Shoulder Protocol

Overview

Indications

Scheduling

Patient Prep

Series Details

Filming

Billing

ICD9 Codes

Sample Report

Examples

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Shoulder Protocol

Overview

Imaging the shoulder is optimal with a dedicated shoulder coil and careful patient positioning in external rotation with the shoulder as close as reasonably possible to the center of the magnet. Axial proton density, coronal oblique T2 fat sat and proton density, and sagittal oblique T2 provide an assessment of the rotator cuff, biceps, deltoid, acromio-clavicular joint, the gleno-humeral joint and surrounding large structures. If a labral injure is suspected, the optional fat sat gradient echo sequence (series 6) may be helpful or it may be necessary to bring the patient back for an MR shoulder arthrogram with intra-articular injection of dilute gadolinium.

	Localizer	Axial PD	Coronal PD	T2 Fat Sat	Sagittal T2	GRE (labrum)
*IMAGING PARAMETERS*
Plane	Coronal	Axial	Oblique	Oblique	Oblique	Axial
Mode	2D	2D	2D	2D	2D	2D
Pulse Seq	GE	FSE	FSE	FSE	FSE	Gradient Echo
Imaging Options	NPW	VBw, Fast NPW	FC, NPW, VBw, Fast	NPW VBw	NPW Fast	NPW
*SCAN TIMING*
# of Echoes	1	1	1	1	1	1
TE	20	30	32	85	120	Minimum
TR	500	4150	4025	3800	3000	500
Flip Angle	30	ET=10	ET=12	ET=10	ET=8	30
Bandwidth	15.6	31.2	16	16		15.63
*ADDITIONAL PARAMETERS (see attached instructions)*
SAT		S,I		Fat		Fat
*ACQUISITION TIMING*
Freq	256	512	256	256	256	512
Phase	128	384	160	160	160	256
NEX	2	2	2	3	3	2
Phase FOV						--
Locs Before Pause						--
Freq DIR	S/I	R/L	S/I	S/I	S/I	R/L
Auto Center Freq	Water	Water	Water	Water	Water	Water
Auto Shim						On
Contrast
*SCANNING RANGE*
FOV	24	14 (12-18)	16 (12-20)	16 (12-20)	16	16
Slice Thickness	6	3.5	4	3.5	5	3.7
Spacing	2	0	0	.5	.5	0.3
Start - End						S60-S18
# Slices						12
*Scan Time*		6:14	4:33	3:56	3:56	4:20

Common Indications	ICD9 Codes
Shoulder pain	719.41
Shoulder instability	718.11
Shoulder mass, lump or bump	719.61

Scheduling Guidelines:

First ask

Have you recently injured the shoulder? Date of injury?

Did you have X-rays? Please bring your shoulder X-rays if not at New York Hospital.
Did you ever dislocate the shoulder?
Ever have surgery on the shoulder? Date of surgery?
Ever have cancer? Type? Date diagnosed?
Is there a shoulder mass?

If patient has history of cancer or if there is a mass, of if there has been prior surgery then schedule during the morning, preferably before 11am.

Otherwise you may schedule anytime.

45 minute slot

Patient preparation:

Positioning: supine with arm at side and palm facing up. It is useful to tuck the hand under the hip to help keep the shoulder motionless. It is important to shift the patient to one side of the magnet so the shoulder being imaged is closer to the center, “sweet spot” of the magnet. This is especially helpful for fat saturation. Place a vitamin E capsule at the site of any mass or symptoms. A wide strap over the shoulder cinched down tight to the table can help reduce shoulder motion during breathing.

Coil: shoulder coil

Landmark: mid-coil

Series 1: Coronal Locator:

This sequence is performed with a large field-of-view so it is not necessary to indicate an offset. Although no adjustment is required, extremely large patients or patients lying on thick cushions may benefit from shifting the coverage to be more anterior.

