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  • 1. JOURNÉES  FRANCOPHONES     D'IMAGERIE  MÉDICALES       IMAGE  GUIDED  MSK  INTERVENTIONS     Gregory E Antonio MD St  Teresa’s  Hospital   Hong  Kong,  CHINA    
  • 2. Acknowledgement   §  Department  of  Imaging  &  IntervenGonal   Radiology,  Chinese  University  of  Hong  Kong,     §  St  Teresa’s  Hospital,  Scanning  Department,   Hong  Kong  
  • 3. DeclaraGon  of  Interest   §  Consultant  Radiologist    St  Teresa’s  hospital,  Hong  Kong,  China   §  Honorary  Clinical  Professor    Dept.  of  Imaging  &  Interven>onal  Radiology,      Chinese  University  of  Hong  Kong   §  Honorary  Consultant    Dept.  of  Diagnos>c  Radiology  &  Organ  Imaging,      Prince  of  Wales  hospital,  Hong  Kong   §  Book  RoyalGes:     ú  Oxford  University  Press;     ú  Cambridge  University  Press;     ú  Shantou  University  Press;     ú  AMIRSYS  Press  
  • 4. Franco-­‐Chinese  ConnecGons   §  “Je  pense,  donc  je  suis…..    I  think  therefore  I  am”       ú  Rene  DESCARTES   ú  Cartesian  Co-­‐ordinate  system   ú  Basis  of  CT  guided  MSK  INTERVENTION   §  “1  PICTURE  is  worth  10000  words”   ú  Not  by  Confucius  (from  USA)   ú  A^ributed  to  Chinese  for  CREDIBILITY   (used  in  an  adverGsement  in  1927)   http://en.wikipedia.org/wiki/Ren%C3%A9_Descartes http://www.phrases.org.uk/meanings/a-picture-is-worth-a-thousand-words.html www.biography.com/people/confucius
  • 5. QUIZ  CASE  
  • 6. 38  y.o.  female,    abdo  pain   Axial •  Tubular/ curvilinear subcutaneous lesions & streaky fat •  DDx: infection/ infestation, vascular malformation Sagittal
  • 7. DistribuGon  reminds  you  of  anything?   3D Tangential lateral Coronal •  Lesions distributed in a matrix of lines
  • 8. Acupuncture  meridians/  grid   www.healingtaoinstitute.com www.ourpsychicart.com http://hkhousewife.com www.123rf.com
  • 9. Dx:  Acupoint  Cat-­‐gut  Embedment  for  Sliming   §  Cannula   §  Feed  absorbable   sutures  into  S/C  fat   with  stylet   §  Embedded  suture   provides  conGnuous   acupoint  sGmulaGon   §  ??  A  rare  case  for  the   museum   www.taipei.gov.tw
  • 10. A  rare  case?  You  know  there  will  be  more  when  Coupons  are  offered  
  • 11. The  Issues   §  MSK  IntervenGons  come  in  many  forms   §  Radiologists  are  not  the  only  therapists  using   a  grid  system  for  Targeted  minimally  invasive   intervenGon  (including  MSK  intervenGon)   §  Our  advantage/  experGse  lies  in  using  image   guidance  to  “show”  where  and  what  we  are   treaGng   §  Providing  exquisite  Images  showcases  our   experGse  to  our  referrers  &  paGents,  building   confidence  and  rapport  
  • 12. Aims  of  presentaGon   Present  a  pracGcal  approach  to  MSK   intervenGon  using:   § Readily  available  imaging  equipment   § Low-­‐tech  (economical)  instruments  &   medicaGon   § To  provide  exquisite  “Wrap-­‐up”  shots  to   showcase  your  experGse  (cine  loops/  MPR  or  3D   color  images)  
  • 13. Image  guided  MSK  IntervenGons   Core   §  Abscess/  collecGon  for  aspiraGon  /  injecGon   §  Joint  aspiraGon  /  injecGon   §  Bone  biopsy   §  Sol  Gssue  biopsy   Advanced   §  Nerve  root  blocks/  Epidural  blocks   §  Vertebroplasty   §  Radiofrequency  ablaGon   §  PalliaGve  treatment  
  • 14. Bread  &  Bu^er   MSK  INTERVENTIONS:  CORE  
