

ndin

gs.

K10

(4)

No

neck

pai

n or

ten

dern

ess.

Unc

onsc

ious

hea

d in

jury

XR

C s

pine

(I)

Indi

cate

d (B

)M

ust

be o

f go

od q

ualit

y to

allo

w a

ccur

ate

eval

uatio

n.(s

ee K

3/4)

But

rad

iogr

aphy

may

be

very

dif

ficu

lt in

the

sev

erel

ytr

aum

atis

ed p

atie

nt a

nd m

ust

avoi

d m

anip

ulat

ion

(see

K11

also

K12

).

Nec

k in

jury

: w

ith p

ain

XR

C s

pine

(I)

Indi

cate

d (B

)C

ervi

cal

spin

e X

Rs

can

be v

ery

diff

icul

t to

eva

luat

e.R

adio

grap

hy a

lso

diff

icul

t an

d:1.

Mus

t sh

ow C

7/T

1.2.

Sho

uld

show

odo

ntoi

d pe

g (n

ot a

lway

s po

ssib

le a

ttim

e of

ini

tial

stud

y).

3. M

ay n

eed

spec

ial

view

s, C

Tor

MR

I es

peci

ally

whe

n X

R e

quiv

ocal

or

com

plex

les

ions

.

CT

(II)

or

MR

ISp

ecia

lised

Dis

cuss

with

dep

artm

ent

of c

linic

al r

adio

logy

.K

12(0

)in

vest

igat

ion

(B)

90

K. TraumaC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Nec

k in

jury

: w

ithX

R (

I)In

dica

ted

(B)

For

orth

opae

dic

asse

ssm

ent.

neur

olog

ical

def

icit

MR

I (0

)In

dica

ted

(B)

Som

e co

nstr

aint

s w

ith l

ife

supp

ort

syst

ems.

MR

I be

stan

d sa

fest

met

hod

of d

emon

stra

ting

intr

insi

c co

rdda

mag

e, c

ord

com

pres

sion

, lig

amen

tous

inj

urie

s an

dve

rteb

ral

frac

ture

s at

mul

tiple

lev

els.

CT

mye

logr

aphy

K13

may

be

cons

ider

ed i

f M

RI

not

avai

labl

e.

Nec

k in

jury

: w

ith p

ain

XR

C s

pine

;Sp

ecia

lised

Vie

ws

take

n in

fle

xion

and

ext

ensi

on (

cons

ider

but

XR

ini

tially

nor

mal

;fl

exio

n an

din

vest

igat

ion

(B)

fluo

rosc

opy)

as

achi

eved

by

the

patie

nt w

ith n

osu

spec

ted

ligam

ento

usex

tens

ion

(I)

assi

stan

ce a

nd u

nder

med

ical

sup

ervi

sion

. MR

I m

ayin

jury

K14

be h

elpf

ul h

ere.

Th

ora

cic

and

lu

mb

ar s

pin

eT

raum

a: n

o pa

in, n

oX

R (

II)

Not

ind

icat

edPh

ysic

al e

xam

inat

ion

is r

elia

ble

in t

his

regi

on. W

hen

neur

olog

ical

def

icit

rout

inel

y (B

)th

e pa

tient

is

awak

e, a

lert

and

asy

mpt

omat

ic, t

heK

15pr

obab

ility

of

inju

ry i

s lo

w.

Tra

uma:

with

pai

n, n

oX

R p

ainf

ulIn

dica

ted

(B)

Alo

w t

hres

hold

to

XR

whe

n th

ere

is p

ain/

tend

erne

ss,

neur

olog

ical

def

icit

orar

ea (

II)

a si

gnif

ican

t fa

ll, a

hig

h im

pact

RTA

, oth

er s

pina

lpa

tient

not

abl

e to

be

frac

ture

pre

sent

or

it is

not

pos

sibl

e to

clin

ical

lyev

alua

ted

eval

uate

the

pat

ient

. Inc

reas

ing

use

of C

Tan

d M

RI

K16

here

.

91

K. Trauma

Tra

uma:

with

neu

rolo

gica

lX

R (

II)

Indi

cate

d (B

)de

fici

t —

pai

nM

RI

(0)

Indi

cate

d (B

)W

here

tec

hnic

ally

pos

sibl

e. C

Tof

ten

used

as

patie

ntun

derg

oing

CT

for

othe

r re

ason

s. B

ut M

RI

best

met

hod

of d

emon

stra

ting

intr

insi

c co

rd d

amag

e, c

ord

K17

com

pres

sion

and

ver

tebr

al f

ract

ures

at

mul

tiple

lev

els.

Pel

vis

and

sac

rum

Fall

with

ina

bilit

y to

XR

pel

vis

(I)

Indi

cate

d (C

)Ph

ysic

al e

xam

inat

ion

may

be

unre

liabl

e. C

heck

for

bear

wei

ght

plus

lat

eral

XR

fem

oral

nec

k fr

actu

res,

whi

ch m

ay n

ot s

how

on

initi

alhi

p (I

)X

R, e

ven

with

goo

d la

tera

l vi

ews.

In

sele

cted

cas

esN

M o

r M

RI

or C

Tca

n be

use

ful

whe

n X

R n

orm

al o

rK

18eq

uivo

cal.

Ure

thra

l bl

eedi

ng a

ndR

etro

grad

eIn

dica

ted

(C)

To s

how

ure

thra

l in

tegr

ity, l

eak,

rup

ture

. Con

side

rpe

lvic

inj

ury

uret

hrog

ram

(II

)cy

stog

ram

if

uret

hra

norm

al a

nd s

uspi

cion

of

blad

der

K19

leak

.

Tra

uma

to c

occy

x or

XR

coc

cyx

(I)

Not

ind

icat

edN

orm

al a

ppea

ranc

es o

ften

mis

lead

ing

and

find

ings

do

cocc

ydyn

iaK

20ro

utin

ely

(C)

not

alte

r m

anag

emen

t.

92

K. TraumaC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Up

per

lim

bSh

ould

er i

njur

yX

R s

houl

der

(I)

Indi

cate

d (B

)So

me

disl

ocat

ions

pre

sent

sub

tle f

indi

ngs.

As

am

inim

um, o

rtho

gona

l vi

ews

are

requ

ired

. US,

MR

Ian

d C

Tar

thro

grap

hy a

ll ha

ve a

rol

e in

sof

t tis

sue

K21

inju

ry.

Elb

ow i

njur

yX

R e

lbow

(I)

Indi

cate

d (B

)To

sho

w a

n ef

fusi

on. R

outin

e fo

llow

-up

XR

s no

tin

dica

ted

in ‘

effu

sion

, no

obvi

ous

frac

ture

’(s

ee a

lso

K22

Sect

ion

M).

Inc

reas

ing

use

of C

Tan

d M

RI

here

.

Wri

st i

njur

yX

R w

rist

(I)

Indi

cate

d (B

)Sc

apho

id f

ract

ures

can

be

invi

sibl

e at

pre

sent

atio

n.N

M (

II)

orSp

ecia

lised

Mos

t ce

ntre

s re

peat

XR

at

10–1

4 da

ys i

f th

ere

are

MR

I (0

)in

vest

igat

ion

(B)

stro

ng c

linic

al s

igns

and

ini

tial

XR

neg

ativ

e. S

ome

depa

rtm

ents

use

CT,

NM

or

MR

I to

exc

lude

fra

ctur

eea

rlie

r th

an t

his.

Inc

reas

ing

use

of M

RI

as t

he o

nly

K23

exam

inat

ion.

Low

er l

imb

Kne

e in

jury

XR

kne

e (I

)N

ot i

ndic

ated

Esp

ecia

lly w

here

phy

sica

l si

gns

of i

njur

y ar

e m

inim

al.

(fal

l/blu

nt t

raum

a)ro

utin

ely

(B)

Inab

ility

to

bear

wei

ght

or p

rono

unce

d bo

nyte

nder

ness

, par

ticul

arly

at

pate

lla a

nd h

ead

of f

ibul

a,m

erit

radi

ogra

phy.

CT

/MR

I m

ay b

e ne

eded

whe

reK

24fu

rthe

r in

form

atio

n is

req

uire

d (s

ee D

23).

