JOURNÉES	
  FRANCOPHONES	
  	
  
D'IMAGERIE	
  MÉDICALES	
  

	
  
	
  

IMAGE	
  GUIDED	
  MSK	
  INTERVENTIONS	
  

	
  ...
Acknowledgement	
  
§  Department	
  of	
  Imaging	
  &	
  IntervenGonal	
  

Radiology,	
  Chinese	
  University	
  of	
...
DeclaraGon	
  of	
  Interest	
  
§  Consultant	
  Radiologist	
  

	
  St	
  Teresa’s	
  hospital,	
  Hong	
  Kong,	
  Ch...
Franco-­‐Chinese	
  ConnecGons	
  
§  “Je	
  pense,	
  donc	
  je	
  suis…..

	
  	
  I	
  think	
  therefore	
  I	
  am”...
QUIZ	
  CASE	
  
38	
  y.o.	
  female,	
  	
  abdo	
  pain	
  

Axial

•  Tubular/ curvilinear subcutaneous lesions & streaky fat
•  DDx: i...
DistribuGon	
  reminds	
  you	
  of	
  anything?	
  

3D Tangential lateral

Coronal

•  Lesions distributed in a matrix o...
Acupuncture	
  meridians/	
  grid	
  

www.healingtaoinstitute.com
www.ourpsychicart.com
http://hkhousewife.com
www.123rf....
Dx:	
  Acupoint	
  Cat-­‐gut	
  Embedment	
  for	
  Sliming	
  
§  Cannula	
  
§  Feed	
  absorbable	
  

sutures	
  int...
A	
  rare	
  case?	
  You	
  know	
  there	
  will	
  be	
  more	
  when	
  Coupons	
  are	
  offered	
  
The	
  Issues	
  
§  MSK	
  IntervenGons	
  come	
  in	
  many	
  forms	
  
§  Radiologists	
  are	
  not	
  the	
  only...
Aims	
  of	
  presentaGon	
  
Present	
  a	
  pracGcal	
  approach	
  to	
  MSK	
  
intervenGon	
  using:	
  
§ Readily	
...
Image	
  guided	
  MSK	
  IntervenGons	
  
Core	
  
§  Abscess/	
  collecGon	
  for	
  aspiraGon	
  /	
  injecGon	
  
§ ...
Bread	
  &	
  Bu^er	
  

MSK	
  INTERVENTIONS:	
  CORE	
  
ABSCESS	
  /	
  COLLECTION	
  FOR	
  
ASPIRATION/	
  INJECTION	
  
Abscess Aspiration:	
  69	
  y.o.	
  female

Sagittal

Axial

Coronal

Sagittal

Leg Abscess: 69 y.o. female

Abscess aspi...
Thick	
  fluid:	
  The	
  Swirling	
  sign	
  on	
  USG:	
  45	
  y.o.	
  female	
  
	
  
	
  

USG
•  Particulate matter s...
AspiraGon	
  of	
  thick	
  fluid	
  
	
  

USG

USG

•  20G Spinal needle
•  Aim for the furthest and deepest/ dependent c...
SASD	
  Bursal	
  AspiraGon/	
  InjecGon:	
  41	
  y.o.	
  
male	
  

Pre-aspiration USG

Needle in situ

•  Needle tangen...
JOINT	
  ASPIRATION	
  
M	
  &	
  M	
  
§  152mm	
  20G	
  Bevel	
  Gp	
  Spinal	
  needle	
  (BD	
  

Medical	
  ref:	
  405211)	
  
§  100mm	
...
55	
  y.o.	
  female,	
  lel	
  hip	
  pain:	
  T2W	
  FS	
  Ax	
  
§  Lt.	
  SIJ:	
  
ú  Effusion	
  
ú  Marrow	
  edem...
Trajectory	
  visualizaGon	
  and	
  planning	
  

Axial

Axial

•  CT allow better demonstration of joint configuration t...
“Wiggle	
  needle”	
  into	
  joint	
  

Axial

Axial
Serial selective CT

• 
• 
• 
• 

Note OK for Size of needle ~ Width...
Super-­‐selecGve	
  needle	
  Gp	
  placement	
  

Axial

Serial selective CT
•  Limitations of Co-axial needle: can’t ben...
AspiraGon	
  with	
  Saline	
  exchange	
  (Gght	
  joint	
  &	
  thick	
  pus)	
  

