conserved a treatment did not help and this was just a pre image and that didn't have a post image yet he came back after six months iii VAS and he said why should I do an MRI If I'm really pain free? So this are just a pre-up images I treated those two discs which
stop back and take a look at it and have a dialogue with the orthopedic gynecologist. I'll tell you even if it's metastatic lesion, you may still wanna have a conversation with him because sometimes they're gonna resect that or do an arthroplasty for a pathologic fracture. And it would be nice to go on a pathway that they are gonna be in. So it's really that interaction.
Obviously you're gonna be mindful of adjacent neurovascular structures. Nick did a great paper on radiographics looking at all these things. And it's really to keep that in mind. You wanna know the anatomy. Compressibility of the
site can also be an issue. And in spine, you wanna consider going for spinal lesions transpedicular versus extrapedicular. And this is a case. You can see there's a lesion here in the upper lumbar spine. Extrapedicular course was taken. You can see the
75 year old gentleman who had mesothelioma, he'd been a construction worker his whole life had a lot of
exposure to asbestos and one of the problems of mesothelioma is that sometimes it will not metastasize all that much, but wherever it is it will tend to go right through tissue plains. And this poor guy, the tumor was going right through his chest wall through the ribs and he had unremitting pain because it also invaded
the inter coastal nerves. So in this particular case what we did is we put in multiple probes and we destroyed all the inter coastal nerves on that side, and provided him with pretty good pain relief.
is something called aggressive fibromatosis. This isn't malignant
disease but is locally, extremely aggressive, it can be a very, very difficult to trick, is difficult to operate on. Sometimes it will respond a chemotherapy often it won't and the usual recourse if a tumor like this is growing is you've to get
the patient radiation, external beam radiation. So we started doing is actually ablating these things with a cryoprobes. You can see here that we've put in four different probes, you can see the ice ball that' s formed and encompassed pretty much the
entire lesion is what it looks like when you're in the room, the patient looks a little bit like pin pushing.
history is an 86 year old female with a history of osteoporosis and prior vertebral compression fractures presenting to the emergency department with complaints of back pain after a recent fall.
Now she has point tenderness that was noted at the mid thoracic level, no discrete neurologic deficits like radiculopathy bladder or bowel symptoms or numbness was noted but she did have trouble ambulating without assistance which was not at her baseline and that was attributed mostly to her pain.
She had no history of malignancy, no prior surgeries and no evidence of any systemic or active infection. Given that she was an ED, they went straight to the CT. And here on the spatial view of the thoracic spine you can see multilevel compression fractures,
the one that's the most prominent is at the T6 level but given her underlying osteopenia and osteoporosis you really can't tell the acuity of these fractures, there were no real priors for comparison purposes. She was admitted to the general medicine inpatient service for pain control.
After 3 days of continued pain despite medical management as well as the inability to ambulate independently due to her pain intolerance our service was consulted for a possible vertebroplasty. We went up to see her , examined her,
found that she still had pain at that mid thoracic level and we recommended an MRI. Here we have the spacial view the thoracic spine which kind of correlates with the physical exam and her presenting symptoms. This is a star sequence which has a short tell in version recovery sequence that demonstrate the myeloma.
Not only have that T6 level, but one right below it at the T7 level. We kinda of see.>> I'm trying to put it that way. Is it this way? >> Yeah great.
Here and here. So given her presenting symptoms and what we see on imaging we proceeded with vertebroplasty. Here on the first image, you can kind of see on an oblique view, the outline of the pedicle which we go down the barrel making
sure not to violate the medeal wall. Once you are able to contact the posterior wall, the vertebral body, you can go on the lateral view, and go in. And here you kind of see in the thoracic level,
we went up both levels with 13 gauge needles. And we proceeded with cement insertion to the vertebral body. So at hospital admission her visual analog pain scale was 10 out of 10. 24 hours after vertebroplasty was reported that she had significant improvement in her symptoms,
rating at 2 out of 10. In addition, she was slowly able to ambulate without assistance, kind of going back to her base line level. 48 hours after the procedure,she
was discharged back to her skilled nursing facility. So, the scope of my presentation today is just gonna basically horn in on the things we do before you actually take a patient to vertebroplasty. In an inpatient setting,
really easy. The patient has being worked up, they're having persistent pain, they go to you. Pretty cut and dry but if you're having this patient referred to you, at an outpatient clinic,
being referred by a PA and PE or some urgent care clinic without the appropriate work up. It's really important to kinda see all the variables that are involved in the management of these patients before you take them to vertebroplasty. So that you can educate the patient as well as be a valuable resource to your referring providers.
So I'll talk a little bit about compression fractures.
- Good afternoon to everybody, this is my disclosure. Now our center we have some experience on critical hand ischemia in the last 20 years. We have published some papers, but despite the treatment of everyday, of food ischemia including hand ischemia is not so common. We had a maximum of 200 critical ischemic patients
the majority of them were patient with hemodialysis, then other patients with Buerger's, thoracic outlet syndrome, etcetera. And especially on hemodialysis patients, we concentrate on forearms because we have collected 132 critical ischemic hands.
