The human spine is a complex anatomical and functional complex consisting of components that are heterogeneous in tissue composition, anatomical structure and functions. The severity of diseases and injuries of the spine, the nature of their course, as well as the choice of treatment methods are directly dependent on the degree of involvement of these components in the pathological process and the nature of the pathological changes that occur in them. At the same time, only one component of the spinal column, the vertebrae, has natural x-ray contrast and, therefore, is displayed on ordinary x-rays, which necessitates the use of a number of special methods of x-ray examination (direct and indirect X-ray functional, artificial contrasting and computational X-ray diagnostics).

The basis of the X-ray examination of the spine is a conventional X-ray. Its full complex includes the production of radiographs in the study of the cervical region in five projections, the thoracic - in four and the lumbar, as well as the cervical - in five. When examining the cervical region, these projections are: two standard, i.e. posterior and lateral, two oblique (at an angle of 45° to the sagittal plane) to bring out the articular spaces of the intervertebral joints and the "through the mouth" radiograph, which allows obtaining an image in the posterior projection of the two upper cervical vertebrae, overlapped on the standard posterior radiograph by the shadows of the facial skull and occipital bone . The study of the thoracic spine, in addition to the standard ones, is also performed in two oblique projections, performed for the same purpose as in the study of the cervical spine, however, the child's body deviates from the sagittal plane at an angle of not 45°, but 15°. Four of the five projections used to examine the lumbar spine are similar to the first four projections for examining the cervical spine. The fifth is the lateral one, performed when the central beam of rays is deflected in the caudal direction at an angle of 20-25° with its centering on LIV. Radiography in this projection is performed in order to identify signs of osteochondrosis of the lower lumbar intervertebral discs.

The use of all of the above projections allows you to obtain detailed information about the features of the anatomical structure of all parts of the vertebrae, however, the indications for their use are relatively limited, since X-ray diagnostics of most of the most common pathological changes in the bone components of the spinal column in children can be provided on the basis of an analysis of radiographs produced only in two standard projections - rear and side.

Interpretation of data from conventional radiography allows obtaining information about the features of the spatial position of the spine (or its parts) in the frontal and sagittal planes and vertebrae in the horizontal, about the features of the shape, size, contours and internal structure of the vertebrae, the nature of the anatomical relationships between them, the shape and height of the intervertebral spaces , as well as the magnitude of the local bone age of the spine. As you know, the biological age of various systems of the human body does not always coincide with the passport. The most accurate indicator of the age period of the formation of the osteoarticular system is the degree of ossification of the bones of the wrist and the epiphyses of the short tubular bones of the hand. However, in some diseases of one or another part of the musculoskeletal system in childhood, there is a change in the rate of its development compared to the rate of development of the skeleton as a whole. The severity of this change is one of the indicators of the severity of the pathological process that caused them.

The stages of ossification of the apophyses of the vertebral bodies are used as an X-ray indicator of the age period of spinal formation (D. G. Rokhlin, M. A. Finkelstein, 1956; V. A. Dyachenko, 1954). According to our studies, in the process of ossification of these apophyses, six clearly distinguishable stages can be distinguished, each of which normally corresponds to a certain passport age. The discrepancy between the standard age of the stage of ossification of the vertebral body apophyses revealed during X-ray anatomical examination and the passport age of the child is regarded as an indicator of a violation of the rate of formation of the spine, in the case of a lower age than the passport age of the stage - in the direction of slowing down, more - in the direction of acceleration.

An additional means of obtaining information for standard X-ray anatomical analysis is layer-by-layer radiography, or, as it is more commonly called, tomography, which makes it possible to study the vertebrae in layers without complicating the analysis of the projection layering of images of parts of these vertebrae at different distances from the film. The main indication for the use of tomography in diseases of the spine is the need to resolve the issue of the presence or absence and nature of pathological changes in the bone structure that are not detected on conventional radiographs behind the shadow of reactive sclerosis or due to their small size.

The diagnostic value of tomographic data largely depends on the correct choice of projections for the study and the correct determination of the depth of tomographic slices. We consider it expedient to perform a layer-by-layer radiography of the spine in a lateral projection for the following reasons. In the position of the patient lying on his side, the spine along its entire length is parallel to the surface of the imaging table, which is one of the leading conditions for obtaining a high-quality tomographic image, while in the supine position, due to the presence of physiological curves of the spine, this condition is not met. Further, on the tomograms made in the lateral projection, both the anterior and posterior sections of the vertebrae are displayed on the same section, the latter in the most favorable form for analysis, which allows us to limit ourselves to a relatively small number of sections. On tomograms made in the posterior projection, either only the bodies or individual parts of the vertebral arches are displayed. In addition, a study in the posterior projection excludes the possibility of using such a convenient anatomical landmark as the tops of the spinous processes to determine the level of the cut.

The significance of the correct choice of the depth of the tomographic slice is determined by the fact that the indications for the use of layered radiography occur, as a rule, with relatively small pathological foci, as a result of which an error in determining the depth of the slice by 1 or even 0.5 cm can lead to the failure of their image on film. The use of a simultaneous cassette, which makes it possible to obtain a sequential image of several layers of a filmed object in one run of the tomograph at any given distance between the layers, impresses with its simplicity and high probability of coincidence of one of the slices with the location of the destruction site. At the same time, this method of tomography is associated with unjustified consumption of X-ray films, the analysis of the image on most of which does not carry diagnostic information, since they display unchanged parts of the vertebrae.

Much more justified is the so-called selective tomography, aimed at isolating a strictly defined area of ​​the body or the vertebral arch. The calculation of the depth of the cut in cases where the area of ​​pathologically altered bone tissue is to some extent visible on a conventional posterior radiograph is made on the basis of simple radiometry data. The distance from the pathological focus to the base of the spinous process of the vertebra is measured, then, after laying the patient, the distance from the surface of the imaging table to the apex of the spinous process of the vertebra to be examined is measured, and a value equal to the distance measured from the radiograph between the pathological focus and base of the spinous process. The foregoing can be illustrated by the following specific example. Let's assume that the usual radiograph revealed an increase in size and a change in the bone structure of the right upper articular process of one of the thoracic vertebrae. The distance between this articular process and the base of the spinous process on a radiograph is 1.5 cm. if the patient lies on the right side) and 12 + 1.5 cm (if the patient lies on the left).

If it is difficult to locate the site of destruction or other pathological changes in the bone tissue on the posterior radiograph, its identification on the tomogram is usually ensured by performing three tomographic sections: at the level of the base of the spinous process and the right and left articular. On the first of these tomographic sections, the spinous processes are displayed along their entire length, the lumen of the spinal canal and the central sections of the vertebral bodies, on the other two, the corresponding upper and lower articular processes and the lateral sections of the arches and vertebral bodies.

The standard x-ray anatomical study, although it has sufficiently high informative capabilities, does not provide the fullness of the diagnosis of mild pathological conditions of the intervertebral discs and dysfunctions of the spinal column. The solution of these issues requires the use of methods of artificial contrasting and direct and indirect X-ray functional studies.

Artificial contrasting of the intervertebral discs - discography - has found application mainly in the diagnosis and determination of the severity of osteochondrosis of the intervertebral discs. As contrast agents, iodine-containing compounds on a fatty or water basis are used in the amount of 0.5-1 cm3 per intervertebral disc. Radiography of the spine after disc contrasting is performed in two standard projections. Some authors recommend, in addition, to perform radiographs in various functional positions.

In an unchanged or slightly changed intervertebral disc, only the gelatinous nucleus is contrasted, which is displayed on the posterior radiographs in adults and adolescents in the form of two horizontal stripes, in children - in the form of an oval or rounded shadow. On the lateral radiograph, the gelatinous nucleus of the intervertebral disc in adults has a C-shape, in children it is triangular.

Fragmentation of intervertebral discosis, typical for severe osteochondrosis, is manifested on discograms by the flow of a contrast agent into the spaces between the fragments of the fibrous ring, as well as a decrease in the size and irregularity of the shape of the gelatinous nucleus. Discography is also used to determine the stages of movement of the gelatinous nucleus in children suffering from structural scoli-

In the presence of a number of diagnostic advantages, contrast discography in a pediatric clinic has limited indications. First of all, in vivo and out of surgical intervention, the introduction of a contrast agent is possible only in the discs of the cervical and middle and lower lumbar spine. (Artificial contrasting of the intervertebral discs of the thoracic region by the researchers was performed during the spinal fusion operation). Further, osteochondrosis of the intervertebral discs in children develops relatively rarely, and, finally, according to our research, reliable information about the condition of the discs can be obtained on the basis of a technically simpler and atraumatic direct X-ray functional study.

Information about the state of the static-dynamic functions of the musculoskeletal system by means of X-ray examination is achieved in two ways - based on the analysis of the details of the anatomical structure of bones on standard radiographs, reflecting the magnitude of the functional loads falling on a particular section of the osteoarticular system, and by radiography of the joints or of the spine in the process of their supporting or motor functions. The first of these methods is called the method of indirect X-ray functional research, the second - direct.

