Fluoroscopy: An essential diagnostic modality in the age of high-resolution cross-sectional imaging

Abstract

The importance of fluoroscopy as an imaging modality has been minimized relative to other cross-sectional modalities, including high-resolution computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Fluoroscopy examinations have decreased in clinical practice due to reduced appreciation of its usefulness, insufficient training of residents, fewer staff with adequate expertise, and poor reimbursements relative to other modalities. We revisit and build upon the prior literature and history of this decreased utilization. We then seek to prove continued value, through categorized examples and within multiple subspecialties, wherein fluoroscopy plays an integral part toward clinical diagnoses as well as optimizing patient outcomes. This is particularly true for motility and esophageal disorders, where structure and function with real-time evaluation is essential. We additionally show several post-operative cases where the synergy of fluoroscopy with CT and endoscopy is apparent. The fluoroscopic radiologist also has the unique ability to vary patient positioning, as opposed to traditional CT or MRI, where orthogonal views are employed without positional or temporal changes. We turn attention to the modern era, with synergistic and novel cases demonstrating that fluoroscopy remains instrumental toward achieving a diagnosis alongside other modalities. Our cases stress the need to maintain expertise in fluoroscopy skill, and underline its continued importance in residency training programs. We conclude that fluoroscopy is a relatively inexpensive modality that is often under-appreciated in diagnostic radiology. We suggest that competency in fluoroscopy is crucial for future generations of radiologists to both work with their peers, as well as to aid clinicians in the optimal treatment of patients.

MRI‐enema for the assessment of pelvic intestinal anastomotic integrity

“…Anecdotally, fluoroscopy capacity and experience are diminishing in the NHS in favour of cross‐sectional techniques and so this study appears timely. Although it is difficult to know whether this change is reflected internationally, a recent publication from Johns Hopkins in 2020 reviewing the status of fluoroscopy identified ‘insufficient training of residents, fewer staff with adequate expertise, and poor reimbursements relative to other modalities’ [12]. Notwithstanding, MRI will be more expensive and less accessible than fluoroscopy in many hospitals which could hamper its wider implementation.…”

“…WSCE utilizes x-ray fluoroscopy to investigate the flow of contrast through the anastomosis with representative fluoroscopic images acquired, supplemented by higher quality radiographs when required [11]. WSCE using x-ray fluoroscopy has a number of limitations, including limited accuracy with a sensitivity of 78% and a positive predictive value of 62% [10], use of ionizing radiation (particularly relevant for younger patients), limited two-dimensional images, paucity of anatomical information and diminishing fluoroscopy capacity in the UK National Health Service (NHS) and North America, with associated decrease in fluoroscopic skills and interpretative expertise [12]. Unsurprisingly, therefore, some surgeons consider clinical assessment superior and sufficient, questioning the need for routine WSCE [10,11,13].…”

Comparison of the Medical Uses and Cellular Effects of High and Low Linear Energy Transfer Radiation

“…Fluoroscopy using continuous X-ray images combined with contrasting dyes (barium, iodine, or gadolinium) allows real-time imaging of internal organs [ 42 , 43 , 44 ]. Contrast agents administered orally or injected intravenously, intra-articularly, intrathecally, or into the uterus allow imaging of the gastrointestinal system, heart, brain, blood vessels, nervous system, or uterus and fallopian tubes [ 44 , 45 ].…”

“…A comparison of the radiation exposure for fluoroscopy with CT scans shows that in some cases, fluoroscopy results in higher radiation exposure. For instance, the continuous radiation exposure required for barium lower gastrointestinal imaging results in absorbed energy ~20–50 mGy [ 42 , 46 ], which can be higher than the total radiation required for advanced CT with contrast dye of the same area (~15 mGy) [ 35 ]. In contrast, a fluoroscopic myelogram (spinal imaging) delivers ~13 mGy, an upper GI study with barium delivers ~6 mGy, and a hysterosalpingogram results in ~1.2 mGy, compared with a spinal CT ~20 mGy, an abdominal CT image ~10–20 mGy, head or neck CT ~5 mGy, and pelvic CT up to ~10 mGy [ 44 , 47 , 48 , 49 ].…”

X‐Ray Markers for Thin Film Implants

“…A technique which is widely employed for this purpose is X‐ray imaging, specifically computerized tommgraphy (CT) scanning and fluoroscopy. [ 13 ] CT scanning is a technique widely used in neurology that can also be used to localize cortical electrodes, such as electrocoticography (ECoG) devices. [ 14 ] Fluoroscopy is a particular type of live X‐ray imaging that can produce moving images by transmission of X‐rays through the body.…”