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Published online before print August 27, 2003, 10.1148/radiol.2291020314
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(Radiology 2003;229:153-158.)
© RSNA, 2003

Musculoskeletal Imaging

CT Arthrography of the Glenohumeral Joint: CT Fluoroscopy Versus Conventional CT and Fluoroscopy—Comparison of Image-Guidance Techniques1

Christoph A. Binkert, MD, Francis R. Verdun, PhD, Marco Zanetti, MD, Christian W. Pfirrmann, MD and Juerg Hodler, MD, MBA

1 From the Department of Radiology, University Hospital Balgrist, Zurich, Switzerland (C.A.B., M.Z., C.W.P., J.H.); and Institute for Applied Radiophysics, Lausanne, Switzerland (F.R.V.). Received April 1, 2002; revision requested June 13; final revision received November 18; accepted February 3, 2003. Address correspondence to C.A.B., Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (e-mail: cbinkert@partners.org)


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
PURPOSE: To compare examination time with radiologist time and to measure radiation dose of computed tomographic (CT) fluoroscopy, conventional CT, and conventional fluoroscopy as guiding modalities for shoulder CT arthrography.

MATERIALS AND METHODS: Glenohumeral injection of contrast material for CT arthrography was performed in 64 consecutive patients (mean age, 32 years; age range, 16–74 years) and was guided with CT fluoroscopy (n = 28), conventional CT (n = 14), or conventional fluoroscopy (n = 22). Room times (arthrography, room change, CT, and total examination times) and radiologist times (time the radiologist spent in the fluoroscopy or CT room) were measured. One-way analysis of variance and Bonferroni-Dunn posthoc tests were performed for comparison of mean times. Mean effective radiation dose was calculated for each method with examination data, phantom measurements, and standard software.

RESULTS: Mean total examination time was 28.0 minutes for CT fluoroscopy, 28.6 minutes for conventional CT, and 29.4 minutes for conventional fluoroscopy; mean radiologist time was 9.9 minutes, 10.5 minutes, and 9.0 minutes, respectively. These differences were not statistically significant. Mean effective radiation dose was 0.0015 mSv for conventional fluoroscopy (mean, nine sections), 0.22 mSv for CT fluoroscopy (120 kV; 50 mA; mean, 15 sections), and 0.96 mSv for conventional CT (140 kV; 240 mA; mean, six sections). Effective radiation dose can be reduced to 0.18 mSv for conventional CT by changing imaging parameters to 120 kV and 100 mA. Mean effective radiation dose of the diagnostic CT arthrographic examination (140 kV; 240 mA; mean, 25 sections) was 2.4 mSv.

CONCLUSION: CT fluoroscopy and conventional CT are valuable alternative modalities for glenohumeral CT arthrography, as examination and radiologist times are not significantly different. CT guidance requires a greater radiation dose than does conventional fluoroscopy, but with adequate parameters CT guidance constitutes approximately 8% of the radiation dose.

© RSNA, 2003

Index terms: Computed tomography (CT), comparative studies, 414.1211 • Computed tomography (CT), guidance • Shoulder, CT, 414.1211


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Computed tomography (CT) has been used to guide interventional procedures for many years (1,2). A limitation of conventional CT is the lack of real-time depiction during interventional procedures. More recently, a CT fluoroscopy system that provides real-time reconstruction and display of CT images has become available for clinical use (3). The clinical efficacy of CT fluoroscopy for different diagnostic and therapeutic applications has been reported (4–18); however, authors of only a few studies have compared CT fluoroscopy with conventional CT as a guiding modality for use in interventional procedures (16,19,20). Comparison of CT fluoroscopy times with procedure times in these studies was limited by procedural variability that arose from differences in the size and location of the lesions that were treated. The purpose of the present study was to compare examination and radiologist times and radiation dose when CT fluoroscopy, conventional CT, and conventional fluoroscopy were used as guiding modalities for shoulder CT arthrography.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Patients
Between February and July 2000, 64 consecutive patients with anterior instability of the shoulder were referred for CT arthrography and enrolled in this prospective study. The study population included 50 men and 14 women with a mean age of 32 years (age range, 16–74 years). All patients underwent intraarticular injection of 12–15 mL of diluted iodinated contrast material (two parts iopamidol [Iopamiro 200; Bracco, Milan, Italy] and one part normal saline) with a 20-gauge needle, followed by CT arthrography. The injection of contrast material was guided with CT fluoroscopy, conventional CT, or conventional fluoroscopy. The injection guiding modality was left unchanged for 1 week and was then changed to another guiding modality; therefore, patients were assigned to a modality according to examination date. CT fluoroscopy was used in 28 patients; conventional CT, in 14; and conventional fluoroscopy, in 22. Of the patients who underwent CT fluoroscopy, 22 were male and six were female (mean age, 32 years; age range, 16–67 years). Of the patients who underwent conventional CT, 10 were men and four were women (mean age, 30 years; age range, 19–42 years). Of the patients who underwent conventional fluoroscopy, 18 were male and four were female (mean age, 33 years; age range, 17–74 years).

