To prospectively evaluate the feasibility, safety, and targeting accuracy of robotic-assisted CT-guided percutaneous bone procedures. This prospective multicenter pilot study included adult patients undergoing CT-guided percutaneous bone consolidation or tumor ablation between September 2024 and January 2025 at three academic institutions. All procedures were planned and performed using the Epione® robotic platform. Targets included the thoracic and lumbar spine and the pelvis. The primary endpoint was feasibility of robotic-assisted needle insertion, defined as successful needle placement without conversion to manual technique. Secondary endpoints included safety, targeting accuracy, procedural time, and radiation dose. Targeting accuracy was measured as lateral tip deviation and angular deviation between planned and final needle positions. Thirty-four patients underwent 90 needle insertions, including 66 in the spine (73.3

PURPOSE:To report initial experience and learning curve with robotic-assisted percutaneous ablations of abdominal lesions. MATERIALS AND METHODS:Fifty-four consecutive patients undergoing robotic-assisted ablation were retrospectively analyzed in this single-center observational study. Feasibility, that is, successful robotic applicator insertion with no conversion to freehand technique or major adjustment, safety, accuracy, and procedure timings were assessed. Exploratory cumulative sum analyses were performed to assess the robotic device learning curve. RESULTS:Fifty-seven lesions in 54 patients (mean age, 66.1 years [SD ± 12.6]; 64.8% [35 of 54] men); 47 (87.0%) liver, 5 (9.3%) kidney, and 2 (3.7%) adrenal lesions were treated with robotic-assisted ablation. Forty-three lesions (75.4%) were treated with microwave ablation, 10 (17.5%) with cryoablation, and 4 (7.0%) with irreversible electroporation. A total of 94 applicators were inserted with robotic assistance (40.7%, multiapplicator procedures), including 78.7% off axial-plane trajectories. Patients were divided into 2 similar-sized learning curve cohorts (initial, 21 cases and 29 applicators; middle, 18 cases and 30 applicators) and 1 later proficiency cohort (15 cases and 35 applicators) after 6-month interval without device access. Feasibility was 93.6% (88 of 94 applicators), with all nonfeasibility in the initial cohort (P ≤ .001). Five complications occurred (4 minor and 1 major [renal failure]), only 1 (self-limited pneumothorax) related to robotic guidance. Median lateral deviation was 4.8 mm (range, 0-19.7 mm). Most placements (62.8%) required no or depth-only manual adjustment. Mean device use duration was 33 minutes (SD ± 18). Performance plateaued after around 20 cases. CONCLUSIONS:After an initial learning curve, proficiency in robotic-assisted ablation was retained after a 6-month interval, resulting in consistent procedure times and maintained accuracy.

To develop expert consensus recommendations for patient selection and procedural techniques in cryoneurolysis for chronic pain management using a Delphi process. A panel of 22 international interventionists participated in a two-round Delphi process. Participants rated 42 statements on a 10-point Likert scale (1 = strongly disagree, 10 = strongly agree). Consensus was predefined as ≥ 75

IntroductionCementation (sacroplasty) with or without ablation has been shown to improve pain and function for patients with sacral metastatic disease. Percutaneous screw fixation with sacroplasty (PSFS) may provide superior outcomes in select patients.MethodsThirty patients with sacral metastases who underwent sacroplasty with or without ablation and screw fixation at a single institution were retrospectively reviewed. Patients were compared based on treatment (PSFS or sacroplasty alone) and fracture status (pathological or impending) with an ANCOVA. Traumatic fractures were excluded. Patients were followed for 4.4 months on average (range, 2 weeks to 36.5 months). Functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score. The rate of secondary procedures as well as changes in narcotic usage were noted.ResultsPatients with pathological fractures who underwent PSFS demonstrated increased postoperative MSTS scores compared to those who underwent sacroplasty (51% ± 19 versus 25% ± 13, p = 0.005). Patients with impending pathological fractures who underwent PSFS did not demonstrate statistically significant increased postoperative MSTS scores compared to those who underwent sacroplasty alone (38% ± 17 versus 32% ± 12, p = 0.72).DiscussionPSFS may provide additional benefit for patients with pathological fractures, while sacroplasty alone may be sufficient for those with impending pathologic fractures secondary to sacral metastatic disease. This study was limited by its retrospective design and sample size; however, the results may aid in treatment indications for sacral metastases and guide further research Level of Evidence Level III, Therapeutic Study.

Pelvic bone metastases frequently result in severe pain and disability. Open surgical reconstruction is associated with a high complication and mortality rate. Percutaneous screw fixation is a minimally invasive treatment that is safe and effective for the management of periacetabular metastases. This article details our technique for pelvic screw fixation, including (1) perioperative care, (2) navigation and needle guidance, (3) access, (4) biopsy and ablation, (5) screw placement, and (6) cement augmentation.

