Root Injection Research Articles

Symptomatic, Magnetic Resonance Imaging–Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy

ObjectiveThe purpose of this study was to compare the outcomes of overall improvement, pain reduction, and treatment costs in matched patients with symptomatic, magnetic resonance imaging–confirmed cervical disk herniations treated with either spinal manipulative therapy (SMT) or imaging-guided cervical nerve root injection blocks (CNRI). MethodsThis prospective cohort comparative-effectiveness study included 104 patients with magnetic resonance imaging–confirmed symptomatic cervical disk herniation. Fifty-two patients treated with CNRI were age and sex matched with 52 patients treated with SMT. Baseline numerical rating scale (NRS) pain data were collected. Three months after treatment, NRS pain levels were recorded and overall “improvement” was assessed using the Patient Global Impression of Change scale. Only responses “much better” or “better” were considered “improved.” The proportion of patients “improved” was calculated for each treatment method and compared using the χ2 test. The NRS and NRS change scores for the 2 groups were compared at baseline and 3 months using the unpaired t test. Acute and subacute/chronic patients in the 2 groups were compared for “improvement” using the χ2 test. Results“Improvement” was reported in 86.5% of SMT patients and 49.0% of CNRI patients (P = .0001). Significantly more CNRI patients were in the subacute/chronic category (77%) compared with SMT patients (46%). A significant difference between the proportion of subacute/chronic CNRI patients (37.5%) and SMT patients (78.3%) reporting “improvement” was noted (P = .002). ConclusionSubacute/chronic patients treated with SMT were significantly more likely to report relevant “improvement” compared with CNRI patients. There was no difference in outcomes when comparing acute patients only.

Correlation of Foraminal Area and Response to Cervical Nerve Root Injections.

Introduction: Patients with age-related degenerative changes in the cervical spine leading to cervical spondylosis may be symptomatic or asymptomatic. Older patients with radicular pain tend to have a better response to epidural steroid injections, but it is often difficult to predict which patients will have a positive response to selective nerve root block (SNRB). We analyzed whether the cervical neuroforaminal area measured on MRI predicts immediate therapeutic responses to SNRB in patients who have cervical radiculopathy.Methods: We retrospectively reviewed all patients who had cervical SNRBs treated at a single tertiary referral center. We recorded patient demographics, the neuroforaminal area of the symptomatic and contralateral sides, Visual Analog Scale (VAS) score pre- and post-injection, history of previous cervical surgery, comorbidities, and history of tobacco use.Results: Sixty-four patients with symptoms of cervical radiculopathy treated with neuroforaminal nerve root injections had appropriate imaging and VAS scores recorded. The average foraminal area of the symptomatic side before treatment was significantly smaller than the contralateral asymptomatic neuroforamen (p<0.0001). Those patients with the smallest neuroforamen had a positive response to SNRB. Diabetes and tobacco use did not influence patient response to treatment.Conclusions: Measurement of neuroforaminal areas on MRI may represent a useful pre-procedural technique to predict which patients with symptoms of cervical radiculopathy secondary to foraminal stenosis are likely to respond to selective nerve root injections. The predictive ability appears to be limited to those patients with severe stenosis and was less useful in those patients with moderate or mild stenosis.

Infection of Helicoverpa armigera by endophytic Beauveria bassiana colonizing tomato plants

Beauveria bassiana was isolated from leaf tissue of a wild tomato plant. This isolate (reference WG-40) and a further two isolates of B. bassiana from soil (reference WG-14 and WG-19) were evaluated for their ability to endophytically colonize tomatoes and subsequently infect Helicoverpa armigera larvae. The three isolates were inoculated on to tomato plants using root dip, injection, solid substrate and direct foliar application methods. A detached leaf assay was used to evaluate B. bassiana-induced mortality of second and fourth instar larvae of H. armigera at 1, 3 and 5weeks post plant inoculation with B. bassiana. Isolate WG-40 was the most effective at colonizing tomato plants compared to WG-14 and WG-19 that originated from soil. Root dipping was the most successful inoculation method. Larval mortality of H. armigera was significantly affected by the larval stage and the application method used to establish the fungus. Second instar larvae were more susceptible than fourth instar at all time intervals evaluated. Isolate WG-40 was the most pathogenic and achieved the highest insect mortality. Pupation and adult emergence were inversely correlated to the fungal infection. A few adverse growth effects on the tomato plants were observed as a consequence of endophytic colonization by B. bassiana, although the response was related to application method and fungal isolate. These findings suggest that endophytic colonization of B. bassiana has potential as an effective strategy to control H. armigera in tomatoes.