And essentially, we can divide the pathophysiology of this ischemic. Three causes, first is that the big artery disease of the humeral and below the elbow arteries. The second cause is the small artery disease
of the hand and finger artery. And the third cause is the presence of an arterial fistula. But you can see, that in active ipsillateral arteriovenous fistula was present only 42% of these patients. And the vast majority of the patients
who had critical hand ischemia, there were more concomitant causes to obtain critical hand ischemia. What can we do in these types of patients? First, angioplasty. I want to present you this 50 years old male
with diabetes type 1 on hemodialysis, with previous history of two failed arteriovenous fistula for hemodialysis. The first one was in occluded proximal termino-lateral radiocephalic arteriovenous fistula. So, the radial artery is occluded.
The second one was in the distal latero-terminal arteriovenous fistula, still open but not functioning for hemodialysis. Then, we have a cause of critical hand ischemia, which is the occlusion of the ulnar artery. What to do in a patient like this?
First of all, we have treated this long occlusion of the ulnar artery with drug-coated ballooning. The second was treatment of this field, but still open arteriovenous fistula, embolized with coils. And this is the final result,
you can see how blood flow is going in this huge superficial palmar arch with complete resolution of the ischemia. And the patient obviously healed. The second thing we can do, but on very rarely is a bypass. So, this a patient with multiple gangrene amputations.
So, he came to our cath lab with an indication to the amputation of the hand. The radial artery is totally occluded, it's occluded here, the ulnar artery is totally occluded. I tried to open the radial artery, but I understood that in the past someone has done
a termino-terminal radio-cephalic arteriovenous fistula. So after cutting, the two ends of the radial artery was separated. So, we decided to do a bypass, I think that is one of the shortest bypass in the world. Generally, I'm not a vascular surgeon
but generally vascular surgeons fight for the longest bypass and not for the shortest one. I don't know if there is some race somewhere. The patient was obviously able to heal completely. Thoracic sympathectomy. I have not considered this option in the past,
but this was a patient that was very important for me. 47 years old female, multiple myeloma with amyloidosis. Everything was occluded, I was never able to see a vessel in the fingers. The first time I made this angioplasty,
I was very happy because the patient was happy, no more pain. We were able to amputate this finger. Everything was open after three months. But in the subsequent year, the situation was traumatic. Every four or five months,
every artery was totally occluded. So, I repeated a lot of angioplasty, lot of amputations. At the end it was impossible to continue. After four years, I decided to do something, or an amputation at the end. We tried to do endoscopic thoracic sympathectomy.
There is a very few number of this, or little to regard in this type of approach. But infected, no more pain, healing. And after six years, the patient is still completely asymptomatic. Unbelievable.
And finally, the renal transplant. 36 years old female, type one diabetes, hemodialysis. It was in 2009, I was absolutely embarrassed that I tried to do something in the limbs, inferior limbs in the hand.
Everything was calcified. At the end, we continued with fingers amputation, a Chopart amputation on one side and below the knee major amputation. Despite this dramatic clinical stage, she got a double kidney and pancreas transplant on 2010.
And then, she healed completely. Today she is 45 years old, this summer walking in the mountain. She sent to me a message, "the new leg prostheses are formidable". She's driving a car, totally independent,
active life, working. So, the transplant was able to stop this calcification, this small artery disease which was devastating. So, patients with critical high ischemia have different pathophysiology and different underlying diseases.
Don't give up and try to find for everyone the proper solution. Thank you very much for your attention.
4 grade of Pfirrmann in L5S1, with discogenic and facet pain, with failure of medical and physical treatment.
And we choose another type of screws, dynamic screws. Not for fixation, but we put the screws under the facet. It's composed by a titanium anchor and a polyurethane stabilizer. The access kit is very similar to previous, but the technical is
a little bit different because we put the access needle, Kirschner wire, dilators, and the tap, and a countersink to create a space for the screws. But when we put the anchor and the stabilizer, we put the screws under the facet. Not to fix them, but to obtain a push up,
a superior push up of the facet and to limit the hyperextension. Then we repeat the procedure on the other pedicle. This is the final position of the implant, and the CT check. We can appreciate
the difference. Here the screws is under the facet not through the facet, as the case before, and the CT check confirms the correct implant of the screws. We also evaluate patient in the study with a two-year follow up.
We had a good reduction of pain evaluated by means of VAS score, and functions by means Oswestry. So we demonstrated that Percudyn system was a good
Another example is a 51 year old gentleman who had a metastatic
rectal carcinoma, he had radiation and chemotherapy and so on and so forth, but he had a medistatic deposit in his right side of his pelvis. Which was re-fracturated the usual treatments, you can see here as cone beam CT image, you can see there's a mark destruction of the
post year aspect of the iliac bone. So what we did in this case is we took a cryoprobe, put it right down in that area, destroyed as much of the tumor as we could. You can see we've put two different probes in here,
there's obviously some destruction of the astabulum though, so it's gonna be hard to bear weight on that. So we fill that up with some cement, in order to provide some structural support. So it doesn't look very pretty on the X-Ray but it got the job done.
