Trans-isthmic pars interarticularis screw fixation under CT and fluoroscopic guidance: technical success and clinical outcome in patients with symptomatic low-grade lumbar isthmic lysis.

OBJECTIVES: To assess the technical success of trans-isthmic screw fixation with simultaneous CT and fluoroscopic guidance in patients with symptomatic low-grade isthmic spondylolisthesis. METHODS: Fifty patients (28 women and 22 men; mean age ± standard deviation: 50 years ± 18.9) presenting with symptomatic low back pain with isthmic spondylolisthesis refractory to medical management were treated by means of trans-isthmic pars interarticularis percutaneous screw fixation. The procedure was performed under local anesthesia with double CT and fluoroscopic guidance. Primary outcome was technical success of the procedure, which was assessed with a post-procedure CT using the same success criteria as surgical screw placement with regard to entry point, trajectory, and screw tip. Secondary outcome was pain decrease assessed by the Visual Analog Scale (VAS). RESULTS: Ninety-nine procedures were performed in 50 patients and 99 screws were inserted. Postoperative CT assessment showed satisfactory screw placement in 96 cases, reflecting a technical success rate of 96.9%. No complications occurred during or after the procedure. Pain assessment showed a pain decrease of VAS score from a median of 7 (min 5, max 10; MAD 1.4) to 2 (p < 0.0001) (min 0, max 7, MAD 1.7) with a mean follow-up of 39 months. CONCLUSION: Trans-isthmic screw fixation performed under CT and fluoroscopic guidance presents a high technical success and appears as a safe procedure and effective procedure in patients with symptomatic low-grade isthmic lysis. KEY POINTS: • Trans-isthmic pars interarticularis percutaneous screw insertion is feasible under double CT and fluoroscopic guidance by a radiologist with a high technical success. • This technique can be performed under local anesthesia only. • In patients with chronic low back pain, isthmic screwing allows long-term pain improvement.

Percutaneous discectomy under CT and fluoroscopy guidance: an international multicentric study.

PURPOSE: To evaluate the technical efficacy, safety, and reproducibility of automated percutaneous lumbar discectomy (APLD) under CT and fluoroscopic guidance, for treating radiculopathy caused by lumbar disc herniation in patients impervious to conservative treatment. METHODS: A total of 77 patients with symptomatic lumbar disc herniation were treated with APLD in a prospective multicentric study performed in four centers across three countries. Magnetic resonance imaging and/or computed tomography was used to evaluate the disc herniation before and after the procedure. Only local anesthesia was used during these procedures. Clinical outcomes were measured with the visual analog scale (VAS) for pain at one and 6 months after the procedure. RESULTS: Technical success rate was 100% with a mean intervention duration of 30 min (15-45 min). No complications occurred during the procedure. Post-lumbar puncture syndrome occurred in three patients who were successfully treated with blood patches. VAS decreased from a mean of 8 before the intervention to 3 1 month after (p value = 0.001). The requirement for analgesia decreased from 100 to 27%. No statistically significant differences in outcomes were found between the centers. CONCLUSION: APLD with dual imaging guidance under local anesthesia is a safe, feasible, and reproducible technique to treat symptomatic lumbar disc herniation.

CT-guided fixation of pelvic fractures after high-energy trauma, by interventional radiologists: technical and clinical outcome.

