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Summary

This on-demand teaching session is perfect for medical professionals. It will provide insight into the diagnosis and management of osteoarthritis from a radiology standpoint, while also exploring potential therapies that target the hypervascular state of the disease. This session will discuss topics such as topical and oral analgesia, joint injections, platelet rich plasma, and genicular artery embolization. Join us to unlock the secrets of MFK Interventional Radiology and equip yourself with up-to-date knowledge for improving patient diagnosis and outcomes.

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Description

The IR Bites 2.0 lecture series provides medical professionals and medical students with a short and succinct overview of important topics in interventional radiology. This lecture series builds on the IR Bites 1.0 series and aims to cover topics in the CIRSE curriculum. This session will be led by Dr Indra Mandal, current ST2 in Oxford and focus on the latest IR based orthopaedic interventions.

Learning outcomes for the session:

  • Understand the role of radiology in the diagnosis and management of osteoarthritis
  • Understand the role of Radiology in diagnosis and management of back pain
  • Learn about emerging techniques in musculoskeletal Interventional Radiology

Learning objectives

Learning Objectives:

  1. Understand the key pathological features associated with Osteoarthritis
  2. Appreciate the importance of a multidisciplinary approach to management of Osteoarthritis
  3. Become familiar with the importance of imaging-guided interventions for Osteoarthritis
  4. Understand the potential role of Genicular Artery Embolization and Nerve Ablation in Osteoarthritis treatment
  5. Recognize the importance of individual patient considerations in the management of Osteoarthritis
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay. Uh uh All right, good evening everyone. I'm Chris and uh speaker tonight is a radiology registrar and one of the co founders of our, our juniors introduced Mumble. So, uh I know a lot of you have been waiting patiently and this talk is going to be filled with absolute gems on MFK Interventional Radiology. So thank you for joining and without further a do our handover to Indra and, and just wanted to check, everyone can see the slides, okay. He may be dropping in an ox. He's having to join from his phone this evening, given the hospital firewall situation. Um So I would just hang fire for handing over and All right. Enjoy you ready. So, uh but can you hear me? Quest were all good? Yeah, good. So hopefully if that's OK. Um Zooming, which is one that will be through on him if you can't him? Okay. So, um good on osteoarthritis because I think that's where uh sk intervention that's done by interventional radiology is going to head in the future. But uh in this talk will cover a few other areas as well. So just an introduction to osteoarthritis. So as we know it's one of the biggest causes of pain and disability in the UK. And, um, almost nine million people are affected by this condition in some form, uh, in any joint. Uh, the knee is the most common joint where osteoarthritis happens, but it happens in many, many other joints. Very common in place for osteoarthritis summer. Okay. That's tough. Okay. I'm help going in. Um, sorry, I'm having some issues with my, um, with viewing my slides, but we'll, we'll continue on. So I think we're on the imaging features of osteoarthritis. So the four common features that we usually talk about the joint space narrowing and that's the earliest feature of osteoarthritis that you see. So on this picture, uh, you can see the space between the tibia and the, um, the femur is less than it should be. So, normally should be wider than that. And that's the earliest sign of osteoarthritis, but it's not very specific because lots of people have a bit of joint space narrowing. So you can't call everyone with just a little bit of joint space narrowing as osteoarthritic, but it is one of the early changes. Um, you also get subchondral pathology. So under the cartilage, you get either cyst formation. Um, so areas of low attenuation or you get subchondral sclerosis, which is, it appears wider than it should be. So, both of those are again signs of osteoarthritis and then you also get osteophytes which are extra bony growths on the side of the bone. So normally the bone should have very nice contours, but you might get extra spikes, bone because of disorganized bone remodeling. And that's another feature of osteoarthritis. So those four other kind of classic X ray features that you might get exams or once you read about in textbooks, um, MRI, they're gonna features are similar. Um, but we don't often do MRI for osteoarthritis. It's only in very, very specific cases. Like, say, for example, someone's presenting with joint pain, you're not really sure what it is. You might do an MRI for another reason that just find osteoarthritis. So, um, but the mainstay of diagnosis is the X ray. So that's typically what we do. Well, no, it's, it's, but you get an extra. So we'll move on to the next slide and, and talk about management. Um, so in terms of management and this is going to get a bit boring during a lecture. But the, the management of osteoarthritis is pretty well. There's not many options to be honest. So to start with, you managed to, uh, wait, they shouldn't manage the weight because that reduces the, you know, dietary factors and other stuff are important as well. Like you got to control your diet, not just because of the weight per se, but there's probably a causal link that we're not 100%. Um, function is really important, right? So, not just pain, but having good function of the media and, and being able to walk and exercises are really, really important for that. So it's, it's important that uh patient's have a video. So it's, um, so physio is really