Patient symptoms almost completely disappeared. This is same patient you can see the tumor does, we are not curing this patients, the tumor has come back, there's a second lesion that has appeared anteriorly and a patients symptoms were returning.
So the thing is, with this paliative of procedures we are not gonna cure this people, but what you're trying to do is give them as better quality of life for as long as possible.
And this is a 55-year-old fire fighter, who ended up with
up with a right upper extremity amputation, synovial sarcoma. And so, in ultra sound basically shows this brachial plexus neuroma, right here. This is an image showing the probe line longitudinally through the
brachial plexus neuroma. The black arrows down here show the brachial plexus with this big neuroma on top of it and that's the ablation probe through it. A kind of surgical oblique image basically showing the two probes do it. Here's that T2 image with fast sat showing that neuroma right here
in surgical plane. So again from a more traditional axio imaging approach, the scalene muscles are outlined in green here with the neuroma in red. And bone window showing the probe right into the neuroma splitting the scalene musculature and here's a soft tissue when the're showing
the same thing. So, this is kinda of borrowing a lot of things that actually Dr.Prologo who'll talk about in a second has turned is really kind of a pioneer in this space for it. This is literature from dorsal penile nerve ablation which is a technique
he developed for premature ejaculation. And similarly pudental neuralgia in 2013 and other people that he put together. And so I'm kind of piggy banking on top of him. He's kind of the captain of this ship but he's definitely made me a believer. I tell people he's taken me to the cyroablation for nerve pain church
and I'm definitely singing his praises at this point.
Hey guys. Welcome back from lunch. We're gonna get started. So our next speaker is Hits and Misses: an interactive mortality and morbidity session with Dr. Charles Martin. Dr Charles Martin received his medical degree from Case Western Reserve University School of Medicine. He then
completed his radiology residency with University Hospitals of Cleveland and his vascular and interventional fellowship with New Haven Hospital. He currently serves as an assistant professor and clinical director of radiology at
Cleveland Clinic. Dr.Martin is also involved with oncology research and actively involved in trials for patients with unresectable hepatocellular carcinoma. Today Dr.Martin will lead an interactive M&M session with us...so we
encourage questions because this works when you have questions. Thank you. Ok good afternoon. Ok so as far as the session goes the cases are just gonna be relatively... pretty pretty common things. We have a
monthly M&M session in Cleveland and I kind of am one of the people who are under the opinion that anything could happen to anyone at anytime. And it's usually kind of the the run-of-the-mill things that kind of when they go
sideways that's usually kind of the ones that you really have to kind of figure out kind of what to do and how to kind of handle. So here we go. And then anytime somebody has questions just shouting them out come up to one of the
microphones let's keep it really kind of free form and low key. So there's my disclosures. I'm my part of a medical
This a 75 year old gentleman, who had an invasive small cell liposarcoma.
He'd been operated on three times previously in an effort to get rid of this large retroperitoneal tumor. But as is often the case of retroperitoneal sarcomas, you really can't get them all out. So he had radiation and chemo
and the whole thing, but you can see this lesion is not only invaded the sacrum and iliac bone. You can see it's starting to invade the spine. So it's very extensive destruction and had unremitting radiating pain because he had lumbar nerves that were also encompassed by
this lesion. This is a cone beam CT image so what we did in this case is we put multiple probes. You can see the ice ball, here around the tip of the probes. So we destroyed as much of the deep portion of the tumor as we could.