93

K. Trauma

Ank

le i

njur

yX

R a

nkle

(I)

Not

ind

icat

edFe

atur

es w

hich

jus

tify

XR

inc

lude

: th

e el

derl

y pa

tient

,ro

utin

ely

(B)

mal

leol

ar t

ende

rnes

s, m

arke

d so

ft t

issu

e sw

ellin

g an

dK

25in

abili

ty t

o be

ar w

eigh

t.

Foot

inj

ury

XR

foo

t (I

)N

ot i

ndic

ated

Unl

ess

ther

e is

tru

e bo

ny t

ende

rnes

s. E

ven

then

the

rout

inel

y (B

)de

mon

stra

tion

of a

fra

ctur

e ra

rely

inf

luen

ces

man

agem

ent.

Onl

y ra

rely

are

XR

s of

foo

t an

d an

kle

indi

cate

d to

geth

er;

both

will

not

be

done

with

out

good

reas

on. C

linic

al a

bnor

mal

ities

are

usu

ally

con

fine

d to

K26

foot

or

ankl

e.

Stre

ss f

ract

ure

XR

(I)

Indi

cate

d (B

)A

lthou

gh o

ften

unr

ewar

ding

.

NM

(II

) or

Indi

cate

d (B

)Pr

ovid

es a

mea

ns o

f ea

rly

dete

ctio

n as

wel

l as

vis

ual

MR

I (0

)ac

coun

t of

the

bio

mec

hani

cal

prop

ertie

s of

the

bon

e.K

27So

me

cent

res

use

US

here

.

Th

e Fo

reig

n B

od

y (F

B)

Soft

tis

sue

inju

ry:

XR

(I)

Indi

cate

d (B

)A

ll gl

ass

is r

adio

-opa

que;

som

e pa

int

is r

adio

-opa

que.

FB (

met

al, g

lass

, pai

nted

Rad

iogr

aphy

and

int

erpr

etat

ion

may

be

diff

icul

t;w

ood)

rem

ove

bloo

d-st

aine

d dr

essi

ngs

firs

t. C

onsi

der

US,

K28

espe

cial

ly i

n ar

eas

whe

re r

adio

grap

hy d

iffi

cult.

94

K. TraumaC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Soft

tis

sue

inju

ry:

XR

(I)

Not

ind

icat

edFB

(pl

astic

, woo

d)ro

utin

ely

(B)

Plas

tic is

not

rad

io-o

paqu

e: w

ood

is r

arel

y ra

dio-

opaq

ue.

K29

US

(0)

Indi

cate

d (B

)So

ft-t

issu

e U

S m

ay s

how

non

-opa

que

FB.

Swal

low

ed F

B s

uspe

cted

XR

sof

tIn

dica

ted

(C)

Aft

er d

irec

t ex

amin

atio

n of

oro

phar

ynx

(whe

re m

ost

in p

hary

ngea

l or

upp

erti

ssue

s of

FBs

lodg

e), a

nd i

f FB

lik

ely

to b

e op

aque

.oe

soph

agea

l re

gion

neck

(I)

Dif

fere

ntia

tion

from

cal

cifi

ed c

artil

age

can

be d

iffi

cult.

Mos

t fi

sh b

ones

inv

isib

le o

n X

R. M

aint

ain

a lo

wA

XR

(II

)N

ot i

ndic

ated

thre

shol

d fo

r la

ryng

osco

py o

r en

dosc

opy,

esp

ecia

lly i

f(f

or c

hild

ren

see

rout

inel

y (B

)pa

in p

ersi

sts

afte

r 24

hou

rs (

see

K33

). N

B:

for

Sect

ion

M)

K30

poss

ible

inh

aled

FB

in

child

ren

see

Sect

ion

M (

M23

).

Swal

low

ed F

B:

smoo

than

d sm

all

(e.g

. coi

n)C

XR

(I)

Indi

cate

d (B

)T

he m

inor

ity o

f sw

allo

wed

FB

s w

ill b

e ra

dio-

opaq

ue.

In c

hild

ren

a si

ngle

, slig

htly

ove

r-ex

pose

d, f

ront

alC

XR

to

incl

ude

neck

sho

uld

suff

ice.

In

adul

ts, a

late

ral

CX

R m

ay b

e ne

eded

in

addi

tion

if f

ront

al C

XR

nega

tive.

Maj

ority

of

FBs

that

im

pact

, do

so a

t cr

ico

phar

ynge

us. I

f th

e FB

has

not

pas

sed

(say

with

in 6

days

), A

XR

may

be

usef

ul f

or l

ocal

isat

ion.

AX

R (

II)

Not

ind

icat

edK

31ro

utin

ely

(B)

95

K. Trauma

Shar

p or

pot

entia

llyA

XR

(II

)In

dica

ted

(B)

Mos

t sw

allo

wed

for

eign

bod

ies

that

pas

s th

epo

ison

ous

swal

low

ed F

B:

oeso

phag

us e

vent

ually

pas

s th

roug

h th

e re

mai

nder

of

(e.g

. bat

tery

)th

e ga

stro

inte

stin

al t

ract

with

out

com

plic

atio

n. B

utlo

catio

n of

bat

teri

es i

s im

port

ant

as l

eaka

ge c

an b

eda

nger

ous.

CX

R (

I)N

ot i

ndic

ated

Unl

ess

AX

R n

egat

ive.

K32

rout

inel

y (B

)

Swal

low

ed F

B:

larg

eC

XR

(I)

Indi

cate

d (B

)D

entu

res

vary

in

radi

o-op

acity

; m

ost

plas

tic d

entu

res

obje

ct (

e.g.

den

ture

s)ar

e ra

diol

ucen

t. A

XR

may

be

need

ed i

f C

XR

neg

ativ

e,as

may

bar

ium

sw

allo

w o

r en

dosc

opy.

Lat

CX

R m

ayK

33be

hel

pful

.

Ch

est

Che

st t

raum

a: m

inor

CX

R (

I)N

ot i

ndic

ated

The

dem

onst

ratio

n of

a r

ib f

ract

ure

does

not

alte

rK

34ro

utin

ely

(B)

man

agem

ent.

Che

st t

raum

a: m

oder

ate

CX

R (

I)In

dica

ted

(B)

Fron

tal

CX

R f

or p

neum

otho

rax,

flu

id o

r lu

ngco

ntus

ion.

Ano

rmal

CX

R d

oes

not

excl

ude

aort

icin

jury

and

art

erio

grap

hy/C

T/M

RI

shou

ld b

eK

35co

nsid

ered

.

96

K. TraumaC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Stab

inj

ury

CX

R (

I)In

dica

ted

(C)

PAan

d/or

oth

er v

iew

s to

sho

w p

neum

otho

rax,

lun

gda

mag

e or

flu

id. U

S us

eful

for

ple

ural

and

per

icar

dial

K36

flui

d.

Ster

nal

frac

ture

XR

lat

eral

In

dica

ted

(C)

In a

dditi

on t

o C

XR

. Thi

nk o

f th

orac

ic s

pina

l an

dK

37st

ernu

m (

I)ao

rtic

inj

urie

s to

o.

Abd

omen

(in

clud

ing

Supi

ne A

XR

(II

)In

dica

ted

(B)

US

valu

able

for

det

ectin

g ha

emat

oma

and

poss

ible

kidn

ey).

Blu

nt o

r st

ab+

erec

t C

XR

(I)

inju

ry t

o so

me

orga

ns, e

.g. s

plee

n, l

iver

. CT

may

be

inju

ryK

38ne

eded

(se

e K

40–K

42).

Ren

al t

raum

aIm

agin

gIn

dica

ted

(B)

Dis

cuss

with

rad

iolo

gist

. In

agre

emen

t w

ith l

ocal

polic

y an

d av

aila

bilit

y. U

S of

ten

suff

icie

nt f

or m

inor

loca

l in

jury

. Man

y ce

ntre

s us

e a

limite

d IV

U, m

erel

yto

ens

ure

norm

ality

of

cont

rala

tera

l ki

dney

. Som

epa

tient

s w

ith m

ajor

inj

ury

(see

bel

ow)

unde

rgo

CT,

mak

ing

IVU

unn

eces

sary

. Con

side

r re

nal

arte

ryda

mag

e, e

spec

ially

in

dece

lera

tion

inju

ries

;ar

teri

ogra

phy

may

be

need

ed. N

M m

ay b

e he

lpfu

l to

K39

asse

ss r

esid

ual

func

tion.

