Accurate Needle Placement Research Articles

Comparison of freehand-navigated and aiming device-navigated targeting of liver lesions

Accurate needle placement is crucial for the success of percutaneous radiological needle interventions. We compared three guiding methods using an optical-based navigation system: freehand, using a stereotactic aiming device and active depth control, and using a stereotactic aiming device and passive depth control. For each method, 25 punctures were performed on a non-rigid phantom. Five 1 mm metal screws were used as targets. Time requirements were recorded, and target positioning errors (TPE) were measured on control scans as the distance between needle tip and target. Time requirements were reduced using the aiming device and passive depth control. The Euclidian TPE was similar for each method (4.6 ± 1.2-4.9 ± 1.7 mm). However, the lateral component was significantly lower when an aiming device was used (2.3 ± 1.3-2.8 ± 1.6 mm with an aiming device vs 4.2 ± 2.0 mm without). Using an aiming device may increase the lateral accuracy of navigated needle insertion.

Novel Pneumatic Device for High Speed Needle Insertion in Brachytherapy

Novel Pneumatic Device for High Speed Needle Insertion in Brachytherapy

Challenges in abdominal/pelvic biopsy techniques

There are various methods and techniques that can be utilize for abdominal biopsy. Some of these techniques have been utilized for over four decades. However, there are different variations to these techniques that have been recently developed to increase tissue retrieval and decrease complications. This manuscript will review a number of different modifications of prior CT or ultrasound techniques utilized with either CT or ultrasound that are helpful to be more effective in tissue retrieval. Newer guidance systems including the use of contrast-enhanced sonography and multi-modality image fusion biopsy guidance are reviewed. These different techniques can increase tissues retrieval, increase accuracy of needle placement, decrease the time for the procedure, and minimize complications.

AB0969 Accuracy of blind intra-articular injections in patients with osteoarthritis of the knee. An ultrasonography controlled study

BackgroundViscosupplementation by intra-articular injections (IAI) of hyaluronic acid in the knee is widely used for symptom relief in patients with osteoarthritis of this joint. Previous studies have demonstrated that blind...

The Anterior Approach for a Non–Image-Guided Intra-articular Hip Injection

The purpose of this study was to investigate and validate the accuracy and safety of a technique using an anterior approach for non-image-guided intra-articular injection of the hip by use of anatomic landmarks. We enrolled 55 patients. Injections were performed before supine hip arthroscopy after landmarking and before application of traction. After the needle insertion, success was confirmed with an air arthrogram and by direct visualization after arthroscope insertion. Accuracy and difficulty achieving correct needle placement were correlated with age, weight, height, body mass index, body type, gender, and surgical indication, as well as femoral and pelvic morphology. Forty-five patients who underwent injection in the office were followed up separately to document injection side effects. Needle placement accuracy was correlated to patients' demographics. All statistical tests with P values were 2 sided, with the level of significance set at P < .05. There were 51 correct needle placements and 4 misses, yielding a 93% success rate. The most common location for needle placement was the upper medial head-neck junction. Female gender was correlated with a more difficult needle placement and misses in relation to group size (P = .06). The reasons for misplacements of the needle were a high-riding trochanter, increased femoral version, thick adipose tissue over the landmarks, and variant of ilium morphology. Of 45 patients in the side effect study arm, 3 reported sensory changes of the lateral femoral cutaneous nerve that resolved within 24 hours. Hip injections by use of the direct anterior approach, from the intersection of the lines drawn from the anterior superior iliac spine and 1 cm distal to the tip of the greater trochanter, are safe and reproducible. Patient characteristics, such as increased subcutaneous adipose tissue or osseous anatomic variants, can lead to difficulty in placing the needle successfully. These characteristics can be predicted with the aid of physical examination and careful study of the pelvic radiographs. Level IV, therapeutic case series.