What types of degenerative lumbar pathologies respond to nerve root injection? A retrospective review of six hundred and forty one cases.

Peri-radicular injection is a widely used procedure for treating lumbar radicular pain, but it remains unclear what types of lumbar pathologies respond well to this treatment. We aimed to investigate the efficacy of peri-radicular injection for degenerative lumbar disorders and to determine what types of pathologies respond well to this treatment. We reviewed the records of 641 consecutive patients who underwent peri-radicular injection for degenerative lumbar pathologies with mean follow-up of 23.4 months. The pathologies included herniated disc in 286 patients, spinal stenosis in 141, degenerative spondylolisthesis in 136, failed back surgery in 24, isthmic spondylolisthesis in 22, degenerative scoliosis in 18, and foraminal stenosis in 14. Outcome measure was whether or not surgery is avoided by using peri-radicular injection. The rate of obviating surgery was determined in each pathology. Peri-radicular injection obviated surgeries in 331 patients (51.7%). There were no complications related to the procedure, including neurological deterioration, infection, and haematoma. The rate of obviating surgery was 42.0% in disc herniation, 52.9% in degenerative spondylolisthesis, 67.4% in spinal stenosis, 54.5% in isthmic spondylolisthesis, 57.1% in foraminal stenosis, 61.1% in degenerative scoliosis and 54.1% in failed back surgery. Poor outcomes were observed in herniated disc with spinal stenosis (17.9% success), foraminal disc herniation (33.3%), recurrent disc herniation (18.2%) and failed back surgery with instability (33.3%). This study demonstrated that 51.7% of patients with degenerative lumbar pathologies were successfully treated by peri-radicular injection. Efficacy was limited in cases of herniated disc with spinal stenosis, foraminal disc herniation, recurrent disc herniation and failed back surgery with instability.

CT-guided nucleoplasty with radiofrequency energy for the treatment of lumbar disk herniation.

A clinical randomized controlled trial. This study sought to compare the clinical effectiveness of CT-guided nucleoplasty, CT-guided nucleoplasty combined with nerve root injection, and CT-guided transforaminal lumbar epidural injections in treating patients with contained lumbar disk herniation and leg pain, which are caused by radicular encroachment. Lumbar disk herniation is the most common cause of nerve root pain. The conservative treatment is proved to be effective for the majority of these patients, and the remaining patients are not ideal surgical candidates. Studies have found that minimally invasive percutaneous disk procedures may be preferable to open surgery in certain clinical situations. However, nucleoplasty in treating contained lumbar disk herniation and leg pain caused by radicular encroachment is still a controversy. A total of 97 patients with leg pain and MRI evidence of small-sized or medium-sized herniated disks correlating with the symptoms participated in the study. The patients were randomly allocated into 3 groups: the CT-guided nucleoplasty group (N=33), the CT-guided nucleoplasty with nerve root injection group (N=35), and CT-guided transforaminal lumbar epidural injections group (N=29). Numeric Rating Scale (NRS) pain score and Oswestry Disability Index (ODI) values were applied at pretreatment and 1 week, 1 month, 3 months, and 12 months at posttreatment. There were statistically significant decreases (P=0.000) in the NRS and ODI scores for all posttreatment time points when compared with the pretreatment values in all the 3 groups. The average NRS and ODI results for the transforaminal lumbar epidural injections group were significantly higher than those for the other 2 groups at 3 and 12 months posttreatment (P<0.05). The combination of nucleoplasty with nerve root injection produced a significantly greater reduction in the NRS and ODI scores when compared with nucleoplasty at 1 week (P=0.000 for NRS and P=0.004 for ODI) and 1 month (P=0.000 for NRS and P=0.007 for ODI) after the treatment. The results of this study suggest that CT-guided nucleoplasty with radiofrequency energy is a relative effective and safe technique for treating leg pain caused by radicular encroachment. Furthermore, nucleoplasty combined with nerve root injection had achieved a significant greater improvement in pain management and functional level in short term (within 1 mo) after treatment than nucleoplasty alone.