OBJECTIVE: The aim of our study was to evaluate screw placement accuracy, safety, complications, and clinical outcomes including functional and pain score, in 32 patients treated with CT-guided pelvic ring fixation after high-energy trauma. MATERIALS AND METHODS: Consecutive patients who were treated by CT-guided fixation of sacral or acetabular fractures after high-energy trauma were included. All procedures were performed under general anesthesia, with dual CT and fluoroscopic guidance, by interventional radiologists. Fractures were minimally displaced or reduced unstable posterior pelvic ring disruptions, with or without sacroiliac disjunction (Tile B or C) and minimally displaced acetabular fractures. The primary outcome evaluated was screw accuracy. Secondary outcomes included patient radiation exposure, duration of the procedure, complications, clinical functional score (Majeed score), and pain scale (VAS, visual analog scale) evaluation during a follow-up period from 4 to 30 months postoperatively. RESULTS: Thirty-two patients were included (mean age 46) and 62 screws were inserted. Screw placement was correct in 90.3% of patients (95% of screws). Mean procedure duration was 67 min and mean patient radiation exposure was 965 mGy cm. Mean follow-up was 13 months and no complications were observed. The mean Majeed score at final follow-up was 84/100 and the mean VAS was 1.6/10. CONCLUSION: This technique is an effective and safe procedure in specific cases of pelvic ring and acetabulum fractures. It allows accurate screw placement in a minimally invasive manner, leading to effective management of poly-traumatized patients. KEY POINTS: • CT-guided pelvic ring fixation, including sacroiliac and acetabular fractures, is an effective and safe procedure. • It allows accurate and minimally invasive screw placement, leading to effective management of poly-traumatized patients. • Multidisciplinary cooperation is essential to ensure efficiency and safety.

Symptomatic Schmorl's nodes: role of percutaneous vertebroplasty. Open study on 52 patients.

PURPOSE: To assess the feasibility and clinical outcome of combined CT and fluoroscopy-guided percutaneous vertebroplasty in the management of painful Schmorl's nodes (SN). METHODS: A prospective study was carried out from January 2014 to January 2016 in 52 consecutive patients. Thirty-two men and 30 women aged between 42 and 88 years old were consecutively included. Technical success was defined as the ability to deposit cement in the subchondral endplate anteriorly, around the SN and posteriorly to the SN, in a cupule-like shape. Data regarding procedure time, amount of cement injection, and cement leakage were also noted. Assessment of pain was performed with VAS score and Oswestry disability index. All patients underwent a clinical and radiological follow-up at 1 day, 1 month, 6 months, and 1 year after procedure. RESULTS: Technical success was 100%. Mean procedural time was 15 min, and mean injected cement volume was 2.8 mL. The VAS and Oswestry disability index decreased respectively from 7.2 ± 1.5 to 2.1 ± 1.0 and from 59.2 ± 16.2 to 17.1 ± 5.0 at 1 month. Follow-up mean VAS scores were 2.4 (± 1.4) at 6 months and 2.2 (± 1.2) at 12 months. CONCLUSION: PVP appears as a feasible procedure in patients with painful SN with satisfying pain decrease in the following year after procedure.

Ultrasound-guided percutaneous release of the carpal tunnel: comparison of the learning curves of a senior versus a junior operator. A cadaveric study.

OBJECTIVE: The purpose was to evaluate, in a cadaveric cohort, the feasibility and the learning curve of ultrasound-guided percutaneous carpal tunnel release. MATERIALS AND METHODS: Fourteen carpal tunnel releases were carried out on unembalmed cadavers by a senior and a junior radiologist. Procedures were realized with an 18-MHz linear probe. An anatomical evaluation was first performed using ultrasound to detect any anatomical variant. After hydrodissection of the carpal tunnel with lidocaine, a 3-mm hook knife was introduced into the security zone to perform a retrograde section of the transverse carpal ligament (TCL) under ultrasound guidance. Anatomical dissection was performed for each wrist. The main evaluation criterion was the complete TCL section. The procedure duration (minutes), skin incision size (millimeters), the integrity of the median nerve, thenar motor branch, and palmar vascular arch were also evaluated. RESULTS: The senior operator was able to perform a complete release after training on three specimens and the junior operator after four specimens (p > 0.05). In most of the cases when complete release was not achieved, it was due to an incomplete section of the distal TCL (10 mm missing section on average). Mean duration time of procedure was 14 min (11 min for the senior versus 17 min for the junior, p > 0.05). Damage of neither the median nerve nor the vascular structure was observed. Mean size of the skin incision was 3 mm. CONCLUSION: The ultrasound-guided percutaneous release of the carpal tunnel is demonstrated to be a procedure with a rapid learning curve.