97

K. Trauma

Maj

or

trau

ma

Maj

or t

raum

a —

gen

eral

C-s

pine

XR

(I)

,In

dica

ted

(B)

Stab

ilise

pat

ient

’s c

ondi

tion

as a

pri

ority

. Per

form

onl

ysc

reen

in

the

unco

nsci

ous

CX

R (

I),

the

min

imum

XR

s ne

cess

ary

at i

nitia

l as

sess

men

t.or

con

fuse

d pa

tient

pelv

is X

R (

I),

C-s

pine

XR

can

wai

t so

lon

g as

spi

ne a

nd c

ord

CT

head

(II

)su

itabl

y pr

otec

ted,

but

CT

C-s

pine

may

be

com

bine

dw

ith C

The

ad. P

elvi

c fr

actu

res

ofte

n as

soci

ated

with

K40

maj

or b

lood

los

s. S

ee H

ead

Inju

ry K

1–K

4.

Maj

or t

raum

a —

CX

R (

I),

Indi

cate

d (B

)Pn

eum

otho

rax

mus

t be

exc

lude

d. P

elvi

c fr

actu

res

abdo

men

/pel

vis

Pel

vis

XR

(I)

whi

ch i

ncre

ase

pelv

ic v

olum

e of

ten

asso

ciat

ed w

ithm

ajor

blo

od l

oss.

CT

abdo

(II

I)In

dica

ted

(B)

Sens

itive

and

spe

cifi

c, b

ut t

ime-

cons

umin

g an

d m

ayde

lay

surg

ery.

CT

shou

ld p

rece

de p

erito

neal

lav

age.

Incr

easi

ng i

nter

est

in t

he u

se o

f U

S in

em

erge

ncy

K41

room

to

show

fre

e fl

uid

plus

sol

id o

rgan

-inj

ury.

Maj

or t

raum

a –

ches

tC

XR

(I)

Indi

cate

d (B

)A

llow

s im

med

iate

man

agem

ent

(e.g

. pne

umot

hora

x).

CT

Che

st (

III)

Indi

cate

d (B

)E

spec

ially

use

ful

to e

xclu

de m

edia

stin

al h

aem

orrh

age.

K42

Low

thr

esho

ld f

or p

roce

edin

g to

art

erio

grap

hy.

98

K. TraumaC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

L. C

ance

r

Par

oti

dD

iagn

osis

US

(0)

Indi

cate

d (B

)To

est

ablis

h pr

esen

ce o

f a

mas

s, p

artic

ular

ly i

nsu

perf

icia

l le

sion

s.

MR

I (0

) or

Indi

cate

d (B

)U

sefu

l in

the

dee

p po

rtio

n of

the

gla

nd a

nd b

efor

eL

1C

T(I

I)co

mpl

ex s

urge

ry.

Stag

ing

MR

I (0

) or

Indi

cate

d (B

)E

spec

ially

whe

n co

mpl

ex s

urge

ry c

onte

mpl

ated

; to

see

L2

CT

(II)

rela

tions

and

inv

olve

men

t of

dee

p lo

be.

Lary

nx

Dia

gnos

isIm

agin

gN

ot i

ndic

ated

Thi

s is

a c

linic

al d

iagn

osis

.L

3ro

utin

ely

(B)

Stag

ing

CT

(II)

or

Indi

cate

d (B

)M

RI

has

the

adva

ntag

e of

dir

ect

coro

nal

imag

ing.

L4

MR

I (0

)M

RI

will

eve

ntua

lly s

uper

sede

.

99

L. Cancer

Man

y of

the

clin

ical

pro

blem

s re

late

d to

the

diag

nosi

s of

can

cer

have

alr

eady

par

tly b

een

cove

red

with

in th

e in

divi

dual

sys

tem

sec

tions

. Bri

efno

tes

are

prov

ided

her

e ab

out

the

use

of i

mag

ing

in t

he d

iagn

osis

, st

agin

g an

d fo

llow

-up

of s

ome

of t

he c

omm

on p

rim

ary

mal

igna

ncie

s.Pa

edia

tric

mal

igna

ncie

s ar

e no

t in

clud

ed a

s th

eir

man

agem

ent

is a

lway

s at

spe

cial

ist

leve

l. Fo

r br

east

can

cer

see

Sect

ion

J. A

CX

R i

sne

cess

ary

at p

rese

ntat

ion

for

mos

t m

alig

nant

les

ions

to

iden

tify

pos

sibl

e pu

lmon

ary

Met

asta

ses.

Con

cern

abo

ut r

adia

tion

in

diag

nost

ic i

mag

ing

is g

ener

ally

les

s re

leva

nt i

n th

is s

ecti

on.

CX

R i

s al

so p

art

of m

any

follo

w-u

p pr

otoc

ols

(e.g

. te

stic

ular

lesi

ons)

.F

ollo

w-u

p in

vest

igat

ions

to

mon

itor

prog

ress

(e.

g. p

ost-

chem

othe

rapy

) ar

e of

ten

requ

ired

; so

me

are

driv

en b

y tr

ial

prot

ocol

s ra

ther

than

clin

ical

nee

d an

d th

us s

houl

d be

app

ropr

iate

ly f

unde

d.

Th

yro

idD

iagn

osis

US

(0)

and

Indi

cate

d (A

)Se

e N

eck

Sect

ion

B1.

US

guid

ed c

ore

biop

sy i

sN

M (

I)in

crea

sing

ly b

eing

use

d, e

spec

ially

for

‘co

ld’

nodu

les

L5

on N

M.

Stag

ing

CT

(II)

or

Indi

cate

d (B

)To

ass

ess

loca

l ex

tent

(e.

g. r

etro

ster

nal

exte

nsio

n an

dM

RI

(0)

node

s).

NM

(IV

)In

dica

ted

(B)

Aft

er t

hyro

idec

tom

y. N

M i

s al

so u

sed

in f

ollo

w-u

pL

6w

hen

recu

rren

ce i

s su

spec

ted.

Lun

gD

iagn

osis

CX

R P

Aan

dIn

dica

ted

(B)

But

can

be

norm

al, p

artic

ular

ly w

ith c

entr

al t

umou

rs.

Lat

(I)

CT

(III

)In

dica

ted

(B)

Man

y ce

ntre

s pr

ocee

d di

rect

ly t

o br

onch

osco

py w

hich

allo

ws

biop

sy. C

Tis

sup

erio

r in

ide

ntif

ying

les

ions

L7

resp

onsi

ble

for

haem

opty

sis.

Stag

ing

CT

ches

t, up

per

Indi

cate

d (B

)D

espi

te l

imita

tions

in

spec

ific

ity o

f no

dal

abdo

men

(II

I)in

volv

emen

t, et

c. S

ome

cent

res

perf

orm

NM

for

poss

ible

ske

leta

l m

etas

tase

s.

100

L. CancerC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

MR

I (0

)Sp

ecia

lised

Ass

ists

in

estim

atin

g lo

cal

inva

sion

of

ches

t w

all,

inve

stig

atio

n (B

)pa

rtic

ular

ly f

or a

pica

l an

d pe

riph

eral

les

ions

and

med

iast

inal

inv

asio

n. H

elps

dis

tingu

ish

adre

nal

aden

oma

from

met

asta

sis.

NM

(IV

)Sp

ecia

lised

FDG

-PE

Tas

a s

ingl

e ex

pens

ive

inve

stig

atio

n ca

nin

vest

igat

ion

(B)

iden

tify

smal

l m

etas

tatic

foc

i; m

ay s

ave

a lo

t of

oth

erL

8in

vest

igat

ions

and

ina

ppro

pria

te s

urge

ry.

Oes

op

hag

us

Dia

gnos

isB

ariu

m s

wal

low

Indi

cate

d (B

)B

efor

e en

dosc

opy

in d

ysph

agia

.L

9(I

I)

Stag

ing

CT

(III

)In

dica

ted

(B)

Des

pite

lim

itatio

ns i

n se

nsiti

vity

and

spe

cifi

city

of

noda

l in

volv

emen

t. Si

mpl

er t

han

MR

I fo

r lu

ng, l

iver

and

intr

a-ab

dom

inal

nod

es.

Tran

soes

o-In

dica

ted

(A)

Incr

easi

ng u

se o

f tr

anso

esop

hage

al U

S fo

r lo

cal

L10

phag

eal

US

(0)

stag

ing

whe

re a

vaila

ble.

