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Technique

Thoracic procedure
  • The patient is positioned prone. Some patients cannot remain in a prone position and are placed three-quarter prone; the flexibility of the C-arm system allows the operator to adjust for these differences.
  • The optimal approaches are transpedicular or intercostovertebral. The pedicles of the upper thoracic spine can accommodate 15-gauge needles. For transpedicular technique see lumbar level.
  • Exclusive fluoroscopy guidance requires two fluoroscopic views to be able to appreciate the exact needle position. Biplane fluoroscopic equipment facilitates the rapid acquisition of guidance information in two planes. It takes longer with a single-plane than with a biplane system, but it is feasible to use a single-plane fluoroscopic system.
  • The intercostovertebral approach: The thoracic spine is reached via an oblique, posterolateral, intercostal approach at an angle 35° from the patient's sagittal plane. Preoperative CT scan determines the entry point (Fig.1). For an optimal approach, the entry point and its distance from the midline (spinous process) can be measured on the axial CT scan or MR film of the patient. 

Fig. 1: Preoperative CT-scan determines the entry point.

  • The entry point and angulation must be chosen to allow the placement of the needle tip in the anterior third of the vertebral body by using intercostovertebral approach. The pathway must avoid vascular, visceral and neural structures.
  • The puncture point is located at the level of the pathologic vertebral body, 4.5-5 cm from the midline (preoperative CT scan measurement). The appropriate oblique projection requires a 30-35° angulation of the anteroposterior fluoroscopy tube. 

Fig. 2: Intercostovertebral technique (Laredo Technique). Posterolateral, intercostal approach at an angle 35° from the patient's sagittal plane.

Fig. 3: Diagram of anatomical relations in 35° oblique procubitus position (oblique projection 35°). 1 Transverse process. 2 Costovertebral joint. 3 Disk. 4 Controlateral lamina. 5 Vertebral body. 6 External edge of the articular process. 7 Line of pleural reflection. 8 Rib head.

 

Fig. 4: Puncture showed in red represents the cementoplasty needle under oblique fluoroscopy control. Posterolateral, intercostal approach at an angle 35° from the patient's sagittal plane.

  •  22-gauge spinal needle is used for local anesthesia and is advanced to the costovertebral joint under fluoroscopic control. A 10-gauge vertebroplasty needle is placed parallel to the 22-gauge needle using the same pathway. The vertebroplasty needle is advanced under fluoroscopic control (oblique projection) in the direction of X-ray beam. On oblique projection, the head of the adjacent rib defines the direction of puncture. Once the needle is in contact with the vertebral body, the lateral projection is used for insertion of the needle in the anterior one third of the vertebrae. Use the AP projection to ensure that the needle tip approaches or extends beyond the midline (see movie, case).