Pelvic Biopsy and Drainage Procedures Quiz

Joint Injection and Vertebroplasty Procedures

• Joint injections are used to treat pain in joints.
• Vertebroplasty is a nonsurgical procedure to stabilize collapsed vertebrae.
• Interventional radiologists perform both procedures using imaging guidance.

Aspiration/Drainage

• Diagnostic aspiration is used when the nature of a collection is unclear, or when a small collection is difficult to drain.
• It is used to assess collection content (thin vs. thick fluid, pus) and provides bacterial sensitivity.
• A 20G needle is often used, but if aspiration fails, a further puncture may be needed.
• Drainage aims to leverage gravity to drain collections. The drain site should be in a dependent position, preferably below the collection level.
• Ultrasound is helpful to assess viscosity, loculi, and septa of the collection.
• The type and number of drains needed depend on the properties (anechoic, few scattered echoes, extensive/swirling echoes, diffuse echoes with gas)

Drainage Catheter Selection

• 6-8Fr catheter for clear fluid
• 8-10Fr catheter for thin pus
• 10-12Fr catheter for thick pus
• 12-22Fr catheter for collections with debris

Procedure (Aspiration/Drainage)

• The chosen catheter's technique is followed.
• Prepare and anesthetize skin and puncture site.
• Create a sufficient skin incision for catheter insertion, using imaging guidance.
• A guidewire is placed into collection.
• The tract is dilated (1-2Fr larger than drainage catheter).
• A guidewire is securely fixed to avoid kinking.
• Attach the drainage catheter stiffener to the guidewire.
• Securely fix the catheter.
• Attach the catheter to the patient using sutures, adhesive systems, or waterproof tape.
• Placement should be practical and comfortable.

Specific Site Considerations (e.g., Subphrenic Abscess)

• Subphrenic collections are often postoperative.
• These collections are in inconvenient locations (below pleural reflection)
• Combine ultrasound and fluoroscopy for approach planning.
• Intercostal approach is sometimes an option to avoid the pleura.
• Potential complications (e.g., empyema) should be discussed during consent.

Upper Abdominal Solid Organ Abscesses

• Liver, renal, and splenic abscesses can be drained percutaneously.
• Success rates typically around 90%.
• Ultrasound and sometimes CT guidance is common.
• Drainage of complications like peripancreatic abscesses, pseudocysts, and phlegmons is frequent.
• Vascular organs (spleen) require smaller catheters.

Pericolic Abscess

• These (often secondary) result from diverticular, periappendiceal, or postoperative collections.
• CT guidance is essential.
• Care to avoid puncturing adjacent loops.
• Further follow-up imaging is usually with CT.

Pelvic Collections

• Difficulty in identifying a route that doesn't impact bowel or bladder.
• Collections often reside in the prerectal space (gravity).
• Transrectal, transvaginal, and transgluteal approaches are options, with transgluteal being most frequent.

Transvaginal Approach

• Lithotomy position for the patient.
• Sedation is often recommended.
• Vaginal wall can be difficult to traverse.
• Vagina and perineum are cleaned with povidone iodine solution.
• Catheters up to 12Fr can be used, requiring serial fascial dilators over a stiff guidewire.

Pancreas Procedures

• Peripancreatic abscesses, pseudocysts, and phlegmons are common.
• Collections (lesser sac) can usually be approached from the anterior through the transverse mesocolon.
• Left paracolic gutter abscesses and need CT guidance.
• Frequent CT scans may be needed (e.g., follow-up).
• Large pseudocysts can be treated by cyst gastrostomy.

Intercostal Chest Drains

• Used to remove fluid or air from the pleural space.
• Common indications include pneumothorax (simple or tension), pneumothorax in patients with chronic lung disease, pleural effusion, or hemothorax.

Optimum Drain Position

• Position of the drain depends on why it was inserted.
• Pneumothorax: Towards lung apex.
• Pleural fluid drainage: Towards cardiophrenic border.

Bilateral Chest Drains

• Bilateral chest drains are used for multiple pneumothoracies.
• Surgical emphysema may be present.
• The left drain may require withdrawal.
• Pneumothorax is often not visible on chest x-ray.

Problems with Chest Drains

• Pain
• Damage to neurovascular bundles
• Trauma to liver, spleen, lungs
• Need proper drainage port placement.
• Surgical emphysema and drain failure can be a complication.

Complications (general)

• Acute sepsis requires broad-spectrum antibiotics.
• Prompt resuscitation is essential.
• Liaison with the clinical team is important.
• Monitor pulse and blood pressure during procedure.
• CT scans are helpful for planning further therapy such as arterial embolization.

Vertebroplasty

• Purpose is to stabilize fractured vertebrae, improving pain and preventing collapse.
• Treatment for vertebral compression fractures that don't respond to simpler treatments.
• Interventional radiologists typically perform the procedure on an outpatient basis.

Vertebroplasty - Indications

• Painful osteoporotic fractures within the last year.
• Refractoriness to traditional pain management.
• No long-term pain relief from analgesic medications.
• Significant pain interfering with daily activities.
• Pain related to benign or malignant tumor.
• Patient needs the procedure, given many compression fractures.

Vertebroplasty - Procedure

• X-ray equipment, a hollow needle (trocar), orthopedic cement, barium powder, and a solvent are used.
• The specific technique is given, using imaging guidance.
• Inject cement into weakened vertebrae, strengthening them and lessening risk of fracture.
• The cement hardens quickly (typically within 20 minutes).
• Post-procedure pressure and bandage and possible CT scan to check distribution are needed.

Vertebroplasty - Setup and Performance

• The skin near fracture site is prepped and draped.
• Local anesthetic is injected nearby the fracture site.
• Using x-ray guidance, a trocar is passed through the spinal muscles to precisely position the trocar within the fractured vertebra.
• Cement is injected within the fractured vertebra.
• Pressure is applied to control any bleeding.
• An intravenous IV is used for sedative medication.

Vertebroplasty - Benefits

• Increases functional abilities
• Returns to previous activity levels without therapies
• Prevents further vertebral collapse
• Usually provides immediate and significant pain relief.
• Many patients become symptom free

Vertebroplasty - Limitations

• Not for herniated discs or arthritic pain.
• Limited use in younger, otherwise healthy individuals.
• Not for correcting pre-existing spine curvature.

Vertebroplasty - Risk

• Possible complications: Infection (rare).
• Orthopedic cement leakage.
• Pain, neurological symptoms.
• Paralysis (rare).
• Allergic reactions to contrast material if used in procedure.

Radiology for Vertebral Augmentation Procedure

• Plain films
• MRI(Low Signal T1, High signal T2): Indicator for age is the history.

Troubleshooting - Transpedicular Approach

• Trajectory (Too Steep): Final placement will be anterior and on near side.

Needle Positioning and Placement

• Accurate needle placement is essential for successful cement injection and reduces complications.
• Use high-quality fluoroscopy imaging.
• Safest approach is transpedicular (often bilateral).

Other Notes

• Appropriate patient positioning is critical.
• The location of the procedure, and appropriate time are also crucial for effectiveness.