An Augmented Fluoroscopic Guidance Technique to Improve Needle Placement and Cement Injection for Sacroplasty
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LETTER TO THE EDITOR
An Augmented Fluoroscopic Guidance Technique to Improve Needle Placement and Cement Injection for Sacroplasty Min Lang1
•
Aya Rebet2 • Benjamin A. Tritle3 • Amanjit S. Gill4
Received: 23 April 2020 / Accepted: 15 May 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
To the Editor: Sacroplasty is widely adopted to treat sacral insufficiency fracture (SIF)-related pain. Accurate needle placement and clear visualization of cement injection relative to the sacral foramina remain challenging due to the complex sacral anatomy [1]. Cement extravasation into the sacral foramina risks neural injury and venous cement embolism [2]. Here, we describe a guidance technique that augments live fluoroscopy with pre-defined needle trajectory and sacral foramina control lines from planning cone-beam CT (CBCT). Sacroplasty was pursued for two patients with severe lower back pain due to pathologic SIFs. Planning CBCT of the sacrum anatomy was obtained with patient prone on the angiography table. Next, fusion with preoperative imaging was performed to confirm fracture location and extent (Discovery IGS740 suite, GE Healthcare, Chicago, IL). Needle trajectory was planned on the CBCT crosssectional views, entering the patient’s lower back, medial to the sacroiliac joints, then traversing the sacral alae in a caudal and slightly lateral orientation (Fig. 1A, B). The
& Min Lang [email protected] 1
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
2
General Electric Healthcare, Interventional Imaging, Buc, France
3
Radiology Associates of Northern Kentucky, Crestview Hills, KY, USA
4
Department of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
final needle target was the anterior cortex of the sacral alae at the level of the fracture. Injection control lines were marked on CBCT to delineate the sacral foramina boundaries along the planned needle trajectory, anterior sacrum surface close to the planned target point, and posterior sacrum surface close to the needle entrance point (Fig. 1C–E). The planned needle trajectory and injection control lines from the planning CBCT were overlaid onto live fluoroscopy (Needle ASSIST, GE Healthcare). The needle (Kyphon V Osteo Introducer 13-gauge Trocar; Medtronic) was advanced along the planned trajectory using software generated ‘‘bullseye’’ view (en face) for needle insertion at the planned entrance point and with the planned orientation, and progress view (en profile) for advancement to the target depth. Patient motion with needle insertion was systematically detected with CBCT/fluoroscopy bone overlay and dynamically corrected from table side. The accuracy of the needle placement relative to the SIF and the initially planned trajectory was assessed using 3D stereotaxic reconstruction based on two fluoroscopic views (Fig. 2A, B). No readjustments were requi
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