important so they can strengthen the muscles and that again, promote function of the knee joint and then you management manage the pain itself. So, um, just to start where you start with topical NSAID. So, uh the reason why NSAID like one paracetamol is actually we think osteoarthritis is more inflammatory than it once was. So traditionally, it's been taught that it's just simple wear and tear. But, you know, latest research is showing that that's not the case and there is a component of information. Um And so we're finding that the non steroidal anti inflammatories work better than say paracetamol for that reason. So, uh topical NSAID is kind of start with that. Moving on to oral, you know, over the counter analgesia that you get the next step up from that is giving medications into the joint. So colloquially, this is referred to as a joint injection. Um What you do is you can inject a different bunch of medications. For example, you can enjoy steroids or sometimes you can inject a clan aesthetic. But I think steroid the is being used across the arthritis. They give good short term relief, but they're not suitable in the long run because if you keep giving the needed steroids that can impair healing and cause issues. So that's not a long term solution is more of a short term thing to just get temporary control of pain. Um And any chronic pain, say there's a big psychological element to that as well and that's not something you can neglect. So you have to manage the patient expectations and make sure that uh you know, you're doing your best to the communication and, and making sure all of the bio social, uh social factors are accounted for because ultimately, you know, chronic pain is very complex and we still don't know a lot about it. And so it requires a multifaceted approach rather than just throw medications at it. So that's kind of something important to bear in mind, especially for older people. You should think that if you're giving them an inset, um, you need to give or you might need to give gastro protection as well because it increases the risk of bleeding from gastric ulcers. So, um, you know, consider giving PPI as well for these patient's, they're going to be on long term and said's, if the osteoarthritis is really, really bad, you've got end stage osteoarthritis and your joint is really deformed, then you'd be a candidate for joint replacement. Um And so that's kind of the main management options. Uh, next side, Chris. Uh And so I think that really highlights this treatment gap. So a lot of patient's don't, they just don't respond to the traditional, you know, I guess you can say conservative or medical management. Um, yeah, they don't have disease that foreign joint, um, don't have stuck in the middle because they've run of options. You can't give steroids forever because they have risks associated with them. Um, in addition to that, if you think about the waiting times, at least in the UK and the NHS, they're very, very long, like, even to see an orthopedic surgeon that might take a year on top of that work up for, you know, joint replacement therapy. It's a very long time. So, um you know, if the patient's are not responding to traditional medications and waiting for surgery, there's a big gap, there's, you know, there's a big unmet need and um given osteoarthritis is such a common condition, I think it's been a hot topic for potential new therapies to develop. And so, um I'll be of moving on to that. Uh next slide, Chris, as we said before, previously, radiology involvement in the treatment of this disease has been steroid injections or injecting any kind of drug because that's done under ultrasound guidance. Um It's not exclusively done by radiologists, but it's mostly radiologists who are doing this procedure. Um But in terms of meetings, unmet need for patient's who don't have any other options to kind of options have emerged. And I think the most promising one is genicular artery embolization, but also nerve ablation is something that has uh has cropped up. So, next slide. Um Yeah. So as I mentioned that intra articular injections or injections into the joint are kind of an established radiology treatment for osteoarthritis. So what that involves is using the ultrasound probe to scan in over the joint and locate the joint, uh and then just pass the needle close to that and injecting the medication there. A lot of previously, this used to be done blind, but ultrasound has increased the accuracy of uh delivery of medication because often when you, if you go blind, you don't actually know if you're hitting the joint, um sometimes it does work because you know, if you put it near the joint is it's near enough and the drug diffuses, but for the more accurate drug delivery, um it's important that you use ultrasound and uh excuse me, I think now most joint injections are done on the ultrasound. Um So what usually do is you find the super patella recess. So it's a kind of area of joint fluid just above where you'd expect the joint to be and you inject it into that because that is in communication with the joint. Um Sometimes it can be hard to see the joint itself unless there is an infusion because if there's a joint effusion, it's a bit bigger and you can hit the target a bit easier. Um And that's why it's a super Boteler recess that's usually targeted. Um As I mentioned, it gives good or decent short term pain relief, but you can't use it long term because of the risk of damage to the cartilage and impairment, impairment of the healing process. Um, platelet rich plasma is another thing you can inject into the joint. So you basically take the patient's own blood and extract the bit that's rich in platelets. Uh And apparently that's meant to promote healing. I don't know exactly how that works. But that's another and a potential therapy that, that has been trialed in some patient's and osteoarthritis. Um the next slide. So as we mentioned, so osteoarthritis is a lot more