Live

r: p

rim

ary

lesi

on

Dia

gnos

isU

S (0

)In

dica

ted

(B)

The

maj

ority

of

lesi

ons

will

be

iden

tifie

d.

MR

I (0

) or

In

dica

ted

(B)

If b

ioch

emic

al m

arke

rs e

leva

ted

and

US

nega

tive

orC

T(I

II)

liver

ver

y ci

rrho

tic. E

nhan

ced

MR

I an

d ar

teri

al p

hase

L11

CT

mos

t ac

cura

te i

n de

linea

ting

tum

our

exte

nt.

101

L. Cancer

Stag

ing

MR

I (0

) or

Indi

cate

d (B

)M

RI

prob

ably

the

opt

imal

inv

estig

atio

n in

ass

essi

ngC

T(I

II)

invo

lved

seg

men

ts a

nd l

obes

. Int

ra-o

pera

tive

US

L12

usef

ul w

here

ava

ilabl

e.

Live

r: s

eco

nd

ary

lesi

on

Dia

gnos

isU

S (0

)In

dica

ted

(B)

US

will

sho

w t

he m

ajor

ity o

f m

etas

tase

s an

d gu

ides

biop

sy.

CT

(III

) or

Indi

cate

d (B

)W

hen

US

nega

tive

and

clin

ical

sus

pici

on h

igh.

MR

IM

RI

(0)

bette

r fo

r ch

arac

teri

sing

les

ions

. CT

arte

rial

port

ogra

phy

is s

ensi

tive

but

not

spec

ific

, but

man

yno

w u

se t

ripl

e ph

ase

spir

al C

Tte

chni

ques

fol

low

ing

intr

aven

ous

enha

ncem

ent.

CT

and

MR

I of

ten

part

of

othe

r st

agin

g an

d fo

llow

-up

prot

ocol

s. I

ncre

asin

gL

13in

tere

st i

n PE

Tfo

r ve

ry s

mal

l m

etas

tatic

foc

i.

102

L. CancerC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Pan

crea

sD

iagn

osis

Imag

ing

Indi

cate

d (B

)M

uch

depe

nds

on l

ocal

exp

ertis

e an

d bo

dy h

abitu

s.U

S us

ually

suc

cess

ful

in t

hin

patie

nts;

CT

bette

r in

the

mor

e ob

ese.

MR

I fo

r cl

arif

icat

ion

of p

robl

ems.

Bio

psy

usin

g U

S or

CT.

ER

CP

or M

RC

Pm

ay a

lso

be n

eede

d.E

ndos

copi

c U

S, w

here

ava

ilabl

e, m

ost

sens

itive

.L

14In

crea

sing

int

eres

t in

PE

T.

Stag

ing

CT

(III

) or

Indi

cate

d (B

)E

spec

ially

if

radi

cal

surg

ery

cont

empl

ated

. Wid

e lo

cal

MR

I (0

)va

riat

ion:

som

e ce

ntre

s us

e an

giog

raph

y, o

ther

s sp

iral

L15

abdo

men

CT;

lap

aros

copi

c U

S al

so u

sed.

Co

lon

an

d r

ectu

mD

iagn

osis

Ba

enem

a (I

II)

Indi

cate

d (B

)M

uch

depe

nds

on l

ocal

pol

icy,

exp

ertis

e an

dor

col

onos

copy

avai

labi

lity.

See

Sec

tion

G. I

ncre

asin

g in

tere

st i

n C

Tan

d M

RI

of t

he c

olon

, esp

ecia

lly w

ith v

irtu

alL

16en

dosc

opic

tec

hniq

ues.

Stag

ing

US

(0)

Indi

cate

d (B

)Fo

r liv

er m

etas

tase

s. E

ndol

umin

al U

S us

eful

for

loc

alre

ctal

spr

ead.

CT

(II)

or

Indi

cate

d (B

)L

ocal

pre

-ope

rativ

e st

agin

g to

ass

ess

rect

al l

esio

nsM

RI

(0)

befo

re p

re-o

pera

tive

radi

othe

rapy

. Man

y ce

ntre

s no

wab

dom

en, p

elvi

str

eat

liver

sec

onda

ries

ver

y ag

gres

sive

ly, w

hich

may

nece

ssita

te M

RI

and/

or d

etai

led

CT.

MR

I an

d C

Tof

ten

com

plem

enta

ry;

both

can

ass

ess

othe

r ab

dom

inal

L17

spre

ad. I

ncre

asin

g in

tere

st i

n PE

The

re.

103

L. Cancer

Rec

urre

nce

US

(0)

live

rIn

dica

ted

(B)

For

liver

met

asta

ses.

Som

e de

bate

abo

ut t

he v

alue

of

rout

ine

US

follo

w-u

p in

asy

mpt

omat

ic p

atie

nts.

CT

(III

) or

Indi

cate

d (B

)Fo

r liv

er m

etas

tase

s an

d lo

cal

recu

rren

ce.

MR

I (0

)ab

dom

en, p

elvi

s

NM

(IV

)Sp

ecia

lised

PET

and

mon

oclo

nal

antib

odie

s ca

n id

entif

y liv

erL

18in

vest

igat

ion

(B)

met

asta

ses

and

loca

l re

curr

ence

.

Kid

ney

Dia

gnos

isL

19U

S (0

)In

dica

ted

(B)

See

Ren

al M

ass

H7.

Stag

ing

CT

(III

) or

MR

IIn

dica

ted

(B)

For

loca

l ex

tent

, ven

ous,

nod

al a

nd u

rete

ric

(0)

abdo

men

invo

lvem

ent,

oppo

site

kid

ney

etc.

CT

(III

) C

hest

Not

ind

icat

edT

he p

rese

nce

of l

ung

met

asta

ses

does

not

usu

ally

rout

inel

y (B

)in

flue

nce

man

agem

ent.

NM

(I)

Spec

ialis

edC

onve

ntio

nal

NM

can

ass

ess

cont

rala

tera

l fu

nctio

n.L

20in

vest

igat

ion

(C)

Incr

easi

ng i

nter

est

in P

ET.

104

L. CancerC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Rec

urre

nce

CT

(III

)In

dica

ted

(B)

For

sym

ptom

s su

gges

ting

rela

pse

arou

nd n

ephr

ecto

my

L21

abdo

men

bed.

Rou

tine

follo

w-u

p no

t re

com

men

ded.

Bla

dd

erD

iagn

osis

Imag

ing

Not

ind

icat

edC

ysto

scop

y is

the

opt

imal

(al

thou

gh n

ot i

nfal

lible

, e.g

.L

22ro

utin

ely

(B)

dive

rtic

ulum

) in

vest

igat

ion.

Stag

ing

IVU

(II

)In

dica

ted

(B)

To a

sses

s ki

dney

s an

d ur

eter

s fo

r fu

rthe

r ur

othe

lial

tum

ours

.

CT

(III

) or

MR

IIn

dica

ted

(B)

Whe

n ra

dica

l th

erap

y co

ntem

plat

ed. M

RI

is p

roba

bly

(0)

abdo

men

mor

e se

nsiti

ve. C

Tw

idel

y us

ed f

or r

adio

ther

apy

L23

and

pelv

ispl

anni

ng.

Pro

stat

eD

iagn

osis

Tran

srec

tal

Indi

cate

d (B

)So

me

vari

atio

n ac

cord

ing

to l

ocal

ava

ilabi

lity

and

US

(0)

expe

rtis

e. T

rans

rect

al U

S is

wid

ely

used

tog

ethe

r w

ithL

24gu

ided

bio

psie

s. S

ome

inte

rest

in

MR

I an

d PE

The

re.

Stag

ing

MR

I (0

)/C

T(I

II)

Spec

ialis

edSo

me

vari

atio

n in

ran

ge o

f in

vest

igat

ive

and

pelv

is,

inve

stig

atio

n (B

)th

erap

eutic

pol

icie

s. S

tagi

ng c

ontin

ued

into

the

abdo

men

whe

n pe

lvic

dis

ease

fou

nd.

NM

(II

)In

dica

ted

(A)

To a

sses

s sk

elet

al m

etas

tase

s, w

hen

PSA

isL

25si

gnif

ican

tly e

leva

ted.

105

L. Cancer

Test

icle

Dia

gnos

isL

26U

S (0

)In

dica

ted

(B)

Esp

ecia

lly w

hen

clin

ical

fin

ding

s eq

uivo

cal

or n

orm

al.