Abstract No. 382 - High technical success rate for liver needle placement with the CT-guide navigation system

Purpose To evaluate the efficacy of using the ActiViews CT-Guide® navigation system in the accurate placement of needles in liver biopsy and liver ablation. The system allows registration of a CT data set to an optical navigation system allowing free-hand needle placement using a virtual image analogous to CT fluoro. The system easily allows needle placement in off-axial trajectories. Materials and Methods Cohort study of twenty sequential patients undergoing CT guided hepatic needle placement, for either biopsy or thermal ablation, were enrolled in this study. IRB approved. Informed consent. Demographics were captured. Adequacy of needle tip placement was measured. Target parameters such as lesion size and depth from skin were noted. Total navigation time, number of scans performed and radiation dose were noted. Device related adverse events were monitored. All procedures were performed by experienced radiologists. Results Of the 20 patients, there were 7 females/13 males. Average age was 63 (range 43-80 years). All twenty needle placement procedures were technically successful. Average lesion size was 3.3 cm, 3.6 cm for the 14 biopsies biopsies and 1.8cm for the 6 ablations. Lesion depth was 8.1cm on average, 7.2 cm for biopsies and 9.7 cm for ablations. Navigation time was 3.9 minutes on average; 3.3 minutes for biopsies and 5.3 minutes for ablations. Radiation dose, measured as Dose Linear Product, DLP, was 1779 for all, 1675 for biopsies, and 2010 for ablations. There were no device related adverse events in the study group. Conclusion The CT-Guide® navigation system (ActiViews Inc., Wakefield, MA) has proven to be safe and effective in assisting in CT guided needle navigation. Our technical success rate was 100%. The system is easy-to-use after a short learning curve and proved especially useful in situations where lesions are only transiently visible on arterial phase, and in cases requiring multiple ablations. At our institution it has become standard to use this device for almost all ablations and most challenging biopsies.

Abstract No. 309 - Percutaneous lumbar sympathectomy: technique and clinical outcome review

Purpose Percutaneous sympathectomy has been used for treatment of complex regional pain syndromes (1), plantar hyperhydrosis (2,3), and peripheral vascular disease (PVD) with critical limb ischenia (CLI). We report technique of CT guided percutaneous sympathectomy using anhydrous ethanol in patients with CLI. Materials and Methods CT guided percutaneous lumbar sympathetic ablations were performed in a group of 5 patients (avg. age 68, range 61-82) with advanced PVD (Fontaine Stage IV). All had rest pain, clinical CLI and impending amputation. Patients were assessed for preprocedure and post procedure pain, color and warmth after the procedure, 4 hrs later and 2-3 months later. Results All patients showed a positive response of increased warmth, color, flushing and lessening of pain at the end of the procedure. Over three months follow-up, none underwent amputation, and 4 of the 5 (80%) maintained residual improvement in color and warmth. One returned to baseline appearance, but without amputation. No procedural complications were encountered. Conclusion CT guided lumbar sympathectomy with anhydrous ethanol is safe and effective in advanced PVD to stave off impending amputation. CT guidance increases accuracy of needle placement, decreases the volume of ablative chemical needed and may be able to reduce the incidence of complications reported in the literature (5).

Developing a method to plan robotic straight needle insertion using a probability-based assessment of puncture occurrence

Needle-based treatments for cancer require accurate placement of the needle tip into the target tissue. However, it is often difficult to insert a needle accurately because of the cancer displacement caused by organ deformation. Therefore, developing a planning method based on a numerical simulation that analyzes organ deformation is important for accurate needle insertion. However, predicting the puncture conditions, including the force applied to the needle is not trivial owing to marked variations in the experimental data. The purpose of this research is to develop a novel method for predicting a robust path for straight needle insertion with various puncture points. The method is based on the probabilities of the various puncture conditions and evaluates the expected accuracy of needle placement. First, a probability-based puncture condition was established and the expected accuracy of needle placement was defined. We also performed in vitro needle insertion experiments using a porcine liver. Significant variations in puncture force were observed. Accordingly, we established a probability distribution for the tissue stress caused by the puncture. An in vitro experiment was performed to measure needle placement accuracy using the optimized path. Experimental results show that the proposed method achieves a mean accuracy of 1.5 mm.