Cosmetic Adolescent Filler: An Innovative Treatment of the "Selfie" Complex.

PURPOSE: "Selfie" photography is increasing among teenagers, accentuates congenital anomalies, and impacts self-confidence. Tear trough deformity is most commonly due to aging, but also occurs as a congenital anomaly and can be a major source of insecurity and embarrassment. OBJECTIVE: The purpose of this study is to show the efficacy and safety of hyaluronic acid gel filler in a teenage patient with congenital tear trough deformity. MATERIAL AND METHOD: We describe the case of a teenager who underwent hyaluronic acid gel filling to the tear trough deformity at age 14 years. Prospective follow up was assessed for 5 years. RESULTS: The patient improved clinical appearance and self confidence. Her satisfaction level was high, and no complication occurred during entire follow up. CONCLUSION: In this case, hyaluronic gel acid filler was safe and effective for augmentation of congenital tear trough. The patient was satisfied and experienced increased self-esteem.

Percutaneous vertebroplasty under local anaesthesia: feasibility regarding patients' experience.

OBJECTIVE: Evaluate patients' intraoperative experience of percutaneous vertebroplasty (PV) performed without general anaesthesia in order to assess the feasibility of local anaesthesia and simple analgesic medication as pain control protocol. METHODS: Ninety-five patients who underwent single-site PV were consecutively included in the study between 2011 and 2013. Each procedure was achieved under local anaesthesia and perfusion of paracetamol, tramadol and dolasetron, with combined CT and fluoroscopy guidance. Numeric pain scale (NPS) was collected before, during and after intervention. After intervention, patients were asked to evaluate their experience as "very bad", "bad", "fair", "good" or "very good", independently of the pain. RESULTS: Indications for vertebroplasty were osteopenic fractures (78 %), aggressive angiomas (13 %) and somatic tumours (9 %). In 76 % of cases, patients' experience was described as "very good" (44 %) or "good" (32 %), whereas 19 % described it as "fair" and 5 % as "very bad". Mean operative NPS was 5.5. After intervention, NPS was significantly lower with a decrease of 4.5 points. No differences were found according to the localization, type of lesion, age or sex either in terms of experience or NPS. CONCLUSION: Percutaneous vertebroplasty is feasible under local anaesthesia alone, with a very good or good experience in 76 % of the patients. KEY POINTS: • Vertebroplasty is a first-line therapy for consolidation and pain control of vertebral lesions. • This procedure is commonly performed under general anaesthesia or conscious sedation. • We perform vertebroplasty under local anaesthesia and simple analgesic protocol with acceptable experience. • Percutaneous vertebroplasty can safely be proposed in a fragile population.

CT- and fluoroscopy-guided percutaneous discectomy for lumbar radiculopathy related to disc herniation: a comparative prospective study comparing lateral to medial herniated discs.

OBJECTIVE: To evaluate and compare two groups of patients with sciatica due to intervertebral disc herniation with no neurologic deficit. The groups consisted of patients with intervertebral disc herniation in a medial location (group 1) and those in a lateral location (group 2). MATERIALS AND METHODS: A total of 200 patients were included in the study and were followed for a minimum of 6 months. In our series, we treated 80 postero-lateral herniated discs (40% of cases), 46 postero-medial herniated discs (23%), and 74 foraminal herniated discs (37%). Level L3-L4 was treated in 30 cases (15%), L4-L5 in 98 cases (49%), and L5-S1 in 72 cases (36%). The procedure was performed under dual guidance: fluoroscopic and CT. A helical probe was activated. It penetrates the herniated disc and causes the pulpous material to be mechanically evacuated through the probe. All 200 patients were followed for a minimum of 6 months. RESULTS: In group 1, the patients had a mean pain score of 7.9 ± 2.5 VAS units (range 6-10 units) prior to intervention. This was reduced to 3.2 ± 2.1 VAS units (range 0-10 units) at 48 h follow-up and increased to 3.9 ± 1.2 VAS units (range 0-10 VAS units) at 1 month follow-up and further reduced to 2.7 ± 1.2 units (range 0-10 VAS units) at 6 month follow-up. In group 2, the patients had a mean pain score of 8.2 ± 3.2 VAS units (range 6-10 units) prior to intervention. This was reduced to 2.8 ± 1.5 VAS units (range 0-10 units) at 48 h follow-up and decreased to 1.5 ± 0.9 VAS units (range 0-10 units) at 1 month and further reduced to 1.1 ± 0.5 VAS units (range 0-10 units) at 6 months. CONCLUSION: Our study showed that results were more satisfactory for the hernia located laterally (postero-lateral, foraminal, and extra-foraminal) as compared to the hernia located posteromedially.