Stag

ing

CT

(III

) ch

est,

Indi

cate

d (B

)M

anag

emen

t no

w d

epen

ds h

eavi

ly o

n ac

cura

teL

27ab

dom

en, p

elvi

sra

diol

ogic

al s

tagi

ng. I

ncre

asin

g in

tere

st i

n PE

T.

Follo

w-u

pC

T(I

II)

Indi

cate

d (B

)So

me

cent

res

still

rou

tinel

y ex

amin

e th

e ch

est

as w

ell,

abdo

men

espe

cial

ly f

or p

atie

nts

with

out

bioc

hem

ical

evi

denc

eof

dis

ease

. Som

e de

bate

as

to w

heth

er w

hole

pel

vis

isne

eded

at

follo

w-u

p un

less

the

re a

re i

dent

ifie

d ri

skfa

ctor

s.

NM

(IV

)Sp

ecia

lised

PET

can

asse

ss v

iabi

lity

of r

esid

ual

mas

ses.

L28

inve

stig

atio

n (C

)

Ova

ryD

iagn

osis

US

(0)

Indi

cate

d (B

)T

he m

ajor

ity o

f le

sion

s ar

e di

agno

sed

by U

S(i

nclu

ding

TV

with

Dop

pler

), l

apar

osco

py o

rla

paro

tom

y. S

ome

are

iden

tifie

d by

CT

/MR

Iin

vest

igat

ions

for

abd

omin

al s

ympt

oms.

MR

I us

eful

L29

for

eluc

idat

ing

prob

lem

s.

106

L. CancerC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Stag

ing

CT

(III

)/M

RI

(0)

Spec

ialis

edM

any

spec

ialis

ts r

equi

re C

Tor

MR

I in

add

ition

to

abdo

men

, pel

vis

inve

stig

atio

n (B

)st

agin

g by

lap

arot

omy.

CT

is s

till

mor

e w

idel

yL

30av

aila

ble.

Follo

w-u

pC

T(I

II)

Spec

ialis

edU

sual

ly t

o as

sess

res

pons

e to

adj

uvan

t th

erap

y. A

lso

L31

abdo

men

, pel

vis

inve

stig

atio

n (B

)us

ed, a

long

with

mar

kers

, to

dete

ct r

elap

se.

Ute

rus:

cer

vix

Dia

gnos

isIm

agin

gN

ot i

ndic

ated

Usu

ally

a c

linic

al d

iagn

osis

. MR

I m

ay a

ssis

t in

L32

rout

inel

y (B

)co

mpl

ex c

ases

.

Stag

ing

MR

I (0

) or

CT

Indi

cate

d (B

)M

RI

prov

ides

bet

ter

dem

onst

ratio

n of

tum

our

and

(III

) ab

dom

enlo

cal

exte

nt. A

lso

bette

r fo

r pe

lvic

nod

es. P

ara-

aort

ican

d pe

lvis

node

s an

d ur

eter

s m

ust

also

be

exam

ined

. Som

eL

33ce

ntre

s no

w u

se t

rans

rect

al U

S fo

r lo

cal

inva

sion

.

Rel

apse

MR

I (0

) or

CT

Spec

ialis

edM

RI

prov

ides

bet

ter

info

rmat

ion

in t

he p

elvi

s. B

iops

y(I

II)

abdo

men

inve

stig

atio

n (B

)(e

.g. o

f no

dal

mas

s) e

asie

r w

ith C

T.L

34an

d pe

lvis

Ute

rus:

bo

dy

Dia

gnos

isU

S (0

) or

Indi

cate

d (B

)M

RI

can

give

val

uabl

e in

form

atio

n ab

out

beni

gn a

ndL

35M

RI

(0)

mal

igna

nt l

esio

ns.

Stag

ing

MR

I (0

) or

Spec

ialis

edB

oth

CT

and

MR

I ca

n sh

ow e

xtra

-ute

rine

dis

ease

. But

L36

CT

(III

)in

vest

igat

ion

(B)

MR

I ca

n al

so d

emon

stra

te i

ntra

-ute

rine

ana

tom

y.

107

L. Cancer

Lym

ph

om

aD

iagn

osis

CT

(III

)In

dica

ted

(B)

CT

good

at

eval

uatin

g no

dal

site

s th

roug

hout

the

bod

y.A

lso

allo

ws

biop

sy a

lthou

gh e

xcis

ion

of w

hole

nod

epr

efer

able

whe

re p

ossi

ble.

NM

(II

I)Sp

ecia

lised

NM

(ga

llium

) ca

n sh

ow f

oci

of o

ccul

t di

seas

e (e

.g.

L37

inve

stig

atio

n (B

)m

edia

stin

um).

PE

Tus

ed i

n so

me

cent

res.

Stag

ing

CT

(III

) ch

est,

Indi

cate

d (B

)D

epen

ding

on

site

of

dise

ase,

hea

d an

d ne

ck m

ay a

lso

L38

abdo

men

, pel

vis

need

to

be e

xam

ined

. Inc

reas

ing

inte

rest

in

PET

here

.

Follo

w-u

pC

T(I

II)

orIn

dica

ted

(B)

Incr

easi

ng r

ole

for

MR

I in

lon

g te

rm f

ollo

w-u

p an

dM

RI

(0)

resi

dual

mas

ses.

NM

(II

I)Sp

ecia

lised

Con

side

r N

M f

or g

alliu

m p

ositi

ve d

isea

se. S

ome

L39

inve

stig

atio

n (B

)ce

ntre

s us

e PE

T.

108

L. CancerC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Mu

scu

losk

elet

al t

um

ou

rsD

iagn

osis

XR

(I)

+In

dica

ted

(B)

Imag

ing

and

hist

olog

y co

mpl

emen

tary

. Bes

t be

fore

MR

I (0

)bi

opsy

: Se

e M

uscu

losk

elet

al S

ectio

n D

. NM

nee

ded

toL

40en

sure

tha

t le

sion

is

solit

ary.

Stag

ing

MR

I (0

) lo

cal

Spec

ialis

edSe

e M

uscu

losk

elet

al S

ectio

n D

. CT

for

lung

dise

ase

+C

Tin

vest

igat

ion

(C)

met

asta

ses.

L41

ches

t (I

II)

Met

asta

ses

fro

m u

nkn

ow

n p

rim

ary

tum

ou

rD

iagn

osis

of

prim

ary

Imag

ing

Not

ind

icat

edR

arel

y be

nefi

cial

. Som

e ex

cept

ions

for

spe

cial

ists

,le

sion

L42

rout

inel

y (C

)yo

unge

r pa

tient

s or

fav

oura

ble

hist

olog

y.

Bre

ast

— s

ee S

ecti

on

J

109

L. Cancer

M.

Pae

dia

tric

sM

inim

ise

x-ir

rad

iati

on

in

ch

ild

ren

, es

pec

iall

y th

ose

wit

h l

on

g te

rm p

rob

lem

s

(for

hea

d in

jury

in

child

ren

see

Tra

uma

Sect

ion

K)

CN

SC

onge

nita

l di

sord

ers

MR

I (0

)In

dica

ted

(C)

Def

initi

ve e

xam

for

all

mal

form

atio

ns a

nd a

void

sx-

irra

diat

ion.

Sed

atio

n us

ually

req

uire

d fo

r yo

ung

child

ren.

Con

side

r U

S in

neo

nate

s. 3

D C

Tm

ay b

eM

1ne

eded

for

bon

e an

omal

ies.

Abn

orm

al h

ead

US

(0)

Indi

cate

d (B

)U

S in

dica

ted

whe

re a

nter

ior

font

anel

le i

s op

en.

appe

aran

ce —

SXR

(I)

Spec

ialis

edW

here

sut

ures

are

clo

sed/

clos

ing.

MR

I in

dica

ted

for

hydr

ocep

halu

s —

inve

stig

atio

n (C

)ol

der

child

ren.

(C

Tm

ay b

e ap

prop

riat

e if

MR

I no

tod

d su

ture

sM

2av

aila

ble.

)

Epi

leps

ySX

R (

I)N

ot i

ndic

ated

Poor

yie

ld.

rout

inel

y (B

)

MR

I (0

) or

Spec

ialis

edM

RI

usua

lly m

ore

appr

opri

ate

than

CT.