Feasibility Study of Needle Placement in Percutaneous Vertebroplasty: Cone-Beam Computed Tomography Guidance Versus Conventional Fluoroscopy

To investigate the accuracy, procedure time, fluoroscopy time, and dose area product (DAP) of needle placement during percutaneous vertebroplasty (PVP) using cone-beam computed tomography (CBCT) guidance versus fluoroscopy. On 4 spine phantoms with 11 vertebrae (Th7-L5), 4 interventional radiologists (2 experienced with CBCT guidance and two inexperienced) punctured all vertebrae in a bipedicular fashion. Each side was randomization to either CBCT guidance or fluoroscopy. CBCT guidance is a sophisticated needle guidance technique using CBCT, navigation software, and real-time fluoroscopy. The placement of the needle had to be to a specific target point. After the procedure, CBCT was performed to determine the accuracy, procedure time, fluoroscopy time, and DAP. Analysis of the difference between methods and experience level was performed. Mean accuracy using CBCT guidance (2.61mm) was significantly better compared with fluoroscopy (5.86mm) (p<0.0001). Procedure time was in favor of fluoroscopy (7.39 vs. 10.13min; p=0.001). Fluoroscopy time during CBCT guidance was lower, but this difference is not significant (71.3 vs. 95.8s; p=0.056). DAP values for CBCT guidance and fluoroscopy were 514 and 174mGy cm(2), respectively (p<0.0001). There was a significant difference in favor of experienced CBCT guidance users regarding accuracy for both methods, procedure time of CBCT guidance, and added DAP values for fluoroscopy. CBCT guidance allows users to perform PVP more accurately at the cost of higher patient dose and longer procedure time. Because procedural complications (e.g., cement leakage) are related to the accuracy of the needle placement, improvements in accuracy are clinically relevant. Training in CBCT guidance is essential to achieve greater accuracy and decrease procedure time/dose values.

Robotic-Assisted, Ultrasound-Guided Abdominal Cerclage During Pregnancy: Overcoming Minimally Invasive Surgery Limitations?

Herein, we report robotic abdominal cerclage placement under ultrasound guidance. The da Vinci Si system (Intuitive Surgical, Sunnyvale, CA) allows a simultaneous display of the operative field and transvaginal ultrasound images. Additionally, the vaginal ultrasound probe assisted in the manipulation of the uterus to improve visualization without placing excessive pressure on the gravid uterus. Ultrasound guidance improves needle placement accuracy and reduces potential for injuries.

MR Imaging-guided Lumbosacral Spinal Injection Procedures

Magnetic resonance (MR)-guided spinal injection procedures describe techniques for percutaneous drug delivery procedures in which MR imaging is used for visualization of the anatomic target, for accurate image-guided needle placement, monitoring of the injectant, and for visualization of the distrib

Percutaneous Imaging-guided Spinal Facet Joint Injections

The spine is the most common cause of chronic back pain. It can cause significant loss of function or disruption in activity of daily living and is extremely common in the elderly. Of the various causes of spinal pain, facet joint syndrome is often a diagnosis of exclusion, as it is difficult to differentiate the latter from pain secondary to degenerative disk disease or spinal stenosis because of overlapping clinical features and poor correlation between the clinical presentation and the imaging abnormalities. Further, localizing the source of pain is challenging as facet joint disease may not be limited to only 1 joint. Pain arising from the facet joints can be attributed to segmental instability, synovitis, synovial entrapment, trauma, meniscoid impingement, chondromalacia, and osteoarthritis. Facet joint injection is performed under fluoroscopy or computed tomography guidance, which facilitates accurate needle placement while reducing potential injury to the surrounding vital structures. Indications of facet joint injection include clinical suspicion of facet joint syndrome, chronic pain not relieved by trial of nonsteroidal anti-inflammatory drugs and physiotherapy, patients with confirmed facet joint syndrome, presence of adjacent segment deterioration after spinal fusion or persistent low back pain after a stable posterolateral fusion, and patients in whom oral or systemic drug therapy have to be withdrawn because of adverse effect or have exceeded the maximum tolerable dose. Given the high success rate and low complications, image-guided facet injection is deemed safer and more effective compared with conventional “blind” injections.

