Real-time ultrasound-MRI fusion image virtual navigation for locating intraspinal tumour in a pregnant woman

Potential Application of MR-MR-US Fusion Imaging Navigation with Needle Tail Intelligent Positioning in Guiding Puncture in Percutaneous Transforaminal Endoscopic Discectomy

This study sought to investigate the feasibility of using magnetic resonance-magnetic resonance-ultrasound (MR-MR-US) fusion imaging navigation (FIN) with needle tail intelligent positioning (NTIP) to guide puncture in percutaneous transforaminal endoscopic discectomy (PTED). First, in a pig experiment, we found that puncture errors in lumbar intervertebral foramen (LIF) puncture using magnetic resonance-magnetic resonance-ultrasound (MR-MR-US) FIN with NTIP for experienced and novice operators were 2.00 ± 1.00 and 2.57 ± 0.98 mm, respectively (p = 0.231), suggesting this technique was minimally dependent on experience. Then, two experienced surgeons agreed (inter-observer agreement к=0.801) that the quality of MR-MR fusion images was good or sufficient. Finally, we performed PTED in eight patients using MR-MR-US FIN with NTIP, and no significant complications were reported during LIF puncture. Overall, MR-MR-US FIN with NTIP may be a potential application for guiding puncture in PTED, but more clinical studies with a larger sample size are required to further evaluate the advantages of MR-MR-US FIN with NTIP.

O2-O3 chemodiscolysis: How much, how long? Retrospective outcome evaluation of different treatment sessions in partially-responder patients

PURPOSE

To retrospectively evaluate the clinical and instrumental outcome of different treatment sessions of oxygen-ozone (O₂-O₃) chemodiscolysis in patients with lumbar disc herniation.

METHODS

We evaluated 73 patients partially responders to a single session of oxygen-ozone (O₂-O₃) chemodiscolysis and submitted to multiple injections sessions. All patients completed a pre- and post-treatment clinical (VAS and modified McNab score) and instrumental MRI follow-up. Imaging evaluation included assessment of intervertebral disc area (IDA). Pre- and post-treatment differences were compared to evaluate differences in variation between groups. Correlation analysis was used to evaluate the relationship between morphological and clinical parameters.

RESULTS

Based on the type and number of treatments performed, patients were divided into three groups: Group A) patients submitted to an additional periradicular anaesthetic/steroid injection; Group B) patients submitted to an additional session of intradiscal O₂-O₃ injection; Group C) patients submitted to two further sessions of intradiscal O₂-O₃ injection.The results showed an improvement of pain scores in all groups, and a smaller disc area change in group B. Comparing the differences between pre- and post-treatment features among the three different groups of patients, we did not find any statistically significant difference. Correlation analysis did not show any statistically significant correlation between the morphological changes of the intervertebral disc and the clinical output scores.

CONCLUSIONS

In our retrospective observation of partially responder patients, multiple intradiscal ozone injections were not associated with a higher disc shrinkage nor superior clinical outcome compared to a single intradiscal O₂-O₃ application with an additional periradicular injection session.

The total resection rate of glioma can be improved by the application of US-MRI fusion combined with contrast-enhanced ultrasound

OBJECTIVE

This study was performed to evaluate the diagnostic performance of ultrasound-magnetic resonance imaging (MRI) fusion combined with contrast-enhanced ultrasound and to explore its role in improving the total tumor resection rate.

METHODS

Between January 2018 and December 2018, 16 patients in the observation group and 23 patients in the control group were enrolled in this study. The tumor depth and brain shift distance were analyzed, as well as the peak intensity and microvessel density of different grades of gliomas in the observation group. Finally, we compared the difference in total resection rate between the observation and control groups.

RESULTS

Using ultrasound during operations, we found a significant negative correlation between brain shift distance and tumor depth, with correlation coefficient r=-0.868(P<0.05). In glioma, the peak intensity and microvessel density increased synchronously with glioma grade(r=0.806, P<0.05). The total resection rate of lesions was significantly higher in the observation group than in the control group (P<0.05).

CONCLUSIONS

The application of ultrasound-MRI fusion combined with contrast-enhanced ultrasound can improve the total resection rate of lesions, thus playing an important role in clinical practice.