inflammatory than we want to thought. Um And, and so there's, there's some early or pre clinical studies that show that osteoarthritis is actually quite a hypervascular state. Um And the disease process comes with neovascularization to new abnormal blood vessels forming. Um And so this is a potential therapy target because if the patient's who have a problem, all have this problematic vessels, you can target those and then leave the main vessels intact and it just allows more precise treatment as a general principle. Um And so this is the kind of preclinical thinking behind genicular artery embolization. Um And so if you take these patient's to angiography, um So what that means is you put a catheter into the vessels and inject inject contrast. Um It's kind of the mainstay of what you do in interventional radiology, you'll see that there is hyperemia or excessive blood flow in those areas. So on this image there, you can see on the left hand image, um the normal vessels are just straight lines, but you can see the smudged appearance on the kind of lateral aspect of the knee that's on neovascularization and that's not normal, um you know, normal joints and do that. So that's kind of the pathology or pathological correlate of osteoarthritis. Um genicular artery embolization start a new procedure. It's already been, it already happens like if someone bleeds a lot after a knee replacement, um they do this procedure to stop the bleeding. So it's not like it's a completely new crazy procedure. We always do it for bleeding, but this is a new indication because we've seen that there are abnormal vessels to target. Um And so what you do is you go into the arteries and you inject particles to block off these vessels but keeping the main vessels intact. And, and that's how you do the procedure. Um And it's, it's still relatively early, but the the evidence is positive for pain control. Um The recent study that has shown that even after two years, a lot of patient's still have good pain control, not everyone but the vast majority of patient do. And so it's a very promising kind of area or potential new therapy. Um So next slide and I thought I'd use this opportunity to talk about what embolization actually is. Um some of you might have seen it in your safe foundation placements or, or heard of it as a, as a medical student. But it seems a bit weird, doesn't it? Like, why, why would you block off the vessel? But that's what embolization is, it's blocking off a vessel for a particular therapeutic reason. Um The most well established indications the embolization is bleeding. So say, for example, the patient's dropping the hemoglobin and on CT you see active bleeding, um that is a target for embolization. So what you can do is block off that bleeding, blood vessel and stop the bleeding um in condition or benign or chronic conditions that are hypervascular. So for example, fibroids, you can block off the blood supply to the fibroids and shrink it and improve symptoms. So it's very well established for fibroid and uh and also now for prostate. So in large prostate shrink very well or prostate artery embolization. Um so those are kind of the main reasons why you would do amble ization that are very well established. Um So then the question is right, you want to block off this vessel, how do you actually do that? And you know, it's there's so many different agents you can use to block of the blood vessel. And I think talking about all of them is way beyond the scope of this lecture. But ultimately, you've got two main things, you've got some bit of temporary. So you put them in they stop the blood flow and then the body resolves them after a certain period of time and then it's gone again. And that's usually used for say, emergency in some emergency cases. You might use that because you don't need permanent occlusion of the vessel. Um There's a lot of the others are permanent to say, for example, you're doing a fibroid embolization, you can't put something that's temporary because you won't have solved the problem. So a fibroid embolization or definitely in a permanent embolic, otherwise the patient's symptoms are just going to come back. So, you know, broadly speaking, they can be split into temporary and permanent blocks. Um and the other one is more to do with the technique. But when you inject some blocking agents stay exactly where you inject where some are more liquid. And when you inject it flows distantly into the small vessels. So those are just different ways in which you can inject am bolic material for for the reason you want to. Um And the overall aim of this, generally speaking is to reduce the profusion pressure. So if someone's bleeding a lot, you reduce the perfusion enough, so that it becomes a trickle and then slow flow blood will clot because the body will, will clot it, that's verticals triad. So that's how the bleeding completely stops. Um Now, obviously, the risk is if you completely close off a vessel, it might, it might cause downstream ischemia. That is a risk of embolization always. And so we kind of use techniques to avoid it. And you know exactly how that happens is again, very, very complicated. But generally speaking, the aim is to occlude it enough for the indication you need, but you don't want to completely close everything off because of the risk of a scheme you and it's just getting that balance. So generally speaking, and that's those are the principles of embolization. Uh next slide. Uh So in terms of how that applies to the genicular artery, so the genicular arteries there's or the six in total, but they, they come off the common femoral artery generally. Um and they're very small arteries. Um But because they come off the common femoral, if you can access the common femoral, you can navigate a wire and a catheter into them in order to do the embolization. Um And how generally we get into the vascular system is through the Seldinger technique. So how that works is initially