And we reinforced the spine that was being invaded with some cement. So I told him that afterwards, I hope that his pain would improve, but he'll be unable to walk since I had to destroy three lumbar nerves completely. And he actually was able to walk afterwards with a walker,
but his pain was completely gone and that's really what he wanted. So these patients are very motivated as well and they're all quite tolerant of things that most of us would view us devastating side effects, and again
this is what this gentleman looked like with this multiple probes
thank you dr. bloody and dr. Abelman to do so i'm going to present the v close randomized clinical trial 12-month data this compared the vco closure system to a radiofrequency ablation via closure fast these are my disclosures so Venus seal
is a proprietary cyanoacrylate adhesive that closes disease veins the catheter has been engineered such that it will not stick in the adhesive and it has a proprietary dispenser gun that delivers the adhesive in precise doses so the v
close study was the u.s. pivotal trial that led to the FDA approval of this product it was perspective and randomized 121 comparing Venus seal to closure fast the purpose was to demonstrate safety
and efficacy and non-inferiority compared to radiofrequency ablation at three months there were two hundred and forty-two patients 20 of them were role in to have the investigators familiar with using Venus seal the primary
endpoint was duplex ultrasound determine closure of the GSU to be non-inferior to radio frequencies secondary endpoints included intra-operative pain on a 0 to 10 scale bruising an adverse events follow-up visits are shown here and no
injunctive therapy in either group was allowed into tell three months after the study started so this is the division of the groups and a hundred ninety subjects completed the 12-month visit there are 13 loss to follow-up in the Venus steel
group and 19 in the RFA group patient characteristics were well-matched between the two groups including dcss which is about five-and-a-half aberdeen of questionnaires and eq-5d quality of life measures
interestingly interprocedural pain was the same between the two groups and they do have some theories about why that is but both during vain access and during treatment there was no difference between the two groups bruising was
somewhat less in the Venus steel group at day 3 complete closure definition was very strictly defined there could be no areas of discrete patency that were longer than five centimeters in diameter either by compression or in showing flow
these were checked by a core lab and at the site at three months the closure rate with Venus seal using that definition was ninety-nine percent and an RFA was ninety-six percent and this was statistically significant for
non-inferiority at through 12 months at 12 months the closure rate for Venus seal with ninety-seven percent in an RFA ninety-seven percent that may seem odd that the closure rate improved but remember at three months the patients
could have adjunct of procedures such as microphone back to me and we did find that some of the RFA's that were open previously closed in the interim this kaplan-meier curve shows time to recanalization and it was ninety-seven
percent in the universal group 91% in the RFA group and that's because of course at the beginning some of those RFA's were open and this was highly statistically significant for non inferiority and almost statistically
significant for superiority in the Venus steel group Venus qualities of Venus clinical severity scores improved in a similar fashion across both groups to 12 months as did the quality of life scales the Aberdeen and the eq-5d were
virtually identical in the two groups at 12 months adverse events the most common in both groups was phlebitis this is very broadly defined and included any inflammation in either the treatment or not in the treatment zone there were no
statistically significant differences in adverse events between the two groups safety side effects were minor there were no procedural or device-related SI ease into operative pain levels were not again different between the two groups
but note that the pain level in both groups was very low to on a scale of one to 10 so 10 to 10 and my theory that patients that select out for randomized trials tend to be a little bit more stoic group than my practice in general
the effectiveness rates in both groups were very good and there was a non-inferiority with me to steal compared to RFA in closure quality of life and Venus clinical severity score and we're continuing to follow these
patients out we've just been finished collecting to your data and it has not yet been analyzed thank you
lower back pain since more than 15 years, nothing helped, he was unstable on the SI joint,
they wanted to fuse him here on several segments, I injected the joint here and he really had back pain, Pelvis leg seven and the back more than five. And for me it was a pure SI joint disease and injection helped.
I'm not denervating because long term outcome for me is not satisfactory so I fuse them, you have seen this device the SI fusion 2011 but he still had some back pain So what I did continuous, Back pain about five years, this was the MRI, you see here the modic signs,
here and here. And now I use the interdiscal hydrogel because the ablation method, they ablate the nerve had some problems during this days at that time so I inject the hydrogel, sorry I'm wrong on this patient I ablated the nerve and this was this patient.
I ablate the pain nerve, you have to map it, so here nerve is here one, two, three and I inject the hydrogel. I thought because this patient flew over from a country outside Europe, from
East Europe came over and wanted to do belt and suspenders so here you see the ablation of this pain nerve, post ablation and here the hydrogel and here. In this patient I did not use PRP. I thought that would be a bit much.
So this was six weeks post ablation images. And now the follow up, this was as a fusion it worked on the leg and the pelvic pain so really good. But not so much on the back pain. This gel sticks and the ablation and you see how it is. And he came back always for his follow up now 30 months out and
he was happy and fine with this. No fusion, too little well as joined is also little ablation but just a little injection and the ablation as said.
This is an example of a unipedicular approach. You can see the cement has actually gone into the vertebral segment. It's amazing how often even with a half CC of cement, there'll be a plane of plasma sitting in there between the fragments and
the cement will just shoot right across to the other side, and you've got a half CC, you're done. This is another example. You can see in this particular case, you can see that the needle is just immediately above the cortex. Is
that showing there? It's not really showing on the screen for some reason. We can see that the needle is just barely above the inferior cortex of the pedicle.
