Percutaneous thoraco-lumbar vertebral access under CT and fluoroscopic guidance: a survival guide.

Congress:

ECR 2020

Poster Number:

C-03764

Type:

Educational Exhibit

Keywords:

Performed at one institution, Not applicable, Image verification, Vertebroplasty, Biopsy, Fluoroscopy, CT, Neuroradiology spine, Musculoskeletal spine, Interventional non-vascular, Interventional Radiology

Authors:

L. J. Pavan¹, F. Torre¹, A. PRESTAT¹, A. Rudel¹, N. Stacoffe², H. VASSEUR¹, N. Amoretti¹; ¹Nice/FR, ²Lyon/FR

DOI:

10.26044/ecr2020/C-03764

DOI-Link:

https://dx.doi.org/10.26044/ecr2020/C-03764

Fig. 1: Transpedicular access. a) volume rendering view of ideal trocar path and b)...

Fig. 2: Intercosto-vertebral access. a) volume rendering view of ideal trocar path and...

Fig. 3: Intercosto-vertebral access through the transverse process. a) CT control of 20...

Fig. 5: Extra-pedicular access. a) volume rendering view of ideal entry point; b) CT...

Learning objectives

To explain how to choose a proper vertebral access under combined CT and fluoroscopic guidance in tricky situations, such as vertebroplasty, kyphoplasty and biopsy.

Background

Thoraco-lumbar vertebral accesses under fluoroscopic guidance are based on anatomical vertebral findings and consist essentially in transpedicular access with some exceptions (e.g. extrapedicular modified inferior endplate access [1]). CT guidance, instead, allows different accesses to the vertebral body, since they’re not strictly tied to anatomical landmarks. Furthermore the access can be adapted in order to fit fracture type and lesion location.

Findings and procedure details

In our daily practise we manage to perform all thoraco-lumbar vertebral procedures with three main vertebral accesses: Transpedicular: a safe access that should be chosen when pedicles allow a proper positioning in the vertebral body, mainly in lumbar vertebrae. In lumbar vertebrae, the junction between the transverse process and the superior articular process is usually a good vertebral entry point (Fig. 1). Intercosto-vertebral (or parapedicular): in thoracic vertebrae, an access through the costo-vertebral joint passing cranially to the transverse process (with more possibility of redirectioning...

Conclusion

CT guidance allows to properly choose the most suitable access, by evaluating vertebral anatomy, fracture type and lesion morphology. Multiple intra-procedural CT scans confirm the correct progression of the trocar and its proper position before biopsy, cement injection or other procedures. Fluoroscopy enables a constant and continuous control of the needle progression between intra-procedural CT scans. The transpedicular and intercosto-vertebral access are the preferred choices. The possibility to perform extra-pedicular access in lumbar vertebrae allows to treat patients even in the presence of orthopaedic hardware,...

Personal information and conflict of interest

L. J. Pavan; Nice/FR - nothing to disclose F. Torre; Nice/FR - nothing to disclose A. Prestat; Nice/FR - nothing to disclose A. Rudel; Nice/FR - nothing to disclose N. Stacoffe; Lyons/FR - nothing to disclose N. Amoretti; Nice/FR - nothing to disclose H. Vasseur; Nice/FR - nothing to disclose

References

Beall DP, Parsons B, Burner S. Technical Strategies and Anatomic Considerations for an Extrapedicular Modified Inferior Endplate Access to Thoracic and Lumbar Vertebral Bodies. Pain Physician. dicembre 2016;19(8):593–601. Liu L, Cheng S, Wang Q, Liang Q, Liang Y, Jin W, Zhou Q, Wang Z. An anatomical study on lumbar arteries related to the extrapedicular approach applied during lumbar PVP (PKP). PloS One. 2019;14(3):e0213164. Heo DH, Cho YJ. Segmental artery injury following percutaneous vertebroplasty using extrapedicular approach. J Korean Neurosurg Soc. febbraio 2011;49(2):131–3.