RC 109 - Musculoskeletal interventions: what's new?
1. To appreciate the indications for ablations and embolisation.
2. To learn about different techniques and combination of them.
3. To discuss the results and literature data of interventional radiology procedures.
In a modern era of interventional strategies, ablation and embolization use is not anymore limited to usual target organs but these techniques are finding new rooms, remarkably in MSK tumours. In the literature, the most encountered benign tumours treated via ablation and/or embolization are osteoid osteoma, osteoblastoma, chondroblastoma and osteochondroma, giant cell tumour, aneurysmal bone cyst, eosinophilic granuloma, vertebral haemangioma and fibrous dysplasia. In turn, malignancies of the soft tissue and bones (primary sarcomas) are rare, likely spinal metastases are the most common (derived by carcinomas of the breast, lung, prostate, kidney and uterus). Shall be underlined that in most cases palliative measures are related to malignant cancer and patient's quality of life and motility are the priority. Among first weapon such as thermal ablation (both MW, RF and Laser) cryotherapy is raising the interest of the IR's community due to the powerful pain management feature and the possibility of an instant check of the ice ball, preserving nervous tissues, specially for vertebral metastases use. Nevertheless, ablation may be applied both for curative and palliative strategies when combined with cement injection, allowing a precise patient's selection to be made. Embolization has a strong importance applied to hypervascular lesions, may also reduce recurrence rate and potentially extend survival one. New heroes of oncologic interventions and probably future fashion are MR-guided HIFU and irreversible electroporation (IRE), even though bringing higher cost. Improved research of the field is strongly needed to assess a proper cost-benefit analysis and limits of these approaches.
1. To appreciate the rationale for the using of interventional radiology procedures.
2. To learn about different techniques and treatment strategy.
3. To discuss results and literature data in comparison with other treatments.
Vertebral augmentation techniques include standard vertebroplasty, balloon kyphoplasty and percutaneous implant insertion combined to PMMA injection. Indications include osteoporotic, traumatic, pathologic and cancer-related fractures as well as benign (e.g. symptomatic atypical aggressive haemangiomas) or malignant (e.g. metastatic) lesions. Under proper patient selection, these techniques provide pain relief and functional improvement along with spine alignment height restoration and endplate reduction. Additionally, kyphotic angle restoration or maintenance seems to prevent future vertebral fracture in the adjacent levels and improved sagittal balance. Studies in the literature report that load distribution in patients with vertebral fractures post-vertebroplasty returns to values of normal population. Variety in the morphology, location, and aetiology of vertebral fractures demands a tailored patient-centred approach. Percutaneous technique for intervertebral disc herniation and discogenic pain can be either decompression or biomaterial implantation techniques. The former can be classified into mechanical (discectomy), thermal (RF, laser, coblation, IDET) or chemical (Discogel, ozone) methods whilst the latter includes hydrogel, PRP and stem cell therapies. Decompression techniques are indicated for small- to medium-sized symptomatic contained hernias. Percutaneous techniques are performed as outpatient, low-cost procedures and are governed by good patient compliance, high success (75-85%) and low complication rates (<1-2%). In case of treatment failure, percutaneous techniques can be repeated without interfering with surgery at a later stage. Percutaneous vertebral augmentation and discectomy techniques compared to surgical approaches are favoured in terms of reduced blood loss and operating time, shorter hospital stay, fewer complications and less postoperative pain.
1. To appreciate the high imaging quality and guidance accuracy using CBCT for biopsy and pain treatment.
2. To learn about the advantages of CBCT guided interventions, reconstruction algorithms, image enhancement and dose reduction.
3. To discuss about techniques, limitations of CBCT and future applications.
Cone beam-CT imaging (CB-CT) is actually widely available and allows, because of high-quality multiplanar reconstructions and using dedicated guiding software, to perform various bone interventions. Bone biopsies are feasible using CB-CT guidance with the same accuracy as CT-scan guidance and requiring less radiation exposure for patients and operators. Furthermore, pain palliation procedures such as cementoplasty and percutaneous osteosynthesis are actually possible with very high accuracy and technical success rates. New techniques and software are under development to decrease radiation dose, improve guidance for in case where CB-CT acquisition can be complicated and be easily integrated in an everyday workflow.