Protocol Guide

Please protocol all available studies on RadDash and keep the queue ideally a week out as clean as possible (= less phone calls, less pages on call)

Here are some protocoling tips: 

1.      Almost ALL MSK CT’s do not require contrast. The exceptions are: 

a.      Abscess 

b.      Soft tissue tumor (not bone tumors or spines) 

2.      Almost ALL MSK MRI’s do not require contrast. The exceptions (which are also debatable) are: 

a.      Primary bone and soft tissue tumors (add LAVA/VIBE/TIGRE pre/post - ask Jad if questions)

b.      Discitis, septic arthritis or soft tissue infection (if the question is primarily osteomyelitis, there is a specific protocol performed without contrast)

c. Post-surgical spines within one year.

*For screening of metastases (e.g. spine) without a known diagnosis, MRI can usually be done without contrast

4. For the spine:

a. Spine MRI's may show up as "MR.XS.LSPINE (NEURO)" "MR.XS.TSPINE (NEURO)" and "MR.XS.CSPINE (NEURO)". To make sure this should be protocoled by MSK,  check the indication under the fields "Signs" and "Clinical context". Next, check the field "MGH Specific". It should say "Musculoskeletal Interpretation". If it is not the case, then you can reassign it to the NEURO queue. 

5.      For feet: 

a.      Osteomyelitis:

• Check the history/LMR note for most foot MRI’s – because the ordering clinician doesn’t always say that the study is for osteomyelitis when they order the study. 

• We have an osteomyelitis protocol, which is 3 plane STIR and 3 plane T1 images. No contrast is needed.

• Specify the body part to focus on (e.g. please include calcaneus and midfoot through base of metatarsals, please focus on ulcer and fifth toe with 5 cm field of view, etc.)

b.      Please don’t use “forefoot,” “midfoot,” or “hindfoot” protocols unless you’re 100% sure that’s what you want. We get feet wrong a high percentage of the time. By using the preset protocol it gives the techs a chance to set it and forget it and not actually look at the images. Also, they don’t reliably cover the right area anyways. It may take a little longer, but it’s worth going into the case, looking at any prior imaging, and writing a protocol like “MRI foot centered at the TMT joints, covering talus to mid metatarsals using forefoot sequences” (or midfoot sequences etc etc). And in general, try to avoid using midfoot unless you are ONLY interested in the Lis-Franc ligament.

c.      For CT foot/ankle GOUT protocols – this is a noncontrast dual energy scan that can only be done on certain scanners. If you specify “Gout protocol” the techs should know where to schedule and how to do it. 

6.      For the extremity:

a.      There is now a bone tumor protocol, a soft tissue protocol, and a sports extremity protocol depending on the indication. 

b.      Try to make the field of view as small as possible. The techs are fearful of “missing the lesion” and will often open the field of view to make sure they don’t miss anything – but as a result we get a terrible, low-resolution image. If you know where the lesion is, ask to limit the field of view to that area. If you don’t know where the lesion is, use a bigger field of view. Corollary – for chest wall studies use “long bone” instead of “chest wall” protocol because the field of view for the latter is HUGE.

7.         For the chest or abdominal wall:

a.     As mentioned above, do not select Chest Wall MRI. Try “long bone protocol with contrast” or "soft tissue tumor" for tumors (a combination of T1, T2 fat sat, and T1 post gado fat sat) with a focused field of view (FOV). Otherwise you will often get the full FOV of the chest,  which is not very helpful, especially for small, palpable lesions along the chest wall

8. Brachial Plexus

a. July 2025: As of now, we're doing all brachial plexus MRI studies with and without gadolinium

The MECHANICS of protocoling

         Protocoling is done with RadDash. Access RadDash via Reshub (accessible only from in-house) (see Figure 1 below). You will get a screen that looks like Figure 2.