Management Challenges of Metastatic Spinal Cord Compression in Pregnancy

Primary and secondary spinal tumours with cord compression often represent a challenging condition for the patient and clinicians alike, even more so during pregnancy. The balance between safe delivery of a healthy baby and management of the mother's disease bears many clinical, psychological, and ethical dilemmas. Pregnancy sets a conflict between the optimal surgical and oncological managements of the mother's tumour and the well-being of her foetus. We followed the CARE guidelines from the EQUATOR Network to report an exemplificative case of a 39-year-old woman with a 10-year history of breast cancer, presenting in the second trimester of her first pregnancy with acute onset severe thoracic spinal instability, causing mechanical pain and weakness in lower limbs. Neuroradiological investigations revealed multilevel spinal deposits with a pathological T10 fracture responsible for spinal cord compression. The patient was adamant that she wanted a continuation of the pregnancy and her baby delivered. After discussion with her oncologist and obstetrician, we agreed to perform emergency spinal surgery—decompression and instrumented fixation. The literature search did not reveal a similar case of spinal metastatic breast cancer undergoing spinal instrumentation and delivery of a healthy baby a few months later. Following the delivery, the patient had further oncological treatment, including chemotherapy and radiotherapy. The paucity of such reports prompted us to present this case and highlight the relevance of a multidisciplinary approach involving obstetrician, oncologist, spinal surgeon, and radiologist to guide the optimal decision-making process.

Ultrasound guidance for transforaminal percutaneous endoscopic lumbar discectomy may prevent radiation exposure: A case report

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has become a mature and mainstream minimally invasive surgical technique for treating lumbar disc herniation (LDH). Repeated fluoroscopy, with more than 30 shots on average, is inevitable to ensure its accuracy and safety. However, exposure to X-rays may pose a threat to human health. We herein report a case of ultrasound (US)-assisted PELD in two levels of LDH to explore a new possibility that can reduce the radiation dose during puncture and cannulation in PELD.

CASE SUMMARY

A 38-year-old man with low back pain and left leg pain for more than 7 years came to our clinic, his symptoms had aggravated for 1 month, and he was diagnosed with L3-4 and L4-5 disc herniations. He received US-guided PELD with good results: His straight leg elevation increased from 40 to 90 degrees after PELD, and his visual analog scale (VAS) and Oswestry Disability Index scores both significantly decreased immediately and 6 mo after PELD. With the guidance of US, he received only two shots of fluoroscopy (fluoroscopic time: 4.4 s; radiation dose: 3.98 mGy). To our knowledge, this is the first case of US-guided puncture and cannulation of PELD for LDH at two levels.

CONCLUSION

US could be used to guide PELD and has the potential to largely reduce radiation than traditional X-ray guidance.

Reduced Radiation Exposure and Puncture Time of Percutaneous Transpedicular Puncture with Real-Time Ultrasound Volume Navigation

OBJECTIVES

The present study introduced ultrasound volume navigation (UVN) to reduce the radiation exposure and puncture time of percutaneous transpedicular puncture in percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP).

METHODS

We retrospectively reviewed the medical records of patients with osteoporotic vertebral compression fracture who had undergone PVP or PKP guided by UVN or fluoroscopy from September 2017 to December 2017.

RESULTS

We enrolled 10 patients (6 women, 4 men) with 24 pedicles involved in the present study. Significant reductions in fluoroscopy frequency (2.58 vs. 17.42; P < 0.01), exposure time (2.36 vs. 15.69 seconds; P < 0.01), and puncture time (4.13 vs. 19.21 minutes; P < 0.01) for each pedicle were observed in the UVN group compared with the fluoroscopy group. Obvious correlations among fluoroscopy frequency, exposure time, and puncture time for each pedicle were observed (P < 0.01). The visual analog scale scores and Oswestry Disability Index were both significantly improved after the procedures. All patients achieved excellent or good clinical outcomes. No complications were observed in any patient.

CONCLUSIONS

UVN could obviously reduce the radiation exposure and puncture time of percutaneous transpedicular puncture in PVP and PKP.

Real-time fusion-imaging in low back pain: a new navigation system for facet joint injections

AIMS AND OBJECTIVES

The aim of the current study is to present our experience in lumbar spine interventional procedures performed with a newly developed multimodal echo-navigator (EcoNav) and to evaluate short-term clinical outcomes of a series of patients affected by facet joint disease (FJD) treated with steroid and anaesthetic injection under fusion-imaging guidance, compared to a cohort of patients that received the same treatment under computed tomography (CT) guidance.

METHODS

Sixty-five consecutive patients (34 females; mean age 68.3 ± 12.8 years) with a clinical diagnosis of non-radicular low back pain lasting for more than 6-weeks and magnetic resonance (MR) or CT confirmed FJD were enrolled for image-guided FJI. Twenty-eight patients underwent FJI with fusion-guided technique, while CT-guided procedures were performed in the other cases. Clinical and procedural data were recorded and compared at a mean follow-up of 6.1 ± 2.0 months.

RESULTS

A significant improvement in clinical parameters was observed for both fusion-guided and CT-guided group. Comparing both groups, no statistically significant difference could be detected neither at baseline conditions nor during the follow-up period. No significant periprocedural complication occurred in both groups. A satisfaction rate of 92.3 and 81.1% was reported for fusion-guided and CT-guided group, respectively.

CONCLUSION

EcoNav fusion-imaging system represents a safe, feasible, effective and reproducible guidance option in FJD infiltration procedures, also avoiding use of ionising radiations.