Bladder Neck Injection of a Polydimethylsiloxane-Bulking Agent Under Pneumovesicum for Treatment of Children with Urinary Incontinence: Report of 3 Cases

Abstract Introduction: To present the surgical technique and initial outcomes of bladder neck injection (BNI) of bulking agent under CO2-induced pneumovesicum to better visualize the bladder neck. Three children (one 12 year old and two 14 year olds) who underwent polydimethylsiloxane BNI under pneumovesicum for treatment of bladder neck incompetence were retrospectively reviewed. Patient diagnoses included an imperforate anus, joint hypermobility syndrome, and an ectopic ureter, respectively. BNI was performed with an antegrade approach under 10 mm Hg CO2 pneumovesicum after insertion of a 5-mm diameter trocar in the bladder dome. A single injection was given in all cases. BNI was successfully completed in all patients. Bleeding that developed during bladder access or injection did not interrupt accurate positioning of the needle or confirmation of mucosal coaptation in the bladder neck. At 6 months postoperatively, all patients reported social continence, defined as minimal incontinence requiring no more than one pad daily. No intraoperative morbidity or postoperative deterioration of the upper urinary tract due to technique was observed. Antegrade BNI under pneumovesicum affords better visualization of the bladder neck, resulting in more accurate needle placement and better mucosal coaptation confirmation. Studies of larger patient samples are necessary to better study the efficacy of BNI with the patient under pneumovesicum.

Use of Ultrasound in Needle Placement in Intercostal Muscles: A Method for Increased Accuracy in Cadavers

ObjectiveTo validate the use of ultrasound technology for the positioning and leveling of intercostal needle placement. DesignDouble-blinded experimental study. SettingAn anatomy laboratory. ParticipantsTwo board-certified physical medicine and rehabilitation physicians, 2 first-year medical students, 1 anatomist, and 8 cadavers. InterventionsFour unfixed cadavers were used for unguided needle placement, and 3 unfixed and 1 partially fixed cadavers were used for ultrasound-guided needle placement. Ultrasound-guided needle placement was then confirmed with computed tomography and blind dissection. Main Outcome MeasureThe accuracy of needle placement. ResultsThe unguided study showed needle placement in an intercostal muscle 89% of the time, but in only 15.4% of the time was the correct level sampled. In the 96 needle placements completed, the unguided needle placements had an accuracy of 8.3%, while ultrasound-guided needle placements had an accuracy of 93% (χ2 with P<.005). ConclusionsUltrasound guidance dramatically increases needle placement accuracy for intercostal nerve blocks and intercostal muscle sampling for electromyography.

Ultrasound Guidance Decreases Complications and Improves the Cost of Care Among Patients Undergoing Thoracentesis and Paracentesis

Ultrasound guidance enables visualization of the needle insertion site for thoracentesis and paracentesis. The improved accuracy of needle placement using ultrasound may reduce risk of complications and their costs associated with these procedures. Using claims data from the Premier Perspective hospital database from January 1, 2007, through December 31, 2008, we conducted an observational cohort study examining the effect of ultrasound guidance on risk of pneumothorax among patients undergoing thoracentesis and on risk of bleeding complications after paracentesis. Patients at elevated risk of these outcomes for reasons beyond the procedure of interest were excluded. Adjusted risk of events was assessed using multivariate logistic regression controlling for patient and hospitalization characteristics. Hospitalization cost and length of stay (LOS) were estimated using multivariate ordinary least squares regression of log-transformed values. We analyzed 61,261 thoracentesis and 69,859 paracentesis patient records. Approximately 45% of these procedures were ultrasound guided. Pneumothorax occurred in 2.7% (n = 1,670) of patients undergoing thoracentesis. Of patients undergoing paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk of pneumothorax after thoracentesis by 19% (OR, 0.81; 95% CI, 0.74-0.90) and by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). Pneumothorax increased the total cost of hospitalization by $2,801 (P &lt; .001) and LOS by 1.5 days (P &lt; .001). Bleeding complications increased cost by $19,066 (P &lt; .0001) and LOS by 4.3 days (P &lt; .0001). The data indicate that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis. These complications resulted in measurable increases in hospitalization costs and LOS.