This study was approved by the institutional review board of our hospital, and informed consent was obtained from all patients.

Technical Aspects
The injections of contrast material were performed by one of two radiologists (C.A.B. or J.H.) who were experienced (1 and 10 years, respectively) in musculoskeletal radiology, including imaging-guided injections. All CT examinations were performed with a continuous-rotation fan-beam geometry CT scanner (Somatom Plus 4, CARE Vision; Siemens Medical Systems, Erlangen, Germany) equipped with an option that allowed real-time imaging (16,21). Similar to conventional fluoroscopy, this scanner is activated by pushing a foot switch. After the pedal is released, the last image remains displayed on the in-room monitor. The radiologist can move the CT table by using a joystick for craniocaudal adjustments.

For this study, CT fluoroscopic images were acquired with a rotation speed of 0.75 second per rotation, a current of 50 mA, a voltage of 120 kV, and a collimation of 5 mm. Images were calculated at a rate of six images per second with a 256 x 256 matrix and displayed in full resolution (1,024 x 1,024 matrix) on the in-room monitor. The radiologist was the only person in the room with the patient and was protected by a lead apron and a thyroid shield. The patient was placed in the supine position on the CT table, with a lead drape around his or her body just caudal to the shoulders. After sterile preparation of the skin, a needle was advanced into the glenohumeral joint with local anesthesia. Needle advancement was monitored by intermittently obtaining short fluoroscopic CT scans, a process known as the "quick-check" method (21) (Fig 1, A–C). With this method, the radiologist’s hand was never exposed to direct radiation. Once the needle entered the joint space, contrast material was injected through an extension tube. The injection was controlled with intermittent CT fluoroscopy (Fig 1, D–F).



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  		Figure 1. Transverse images obtained with CT fluoroscopic guidance of glenohumeral injection of contrast material. (A) Needle entry site is localized with a hemostat. (B, C) Stepwise needle advancement is depicted with CT fluoroscopy. (D-F) Injection of contrast material is controlled with intermittent CT fluoroscopy.

 
The patient setup used for single-section conventional CT was identical to that used for CT fluoroscopy; however, instead of physician-determined intermittent sequences, the technologist was asked to acquire a single confirmatory section whenever the radiologist thought it necessary to check the position of the advancing needle. The parameters used during conventional CT needle guidance were rotation speed of 1.5 seconds per rotation, tube current of 240 mA, voltage of 140 kV, and collimation of 5 mm. The operator left the room during each image acquisition.

Injections guided with conventional fluoroscopy were performed with a fluoroscopic unit (Siregraph D3; Siemens Medical Systems). The needle was aimed at the superior inner fourth of the humeral head. Needle position and intraarticular contrast material distribution were intermittently checked with short sequences of fluoroscopy. After injection, the needle was removed and the patient was moved to the CT scanner, which is located next to the fluoroscopic unit at our institution.

After contrast material was injected, all CT arthrographic examinations were performed in an identical fashion with the same scanner that was used for the CT-guided injections. Single-section images were acquired with a rotation speed of 1.5 seconds per rotation, a tube current of 240 mA, a voltage of 140 kV, a collimation of 3 mm, and a table feed of 3 mm.

Glenohumeral injection of contrast material for CT arthrography was technically successful in all patients. No procedure-related complications were observed.

Time Assessment
Time points were recorded for conventional CT and CT fluoroscopy when the patient entered the CT scanner, when the radiologist was called after the patient was positioned on the CT table, when the radiologist entered the CT room, when the radiologist left the CT room, and when the patient left the CT scanner. Time points were recorded for conventional fluoroscopy when the patient entered the fluoroscopy room, when the radiologist was called after the patient was positioned on the fluoroscopy table, when the radiologist entered the CT room, when the radiologist left the CT room, when the patient left the fluoroscopy unit, when the patient entered the CT scanner, and when the patient left the CT scanner. These times were recorded on a standardized data sheet, and the same watch was used for each patient.