•  Gravity is against us, the thicker...
JOINT	
  INJECTION	
  
Arthrography:	
  “Universal”	
  contrast	
  mixture	
  
§  Provides	
  joint	
  distension	
  aside	
  from	
  contrast	
...
Shoulder	
  USG	
  guided:	
  	
  32	
  y.o.	
  male	
  

Axial USG
Intra-­‐arGcular/	
  Peri-­‐arGcular	
  therapeuGc	
  
injecGon	
  
§  Pain	
  relief:	
  Local	
  AnestheGcs/	
  CorGcos...
Pain	
  Relief:	
  “Universal”	
  Cocktail	
  
§  For	
  joint	
  /	
  peri-­‐arGcular	
  /	
  nerve	
  root	
  injecGons...
Wrap-­‐up	
  shot:	
  SI joint Injection	
  (30	
  y.o.	
  male)

Axial

Serial selective CT

§  No	
  need	
  to	
  go	
...
FACET	
  &	
  PSUEDO	
  JOINT	
  INJECTION	
  
Wrap-­‐up	
  shot:	
  L4/5	
  Facet	
  joint	
  injecGon	
  (37	
  y.o	
  female)	
  

Axial

Sagittal

Axial

Serial sele...
Wrap-­‐up	
  shot:	
  	
  L5/S1	
  Facets	
  &	
  L5/S1	
  Pseudo-­‐joint	
  	
  (37	
  y.o.	
  	
  female)	
  

Sagittal
...
Post-­‐procedure	
  summary:	
  	
  Resemblance?	
  	
  

Five needles:
L4/5 & L5/S1 facets, right L5/S1 pseudo-joint

Fiv...
SOFT	
  TISSUE	
  BIOPSY	
  
Sol	
  Gssue	
  biopsy	
  
§  Ultrasound	
  is	
  “King”	
  
§  CT	
  for	
  deep/	
  obscured/	
  complex	
  lesions	
 ...
USG	
  sol	
  Gssue	
  biopsy:	
  TruCut	
  needle


•  Needle notch produces readily visible interface
Co-axial CombinaGon


•  Co-axial needle allows better navigation and angulation
•  Multiple sampling by changing angulati...
Lipomatous	
  mass	
  biopsy:	
  wrap-­‐up	
  shot	
  

Sagittal

Coronal

Axial

Co-axial Biopsy CT MPR
•  Co-axial and T...
BONE	
  BIOPSY	
  
Bone	
  Biopsy	
  Needles	
  
§  100mm	
  long	
  9G	
  or	
  11G	
  Diamond	
  Tip	
  Bone	
  Biopsy	
  

needle	
  (Bio...
Bone Biopsy	
  Needle
Co-­‐axial	
  CombinaGon
Wrap-­‐up	
  shot:	
  Bone	
  biopsy	
  (46	
  y.o.	
  
male)	
  
Axial

Axial

Coronal

Coronal

Axial

Axial

Axial

Axi...
Wrap-­‐up	
  shot:	
  Disco-­‐Vertebral	
  biopsy	
  (31	
  y.o.	
  male)	
  

Sagittal

Coronal

Axial

Pre-biopsy CT MPR...
VERTEBRAL	
  BIOPSY	
  
25	
  y.o.	
  	
  male	
  back	
  pain:	
  MRI	
  

Sagittal

Axial

Coronal

Axial

•  Lesion in T6 Left posterior elemen...
PET	
  localizaGon	
  of	
  acGve	
  component	
  

Sagittal

Coronal

Axial

Pre-biopsy MRI MPR

Sagittal

Coronal

Axial...
Pre-­‐biopsy	
  CT	
  

Sagittal

Coronal

Axial

Sagittal

Coronal

Axial

Pre-biopsy MRI MPR

Pre-biopsy CT MPR
Pedicular	
  biopsy:	
  Step	
  by	
  step	
  

Axial

Axial

Axial

Axial

Serial selective CT
• 
• 
• 
• 

Sagittal

Cor...
Wrap-­‐up	
  Shot:	
  Pedicular	
  biopsy	
  

Sagittal

Coronal

Axial

Axial

Pre-biopsy MRI MPR

Sagittal

Coronal

Axi...
Laminar	
  biopsy:	
  Step	
  by	
  step	
  

Axial

Axial

Axial

Axial

Serial selective CT

•  Oblique approach from co...
Wrap-­‐up	
  Shot	
  Laminar	
  biopsy	
  

Coronal

Sagittal

Axial

Pre-biopsy MRI MPR

Coronal

Sagittal

Axial

Axial
...
MSK	
  INTERVENTIONS:	
  ADVANCED	
  
NERVE	
  ROOT	
  /	
  EPIDURAL	
  
INJECTION	
  
Spinal Nerve Root /	
  Epidural	
  InjecGons
§  Symptomatic relief using long-­‐

acGng	
  local anaesthesia and
corGcost...
M	
  &	
  M	
  
§  127mm	
  22G	
  Bevel	
  Gp	
  Spinal	
  needle	
  (BD	
  
§ 
§ 
§ 
§ 

Medical	
  ref:	
  405148)...
Wrap-­‐up	
  shot:	
  L4/5	
  perineural	
  /	
  epidural	
  injecGon	
  (75	
  y.o.	
  female)	
  