A simple technique to improve the administration of nerve root blocks.

Nerve root injections require radiographic imaging and good technical skill. We describe a simple method to aid planning the administration of lumbar nerve root injections with the use of biplanar fluoroscopy. Axial magnetic resonance imaging at the level of the target nerve root is used. An empirical angle of inclination of 60° is created from the nerve root to the skin of the back with the apex enabling the lateral entry point to be determined (Fig 1). The transforaminal injections are then performed with the simple expedient of a skin marker line at the appropriate lateral distance from the midline for needle entry. Figure 1 Method to aid planning the administration of lumbar nerve root injections

Percutaneous Disc Decompression for Lumbar Radicular Pain: A Review Article

Open discectomy remains the standard of treatment for patients with lumbar radicular pain secondary to a prolapsed intervertebral disc. Open discectomy performed in patients with small, contained herniations may result in poor outcomes. The various techniques of percutaneous disc decompression (PDD) have been developed to address this population. A literature search was conducted on articles, which address PDD for lumbar radicular pain. Published techniques include chymopapain chemonucleolysis, percutaneous laser disc decompression (PLDD), automated percutaneous lumbar discectomy (APLD), Dekompressor, nucleoplasty, and targeted disc decompression (TDD). In addition, the rationale of provocative discography, selective nerve root injections, and intra-op discograms before performing PDD is discussed in detail. Dekompressor and nucleoplasty have the best level of evidence with a score of 2B+. The chymopapain chemonucleolysis has the most publications, but it is also accompanied by the most significant adverse complications and so it is scored as a 2B+/-. The other techniques are supported mainly by observational studies and thus their scores range between 0 and 2B+/-. There is no supporting evidence for provocative discography in patients with lumbar radicular pain. The evidence for a positive selective nerve root injection as an inclusion criteria or the need for an intra-op discogram shows mixed results. Nucleoplasty and Dekompressor have a weak positive recommendation for the treatment of patients with lumbar radicular pain. There is no role for provocative discography in this group of patients, although the evidence for a selective nerve root injection or an intra-op discogram is inconclusive.

PMM.64 Prolonged Entonox use: A rare cause of bone marrow suppression

IntroductionNitrous oxide has been used for decades as an inhalational analgesic in labour. It is considered to be generally safe as it is rapidly eliminated via the lungs preventing accumulation...

Diagnosis and Treatment of Degenerative Lumbar Scoliosis with Root Pain

Introduction Degenerative lumbar scoliosis is a common type in degenerative lumbar disease. In clinic, root pain is very general except back pain. The objective of our research is to explain and summarize which segments frequently occur root pain, what is the diagnosis methods, and significance of surgical treatment. Materials and Methods The research included retrospectively 46 patients suffering degenerative lumbar scoliosis with root pain, undergoing surgical treatment in our hospital during May 2005 to September 2009, all of them have complete follow-up data. The segments of root pain were judged through physical examination, radiography, and selective nerve root injection. According to the the scoliosis type and degree, we chose different surgical procedures, (1) simple decompression, (2) decompression with short segment fixation, (3) decompression and orthopedics with long segment fixation. The patients’ radiographic results were analyzed by X-ray and MRI, functional conditions were evaluated by Oswestry disability index (ODI) and visual analog scale (VAS). Results The research included 46 patients, the average follow-up was 5.8 years. Male patients were 20, and female patients were 26 in our research. According to segments of root pain: L2-3 (4 patients), L3-4 (9 patients), L4-5 (21 patients), L5-S1 (12 patients); surgical procedures: simple decompression (4 patients), decompression with short segment fixation (35 patients), decompression and orthopedics with long segment fixation (7 patients). A total of 42 patients had bony fusion by radiography. In scoliosis orthopedics group, the cobb angle dropped from 19.3 ± 15.2 degrees preoperatively to 9.2 ± 5.3 degrees at final follow-up. ODI of all patients dropped from 59.22 ± 22.31 preoperatively to 15.23 ± 11.12; and VAS dropped from 7.3 ± 1.8 to 2.3 ± 1.4 at final follow-up, respectively. Conclusion (1) Root pain of degenerative lumbar scoliosis usually located to the segment, which just under the bulge side (39/46, 84.8%), rather than concave side. (2) Radiography and selective nerve root injection were helpful to ensure the pain segment and position. (3) Most degenerative lumbar scoliosis patients undergoing root pain can proceed simple decompression or decompression with short segment fixation, only few patients need to proceed decompression and orthopedics with long segment fixation. Disclosure of Interest None declared