AbstractPatients with advanced cholangiocarcinoma have poor prognosis and often experience severe tumor-related symptoms. Malignant biliary obstruction and cancer pain are common complications associated with advanced cholangiocarcinoma. We review percutaneous palliative interventions that can improve quality of life for these patients.

Digital flat-panel detector cone-beam CT (CBCT), introduced in the early 2000s, was historically used in interventional radiology primarily for liver-directed therapies. However, contemporary advanced imaging applications, including enhanced needle guidance and augmented fluoroscopy overlay, have evolved substantially over the prior decade and now work synergistically with CBCT guidance to overcome limitations encountered with other imaging modalities. CBCT with advanced imaging applications has become increasingly used to facilitate a broad range of minimally invasive procedures, particularly relating to pain and musculoskeletal interventions. Potential advantages of CBCT with advanced imaging applications include greater accuracy for complex needle paths, improved targeting in the presence of metal artifact, enhanced visualization during injection of contrast medium or cement, increased ease when space in the gantry is limited, and reduced radiation doses versus conventional CT guidance. Nonetheless, CBCT guidance remains underutilized, partly relating to lack of familiarity with the technique. This article describes the practical implementation of CBCT with enhanced needle guidance and augmented fluoroscopy overlay and depicts the technique's application for an array of interventional radiology procedures, including epidural steroid injections, celiac plexus block and neurolysis, pudendal block, spine ablation, percutaneous osseous ablation fixation and osteoplasty, biliary recanalization, and transcaval type II endoleak repair.

The healthcare sector generates approximately 10% of the total carbon emissions in the United States. Radiology is thought to be a top contributor to the healthcare carbon footprint due to high energy-consuming devices and waste from interventional procedures. In this article, we provide a background on Radiology's environmental impact, describe why hospitals should add sustainability as a quality measure, and give a framework for radiologists to reduce the carbon footprint through quality improvement and collaboration.

Metastatic disease to the bone and soft tissue creates significant morbidity because of pain resulting in decreased functional status. Palliative chemotherapy and radiation therapy were historically the mainstays of pain reduction. Minimally invasive technologies such as image-guided ablation and cementoplasty have become common in interventional radiology. Advances in image guidance and ablation technologies have improved the multidisciplinary approach in the management of bone and soft-tissue disease. The minimally invasive nature of the interventions allows prompt initiation or continuation of chemotherapy and radiation therapy. These safe and efficacious procedures have improved patient quality of life by decreasing pain and improving function.

Substantial advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions offer a robust armamentarium for interventional radiologists for management of cancer. The authors outline the most recent advances in such interventions and the role of interventional radiologists in managing cancer in modern-era practice. Percutaneous minimally invasive musculoskeletal interventions including thermal ablation, cementation with or without osseous reinforcement by implants, osteosynthesis, neurolysis, and embolization, as well as palliative injections, have been successfully used by interventional radiologists to achieve durable, timely, safe, effective palliation in a multidisciplinary setting and have been progressively incorporated into the management paradigm for patients with cancer with musculoskeletal involvement. Familiarity with the described interventions and implementation of procedural safety measures, combined with integration of these procedures into clinical practice with the support of the National Comprehensive Cancer Network and the American College of Radiology, as well as continued technologic advances in procedural equipment design, will further enhance the role of interventional radiologists in cancer management. ©RSNA, 2022.

The purpose of this study was to evaluate the effect of bone radiofrequency (RF) ablation in the spine with and without controlled saline infusion. RF ablation with and without controlled saline infusion was performed in the vertebral bodies of 2 swine with real-time temperature and impedance recordings. Histology and magnetic resonance (MR) imaging results were reviewed to evaluate the ablation zone size, breach of spinal canal, and damage to the spinal cord and nerves. There was no difference in maximum and mean temperatures between controlled saline and noninfusion groups. The impedance and power output were not significantly different between the groups. MR imaging and histopathology demonstrated ablation zones confined within the vertebral bodies. Ablation zone size correlated on MR imaging and histopathology by groups. No ablation effect, breach of posterior cortex, spinal cord injury, or nerve or ganglion injury was observed at any level using MR imaging or histology. Controlled saline infusion does not appear to impact bone RF ablation and, specifically, does not increase the ablation zone size.