CT quantification of hemoperitoneum volume in abdominal haemorrhage: a new method.

INTRODUCTION: In emergency departments, focused assessment for sonographic examination of trauma patients (FAST) accurately detects hemoperitoneum in unstable patients. Currently, only an approximation of the volume of free intraperitoneal fluid (FIPF) can be done using ultrasound (US) and CT scans. We previously reported a new method developed on an experimental cadaveric model using US examination of the abdomen and applying a mathematic formula to effusion measurements to evaluate the exact volume of FIPF. The aim of this prospective study is to extrapolate this method in a clinical practice and apply it to CT measurements of the same area. PATIENTS AND METHODS: We included prospectively eleven patients admitted with acute intraperitoneal haemorrhage: 10 patients with post-traumatic hemoperitoneum and 1 patient with a ruptured extra-uterine pregnancy. The mean age was 43.2 years (extremes: 21-82). There were six males and five females. All of these patients had to undergo emergency surgery by laparotomy or laparoscopy. The amount of FIPF was assessed preoperatively on axial sections of CT scan, by measuring fluid thickness in millimetres in the hepatorenal pouch (Morrison's pouch), between the inferior aspect of the liver and the anterior aspect of the right kidney. During the emergency surgical procedure, we collected and quantified FIPF volume by direct measure in all cases. RESULTS: The correlation between fluid thickness x (mm) on the CT scan and the estimated amount of FIPF was established by the following linear function: volume (mL) = 81.068x + 263.2. The Spearman's R obtained is 0.779 and the significance level is 0.005. We found a constant correlation between FIPF measured by radiologic procedure and direct per-operative measurement of FIPF. CONCLUSION: This new linear function can be used to measure the exact volume of FIPF. This evaluation can help surgical decisions, especially when abdominal trauma is associated with other haemorrhagic lesions.

Symptomatic lumbar facet joint cysts treated by CT-guided intracystic and intra-articular steroid injections.

OBJECTIVE: To evaluate percutaneous computed tomography (CT)-guided intracystic and intra-articular steroid injections for the treatment of lumbar facet joint cyst causing radicular pain. METHODS: A single-centre prospective study involving 120 consecutive patients with symptomatic lumbar facet joint cyst-induced radicular pain was done (72 women, 48 men). The average age was 68.2 years (52-84). Patients were treated by percutaneous CT-guided intracystic and intra-articular steroid injections. The clinical course of nerve root pain was evaluated after 1 day, and 1, 3 and 6 months, with long-term follow-up after 12 months. RESULTS: Patient follow-ups in our series show supportive results: within 120 patients, 54% of patients were satisfied with a long-lasting result from the first intra-cystic and intra-articular steroid injections (n = 65), while 20.8% were satisfied with a long-lasting result from a second intervention. Combining these two results shows that 75% of patients were satisfied with a long-lasting result. CONCLUSIONS: Our results showed that percutaneous treatment of vertebral lumbar facet joint cysts by double injections is an effective and economic therapeutic technical management among 75% of our patients. Thus we recommend that it should be considered as a first choice of treatment. KEY POINTS: Lumbar facet joint cysts are a common feature of back and radicular pain. They may be treated effectively by interventional radiologists using CT guidance. Percutaneous treatment using double injections can save surgery in 75% of patients.