The short- and medium-term effectiveness of CT-guided selective cervical nerve root injection for pain and disability

CT-guided cervical nerve root injection with corticosteroid and/or local anesthetic is a recognized technique in the evaluation and treatment of cervical radiculopathy. There are few prospective studies on the efficacy of the various techniques employed in cervical nerve root injection. We present our results from a 1-year prospective series using a CT-guided anterolateral transforaminal approach for cervical nerve root injection of bupivacaine and dexamethasone. Pain using a numeric rating scale was assessed at pre-injection, 15 min post-injection, 1 month, and 3 months. Disability was assessed using the Oswestry Neck Disability Index (NDI) questionnaire at pre-injection, 1 month post-injection, and 3 months. In total, 50 patients were followed for 3 months. The mean reductions in pain were: 15 min (77 %), 1 month (39 %), and 3 months (33 %). The mean reductions in NDI were: 1 month (26 %) and 3 months (also 26 %). Results were statistically significant. CT-guided selective cervical nerve root injection in the treatment of cervical radicular pain and related disability produces statistically significant reductions in pain and disability to at least 3 months post-procedure.

Should we start carrying out HVT on disc herniations?

Treating disc herniation with High Velocity Thrust (HVT) manipulations is something the osteopathic profession is currently very cautious about. HVT is often described as a contraindication to spinal manipulation on the principle that it would aggravate the symptoms by increasing the herniation. A more invasive alternative to osteopathy is imaging-guided nerve root injection. There is a fair amount of evidence around this procedure but a lack of placebo-controlled trials and a lack of evidence on the efficacy of using anaesthetics alone or adding corticosteroids.

Outcome Study of Real-time MR-guided Cervical Periradicular Injection Therapy in an Open 1.0 Tesla MRI System

To evaluate the accuracy, safety, and efficacy of cervical nerve root injection therapy using magnetic resonance guidance in an open 1.0 T MRI system. Between September 2009 and April 2012, a total of 21 patients (9 men, 12 women; mean age 47.1 ± 11.1 years) underwent MR-guided cervical periradicular injection for cervical radicular pain in an open 1.0 T system. An interactive proton density-weighted turbo spin echo (PDw TSE) sequence was used for real-time guidance of the MR-compatible 20-gauge injection needle. Clinical outcome was evaluated on a verbal numeric rating scale (VNRS) before injection therapy (baseline) and at 1 week and 1, 3, and 6 months during follow-up. All procedures were technically successful and there were no major complications. The mean preinterventional VNRS score was 7.42 and exhibited a statistically significant decrease (P < 0.001) at all follow-up time points: 3.86 ± 1.53 at 1 week, 3.21 ± 2.19 at 1 month, 2.58 ± 2.54 at 3 months, and 2.76 ± 2.63 at 6 months. At 6 months, 14.3 % of the patients reported complete resolution of radicular pain and 38.1 % each had either significant (4-8 VNRS score points) or mild (1-3 VNRS score points) relief of pain; 9.5 % experienced no pain relief. Magnetic resonance fluoroscopy-guided periradicular cervical spine injection is an accurate, safe, and efficacious treatment option for patients with cervical radicular pain. The technique may be a promising alternative to fluoroscopy- or CT-guided injections of the cervical spine, especially in young patients and in patients requiring repeat injections.

