Msk imaging msk intv rad gantonio

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

38
y.o.
female,

abdo
pain

Axial

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

Sagittal

DistribuGon
reminds
you
of
anything?

3D Tangential lateral

Coronal

•  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

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 aspiration

•  USG is king: high local resolution, real-time, radiation-free imaging
•  Often larger bore needles are required to aspirate thick fluid/ pus

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)

AspiraGon
of
thick
ﬂuid

USG

USG

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

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

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

Axial

edema

§  Dx:
ArthriGs,
?
SepGc
or

Inﬂammatory

Trajectory
visualizaGon
and
planning

Axial

Axial

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

“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

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

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

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)

Axial

Serial selective CT

§  No
need
to
go
into
depth
of
joint
(unlike
aspiraGon)

§  Wrap
up
shot
saved
and
printed
for
paGent
/
referrer

FACET
&
PSUEDO
JOINT
INJECTION

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

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

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

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

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

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)

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

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

25
y.o.

male
back
pain:
MRI

Sagittal

Axial

Coronal

Axial

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

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

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

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

Wrap-‐up
Shot:
Pedicular
biopsy

Sagittal

Coronal

Axial

Axial

Pre-biopsy MRI MPR

Sagittal

Coronal

Axial

Needle CT MPR

Laminar
biopsy:
Step
by
step

Axial

Axial

Axial

Axial

Serial selective CT

•  Oblique approach from contralateral side

Sagittal

Coronal

Axial

Needle CT MPR

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

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)

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

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

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

Sagittal

Coronal

Axial

Pre-vertebroplasty CT MPR

•  Fluid filled fracture cleft
•  Pedicular involvement

T12
Vertebroplasty:
step-‐by-‐step

Sagittal

Coronal

Axial

• 
• 
• 
• 

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)

MPR
Contrast
conﬁrmaGon

Sagittal

Coronal

Axial


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

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).

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

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)

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

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

MRI
/
CT
correlaGon

Sagittal

Sagittal

Axial

Axial

MRI MPR

Sagittal

Axial

CT MPR

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

RFA
of
Osteoid
Osteoma

Axial

Axial

Serial selective CT
•  Create tunnel with bone biopsy needle
•  Withdraw needle
•  Insert electrode

Axial

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

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

Alcohol
injecGon

Axial

Axial

Serial selective CT

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

Axial

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

Msk imaging msk intv rad gantonio

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