get a needle and put it into the artery under ultrasound guidance. Uh That's what kind of the imaging comes in. A lot of in the past, people used to do it blind and some people still do just, you know, feel where the femoral artery is and then it it um but complications to reduce if you use ultrasound. And so now the majority of access is uh is image guided once you have a needle into the artery you then put a guidewire through that needle and that maintains your access so that you don't lose it, get rid of the needle cause you don't want something sharp stuck in there for a long time. And then over that wire, you put a sheath which is basically like a cannula. Um But it has a hemostatic valve at the end to prevent backflow from like you prevents blood back flowing, but you can still put stuff in. Um But it's just, it's essentially a fancy Cannula then that's it. You have access into the vessel. So then you can put like various devices or anything in there to get to where you want to go. Uh So when you've secured your access, you then put a wire and the catheter to try and get into the arteries and, and that's pretty much it. I mean, it sounds very simple, doesn't it? But um in principle, it is very simple, you know, it's not rocket sign. Um You obviously have to know your anatomy and know the imaging in order to do that safely. Um But that's kind of the principle of how you do a genicular artery and the equalization that slide. Uh So I thought I'd also talk about nerve blocks because again, there, the genicular nerve ablation or block is also a technique news to treat osteoarthritis pain. So you can block any nerve you want, you know, any nerve, if you can access it, you can block it in order to securities pain. And you know, that's done in a lot of indications, not just knee pain. Historically, what you do is you use your understanding Manatt a me use surface landmarks and then basically is a nerve stimulator to see where the nerve is. Um That seems a bit old school now that we have really good ultrasound that can image nerves. Um but you know, that's historically how it's done and how technology has evolved through time and what the aim is is once you're there, you can either inject a drug. Um And the what you do is you inject either local anesthetic or steroid or something near the nerve, but not directly in it. Because if you think if you inject local anesthetic right into the nerve, it can block action potentials and its neurotoxic. So you want it to be nearby and it kind of just a few that then um alternatively for ablation and we'll move on to the next slide. Um It's the same process of localizing the nerve, but instead of going in with a needle and injecting a drug, what you do is you go in with a radio frequency electrode and effectively burn or a blatant nerve. Um And so genicular nerve block is that there's, there's four nerves for main nerves, supplying the knee. And you basically use ultrasound, use your knowledge of the landmarks to where it is and then you just go and either inject it with a long acting local anesthetic or you can go in with a radio frequency ablation and ablation nerves. So that's kind of an introduction into to nerve blocks and not just radiologist do that. I think anesthetists probably do the most nerve blocks because it's usually done for pain relief and surgery. So that's going to be with a bit more of a shorter acting agent. But they need statistics are kind of masters of nerve blocks. But um for chronic pain, we can, you know, you can also do it. Radiologists can also do that and some certainly do. So that's kind of a summary of osteoarthritis. I'll pause for a second and see if there's any questions. But if not, we can, uh we can move on. Okay. I've not seen any questions on the chat. So I'll just move on to the next one. So Chris, we'll move on to uh inflammatory M S K conditions. So again, some of this is going to be a bit of a repeat, but essentially, uh there's inflammatory MSK A conditions represents a very large group of conditions, all of which involved inflammation of an M S K structure. So we've already talked about joints and, and osteoarthritis is a bit more inflammatory than we want thought. Um But say if it's the capsule, it's called capital itis if it's a bursa. So an extension of the joint fluid near the joint, that's bursitis and if it's tender and it's tendonitis. So any M S K structure can be inflamed. Each of them have their own name, but we kind of group them under influence AM S K conditions because their management is pretty similar. Um The ones we'll talk about us that I'll mention as example, the achilles tendinopathy, um adhesive capsulitis. And I don't think I will talk about condo litis, but I kind of mentioned uh adhesive capsulitis. So we'll move on to that. Uh You might know it as frozen shoulder. But actually what it is is it's inflammation of the joint capsule of the shoulder. It's very brittle meant next like uh what it is is the joint capsule of the shoulder gets inflamed and with that information, eventually a contract and that becomes really painful. And so the shoulder can feel really stiff and uh patient's might not be able to move it, not just in one direction but all directions. And so if someone presents with chronic pain and stiffness and you can't pinpoint that particular movements just globally reduced. You should always think or do they have frozen shoulder or adhesive capsulitis. Um The main risk factor, particularly medical exams, diabetes. So always be aware of that, that middle aged person showed up in diabetes is to these are capital itis until proven otherwise. Um now here, the imaging is really important um because not to make the diagnosis but to rule out other pathologies because shoulder is very, very tricky. So you always get an X ray because you want to make sure that it's not osteoarthritis that's driving this pain. But also you want an ultrasound because ultrasound is very good at, we're