The study of the state of the functions of the spine on the basis of indirect indicators includes an assessment of the architectonics of the bone structure and the degree of mineralization of the bone tissue. The latter is included in the complex of indirect X-ray functional research on the grounds that its changes are the result of a violation of the functions of either the bone tissue itself or the functions of the musculoskeletal system as a whole. The main object of research in the analysis of the bone structure are the so-called lines of force, which are clusters of equally oriented, intense bone plates. Equally directed lines of force are grouped into systems, the number and nature of which were described in Chap. I. The architectonics of the bone structure, as established by many researchers, is a highly reactive functional system that quickly responds by changing the severity of field lines or their reorientation to any, even minor, changes in static-dynamic conditions.

The mildest degree of disruption of the normal architectonics of the bone structure of the vertebral bodies and arches consists in the partial or complete resorption of the lines of force in those departments, the load on which has decreased, and in their strengthening in the departments experiencing an increased load. More pronounced biomechanical disorders, especially nervous trophic disorders, are accompanied by the so-called dedifferentiation of the bone structure - complete resorption of all lines of force. An indicator of pronounced changes in the nature of the distribution of static-dynamic loads within the spinal column or one of its departments is the reorientation of the lines of force - their vertical orientation in the vertebral bodies and arcuate - in the arches is replaced by a horizontal one.

A routine X-ray anatomical technique for detecting changes in the degree of mineralization of bone tissue is a visual comparative assessment of the optical densities of an X-ray image of affected and healthy vertebrae. The subjectivity and approximate nature of this method hardly require special evidence. Photodensitometry is an objective method of radiological assessment of the degree of bone mineralization, the essence of which is to carry out photometry of the optical density of the x-ray image of the vertebrae and compare the obtained indicators with the photometric indicators of the norm standard. To ensure the reliability of the photodensitometric diagnosis of osteoporosis or osteosclerosis, the standard of the norm must meet three requirements: 1) the optical density of its x-ray image must be comparable with the optical density of the x-ray image of the vertebrae; 2) the standard should contain samples of the optical density of normal bone of various thicknesses (to provide a quantitative characteristic of changes in mineral saturation); 3) the standard must have a thickness that allows it to be placed under the soft tissues of the body during X-ray without violating the correct laying and causing discomfort to the child. The standards made of artificial materials satisfy this condition to the greatest extent.

The creation of gradations of the optical density of the standard is achieved by giving it a wedge-shaped or stepped shape. X-rays of the spine in the case of the proposed photodensitometric study are made with the lining of the standard under the soft tissues of the lumbar region to ensure the identity of the exposure conditions of the vertebrae and the standard and the conditions for developing the X-ray film. A qualitative assessment of the mineralization of the bone tissue of the vertebrae is carried out by comparing the photometric parameters of the optical density of their x-ray image and the x-ray image of a section of the standard containing a sample of the optical density of normal bone tissue of the same thickness. When a difference in indicators is detected, indicating deviations from the norm in the degree of mineralization of the vertebrae, additional photometry of the standard is carried out in order to determine more or less than the proper optical density of the studied vertebra (or vertebrae) and what specific thickness of normal bone tissue it corresponds to.

The most convenient type of quantitative characteristic of changes in the mineral saturation of the vertebrae (but not its absolute value) is its ratio to the due, expressed as a percentage. The thickness of the vertebral body, measured from the X-ray image made in the opposite projection, is taken as 100%, the thickness of the normal bone, which corresponds to the optical density of the X-ray image of the vertebra, is x%.

Let us assume that the optical density of the vertebral body on the lateral radiograph, which has a frontal size of 5 cm, corresponds to the optical density of a normal bone 3 cm thick. The following proportion is compiled: 5 cm - 100%, 3 cm - x%

Hence, the degree of mineral saturation of the bone tissue of the vertebra is from due = 60%

The most technically advanced means of obtaining information about the process of the implementation of a motor function is film radiography, i.e. filming from the x-ray screen of the moving spine. However, for the purposes of X-ray diagnostics of dysfunctions of the disc-ligamentous apparatus of the spinal column, film radiography can be successfully replaced by conventional radiography, performed in several, rationally chosen phases of movement. Filming, as you know, is done at a speed of 24 frames per second, and when using the "magnifier of time" - at an even higher speed. This means that the time interval between the exposure of two adjacent frames is at least 54 s. In such a short time, the ratios between the bodies and arches of the vertebrae do not have time to noticeably change, and almost identical images are obtained on several adjacent frames. Thus, there is no need to study all received frames, it is enough to analyze only some of them. Moreover, the number of frames required to characterize motor function is relatively small. Cinematography was used primarily to determine the normal range of spinal mobility. The data obtained in this case practically did not differ from the data obtained by the authors who used conventional radiography for the same purpose in the two extreme positions of the spine movement - flexion and extension or lateral inclinations.

According to our research, the necessary and sufficient amount of information about the state of the intervertebral discs and the motor function of the spine or its departments can be obtained on the basis of the analysis of radiographs taken in three functional positions: during physiological unloading, i.e. in the position of the patient lying down with standard laying, with a static load, i.e. in the position of the patient standing, and in the extreme phases of the movements characteristic of the spine. The choice of projections for radiography (posterior or lateral), as well as the number of images in the third functional position (in both extreme positions of a particular movement or only in one of them) are determined by the leading focus of the study (identification of intervertebral disc dysfunctions, violations of the stabilizing functions of the disc ligament apparatus , determination of the volume of mobility of the spine or its departments), as well as the plane of maximum manifestation of the studied pathological changes.

A prerequisite for performing radiographs during a direct X-ray functional study is to maintain the identity of the skin-focal distance, the position of the frontal or sagittal plane of the patient's body in relation to the surface of the imaging table and the identity of the centering of the central X-ray beam. The need to comply with these conditions is due to the fact that the interpretation of data from a direct X-ray functional study includes a comparative analysis of a number of linear values ​​and the location of a number of X-ray anatomical landmarks that are directly dependent on the conditions for performing radiography.

X-ray functional diagnostics of the state of intervertebral discs is based on the assessment of their elastic properties, the state of motor and stabilizing functions. The first two indicators are evaluated by comparative analysis the results of radiometry of the height of the paired marginal sections of the intervertebral spaces (right and left or anterior and posterior) under various conditions of static-dynamic loads. The state of the stabilizing function is determined based on the analysis of the relationships between the vertebral bodies in various functional positions.

Indicators of the normal elastic properties of the disc are a uniform increase in their height on x-rays made in the patient's supine position, compared with the height on x-rays made under static load, by at least 1 mm and the amplitude of fluctuations in the height of the marginal parts of the disc from maximum compression to maximum straightening (with active movements of the body), equal to 3-4 mm in the thoracic spine and 4-5 mm in the lumbar.

The X-ray functional sign of the normal motor function of the disc is the same increase and decrease in the height of its marginal sections during the transition of the body from one extreme position of movement in any plane to another, or, in other words, the appearance on radiographs produced, for example, with lateral inclinations to the right and to the left, wedge-shaped deformation of the Disks, completely identical in quantitative indicators, but opposite in direction.

It is well known that, in addition to ensuring the movements of the spine, the intervertebral discs also have a stabilizing function, completely eliminating the displacement of the vertebral bodies relative to each other in width. Hence, the X-ray functional sign of a violation of the stabilizing function of the disc is a stable or appearing only when the spine moves, the displacement of the body of one or more vertebrae relative to the underlying one. The degree of this displacement due to the presence of bone limiters (almost vertically located articular processes) is small (no more than 2-2.5 mm) and is detected only with a thorough X-ray anatomical analysis.

Each type of pathological restructuring of the intervertebral discs (osteochondrosis, fibrosis, dislocation of the gelatinous nucleus, excessive extensibility) has its own complex of functional disorders, which allows their X-ray diagnosis without the use of contrast discography by direct X-ray functional examination.

Osteochondrosis of the intervertebral discs

The radiological functional syndrome of its early stages consists of a decrease in the elasticity of the intervertebral disc and a unilateral impairment of motor function, since the pathological process at first is most often segmental. Under the influence of physiological unloading, the size of the affected disk increases by a smaller amount than that of the unaffected one. On radiographs made when the body is tilted to the side opposite to the location of the affected disc segment (for example, to the right if the left side of the disc is damaged), the height of this segment increases by a smaller amount than the symmetrical to it, in this case, the right one, with the reverse direction of the slope. Severe, total osteochondrosis is manifested by radiological signs. In addition to the absence of reactions to physiological unloading, reduced amplitude of oscillations of the marginal sections, signs of pathological mobility between the bodies and articular processes of the vertebrae are revealed.