That's a 43 year old Breast Cancer patient [INAUDIBLE] 90% means, 100% is completely immobile. 90% is nearly immobile. As are three, Asia E means okay so no [INAUDIBLE] bleacher yet. Three years after primary exition And the iii gives you an indication
please do a iii excision of the whole verge of parectomy on this patient, so and now I look to Peter and all the other radiologists which you do a big wide incision to iii to be in this patient, so nobody would do this but that's what you were taught such as [INAUDIBLE] and these patients have to operate, and this [INAUDIBLE]
published this in 2005 in spine where it didn't operate, just chemo radiation and the pain was better. So and that's why, we are not over-treating due to this surg-management course, we teach you, we tell you
exactly with those patients if you have to do big surgery [UNKNOWN] they are weeks and weeks in the hospital, most of them die anyway in the hospital. I have seen rarely a metastatic prostate Cancer leaving the hospital alive after surgery,
long ICU hospital stays and so on. We have talked about that here and of course this is [INAUDIBLE] just because they do a little outpatient one two oven night stay
On this T2-weighted and non enhanced fat saturated T1-weighted image of the pancreatic tail, we can see a large lesion that has solid and
cystic components. We know this is solid component because when we provide gadolinium, as I click here, we can see that these enhance. And so we can see that there is large solid component within this large tumor. [BLANK_AUDIO] However, solid and pseudopapillary
tumors can also be entirely solid, and they can also just be totally calcified, for example in this patient. Here's another patient. In fact, this was a young man with a mass in the head of the pancreas, and we can see that there is no cystic component. This is a solid mass, and not only was there a mass in the head of the pancreas, but also metastases within the pancreas. These tend to be low grade
malignancies, and so this patient actually had a ripples/g resection of the head of the pancreas and also hepatectomy. And patient did quite well afterwards with no evidence of recurrence. [BLANK_AUDIO] What
over to see me I treated him in Europe, he flew over from Toronto. No coincident iii I had deep lumber pain not radiating at a disco cram and free to as one, had a five iii injection already in Canada and three two as one without benefit and they said okay now we
do a three level this replacement three level fusion or free level iii and we thought now I don't wanna have free-level fusion or free-level disc replacement? No. I don't wanna have this. So this is where the [INAUDIBLE] result from the notes from the
Canadian colleagues, so very very highly positive here, positive also here, and here. So we have actually three painful discs on this patient which is a lot, so I put in three disks and the post op three sticks one here, one here, one here together with 0.8 mil of PRP and BRS
six months was one. And this was about one and a half years ago and I tried to track
operation and radiation, whatever, three operations within from May to January [INAUDIBLE] and that was the outcome, 14th of December 2006, which was about seven months after the onset of the tumor and that was the outcome three years later .
The guys survive five years , moving things and although the seven patients were actually the insurance companies pay even the treatment
So these complications that we're talking about as well, with really good technique, with employing multiple sort of adjuvant things
to how you do your embolization can actually be reduced. So here's a patient that was embolized prior to my working at the University of Colorado. It's a 43 year old female on chemo for metastatic rectal cancer. She has to keep getting her chemo cancelled because she keep's showing up with her platelets too low, they can't get them up despite transfusing her with platelets and so they have
to keep cancelling chemo appointments and so she asked is there anything we can do and one of our oncologist sent the patient to us. This patient was embolized by one of my partners. She was referred for partial embolization, you can see she has quite a large spleen, it was 18 centimeters at the time and that was probably due to a combination
of lots of chemo and previous selective internal radiation therapy and this was sort of in the time before people were doing lobar to try to decrease the portal hypertension caused by cert. And then so this is sort of the angiogram that was done, she isolated the lower pole, she embolized that whole lower pole with about
half a vile of beads a one to three of three to five hundreds and then she took the rest of it and just kinda flashed it into the main splenic artery. And she ended up getting a decent result from the stand point of the amount of spleen that was devascularized you can see what it looked
like at one week and then following ten months. The problem is this patient spent two weeks in the hospital had a couple of parecentesis, a couple of thoracentesis and was on a dilaudid PCA for a week and so not exactly our favorite thing to ever happen but that was kinda how it worked.
She then came back ten months later Later and this is images from her ultra sound of the devascularized portion of the spleen in the associated ascites adjacent to it. And prior to this embolization, her platelets were 39 immediately following they went up to 155,
but she actually recurred a year later which you can kind of expect if you had actually, done the volumes on the spleen. She actually took about 40% of the spleen and most of the data says if you don't take at least 50% you are going to recur with respect to the thrombocytopenia.
Platelets 89 at this time referred for another splenic embo. So I brought her to the suite and I did it a little bit different than my partner to try to reduce these complications. This is the hematology patient who basically has a normal liver function and so I can do a lot of tricks in this patient that I
can't do in my liver patients. In particular I gave her inter arterial toradol right before I started the procedure. I started the steroid taper with the first dose given in the holding room prior to starting the procedure and then I did a seven day steroid taper, I gave two weeks of antibiotics and then for patients who can get nonsteroidal anti-inflammatories, I give three days
of burst NSAIDs so I give 800 tid of Ibuprofen. And it's amazing the difference that that makes relative to what you normally see with these splenic embo patients and nonsteroidals just they work better in these patients, I don't know why but they do. And so I basically did an angiogram just like that, picked on another
lower pole vessel, embolized it to stasis with 500 to 700 micron particles cuz again the pain can be related to the size of the particles you use. The smaller you use the more likely you are to have pain but you don't want to use too big a particle because, There was a nice study published in the pre transplant literature
from Europe, which demonstrated that if you use particles larger than 800, you tended to get more recurrence of the thrombocytopenia, because they develop intra-splenic collaterals. And so this patient was put on a PCA overnight, didn't need the PCA in the morning.