  • 16. Abscess Aspiration:  69  y.o.  female Sagittal Axial Coronal Sagittal Leg Abscess: 69 y.o. female Abscess aspiration •  USG is king: high local resolution, real-time, radiation-free imaging •  Often larger bore needles are required to aspirate thick fluid/ pus
  • 17. Thick  fluid:  The  Swirling  sign  on  USG:  45  y.o.  female       USG •  Particulate matter swirling within and between compartments •  Cine loop recorded on Mobile phone by patient / referrer (saves disk space)
  • 18. AspiraGon  of  thick  fluid     USG USG •  20G Spinal needle •  Aim for the furthest and deepest/ dependent compartment for aspiration
  • 19. SASD  Bursal  AspiraGon/  InjecGon:  41  y.o.   male   Pre-aspiration USG Needle in situ •  Needle tangential to supraspinatus tendon •  Use rotatory movement to get into bursa if minimal collection
  • 21. M  &  M   §  152mm  20G  Bevel  Gp  Spinal  needle  (BD   Medical  ref:  405211)   §  100mm  long  17G  Diamond  Gp  Co-­‐axial  needle   (Temno  ref:  PP1710)  
  • 22. 55  y.o.  female,  lel  hip  pain:  T2W  FS  Ax   §  Lt.  SIJ:   ú  Effusion   ú  Marrow  edema   ú  Erosions   ú  Peri-­‐arGcular  sol  Gssue   Axial edema   §  Dx:  ArthriGs,  ?  SepGc  or   Inflammatory  
  • 23. Trajectory  visualizaGon  and  planning   Axial Axial •  CT allow better demonstration of joint configuration than fluoroscopy •  Especially for overlying osteophytes and joint space curvature / corners
  • 24. “Wiggle  needle”  into  joint   Axial Axial Serial selective CT •  •  •  •  Note OK for Size of needle ~ Width of Joint; thin needles (over 20 G) are flimsy “Walk” needle tip along cortical surface to enter joint Patients may “wiggle” joint to allow further entry of “thick” needle Advance Co-axial needle with rotational movement and firm pressure
  • 25. Super-­‐selecGve  needle  Gp  placement   Axial Serial selective CT •  Limitations of Co-axial needle: can’t bend around tight corners •  Thin Spinal needle within Co-axial needle can reach deeper +/- negotiate gentle corners
  • 26. AspiraGon  with  Saline  exchange  (Gght  joint  &  thick  pus)   •  Gravity is against us, the thicker material is always furthest from the needle •  Thin needle (to get deeper) makes aspirating thick material difficult •  Try a “fluid exchange” or Modified Lavage technique, to partially counteract gravity & equalize suction pressure
  • 28. Arthrography:  “Universal”  contrast  mixture   §  Provides  joint  distension  aside  from  contrast   §  10  ml  saline  +  5  mL  Iodinated  contrast    +  0.1  mL   Gadolinium   §  Fall  back  on  single  contrast  CT  arthrogram  if  MRI   fails  
  • 29. Shoulder  USG  guided:    32  y.o.  male   Axial USG
  • 30. Intra-­‐arGcular/  Peri-­‐arGcular  therapeuGc   injecGon   §  Pain  relief:  Local  AnestheGcs/  CorGcosteroids/   Hyaglen   §  Brisement  for  adhesive  capsuliGs   §  Radio-­‐isotope  Synovectomy   §  Rupture/  DisrupGon  of  Synovial  cyst  / Ganglion    
  • 31. Pain  Relief:  “Universal”  Cocktail   §  For  joint  /  peri-­‐arGcular  /  nerve  root  injecGons   §  Depo  Medrol  1  vial/    Kena-­‐cort  1  vial   §  Marcaine  0.25%  1  vial   §  1:1  to  1:2  mixture  
  • 32. Wrap-­‐up  shot:  SI joint Injection  (30  y.o.  male) Axial Serial selective CT §  No  need  to  go  into  depth  of  joint  (unlike  aspiraGon)   §  Wrap  up  shot  saved  and  printed  for  paGent  /  referrer