Variable Correlation of Grid Coordinates to Core Location in Template Prostate Biopsy

Purpose: Transperineal template prostate biopsy has been proposed to facilitate systematic biopsy in patients undergoing repeat biopsy who are at high risk for cancer. Advocates tout the reliability of the grid to define biopsy location compared to hand-held transrectal ultrasound guided biopsy. However, accuracy of the biopsy needle depends on bevel position, tissue deformity, and technique. Due to this potential for error, we sought to determine whether the use of transperineal template biopsy would assure reproducibly accurate needle placement. Materials and Methods: A standard 0.5 cm brachytherapy grid was utilized for transperineal biopsy. A single grid hole was used to obtain biopsies. The bevel of the needle was rotated to a different position with each biopsy, and the angle of the needle was varied to test the ability of the grid to “map” the prostate. Results: We observed wide variation of needle location through a single brachytherapy grid hole. We are able to show that at 5 cm depth, an area of 2.47 mm² is possible to biopsy and at a depth of 25 cm; approximately 7.56 mm² is possible to biopsy. This gives a precision of biopsy of at the most shallow depth 22% and at the deepest 7%. Conclusion: There is potential for technical and equipment associated error with transperineal template guided prostate biopsy. The grid alone can account for substantial sources of error, so technique remains critical if the grid coordinates are to be used to predict presence or extent of cancer.

Evaluation of an Electromagnetic Image-Fusion Navigation System for Biopsy of Small Lesions: Assessment of Accuracy in an In Vivo Swine Model

To evaluate the accuracy of a novel combined electromagnetic (EM) navigation/image fusion system for biopsy of small lesions.Using ultrasound (US) guidance, metallic (2 × 1 mm) targets were imbedded in the paraspinal muscle (n = 28), kidney (n = 18), and liver (n = 4) of four 55- to 65-kg pigs. Baseline helical computed tomography (CT) imaging (Brilliance; Philips) identified these biopsy targets and six and nine cutaneous fiducial markers. CT data were imported into a MyLab Twice system (Esaote, Genoa, Italy) for CT/US image fusion. After verification of successful image fusion, baseline registration error and respiratory motion error were assessed by documenting deviation of the US and CT position of the targets in real time. Biopsy targeting was subsequently performed under conditions of normal respiratory using 15-cm 16G eTrax needles (Civco). To mimic the conditions of poor US visualization, only reconstructed CT information was displayed during biopsy. Accuracy of targeting was measured by repeat CT scanning as the distance of the needle tip to the target center. Targeting accuracy of free-hand vs. guided technique, and electromagnetic (EM) sensor positioning (ie, on the hub or within the needle stylus tip) were evaluated.In muscle, needle registration error was 0.9 ± 1.2 mm and respiratory motion error 4.0 ± 1.0 mm. Target accuracy was 4.0 ± 3.2 mm when an EM sensor was imbedded in the needle tip. Yet, with the EM sensor back on the needle hub, greater targeting accuracy was achieved using an US guide (3.2 ± 1.6 mm) vs. freehand (5.7 ± 3.2 mm, P = .04). For kidney, registration error was 1.8 ± 1.7 mm and respiratory motion error 4.9 ± 1.0 mm. For the deeper kidney targets, target accuracy was 4.4 ± 3.2 mm with a tip EM sensor, which was an improvement over the hub EM sensor positioning (9.3 ± 4.6 mm; P < .01). An additional source of fusion error was noted for liver. Beyond 17 ± 1 mm of respiratory motion, targets were observed to move >3 cm with US transducer/needle compression resulting in 14 ± 1.4 mm targeting accuracy.A combined image-fusion/EM tracking platform can provide a high degree of needle placement accuracy (<5 mm) when targeting small lesions. Results fall within accuracy of respiratory error; with best results obtained by incorporating an EM sensor into the tip of the biopsy system.