Fibrosis of intervertebral discs

X-ray functional syndrome of this type of pathological restructuring of the disc consists of X-ray functional signs of a sharp decrease in elasticity and an almost complete absence of motor function (the shape of the disc practically does not change during body movements). The stabilizing function of the disc is fully preserved, which distinguishes the radiological functional syndrome of fibrosis from the radiographic manifestations of pronounced osteochondrosis.

Dislocation of the gelatinous nucleus

The process of restructuring the intervertebral disc goes through three main stages: partial displacement of the gelatinous nucleus, characterized at first by a slight, and then by a pronounced change in its shape while maintaining its normal location; complete movement of the gelatinous nucleus from the central sections to one of the edges of the disk; degenerative-dystrophic lesion of the type of fibrosis or osteochondrosis. Partial displacement of the gelatinous nucleus is characterized by the wedge-shaped intervertebral space on the radiograph taken in the standing position, due to its increase in comparison with the proper height on the side to which the dislocation of the nucleus is directed. The elastic properties of the disc are not violated. When the body is tilted towards the base of the wedge, the height of this part of the disk, although somewhat reduced, remains more than expected. The motor function of the opposite part of the disc is not impaired, under the influence of the inclination its height exceeds the proper one.

Complete relocation of the gelatinous nucleus

The wedge shape of the disk is more pronounced (on a radiograph taken under static load) and is due not only to an increase in its height from the side of the base of the wedge, but also to a decrease in comparison with the proper one from the side of its top. The elasticity of the disk sections located at the top of the wedge is reduced - when tilted towards the base of the wedge, the height of the reduced sections of the disk increases slightly and does not reach the proper level. The reaction to this inclination of the expanded part of the disk is the same as in the case of partial displacement of the gelatinous nucleus, but the resistance to compression is even more pronounced.

Excessive extensibility of the intervertebral discs

The X-ray functional syndrome of this type of pathology of the intervertebral discs consists of X-ray functional signs of pathological mobility between the vertebral bodies, combined with an amplitude of fluctuations in the height of the marginal parts of the disc exceeding normal values ​​from maximum compression to maximum stretching in the extreme phases of a particular movement of the spine, which distinguishes the X-ray functional syndrome of increased disc extensibility from X-ray functional manifestations of severe osteochondrosis.

The amount of mobility of the spine in the frontal plane is determined by the total value of the arcuate curvatures formed during inclinations to the right and left, measured by the Cobb or Fergusson method. The normal volume of lateral mobility of the thoracic spine in children, according to our research, is 20-25° (10-12° in each direction), the lumbar - 40-50° (20-25° to the right and left).

The range of mobility in the sagittal plane is characterized by the difference in the values ​​of thoracic kyphosis and lumbar lordosis on radiographs taken in the extreme positions of flexion and extension of the spine. Its normal value in the thoracic spine is 20-25°, in the lumbar - 40°.

The volume of rotational mobility (when the body rotates to the right and to the left) is defined as the sum of the angles of rotation measured on radiographs made when the body is rotated around the vertical axis to the right and left. The normal volume of this type of mobility of the motor segments of the spine is 30° (15° to each side).

Violations of the functions of the musculoskeletal apparatus of the spine have three main options: violation of the stabilizing function, fibrous degeneration of muscles and ligaments, and violation of muscle balance.

X-ray functional signs of a violation of the stabilizing function of the ligamentous apparatus are stable or occurring only in the process of movement, violations of the relationships between the vertebral bodies and in the intervertebral joints. The main cause of pathological mobility between the vertebral bodies is a violation of the stabilizing function of the intervertebral discs, but since ligaments also take part in limiting the displacement of the vertebral bodies in width, the appearance of pathological mobility indicates a violation of their functions. Relationship disorders in the intervertebral joints due to the peculiarities of their spatial location in the thoracic spine and the variability of location in the lumbar are reliably diagnosed on radiographs made in standard projections, only with a significant degree of severity. The X-ray sign of pronounced subluxations is the contact of the tip of the lower articular process of the overlying vertebra with the upper surface of the arch of the underlying one. Identification of more subtle violations of the stability of the intervertebral joints is achieved by conducting a direct x-ray functional study in oblique projections.

Disturbance of muscular balance and fibrous degeneration of ligaments can be determined by means of direct X-ray functional examination only on the basis of taking into account a set of indicators. The leading X-ray functional sign of these changes is the limited mobility of the spine in one or more planes. At the same time, this sign is not pathognomonic, since the amount of mobility of the spine is determined by the state of the functions of not only the muscles and ligaments, but also the intervertebral discs. Based on this, limited mobility of the spine or its individual segments can be considered as an X-ray functional indicator of muscular-ligamentous contractures only if combined with X-ray functional signs of normal elasticity of the intervertebral discs.

Muscular-ligamentous contractures, limiting the motor function of the spine, thereby create obstacles for the full manifestation of the elastic properties of the discs, especially for straightening its marginal sections during movements. Considering this circumstance, a sufficient basis for concluding that there is no pronounced restructuring of the intervertebral discs by the type of fibrosis, congenital hypoplasia, or complete dislocation of the gelatinous nucleus is an increase in their height during physiological stress (compared to the height on radiographs made in the patient's standing position) and the symmetry of compression and expansion of the marginal sections of the disc during lateral tilts or flexion and extension. Osteochondrosis of the intervertebral discs does not cause mobility restrictions.

Injuries and diseases of the spine can have a pathological effect on the membranes and roots of the spinal cord, and in some cases, on the spinal cord itself due to the spread of tumor masses in the corresponding direction, the formation of marginal bone growths in osteochondrosis of the intervertebral discs, dorsal displacement of free posterior hemivertebrae or fragments of damaged bodies and arches. Data on the presence of prerequisites for the occurrence of neurological disorders can be obtained by analyzing conventional radiographs based on a certain direction of marginal bone growths, a local decrease in the distance from the posterior surface of the vertebral bodies to the base of the spinous processes (on a lateral radiograph), or projection of bone fragments against the background of the spinal canal, however a reliable conclusion can only be made on the basis of the interpretation of data from contrast myelography or peridurography.

In the production of myelography, a contrast agent is injected into the intershell space by spinal puncture at the level of the lower lumbar vertebrae (after preliminary removal of 5 ml of cerebrospinal fluid). In the production of peridurography, a contrast agent is injected into the periothecal space through the posterior sacral approach. Each of these methods of X-ray examination has its own advantages and disadvantages.

Myelography creates good conditions for studying the shape and frontal and sagittal dimensions of the spinal cord and thus for detecting its compression, displacements inside the spinal canal, volumetric processes, etc. With this method, contrasting of the roots of the spinal nerves is achieved (Ahu H., Rosenbaum A ., 1981). At the same time, processes that cause an irritating, rather than compressive, effect on the spinal cord are less clearly detected on myelograms. In addition, the introduction of a contrast agent into the intershell space of the spinal cord can cause a number of undesirable side effects (nausea, headache and even spinal epilepsy). Similar complications are observed in 22-40% of patients (Langlotz M. et al., 1981). The production of myelography in the vertical position of the patient's body reduces the number of these complications, but does not eliminate them completely.

Peridurography, on the contrary, has undoubted advantages over myelography in the diagnosis of posterior hernias of the intervertebral disc, mild marginal bone growths, non-ossified cartilaginous exostoses directed towards the spinal canal or spinal nerve roots; does not give undesirable side effects, but is much less informative regarding the state of the spinal cord.

Identification in the X-ray image of the structures of the spinal canal that do not have natural contrast is achieved by the introduction of contrast agents having both a higher and lower molecular weight than soft tissues. The undoubted advantage of the first of them is the provision of high contrast of the resulting image, however, the introduction of the amount of "opaque" contrast agent necessary to fill the intershell or perithecal space can lead to its shadow overlapping the image of small soft tissue formations. The introduction of small amounts is fraught with the danger of uneven distribution of the contrast agent and creating a false impression of the presence of pathological changes. Contrast agents with a lower molecular weight (gases) due to their "transparency" for x-rays do not cause overlapping adhesions, cartilage fragments; Uniform execution of contrasted spaces occurs with the introduction of even small amounts of gas. The disadvantage of this method of contrasting is the low contrast of the resulting image.

The amount of contrast agent varies depending on the age of the child from 5 to 10 ml. Its introduction and subsequent radiography of the spine are performed on an imaging table with a raised head end - with pneumoperidurography for better distribution of gas in the cranial direction, with the use of liquid contrast agents that irritate the brain - with the opposite purpose, i.e. for the purpose of deposition of a contrast agent for a limited extent.

Radiographs of the spine after contrasting the spinal canal are usually made in two standard projections - anteroposterior and lateral, however, if necessary, radiography is performed in a lateral projection in the position of maximum extension of the spine.