Sagittal

Coronal

Ax...
Wrap-­‐up	
  shot:	
  Co-­‐axial	
  approach	
  L5	
  injecGon	
  (39	
  y.o.	
  male)	
  

Axial

Axial

Axial

Axial

Se...
VERTEBROPLASTY:	
  THE	
  BASICS	
  
IndicaGons	
  for	
  Vertebroplasty	
  
§  SymptomaGc	
  vertebral	
  body	
  hemangioma	
  1	
  	
  
§  Primary	
  neop...
CLASSIC	
  VERTEBROPLASTY:	
  
TRANS-­‐PEDICULAR	
  APPROACH	
  
“Clel”	
  type	
  T12	
  OsteoporoGc	
  fracture	
  
	
  
Sagittal

Coronal

Axial

Pre-vertebroplasty CT MPR

•  Fluid fi...
T12	
  Vertebroplasty:	
  step-­‐by-­‐step	
  

Sagittal

Coronal

Axial

Pre-vertebroplasty CT MPR
• 
• 
• 
• 

Axial

Ax...
MPR	
  Contrast	
  confirmaGon	
  

Sagittal

Coronal

Axial

Pre-vertebroplasty CT MPR

Sagittal

Coronal

Axial

Post-con...
Vertebroplasty:	
  Wrap-­‐up	
  Shot	
  
	
  
Sagittal

Coronal

Axial

Cement with needle MPR

Sagittal

Coronal

Axial

...
Signs	
  for	
  potenGal	
  success:	
  vertebroplasty	
  
§  Marrow	
  edema	
  
§  Fluid	
  in	
  fracture	
  gap	
  
...
Vertebral	
  fracture	
  height	
  &	
  gas:	
  73	
  y.o.	
  male	
  

Sagittal

Sagittal

Prone
• 
• 
• 
• 

Supine

Pro...
RADIOFREQUENCY	
  	
  
THERMAL	
  ABLATION	
  
Radiofrequency	
  thermal	
  ablaGon	
  
§  CoagulaGon	
  necrosis	
  in	
  tumor	
  Gssue	
  by	
  RF-­‐

generated	
  h...
RFA	
  technique	
  
§  Pre-­‐procedure	
  planning	
  of	
  trajectory	
  through	
  

overlying	
  bone	
  to	
  reach	...
34	
  y.o.	
  male:	
  right	
  thigh	
  pain	
  

Sagittal

Coronal

Axial

Coronal
Sagittal

Axial

MRI MPR

MRI MPR

• ...
MRI	
  /	
  CT	
  correlaGon	
  

Sagittal

Sagittal

Axial

Axial

MRI MPR

Sagittal

Axial

CT MPR

•  Nidus with centra...
RFA	
  of	
  Osteoid	
  Osteoma	
  

Axial

Axial

Serial selective CT
•  Create tunnel with bone biopsy needle
•  Withdra...
PALLIATIVE	
  TREATMENT	
  
Lel	
  bu^ock	
  pain:	
  59	
  y.o.	
  male,	
  PHx	
  HCC	
  

Coronal

Axial

Axial

Axial

CT MPR
•  For pain relief 1...
Lel	
  bu^ock	
  pain:	
  86	
  y.o.	
  male,	
  NSCLC	
  

Coronal

Coronal

Coronal

Axial

Axial

Axial

PET CT

PET CT...
Alcohol	
  injecGon	
  

Axial

Axial

Serial selective CT

•  Penetrate cortex with bone biopsy needle
•  Insert long spi...
CONCLUSION	
  
§  Musculo-­‐Skeletal	
  IntervenGonal	
  Radiology	
  

enables	
  Radiologists	
  to	
  become	
  Pain	
...
THANK	
  YOU	
  
	
  

ANTONIO@STHSCAN.COM	
  
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Msk imaging msk intv rad gantonio