From these data, room time, total examination time, and radiologist time were each calculated in minutes. Total examination time was defined as the sum of the time the patient was in the fluoroscopy room, the time required for room change, and the time the patient was in the CT room. The time between when the telephone call was placed to the radiologist after the patient was positioned in the scanner and when the radiologist entered the room was then subtracted from this result to eliminate a bias unrelated to the modality.

Radiologist time was defined as the interval between when the radiologist entered and left the fluoroscopy or CT room. This interval included talking to the patient, prepping and draping the patient’s shoulder, administering local anesthesia, and injecting contrast material.

Radiation Dose Assessment
Conventional fluoroscopy.—To assess the radiation dose delivered during conventional fluoroscopy, 5-, 10-, and 15-cm slabs of polymethylmethacrylate were imaged. A fixed focus-to-image amplifier distance of 1 m and a fixed field size of 100 cm2 were used. To simulate the clinical setting, a distance of 10 cm between the absorbers and the image amplifier was chosen. An 11-cm3 ionizing chamber, which was connected to a dosimeter (3036; Radcal, Monrovia, Calif), was placed at the entrance of the absorbers to estimate the entrance skin dose for various polymethylmethacrylate thicknesses. This dosimeter was calibrated in accordance with International Electrotechnical Committee standards (22). The actual average field size of fluoroscopy and the average shoulder thickness were calculated in 10 consecutive patients. The averaged absorbed skin dose value was then converted into organ and effective dose values by means of commercially available software (ODS 60 Organ Doses Calculation Software; Rados Technology, Turku, Finland).

CT fluoroscopy and conventional CT.—To assess the radiation dose during a CT examination, normalized CT dose index values were measured in air (at the gantry rotation axis level) and in a standard 32-cm-diameter body phantom at 120 and 140 kV for 3- and 5-mm collimations, respectively, with a 10-cm long CT pencil ionization chamber connected to a dosimeter. This dosimeter was calibrated in accordance with standard 61267 (22). The measured normalized and weighted CT dose index values were compared with those indicated by the manufacturer. Standard software developed by the Danish National Board of Health (www.mta.au.dk) was used to assess the dose delivered to the bone marrow, lungs, and thyroid and the effective dose.

Statistical Evaluation
To compare mean room times, total examination times, and radiologist times for the three modalities, one-way analysis of variance and Bonferroni-Dunn posthoc tests were performed with software (Statview 4; SAS Institute, Cary, NC). Results were considered significant if P values were less than .05 for analysis of variance and less than .0167 for the Bonferroni-Dunn tests. The analysis was not adjusted for the patients’ sex or age or for the shoulder (right or left) examined because these factors were not assumed to be relevant for the time measurements.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Time Measurements
Fluoroscopy and CT room times, total examination times, and radiologist times are summarized in Table 1. The mean total examination time was 28.0 minutes for CT fluoroscopic guidance, 28.6 minutes for conventional CT guidance, and 29.4 minutes for conventional fluoroscopic guidance. The differences were not statistically significant. The time required for the room change was very short (mean, 3.2 minutes) because the fluoroscopy unit and CT scanner are next door to each other and because the CT scanner was strictly scheduled to prevent any delay between the CT and fluoroscopic examination. Radiologist times were 9.0 minutes for conventional fluoroscopy, 9.9 minutes for CT fluoroscopy, and 10.5 minutes for conventional CT. Although there was a tendency in favor of conventional fluoroscopy, the differences between these means were not statistically significant.


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  		TABLE 1. Mean Examination, Room, and Radiologist Times

 
Radiation
Conventional fluoroscopy.—The measured dose rates for different polymethylmethacrylate absorber thicknesses can be fit to the following equation: Dose rate = 0.99 · exp (0.168 · ThPMMA) (R = 0.9998) (Fig 2), where ThPMMA is thickness of polymethylmethacrylate. The median measured shoulder thickness was 14 cm (mean, 13.7 cm; range, 7–19 cm), and the median field size was 83 cm2 (mean, 92.1 cm2; range, 64–192 cm2). The mean fluoroscopy time was 9 seconds. On the basis of these results, the mean absorbed organ doses and the effective radiation dose were calculated (Table 2).



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  		Figure 2. Graph depicts phantom measurements used for determination of effective dose associated with fluoroscopic guidance. With technical parameters set the same as in clinical fluoroscopy, dose rates were measured with 5-, 10-, and 15-cm polymethylmethacrylate (PMMA) absorbers. From these dose rates, the effective dose to the patient can be calculated when shoulder thickness, field size, and duration of fluoroscopy are known.

