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Dr.
Joseph Gagliardi
responds:
Before the patient even enters the fluoroscopy room, I have set up and preloaded
all syringes with the appropriate fluids, i.e. lidocaine, nonionic contrast
agent, and a dilute solution of gadolinium-DTPA mixed in saline (we use
0.5 cc of gad./100 cc of saline). We have a 1.5T magnet for weaker magnets,
some use stronger concentrations of gadolinium - as high as 2.0 cc of gadolinium
in 100 cc of saline. In my opinion having the room completely ready allows
for less patient stress and makes the procedure go smoothly.
I place the patient in the supine position with the symptomatic hip closest
to me. I like to put a pillow under the knee so as to flex the joint a bit
and hopefully create less stress around the hip. I then palpate for the
femoral pulse and mark this with a sterile marker (some put a metal marker
over the spot). I then clean the hip area 3 times with betadine solution.
I then locate a spot under fluoroscopy in which the needle tip for the lidocaine
is near the mid to lower intertrochanteric line and angle the tip medial
and cephalad to the femoral neck/subcapital location and stop when I hit
bone. Sometimes I have to inject some lidocaine as I advance the 20 g spinal
needle to the femur.
At this point I attach the connecting tubing attached to the syringe with
iodinated contrast to the spinal needle and confirm intra-articular location
with a few drops. The contrast should flow away from the needle easily,
if not, or if pooling of contrast is noted, I then reposition the needle
and try again. Once in the joint, I hook up a new connecting tube attached
to the diluted gad/saline solution and inject 15 to 20 cc of solution. I
choose not to add epinephrine to the mixture although some do. Also, I like
to keep the iodinated contrast and gad mixture separate, although some don't.
Once done, we walk the patient to MRI for imaging which consists of axial,
coronal and sagittal fat saturated T-1 weighted sequences centered on the
hip of interest and coronal FSE T-2 weighted sequences of both hips. |
