Msk imaging msk intv rad gantonio

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JOURNÉES FRANCOPHONES D'IMAGERIE MÉDICALES IMAGE GUIDED MSK INTERVENTIONS Gregory E Antonio MD St Teresa’s Hospital Hong Kong, CHINA

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Transcript of Msk imaging msk intv rad gantonio

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JOURNÉES  FRANCOPHONES    D'IMAGERIE  MÉDICALES      IMAGE  GUIDED  MSK  INTERVENTIONS    

Gregory E Antonio MD St  Teresa’s  Hospital  Hong  Kong,  CHINA    

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Acknowledgement  

§  Department  of  Imaging  &  IntervenGonal  Radiology,  Chinese  University  of  Hong  Kong,    

§  St  Teresa’s  Hospital,  Scanning  Department,  Hong  Kong  

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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  

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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

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QUIZ  CASE  

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38  y.o.  female,    abdo  pain  

Axial Sagittal

•  Tubular/ curvilinear subcutaneous lesions & streaky fat •  DDx: infection/ infestation, vascular malformation

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DistribuGon  reminds  you  of  anything?  

Coronal

3D Tangential lateral

•  Lesions distributed in a matrix of lines

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Acupuncture  meridians/  grid  

www.healingtaoinstitute.com www.ourpsychicart.com http://hkhousewife.com www.123rf.com

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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

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A  rare  case?  You  know  there  will  be  more  when  Coupons  are  offered  

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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  

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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)  

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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  

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MSK  INTERVENTIONS:  CORE  Bread  &  Bu^er  

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ABSCESS  /  COLLECTION  FOR  ASPIRATION/  INJECTION  

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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

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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

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AspiraGon  of  thick  fluid    

•  20G Spinal needle •  Aim for the furthest and deepest/ dependent compartment for aspiration

USG USG

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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

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JOINT  ASPIRATION  

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M  &  M  

§  152mm  20G  Bevel  Gp  Spinal  needle  (BD  Medical  ref:  405211)  

§  100mm  long  17G  Diamond  Gp  Co-­‐axial  needle  (Temno  ref:  PP1710)  

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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

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Trajectory  visualizaGon  and  planning  

•  CT allow better demonstration of joint configuration than fluoroscopy •  Especially for overlying osteophytes and joint space curvature / corners

Axial Axial

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“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

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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

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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

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JOINT  INJECTION  

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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  

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Shoulder  USG  guided:    32  y.o.  male  

Axial USG

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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    

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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  

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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

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FACET  &  PSUEDO  JOINT  INJECTION  

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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

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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

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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

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SOFT  TISSUE  BIOPSY  

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Sol  Gssue  biopsy  

§  Ultrasound  is  “King”  §  CT  for  deep/  obscured/  complex  lesions  

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USG  sol  Gssue  biopsy:  TruCut  needle

•  Needle notch produces readily visible interface

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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

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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

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BONE  BIOPSY  

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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)  

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Bone Biopsy  Needle

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Co-­‐axial  CombinaGon

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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

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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

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VERTEBRAL  BIOPSY  

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25  y.o.    male  back  pain:  MRI  

•  Lesion in T6 Left posterior elements •  Pedicle, lamina and ? transverse process involvement

Sagittal

Axial

Coronal

Axial

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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

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Pre-­‐biopsy  CT  

Sagittal Coronal

Axial

Sagittal Coronal

Axial

Pre-biopsy MRI MPR Pre-biopsy CT MPR

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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

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Wrap-­‐up  Shot:  Pedicular  biopsy  

Sagittal Coronal

Axial

Sagittal Coronal

Axial Axial

Needle CT MPR Pre-biopsy MRI MPR

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Laminar  biopsy:  Step  by  step  

Sagittal Coronal

Axial

Axial

Axial Axial

Axial

•  Oblique approach from contralateral side

Needle CT MPR Serial selective CT

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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

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MSK  INTERVENTIONS:  ADVANCED  

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NERVE  ROOT  /  EPIDURAL  INJECTION  

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Spinal Nerve Root /  Epidural  InjecGons §  Symptomatic relief using long-­‐

acGng  local anaesthesia and corGcosteroids

Drawings from Netter

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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  

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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

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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

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VERTEBROPLASTY:  THE  BASICS  

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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  

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CLASSIC  VERTEBROPLASTY:  TRANS-­‐PEDICULAR  APPROACH  

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“Clel”  type  T12  OsteoporoGc  fracture    

•  Fluid filled fracture cleft •  Pedicular involvement

Pre-vertebroplasty CT MPR

Sagittal Coronal

Axial

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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

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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

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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

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Signs  for  potenGal  success:  vertebroplasty  

§  Marrow  edema  §  Fluid  in  fracture  gap  §  Gas  in  fracture  gap  §  Movement  with  flexion  /  extension  

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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

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RADIOFREQUENCY    THERMAL  ABLATION  

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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  

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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    

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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

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MRI  /  CT  correlaGon  

•  Nidus with central calcification and surrounding bone sclerosis & cortical thickening

Sagittal

Axial Axial Axial

Sagittal Sagittal

MRI MPR CT MPR

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RFA  of  Osteoid  Osteoma  

•  Create tunnel with bone biopsy needle •  Withdraw needle •  Insert electrode

Serial selective CT

Axial Axial Axial

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PALLIATIVE  TREATMENT  

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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

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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

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Alcohol  injecGon  

•  Penetrate cortex with bone biopsy needle •  Insert long spinal needle •  Inject contrast mixed with alcohol

Axial Axial Axial

Serial selective CT

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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.  

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