  1. 1. JOURNÉES  FRANCOPHONES     D'IMAGERIE  MÉDICALES       IMAGE  GUIDED  MSK  INTERVENTIONS     Gregory E Antonio MD St  Teresa’s  Hospital   Hong  Kong,  CHINA    
  2. 2. Acknowledgement   §  Department  of  Imaging  &  IntervenGonal   Radiology,  Chinese  University  of  Hong  Kong,     §  St  Teresa’s  Hospital,  Scanning  Department,   Hong  Kong  
  3. 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. 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. 5. QUIZ  CASE  
  6. 6. 38  y.o.  female,    abdo  pain   Axial •  Tubular/ curvilinear subcutaneous lesions & streaky fat •  DDx: infection/ infestation, vascular malformation Sagittal
  7. 7. DistribuGon  reminds  you  of  anything?   3D Tangential lateral Coronal •  Lesions distributed in a matrix of lines
  8. 8. Acupuncture  meridians/  grid   www.healingtaoinstitute.com www.ourpsychicart.com http://hkhousewife.com www.123rf.com
  9. 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. 10. A  rare  case?  You  know  there  will  be  more  when  Coupons  are  offered  
  11. 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. 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. 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. 14. Bread  &  Bu^er   MSK  INTERVENTIONS:  CORE  
  15. 15. ABSCESS  /  COLLECTION  FOR   ASPIRATION/  INJECTION  
  16. 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. 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. 18. AspiraGon  of  thick  fluid     USG USG •  20G Spinal needle •  Aim for the furthest and deepest/ dependent compartment for aspiration
  19. 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
  20. 20. JOINT  ASPIRATION  
  21. 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. 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. 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. 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. 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. 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
  27. 27. JOINT  INJECTION  
  28. 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. 29. Shoulder  USG  guided:    32  y.o.  male   Axial USG
  30. 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. 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. 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
  33. 33. FACET  &  PSUEDO  JOINT  INJECTION  
  34. 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. 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. 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
  37. 37. SOFT  TISSUE  BIOPSY  
  38. 38. Sol  Gssue  biopsy   §  Ultrasound  is  “King”   §  CT  for  deep/  obscured/  complex  lesions  
  39. 39. USG  sol  Gssue  biopsy:  TruCut  needle •  Needle notch produces readily visible interface
  40. 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. 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. 42. BONE  BIOPSY  
  43. 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. 44. Bone Biopsy  Needle
  45. 45. Co-­‐axial  CombinaGon
  46. 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. 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
  48. 48. VERTEBRAL  BIOPSY  
  49. 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. 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. 51. Pre-­‐biopsy  CT   Sagittal Coronal Axial Sagittal Coronal Axial Pre-biopsy MRI MPR Pre-biopsy CT MPR
  52. 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. 53. Wrap-­‐up  Shot:  Pedicular  biopsy   Sagittal Coronal Axial Axial Pre-biopsy MRI MPR Sagittal Coronal Axial Needle CT MPR
  54. 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. 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
  56. 56. MSK  INTERVENTIONS:  ADVANCED  
  57. 57. NERVE  ROOT  /  EPIDURAL   INJECTION  
  58. 58. Spinal Nerve Root /  Epidural  InjecGons §  Symptomatic relief using long-­‐ acGng  local anaesthesia and corGcosteroids Drawings from Netter
  59. 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. 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. 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
  62. 62. VERTEBROPLASTY:  THE  BASICS  
  63. 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  
  64. 64. CLASSIC  VERTEBROPLASTY:   TRANS-­‐PEDICULAR  APPROACH  
  65. 65. “Clel”  type  T12  OsteoporoGc  fracture     Sagittal Coronal Axial Pre-vertebroplasty CT MPR •  Fluid filled fracture cleft •  Pedicular involvement
  66. 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. 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. 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. 69. Signs  for  potenGal  success:  vertebroplasty   §  Marrow  edema   §  Fluid  in  fracture  gap   §  Gas  in  fracture  gap   §  Movement  with  flexion  /  extension  
  70. 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)
  71. 71. RADIOFREQUENCY     THERMAL  ABLATION  
  72. 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. 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. 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. 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. 76. RFA  of  Osteoid  Osteoma   Axial Axial Serial selective CT •  Create tunnel with bone biopsy needle •  Withdraw needle •  Insert electrode Axial
  77. 77. PALLIATIVE  TREATMENT  
  78. 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. 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. 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. 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.  
  82. 82. THANK  YOU     ANTONIO@STHSCAN.COM  

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