Percutaneous vertebroplasty in tumoral spinal fractures with posterior vertebral wall involvement: Feasibility and safety.

PURPOSE: to evaluate the technical feasibility and safety of CT and fluoroscopy guided percutaneous vertebroplasty in the treatment of tumoral vertebral fractures with posterior wall involvement. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this study. Sixty-three consecutive adult patients (35 women, 28 men; mean age+/- standard deviation: 69 years+/- 14) with tumoral spinal fractures that compromised the posterior wall were treated by means of percutaneous vertebroplasty with CT and fluoroscopy guidance. Only local anesthesia was used during these procedures. Postoperative outcome was assessed using the Kostuik index. RESULTS: Sixty-three vertebroplasties were performed on thirty-four thoracic (54%), twenty-six lumbar (41%), and three (5%) cervical vertebrae. The etiologies of the fractures were metastasis in twenty-eight (44%), myeloma in twenty-five (40%) and hemangioma in ten (16%). Almost all fractures (94%) were consolidated after vertebroplasty (score of Kostuik <3) (p < 0.001). No major complications were reported in our series of cases. CONCLUSION: This study suggests that tumoral spinal fractures with posterior vertebral wall involvement can be successfully and safely treated by CT- and fluoroscopy-guided percutaneous vertebroplasty.

Vertebral split fractures: technical feasibility of percutaneous vertebroplasty.

OBJECTIVE: The treatment of vertebral split fractures remains controversial, consisting of either corset or internal fixation. The aim of this study was to evaluate the technical feasibility of CT- and fluoroscopy-guided percutaneous vertebroplasty in the treatment of vertebral split fractures. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this study. Sixty-two consecutive adult patients who had post-traumatic vertebral split fractures (A2 according to the AO classification) without neurological symptoms were prospectively treated by percutaneous vertebroplasty. All these procedures were performed by an interventional radiologist under computed tomography (CT) and fluoroscopy guidance by using only local anaesthesia. Postoperative outcome was assessed using the visual analogue scale (VAS) and Oswestry disability index (ODI) scores. RESULTS: Vertebroplasty was performed on thoracic and lumbar vertebrae, creating a cement bridge between the displaced fragment and the rest of the vertebral body. Seven discal cement leakages (11%) were observed, without occurrence of adjacent vertebral compression fractures. The mean VAS measurements ± standard deviation (SD) significantly decreased from 7.9 ± 1.5 preoperatively to 3.3 ± 2.1 at 1 day, 2.2 ± 2.0 at 1 month, and 1.8 ± 1.4 at 6 months (P<0.001). The mean ODI scores ± SD had also a significant improvement: 62.3 ± 17.2 preoperatively and 15.1 ± 6.0 at the 6-month follow-up (P<0.001). CONCLUSION: This study suggests that type A2 vertebral fractures could be successfully treated by CT- and fluoroscopy-guided percutaneous vertebroplasty.

[Imaging of bone metastases]. / Sémiologie des métastases osseuses en radiologie conventionnelle.

Bone metastases are detected at initial diagnosis of cancer in 25% of cases and bone metastases are common in the course of a majority of cancer types. The spine and proximal long bones are the most affected sites. Knowledge of the basic radiological semiology is important to make the proper diagnosis of metastasis(s) bone(s), especially in situations in which the clinical context is not suggestive of metastases (such as cases where bone metastases are inaugural or cases of peripheral solitary metastasis). Tumor aggressiveness can be assessed at the level of the cortical bone and periosteum. Lodwick criteria are useful for the diagnosis of malignancy and tumor aggressiveness at initial diagnosis on plain radiographs, which are very important in the context of bone metastases. A CT scanner is required to confirm the malignancy of a bone lesion. MRI is complementary to the scanner including for the assessment of bone marrow involvement and tumor extensions.