pretty good at looking at the rotator cuff and you want to make sure you haven't missed uh you know, like a super spin artist tower or something like that because all of them can present with a bit of shoulder pain, a bit of, you know, movement problems. So, imaging is very, very important cause you want to get the diagnosis right? And the treatment and even physio regimen or different. So, imaging is very, very important in the shoulder or is perhaps it's not quite as important to save the knee osteoarthritis. Um Management, again, the first bit of management is pretty much the same as uh osteoarthritis. So, physio pain medications, occasionally you can do steroids to control pain temporarily, but not for long term. Um But it's the other kind of more advanced options that different are a bit more interesting. So, hydrodilation is when they basically just inject stuff into the joint and widen that joint space. Um I'm not sure on the evidence of that, but it is a kind of new, new treatment, um, nerve blocks we've already talked about. So in this case, it's a super scapula enough that supplies the glenohumeral joint. And so similar to, we talked about genicular block on particular nerve ablation, same principle, usual landmarks, find enough block it. Um So just so you'll probably get really borrowing towards the end of it. So management is pretty similar. Um and arterial embolization. Again, we talked about G E there's people doing this and shoulders as well. And of course, the surgical option is uh arthroscopy where you release the capsule. Uh we'll talk a bit about embolization. So, um as mentioned, anything that vascular and has abnormal vessels are potential targets for embolization. Um So, excuse me, that is a capsulitis like osteoarthritis also shows changes on angiography. Uh So what you can do is you can go in and find these abnormal arteries and just embolize those ones and leave the main ones. And that's really, really important because you want to cut off the blood supply to vital structures and shoulder or down the arms. So that's typically how we go and for the shoulder, how you, how you get it. You don't go through the leg, you go through the wrist. So radial access and accessing the radial artery for a procedure. Um It's being done increasingly for I R procedures. But um it's, it's much easy to access the shoulder because it's just a straight line. Whereas going through the groin has more bend and it's a bit more of a windy course. So you'd rather not take that if you can. Um So Kris next slide, uh one more realized day, I just talked ahead. Um So I thought we talked about radial access and just kind of explain the principle of it. So the first thing you have to do is make sure that they have good collateral circulation. So the owner um the radial and ulnar arteries form an arch in the arm or in hand. Sorry. But what you want to check is that if you were to include the radial artery, which is always a problem when you get putting something in there, will the owner art res apply it canned or is there really a high chance of ischemia? Um And in the past, you might have heard of Alan's test before we do an arterial blood gas. Um That's what I used to do, but we do something different called Barbosa's test where you occlude them any check collateral circulation. But the principle is as, as anything in I R, if you do something and cause a complication, how bad is it? And is it worth the risk because you know, everything is risk benefit. So that's why you're doing it here. And under ultrasound, you also measure how big the radial artery is because you need to make sure that the instruments you put in don't completely occlude the vessels. So you still need to flow around it. Um And different equipment has different size requirements. Again, I'm not going to talk about all of that, but that's kind of the principle getting into the arteries. Exactly. The same as the femoral in the first instance. So selling a technique need or wire, get the sheet. Then the only difference is your radial artery is very small and it can spasm and that's what you ideally don't want. So usually give a bunch of drugs into that to try and prevent spasms, a muscle contraction of the of the arteries. Um So you tend to give a cocktail of three drugs, a calcium channel blocker GTM, which is a basal dilator and Heparin, uh which anticoagulant to try and these blood clots. Um and that kind of, it's called a radial cocktail. Sometimes you just mix it in a syringe and inject it slowly um slowly because otherwise, you know, patient's can experience stinging as you inject it. Um It's the whole reason for that is let's try and prevent vasospasm, which, which is obviously not, not idea. Um It doesn't apply in the case of shoulder, but generally when you go radial, you have to go into the aortic arch. And anytime you pass wires through the aortic arch, there is a small risk of stroke, don't know exactly what it is, but that's always something you can send patient's for when you go radial access for the body. In this case, you're not going far enough, right, stopping at the shoulders. Uh Risk is than that. But as general access for radial artery procedures, that is a thing that you can send patient's for. Um you do the procedure and then when you want to close the radial artery, they use something, order compression band. So they're just, it's just to provide pressure and the release it slowly. Um It just seems you're having to push for so long. Um So that's kind of what you do in order to put pressure on the vessel and stop any bleeding when you take your stuff out. Um So move onto the next one, just achilles tendinopathy, which is another emerging uh target for interventional radiology. So, um again, closing the name the achilles tendon in flames and that presents of pain and stiffness and it's a clinical diagnosis. Patient's will complain of heel pain and they'll have tenderness in that tendon. Um The main thing to