0:00

So let's evaluate case 3.

0:03

We have a 50 year old woman with history of polysubstance abuse

0:06

while control HIV hepatitis C

0:09

and Asthma now presenting with back pain. So she's

0:12

tachycardict 110 beats per minute, and

0:15

she's febriled about 38.8 degrees C.

0:19

So she has a physical examination that's notable for lumbar spinal

0:22

tenderness.

0:23

Blood cultures is drawn and the patient is starting an IV

0:26

antibiotics. The patient is unable to tolerate an MRI and

0:29

it's instead sent for CT.

0:32

So what do we see in the reading room?

0:42

So let's pull that back up here.

0:45

And see if anything caught your attention.

0:50

So this particular area with this focus of gas

0:53

is the area in question.

0:58

So, let's see what the impression on the

1:01

report read.

1:03

So inflammatory change in the posterior prospinal

1:06

tissues in the midline region at the

1:09

l4l5 level.

1:11

the start to be a hypodense paraspinal collection

1:14

2 by 2.5 centimeters

1:17

extending towards the spinal canal through the neural foramen.

1:21

the differential includes a paraspinal abscess

1:25

And epidural flagmon so is myositis or lumbar

1:28

vertebral osteomyelitis?

1:32

the patient started on empiric broad spectrum antibiotics

1:36

So the neurosurgery service actually denied a need for

1:39

Urgent surgical intervention in this particular setting.

1:42

The budget cultures that were obtained did not grow

1:45

any organism.

1:47

So I Interventional Radiology was then consulted and the

1:50

goal was to actually attempt drainage with possible vegetable

1:53

bone biopsy to rule that osteomyelitis.

1:57

So here we see the advancement of the

2:01

biopsy needle by the Interventional Radiologists

2:04

this extra particular route

2:08

And so as we proceed with an extra particular

2:11

route, there are certain things. We want to keep in mind here we

2:14

have.

2:15

The patient on the table and prone position

2:18

we have that region that

2:21

had the little focus of gas just lateral

2:24

to the vertebral column cited

2:27

by the Interventional Radiologists, but the patient

2:30

unfortunately in this particular setting is not as

2:33

Cooperative as one would hope she was particularly mobile

2:36

during the procedure given her Ivy

2:39

drug use. She was somebody who

2:42

really was not very tolerant of the

2:45

fentanyl that she was being given.

2:49

The needle advances unfortunately during the

2:52

movement of the patient into the intervertebral space

2:56

unintended.

2:59

So what vessel is most at risk as the needle

3:02

tip is diverted into the Innovative space. Is

3:05

it the inferior vena cava?

3:07

the lumbar artery

3:09

the abdominantly order

3:10

or the renal artery

3:13

it's lombarding.

3:15

So the lumbar arteries extend and emanate.

3:18

Almost like little insect legs the laugh

3:21

and the right of the abdominal aorta.

3:24

and as they Branch they supplied the

3:27

posterior abdominal wall and the spinal cord and so

3:30

in that region as you can see in this

3:34

Schematic is a region where we would

3:37

one to be aware of these vessels.

3:42

To ensure that they're not inadvertently traversed.

3:45

So the radiologist attempts to readjust the needle towards the

3:48

probabil collections, but notes pulsatile bleeding.

3:51

I would say that in this particular setting the

3:54

Radiologists in question because of the risks

3:57

of the location actually opted to

4:00

use very specific needle coaxial

4:03

needle

4:05

That had introducer sharp needle, but

4:08

also one that had a blunt stylet.

4:11

In the event that he actually encountered

4:14

leading.

4:16

So the portion of the bloody aspirate that the operator then

4:19

notes is then submitted for microbiology analysis,

4:22

but when after that then aspirated

4:25

and submitted the blunt style it

4:28

was an immediately replaced to Tampa not the bleed.

4:31

So why would you not replace the sharp style

4:34

level the sharp stylet was the one that provoked the

4:37

bleeding to begin with?

4:39

So imagine the blunts dialed it's almost like a little finger. That's

4:42

just on that area that actually was

4:45

injured and the goal is for

4:48

that to act as manual digital pressure

4:51

almost in order to prevent the bleeding

4:54

from continuing.

4:56

Intra procedurally with the introduce in place

4:59

introducing it'll not moved anymore with the

5:02

blunt stylet replaced neuro

5:05

and eventual Radiology was then consulted to see

5:08

if they had anything to offer.

5:10

So now the new interventionalists orders a non-con

5:13

CT in order to exclude the presence

5:16

of a hematoma.

5:19

So the tip of the needle is in this

5:22

particular location.

5:26

So that's where the tip is right in this location.

5:30

And what we see here.

5:33

Is a vessel.

5:35

It's coming right along here.

5:38

Right towards that tip.

5:43

So non-con CT first in order

5:46

to exclude a hematoma and then a CTA.

5:49

And that CTA is what we're looking at now with that

5:52

blood vessel, which here is a

5:55

L4 lumbar artery demonstrating that it corresponds

5:58

and it courses right towards the

6:01

tip of that needle.

6:04

So the conclusion here is the following.

6:08

The needle is actually at the level of the posterior branching

6:11

left lumbar artery.

6:13

Here we see that left lumbar artery

6:16

as it courses. And then what we saw in the

6:19

previous CT was at a course is right

6:22

by the needle tip.

6:23

There wasn't any evidence virtual Soto aneurysm.

6:26

It wasn't every evidence of a hematoma either.

6:29

And so what's probably the case is that the needle

6:32

tip is actually within the lumbar artery. Lumen.

6:35

So what would be the worst thing to do in this situation? That would

6:38

probably be to move the needle we have precisely in

6:41

the vessel, which is why when we remove the stylet this

6:44

pulsatile bleeding from The Hub of the introducer. So

6:47

if we were to go past that now we're through and through

6:50

which would be worse.

6:52

So a decision is made to perform embolization of

6:55

the bleeding lumbar artery.

6:57

When we perform an embolization we can

7:00

use coils we can use particles we

7:03

can use Liquid.

7:06

We can use something permanent or we can do something temporary.

7:10

So because of the thought that we did not want to use anything with

7:13

particles in this particular situation. What's thought

7:16

to be the best is something

7:19

that coaxially can be deployed

7:22

and introduced in a way to include the

7:25

area in question. What do

7:28

the team involve here? Then decide we decided

7:31

that for non-attachable coils could

7:34

be placed. Well sequentially retracting the needle

7:37

and so the operator here makes a decision

7:40

to then use non detachable coils or nesters

7:43

as they're called.

7:45

And then pushed through the Hub of the needle to the

7:48

tip.

7:49

and then deployed into the exact location where the

7:52

tip of the needle is corresponds with the

7:56

lumbar artery in question

7:58

the operator

8:00

as he then retracts the needle he deploys

8:03

another around that area in question slowly and

8:06

ultimately notes that hemostasis was achieved.

8:09

Still dressing is place in the station is

8:12

transferred back to the floor after CT scan

8:15

is performed demonstrating no hematoma

8:18

in question.

8:20

Patient also is monitored in that region in the

8:23

lab.

8:24

And repeat CT performed about 10 minutes

8:27

later on the table to ensure that no delayed hematoma

8:30

resulted. The patient was ultimately discharged several

8:33

days. Later.