  • 34. Wrap-­‐up  shot:  L4/5  Facet  joint  injecGon  (37  y.o  female)   Axial Sagittal Axial Serial selective CT Coronal Axial Post-injection MPR •  Only need to get into joint capsule with CT/ US (c.f. into joint space with Fluoroscopy) •  N.B. how large and extensive joint capsule is at Right L4/5
  • 35. Wrap-­‐up  shot:    L5/S1  Facets  &  L5/S1  Pseudo-­‐joint    (37  y.o.    female)   Sagittal Coronal Axial •  If can’t get into joint (e.g. pseudo-arthrosis or ankylosed), perform peri-articular infiltration
  • 36. Post-­‐procedure  summary:    Resemblance?     Five needles: L4/5 & L5/S1 facets, right L5/S1 pseudo-joint Five acupuncture needles http://www.theguardian.com/society/2010/apr/28
  • 38. Sol  Gssue  biopsy   §  Ultrasound  is  “King”   §  CT  for  deep/  obscured/  complex  lesions  
  • 39. USG  sol  Gssue  biopsy:  TruCut  needle •  Needle notch produces readily visible interface
  • 40. Co-axial CombinaGon •  Co-axial needle allows better navigation and angulation •  Multiple sampling by changing angulation / depth of Co-axial needle •  Decreased theoretic seeding along tract with single external pass
  • 41. Lipomatous  mass  biopsy:  wrap-­‐up  shot   Sagittal Coronal Axial Co-axial Biopsy CT MPR •  Co-axial and TruCut combination •  Biopsy upper portion first, then move Co-axial needle to biopsy lower portion
  • 42. BONE  BIOPSY  
  • 43. Bone  Biopsy  Needles   §  100mm  long  9G  or  11G  Diamond  Tip  Bone  Biopsy   needle  (Biopsybell  Osteobell  “T”  ref:  OB1110T)   §  150mm  long  16G  Spring-­‐loaded  TruCut  needle   (CareFusion  Temno  ref:  T1615)   §  125mm  16G  Bone  Biopsy  needle  (Angiomed   Ostycut  ref:  17820060)   §  PenetraGon  Set  with  2.1mm  diameter  cannula  &   1.7mm  diameter  drill  (AprioMed  Bonopty  ref:   10-­‐1072)  
  • 44. Bone Biopsy  Needle
  • 45. Co-­‐axial  CombinaGon
  • 46. Wrap-­‐up  shot:  Bone  biopsy  (46  y.o.   male)   Axial Axial Coronal Coronal Axial Axial Axial Axial Serial selective CT Needle MPR •  Bone Biopsy needle for cortical penetration •  Tru-cut needle for sampling •  Final bone core (try to include cap of surrounding “normal” bone to preserve pathological portion
  • 47. Wrap-­‐up  shot:  Disco-­‐Vertebral  biopsy  (31  y.o.  male)   Sagittal Coronal Axial Pre-biopsy CT MPR •  •  •  •  Disc biopsy for disciitis is a common request. Pure disc biopsy gives low microbiology yield Include bone to increase yield Bone also gives histology specimen Sagittal Coronal Axial Needle MPR
  • 49. 25  y.o.    male  back  pain:  MRI   Sagittal Axial Coronal Axial •  Lesion in T6 Left posterior elements •  Pedicle, lamina and ? transverse process involvement
  • 50. PET  localizaGon  of  acGve  component   Sagittal Coronal Axial Pre-biopsy MRI MPR Sagittal Coronal Axial Pre-biopsy PET MPR •  Hyper-metabolic component in Left pedicle & lamina, and ? edema / necrosis in transverse process
  • 51. Pre-­‐biopsy  CT   Sagittal Coronal Axial Sagittal Coronal Axial Pre-biopsy MRI MPR Pre-biopsy CT MPR
  • 52. Pedicular  biopsy:  Step  by  step   Axial Axial Axial Axial Serial selective CT •  •  •  •  Sagittal Coronal Axial Needle CT MPR Straight forward Trans-pedicular approach Angle needle tip laterally to avoid spinal canal Bone Core needle to penetrate cortex + Tru-cut needle for biopsy Notch of Tru-cut needle turned away from spinal canal
  • 53. Wrap-­‐up  Shot:  Pedicular  biopsy   Sagittal Coronal Axial Axial Pre-biopsy MRI MPR Sagittal Coronal Axial Needle CT MPR