A rare indication for surgery in acute myocardial infarction: spontaneous aortic thrombus causing left main stem occlusion

A 52-year old man presented with acute anterolateral ST elevation myocardial infarction. At angiography, the left coronary artery was not found. Aortic root injection revealed a large filling defect (Fig. 1A). Emergency surgery identified an adherent aortic mass extending into the left coronary artery (Fig. 1B and C). The macroscopic appearance suggested a tumour (Fig. 1D); however, histology demonstrated only an organized thrombus, apparently spontaneous.

Lumbar nerve root injections: a prospective cohort outcomes study comparing age- and gender-matched patients who returned an outcomes-based postal questionnaire with patients who did not return the postal questionnaire

The purpose of this study is to investigate if relying on postal questionnaires returned by patients provides an accurate representation of reported outcomes from patients receiving imaging-guided lumbar nerve root injections (NRIs). Patients who received imaging-guided transforaminal lumbar NRIs were given short questionnaires inquiring about pain level [numerical rating scale (NRS)] and overall improvement [Patient's Global Impression of Change (PGIC)]. Those who did not return the questionnaires (non-responders) were telephoned and asked about pain level and overall change in condition. Age and gender matching of responders and non-responders resulted in 97 patients in each group. The proportion of patients reporting clinically relevant "improvement" or "worsening" in each group was calculated and the Chi-square test was used to detect differences. NRS and PGIC scores for responders and non-responders were compared using Student's ttest and the Mann-Whitney U test, respectively. A higher proportion of non-responders reported clinically relevant improvement (53.6%) compared to responders (42.6%) and responders reported significantly higher levels of worsening of condition (p = 0.01). Both responders and non-responders had significant (p ≤ 0.05) improvement on the 20-30-min and 1-month NRS scores compared to their pre-injection baseline scores. Non-responders had significantly higher baseline NRS scores but no significant difference at the 20-30-min and 1-month NRS scores compared to responders. Patients returning postal questionnaires reported less favorable outcomes compared to those who did not return their questionnaires.

Real-Time MR-Guided Lumbosacral Periradicular Injection Therapy Using an Open 1.0-T MRI System

The objective of this study was to evaluate the accuracy, safety, and efficacy of magnetic resonance (MR)-guided periradicular nerve root injection therapy using an open 1.0-T magnetic resonance imaging (MRI) system with fast dynamic imaging. Between April 2008 and November 2011, a total of 249 MR-guided periradicular nerve root injections were performed in 141 patients experiencing lumbosacral radicular pain. All interventions were performed in an open 1.0-T MRI system. An interactive proton-density-weighted fast spin-echo sequence was used for real-time guidance. An in-room monitor, a wireless MR mouse for operator-controlled multiplanar imaging, a flexible surface coil, and an MR-compatible 20-G needle were used. Informed consent was obtained from all patients. Clinical outcome was evaluated through clinical follow-up and a questionnaire before injection therapy (baseline) and 6 months after using a numeric visual analog scale. All procedures were technically successful. No major complications occurred. At 6 months, of the 103 patients (197 injections; 57 men, 46 women; mean age, 49.5 years; range, 20-80) who enrolled in the outcome analysis, 14.6% reported complete remission of radicular pain; 53.4%, significant relief of pain; 22.3%, mild relief; and 9.7%, no relief of pain. We found a significant decrease of the visual analog scale score from the preintervention compared with the follow-up after 6 months (P < 0.001). No significant difference in the outcome was observed between the patients with degenerative foraminal stenoses and the patients with herniated disks. Magnetic resonance fluoroscopy-guided periradicular injection therapy for the lumbosacral spine under open 1.0-T MRI guidance is accurate, safe, and efficient in the symptomatic treatment of radicular pain. This technique may be a promising alternative to fluoroscopy- or computed tomography-guided spinal injections in the lumbosacral region, especially for young patients and patients undergoing serial therapeutic regimens.

