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JOURNÉES FRANCOPHONES D'IMAGERIE MÉDICALES IMAGE GUIDED MSK INTERVENTIONS
Gregory E Antonio MD St Teresa’s Hospital Hong Kong, CHINA
Acknowledgement
§ Department of Imaging & IntervenGonal Radiology, Chinese University of Hong Kong,
§ St Teresa’s Hospital, Scanning Department, Hong Kong
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
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
QUIZ CASE
38 y.o. female, abdo pain
Axial Sagittal
• Tubular/ curvilinear subcutaneous lesions & streaky fat • DDx: infection/ infestation, vascular malformation
DistribuGon reminds you of anything?
Coronal
3D Tangential lateral
• Lesions distributed in a matrix of lines
Acupuncture meridians/ grid
www.healingtaoinstitute.com www.ourpsychicart.com http://hkhousewife.com www.123rf.com
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
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 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
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)
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
MSK INTERVENTIONS: CORE Bread & Bu^er
ABSCESS / COLLECTION FOR ASPIRATION/ INJECTION
Abscess Aspiration: 69 y.o. female
• USG is king: high local resolution, real-time, radiation-free imaging • Often larger bore needles are required to aspirate thick fluid/ pus
Abscess aspiration Leg Abscess: 69 y.o. female
Sagittal Coronal
Axial Sagittal
Thick fluid: The Swirling sign on USG: 45 y.o. female
• Particulate matter swirling within and between compartments • Cine loop recorded on Mobile phone by patient / referrer (saves disk space)
USG
AspiraGon of thick fluid
• 20G Spinal needle • Aim for the furthest and deepest/ dependent compartment for aspiration
USG USG
SASD Bursal AspiraGon/ InjecGon: 41 y.o. male
• Needle tangential to supraspinatus tendon • Use rotatory movement to get into bursa if minimal collection
Pre-aspiration USG Needle in situ
JOINT ASPIRATION
M & M
§ 152mm 20G Bevel Gp Spinal needle (BD Medical ref: 405211)
§ 100mm long 17G Diamond Gp Co-‐axial needle (Temno ref: PP1710)
55 y.o. female, lel hip pain: T2W FS Ax
§ Lt. SIJ: ú Effusion ú Marrow edema ú Erosions ú Peri-‐arGcular sol Gssue edema
§ Dx: ArthriGs, ? SepGc or Inflammatory
Axial
Trajectory visualizaGon and planning
• CT allow better demonstration of joint configuration than fluoroscopy • Especially for overlying osteophytes and joint space curvature / corners
Axial Axial
“Wiggle needle” into joint
• 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
Serial selective CT
Axial Axial
Super-‐selecGve needle Gp placement
• Limitations of Co-axial needle: can’t bend around tight corners • Thin Spinal needle within Co-axial needle can reach deeper +/- negotiate
gentle corners
Serial selective CT
Axial
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
JOINT INJECTION
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
Shoulder USG guided: 32 y.o. male
Axial USG
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
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
Wrap-‐up shot: SI joint Injection (30 y.o. male)
§ No need to go into depth of joint (unlike aspiraGon) § Wrap up shot saved and printed for paGent / referrer
Serial selective CT
Axial
FACET & PSUEDO JOINT INJECTION
Wrap-‐up shot: L4/5 Facet joint injecGon (37 y.o female)
Post-injection MPR Serial selective CT
• 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
Axial Sagittal Coronal
Axial Axial
Wrap-‐up shot: L5/S1 Facets & L5/S1 Pseudo-‐joint (37 y.o. female)
• If can’t get into joint (e.g. pseudo-arthrosis or ankylosed), perform peri-articular infiltration
Sagittal Coronal
Axial
Post-‐procedure summary: Resemblance?