  • 54. Laminar  biopsy:  Step  by  step   Axial Axial Axial Axial Serial selective CT •  Oblique approach from contralateral side Sagittal Coronal Axial Needle CT MPR
  • 55. Wrap-­‐up  Shot  Laminar  biopsy   Coronal Sagittal Axial Pre-biopsy MRI MPR Coronal Sagittal Axial Axial Needle CT MPR •  Dx: Langerhans Cell Histiocytosis from both pedicular and laminar specimens
  • 58. Spinal Nerve Root /  Epidural  InjecGons §  Symptomatic relief using long-­‐ acGng  local anaesthesia and corGcosteroids Drawings from Netter
  • 59. M  &  M   §  127mm  22G  Bevel  Gp  Spinal  needle  (BD   §  §  §  §  Medical  ref:  405148)   90mm  long  18G  Bevel  Gp  Spinal  needle   (Terumo  ref:  SN*1890)   Contrast   Long-­‐acGng  Local  AnestheGcs   Long-­‐acGng  CorGcosteroids  
  • 60. Wrap-­‐up  shot:  L4/5  perineural  /  epidural  injecGon  (75  y.o.  female)   Sagittal Coronal Axial Post-contrast CT perineurogram MPR •  •  •  •  •  Sagittal Coronal Axial Post-medication CT MPR Oblique needle to direct part of injection into epidural space Contrast confirmation of flow along right L4 nerve root Smaller Epidural extension N.B. injection of medication dilutes the contrast Color tint for injected material
  • 61. Wrap-­‐up  shot:  Co-­‐axial  approach  L5  injecGon  (39  y.o.  male)   Axial Axial Axial Axial Serial selective CT Sagittal Coronal Axial Post-medication CT MPR •  Use 18G spinal needle to navigate between iliac bone & facet joint to get close to L5/S1 foramen •  Turn 18G bevel to face medially, and then pass 22G spinal needle in its lumen •  +/- bend 22G needle before insertion •  Epidural component will help S1 in lateral recess
  • 63. IndicaGons  for  Vertebroplasty   §  SymptomaGc  vertebral  body  hemangioma  1     §  Primary  neoplasGc/  metastaGc  vertebral   fractures  2,  3   §  Acute  compression  vertebral  body  fractures   recalcitrant  to  conservaGve  treatment  4   §  Persistent  pain  >  3  months  aler  fracture  5   §  Unstable  compression  fracture  that   demonstrates  signs  of  movement     1.  Galibert  P  et  al.  Neurochirugie  1987   2.  Co^on  A  et  al.  Radiology  1996   3.  Weill  A  et  al.  Radiology  1996   4.  Diamond  TH  et  al.  AJM  2003   5.  Kaufmann  TJ  et  al.  AJNR  2001  
  • 65. “Clel”  type  T12  OsteoporoGc  fracture     Sagittal Coronal Axial Pre-vertebroplasty CT MPR •  Fluid filled fracture cleft •  Pedicular involvement
  • 66. T12  Vertebroplasty:  step-­‐by-­‐step   Sagittal Coronal Axial Pre-vertebroplasty CT MPR •  •  •  •  Axial Axial Axial Axial Serial selective CT Trans-pedicular approach Needle passes through pedicle fracture Needle Tip in Anterior 1/3 of Vertebral body & in Main Fracture Cleft Contrast flows readily along entire fracture cleft, gas floats up (towards skin)
  • 67. MPR  Contrast  confirmaGon   Sagittal Coronal Axial Pre-vertebroplasty CT MPR Sagittal Coronal Axial Post-contrast MPR •  Check contrast injection with MPR (avoiding extension into spinal canal) •  N.B. gas bubble floats to pedicular fracture line
  • 68. Vertebroplasty:  Wrap-­‐up  Shot     Sagittal Coronal Axial Cement with needle MPR Sagittal Coronal Axial Cement without needle MPR •  Inject cement to fill most of the fracture cleft (for immobilization) •  Push residue cement within needle with stylet before removing needle (to avoid cement spike •  May want to leave some of this residue cement across the pedicle fracture (do this using CT Fluoroscopy).