exclude is tendon rupture. So especially if a patient has an acute onset of history, say they're on a quinolone antibiotic, which is a classic association for exams. Uh those should prompt thinking of tendon rupture. A nothing it's scanned attendant. Um you scan the tendon and make sure there's no break in it. And that's what you do for uh excluding tendon rupture. Again, you can also get it in. Mhm uh uh um uh uh huh and uh yeah or is not always that great. So um really dependent uh the uh the reason we get an option and just to make haven't been ruptured and uh something that you don't want to mask because the treatments very different in terms of freedom. The achilles tendinopathy again, start exactly, uh, emerge any, you know. Mm. Some treating. Yeah. So, try and rest it if you can. Um, short course of pain relief, physiotherapy and exercise is the key you might, so you can't give it for that long. Um, there's a shock wave therapy that you can do for achilles tendon and that's again a kind of newer treatment. I don't know too much about it, but some of the evidence for it, but that is in some cases around Japan, there's a guy N S K and blood as Asian treatment and it seems to work very well for achilles tendinopathy. Thanks the world to try and you know, improve the management of sk conditions that you know, again, potential treatment terms where radiology has a role to Chris, we move on to that um with back pain. So back pain is really common. I mean, like 80% of adults will experience it at some point in their life. So it's a huge quality of life problem. Um, you know, similar in scale to knee osteoarthritis. Um Now, as you kind of probably aware from either medical school exams or clocking any d patient's who present with acute back pain, you want to rule out emergencies. And the three main things, we worry about our cord equina compression and it's a compression of the roots, the number routes or below uh metastatic cord compression. So from cancer, uh or an abscess, which might uh one of the and if you look at patient's who present with back pain to GPS, they resolve within 4 to 6 weeks and the vast majority of patient. So most patient's will come in, they'll have red flags excluded and they'll just have conservative management 4 to 6 weeks. But persistent back pain is a major cause of disability. So, chronic really is three months and more as a definition. But that's kind of where you call it chronic back pain and very, very tricky to solve. Because again, initial it's pain management, busy therapy. But there's no options and radiology involved in some of the non surgical options for these patient's. Um you probably heard about either based nerve blocks, they're called epidural blocks or facet joint blocks. They injections into the facet joints of the joints between the vertebra. Those are two of the main things where radiology has an input in patients with chronic back pain. Um Next slide, we'll talk about injections into the nerve root. So, epidural injections, the epidural is just the space outside the juror. So the brain and spinal cord have three layers and the dura is the outermost layer between bone and you're a there's a bit of fat and the potential space. So that is the space where you aim to inject with but that anything that you give. Um so these are generally done for sciatica. It's a back pain that's in a down at home with distribution. Um And you've got two options, really, one, you can inject the epidural space close to the midline. So in this picture, it's uh maybe uh so just parallel to the spine is process, you enter the, where you get into the epidural space, uh and you inject your drug there. Uh And the benefit of that is it spreads out across multilevels. So uh someone who's just got describing multilevel, um uh still on side, that would be a great target for it, right? Because you put it in, it might spread over a couple of levels, probably the way to go. Um What you could do instead is you can inject a nerve root, which is a slightly different position. So that's trajectory a on that picture, those patient's um you might give if there's symptoms related to one nerve root and, and the benefit of that is you're giving a whole drug at one route. And so that's just a more concentrated injection that, that might work better. And how it's done is you just use X rays. So you use your knowledge of anatomy and your, your physical landmarks to like plan your needle trajectory. So if you look on that picture there, like on the right, there's all the anatomy over laying on it. Um But if you know your anatomy, you can figure out the needle of trajectory and you know, you can rotate the X ray of different ways to see and mhm talk to mm lots of causes of increased pressure. Um So for example, if you have other carpal tunnel structure, so it's something that occupies space with it. So you've got the less space for the nerve and so that impinges on it. Otherwise systemic inflammatory conditions can all those patients' can get carpal tunnel because it's just, it's inflamed and bigger and, and uh and not that all fully understood, it's probably the right words, but effectively you get symptoms because there is increased pressure on the median nerve. Um But yeah, some of these risk factors have listed as a pregnancy again, is a classic association. Don't exactly know why that is. Um but yeah, the mechanism is unknown again in terms of management. So what you initially do is you put someone in a wrist splint. So if you put someone in a neutral risk position, um that seems to be the lowest amount of pressure in the carpal tunnel and it was fixed in that position for a bit. Again, you can give steroid injections in the past the mainstay of surgery. So it's a big scar on a big operation. But more recently, there's a technique developed that is ultrasound guided release. Um So next slide and it's pretty, it's theoretically very simple. Obviously, there are lots of important structures