Initial Needle Placement Research Articles

Ultrasound-guided needle placement for bone marrow aspiration of the anterior iliac crest

IntroductionBone marrow aspirate concentrate (BMAC) use has increased for both primary treatment and as a surgical adjunct of several other musculoskeletal conditions such as degenerative joint disease and rotator cuff tears. Bone marrow harvest, when performed as part of musculoskeletal treatment or in conjunction with orthopedic surgery is commonly performed at the anterior iliac crest. No technique for ultrasound guidance has been validated at the anterior iliac crest. ObjectivesHere we describe a novel approach for bone marrow aspiration at the anterior iliac crest utilizing ultrasound guidance to facilitate safe needle placement using a human cadaveric model. MethodsUsing cadaver hemipelvises, needle placements were attempted along the anterior iliac crest via ultrasound guidance and latex dye was used to mark the site of cortical penetration. ResultsA total of 39 cortical penetrations were attempted on 8 iliac crests. Needle placements were accurately placed on the crest under ultrasound guidance as confirmed by dissection of the relevant anatomy and confirmation of colored dye within the cortical penetration. ConclusionUltrasound can be used as a valuable tool for image guidance during bone marrow needle placement along the anterior iliac crest. This technique for initial needle placement at the anterior iliac crest is safe and feasible for providers with skill in ultrasound guided needle placement to assist with localization along safe zones for quality bone marrow cellular harvest.

Computed Tomography-Navigation™ Electromagnetic System Compared to Conventional Computed Tomography Guidance for Percutaneous Lung Biopsy: A Single-Center Experience.

The aim of our study was to assess the efficacy of a computed tomography (CT)-Navigation™ electromagnetic system compared to conventional CT methods for percutaneous lung biopsies (PLB). In this single-center retrospective study, data of a CT-Navigation™ system guided PLB (NAV-group) and conventional CT PLB (CT-group) performed between January 2017 and February 2020 were reviewed. The primary endpoint was the diagnostic success. Secondary endpoints were technical success, total procedure duration, number of CT acquisitions and the dose length product (DLP) during step ∆1 (from planning to initial needle placement), step ∆2 (progression to target), and the entire intervention (from planning to final control) and complications. Additional parameters were recorded, such as the lesion’s size and trajectory angles. Sixty patients were included in each group. The lesions median size and median values of the two trajectory angles were significantly lower (20 vs. 29.5 mm, p = 0.006) and higher in the NAV-group (15.5° and 10° vs. 6° and 1°; p < 0.01), respectively. Technical and diagnostic success rates were similar in both groups, respectively 95% and 93.3% in the NAV-group, and 93.3% and 91.6% in the CT-group. There was no significant difference in total procedure duration (p = 0.487) and total number of CT acquisitions (p = 0.066), but the DLP was significantly lower in the NAV-group (p < 0.01). There was no significant difference in complication rate. For PLB, CT-Navigation™ system is efficient and safe as compared to the conventional CT method.

Ultrasound-guided aspiration of anterior cruciate ligament mucinous cysts in the posterior intercondylar notch: Technique and short-term outcomes.

To describe our technique of aspirating symptomatic anterior cruciate ligament (ACL) mucinous cysts in the posterior intercondylar notch with ultrasound guidance, and to detail short-term patient outcomes. We identified 13 patients from February 2008 to May 2020 who underwent ultrasound-guided aspiration of symptomatic ACL mucinous cysts in the posterior intercondylar notch. Post-procedural imaging was reviewed to evaluate the degree of cyst decompression. Needle size was noted. Post-procedural symptomatology was also assessed. No or minimal fluid was initially aspirated in 11/13 (84.6%) patients. For the two patients in which the cysts were aspirated completely with initial needle placement, with no need for lavage, a 13-gauge trocar was utilized. Of the remaining cysts, 10/11 were aspirated with an 18-gauge needle and one with a 20-gauge needle. Subsequent lavage was performed in 10 of the remaining 11 patients. After lavage, in eight there was a reduction of at least 50% volume by retrospective image interpretation; of 25% to 50% volume in one patient and of less than 25% volume in one patient. Five of the 13 patients reported immediate post-procedural symptomatic relief. In the other patients, immediate efficacy or post-procedural symptomatology was not documented. Aspiration of symptomatic ACL mucinous cysts is a safe procedure and can provide symptomatic relief that may be temporary, but useful clinically. We recommend needles larger than 18 gauge for the best chance of successful aspiration.