Ict

al a

nd i

nter

-M

3N

M (

II)

inve

stig

atio

n (B

)ic

tal

SPE

CT

also

use

d to

ide

ntif

y fo

cus

befo

re s

urge

ry.

110

M. PaediatricsC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Dea

fnes

s in

chi

ldre

nC

T(I

I)Sp

ecia

lised

Bot

h C

Tan

d M

RI

may

be

nece

ssar

y in

chi

ldre

n w

ithM

4M

RI

(0)

inve

stig

atio

n (C

)co

ngen

ital

and

post

-inf

ectiv

e de

afne

ss.

Hyd

roce

phal

us —

shun

tX

R (

I)In

dica

ted

(B)

XR

sho

uld

incl

ude

who

le v

alve

sys

tem

.m

alfu

nctio

n (s

ee A

10)

US

(0)

orIn

dica

ted

(B)

US

if p

ract

ical

, MR

I in

old

er c

hild

ren

(or

CT

if M

RI

M5

MR

I (0

)un

avai

labl

e). N

M u

sed

to e

valu

ate

shun

t fu

nctio

n.

Dev

elop

men

tal

dela

y —

Cra

nial

MR

I (0

)Sp

ecia

lised

See

also

M15

for

ske

leta

l in

vest

igat

ion

of g

row

thce

rebr

al p

alsy

M6

inve

stig

atio

n (B

)fa

ilure

.

Hea

dach

esSX

R (

I)N

ot i

ndic

ated

If p

ersi

sten

t or

ass

ocia

ted

with

clin

ical

sig

ns r

efer

for

rout

inel

y (B

)sp

ecia

lised

inv

estig

atio

ns.

MR

I (0

) or

Spec

ialis

edIn

chi

ldre

n M

RI

is p

refe

rabl

e if

ava

ilabl

e be

caus

e of

CT

(II)

inve

stig

atio

n (B

)ab

senc

e of

x-i

rrad

iatio

n. S

ee a

lso

A6

for

poss

ible

M7

men

ingi

tis a

nd e

ncep

halit

is

Sinu

sitis

see

als

o A

13Si

nus

XR

(I)

Not

ind

icat

edN

ot i

ndic

ated

bef

ore

5 ye

ars

as t

he s

inus

es a

re p

oorl

yro

utin

ely

(B)

deve

lope

d; m

ucos

al t

hick

enin

g ca

n be

a n

orm

alfi

ndin

g in

chi

ldre

n. A

sing

le u

nder

-tilt

ed O

M v

iew

may

be

mor

e ap

prop

riat

e th

an t

he s

tand

ard

OM

vie

wM

8de

pend

ing

on t

he c

hild

’s a

ge.

111

M. Paediatrics

Nec

k an

d s

pin

e —

Fo

r tr

aum

a se

e Se

ctio

n K

Tort

icol

lis w

ithou

t tr

aum

aX

R (

I)N

ot i

ndic

ated

Def

orm

ity i

s us

ually

due

to

spas

m w

ith n

o si

gnif

ican

tbo

ne c

hang

es. I

f pe

rsis

tent

, fur

ther

im

agin

g (e

.g. C

T)

M9

may

be

indi

cate

d fo

llow

ing

cons

ulta

tion.

Bac

k or

nec

k pa

inX

R (

I)In

dica

ted

(B)

Bac

k pa

in i

s un

com

mon

in

child

ren

with

out

a ca

use.

Follo

w-u

p is

nee

ded

if i

nfec

tion

is s

uspe

cted

.

NM

(II

)Sp

ecia

lised

Whe

n pa

in c

ontin

ues

and

XR

s ar

e no

rmal

. Use

ful

inin

vest

igat

ion

(B)

pain

ful

scol

iosi

s.

MR

I (0

)Sp

ecia

lised

See

also

The

Spi

ne S

ectio

n C

. MR

I de

fine

s sp

inal

inve

stig

atio

n (B

)m

alfo

rmat

ions

and

exc

lude

s as

soci

ated

the

cal

abno

rmal

ity. M

RI

can

also

dem

onst

rate

juv

enile

dis

cM

10le

sion

s.

Spin

a bi

fida

occ

ulta

XR

(I)

Not

ind

icat

edA

com

mon

var

iatio

n an

d no

t in

its

elf

sign

ific

ant

(eve

nro

utin

ely

(B)

in e

nure

sis)

. How

ever

, neu

rolo

gica

l si

gns

wou

ldM

11re

quir

e in

vest

igat

ion.

Hai

ry p

atch

, sac

ral

dim

ple

XR

(I)

Not

ind

icat

edM

ay b

e he

lpfu

l in

old

er c

hild

ren.

rout

inel

y (B

)

112

M. PaediatricsC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

US

(0)

Indi

cate

d (B

)U

S m

ay b

e us

eful

in

the

neon

atal

per

iod

to s

cree

n fo

run

derl

ying

tet

here

d co

rd, e

tc.

MR

I (0

)Sp

ecia

lised

MR

I pa

rtic

ular

ly i

f ne

urol

ogic

al s

igns

are

pre

sent

.M

12in

vest

igat

ion

(B)

Mu

scu

losk

elet

alN

on a

ccid

enta

l in

jury

—X

R (

I) o

fIn

dica

ted

(B)

Loc

al p

olic

ies

will

app

ly;

clos

e cl

inic

al/r

adio

logi

cal

child

abu

se (

for

head

affe

cted

par

tslia

ison

ess

entia

l. Sk

elet

al s

urve

y fo

r th

ose

unde

r tw

oin

jury

see

Sec

tion

K)

year

s af

ter

clin

ical

con

sulta

tion.

May

occ

asio

nally

be

requ

ired

in

the

olde

r ch

ild. C

T/M

RI

of b

rain

may

be

need

ed, e

ven

in t

he a

bsen

ce o

f cr

ania

l ap

pare

nt i

njur

y.

M13

NM

(II

)In

dica

ted

(B)

Sens

itive

for

occ

ult

spin

e/ri

b fr

actu

re.

Lim

b in

jury

: op

posi

te s

ide

XR

(I)

Not

ind

icat

edSe

ek r

adio

logi

cal

advi

ce.

for

com

pari

son

M14

rout

inel

y (B

)

Shor

t st

atur

e,X

R (

I) f

or b

one

Indi

cate

d at

2–18

yrs

: le

ft (

or n

on-d

omin

ant)

han

d/w

rist

onl

y.gr

owth

fai

lure

age

appr

opri

ate

Prem

atur

e in

fant

s an

d ne

onat

es:

knee

(sp

ecia

lised

inte

rval

s (B

)in

vest

igat

ion)

. May

nee

d to

be

supp

lem

ente

d w

ith a

skel

etal

sur

vey

and

MR

I fo

r hy

poth

alam

us a

ndM

15pi

tuita

ry f

ossa

(sp

ecia

lised

inv

estig

atio

ns).

113

M. Paediatrics

Irri

tabl

e hi

pU

S (0

)In

dica

ted

(B)

US

will

del

inea

te e

ffus

ions

whi

ch c

an b

e as

pira

ted

for

diag

nost

ic a

nd t

hera

peut

ic p

urpo

ses.

XR

s ca

n be

dela

yed,

but

sho

uld

be c

onsi

dere

d w

hen

the

sym

ptom

sar

e pe

rsis

tent

. Con

side

r N

M o

r M

RI

whe

n Pe

rthe

s’M

16di

seas

e is

sus

pect

ed a

nd p

lain

XR

s ar

e no

rmal

.

Lim

pX

R p

elvi

s (I

)In

dica

ted

(C)

Gon

ad p

rote

ctio

n is

use

d ro

utin

ely

unle

ss s

hiel

ds w

illob

scur

e ar

ea o

f cl

inic

al s

uspi

cion

. If

slip

ped

epip

hyse

sis

lik

ely,

lat

eral

XR

s of

bot

h hi

ps a

re n

eede

d.

US

(0)

orSp

ecia

lised

Acc

ordi

ng t

o lo

cal

polic

y, e

xper

tise

and

avai

labi

lity.

NM

(II

) or

inve

stig

atio

n (B

)M

17M

RI

(0)

Foca

l bo

ne p

ain

XR

(I)

and

Indi

cate

d (B

)X

R m

ay b

e no

rmal

ini

tially

. US

can

be h

elpf

ulU

S (0

)pa

rtic

ular

ly i

n os

teom

yelit

is.

NM

(II

) or

Spec

ialis

edIn

crea

sing

use

of

MR

I he

re.