 

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  		TABLE 2. Radiation Doses

 
CT fluoroscopy and conventional CT.—The CT dose index measurements for a total charge of 100 mAs are summarized in Table 3. The weighted CT dose index values obtained were within 5% of the ones indicated by the unit. Since no major differences appeared when the section thickness was changed from 3 to 5 mm, the weighted CT dose index value used to estimate patient dose was 7.4 mGy/100 mAs at 120 kV and 11.0 mGy/100 mAs at 140 kV. The mean CT fluoroscopy time was 15 seconds. The mean number of sections obtained was six with conventional CT and 25 with diagnostic CT arthrography. With the knowledge that the neck region was not included during CT scanning and by using the previously mentioned parameters, the mean absorbed organ doses and the effective radiation dose for CT fluoroscopic guidance (120 kV, 50 mA, 5 mm), conventional CT guidance (140 kV, 240 mA, 5 mm), and diagnostic CT arthrography (140 kV, 240 mA, 3 mm) were obtained (Table 2). In addition, the mean absorbed organ dose and the effective radiation dose were calculated for conventional CT, with adjusted parameters of 120 kV and 100 mA (Table 2).


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  		TABLE 3. CT Dose Index Measured in Air and Weighted CT Dose Index Measured in Test Object

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
The capability of CT fluoroscopy to display images in real-time, though useful when approaching mobile lesions such as those in the thorax (15), may generate a higher radiation dose than conventional CT (19). It is therefore uncertain whether CT fluoroscopy should be used for interventional procedures that do not require real-time cross-sectional imaging. To our knowledge, only three studies have addressed this issue by comparing CT fluoroscopy with conventional CT for abdominal abscess drainages, biopsies, and gastrostomies (16,19,20). An inherent limitation to such comparative studies, however, is that variations in size, location, and access path of each lesion may influence the examination time and, indirectly, radiation dose more than the variations of the guiding modality. A direct comparison of guidance techniques in the same patient is ethically impossible unless multiple repetitions are clinically indicated. These limitations can be overcome by undertaking a comparative study with either a phantom model (23) or a procedure that is relatively uniform among different patients. Glenohumeral injection of contrast material is an example of a procedure that is virtually independent of patient factors; therefore, the results presented previously may be helpful in making decisions regarding other types of CT-guided interventions.

Time Assessment
CT fluoroscopy has been shown to substantially decrease examination time when compared with conventional CT in a phantom model (23) and in clinical abdominal interventions (20,21). This effect stems from eliminating the time required for the radiologist to leave the CT table and for the technologist to activate the scanner for each localizing examination. The median procedure time was 32% shorter (17 vs 25 minutes) in a comparison of 203 interventional procedures (20). Mean radiologist time was 19% shorter (29 vs 36 minutes) with CT fluoroscopy than with conventional CT in a study of abdominal interventions (21) and was 66% (50 vs 146 seconds) shorter in a phantom model (23). In our study, the reduction of radiologist time was only 6% (9.9 vs 10.5 minutes) and was not statistically significant. This rather small reduction in radiologist time can be explained by the fact that the measured radiologist time included not only the glenohumeral injection of contrast material but also the draping and prepping of the patient’s shoulder, both procedures that were independent of the chosen modality. This took a fixed amount of the already short radiologist times (range, 7–15 minutes) and may have masked differences with regard to the time required for the injection.

The time required for the room change was unusually short in the present study. This time would be longer in institutions with a greater distance between the fluoroscopy and CT rooms and would result in far longer examination times for conventional fluoroscopically-guided techniques in comparison with those for CT-guided techniques. In addition, CT guidance facilitates scheduling because no coordination between two rooms is necessary. On the other hand, depending on scanner availability and applicable fee schedules, conventional fluoroscopy may be preferable because CT room times are shorter.

Radiation Assessment
An inherent disadvantage of CT fluoroscopy is that it potentially increases the radiation exposure both to the patient and to the radiologist.

Radiation exposure to the patient.—In the present study, the effective radiation dose during glenohumeral injection of contrast material was four times lower for CT fluoroscopy than for conventional CT. Although our study is inconsistent with two previous studies (16,19), it is compatible with a recent large study (20). All mentioned studies, including ours, used the same imaging parameters for CT fluoroscopy (120 kV, 50 mA); however, the imaging parameters for conventional CT were slightly different than ours. Froelich et al (16) used 140 kV and 206–250 mA, Spies et al (19) used 120 kV and 200 mA, Carlson et al (20) used 120 kV and 240–280 mA, and we used 140 kV and 240 mA. The different results can be explained by the use of the quick-check method in all of the patients in our study and in 96.6% (196 of 203) of the patients in the Carlson et al study (20) instead of the real-time technique, which was used for all patients in both studies with higher radiation doses. The real-time technique uses continuous radiation exposure during needle placement, whereas the quick-check method uses intermittent short CT fluoroscopy sequences for stepwise needle advancement. Silverman et al (21) reported a significant decrease of the mean CT fluoroscopy exposure time from 90 to 41 seconds and a significant decrease of the mean patient dose index from 85 to 30 cGy by using the quick-check method instead of continuous CT fluoroscopy.