http://www.theguardian.com/society/2010/apr/28
Five needles: L4/5 & L5/S1 facets, right L5/S1 pseudo-joint
Five acupuncture needles
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 angulation / depth of Co-axial needle • Decreased theoretic seeding along tract with single external pass
Lipomatous mass biopsy: wrap-‐up shot
• Co-axial and TruCut combination • Biopsy upper portion first, then move Co-axial needle to biopsy lower portion
Sagittal Coronal
Axial
Co-axial Biopsy CT MPR
BONE BIOPSY
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)
Bone Biopsy Needle
Co-‐axial CombinaGon
Wrap-‐up shot: Bone biopsy (46 y.o. male)
• 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
Axial
Axial Axial
Axial Coronal
Axial Axial
Coronal
Needle MPR Serial selective CT
Wrap-‐up shot: Disco-‐Vertebral biopsy (31 y.o. male)
• 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 Sagittal Coronal
Axial Axial
Coronal
Pre-biopsy CT MPR Needle MPR
VERTEBRAL BIOPSY
25 y.o. male back pain: MRI
• Lesion in T6 Left posterior elements • Pedicle, lamina and ? transverse process involvement
Sagittal
Axial
Coronal
Axial
PET localizaGon of acGve component
• Hyper-metabolic component in Left pedicle & lamina, and ? edema / necrosis in transverse process
Sagittal Coronal
Axial
Sagittal Coronal
Axial
Pre-biopsy PET MPR Pre-biopsy MRI MPR
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 Sagittal Coronal
Axial
• 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
Serial selective CT Needle CT MPR
Wrap-‐up Shot: Pedicular biopsy
Sagittal Coronal
Axial
Sagittal Coronal
Axial Axial
Needle CT MPR Pre-biopsy MRI MPR
Laminar biopsy: Step by step
Sagittal Coronal
Axial
Axial
Axial Axial
Axial
• Oblique approach from contralateral side
Needle CT MPR Serial selective CT
Wrap-‐up Shot Laminar biopsy
Sagittal Coronal
Axial Axial
Sagittal Coronal
Axial
• Dx: Langerhans Cell Histiocytosis from both pedicular and laminar specimens
Pre-biopsy MRI MPR Needle CT MPR
MSK INTERVENTIONS: ADVANCED
NERVE ROOT / EPIDURAL INJECTION
Spinal Nerve Root / Epidural InjecGons § Symptomatic relief using long-‐
acGng local anaesthesia and corGcosteroids
Drawings from Netter
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
Wrap-‐up shot: L4/5 perineural / epidural injecGon (75 y.o. female)
• 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
Post-contrast CT perineurogram MPR Post-medication CT MPR
Sagittal Sagittal Coronal
Axial Axial
Coronal
Wrap-‐up shot: Co-‐axial approach L5 injecGon (39 y.o. male)
• 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
Serial selective CT Post-medication CT MPR
Sagittal Coronal
Axial
Axial
Axial Axial
Axial
VERTEBROPLASTY: THE BASICS
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
CLASSIC VERTEBROPLASTY: TRANS-‐PEDICULAR APPROACH
“Clel” type T12 OsteoporoGc fracture
• Fluid filled fracture cleft • Pedicular involvement
Pre-vertebroplasty CT MPR
Sagittal Coronal
Axial
T12 Vertebroplasty: step-‐by-‐step
• 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)
Sagittal Coronal
Axial
Axial
Axial Axial
Axial
Pre-vertebroplasty CT MPR Serial selective CT
MPR Contrast confirmaGon
• Check contrast injection with MPR (avoiding extension into spinal canal) • N.B. gas bubble floats to pedicular fracture line
Sagittal Sagittal Coronal
Axial Axial
Coronal
Post-contrast MPR Pre-vertebroplasty CT MPR
Vertebroplasty: Wrap-‐up Shot
• 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).
Sagittal Sagittal Coronal
Axial Axial
Coronal
Cement without needle MPR Cement with needle MPR
Signs for potenGal success: vertebroplasty
§ Marrow edema § Fluid in fracture gap § Gas in fracture gap § Movement with flexion / extension
Vertebral fracture height & gas: 73 y.o. male
• 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)
Sagittal Sagittal
Supine Prone
RADIOFREQUENCY THERMAL ABLATION
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
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
34 y.o. male: right thigh pain
• MRI shows typical osteoid osteoma • Nidus with intermediate T1 and high T2 signal, moderate contrast
enhancement • Adjacent marrow edema
Sagittal Sagittal Coronal
Axial Axial
Coronal
MRI MPR MRI MPR
MRI / CT correlaGon
• Nidus with central calcification and surrounding bone sclerosis & cortical thickening
Sagittal
Axial Axial Axial
Sagittal Sagittal
MRI MPR CT MPR
RFA of Osteoid Osteoma
• Create tunnel with bone biopsy needle • Withdraw needle • Insert electrode
Serial selective CT
Axial Axial Axial
PALLIATIVE TREATMENT
Lel bu^ock pain: 59 y.o. male, PHx HCC
• 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
Coronal
Axial Axial
Axial
CT MPR
Lel bu^ock pain: 86 y.o. male, NSCLC
• PET-CT confirmed destructive metastasis as cause of pain
Coronal Axial
Axial
Axial Coronal
Coronal
PET CT PET CT
Alcohol injecGon
• Penetrate cortex with bone biopsy needle • Insert long spinal needle • Inject contrast mixed with alcohol
Axial Axial Axial
Serial selective CT
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.
THANK YOU ANTONIO@STHSCAN.COM