Symptomatic Magnetic Resonance Imaging–Confirmed Lumbar Disk Herniation Patients: A Comparative Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either High-Velocity, Low-Amplitude Spinal Manipulative Therapy or Imaging-Guided Lumbar Nerve Root Injections

ObjectivesThe purpose of this study was to compare self-reported pain and “improvement” of patients with symptomatic, magnetic resonance imaging–confirmed, lumbar disk herniations treated with either high-velocity, low-amplitude spinal manipulative therapy (SMT) or nerve root injections (NRI). MethodsThis prospective cohort comparative effectiveness study included 102 age- and sex-matched patients treated with either NRI or SMT. Numerical rating scale (NRS) pain data were collected before treatment. One month after treatment, current NRS pain levels and overall improvement assessed using the Patient Global Impression of Change scale were recorded. The proportion of patients, “improved” or “worse,” was calculated for each treatment. Comparison of pretreatment and 1-month NRS scores used the paired t test. Numerical rating scale and NRS change scores for the 2 groups were compared using the unpaired t test. The groups were also compared for “improvement” using the χ2 test. Odds ratios with 95% confidence intervals were calculated. Average direct procedure costs for each treatment were calculated. ResultsNo significant differences for self-reported pain or improvement were found between the 2 groups. “Improvement” was reported in 76.5% of SMT patients and in 62.7% of the NRI group. Both groups reported significantly reduced NRS scores at 1 month (P = .0001). Average cost for treatment with SMT was Swiss Francs 533.77 (US $558.75) and Swiss Francs 697 (US $729.61) for NRI. ConclusionsMost SMT and NRI patients with radicular low back pain and magnetic resonance imaging–confirmed disk herniation matching symptomatic presentation reported significant and clinically relevant reduction in self-reported pain level and increased global perception of improvement. There were no significant differences in outcomes between NRI and SMT. When considering direct procedure costs, the average cost of SMT was slightly less expensive.

Diagnostic Utility of Selective Nerve Root Blocks in the Diagnosis of Lumbosacral Radicular Pain: Systematic Review and Update of Current Evidence

Background: Lumbosacral selective nerve root blocks and/ or transforaminal epidural injections are used for diagnosis and treatment of different disorders causing low back and lower extremity pain. A clear consensus on the use of selective nerve root injections as a diagnostic tool does not currently exist. Additionally, the validity of this procedure as a diagnostic tool is not clear. Objective: To evaluate and update the accuracy of selective nerve root injections in diagnosing lumbar spinal disorders. Study Design: A systematic review of selective nerve root blocks for the diagnosis of low back and lower extremity pain. Methods: Methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less than 50% are presented descriptively and analyzed critically. The level of evidence was classified as good, fair, or limited or poor based on the quality of evidence grading scale developed by the United States Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: In this review, we evaluated studies in which controlled local anesthetic blocks were performed using at least 50% pain relief as the reference standard. Results: There is limited evidence for the accuracy of selective nerve root injections as a diagnostic tool for lumbosacral disorders. There is limited evidence for their use in the preoperative evaluation of patients with negative or inconclusive imaging studies. Limitations: The limitations of this systematic review include a paucity of literature, variations in technique, and variable criterion standards for the diagnosis of lumbar radicular pain. Conclusions: There is limited evidence for selective nerve root injections as a diagnostic tool in evaluating low back pain with radicular features. However, their role needs to be further clarified by additional research and consensus. Key words: Low back pain, lower extremity pain, selective nerve root block, transforaminal epidural injection, discogenic pain, radiculitis, sciatica radiculopathy, nerve root pain

3:30 PM Abstract No. 223 - Use of xperguide cone beam CT in percutaneous procedures in the angiography suit