Oncology patients, particularly those with breast, colorectal, prostate, renal and pancreatic cancers, are living longer due to advances in detection, and treatment. Unfortunately, this has come with a commensurate increase in the prevalence of osseous metastases and skeletal related events approaching 100,000 new patients each year. Patients are now experiencing serious morbidity and mortality due to pathologic fractures, altered structural mechanics, and cancer related bone pain. This patient population poses challenges for conventional open surgical and/or medical management often due to disease extent, location, and, in general, poor surgical candidacy. Percutaneous techniques may also be challenging under image guidance due to limited ability to use traditional orthopedic corridors, loss of cortical landmarks with destructive lesions, and need for live image guidance. Modern angiography suites with cone beam computed tomography (CBCT) and advanced imaging applications including needle guidance, 3D fusion, tumor segmentation, and angio-CT have facilitated the development of novel minimally invasive techniques for pain palliation and stabilization. The interventional radiologist is uniquely positioned to harness these advanced imaging applications and offer effective, safe, minimally invasive treatment options to patients with neoplastic disease within the axial, and appendicular skeletons. The focus of this article is to address the technical aspects of patient preparation, positioning, advanced imaging system capabilities, guidance strategies, and pitfalls during osteoplasty and fixation procedures. (C) 2022 The Author(s). Published by Elsevier Inc.

Osseous breast cancer metastases significantly contribute to patient pain and disability, especially in cases of pathologic fractures. The purpose of this study is to evaluate the use of ablation with or without osteoplasty for pain palliation.

Vertebral compression fractures are a global public health issue with a quantifiable negative impact on patient morbidity and mortality. The contemporary approach to the treatment of osteoporotic fragility fractures has moved beyond first-line nonsurgical management. An improved understanding of biomechanical forces, consequential morbidity and mortality, and the drive to reduce opioid use has resulted in multidisciplinary treatment algorithms and significant advances in augmentation techniques. This review will inform musculoskeletal radiologists, interventionalists, and minimally invasive spine surgeons on the proper work-up of patients, imaging features differentiating benign and malignant pathologic fractures, high-risk fracture morphologies, and new mechanical augmentation device options, and it describes the appropriate selection of devices, complications, outcomes, and future trends.

Phosphaturic mesenchymal tumors (PMTs) can present with vague symptoms of diffuse bone pain with pathologic fractures that often lead to a delayed diagnosis. We present a 60-year-old patient with a PMT that was persistently hypophosphatemic after resection, who was then successfully treated with cryoablation of the tumor. Tumor-induced osteomalacia (TIO) is a rare cause of hypophosphatemia characterized by vague symptoms of gradual muscle weakness and diffuse bone pain with pathologic fractures that often lead to a delayed diagnosis. This condition is usually caused by benign phosphaturic mesenchymal tumors (PMTs). Here, we present a case of persistent PMT after surgical resection treated with image-guided ablation. We present the patient’s clinical examinations and laboratory findings (phosphorus, 1,25 (OH)2d, FGF-23, Intact PTH). Representative histologic images of a PMT are also presented. A 61-year-old male was evaluated for persistent hypophosphatemia and presumed osteomalacia. Six years earlier, he underwent surgical excision of a left ischial mass after presenting with TIO. The pathology was consistent with a PMT; however, hypophosphatemia persisted suggesting incomplete resection. He was treated with calcitriol and phosphate salts. A PET Ga68 dotatate scan of the patient revealed an avid left ischial mixed lytic and sclerotic lesions with marked amount of radiotracer uptake, suggesting persistent tumor. The patient was resistant to re-excision of the tumor due to the extended recovery period from his prior surgery and was treated instead with cryoablation of the tumor. His biochemical findings of hypophosphatemia and elevated FGF23 resolved after the ablation and have remained normal for 5 months after surgery. In patients with TIO, wide surgical excision is the treatment of choice. When this is not possible, image-guided ablation is an alternative therapeutic option.

BACKGROUND:Metastatic bone disease in the periacetabular region represents a potentially devastating problem for patients. Surgical treatment can offer pain relief and restore function. We describe a series of patients treated with minimally invasive osteoplasty and screw fixation with or without ablation. METHODS:Thirty-eight patients with 16 different metastatic tumor subtypes were managed with osteoplasty and screw fixation with or without ablation at a single institution. A retrospective review was performed to determine functional outcomes with use of the 1993 Musculoskeletal Tumor Society (MSTS) score as well as changes in narcotic usage. RESULTS:MSTS scores improved for all patients following surgery. Narcotic usage decreased in >80% of patients. Approximately half of the operations were outpatient procedures. Complications were minimal, there were no delays in chemotherapy or radiation due to surgical wound concerns, and there were no surgery-related deaths. The mean duration of follow-up was 9 months, with a 39% survival rate at the time of writing. Six of the 12 patients who survived for >1 year required additional procedures at a mean of 12 months (range, 4 to 23 months). CONCLUSIONS:Treatment of periacetabular metastatic disease with minimally invasive stabilization with or without ablation provides pain relief and functional improvement with lower complication rates than previously reported open reconstruction techniques. The minimally invasive approach allows for rapid initiation of chemotherapy and radiation. Patients with particularly aggressive cancers that are poorly responsive to systemic therapies and radiation may have progression of disease and may require additional procedures. Conversion to total hip arthroplasty was uncomplicated, and the cement and screw constructs were retained, providing a stable base for the arthroplasty reconstruction. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.