In all mentioned studies, including ours, low milliampere values were chosen for CT fluoroscopy, but the imaging parameters for conventional CT were not reduced compared with those usually used for diagnostic imaging. Teeuwisse et al (24) already described this problem and suggested that milliampere and kilovolt settings be reduced for CT-guided interventions with conventional CT scanners. We calculated the radiation dose for conventional CT guidance in the present study with reduced imaging parameters (120 kV, 100 mA) and found a similar effective radiation dose compared with the one we found with CT fluoroscopy.

Conventional fluoroscopy uses a much lower radiation dose than any other CT modality. In our study, conventional fluoroscopy had an effective radiation dose more than 100 times lower than CT-guidance for glenohumeral injection of contrast material. When the percentage of effective dose caused by the imaging-guided injection is calculated in relation to the effective dose of the entire CT arthrographic examination, conventional fluoroscopy causes only 0.063% of the effective dose (0.0015 mSv/2.4 mSv). CT fluoroscopy, however, is still only responsible for 8% (0.22 mSv/[2.4 mSv + 0.22 mSv]) of the total effective dose (conventional CT with reduced dose: 7% [0.18 mSv ÷ {2.4 mSv + 0.18 mSv}]).

Radiation exposure to the radiologist.—Unlike conventional CT, CT fluoroscopy requires personnel to remain in the CT room during x-ray exposure. The exposure delivered to the hands of the radiologist is of particular concern, because the hand is exposed to the primary beam if the real-time technique is used. Long-handled needle holders have proved to reduce radiation dose to the radiologist’s hand during real-time CT fluoroscopy (3,25), but these devices can be cumbersome and reduce tactile feedback to the radiologist. The quick-check method allows the radiologist to withdraw his or her hand from the imaging plain during x-ray exposure. The quick-check method should therefore be used whenever real-time imaging is not required (20,21,24). Although no direct radiation doses to the radiologist were measured in the present study, our setup is comparable with that of other studies (20,24). An analysis of 203 CT fluoroscopic interventions revealed a measurable reading on the ring badge in one of the seven procedures that used real-time CT fluoroscopy exposure but in none of the 196 procedures that used the quick-check method. The cumulative annual dose for a radiologist who performs CT fluoroscopy procedures with the quick-check method on a regular basis was estimated to be less than 0.1 mSv (24). Besides taking their hand away from the beam, radiologists can further minimize radiation exposure by stepping back during CT fluoroscopy because of the inverse square law (26). In addition, a lead drape should be placed around the patient to reduce scatter exposure (26).

In conclusion, conventional fluoroscopy remains the standard for glenohumeral injection of contrast material for CT arthrography because of an accurate guidance and low radiation dose. CT fluoroscopy and conventional CT are valuable alternative modalities to conventional fluoroscopy. Examination and radiologist times are not significantly different. With adequate CT parameters, the radiation dose associated with CT guidance— although higher than that associated with conventional fluoroscopy— still only constitutes approximately 8% of the entire examination.


   FOOTNOTES
 
Author contributions: Guarantors of integrity of entire study, C.A.B., J.H.; study concepts, C.A.B.; study design, C.A.B., M.Z., J.H.; literature research, C.A.B., C.W.P.; clinical studies, C.A.B., J.H.; data acquisition, C.A.B., F.R.V., J.H.; data analysis/interpretation, all authors; statistical analysis, C.A.B., J.H.; manuscript preparation, C.A.B., F.R.V.; manuscript definition of intellectual content, C.A.B., F.R.V., J.H.; manuscript editing, J.H., M.Z.; manuscript revision/review, F.R.V., M.Z., C.W.P.; manuscript final version approval, C.A.B., J.H.


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DISCUSSION
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S. K. Carlson, J. P. Felmlee, C. E. Bender, R. L. Ehman, K. L. Classic, T. L. Hoskin, W. S. Harmsen, and H. H. Hu
CT Fluoroscopy-guided Biopsy of the Lung or Upper Abdomen with a Breath-hold Monitoring and Feedback System: A Prospective Randomized Controlled Clinical Trial
Radiology, November 1, 2005; 237(2): 701 - 708.
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