Benefits of Ultrasound Imaging for Placement of Caudal Epidural Blockade in 3 Pediatric Patients: A Case Report.

Pediatric caudal epidural blockade, the most common pediatric regional anesthetic, is classically placed using surface landmark technique with infrequent use of ultrasound guidance. We present 3 cases where ultrasound guidance facilitated successful placement and helped prevent complications. One infant had an unanticipated S5 dural sac necessitating needle redirection to avoid subarachnoid injection. A 5-year old had proper needle position with inability to inject secondary to needle blockage confirmed with ultrasound. An expremature infant had initial needle placement anterior to the sacrum with subsequent proper placement using real-time ultrasound imaging. Ultrasound guidance for pediatric caudal placement confers advantages and increased routine use should be considered.

Pre-operative embolization of hypervascular spinal metastasis using percutaneous direct intra-tumoural injection with Onyx under local anesthesia

Intra-operative blood loss remains a major cause of perioperative morbidity for patients with hypervascular spinal metastasis undergoing surgery. Pre-operative embolization is used to reduce intraoperative blood loss and operative time. This is commonly performed under general anesthesia via a trans-arterial approach, which carries a risk of spinal stroke. We propose an alternative technique for embolization of hypervascular metastases using the Onyx embolic agent via a percutaneous direct intra-tumoural injection under local anesthesia and sedation to reduce embolization risks and procedure time, as well as operative blood loss and operative time. A 74-year-old man presented with thoracic myelopathy with back and radicular pain on background of metastatic renal cell carcinoma. Magnetic resonance imaging (MRI) revealed a 3cm mass centered on the right lamina of T10 with extension into the spinal canal. The patient underwent a percutaneous imaging-guided direct intra-tumoural contrast parenchymogram, and Onyx embolization via a single needle. Initial needle placement and tumour assessment was completed in 30min; embolization time was 15min. Complete devascularization was achieved with no complications. Surgical resection was performed with lower than expected operative blood loss (150ml) and operative time (90min). His pre-operative symptoms improved, and he was discharged home the following day. At 6-month follow-up there was no recurrence of his symptoms. Further evaluation of direct percutaneous intra-tumoural Onyx embolization for hypervascular spinal tumours is warranted.

Computer assisted electromagnetic navigation improves accuracy in computed tomography guided interventions: A prospective randomized clinical trial.

PurposeTo assess the accuracy and usability of an electromagnetic navigation system designed to assist Computed Tomography (CT) guided interventions.Materials and methods120 patients requiring a percutaneous CT intervention (drainage, biopsy, tumor ablation, infiltration, sympathicolysis) were included in this prospective randomized trial. Nineteen radiologists participated. Conventional procedures (CT group) were compared with procedures assisted by a navigation system prototype using an electromagnetic localizer to track the position and orientation of a needle holder (NAV group). The navigation system displays the needle path in real-time on 2D reconstructed CT images extracted from the 3D CT volume. The regional ethics committee approved this study and all patients gave written informed consent. The main outcome was the distance between the planned trajectory and the achieved needle trajectory calculated from the initial needle placement.Results120 patients were analyzable in intention-to-treat (NAV: 60; CT: 60). Accuracy improved when the navigation system was used: distance error (in millimeters: median[P25%; P75%]) with NAV = 4.1[2.7; 9.1], vs. with CT = 8.9[4.9; 15.1] (p<0.001). After the initial needle placement and first control CT, fewer subsequent CT acquisitions were necessary to reach the target using the navigation system: NAV = 2[2; 3]; CT = 3[2; 4] (p = 0.01).ConclusionThe tested system was usable in a standard clinical setting and provided significant improvement in accuracy; furthermore, with the help of navigation, targets could be reached with fewer CT control acquisitions.

Radiofrequency Ablation of Non-Small-Cell Carcinoma of the Lung Under Real-Time FDG PET CT Guidance

Radiofrequency ablation (RFA) is a well-established method in treatment of patients with lung carcinomas who are not candidates for surgical resection. Usually computed tomographic (CT) guidance is used for the procedure, thus enabling needle placement and permitting evaluation of complications such as pneumothorax and bleeding. (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is generally used for tumor activity assessment and is therefore useful in follow-up after tumor treatment. A method that provides real-time image-based monitoring of RFA to ensure complete tumor ablation would be a valuable tool. In this report, we describe the behavior of preinjected FDG during PET CT-guided RFA of a non-small-cell lung carcinoma and discuss the value of FDG as a tool to provide intraprocedure monitor ablation. The size and the form of the activity changed during ablation. Ablation led to increase of the size and blurring and irregularity of the contour compared to pretreatment imaging. The maximal standardized uptake value decreased only slightly during the procedure. Therefore, before RFA, FDG PET can guide initial needle placement, but it does not serve as a monitoring tool to evaluate residual viable tissue during the procedure.

Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study

Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate. Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy. The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread. The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients. Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections.

Intrathecal Cefazolin-Induced Seizures Following Attempted Discography

This report describes a 39 year-old woman who underwent attempted discography and intradiscal electrothermal therapy (IDET) of the L5/S1 intervertebral disc. The procedure was abandoned after multiple unsuccessful attempts to cannulate the disc. The case was complicated by at least two lumbar dural punctures, confirmed by injection of nonionic contrast that contained 12.5 mg/mL of cefazolin, included for prophylaxis of discitis. About 45 minutes later the patient developed severe back pain. Shortly thereafter she became progressively agitated and confused, and developed intractable seizures and coma. Despite aggressive treatment the patient could not be resuscitated and expired several hours later. Convulsions were initially attributed to an adverse reaction to meperidine and promethazine, given for the back pain, however this explanation proved to be untenable. In addition, the accidental administration of an ionic contrast agent, such as Hypaque(R), was excluded. Based on a detailed review of the case and the literature, it was concluded that the patient succumbed from an unintentional dose of intrathecal cefazolin, which had been diluted in the nonionic contrast agent that was used to confirm needle placement. Available evidence indicates that cefazolin is a potent epileptogenic agent when given intrathecally. The facts of the case and the evidence supporting the conclusion are presented. It is recommended that cefazolin not be mixed with the contrast agent used to document initial needle placement during discography.

Defining the cross-sectional anatomy important to interscalene brachial plexus block with magnetic resonance imaging

Background and Objectives. Interscalene brachial plexus block is a useful technique to provide anesthesia and analgesia for the shoulder and proximal upper extremity. The initial needle direction at the interscalene groove has been described as being “perpendicular to the skin in every plane” (1). A cross-sectional (axial) approach may offer a more easily conceptualized directed needle placement. The purpose of this study is to define the cross-sectional anatomy and idealized needle angles important to interscalene brachial plexus block. Methods. Following IRB approval, 50 patients were studied. Cross-sectional volume coil T1-weighted magnetic resonance images (MRI) were obtained from 50 patients undergoing cervical region imaging for other reasons. At the interscalene groove, a simulated needle path to contact the ventral rami or trunks of the brachial plexus was approximated at the level of C6 or C6–C7 interspace. The angle of this needle path intersecting the sagittal plane was recorded for each patient. Results. The mean angle of the simulated needle path relative to sagittal plane was determined to be 61.1 ± 6.1° (range, 50–78°). In 13 of 50 (26%) MRI scans, the cervical nerve roots were not visualized at the level of C6 and were measured at the C6–C7 level. Conclusions. These findings suggest initial needle placement at the interscalene groove should be angled less perpendicularly relative to the sagittal plane than is often observed. A cross-sectional approach enables more practical visualization of initial needle placement. A more accurate initial needle placement may minimize the number of needle passes necessary to contact the nerve roots, thereby more efficiently obtaining a successful block.

Early Experience With Automated Percutaneous Lumbar Discectomy in the Treatment of Lumbar Disc Herniation

Seventeen patients with symptomatic lumbar disc herniation were treated with automated percutaneous lumbar discectomy employing local anesthetic in an outpatient setting. Operative technique included (1) intravenous sedation and single-dose antibiotics, (2) prone oblique patient positioning for initial needle placement, and (3) postdiscectomy interspace lavage with bupivacaine hydrochloride. There were no postoperative complications and the procedure was well-tolerated by all patients. Although results have thus far been less successful than previously reported, with improved patient selection by means of routine magnetic resonance imaging (or computed tomographic discography in select cases), success rates (nine of 17 patients) might approach those achieved by chemonucleolysis. The successful response of four patients with so-called midline L4-L5 discs has been particularly encouraging, and it may be that percutaneous lumbar discectomy will be an effective and a reasonable treatment alternative for this particular subgroup of patients.