M18

MR

I (0

)in

vest

igat

ion

(B)

Clic

king

hip

—U

S (0

)In

dica

ted

(B)

XR

may

be

used

to

supp

lem

ent

US

exam

inat

ion

ordi

sloc

atio

nw

here

exp

ertis

e is

not

ava

ilabl

e. X

R i

ndic

ated

in

the

M19

olde

r in

fant

.

114

M. PaediatricsC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Osg

ood–

Schl

atte

r’s

XR

kne

e (I

)N

ot i

ndic

ated

Alth

ough

bon

y ra

diol

ogic

al c

hang

es a

re v

isib

le i

ndi

seas

ero

utin

ely

(C)

Osg

ood–

Schl

atte

r’s

dise

ase

thes

e ov

erla

p w

ith n

orm

alap

pear

ance

s. A

ssoc

iate

d so

ft t

issu

e sw

ellin

g sh

ould

be

M20

asse

ssed

clin

ical

ly r

athe

r th

an r

adio

grap

hica

lly.

Car

dio

tho

raci

cA

cute

che

st i

nfec

tion

CX

R (

I)N

ot i

ndic

ated

Initi

al a

nd f

ollo

w-u

p fi

lms

are

indi

cate

d in

the

rout

inel

y (B

)pr

esen

ce o

f pe

rsis

ting

clin

ical

sig

ns o

r sy

mpt

oms

or i

nth

e se

vere

ly i

ll ch

ild. C

onsi

der

the

need

for

CX

R i

nfe

ver

of u

nkno

wn

orig

in. C

hild

ren

may

hav

eM

21pn

eum

onia

with

out

clin

ical

sig

ns.

Rec

urre

nt p

rodu

ctiv

eC

XR

(I)

Not

ind

icat

edC

hild

ren

with

rec

urre

nt c

hest

inf

ectio

n te

nd t

o ha

veco

ugh

rout

inel

y (C

)no

rmal

CX

Rs

(apa

rt f

rom

bro

nchi

al w

all

thic

keni

ng).

Rou

tine

follo

w-u

p C

XR

not

ind

icat

ed u

nles

s co

llaps

epr

esen

t on

ini

tial

CX

R. S

uspe

cted

cys

tic f

ibro

sis

M22

requ

ires

spe

cial

ist

refe

rral

.

Inha

led

FB (

susp

ecte

d)C

XR

(I)

Indi

cate

d (B

)H

isto

ry o

f in

hala

tion

ofte

n no

t cl

ear.

Bro

ncho

scop

y is

(see

Sec

tion

K)

indi

cate

d, e

ven

in t

he p

rese

nce

of a

nor

mal

CX

R.

NM

/CT

may

be

help

ful

to s

how

sub

tle a

ir t

rapp

ing.

Wid

e va

riat

ion

in l

ocal

pol

icy

abou

t ex

pira

tory

film

s,M

23fl

uoro

scop

y, C

Tan

d N

M (

vent

ilatio

n sc

intig

raph

y).

115

M. Paediatrics

Whe

eze

CX

R (

I)N

ot i

ndic

ated

Chi

ldre

n w

ith a

sthm

a us

ually

hav

e no

rmal

CX

R a

part

rout

inel

y (B

)fr

om b

ronc

hial

wal

l th

icke

ning

. Sud

den

unex

plai

ned

whe

eze

CX

R i

ndic

ated

, may

be

due

to i

nhal

ed F

BM

24(a

bove

).

Acu

te s

trid

orX

R n

eck

(I)

Not

ind

icat

edE

pigl

ottit

is i

s a

clin

ical

dia

gnos

is, b

ut c

onsi

der

FBM

25ro

utin

ely

(B)

(abo

ve).

Hea

rt m

urm

urC

XR

(I)

Not

ind

icat

edSp

ecia

list

refe

rral

may

be

need

ed;

card

iac

US

ofte

nM

26ro

utin

ely

(C)

may

be

indi

cate

d.

Gas

tro

inte

stin

al —

see

als

o Se

ctio

n G

for

mor

e ge

nera

l ab

dom

inal

pro

blem

s

Intu

ssus

cept

ion

AX

R (

II)

Indi

cate

d (C

)L

ocal

pol

icie

s re

quir

e cl

ose

paed

iatr

ic, r

adio

logi

cal

and

surg

ical

lia

ison

. Whe

re e

xper

tise

is a

vaila

ble,

bot

hU

S an

d co

ntra

st e

nem

a (a

ir o

r ba

rium

) ca

n co

nfir

mdi

agno

sis

and

guid

e re

duct

ion.

Fur

ther

im

agin

gSp

ecia

lised

M27

inve

stig

atio

n (B

)

116

M. PaediatricsC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Swal

low

ed F

Bs

AX

R (

II)

Not

ind

icat

edE

xcep

t fo

r sh

arp

or p

oten

tially

poi

sono

us F

Bs,

e.g

.(s

ee S

ectio

n K

)ro

utin

ely

(C)

batte

ries

. See

Sec

tion

K. I

f th

ere

is d

oubt

whe

ther

the

FB h

as p

asse

d, a

n A

XR

aft

er 6

day

s m

ay b

e in

dica

ted.

CX

R (

I)In

dica

ted

(C)

If t

here

is

doub

t w

heth

er t

he F

B h

as p

asse

d, a

n A

XR

M28

(inc

ludi

ng n

eck)

afte

r 6

days

may

be

indi

cate

d.

Min

or t

raum

a to

abd

omen

AX

R (

II)

Not

ind

icat

edU

S m

ay b

e us

ed a

s in

itial

inv

estig

atio

n bu

t C

Tis

rout

inel

y (C

)m

ore

spec

ific

, par

ticul

arly

in

visc

eral

tra

uma.

XR

sm

ay s

how

bon

e in

jury

in

seve

re t

raum

a. T

hepr

inci

ples

for

the

inv

estig

atio

n of

maj

or t

raum

a in

child

ren

sim

ilar

to t

hose

in

adul

ts (

see

Maj

or T

raum

a,M

29K

40–K

42).

Proj

ectil

e vo

miti

ngU

S (0

)In

dica

ted

(A)

US

can

conf

irm

the

pre

senc

e of

hyp

ertr

ophi

c py

lori

cst

enos

is, e

spec

ially

whe

re c

linic

al f

indi

ngs

are

M30

equi

voca

l.

Rec

urre

nt v

omiti

ngU

pper

GI

Not

ind

icat

edT

his

sym

ptom

cov

ers

a w

ide

rang

e fr

om o

bstr

uctio

n in

cont

rast

stu

dyro

utin

ely

(C)

the

neon

atal

per

iod

to r

eflu

x, p

osse

ters

and

chi

ldre

nw

ith m

igra

ine.

US

may

be

help

ful

to c

onfi

rmm

alro

tatio

n. H

owev

er, u

pper

GI

cont

rast

stu

dies

may

be i

ndic

ated

to

excl

ude

mal

rota

tion

even

with

nor

mal

abdo

min

al X

R. C

ontr

ast

stud

ies

in n

eona

tes

shou

ld b

eun

dert

aken

as

a sp

ecia

lised

inv

estig

atio

n. C

onsi

der

NM

for

gas

tric

em

ptyi

ng a

nd g

astr

o-oe

soph

agea

lM

31re

flux

.

117

M. Paediatrics

Pers

iste

nt n

eona

tal

US

(0)

Indi

cate

d (B

)E

arly

(<

10

wee

ks)

and

prom

pt i

nves

tigat

ion

isja

undi

cees

sent

ial.

The

abs

ence

of

dila

tatio

n in

the

int

rahe

patic

NM

(II

)In

dica

ted

(B)

bile

duc

t do

es n

ot e

xclu

de a

n ob

stru

ctiv

eM

32ch

olan

giop

athy

.

Rec

tal

blee

ding

NM

(II

)Sp

ecia

lised

If M

ecke

l’s d

iver

ticul

um i

s a

poss

ibili

ty d

o N

M f

irst

.in

vest

igat

ion

(B)

Smal

l bo

wel

con

tras

t st

udie

s m

ay a

lso

be n

eces

sary

.N

M a

lso

usef

ul i

n in

vest

igat

ion

of i

nfla

mm

ator

ybo

wel

dis

ease

. End

osco

py i

s pr

efer

able

to

Ba

enem

afo

r as

sess

men

t of

pol

yps

and

infl

amm

ator

y bo

wel

M33

dise

ase.