Purpose C-arm Cone Beam CT (CBCT) is a relatively new technology installed in some angiographic suits to optimize and aid therapeutic delivery.We present our experience using the Philips Xperguide software and image fusion capability in percutaneous procedures in the angiography suite. The aim was to assess the efficacy, safety and clinical applications of CBCT guided procedures. Materials and Methods Using a single plane C-arm angiography system with a flat-panel detector (Allura Xper FD20 Philips Medical Systems, Netherlands), we performed range of procedures, including targeted biopsies, facet joint injections, drainages and radiologically inserted gastrostomy tube insertions (RIG). CBCT was performed in all patients to acquire pre-procedural imaging which was used for Xperguide planning. The CBCT was used in conjunction with live fluoroscopy to perform the procedures. Where appropriate, the contrast enhanced CT performed prior to the procedure was fused with the CBCT. These included targeted biopsies or for collections which were in proximity to fluid filled bowel loops. Technical difficulties. Ionizing radiation dose and total fluoroscopic times, technical success and complications were recorded. Results To date 30 cases have been performed at our centre: Biopsies (n=7), Facet joint/nerve root injection (n=9), Drainages (n=10) and RIGs (n=4). Image Fusion was performed in 7 cases. CBCT guided interventional procedures were efficacious with a 93.3% technical success rate. One nerve root was abandoned due to body habitus/poor visualization. A drainage was abandoned due to technical challenges. No immediate complications occurred. Average screening time was 3.6min (range 0.8 - 12.3mins). The ionising radiation dose (dose area product) mean was 22018.5 μGycm2 (range 8699 - 62890 μGycm2). Conclusion CBCT offers excellent 3D spatial and fluoroscopy guided temporal resolution with image fusion capabilities. CBCT guided procedures are efficacious and safe with the flexibility to perform procedures in the angiography suite that would otherwise benefit from CT guidance. In cases with challenging anatomy, CBCT guidance proved to be a particularly useful tool in particular in cases where live fluoroscopy is required.

Bentall procedure for adult patient with supravalvular aortic stenosis and coronary aneurysms

We report a complex case of a 35-year-old gentleman who presented with large anterior myocardial infarction. Coronary angiography showed multiple coronary aneurysms of all proximal major coronaries with a total occlusion of the LAD artery. A diffuse form of supravalvular aortic stenosis was discovered incidentally upon aortic root injection and was confirmed with CT aortogram. Echocardiography revealed akinesia of the anterior wall with preserved thickness and depressed left ventricular function (EF = 25%). Aortic valve was competent with normal leaflet structure. The patient underwent Bentall procedure with LIMA to LAD coronary bypass grafting with the use of cardiopulmonary bypass utilizing the right axillary artery for arterial cannulation and routine right atrial venous cannulation. The post-operative course was uneventful. The patient was discharged home after 7 days and came back for follow up after 6 months in good condition.

Augmented reality visualisation using an image overlay system for MR-guided interventions: technical performance of spine injection procedures in human cadavers at 1.5 Tesla

To prospectively assess the technical performance of an augmented reality system for MR-guided spinal injection procedures. The augmented reality system was used with a clinical 1.5-T MRI system. A total of 187 lumbosacral spinal injection procedures (epidural injection, spinal nerve root injection, facet joint injection, medial branch block, discography) were performed in 12 human cadavers. Needle paths were planned with the Perk Station module of 3D Slicer software on high-resolution MR images. Needles were placed under augmented reality MRI navigation. MRI was used to confirm needle locations. T1-weighted fat-suppressed MRI was used to visualise the injectant. Outcome variables assessed were needle adjustment rate, inadvertent puncture of non-targeted structures, successful injection rate and procedure time. Needle access was achieved in 176/187 (94.1 %) targets, whereas 11/187 (5.9 %) were inaccessible. Six of 11 (54.5 %) L5-S1 disks were inaccessible, because of an axial obliquity of 30˚ (27˚-34˚); 5/11 (45.5 %) facet joints were inaccessible because of osteoarthritis or fusion. All accessible targets (176/187, 94.1 %) were successfully injected, requiring 47/176 (26.7 %) needle adjustments. There were no inadvertent punctures of vulnerable structures. Median procedure time was 10.2 min (5-19 min). Image overlay navigated MR-guided spinal injections were technically accurate. Disks with an obliquity ≥27˚ may be inaccessible.