X-ray examination - the use of X-rays in medicine to study the structure and function of various organs and systems and to recognize diseases. X-ray examination is based on the unequal absorption of X-ray radiation by different organs and tissues, depending on their volume and chemical composition. The more the organ absorbs x-rays, the more intense the shadow it casts on the screen or film. For x-ray examination of many organs, artificial contrasting is used. A substance is introduced into the cavity of an organ, into its parenchyma or into its surrounding spaces, which absorbs X-rays to a greater or lesser extent than the organ under study (see Shadow contrast).

The principle of X-ray examination can be represented in the form of a simple diagram:
x-ray source → research object → radiation receiver → doctor.

The X-ray tube serves as a source of radiation (see). The object of the study is the patient, directed to identify pathological changes in his body. In addition, healthy people are also examined to detect latent diseases. A fluoroscopic screen or a film cassette is used as a radiation receiver. With the help of a screen, fluoroscopy is performed (see), and with the help of a film - radiography (see).

X-ray examination allows you to study the morphology and function of various systems and organs in the whole organism without disturbing its vital activity. It makes it possible to examine organs and systems at different age periods, allows you to detect even small deviations from the normal picture and thus make a timely and accurate diagnosis of a number of diseases.

X-ray examination should always be carried out according to a certain system. First, they get acquainted with the complaints and the history of the disease of the subject, then with the data of other clinical and laboratory studies. This is necessary because X-ray examination, despite all its importance, is only a link in the chain of other clinical research. Next, they draw up a plan for an x-ray study, that is, they determine the sequence of applying certain methods to obtain the required data. After completing the X-ray examination, they begin to study the obtained materials (X-ray morphological and X-ray functional analysis and synthesis). The next step is the comparison of x-ray data with the results of other clinical studies (clinical-radiological analysis and synthesis). Further, the obtained data are compared with the results of previous X-ray studies. Repeated x-ray examinations play an important role in the diagnosis of diseases, as well as in the study of their dynamics, in monitoring the effectiveness of treatment.

The result of the x-ray examination is the formulation of the conclusion, which indicates the diagnosis of the disease or, if the data obtained are insufficient, the most likely diagnostic possibilities.

Subject to the correct technique and methodology, X-ray examination is safe and cannot harm the subjects. But even relatively small doses of X-ray radiation are potentially capable of causing changes in the chromosomal apparatus of germ cells, which can manifest itself in subsequent generations by changes harmful to offspring (developmental anomalies, a decrease in overall resistance, etc.). Although each X-ray examination is accompanied by the absorption of a certain amount of X-ray radiation in the patient's body, including his gonads, the likelihood of this kind of genetic damage in each specific case is negligible. However, in view of the very high prevalence of X-ray examinations, the problem of safety in general deserves attention. Therefore, special regulations provide for a system of measures to ensure the safety of X-ray examinations.

These measures include: 1) conducting X-ray examinations according to strict clinical indications and special care when examining children and pregnant women; 2) the use of advanced x-ray equipment, which allows to reduce the radiation exposure to the patient to a minimum (in particular, the use of electron-optical amplifiers and television devices); 3) the use of various means of protecting patients and personnel from the effects of X-ray radiation (enhanced radiation filtration, the use of optimal technical conditions for shooting, additional protective screens and diaphragms, protective clothing and protectors of the gonads, etc.); 4) reducing the duration of X-ray examination and the time spent by personnel in the field of action of X-ray radiation; 5) systematic dosimetric monitoring of radiation exposure of patients and personnel of X-ray rooms. Dosimetry data are recommended to be entered in a special column of the form, on which a written conclusion is given on the X-ray examination performed.

X-ray examination may only be carried out by a doctor with special training. The high qualification of the radiologist ensures the effectiveness of radiodiagnostics and the maximum safety of all x-ray procedures. See also X-ray diagnostics.

X-ray examination (X-ray diagnostics) is an application in medicine for studying the structure and function of various organs and systems and for recognizing diseases.

X-ray examination is widely used not only in clinical practice, but also in anatomy, where it is used for the purposes of normal, pathological and comparative anatomy, as well as in physiology, where X-ray examination makes it possible to observe the natural course of physiological processes, such as contraction of the heart muscle, respiratory movements of the diaphragm, peristalsis of the stomach and intestines, etc. An example of the use of X-ray examination for preventive purposes is (see) how method of mass survey of large human contingents.

The main methods of X-ray examination are (see) and (see). Fluoroscopy is the simplest, cheapest and most easily performed method of X-ray examination. An essential advantage of fluoroscopy is the ability to conduct research in various arbitrary projections by changing the position of the body of the subject in relation to the translucent screen. Such a multi-axis (poly-positional) study makes it possible to establish during the transillumination the most advantageous position of the organ under study, in which certain changes are revealed with the greatest clarity and completeness. At the same time, in some cases it is possible not only to observe, but also to feel the organ under study, for example, the stomach, gallbladder, intestinal loops, by the so-called X-ray palpation, carried out in lead rubber or using a special device, the so-called distinctor. Such targeted (and compression) under the control of a translucent screen provides valuable information about the displacement (or non-displacement) of the organ under study, its physiological or pathological mobility, pain sensitivity, etc.

Along with this, fluoroscopy is significantly inferior to radiography in terms of the so-called resolution, i.e., the detectability of details, since, compared with the image on a translucent screen, it more fully and accurately reproduces the structural features and details of the organs under study (lungs, bones, internal relief of the stomach and intestines etc.). In addition, fluoroscopy, compared with radiography, is accompanied by higher doses of x-ray radiation, i.e., increased radiation exposure to patients and staff, and this requires, despite the rapidly transient nature of the phenomena observed on the screen, to limit the time of transmission as much as possible. Meanwhile, a well-executed radiograph, reflecting the structural and other features of the organ under study, is available for repeated study by different people at different times and is, therefore, an objective document that has not only clinical or scientific, but also expert, and sometimes forensic value. .

Repeated radiography is an objective method of dynamic observation of the course of various physiological and pathological processes in the organ under study. A series of radiographs of a certain part of the same child, taken at different times, makes it possible to trace in detail the process of development of ossification in this child. A series of radiographs made over a long period of a number of chronically current diseases (stomach and duodenum, and other chronic bone diseases) makes it possible to observe all the subtleties of the evolution of the pathological process. The described feature of serial radiography makes it possible to use this method of X-ray examination also as a method of monitoring the effectiveness of therapeutic measures.

Lecture number 2.

Before the doctor of any specialty, after the appeal of the patient, the following tasks are:

Determine if this is normal or pathological

Then establish a preliminary diagnosis and

Determine the order of examination

Then make a definitive diagnosis and

Prescribe treatment, and after which it is necessary

Monitor the results of treatment.

A skillful doctor establishes the presence of a pathological focus already on the basis of an anamnesis and examination of the patient; for confirmation, he uses laboratory, instrumental and radiation methods of examination. Knowledge of the possibilities and basics of interpretation of various imaging methods allows the doctor to correctly determine the order of the examination. The end result is the appointment of the most informative examination and a correctly established diagnosis. Currently, up to 70% of information about the pathological focus is given by radiation diagnostics.

Radiation diagnostics is the science of using various types of radiation to study the structure and function of normal and pathologically altered human organs and systems.

The main goal of radiation diagnostics: early detection of pathological conditions, their correct interpretation, as well as control over the process, restoration of morphological structures and functions of the body during treatment.

This science is based on a scale of electromagnetic and sound waves, which are arranged in the following order - sound waves (including ultrasonic waves), visible light, infrared, ultraviolet, x-ray and gamma radiation. It should be noted that sound waves are mechanical vibrations, for the transmission of which any medium is required.

With the help of these rays, the following diagnostic tasks are solved: clarification of the presence and prevalence of the pathological focus; study of the size, structure, density and contours of education; determination of the relationship of the identified changes with the surrounding morphological structures and clarification of the possible origin of education.

There are two types of rays: ionizing and non-ionizing. The first group includes electromagnetic waves, with a short wavelength, capable of causing tissue ionization; they form the basis of X-ray and radionuclide diagnostics. The second group of rays is considered harmless and forms MRI, ultrasound diagnostics and thermography.

For more than 100 years, mankind has been familiar with a physical phenomenon - rays of a special kind, which have penetrating power and are named after the scientist who discovered them, X-rays.

These rays opened a new era in the development of physics and all of natural science, helped to penetrate the secrets of nature and the structure of matter, had a significant impact on the development of technology, and led to revolutionary changes in medicine.

On November 8, 1895, Wilhelm Conrad Roentgen (1845-1923), professor of physics at the University of Würzburg, drew attention to an amazing phenomenon. While studying the operation of an electrovacuum (cathode) tube in his laboratory, he noticed that when a high voltage electric current was applied to its electrodes, a greenish glow of nearby platinum-cyanogen barium appeared. Such a glow of phosphors was already known by that time. Similar tubes have been studied in many laboratories around the world. But on the X-ray table during the experiment, the tube was tightly wrapped in black paper, and although the platinum-cyanogen barium was at a considerable distance from the tube, its glow resumed with each application of an electric current to the tube. He came to the conclusion that some kind of rays unknown to science arise in the tube, which have the ability to penetrate solid bodies and propagate in the air over a distance measured in meters.

