MSK Interventions/Future trends

Question 1

What can facet joint arthrography identify?

Answer 1

Spinal stenosis

Question 2

What treatment can be done under facet arthrography?

Answer 2

Facet joint injections - Pain management/temporary pain releif does not cure

Question 3

what modalities are used for facet joint injection guidance?

Answer 3

Fluoroscopy
or
CT

Question 4

What is a nerve root block (NRB)?
And why is it done?

Answer 4

Injection of steroid and local anaesthetic to relieve pain from nerve roots
which have become inflamed due to pressure from nearby bone spurs or intervertebral discs
To decrease pain and inflammation which allows rehabilitation

Question 5

What is the procedure of a nerve root block?

Answer 5

Performed under fluoroscopy guidance (or CT)

Procedure:
Patient prone
Local anaesthetic injection just under skin
Spinal needle is then inserted into the epidural space, just next to the affected nerve root
Contrast injected to check position of needle tip
Local anaesthetic and steroid are injected into the epidural space

Question 6

What is radiofrequency ablation?
And what is it used for?

Answer 6

Minimally invasive procedure to treat pain, using a specialised machine - a “radiofrequency generator”

Palliative treatment of spinal metastases to reduce pain

Question 7

What are the advantages of Radiofrequency ablation?
What are the limitations?

Answer 7

Relief can be 3 – 18 months
Minimally invasive/minimal blood loss = short recovery time
Usually a day-case procedure, under General Anaesthetics or Local Anaesthetics + sedation
High success rate, but not usually done if the spinal metastases are close to neurological structures because of the risk of neurological injury
Not a cure only pain relief

Question 8

What imaging guidance is used and what is the procedure for radiofrequency ablation?

Answer 8

Performed under imaging guidance
-fluoroscopy
-CT
-MRI
to direct the radiofrequency probe into the spinal tumour

The radiofrequency probe is attached to a radiofrequency generator,
which creates high-frequency alternating current pulses that heat and destroy the tumour

Question 9

What is thermal ablation of bone tumours?
And what imaging modalities are used for image guidance?

Answer 9

Treats and manages pain in difficult-to-locate bony lesions using electrical currents to produce extreme heat or cold in the tip of the probe

Guided using different imaging modalities:
-CT
-MRI
-US

Question 10

What is thermal ablation used on MSK?

Answer 10

Minimally invasive means of treating a variety of focal benign and malignant osseous lesions
Indications include:
Osteoid osteoma (benign bony tumour)
Osteoblastoma (rare benign bony tumour)
Chondroblastoma (neoplasms arising in the epiphysis or apophysis)
Metastasis (secondary)

Question 11

what is a discography?

Answer 11

A procedure used to look at the intervertebral discs when there is pain in the discs

Question 12

What is Discogenic pain?

Answer 12

Pain in the vertebral discs
Most often the lumbar spine

Question 13

Where do the needles target in the imaging of discography?

Answer 13

Nucleus Pulposus (Centre of disc)
Targeted and contrast is injected

Question 14

What is discography used for?

Answer 14

To verify/assess disc herniation/degeneration

Question 15

What are the disadvantages/risks of discography?

Answer 15

Pain provoking
infected disc

Question 16

What is Percutaneous Vertebroplasty?

Answer 16

Simple procedure
Guided under imaging
Performed under local anaesthesia
Bone cement is injected into a vertebral body/bodies

Question 17

What are the indications for Percutaneous Vertebroplasty?

Answer 17

Indications:
- Thoracic or lumbar compression fracture
- Vertebral body tumours
- Intractable back pain
- Severe painful osteoporosis with height loss/compression fracture
- Failed conservative pain management

Question 18

What is Kyphoplasty/balloon kyphoplasty?

Answer 18

Balloon is used in vertebral body to make more space for cement
cement is injected into the vertebral body
(very similar to Percutaneous Vertebroplasty)

Question 19

What are the indications for balloon kyphoplasty?

Answer 19

Vertebral compression (loss of vertebral height)
Fractures
(superior end plate)

Question 20

What are the advantages of percutaneous vertebroplasty compared to balloon kyphoplasty?

Answer 20

Faster surgery
lest post-op pain due to smaller trochar (needle)

Question 21

What are the advantages of balloon kyphoplasty to percutaneous vertebroplasty?

Answer 21

Better restoration of the vertebral height

Question 22

What are the disadvantages of percutaneous vertebroplasty compared to balloon kyphoplasty?

Answer 22

cement leakage
Height restoration is questionable - however, some studies show that it is similar to height restoration

Question 23

What are the disadvantages of balloon kyphoplasty compared to percutaneous vertebroplasty?

Answer 23

Similar outcomes but cost 20 times more and require an overnight stay

Question 24

Future trend of MSK imaging/treatment?

Answer 24

Digital tomosynthesis

Question 25

what is digital tomosynthesis?

Answer 25

An imaging technique that uses standard X-ray equipment with digital flat panel detectors to create tomographic images from very low-dose projections obtained at different angles

Question 26

what is the radiation dose of digital tomosynthesis comparing to other similar modalities?

Answer 26

The radiation dose is much lower compared to that of CT and is two to three times the dose of a standard radiography

Question 27

What is digital tomosynthesis intended for imaging?

Answer 27

Tomosynthesis is intended for the analysis of high-contrast structures and especially for bones
It is superior to conventional radiography when there are bone superimpositions or when metal structures hide regions of interest

Question 28

What are the advantages of digital tomosynthesis?
What would it be useful for in imaging pathway?

Answer 28

The high resolution and its ability to perform examinations in weight-bearing positions are some of the main advantages of this technique

Potential to have significant impact on patient care and NHS costs

Less radiation than CT

Has the potential to be used as a supplementary imaging tool to CT in the follow up of x-ray examinations investigating complications following internal fixations (ORIFs) of the wrist and ankle, and investigating suspect scaphoid fractures

Question 29

What are the limitations of digital tomosynthesis?

Answer 29

As this is an application to existing DR technology, it is not standard for all general X-ray equipment