Went home with her non steroidals, and actually came back and saw me a month later in clinic, and was just fine. And then she actually did fine until later. You can actually see this a lot colon cancer that's in her liver.
So, she actually died five months following or four months following the procedure? Yeah. Four months following the procedure platelets 255 immediately following the procedure, ann 155 at the time of her death. Probably in part due to her spleen but also because she was getting
chemo at the time, right up to the point of her death.
First case is a 64-years-old male with a neurogenic intermittent claudication, due to degenerative lumbar spinal stenosis confirmed by EMG, and with failure of medical and physical treatment.
We decide to implant a percutaneous interspinous spacer as a stand-alone system, in that case we use Aperius produced by Kyphon Medtronic. And the implant is available in four different size 8, 10, 12 and 14 mm, and it can be introduced by means of four access
Keith needle by corresponding measurements. Procedure, we performed the procedure under fluoroscopic guidance, and with local anesthesia. Subcutaneous Lidocaine, deep ropivacaine and deep sedation with Midazolam and propofol bolus. Patient is in prone position and after we perform the local anesthesia,
we introduce the first 8mm access Keith needle between the two spinous process into the spinous space, interspinous space. And the first accessory was not suitable, and so we moved for the next, 10 mm.
The second was suitable, so we decide to put the corresponding measurement prosthesis. And the prosthesis can be delivered by rotation of the implant, and when we open the wings to keep it in place it can be delivered safely. Here the final results
confirm the good position of the implant, and CT check after the procedure confirm the good position of the interspinous spacer. On the market we can find other three spacers. Lobster is an Italian product by,
thank you so much, [BLANK_AUDIO] Techlamed, and its main characteristics is to be completely removable after its delivering. HeliFix is produced by Alphatec Spine,
and it's a PEEK implant. And In-Space, produced by Johnson & Johnson is a mix, titanium and PEEK. All of them can be introduced by straight access Keith needle. Aperius can be introduced by curved access Keith needle, this is the main difference. We published last year a paper about three-year follow up results
after implant of percutaneous interspinous spacers, evaluating the area of the spinal canal and both neural foramina. And we demonstrate an increasing in a CT check three years after the procedure, and we had a good pain relief demonstrated by mean of VAS score, and the good improvement of functions demonstrated
with Oswestry. So we concluded that Aperius was a good option for a patient with neurogenic intermittent claudication, with failure of medical and physical treatment.
Another example of a really very compressed or gibbus type of vertebrae,
you can see it's more or less a triangular shaped vertebral body. Typically what I'll do is I'll put in my xylocaine needle. Put it down on the cortex of the posterior aspect of the pedicle, you can see that in the lower image over on the right.
I use that as my guide in order to tell me where to put my vertebroplasty needle in. Gradually advance the vertebroplasty needle again. Always looking very carefully at the inferior cortex of the pedicle to make sure I'm staying above it, and not ending up in the intervertebral foramen. And generally speaking I find, you can usually pretty easily get about halfway
into the vertebral body. If you go much further anteriorly than that, you may end up penetrating the anterior cortex. And then you can inject your cement. I find with vertebra like this you're very seldom getting more than a CC,
CC and a half, not much more than that. Sometimes much less as I mentioned before.
So he had to drill through the bone you can see that the probe is directly in the center of the lesion and the ice ball will form around that and compass the entire lesion.
When you do a MR afterwards, you can see that the tissues around it are changed and their signal characteristics. So you know exactly which area of the tumor has been ablated. And is this is just a diagrammatic representation showing that sometimes you don't even have to drill into bone if a lesion is sufficiently
a superficial. You can just lay your probe against the surface of the bone and the ice ball will actually propagate right through intact cortex. If the lesion's too deep you do have to drill for it though. An example of an osteoidosteoma in the anterior femur so you just
lay the probe against the surface of the bone. This is done just with a bupivacaine/g just some local anesthetic, and the patient was gone and out of the room 30 minutes later. If I'd done this with radio frequency ablation the patient would have required a general anesthetic, probably would've had to be
around for about four hours afterwards and would've felt probably a lot worse.
This is another patient, this is a myeloma if you were here yesterday
you have seen lots of examples of myeloma cases. But sometimes CT becomes a great limiting step in most interventional departments so, I try to do lower thoracic lumbar cases using the rotational 3D the DynaCT on the Siemens platform. So this was a patient who had myeloma diagnosed in 2007, was treated,
relapsed in 2013 was treated again with IVIG was good enough, and 2015 showed a spike again and CT at this time showed lytic lesions with collapse of the vertebral bodies. And her pain was extreme, extreme pain when we saw her in the clinic, she was a 10 out of 10 and had point tenderness at multiple levels especially in the lower back. And ODI score
was 55 so she was completely almost bed ridden and her only thing that I can't go to church, I really wanna go to church I can't even do that. So this was the CT that we got on her and you can see that the L1, L3 and L4 vertebras are involved and there's some particle involvement
at the L4 level also. So we did an endo fluoroscopy, we did a microwave at all the three levels you can see the probes at all the levels and then we did the 3D rotation CT just to make sure that the placements of the needle is fine before we started using the microwave ablation.