Roentgen closed himself in his laboratory and, without leaving it for 50 days, studied the properties of the rays he had discovered.

Roentgen's first report "On a new kind of rays" was published in January 1896 in the form of brief theses, from which it became known that open rays are capable of:

Penetrate to some extent through all bodies;

Cause the glow of fluorescent substances (phosphors);

Cause blackening of photographic plates;

Reduce their intensity inversely with the square of the distance from their source;

Spread in a straight line;

Do not change its direction under the influence of a magnet.

The whole world was shocked and excited by this event. In a short time, information about the discovery of Roentgen began to be published not only by scientific, but also by general journals and newspapers. People were amazed that it became possible to look inside a living person with the help of these rays.

Since that time, a new era has come for doctors. Much of what they could only see before on a corpse, they now saw on photographs and fluorescent screens. It became possible to study the work of the heart, lungs, stomach and other organs of a living person. Sick people began to reveal certain changes in comparison with healthy ones. Within the first year after the discovery of x-rays, hundreds of scientific reports appeared in the press devoted to the study of human organs with their help.

In many countries there are specialists - radiologists. A new science - radiology has stepped far forward, hundreds of different methods of X-ray examination of human organs and systems have been developed. In a relatively short period, radiology has done more than any other science in medicine has done.

Roentgen was the first among physicists to be awarded the Nobel Prize, which was awarded to him in 1909. But neither Roentgen himself nor the first radiologists suspected that these rays could be deadly. And only when the doctors began to suffer from radiation sickness in its various manifestations, the question arose of protecting patients and staff.

Modern x-ray complexes provide maximum protection: the tube is located in a casing with a strict limitation of the x-ray beam (diaphragm) and many additional protective measures (aprons, skirts and collars). As a control of "invisible and intangible" radiation, various control methods are used, the timing of control examinations is strictly regulated by the Orders of the Ministry of Health.

Methods for measuring radiation: ionization - ionization chambers, photographic - by the degree of blackening of the film, thermoluminescent - using phosphors. Each employee of the X-ray room is subject to individual dosimetry, which is carried out quarterly using dosimeters. Individual protection of patients and staff is a strict rule in research. The composition of protective products previously included lead, which, due to its toxicity, has now been replaced by rare earth metals. The effectiveness of protection has become higher, and the weight of the devices has significantly decreased.

All of the above makes it possible to minimize the negative impact of ionizing waves on the human body, however, tuberculosis or a malignant tumor detected in time will outweigh the “negative” consequences of the image taken many times over.

The main elements of X-ray examination are: emitter - electrovacuum tube; the object of study is the human body; the radiation receiver is a screen or a film and naturally a RADIOLOGIST who interprets the received data.

X-ray radiation is an electromagnetic oscillation artificially created in special electrovacuum tubes on the anode and cathode of which, by means of a generator device, a high (60-120 kilovolt) voltage is supplied, and a protective casing, a directed beam and a diaphragm allow to limit the irradiation field as much as possible.

X-rays refer to the invisible spectrum of electromagnetic waves with a wavelength of 15 to 0.03 angstroms. The energy of quanta, depending on the power of the equipment, ranges from 10 to 300 or more KeV. The speed of propagation of X-ray quanta is 300,000 km/sec.

X-rays have certain properties that lead to their use in medicine for the diagnosis and treatment of various diseases.

• The first property is penetrating power, the ability to penetrate solid and opaque bodies.
• The second property is their absorption in tissues and organs, which depends on the specific gravity and volume of tissues. The denser and more voluminous the fabric, the greater the absorption of rays. Thus, the specific gravity of air is 0.001, fat 0.9, soft tissue 1.0, bone tissue 1.9. Naturally, the bones will have the greatest absorption of x-rays.
• The third property of X-rays is their ability to cause the glow of fluorescent substances, which is used when conducting transillumination behind the screen of an X-ray diagnostic apparatus.
• The fourth property is photochemical, due to which an image is obtained on x-ray film.
• The last, fifth property is the biological (negative) effect of X-rays on the human body, which is used for good purposes, the so-called. radiation therapy.

X-ray methods of research are performed using an X-ray apparatus, the device of which includes 5 main parts:

X-ray emitter (X-ray tube with cooling system);

Power supply device (transformer with electric current rectifier);

Radiation receiver (fluorescent screen, film cassettes, semiconductor sensors);

Tripod device and table for laying the patient;

Remote Control.

The main part of any X-ray diagnostic apparatus is an X-ray tube, which consists of two electrodes: a cathode and an anode. The cathode is supplied with a constant electricity which heats up the cathode filament. When a high voltage is applied to the anode, electrons, as a result of a potential difference with a large kinetic energy, fly from the cathode and are decelerated at the anode. When the electrons decelerate, the formation of X-rays occurs - bremsstrahlung beams emerging at a certain angle from the X-ray tube. Modern X-ray tubes have a rotating anode, the speed of which reaches 3000 rpm, which significantly reduces the heating of the anode and increases the power and service life of the tube.

Registration of weakened X-ray radiation is the basis of X-ray diagnostics.

The X-ray method includes the following techniques:

• fluoroscopy, that is, obtaining an image on a fluorescent screen (X-ray image intensifiers - through a television path);
• radiography - obtaining an image on an x-ray film placed in a radiolucent cassette, where it is protected from ordinary light.
• additional techniques include: linear tomography, fluorography, X-ray densitometry, etc.

Linear tomography - obtaining a layered image on x-ray film.

The object of study, as a rule, is any area of ​​the human body that has different density. These are air-containing tissues (lung parenchyma), and soft tissue (muscles, parenchymal organs and gastrointestinal tract), and bone structures with a high calcium content. This determines the possibility of examination under conditions of both natural contrasting and with the use of artificial contrasting, for which there are various types of contrast agents.

For angiography and visualization of hollow organs in radiology, contrast agents are widely used that delay X-rays: in studies of the gastrointestinal tract - barium sulfate (per os) is insoluble in water, water-soluble - for intravascular studies, the genitourinary system and fistulography (urographin, ultravist and omnipack), and also fat-soluble for bronchography - (iodlipol).

Here is a brief overview of the complex electronic system of an x-ray machine. At present, dozens of varieties of X-ray equipment have been developed, from general-purpose devices to highly specialized ones. Conventionally, they can be divided into: stationary X-ray diagnostic complexes; mobile devices (for traumatology, resuscitation) and fluorographic installations.

Tuberculosis in Russia has by now assumed the scope of an epidemic, and oncological pathology is steadily growing, and screening FLH is being carried out to detect these diseases.

The entire adult population of the Russian Federation is required to undergo a fluorographic examination once every 2 years, and decreed groups must be examined annually. Previously, for some reason, this study was called a “preventive” examination. The performed image cannot prevent the development of the disease, it only states the presence or absence of a lung disease, and its purpose is to identify early, asymptomatic stages of tuberculosis and lung cancer.

Allocate medium-, large-format and digital fluorography. Fluorographic installations are produced by the industry in the form of stationary and mobile (installed on a car) cabinets.

A special section is the examination of patients who cannot be delivered to the diagnostic room. These are predominantly resuscitation and trauma patients who are either on mechanical ventilation or on skeletal traction. Especially for this, mobile (mobile) X-ray machines are produced, consisting of a generator and a low-power emitter (to reduce weight), which can be delivered directly to the patient's bed.

Stationary devices are designed to study various areas in various projections using additional devices (tomographic attachments, compression belts, etc.). X-ray diagnostic room consists of: treatment room (place of examination); a control room where the apparatus is controlled and a photo laboratory for X-ray film processing.

The carrier of the received information is a radiographic film, called X-ray, with high resolution. It is usually expressed as the number of separately perceived parallel lines per 1 mm. It is produced in various formats from 35x43 cm, for examining the chest or abdominal cavity, up to 3x4 cm, for taking a picture of the tooth. Before performing the study, the film is placed in x-ray cassettes with intensifying screens, which can significantly reduce the x-ray dose.

There are the following types of radiography:

Overview and sighting shots;

Linear tomography;

Special styling;

With the use of contrast agents.

Radiography allows you to study the morphological state of any organ or part of the body at the time of the study.

To study the function, fluoroscopy is used - a real-time examination with X-rays. It is mainly used in studies of the gastrointestinal tract with contrasting of the intestinal lumen, less often as a clarifying addition in lung diseases.

When examining the chest organs, the X-ray method is the "gold standard" of diagnostics. On a chest x-ray, the lung fields, median shadow, bone structures, and soft tissue component are distinguished. Normally, the lungs should be of the same transparency.

