Dr Imran Lasker, FRCRMusculoskeletal Radiology Fellow,

Imperial College NHS Trust, London, UK

Modified with permission from Dr E Dick

Radiology for the Busy

Anaesthetist

Infomed Anaesthetic Update Course: London, June 2018

• HDU/ITU

• Pre & post op

• Trauma

• Lines and tubes

• Knobology

• Spines

• How can the

Radiologist help you?

A

B

C

Airway

30 yo male Cyclist

• Facial injuries

• Le Fort III

• Difficult airway

Airway1

30 yo male Cyclist

• Facial injuries

• Le Fort III

• Difficult airway

Airway1

www.headneckbrainspine.com

ETT balloon over

inflated in vestibule

Tracheal membrane

False lumen & ETT

True lumen

Signs of TracheoBronchial rupture

• Surgical emphysema neck

• Pneumomediastinum

• Malposition of ETT

• ETT Balloon overinflation (N< 2.8cm)

• Transtracheal herniation of ETT (dumbbell

shape)

• Tracheal wall defect– directly seen in 71%

• Gold standard: fibreoptic bronchoscopy

Gunn: Current Concepts in Penetrating Transmediastinal Injury. Radiographics 2014

70 yo man, tried to hang himself

• tied rope around

his neck

• attached it to post

• drove away

Thanks to Dr John Curtis, Aintree Univiersity Hospitals

ETT Balloon below cricoid

20 year old female, playing sport,

blunt neck injury

20 year old female, playing sport,

blunt neck injury

Dyspnea, Hoarse, Swelling R neck

hyoid

P

Aryepiglottic fold

laceration

True vocal cords

Right arytenoid medially displaced

Tracheostomy tube DISPLACED

Narrow Airway - Amyloid

Tube RMB (total left lobe collapse)

Tube RMB (total left lobe collapse)

Free intraperitoneal air - ETT in Oesophagus

NGT Right Main Bronchus

Post RIJV line insertion ? Ptx

Left IJV line

Where is the wire?

Breathing

Collapse vs.

Consolidation

Volume LossNo air bronchogramsRemainder of lung has to expand

Predictable site of consolidation

or collapse

Left lobesRight lobes

Dense

Consolidation

No volume lossAir bronchograms

Right lower lobe consolidation

• No loss of volume

• air space shadowing

• right hemidiaphragm

obscured

• right heart border

clear

Ampoule bronchus intermedius,

RML & RLL collapse

Ampoule bronchus intermedius,

RML & RLL collapse

Tooth LMB, post op, near complete

Left lobe collapse

Radiologists! Think where teeth go

Elderly frail man – TRAUMA CALL

fall 20 foot, haemodynamically

unstable• # T8 to L1

• # R 8/9 rib

• Shattered Sacrum

• Pubic rami #

• PM correlation

• Tooth – RMB

Tooth RMB

Elderly lady, Fall, 2 floors,

Fractured mandible, missing teeth

NGT

Teeth fragments in stomach

? Coin in

trachea

Coin in

Oesophagus

Coronal

plane

Stabbing#.

Stabbing #1.Haemothorax, chest drain,

consolidation

Ultrasound (effusion)

Ultrasound Knobology

Ambience

• Dark room

• Machine

• Cost

• Probe

Ultrasound (Consolidation)

Ultrasound for Ptx

PTx False +ve on US

Abnormality: Pneumothorax

Became increasingly difficult to ventilate during clavicle

fixation

Tension

pneumothorax

ON CT!!

?Pneumothorax

Bullous lung disease

• RTA

RTA, Bullae, Chest drain

outside pleural space

1. upper lobe blood diversion (pulmonary veins)

2. Kerley B lines – tiny horizontal from pleural edge

3. Bats wings –type peri-hilar haziness

4. Alveolar shadowing (hazy shadowing throughout)

Pulmonary

Oedema

Pulmonary Vasculature

55 Yr-old with SOB,

increasing O2

Requirements.

CTPA

Thanks to Dr Elika Kashef

Sub-massive PELarge main PA PE

RV strain

HD stable

CD

T

Trauma subsegmental PE

Trauma subsegmental PE

• Pulmonary

artery HT

Don’t be fooled Xrays!