This was a 3D that showed me correct positioning and how much I have to calculate the bone zone on this and this was the CT axial and the [UNKNOWN] images that we obtained after that to calculate all the bone zone and everything. So this makes the procedure faster sometimes because sometimes we
get this request from our referring physicians that I need this patient done tomorrow. So CT is really at least in our institute it's a clog point and this has really helped me out and the newer platforms are the 3D rotational CT are much better. And this was the final effort we had augmented it with cement.
We had done some pediculoplasty also. And I did rotational CT just to be sure. Because whenever you have someone hurting in the back, you skip a heartbeat. But I knew it was going in the right direction and we could see
that it has gone into the pedicle and into the base of the transverse process at that level. And the patient three to eight weeks follow up was doing extremely good from VAS of ten she had become VAS of two. And her ODI was 16%. She was happily going to the church,
and was quite happy with the result. And this is the team,
no chemotherapy. And that's a lady 57 year old with press carcinoma, multiple bone meds/g multiple liver meds/g and that's the CA level, the cancer level how they go down over the time and she has not
received chemotherapy . She didn't want to have chemotherapy . She came from North America over to Europe and she didn't like she said no chemotherapy for me and these are the breasts, the liver meds/g in a January 2004,
here they got six cycles treatments that we are talking September 2004 and we talk October 2006.
And this is the case. This is a preliminary experience,
so far we have treated only 5 patient and 18 patient were treated in Germany, all over the world. So this is a really new procedure, we are looking forward to enroll patient and to
study this patient. This is a patient with a painful kidney cancer mets in a T-10/g. And the patient was study with MRI and CT. What is important that, to treat this patient we need the collaboration of radiotherapists, physical doctor, or whatever because all the
therapy is pre-planned before the treatment. So we really know the dose we need, we really know the area we can irrigate, and compared to other ablation technique, this is really safe because we can avoid really all that they mention to the
tissues around the lesion we can really reach those we need to kill the tumor. So that's the patients and [COUGH] it's quite. It's quite a really simple procedure, we use the metronic ostin
to do sir, so the canal is bigger than standard veterbroplasty. It's like the first canular was used for balloon calfoplasty/g is eight gauge, and this is the properthery/g canular of the ice where you put the probe inside, so you achieve your approach,
transpediqual approach with standard vertebroplasty needle, then you put the [INAUDIBLE] guide wire then over the guide wire you use the ostin/g to do some by metronic coupled with the proprietary canular that's the final result, that's
the canular that you have. Through this canular, the nafture/g you need to have this device, this device with probe for radiotherapy so the probe goes inside the metastasis everything is controlled by this monitor and usually it takes three minutes of radiotherapy to reach very high curative zones,
those inside the lesion. We also evaluate all around the patient, there is no emission just because the radio therapy is inside the patients. Then after the probe is removed,
we use the system cannula of medtronic/g to inject bone cement and usually we try to fulfill the lesion with bone cement. That's the final results, we perform a CT after the procedure, you see that the lesion is completely full
filled of bone cement. The patient of same procedure can be discharged by the hospital without any pain and all the procedure is made percutaneous so you don't need any incision of the skin.
and they get [INAUDIBLE]. So it was already spread to the lymphoid and this [INAUDIBLE] that [INAUDIBLE] Cause of that because PSA went up,
so which is the tumor market for those who don't know this. Okay another chemotherapy, palliative radiation because you got bone [UNKNOWN] and multiple rib [UNKNOWN] a bit later and the PSA was going up.
The iii started in October 2007 review , these are the vexing and [INAUDIBLE] vaccinations . that's the first vaccination, October, December, January , and after January, zero. [INAUDIBLE] pets
March 2008 , which is about five months later showed no metastases in the bones in the moment that is enriched and the PSA was known mostly letters were completely normal, no changes, no bone metabolism by the Cancer and that's the path of development of the guys who lives today .