Classification of radiological symptoms:

1. Violation of anatomical relationships (scoliosis, kyphosis, developmental anomalies); changes in the area of ​​lung fields; expansion or displacement of the median shadow (hydropericardium, mediastinal tumor, change in the height of the dome of the diaphragm).

2. The next symptom is “darkening or decrease in pneumatization”, caused by compaction of the lung tissue (inflammatory infiltration, atelectasis, peripheral cancer) or fluid accumulation.

3. The symptom of enlightenment is characteristic of emphysema and pneumothorax.

The musculoskeletal system is examined under conditions of natural contrast and allows to detect many changes. It is necessary to remember about age features:

up to 4 weeks - no bone structures;

up to 3 months - the formation of a cartilaginous skeleton;

4-5 months to 20 years the formation of the bone skeleton.

Types of bones - flat and tubular (short and long).

Each bone is composed of a compact and spongy substance. Compact bone substance, or cortical layer, in different bones has a different thickness. The thickness of the cortical layer of long tubular bones decreases from the diaphysis to the metaphysis and is most thinned in the epiphyses. Normally, the cortical layer gives an intense, homogeneous darkening and has clear, smooth contours, while the defined irregularities strictly correspond to the anatomical tubercles, ridges.

Under the compact layer of the bone is a spongy substance, consisting of a complex interlacing of bone trabeculae, located in the direction of action of the forces of compression, tension and torsion on the bone. In the department of the diaphysis, there is a cavity - the medullary canal. Thus, the spongy substance remains only in the epiphyses and metaphyses. The epiphyses of growing bones are separated from the metaphyses by a light transverse strip of growth cartilage, which is sometimes mistaken for a fracture line.

The articular surfaces of bones are covered with articular cartilage. The articular cartilage does not show a shadow on the x-ray. Therefore, between the articular ends of the bones there is a light strip - the X-ray joint space.

From the surface, the bone is covered with periosteum, which is a connective tissue sheath. The periosteum normally does not give a shadow on the radiograph, but in pathological conditions it often calcifies and ossifies. Then, along the surface of the bone, linear or other forms of the shadow of periosteal reactions are found.

The following radiological symptoms are distinguished:

Osteoporosis is a pathological restructuring of the bone structure, which is accompanied by a uniform decrease in the amount of bone substance per unit of bone volume. For osteoporosis, the following radiological signs are typical: a decrease in the number of trabeculae in the metaphyses and epiphyses, thinning of the cortical layer and expansion of the medullary canal.

Osteosclerosis is characterized by signs opposite to osteoporosis. Osteosclerosis is characterized by an increase in the number of calcified and ossified bone elements, the number of bone trabeculae increases, and there are more of them per unit volume than in normal bone, and thereby the marrowy spaces decrease. All this leads to radiological symptoms opposite to osteoporosis: the bone on the radiograph is more compacted, the cortical layer is thickened, its contours both from the side of the periosteum and from the side of the medullary canal are uneven. The medullary canal is narrowed, and sometimes not visible at all.

Destruction or osteonecrosis is a slow process with a violation of the structure of entire sections of the bone and its replacement with pus, granulations or tumor tissue.

On x-ray, the focus of destruction looks like a defect in the bone. The contours of fresh destructive foci are uneven, while the contours of old foci become even and compacted.

Exostoses are pathological bone formations. Exostoses occur either as a result of a benign tumor process, or as a result of an anomaly of osteogenesis.

Traumatic injuries (fractures and dislocations) of bones occur with a sharp mechanical impact that exceeds the elastic capacity of the bone: compression, stretching, flexion and shear.

X-ray examination of the abdominal organs in conditions of natural contrast is used mainly in emergency diagnostics - this is free gas in the abdominal cavity, intestinal obstruction and radiopaque calculi.

The leading role is occupied by the study of the gastrointestinal tract, which allows you to identify a variety of tumor and ulcerative processes affecting the gastrointestinal mucosa. An aqueous suspension of barium sulfate is used as a contrast agent.

The types of examination are as follows: X-ray of the esophagus; fluoroscopy of the stomach; passage of barium through the intestines and retrograde examination of the colon (irrigoscopy).

The main radiological symptoms: a symptom of local (diffuse) expansion or narrowing of the lumen; a symptom of an ulcerative niche - in the case when the contrast agent spreads beyond the border of the organ contour; and the so-called filling defect, which is determined in cases where the contrast agent does not fill the anatomical contours of the organ.

It must be remembered that FGS and FCS currently occupy a dominant place in examinations of the gastrointestinal tract, their disadvantage is the inability to detect formations located in the submucosal, muscular and further layers.

Most doctors examine the patient according to the principle from simple to complex - performing "routine" methods at the first stage, and then supplementing them with more complex studies, up to high-tech CT and MRI. However, now the prevailing opinion is to choose the most informative method, for example, if a brain tumor is suspected, an MRI should be done, and not a picture of the skull on which the bones of the skull will be visible. At the same time, the parenchymal organs of the abdominal cavity are perfectly visualized by the ultrasound method. The clinician must know the basic principles of a complex radiological examination for particular clinical syndromes, and the diagnostician will be your consultant and assistant!

These are studies of the chest organs, mainly the lungs, the musculoskeletal system, the gastrointestinal tract and the vascular system, provided that the latter are contrasted.

Based on the possibilities, indications and contraindications will be determined. There are no absolute contraindications! Relative contraindications are:

Pregnancy, lactation.

In any case, it is necessary to strive for the maximum limitation of radiation exposure.

Any doctor of practical health care repeatedly sends patients for X-ray examination, and therefore, there are rules for issuing a referral for research:

1. the surname and initials of the patient and age are indicated;

2. the type of study is assigned (FLG, fluoroscopy or radiography);

3. the area of ​​examination is determined (organs of the chest or abdominal cavity, osteoarticular system);

4. the number of projections is indicated (general view, two projections or special styling);

5. it is necessary to set the purpose of the study before the diagnostician (exclude pneumonia or a hip fracture, for example);

6. date and signature of the doctor who issued the referral.

Modern methods of X-ray studies are classified primarily by the type of hardware visualization of X-ray projection images. That is, the main types of X-ray diagnostics are differentiated by the fact that each is based on the use of one of several existing types of X-ray detectors: X-ray film, fluorescent screen, electron-optical X-ray converter, digital detector, etc.

Classification of X-ray diagnostic methods

In modern radiology, there are general research methods and special or auxiliary ones. Practical use These methods are only possible with the use of X-ray machines. Common methods include:

• radiography,
• fluoroscopy,
• teleradiography,
• digital radiography,
• fluorography,
• linear tomography,
• CT scan,
• contrast radiography.

Special studies include an extensive group of methods that allow solving a wide variety of diagnostic problems, and there are invasive and non-invasive methods. Invasive ones are associated with the introduction into various cavities (alimentary canal, vessels) of instruments (radio-opaque catheters, endoscopes) for carrying out diagnostic procedures under the control of x-rays. Non-invasive methods do not involve the introduction of instruments.

Each of the above methods has its own advantages and disadvantages, and hence certain limits of diagnostic capabilities. But all of them are characterized by high information content, ease of implementation, accessibility, the ability to complement each other and generally occupy one of the leading places in medical diagnostics: in more than 50% of cases, diagnosis is impossible without the use of X-ray diagnostics.

Radiography

The radiography method is the obtaining of fixed images of an object in the X-ray spectrum on a material sensitive to it (X-ray film, digital detector) according to the principle of inverse negative. The advantage of the method is a small radiation exposure, high image quality with clear detail.

The disadvantage of radiography is the impossibility of observing dynamic processes and the long processing period (in the case of film radiography). To study dynamic processes, there is a method of frame-by-frame image fixation - X-ray cinematography. It is used to study the processes of digestion, swallowing, respiration, blood circulation dynamics: X-ray phase cardiography, X-ray pneumopolygraphy.

Fluoroscopy

The method of fluoroscopy is the obtaining of an x-ray image on a fluorescent (luminescent) screen according to the direct negative principle. Allows you to study dynamic processes in real time, optimize the position of the patient in relation to the X-ray beam during the study. X-ray allows you to evaluate both the structure of the organ and its functional state: contractility or extensibility, displacement, filling with a contrast agent and its passage. The multiprojectivity of the method allows you to quickly and accurately identify the localization of existing changes.

A significant drawback of fluoroscopy is a large radiation load on the patient and the examining physician, as well as the need to conduct the procedure in a dark room.

X-ray television

Telefluoroscopy is a study that uses the conversion of an x-ray image into a television signal using an image intensifier tube or amplifier (EOP). A positive x-ray image is displayed on a TV monitor. The advantage of the technique is that it significantly eliminates the shortcomings of conventional fluoroscopy: radiation exposure to the patient and staff is reduced, image quality (contrast, brightness, high resolution, image magnification) can be controlled, the procedure is performed in a bright room.