Rapid freehand MR‐guided percutaneous needle interventions: An image‐based approach to improve workflow and feasibility

To develop and evaluate software-based methods for improving the workflow of magnetic resonance (MR)-guided percutaneous interventions. A set of methods was developed that allows the user to: 1) plan an entire procedure, 2) directly apply this plan to skin entry site localization without further imaging, and 3) place a needle under real-time MR guidance with automatic alignment of three orthogonal slices along a planned trajectory with preference to the principal patient axes. To validate targeting accuracy and time, phantom experiments (96 targets) and in vivo paraspinal and kidney needle punctures in two pigs (55 targets) were performed. The influence of trajectory obliquity, level of experience, and organ motion on targeting accuracy and time was analyzed. Mean targeting error was 1.8 ± 0.9 mm (in vitro) and 2.9 ± 1.0 mm (in vivo) in all directions. No statistically significant differences in targeting accuracy between single- and double-oblique trajectories, novice and expert users, or paraspinal and kidney punctures were observed. The average time (in vivo) from trajectory planning to verification of accurate needle placement was 6 minutes. The developed methods allow for accurate needle placement along complex trajectories and are anticipated to reduce table time for MR-guided percutaneous needle interventions.

Percutaneous Spinal Fixation Simulation With Virtual Reality and Haptics

In this study, we evaluated the use of a part-task simulator with 3-dimensional and haptic feedback as a training tool for percutaneous spinal needle placement. To evaluate the learning effectiveness in terms of entry point/target point accuracy of percutaneous spinal needle placement on a high-performance augmented-reality and haptic technology workstation with the ability to control the duration of computer-simulated fluoroscopic exposure, thereby simulating an actual situation. Sixty-three fellows and residents performed needle placement on the simulator. A virtual needle was percutaneously inserted into a virtual patient's thoracic spine derived from an actual patient computed tomography data set. Ten of 126 needle placement attempts by 63 participants ended in failure for a failure rate of 7.93%. From all 126 needle insertions, the average error (15.69 vs 13.91), average fluoroscopy exposure (4.6 vs 3.92), and average individual performance score (32.39 vs 30.71) improved from the first to the second attempt. Performance accuracy yielded P = .04 from a 2-sample t test in which the rejected null hypothesis assumes no improvement in performance accuracy from the first to second attempt in the test session. The experiments showed evidence (P = .04) of performance accuracy improvement from the first to the second percutaneous needle placement attempt. This result, combined with previous learning retention and/or face validity results of using the simulator for open thoracic pedicle screw placement and ventriculostomy catheter placement, supports the efficacy of augmented reality and haptics simulation as a learning tool.

A novel Laser Navigation System reduces radiation exposure and improves accuracy and workflow of CT-guided spinal interventions: A prospective, randomized, controlled, clinical trial in comparison to conventional freehand puncture

PurposePhantom model evaluation and prospective randomized clinical trial to assess the clinical feasibility and benefit of using a novel Laser Navigation System (LNS) in CT-guided epidural and perineural injections in comparison to the conventional freehand procedure. MethodsThe LNS guided puncture technique was compared to the standard CT-guided freehand treatment using a phantom model and a randomized clinical trial. Spinal injections were administered by an experienced interventional team to evaluate needle placement accuracy, treatment time and radiation exposure. ResultsIn the LNS group of the phantom model study, the needle entrance point accuracy of 0.5mm (freehand 3.1mm), needle target point accuracy of 2.0mm (freehand 3.5mm), number of control CT slices of 1.4 (freehand 2.7) and needle placement time of 5min 4s (freehand: 9min 18s) showed significant improvements compared to freehand in 60 punctures. In the clinical trial the LNS group achieved needle entrance point accuracy of 1.3mm (freehand 4.6mm), needle angulation accuracy of 0.4° (freehand 2.3°), number of control CT slices of 1.1 (freehand 1.8) and needle placement time of 6min 54s (freehand 9min 00s), showing significant improvements compared to freehand in a total of 58 CT-guided interventions. ConclusionThe LNS group showed significantly improved results in both study designs. Both the phantom model evaluation and the clinical trial of spinal injections showed feasibility and efficacy of using the novel LNS. Even an experienced interventional team worked with it more precise, faster and with reduced radiation exposure.