US

can

be u

sed

to d

iagn

ose

dupl

icat

ion

cyst

s.

Con

stip

atio

nA

XR

(II

)N

ot i

ndic

ated

Man

y no

rmal

chi

ldre

n sh

ow e

xten

sive

fae

cal

mat

eria

l;ro

utin

ely

(C)

impo

ssib

le t

o as

sess

sig

nifi

canc

e of

rad

iolo

gica

l si

gns.

But

AX

R c

an h

elp

spec

ialis

ts i

n re

frac

tory

cas

es.

Con

tras

t en

ema

Not

ind

icat

edIf

Hir

schs

prun

g’s

dise

ase

is s

uspe

cted

, spe

cial

ist

M34

rout

inel

y (B

)re

ferr

al p

lus

biop

sy i

s pr

efer

red

to r

adio

logi

cal

stud

ies.

Palp

able

abd

omin

al/

US

(0)

and

Indi

cate

d (B

)If

mal

igna

ncy

is s

uspe

cted

, fur

ther

im

agin

g sh

ould

be

pelv

ic m

ass

M35

AX

R (

II)

perf

orm

ed i

n a

spec

ialis

ed c

entr

e.

118

M. PaediatricsC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Uro

rad

iolo

gyE

nure

sis

Imag

ing

Not

ind

icat

edU

S an

d ur

odyn

amic

stu

dies

may

be

need

ed i

n ca

ses

ofM

36ro

utin

ely

(B)

pers

iste

nt e

nure

sis.

Con

tinuo

us w

ettin

gU

S (0

)In

dica

ted

(B)

Bot

h ex

amin

atio

ns m

ay b

e ne

eded

to

eval

uate

dup

lex

syst

em w

ith e

ctop

ic u

rete

r.

M37

IVU

(II

)In

dica

ted

Impa

lpab

le t

estis

US

(0)

Indi

cate

d (B

)To

loc

ate

ingu

inal

tes

tis. M

RI

may

be

help

ful

to l

ocat

ean

int

ra-a

bdom

inal

tes

tis, b

ut i

ncre

asin

gly

lapa

rosc

opy

M38

is t

he i

nves

tigat

ion

of c

hoic

e.

Ant

enat

al d

iagn

osis

of

US

(0)

Indi

cate

d (B

)L

ocal

pro

toco

ls s

houl

d be

est

ablis

hed.

Mild

dila

tatio

nur

inar

y tr

act

dila

tatio

nca

n no

rmal

ly b

e m

onito

red

by U

S. L

ow t

hres

hold

for

M39

spec

ialis

t re

ferr

al.

119

M. Paediatrics

Prov

en u

rina

ry t

ract

Imag

ing

US

(0)

Spec

ialis

edT

here

is

wid

e va

riat

ion

in l

ocal

pol

icy.

Muc

h de

pend

sin

fect

ion

//NM

(II

)/in

vest

igat

ions

(C

)on

loc

al t

echn

olog

y an

d ex

pert

ise.

Mos

t pa

tient

scy

stog

raph

y (I

II)

shou

ld r

emai

n on

pro

phyl

actic

ant

ibio

tics

pend

ing

the

resu

lts o

f in

vest

igat

ions

. The

age

of

the

patie

nt a

lso

infl

uenc

es d

ecis

ions

. The

re i

s m

uch

curr

ent

emph

asis

on m

inim

isin

g ra

diat

ion

dose

; he

nce

AX

R i

s no

tin

dica

ted

rout

inel

y (c

alcu

li ra

re).

Exp

ert

US

is t

he k

eyin

vest

igat

ion

in a

ll im

agin

g st

rate

gies

at

this

age

.T

here

afte

r N

M p

rovi

des

data

abo

ut r

enal

str

uctu

re(D

MSA

) an

d ha

s vi

rtua

lly r

epla

ced

the

IVU

her

e. N

Mw

ill e

stab

lish

func

tion,

exc

lude

obs

truc

tion

and

can

also

be

used

for

cys

togr

aphy

(di

rect

or

indi

rect

) to

show

ref

lux.

For

mal

dir

ect

XR

cys

togr

aphy

is

still

need

ed i

n th

e yo

ung

(e.g

. < 2

yrs

) m

ale

patie

nt w

here

delin

eatio

n of

the

ana

tom

y (e

.g. u

reth

ral

valv

es)

isM

40cr

itica

l.

120

M. PaediatricsC

LIN

ICA

L PR

OBL

EMIN

VES

TIG

ATIO

N{D

OSE

}RE

CO

MM

END

ATIO

N{G

RAD

E}C

OM

MEN

T

Selected bibliography

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2 European Union. Council directive 97/43/Euratomof 30 June 1997 on health protection ofindividuals against the dangers of ionisingradiation in relation to medical exposure(OJ L 180, 9.7.1997, p. 22).

3 Roberts, C. J, ‘Towards the more effective use ofdiagnostic radiology. A review of the work of theRCR working party of the more effective use ofdiagnostic radiology 1976–86’. Clin Radiol 1988,39:3–6.

4 National Radiological Protection board and TheRoyal College of Radiologists. Patient dosereduction in diagnostic radiology(ISBN 0 85951 327 0). HMSO London, 1990.

5 RCR working party. ‘A multi-centre audit ofhospital referral for radiological investigation inEngland and Wales’. BMJ 1991, 303:809–12.

6 RCR working party. ‘Influence of the RoyalCollege of Radiologists’ guidelines on hospitalpractice: a multi-centre study’. BMJ 1992,304:740–43.

7 Roberts, C. J., ‘The RCR multi-centre guidelinestudy. Implications for clinical practice’. ClinRadiol 1992, 45:365–8.

8 NHS Executive. Clinical guidelines: usingclinical guidelines to improve patient care withinthe NHS (96CC0001). NHS Executive, Leeds,1996.

121

9 Sackett, D. L., Richardson, W. S., Rosenberg, W.,Haynes, R. B., Evidence-based medicine(ISBN 0 443 05686 2). Churchill Livingstone,Edinburgh, 1997.

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Appendix

List of bodies involved in the consultation exercisefor the 1998 UK RCR guidelines

Royal Colleges, etcAcademy of Medical Royal CollegesFaculty of Accident and Emergency MedicineFaculty of Dental Surgery, RCSFaculty of Clinical Oncology, RCRFaculty of Occupational MedicineFaculty of Public Health MedicineRoyal College of AnaesthetistsRoyal College of General PractitionersRoyal College of Paediatrics and Child HealthRoyal College of Physicians of LondonRoyal College of Physicians and Surgeons of GlasgowRoyal College of Physicians of EdinburghRoyal College of Physicians of IrelandRoyal College of PsychiatristsRoyal College of Obstetricians and GynaecologistsRoyal College of OphthalmologistsRoyal College of PathologistsRoyal College of Surgeons of EdinburghRoyal College of Surgeons of EnglandRoyal College of Surgeons of Ireland

Other organisationsBritish Institute of RadiologyBritish United Provident AssociationMedical Defence UnionMedical Protection SocietyNational Radiological Protection BoardThe Patients’ Association

Speciality groupsAssociation of Chest RadiologistsBritish Society of Nuclear MedicineBritish Society of GastroenterologyBritish Society of Interventional RadiologyBritish Society of NeuroradiologistsBritish Medical Ultrasound SocietyBritish Society of Skeletal RadiologistsDental Radiology Group

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Paediatric RadiologistsMagnetic Resonance Radiologists Association UKRCR Cardiac GroupRCR Breast GroupRCR Clinical Directors’ GroupRCR Interventional Radiology Sub-CommitteeRCR Nuclear Medicine Sub-CommitteeRCR Paediatric GroupRCR/RCOG Standing Committee on Obstetric USRCR/RCP Standing Committee on Nuclear MedicineUK Children’s Cancer Study GroupUK Neurointervention Group

The adaptation of the 1998 UK RCR guidelines into EU2000 referral criteria was performed in consultation with:

European Association of Nuclear MedicineEuropean Association of RadiologyUnion of European Medical Specialists

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European Commission

Referral guidelines for imagingRadiation Protection 118

Luxembourg: Office for Official Publications of theEuropean Communities

2001 —125 pp. — 10 x 19 cm

ISBN 92-828-9454-1

Price (excluding VAT) in Luxembourg: EUR 16