to get carpal tunnel. So it's, you know, technically a difficult procedure because you have to make sure you're safe. But the principle is very simple, you use ultrasound and get a view of the carpal tunnel, you inject local anesthetic. Um And then you create a little bit of space under the flexor attack retinaculum. Um And then you put a hook device in to basically release it. So it's a hook that you put under, but it's got a bit of a, it's got a hook on the back. So as you drag it through, it makes a kind of a micro incision in the Flexeril tenaculum. Um And so that releases pressure in the in the carpal tunnel and or reduce carpal tunnel syndrome, uh symptoms rather. Uh So that's again a new kind of radiology lead technique where you can do something without invasive surgery. And I think in a lot of cases, radio interview, interventional radiology fills that gap. You know, like patient's who you've got medical mountain here and equal surgical and murder. There's this middle, intentional or minimally invasive, whatever word you want to call it. And a lot of that is driven by radiology. So, um hopefully, that's kind of a common theme here that these patient's have failed medical management can have surgery. Uh They're only option is something minimally invasive through the radiology department. Um So move onto oncology and again, um uh M S K interventions have a big role in, in on colorable education to have them escape problems. The main things you kind of see are a like biopsy. So, uh you know, most biopsies now are done by radiologists um uh gone are the days of surgical biopsies. And the majority of cases, usually we can get to buy some kind of imaging, whether that's ultrasound or ct um preoperative tumor embolizations. Another kind of technique that helps with tumor surgery ablation is, is really game genuine. And I think especially in renal cell carcinoma, not M S K to say it's just as good as a partial nephrectomy. So these are all minimally invasive things and then uh palliative care has an important role as well. Um So next side, we'll talk about bone biopsy. So um all that means is if you've got a solid lesion within the bone, you take a sample of it and that's different to a bone marrow, try fine or aspirin that you do on hematology. Um in that you are, you are targeting a specific lesion rather than just getting into the marrow and taking cells. So, um that's kind of what you mean when you say bone biopsy, it's not always done for cancer. Actually, sometimes if you, if you have an MRI and you're really not sure what you're looking at, you might just biopsy yet. So we've had some cases where there's osteomyelitis and but you're not 100% sure on the MRI could be anything. So sometimes you just have to biopsy and send a lab maybe for a culture to get an answer. So there are conditions where there are situations where it's not necessarily malignancy, but you just need to get a biopsy to figure out what's going on. Um And generally speaking, a CT guided, I mean, CT is a great modality to look inside the bone. Like, you know, you can see the cortex, the medulla and then any lesions in it. So that's predominantly what is, what is that? Ultrasound generally is not good for looking at normal bones. But if you have soft tissue within a normal bone, then you might see a an ultrasound. So say, for example, you have a very superficial revolution, you might just ultrasound that rather than CT because it's right on the chest wall and you can get to it and and sometimes fluoroscopy is used, generally speaking, we use a co actual techniques and what that means, it's a specific way of doing it. You put a holly into the, the lesion and then keep it. So when you put your biopsy device in rather than having to get into the lesion again and again, you've got stable access into the lesion that you can just keep going I/O and grabbing as much tissue isn't a lot of biopsies, at least deepens are done with the collapse your technique because it's going to be really annoying to keep getting back into it. Um So next slide, I thought I'd explain a little bit about biopsies in general. Um So again, as I said, radiology performs the vast majority of biopsies. Um, in terms of devices, there are two main ones you can, you. So there's one called the biopsies trade names, but I'm not really sure that the non trade name is, but the biopsy is a device that you put a needle into the lesion and it fires forwards. Um, you actually get a better sample but it's a bit harder to control. And you know, sometimes especially with the ultrasound, you might not see exactly what's beyond the lesion. So it's a bit riskier and uh it's a bit hard to control, but the samples are better. Um uh whereas with the 10 mode device, what you use your advance a trait and then cut over it. So if you look at the top left image there, picture is what you do. You park the end of the the device just in front of the lesion, even advance a trade. So you know exactly where the end of that tray is and then a bit before the tray is the tissue that you grab. So you're a bit more secure and exactly where you're taking the the the the tissue from. But at the cost of a lower quality sample and so different radiologists have different views but what different preferences and what they take. But mhm uh two devices, these biopsies um of course bone, you can't just penetrate with that. You need to drill. Um So that's there's a specific device for bone biopsies, book tissue. Um So next time we'll talk about preop tumor embolization and that's a um important role for interventional radiology. So, so keep mentioning and probably getting bored of this hypervascular things are great targets for embolization and lots of cancers are hypervascular. I mean, as they grow, they're po angiogenesis and new blood vessels. Um you know, not all tumor's hypervascular, but some definitely are chopping them out. We'll call a lot of bleeding. Um Sarcoma is in particular, are