Series 2: Axial Proton Density

This high resolution, high SNR sequence serves several purposes. It evaluates the acromio-clavicular joint, the gleno-humeral joint, the biceps muscle and bicepital groove, the deltoid muscle. The subscapularis muscle and tendon, the infrospinatus muscle and tendon and any fluid collections. The high resolution is particularly important for evaluating the gleno-humeral articular cartilage and labral pathology.

Prescribe form top of acronium to below gleno-humeral joint
Do not reduce matrix or NEX
For more coverage, increase TR or increase slice thickness (up to a maximum of 5mm)
Remind patient to keep shoulder still as this sequence is particularly motion sensitive.

Series 3 & 4: Coronal Proton Density and T2 Fat Sat

These series are important for evaluating the supraspinatus tendon, bony proliferation, the superior labrum, gleno humeral joint cartilage and any fluid collections.

Oblique to parallel supraspinatus tendon and ?? gleno-humeral joint
Prescribe on a slice corresponding to mid-gleno-humeral joint to avoid positioning the acquisition too for superiorly
Use identical prescriptions for the two sequences so that any supraspinatus tendon abnormalities can be easily compared on the two sequences
To expand coverage, adjust TR or slice thickness but do not exceed a slice thickness of 5 mm. Keep the number of slices at 19 if possible so that each series can be fitted with a reference image on a single 20-on-1 of flim.
On series 4 use Manual Prescan

Series 5: Sagittal T2

This sequence also helps evaluate the rotator cuff as well as the acromio-clavicular joint, sub acromial spurs, acromium type, atrophy of rotator cuff muscles and the clavicle.

· Prescrobe obliqued so slices are parallel to glenoid and perpendicular to series 3&4

· Thick slice up to 6 m are acceptable

· Number of slices should be selected so that the series fits on a single sheet of film (i.e. 19 slices to fit on a 20-on-1 sheet of film with a references image)

Series 6: Optional Gradient Echo with Fat Saturation for Labrum

This sequence provides another look at the labrum with more optimized image contrast.

Prescribe in the axial plane for anterior or posterior labrum or in the coronal oblique plane for the superior labrum
Cover only gleno-humeral joint: 11 slices are sufficient
Use manual pre-scan and cstun to optimize fat saturation. This is important if the shoulder is not in magnet iso-center

Filming Instructions: all sequences 12 on 1

Billing Instructions:

Upper extremity 73221

ICD9 Codes:

sprain-strain	840.0-840.9
acromio-clavicular	840.0
coraco-clavicular	840.2
infraspinatus	840.3
rotator cuff	840.4
subscpularis tendon	840.5
supraspinatus	840.6
subgleniod (deltoid)	840.8
shoulder	840.9

loose body, site unspecified	718.01
benign neoplasm, upper limb including shoulder	215.2
benign neoplasm, scapula and long bones of upper limb	213.4
malignant neoplasm, upper limb including shoulder	171.2
malignant neoplasm, scapula and ling bones of upper limb	170.4
secondary malignancy, lymph nodes of axilla and upper limb	196.3
salmonella osteomelitis	03.24

ostiochondropathy	732.9
bone cyst	733.20
aceptic necrosis of bone, site unspecified	733.40
non-specific abnormal radiologic findings, musculoskeletal system	793.7

Sample Normal Dictation:

Clinical Statement:

Technique: Patient was imaged at 1.5 Tesla in a dedicated shoulder coil

Axial proton density

Coronal Oblique proton density and T2 FSE with fat saturation

Sagittal Oblique T2 FSE

2D gradient echo with fat saturation for evaluation of labrum

Findings: The rotator cuff is intact with no abnormality identifed in the supraspinatus, infraspinatus or subscapularis tendons. There is no shoulder effusion and no fluid identified in the subacromial or subdeltoid bursae. The glenoid labrum appears intact although if there is suspicion of gleno-humeral instability an MR arthrogram may delineate labral and ligamentous pathology in greater detail. The long head of the biceps tendon is in the bicipital groove and has a normal appearance. The osseous structures are normal with no significant proliferative changes.

Impression: Normal shoulder MRI

Examples:

Posterior Labral tear

Shoulder Protocol

Common Indications

ICD9 Codes