  • 69. Signs  for  potenGal  success:  vertebroplasty   §  Marrow  edema   §  Fluid  in  fracture  gap   §  Gas  in  fracture  gap   §  Movement  with  flexion  /  extension  
  • 70. Vertebral  fracture  height  &  gas:  73  y.o.  male   Sagittal Sagittal Prone •  •  •  •  Supine Prone anterior height = 15.5 mm (normal = 25.5 mm) Supine anterior height = 20.2 mm (normal = 25.6 mm) ? Nitrogen bubbles drawn out by decompression (movement) Movement = pain (vertebroplasty = glue = fixation)
  • 72. Radiofrequency  thermal  ablaGon   §  CoagulaGon  necrosis  in  tumor  Gssue  by  RF-­‐ generated  heat  1   §  Monopolar/  Bipolar  /  Cluster/  Expandable   Electrode  Tip   1.  Goldberg  et  al.  Radiology  2005  
  • 73. RFA  technique   §  Pre-­‐procedure  planning  of  trajectory  through   overlying  bone  to  reach  target   §  Bone  biopsy  needle  or  drill  to  create  tunnel   §  PosiGon  Gp  of  electrode  in  center  of  lesion   §  Use  RF  sevngs  prescribed  by  manufacturer    
  • 74. 34  y.o.  male:  right  thigh  pain   Sagittal Coronal Axial Coronal Sagittal Axial MRI MPR MRI MPR •  MRI shows typical osteoid osteoma •  Nidus with intermediate T1 and high T2 signal, moderate contrast enhancement •  Adjacent marrow edema
  • 75. MRI  /  CT  correlaGon   Sagittal Sagittal Axial Axial MRI MPR Sagittal Axial CT MPR •  Nidus with central calcification and surrounding bone sclerosis & cortical thickening
  • 76. RFA  of  Osteoid  Osteoma   Axial Axial Serial selective CT •  Create tunnel with bone biopsy needle •  Withdraw needle •  Insert electrode Axial
  • 78. Lel  bu^ock  pain:  59  y.o.  male,  PHx  HCC   Coronal Axial Axial Axial CT MPR •  For pain relief 1 •  Multiple approaches for large lesion •  May be combined with cement injection (RFA → necrotic space for cement) 1.  Callstome et al. Skeletal Radiol 2006
  • 79. Lel  bu^ock  pain:  86  y.o.  male,  NSCLC   Coronal Coronal Coronal Axial Axial Axial PET CT PET CT •  PET-CT confirmed destructive metastasis as cause of pain
  • 80. Alcohol  injecGon   Axial Axial Serial selective CT •  Penetrate cortex with bone biopsy needle •  Insert long spinal needle •  Inject contrast mixed with alcohol Axial
  • 81. CONCLUSION   §  Musculo-­‐Skeletal  IntervenGonal  Radiology   enables  Radiologists  to  become  Pain  Relief   IntervenGonists.   §  We  should  aim  to  provide  the  “Rolls  Royce”   standard  in  both  Imaging  and  Treatment  of   Pain.   §  Thin  slice  CT  and  MPR  gives  us  the  edge.