actually quite vascular and the difficult operations. So we've recently done a couple of cases where we did a pre op embolization for a sarcoma and those normally have liters and liters of blood loss. But because of an amble ization that basically didn't bleed. So, and it really makes the surgery a lot less, you know, the morbidity from surgery is a lot, lot less, probably mortality as well. So, there's one series that's published in MSK 80 units at 70% bloodless surgery, which is, you know, he's a big operations, which is quite, quite importantly and it's one of those procedures you can do that uh make a difference to, to outcome anyway. So, um there's going to be an increasing role for pre opportunity, globalization as, um you know, as, as we go forward and that's not so pain control in phone, that's another area where uh interventional radiology helps in MSK A conditions. Um So, bone mass often cause a lot of pain. You know, the cortex is very, very sensitive. And so uh what you can do is you can traditionally, you can do radiotherapy. But another option inflation. So what you do is you go in and destroy the tumor cells and somehow that improves pain. And I'm sure there's a complicated reason why that is. Um but also if you've got metastasize in the vertebra, not only can they cause pain, but they can cause vertebral like collapse and compression fractures. Excuse me. So what you can interview the patient's because you can go into the biotic Orender like I yeah the mhm But we're plasty. Uh And again, that improves pain control in the acute setting. So it's not going to the next slide and talk about the basics of ablation. Uh So ablation effectively is destroying the tissue by depositing some kind of energy and a co cover the whole Asian. And we'll also have a safe margin for the small micro disease that might be around. Um they're different types available. So the original one is radio frequency ablation, which is a heat space techniques. You literally there's no no other signs that you just heat up and burn the tuna. Um There's a slightly improved heating thing called microwave and it gets rid of some of the technical issues RFA. But it's not as faster. Uh Are there I think is uh uh huh great to do it. You can also freeze it. So there's something called cryo ablation and I think that has the best outcome of renal cell cancer. So what you do is you um the newest technique is Ira or ear about sport electro operation. And that in that you basically putting the current and that breaks pause in the cell membrane and induces apoptosis. You're basically electrocuting themselves. So they're all different methods of depositing some kind of energy within the cells within the tumor to, to kill it off basically. Um So I know, so I rushed a little bit because we had to start it. And I'm so sorry for all the technical issues. I think it's all just uh and hospital which I didn't expect. But um next time the MRI is, I think we've covered a few, given an introduction to a few M S K interventions and in a wide range of conditions and they employ kind of the whole gamut of interventional techniques. We talked about biopsies and ultrasound, guided, targeting ablation and embolization. And you know, these are core techniques to interventional radiology and they're all used within the M S case. This um you know, it's great to see that actually have wide range of pathology or wide range of uses. Um Next time I thought I just include this as a final slide that so most M S K intervention in the UK, at least it's done by msk a radiologist. So they do the vast majority of joint injections and bone biopsies. Although some interventional radiologists do them, the ones that import blood vessels. So, embolization, vascular stuff that's usually done by interventional radiology because they have the most experience in basketball for access. So, you know, like almost a lot of procedures that are done by high are like traditional and, or if you want to call it that are vascular based. And so, you know, they're the best of accessing vestibules to do and this cable. So um that's a lot of the embolization and stuff is being driven by, you know, if you want to call them vascular interventional radiologists. Um then the summary of it is there's um you know, there is no clear cut boundaries and say, for example, you, you like doing I are, but I also want to do some M S K, you can, you can do that. And um you know, the career paths is a radiologist to quite varied economics, make it what you like. So um that's just something to bear in mind as well. And um you know, the role of em embolization as well and particularly will increase, you know, G A is there's going to be, there's a lot of, you know, fast moving trials that are underway. Um And so hopefully that adds to the body of evidence for that. But I think that's the kind of next frontier and M S K intervention. So um that's it from me, I think. Thanks all for listening and thanks for bearing with technical issues and just stay on the line for any questions that you guys might have it. Uh I can't see any questions on the chat. Um Chris, I don't know if you have any, any questions you want to ask or, or anything. Uh I got silence as uh no, no questions. Okay. I'll ask to put on just in case because I know listening to technical issues. Um Chris, but thanks to the uh to all of you who, who came hope you learned something a bit about M S K intervention, especially the kind of stuff you might have heard about like the embolization stuff. Um You know, if you want to find out more about any of this stuff, you know, when, when you're on your either students elective modules or on your taste. Two weeks, you should visit your M S K and your interventional radiology departments because um they're probably doing a lot of or most of this stuff. So if you want to get involved, definitely at uh some of the procedure lists, if that's, that's something interested in. Um But yeah, pencil.