Fluorography

The fluorography method is based on photographing a full-length shadow X-ray image from a fluorescent screen onto film. Depending on the film format, analog fluorography can be small-, medium- and large-frame (100x100 mm). It is used for mass preventive studies, mainly of the chest organs. In modern medicine, more informative large-frame fluorography or digital fluorography is used.

Contrast radiodiagnosis

Contrast X-ray diagnostics is based on the use of artificial contrasting by introducing radiopaque substances into the body. The latter are divided into X-ray positive and X-ray negative. X-ray positive substances basically contain heavy metals - iodine or barium, therefore they absorb radiation more strongly than soft tissues. X-ray negative substances are gases: oxygen, nitrous oxide, air. They absorb X-rays less than soft tissues, thereby creating a contrast with respect to the organ being examined.

Artificial contrasting is used in gastroenterology, cardiology and angiology, pulmonology, urology and gynecology, used in ENT practice and in the study of bone structures.

How an x-ray machine works

Introduction

diagnostics medical examination endoscopic

The last decade of the 20th century is characterized by the rapid development of radiology. The main reason for this is the emergence of a whole series of so-called "new technologies" that have made it possible to dramatically expand the diagnostic potential of the "old" traditional radiology. With their help, the concept of the so-called white spots in classical radiology was essentially "closed" (for example, the pathology of the entire group of parenchymal organs of the abdominal cavity and retroperitoneal space). For a large group of diseases, the introduction of these technologies has dramatically changed the existing possibilities for their radiological diagnosis.

In many ways, it is due to the success of radiodiagnosis in leading clinics in America and Europe that the time for making a diagnosis does not exceed 40-60 minutes from the moment the patient enters the hospital. Moreover, we are talking, as a rule, about serious urgent situations, where delay often leads to irreversible consequences. Moreover, the hospital bed has become less and less used for diagnostic activities. All the necessary preliminary studies, and first of all radiation, are performed at the prehospital stage.

Radiological procedures in terms of the frequency of their use have long been ranked second, second only to the most common and mandatory laboratory tests. The summary statistics of the world's major medical centers shows that, thanks to X-ray methods, the number of erroneous diagnoses during the initial visit of a patient today does not exceed 4%.

Modern imaging tools meet the following fundamental principles: impeccable image quality, equipment safety for both patients and medical staff, reliable operation.

The purpose of the work: to gain knowledge about instrumental methods of examining patients in x-ray, endoscopic and ultrasound studies.

Instrumental methods for X-ray, endoscopic and ultrasound examinations

Methods for studying the structure and functions of human organs using special equipment are called instrumental. They are used for the purpose of medical diagnosis. For many of them, the patient must be psychologically and physically prepared. The nurse must be proficient in the technology of preparing patients for instrumental examinations.

X-ray methods of research

X-ray (X-ray) examination is based on the property of X-rays to varying degrees to penetrate the tissues of the body. The degree of absorption of X-ray radiation depends on the thickness, density and physico-chemical composition of human organs and tissues, therefore, denser organs and tissues (bones, heart, liver, large vessels) are visualized on the screen (X-ray fluorescent or television) as shadows, and lung tissue due to the large amount of air, it is represented by an area of ​​\u200b\u200bbright glow. Wilhelm Conrad Roentgen (1845-1923) - German experimental physicist, founder of radiology, discovered X-rays (X-rays) in 1895. On x-rays of the intestine with contrast, you can see - a change in the lumen of the intestine, an increase in the length of the organ, etc. (Attachment 1).

Figure 1. X-ray room.

There are the following main radiological methods of research:

1. Fluoroscopy (Greek skopeo - to examine, observe) - X-ray examination in real time. A dynamic image appears on the screen, allowing you to study the motor function of organs (for example, vascular pulsation, gastrointestinal motility); the structure of organs is also visible.

2. Radiography (Greek grapho - to write) - X-ray examination with the registration of a still image on a special X-ray film or photographic paper. With digital radiography, the image is fixed in the computer's memory. Five types of radiography are used.

* Full-format radiography.

* Fluorography (small format radiography) - radiography with a reduced size of the image obtained on a fluorescent screen (Latin fluor - flow, flow); it is used in preventive studies of the respiratory system.

* Plain radiography - an image of the entire anatomical region.

* Sighting radiography - an image of a limited area of ​​the organ under study.

* Serial radiography - sequential acquisition of several radiographs to study the dynamics of the process under study.

3. Tomography (Greek tomos - segment, layer, layer) - a layer-by-layer visualization method that provides an image of a tissue layer of a given thickness using an X-ray tube and a film cassette (X-ray tomography) or with the connection of special counting chambers from which electrical signals are supplied on a computer (computed tomography).

4. Contrast fluoroscopy (or radiography) - an X-ray method of research based on the introduction into hollow organs (bronchi, stomach, renal pelvis and ureters, etc.) or vessels (angiography) of special (radiocontrast) substances that delay x-rays, resulting in on the screen (film) receive a clear image of the studied organs.

Before conducting an x-ray examination, the area of ​​the planned examination should be freed from clothing, ointment dressings, adhesive plaster stickers, ECG monitoring electrodes, etc., and asked to remove watches, metal jewelry and pendants.

X-ray examination of the chest organs is an important method for examining patients with diseases of the respiratory system and CVS.

Fluoroscopy and radiography are the most commonly used methods for examining the respiratory organs. X-ray examination allows you to assess the condition of the lung tissue, the appearance in it of areas of compaction and increased airiness, the presence of fluid or air in the pleural cavities. Special preparation of the patient is not required. The study is carried out in the position of the patient standing or, in a serious condition of the patient, lying down.

Contrast radiography of the bronchi (bronchography) is used to detect tumor processes in the bronchi, expansion of the bronchi (bronchiectasis) and a cavity in the lung tissue (abscess, cavity). A radiopaque substance is injected into the bronchial cavity.

Preparation of the patient for bronchography is carried out in several stages:

1. Conducting a test for individual tolerance of iodine-containing drugs (iodine test): within 2-3 days, as directed by a doctor, the patient is offered to drink 1 tbsp. 3% potassium iodide solution. Another option for conducting an iodine test: on the eve of the study, the skin of the inner surface of the patient's forearm is treated with a 5% alcohol solution of iodine. It is necessary to ask the patient about the tolerance of drugs, in particular, anesthetics (tetracaine, lidocaine, procaine), if necessary, conduct intradermal allergological tests. The medical history should reflect the date of the drug tolerance test, a detailed description of the patient's condition (presence or absence of signs of hypersensitivity); the signature of the nurse who observed the patient within 12 hours after the test is required.

2. Purification of the bronchial tree in the presence of purulent sputum: for 3-4 days, according to the doctor's prescription, the patient is prescribed bronchial drainage (by taking the appropriate, optimal for sputum discharge, position with the raised foot end of the bed), expectorants and bronchodilators.

3. Psychological preparation: the patient should be explained the purpose and necessity of the upcoming study. In some cases, patients before the study may develop insomnia, increase blood pressure. In this case, as prescribed by the doctor, the patient is given sedatives and antihypertensive drugs.

4. Direct preparation of the patient for the study: on the eve of the study, the patient is given a light dinner (exclude milk, cabbage, meat). It is necessary to warn the patient that the study is carried out on an empty stomach; On the morning of the study, he should also not drink water, medicines and smoke. The patient needs to be reminded that before the study, he must empty the bladder and intestines (naturally).

5. Premedication: 30-60 minutes before the examination, according to the doctor's prescription, the patient is given special preparations (diazepam, atropine, etc.) in order to create conditions for free access of the bronchoscope. Particular attention should be paid to the patient after the study, since the following complications may develop:

* the appearance or intensification of coughing with sputum with a large amount of radiopaque substance (sometimes the injected substance is released within 1-2 days); while the patient should be provided with a special jar (spittoon) for sputum;

* increased body temperature;

* the development of pneumonia (in rare cases, with poor contrast agent secretion).

If a patient develops symptoms after bronchography, such as fever, worsening of the general condition, a sharp increase in cough, the appearance of shortness of breath, the nurse should immediately inform the doctor about this.

Fluoroscopy and radiography are also often used to study the CCC (heart, aorta, pulmonary artery). X-ray examination allows you to determine the size of the heart and its chambers, large vessels, the presence of displacement of the heart and its mobility during contractions, the presence of fluid in the pericardial cavity. If necessary, the patient is offered to drink a small amount of a radiopaque substance (a suspension of barium sulfate), which makes it possible to contrast the esophagus and judge the degree of enlargement of the left atrium by the degree of its displacement. Special preparation of the patient is not required.