We talk about here seven eight to ten ten oh eight new test twice a year , PSA , and he is still alive and still happy. Glioblastoma
thank you very much Alan and I echo the chairs comments about expressing solidarity with our French friends and also our Turkish friends because the istanbul has been subject to appalling terrorists attacks recently along with Paris so no conflicts so why all the
interest in in blue and the non-thermal on tumescent techniques well the reason is it gives you the chance to treat a full length of triangle vain without all the needles involved with tumescence and without the danger of damaging the
nerves which were Jason to the veins of the lower end of the other limb and so what is the perfect glue well firstly ideally it should be relatively viscous to avoid embolization and and the title of the talk is
slightly curious because a glue done properly absolutely should not embolize and it should stay accurately and precisely what is dispensed you should prepare polymerize fairly quickly so that the sticking action of a war
together occurs very very quickly and ideally after is polymerized it should be soft and elastic and it shouldn't be brittle inside the tissue and obviously should be strong durable with the ideally no need for compression
stockings afterwards and ideally a relatively low doses requirement and the first clue that came on the scene to fulfill these requirements was the Venus steel blue developed by the South Korean company which was subsequently acquired
by covidien anarchist apartment trying and if they're a perfect glue patient probably is you have a patient who's got a very long length vein that you want to treat and presents a very tall patient with a an active also a patient whose
intolerance and needles a patient who's a lake shape is not conducive to fitting a stocking or whether as a result which means compression is is difficult and has to be said ideally a wealthy patients currently blue is quite
expensive and not readily reimbursed in any of the systems that most of us working and so step-by-step well it's a fairly standard office based outpatient local-anesthetic procedure and anyone familiar injuries procedures can you
pick it up very very quickly indeed the access is assaulting elsa ultrasound-guided seldinger technique for a very fine micro puncture kit to pass a wire right up to the federal junction and then the access she's
removed and an introducer and died later is introduced over a while I understand guidance up to the subpoena federal junction then the wire and dilation both removed and the key thing is to position
that the tip of the sheet which is very clearly visible once the other bits and pieces have been taken out of the way and position that five centimeters back from the subpoena family junction 25 centimeters back slightly further than
we used to and then flush with skyline and leave the syringe in place so that introduced it doesn't back fill with blood and the next step is to prime the catheter to draw the clue back into the syringe and
fit into the glue dispenser gun and this is a very specific very expensive gun which dispenses really pull the trigger an exact 9.1 million of glue is that is dispensed you prime it so the squeeze the trigger a few times so the meniscus
of blue which can be seen very clearly passes up to a great landmark on the end of the catheter here and it's very important not to extrude any glue out of the end of the catheter otherwise the whole thing becomes a dms you can't do
what you want to do because the next day just a thread that catheter through the introducer and position it that is exactly the right place which is five centimeters back from the Junction's obviously you you pull the introducer
back a bit further so that the tip of the blue catheter inside the introducer is actually positioned just below the junction the pullback sequence when you pull the trigger twice to dispense two dollars of glue exactly a centimeter
apart in the correct position of the top use ultrasound to localize water press and either use the ultrasound probe or palace for each other is more comfortable but applied very firm pressure to seal that thing for three
minutes and that's the most boring possible Seussical is nothing else to do then immediately pull back and another three centimeters and for that for the rest of the pullback it's one dollop of glue every 33 centimeters with 30
seconds for each one this is what the top end of the junction looks like at the end where it seals are very very quickly and I think the one of the key advantages is that I'm a great ass felt fine but you have a patient is
not renounced our patient with very large very cost is a very large incompetent thing you do have the option of treating all the way to the bottom with a potential of reducing the need for unnecessary for back to me so if you
if you do have a patient is not as well suitable and we might want to further for back to me and there's a potential advantage to this kind of technique the second blue which is the very close glue from there from the Turkish company bio
class slightly different procedure in that it's a continuous pullback you squeeze and pull and pull back at the rate of two centimeters per second so every five centimeters you cover 10 centimeters with a squeeze every 10
centimeters and we'll discuss that a little bit more in the end in the next talk any pitfalls when you can get a little bit there at the top which can confuse your accurate positioning so it's important to keep things flushed
and remove all the air and if you do not about trying to go to be careful not to glue the catheter inside introduce it's like a bit of a nuisance so in summary very straightforward notice an ascetic no capital equipment
no risk of febrile nerve damage and I commend disadvantages to thank you very much
iii to me iii point eight post six weeks there is 1.5 26 months
0.5 and you'll see here the disc and the iii into the disc I don't see it here because it's somewhere, sorry I have to go back sorry this also room bottom, no not on show previous okay here we go back back back yeah that's a hydrogel/g here.
Have to look closer because I don't see it from the distance here and here. Okay, that's the hydrogel/g and the disc here and here. You can see it actually. The here, it even dislocated a little bit, and here.
That's why you should not put it in your herniated disc. If there's, that's contrary indication,
Second case was a 78-years-old female with instability due to rotoscoliosis, with a dilation of left articular space, and shrinkage of right
articular space. So asymmetric spondyloarthropathy with axial back pain, with failure of medical and physical treatment. And we decide to do a percutaneous facet fixation that stabilized the spine, as an aid to fusion through a bilateral immobilization of the facet joint with the screws. The procedure is very simple.
We start with a trocar needle, then we introduce a Kirschner wire under fluoroscopic guidance. Then we introduce the dilators, and then the rasp to create a space for the screws. Then we introduce the screws with, [COUGH] Sorry
about that. [LAUGH] With a screwdriver, and this is the final result when we repeat the procedure on the other pedicle. And the CT check after procedure demonstrates the correct implant of both screws through the facets,
through both the facets. And after one week, we had complete disappearance of symptoms. On the market we have other two device, Bone-Lok produced by Spine Intervention, and Facet Wedge produced by Alphatec Spine. The device is a little bit different because we put the device into
the articular space. And this is a study demonstrating no biomechanical change of one level fixation compared to surgery.
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