Since the first PV procedure,13 fluoroscopy has been the preferred method of image guidance for performing PV, although CT has infrequently been used as a primary or adjunctive tool.44,45 Because this procedure was initiated and popularized by interventional neuroradiolo-gists, biplane fluoroscopic equipment was commonly available and often used. This equipment allows multiplanar, real-time visualization for cannula introduction and cement injection and permits rapid alternation between imaging planes without complex equipment moves or projection realignment (Figure 14.8). However, this type of radiographic equipment is expensive and is not commonly available in in-terventional suites or operative rooms unless it is used for neurointer-ventional procedures.
It takes longer to acquire two-plane guidance and monitoring information with a single-plane than with a biplane system. However, it is feasible and safe to use a single-plane fluoroscopic system as long as the operating physician recognizes the necessity of orthogonal projection visualization during the PV to ensure safety. With a single-plane system for PV, these C-arm moves will mean a slower procedure than that offered by a biplane system.
Gangi et al.45 introduced the concept of using a combination of CT and fluoroscopy for PV. This method gained a brief period of popularity in the United States with the study published of Barr et al.44 Barr subsequently abandoned CT for routine PV. Although the contrast resolution with CT is superior to that of fluoroscopy, with CT one gives up the ability to monitor needle placement and cement injection in real time. Even so, CT may be acceptable for needle placement, particularly if a small-gauge guide needle is first placed to ensure accurate and safe location before a large-bore bone biopsy system is introduced. However, CT certainly is not optimum for monitoring the injection of cement. For this reason, Gangi et al.45 and Barr et al.44 used fluoroscopy in the CT suite during cement introduction. CT does not afford one the opportunity to watch the cement as it is being injected or to alter the injection volume in real time if a leak occurs. Also, unless a large section is scanned with each observation, if leaks occur outside the scan plane, they may be missed if one is looking only locally in the middle of the injected body. Barr et al.44 used general anesthesia with CT-guided surgery because of the need to minimize patient motion. This
was successful but added a small additional risk to the procedure and considerable complexity and cost. For all these reasons, CT has not found a primary role in image guidance for PV; it is reserved for extremely difficult cases.
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