Interventional-Related Spine Anatomy

This chapter on interventional-related spine anatomy provides a concise overview of normal spinal anatomy, as well as commonly encountered pathologic conditions, with a particular emphasis on the relevant imaging findings. The introduction outlines potential sources of back pain and their presenting symptomatology. The chapter reviews the main imaging modalities used to evaluate the spine and discusses their specific advantages and disadvantages. The anatomy of the muscles of the vertebral column, the vertebral column itself, and common variations), intervertebral ligaments and discs, vertebral joints, meninges and spinal cord, spinal nerves, and vasculature of the spinal column and spinal cord are reviewed. The discussion includes multiple radiographic, computed tomography (CT), magnetic resonance imaging (MRI), and angiographic images, as well as illustrations to supplement the text.

Diseases of the Skeletal System

Musculoskeletal (MSK) interventions are a diverse group of procedures aimed at both therapeutic and diagnostic arenas for patient care and management. As the field evolves, MSK interventions are offering a minimally invasive approach as an alternative for open surgical procedures, such a biopsies of the axial and appendicular skeleton for diagnostic and treatment purposes, treatment of benign and malignant tumors or spinal interventions for pain or oncology therapies. However, the proceduralist must be adept with anatomy, devices and practices of referring specialties. This chapter will delve into the technical aspects of MSK procedures as well as recommendation and pitfalls of various procedures.

Clinical Considerations in Hemodialysis Access Intervention

Interventional radiologists developed and refined the endovascular approaches to maintenance of the permanent arteriovenous vascular accesses that are integral to the provision of hemodialysis for patients with end stage renal disease. As methods of percutaneous arteriovenous fistula creation expand the scope of IR, this chapter reviews the clinical indications and preferences pertinent to dialysis access creation with respect to National Kidney Foundation Recommendations. Accesses remain imperfect, plagued by the development of flow-limiting intimal hyperplastic stenoses, and require monitoring and maintenance to minimize complications, morbidity and mortality. The measures of dialysis access function used in the surveillance of vascular accesses that indicate potential stenosis, and the utility of pre-occlusion recanalization of these stenoses are discussed. Complications specific to dialysis access interventions are also addressed.

Nonvascular Interventions: The Gastrointestinal System

The interventional radiologist has a diverse and expanding role to play in the management and treatment of patients with disorders of the gastrointestinal (GI) system. These patients generally fall into one of two broad categories. The first category includes patients who are unable to tolerate or achieve adequate nutrition by mouth. In these patients, the interventional radiologist may be consulted to obtain percutaneous enteral access so that nutrition or hydration may be administered. The second category includes patients with benign or malignant strictures or obstruction of a hollow viscus, be it the esophagus, stomach, or small or large bowel. In these patients, the goal is to treat the obstruction when possible, or else decompress proximal to the obstruction for palliation of symptoms.

Liver Transplant

While there have been many advances in surgical technique and post-operative care of patients undergoing liver transplant since the first performed in 1963, procedural complexity still require a long recovery. To compound this, relative shortage of donor organs require extreme care in pre-operative selection and post-operative management. While current knowledge and team based care has limited complications, they remain not infrequent. Many of these expected problems are managed in consultation with an interventional radiologist and this chapter summarizes the most common encountered problems.

Vascular Diseases of the Hepaticopancreaticobiliary System

The liver, pancreas, and biliary tree exist within a complex, interconnected relationship among each other and the enteric tract. They play vital roles in endocrine physiology, metabolism, and immunity. These anatomically complex organs can be affected by a variety of vascular conditions, ranging from acute and self-limited to chronic and life-threatening. The clinical workup and management of these conditions are as important to the interventional radiologist as the procedures that they are asked to perform to treat them. Knowledge of the diseases themselves, their natural course, and medical management can help to familiarize proceduralists with the reasons for referral and the complications and comorbidities that one can expect when treating these patients. In this chapter, we present a clinical overview of vascular diseases affecting the hepaticopancreaticobiliary systems.

Cardiopulmonary System: Oncologic

Lung cancer is the leading cause of cancer death in both men and women in the United States, with more than 160,000 Americans dying each year, and 1.6 million die of the disease worldwide. Interventional radiology (IR) involvement in the treatment of oncologic processes in the pulmonary system lags that of other organ systems, such as the hepatobiliary and renal systems. Nonetheless, more and more data is being accrued to support the utilization of minimally invasive techniques to treat both primary and secondary lung cancers. This chapter reviews the manifestation of lung cancer, as well as treatment options for oncologic diseases of the lung.

Arteriography and Endovascular Intervention in the Lungs

Massive hemoptysis, which can be caused by a variety of chronic pulmonary diseases, is well-suited to treatment by arterial-directed transcatheter-based therapies. Results after bronchial artery embolization are excellent. Knowledge of the arterial anatomy and pathophysiology is critical to clinical success. Pulmonary embolism is a common entity responsible for over 100,000 deaths in the U.S alone. Understanding cardiopulmonary hemodynamics is helpful in deciding which patients will benefit most from interventional techniques such as catheter-directed thrombolysis and thrombectomy. The role of selective catheterization of pulmonary arteries for therapeutic purposes in the setting of PE continues to evolve. This chapter describes the fundamental clinical and anatomic issues when confronting patients with acute pulmonary vascular disease.

Upper-Extremity Arteries

This chapter evaluates the spectrum of pathologic diseases that affect the upper-extremity arteries, their clinical manifestations, imaging characteristics, and treatment options. We review the role of surgical and endovascular intervention for the treatment of acute upper limb ischemia (AULI) and chronic upper limb ischemia (CULI), the clinical and imaging findings associated with Raynaud’s phenomenon, hypothenar hammer syndrome, distal hypoperfusion ischemic syndrome (DHIS), thromboangittis obliterans (TOA), thoracic outlet syndrome (TOS), giant cell arteritis, Bechet’s disease, radiation arteritis, and traumatic arterial injury, including compartment syndrome and pseudoanuerysm formation. Finally, the evolution of upper-extremity arterial access and use of transradial access (TRA), including benefits and risks, technique, and complications, are discussed.

Imaging Techniques

Minimally invasive interventional radiographic procedures rely on many of the same imaging techniques as are used in diagnostic studies. This chapter describes the imaging modalities most commonly utilized by the interventional radiologist intraprocedurally. These include fluoroscopy, digital subtraction angiography (DSA), sonographic techniques for percutaneous interventions and intravascular ultrasound, and computed tomography (CT) and cone beam CT (CBCT). Imaging techniques used adjunctively in the procedure planning and follow-up phases are also briefly reviewed, including multidetector CT angiography, magnetic resonance angiography (MRA), and sonographic vascular evaluation. Specific interventions are mentioned throughout as a means of illustrating the clinical utilities of these imaging techniques, although specific procedural considerations are discussed more thoroughly elsewhere.