?LVF

Pericardial effusion before and after

drain

Spines (D)

Anatomy of Spine• Denis: 3 column

theory of stability

• Anterior

• Middle

• Posterior

• Generally:– If middle column

disrupted = unstable

– If OK = stable

CSpine - Checklist

7mm

21mm

Male - Trampoline InjuryC5/6

C6/7

Trampoline Injury

67

34 yo, fell off sofa (EtOH)

paraplegic

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

C4/5 bifacetal dislocation

Bifacetal dislocation C 4/5

C4/5 bifacetal dislocation

RA ?atlantoaxial subluxation

Male Ank Spondylitis fall

AS fall, epidural haematoma

has central cord syndrome

Have a low threshold for MRI

Elderly lady, Fall, complete

spinal level at C7

Midline

5

6

↑ ? interlaminar space

↓ disc space

Disc osteophyte bar

C5-C6

Right

5

C5 articular facet #

3 column injury

5

Ant longitudinal ligament

torn

ALL intact

ALL intact

3 column injury

5

C5/6 & C6/7 disc oedemaCord contusion

& oedema

3 column injury

5

Interspinous oedema

Paediatric Spine Imaging

NICE Guidelines

• Updated 2014

• 3 view radiographs first

• CT only if strong suspicion of injury

• Locally, ½ of CTs in kids did not follow

NICE guidelines

•

• In first year of MTC 175 paediatric major

trauma – 1/3rd had CT Cspine, only one

was abnormal!!!!

Paediatric CSpine Checklist

Atlantoaxial distance 5mm

Radiograph Evaluation

• Basion dens interval

– Basion to the tip of dens

– <12 mm

Atlantooccipital and atlantoaxial

distraction

• Basion dens interval

– Basion to the tip of dens

– <12 mm

Keiper et al, Neuroradiology 1998

Child – Fall 4 stories

normal growth plate C1/2

Radiographics 2003

Lumbar Spine

Fall into recycling processor

Polytrauma head, abdo pelvis

L2

L2

L2

Fall into recycling bin, post fixation

Considerations for spinal

anaesthesia

Normal epidural space

T2 fluid bright T1 fluid dark FS T2

Congenital abnormalities

Adult female with Known Spina

Bifida

Spinal dysraphism:

Diastomatomyelia

Syringomyelia

Tethered cord

Fused vertebral bodies

Spinal dysraphism

Diastomatomyelia

Syringomyelia

Tethered cord

Fused vertebral bodies

Spinal dysraphism

Diastomatomyelia

Syringomyelia

Tethered cord

Fused vertebral bodies

Spinal dysraphism

Diastomatomyelia

Syringomyelia

Tethered cord

Fused vertebral bodies

T1 shows epidural fat

Spinal dysraphism

Diastomatomyelia

Syringomyelia

Tethered cord

Fused vertebral bodies

Assessing the Epidural Space

70 yo vasculopath, epidural in situ

5 days, now leg weakness

• recent angioplasty left SFA for acute

severe leg pain & worsening gangrene

• left SFA occlusion

• epidural for pain removed after few days

• Leg weakness

Use T1 and T2 MRI to

Identify blood

T2 T1

Blood – low signal T2, high T1

Normal epidural space

T2 fluid bright T1 fluid dark

T2 T1

Blood – low signal T2, high T1

T2 T1

Blood – low signal T2, high T1

Epidural and psoas abscess T2

Epidural and psoas abscess T2

Epidural and psoas abscess T2

Epidural abscess Sag post gad

Ax post gad, everything bright =

infection – psoas abscess epid

abscess, only IVC = normal

Ax post gad, everything bright =

infection – psoas abscess epid

abscess, only IVC = normal

• HDU/ITU

• Pre & post op

• Trauma

• Lines and tubes

• Knobology

• Spines

• How can the

Radiologist help you?

A

B

C

Thanks to the team:

• Dr Elizabeth Dick• Dr Bob Dick • Dr John Dick • Dr Ian Renfrew • Dr Simon Morley• Prof Wady Gedroyc

• Dr Maria Nordlander

• Dr Shema Hameed

• Dr Afshin Alavi

• Mr Mo Akmal

• Mr Reza Mobasheri

• Miss Nicola Batrick

• Dr Raghu Kamanahalli

• Dr Joel Dunn

• Dr Elika Kashef

• Dr Olga Kirmi

• Dr Ali Alsafi