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Patient positioning

Patient position and entry point

  • For thoracic and lumbar procedures, the patient is in prone position. The optimal approach is transpedicular or posterolateral in lumbar level. Transpedicular or intercostovertebral routes are the optimal approaches in the thoracic level. The pedicles of the upper thoracic spine can accommodate 15-gauge needles.
  • For cervical procedures, anterolateral approach is recommended. Transoral approach can be used for C2.
  • To facilitate the procedure, the approach should be visualized on a preprocedural CT scan (or axial MR imaging). The entry point and its distance from the midline (spinous process) can be measured on the preprocedural CT scan or MR films.
  • The pathway must avoid vascular, visceral and neural structures. The use of CT for the planning of the pathway and positioning of the needle allows a medial positioning of the needle tip in the anterior third of the vertebral body in thoracic and lumbar procedures. Thus a controlateral access is seldom necessary to obtain a good vertebral filling.
  • Cortical perforation can require the aid of a surgical hammer.
  • For thoracic and lumbar procedures, the optimal needle position is the anterior third of the vertebral body or the anterior portion of the tumor.

 

Fig. 1: Lumbar procedure. Transpedicular approach.

 

Fig. 2: Transpedicular procedure. Optimal needle position in lateral projection

 

Fig. 3: Thoracic approach. Intercostovertebral route.

 

Fig. 4:  Intercostovertebral route.

 

Fig. 5:  Changes in angle of approach. The angle varies from 0° in a lumbar L3 transpedicular route to 20 and 30 ° in a thoracic intercostovertebral route. The needle should be always in the axis of the vertebral body.