Contrast radiography (angiocardiography) is used to determine the condition of large vessels and chambers of the heart. A radiopaque substance is injected into the large vessels and cavities of the heart through special probes. This procedure is actually a surgical operation, it is carried out in a specially equipped operating room, as a rule, in the conditions of a cardiac surgery department. On the eve of the study, the patient needs to conduct tests for the tolerance of iodine-containing drugs and anesthetics. The study is carried out on an empty stomach. In addition, the nurse must give the patient Special attention after the study, since the introduction of a radiopaque substance into the cavity of the heart can cause not only early, but also late complications. X-ray examination of the digestive organs makes it possible to assess the state of hollow (esophagus, stomach, intestines, biliary tract) and parenchymal (liver, pancreas) organs. Radiography and fluoroscopy of the digestive organs without a radiopaque agent are used to detect intestinal obstruction or perforation of the stomach and intestines. The use of a radiopaque substance (suspension of barium sulfate) allows you to determine the motor function and relief of the mucous membrane of the digestive tract, the presence of ulcers, tumors, areas of narrowing or expansion of various parts of the digestive tract.

Examination of the esophagus. Preparation of the patient for x-ray examination of the esophagus depends on the indications.

* No special preparation is required to detect a foreign body in the esophagus.

* To assess the motor function of the esophagus and its contours (detection of areas of narrowing and expansion, tumors, etc.), fluoroscopy and / or serial radiography is performed; while the patient before the study is given to drink a radiopaque substance (150-200 ml of a suspension of barium sulfate).

* If it is necessary to conduct a differential diagnosis of organic narrowing and functional damage (esophageal spasms), 15 minutes before the study, as prescribed by the doctor, the patient is administered 1 ml of a 0.1% solution of atropine. In the presence of a pronounced organic narrowing of the esophagus, as prescribed by the doctor, using a thick probe and a rubber pear, the accumulated liquid is suctioned from the esophagus.

Examination of the stomach and duodenum. The preparation of the patient for an x-ray examination consists in the release of these sections of the digestive tract from food masses and gases and begins a few days before the examination. The stages of patient preparation are as follows.

1. Appointment 3 days before the study of a diet that excludes food rich in plant fiber and contains other substances that contribute to increased gas formation. It is necessary to exclude freshly baked rye bread, potatoes, legumes, milk, vegetables and fruits, fruit juices from the diet.

2. On the eve of the study, the patient is prescribed a light dinner (no later than 8 pm). Eggs, cream, caviar, cheese, meat and fish without seasonings, tea or coffee without sugar, porridge boiled in water are allowed.

3. The night before and in the morning 2 hours before the study, the patient is given a cleansing enema.

4. It is necessary to warn the patient that 12 hours before the study, he should stop eating, in the morning on the day of the study, he should also not drink, take any medications and smoke.

Colon examination. To conduct an x-ray examination of the colon - irrigoscopy (lat. irrigatio - irrigation) - a complete cleaning of the intestine from contents and gases is necessary. A radiopaque substance - up to 1.5 liters of warm (36-37 ° C) suspension of barium sulfate - is injected into the intestine with an enema directly in the X-ray room. Contraindications to irrigoscopy: diseases of the rectum and its sphincters (inflammation, tumor, fistula, sphincter fissure). There are situations when the patient cannot keep the fluid injected into the intestines (rectal prolapse, sphincter weakness), which makes this procedure impossible.

Stages of preparing the patient for the study:

1. Appointment 2-3 days before the study of a diet that excludes food rich in plant fiber and contains other substances that contribute to increased gas formation. It is necessary to exclude fresh rye bread, potatoes, legumes, fresh milk, fresh vegetables and fruits, fruit juices from the diet.

2. On the eve of the study, the patient is prescribed a light dinner (no later than 8 pm). Allowed scrambled eggs, kefir, caviar, cheese, boiled meat and fish without seasonings, tea or coffee without sugar, semolina porridge boiled in water.

3. On the eve of the study, before dinner, the patient is given 30 g of castor oil for oral administration (a contraindication to taking castor oil is intestinal obstruction).

4. The night before (30-40 minutes after dinner), the patient is given cleansing enemas with an interval of 1 hour until “clean” washings are obtained.

5. In the morning, 2 hours before the study, the patient is given a cleansing enema, also until “clean” washings are obtained.

6. The study is carried out on an empty stomach. If necessary, according to the doctor's prescription, the patient is allowed a light protein breakfast in the morning (low-fat cottage cheese, whipped protein soufflé or protein omelette, boiled fish), which allows you to cause a reflex movement of the contents of the small intestine into the large intestine and prevent the accumulation of gases in the intestine. In this case, the morning cleansing enema is given 20-30 minutes after breakfast.

7. 30 minutes before the examination, the patient is given a gas outlet tube.

Oral lavage is another way to cleanse the intestines before X-ray and endoscopic examination. For its implementation, iso-osmotic solutions are used, for example, Fortrans. Fortrans package intended for one patient consists of four bags containing 64 g of polyethylene glycol in combination with 9 g of electrolytes - sodium sulfate, sodium bicarbonate, sodium chloride and potassium chloride. Each package is dissolved in 1 liter of boiled water. As a rule, the patient is prescribed the first 2 liters of solution in the afternoon on the day preceding the study; the second portion in the amount of 1.5-2 liters is given in the morning on the day of the study. The action of the drug (intestinal emptying) is not accompanied by pain and tenesmus, begins 50-80 minutes after the start of taking the solution and lasts for 2-6 hours. Bowel emptying with repeated administration of Fortrans in the morning begins 20-30 minutes after taking the drug. The use of Fortrans is contraindicated in patients with non-specific ulcerative colitis, Crohn's disease, intestinal obstruction, abdominal pain of unknown etiology.

X-ray examination of the gallbladder (cholecystography) allows you to determine its shape, position and deformation, the presence of stones in it, the degree of emptying. A radiopaque substance (for example, sodium iopodate - "Bilimin") is given to the patient to drink; while the concentration of the contrast agent reaches a maximum in the gallbladder 10-15 hours after its administration. If a radiopaque substance is administered intravenously, such a study is called intravenous cholegraphy. This method allows contrasting intrahepatic bile ducts. In this case, after 20-25 minutes, you can get an image of the bile ducts, and after 2-2.5 hours of the gallbladder. Preparation of the patient for the study depends on the method of administration of the contrast agent.

The stages of preparing the patient for cholecystography are as follows:

1. Appointment 2-3 days before the study of a diet that excludes food rich in plant fiber and contains other substances that contribute to increased gas formation. It is necessary to exclude from the diet fresh rye bread, potatoes, legumes, fresh milk, fresh vegetables and fruits, fruit juices.

2. On the eve of the study, after a light dinner (with the exception of fats), the patient is given a cleansing enema.

3. 12 hours before the study, the patient takes a radiopaque substance (for example, 3 g of "Bilimin"), drinking warm tea. If the patient is obese, the patient is given to drink "Bilimin" twice - for 3 g at 20 o'clock and at 22 o'clock.

4. It is necessary to warn the patient that the study is carried out on an empty stomach. Directly in the X-ray room, the patient receives a choleretic breakfast (100 g of sour cream or 20 g of butter on a thin piece of white bread).

With intravenous cholegraphy, the stages of preparing the patient for the study include a mandatory test for individual tolerability of the drug (several days before the study), the appointment of a diet with the exclusion of products that contribute to increased gas formation, the setting of cleansing enemas the night before and in the morning on the day of the study. Intravenous cholegraphy is also performed on an empty stomach. Before the study, a radiopaque substance warmed up to the temperature of the human body is injected intravenously slowly (within 4-5 minutes).

Plain radiography of the kidneys and urinary tract makes it possible to determine the shape and position of the renal pelvis and ureters, in some cases - to assess the presence of stones (calculi).

contrast radiography. Depending on the method of administration of the radiopaque substance, two types of contrast radiography of the kidneys and urinary tract are distinguished.

* Retrograde urography is a research method when a radiopaque substance is injected through a urinary catheter under the control of a cystoscope into the desired ureter. Special preparation of the patient is not required.

* With excretory urography, a radiopaque substance is administered intravenously. This research method allows you to identify the presence of stones, anomalies, cicatricial narrowing, tumor formations in the kidneys and urinary tract. The rate of release of the radiopaque substance characterizes the functional ability of the kidneys.

The stages of preparing a patient for an X-ray examination of the kidneys and urinary tract are as follows:

1. Appointment 2-3 days before the study of a diet that excludes food rich in plant fiber and contains other substances that contribute to increased gas formation. It is necessary to exclude fresh rye bread, potatoes, legumes, fresh milk, fresh vegetables and fruits, fruit juices from the diet. With flatulence, according to the doctor's prescription, the patient is given activated charcoal.

2. Carrying out a test for individual tolerance of a radiopaque substance 12-24 hours before the study.

3. Restriction of fluid intake by the patient 12-18 hours before the study.

4. Statement of a cleansing enema (until "clean" washings are obtained) the night before and in the morning 2 hours before the study. The study is carried out strictly on an empty stomach.

The radiopaque agent is administered to the patient directly in the radiology room.