Minimally Invasive Procedures

Kenneth Mandato, M.D., Interventional Radiologist

Lake Medical Imaging provides minimally invasive procedures that often replace traditional surgery.

Venous Ablation:  Varicose Veins

Venous ablation is performed in our office using imaging guidance. After applying local anesthetic to the vein, one of our interventional radiologists inserts a thin catheter, about the diameter of a strand of spaghetti, into the vein and guides it up the greater saphenous vein in the thigh. Then laser energy is applied to the inside of the vein. This heats the vein and seals it. By closing the greater saphenous vein, the twisted and varicosed branch veins, which are close to the skin, shrink and leg appearance improves. Once the diseased vein is closed, other healthy veins take over to carry blood from the leg, thereby re-establishing normal flow.

Benefits of Venous Ablation Treatment

You may return to normal activity the next day with little or no pain (there may be minor soreness or bruising, which can be treated with over-the-counter pain relievers). Because the procedure does not require a surgical incision – simply a nick in the skin about the size of a pencil tip – there are no scars or stitches. Traditionally, surgical ligation or vein stripping was the treatment for varicose veins, but these procedures can be quite painful and often have a long recovery time. The success rate for venous ablation is substantially higher than that for surgery (meaning the recurrence rate is low); in fact, the success rate for venous ablation ranges from 93% to 95%.

Sclerotherapy:  Spider Veins

Sclerotherapy is the most common treatment for spider veins. The procedure takes about one hour, during which time a solution called a “sclerosing agent” is injected into the veins. This causes the inter-lining of the vein to adhere, which results in scar tissue that acts like ‘glue’ to seal off the unwanted veins. There are a few side effects, such as bruising around the injection site, or temporary discoloration of a light brown color along the vein. However, you may resume normal activity immediately.

How many treatments will it take?

The number of treatments depends on the individual and extent of the spider veins; one or possibly more treatments. Typically, the average number of treatments required are three.

Image-Guided Needle Biopsy

J. Laird McMullen, III, M.D.

In many cases, tissue samples can be obtained without open surgery by utilizing interventional radiology techniques. Nearly all biopsies performed by interventional radiologists are image-guided needle biopsies. This means that a needle is placed into an area of abnormality directly through the skin. The needle placement is confirmed with the use of a variety of equipment used by the radiologists including ultrasound (used most often), CT or x-ray fluoroscopy.

Needle biopsies are almost always performed as an outpatient procedure with a short (one hour) observation period thereafter.

For more information, visit: Radiologyinfo.org/Needle Biopsy

Paracentesis and Thoracentesis

Pairoj Sae Chang, M.D. Ph.D.

Pairoj Sae Chang, M.D. Ph.D.

Patients with a variety of illnesses may develop an area of excessive fluid in a body cavity, such as the abdomen or chest. The fluid can be drained by inserting a thin tube (catheter) through a small nick in the skin. In an effort to determine the cause of the fluid build-up or to relieve the symptoms of the excess fluid, interventional radiologists insert a small tube (less than 1/12 of an inch in diameter) through the skin, after numbing the skin with a local anesthetic. The fluid may be sent to the laboratory for analysis.

During:

An ultrasound will be used to help decide where to insert the needle. Your skin will be cleaned and the area around the procedure site covered with a clean sheet. Local anesthesia makes you more comfortable during your procedure and is used to numb the insertion area and dull your pain. However, you may still experience pressure or pushing during the procedure.

A needle will be inserted into your abdominal or chest cavity. A catheter is attached to the needle and the needle is removed. The catheter tubing will be attached to a container with a suction device (a gentle vacuum) to help drain the fluid. Removing large amounts of fluid may take a couple hours.

After:

Once the procedure is completed and the catheter removed, the site will be covered with a bandage. Your referring physician may request that the ascites or pleural fluids be sent to a lab for tests.

For more information, visit: Radiologyinfo.org/Thoracentesis

Vertebral Augmentation

Vertebral Augmentation (VA) is a procedure performed by an interventional radiologist in order to reduce the discomfort associated with vertebral body fractures in the spine.    These fractures are typically secondary to osteoporosis; however, sometimes these fractures can be caused by trauma or tumors.    Vertebral body fracture is often associated with vertebral body height loss.  Studies have shown that if the vertebral body height loss can be improved, then there is less associated morbidity, such as pain and decreased mobility.

At the present time, Medicare and other third-party insurers authorize vertebral augmentation for pain management.  Both vertebroplasty and kyphoplasty are outpatient procedures that also can be performed on an inpatient basis. Vertebroplasty is a delivery of an orthopaedic “cement” (polymethylmethacrylate) mixed with barium. Under fluoroscopy or CT guidance, the orthopaedic cement is administered into the fractured vertebral body through placement of one to two needles. There is often no height restoration of the fractured vertebral body.

Kyphoplasty is a delivery of PMMA mixed with barium into the vertebral body after balloon dilation of the vertebral body.   There are other forms of kyphoplasty that can improve the height of a compressed vertebral body.  VA can be safely performed on up to three fractured vertebral bodies at any given time.

Vertebroplasty

Before:

The interventional radiologist will review your imaging studies and may require additional imaging studies and/or a consultation.  You may be asked to stop certain anticoagulants several days prior to the procedure, and may be directed to consult the physician who prescribed them.  You may continue to take your other medications as usual.   Eight hours prior to the procedure, stop eating solid foods. You may continue drinking liquids up to four hours prior to the procedure and taking your oral medications with few sips of water up to an hour prior to the procedure.    On the day of the procedure, wear loose comfortable clothing. Arrange for a designated driver to drive you home post-procedure.

During:

An IV is started and an antibiotic administered post–procedure.   You are escorted to a fluoroscopy suite where the procedure is performed.   You lie on your stomach and conscious sedation is administered intravenously. After sterile prep of your back, a local anesthetic is administered. Under fluoroscopy, two needles are placed – one through each pedicle of the fractured vertebral body while the orthopaedic cement is introduced. The needles are then removed and adhesive bandages are placed over the puncture sites.  For one level, the procedure time is approximately 30 minutes.   For two or three levels, the procedure time is approximately 60 minutes.

After:

Depending on how quickly you recover from the sedation post-procedure, recovery is one to two hours. You may experience complete pain relief; however, some pain may return after 12 to 24 hours.  The immediate pain relief may be due to the long-acting local anesthetic.   A 50% pain relief post-procedure is considered a success.   Arrange for a designated driver to drive you home post-procedure. During your first night home, we prefer that you are not alone and have an adult with you. You are required to schedule a consultation with us two to three weeks post procedure, so that we may assess your progress.

For more information, visit: Society of Interventional Radiology/Patient Center

Kyphoplasty

Before:

The interventional radiologist will review your imaging studies and may require additional imaging studies and/or a consultation. You may be asked to stop certain anticoagulants several days prior to the procedure.  Before you stop taking your anticoagulants temporarily, you may be required to consult with the physician who prescribed them.  You may continue to take your other medications as usual.   Eight hours prior to the procedure, stop eating solid foods. You may continue drinking liquids up to four hours prior to the procedure and taking your oral medications with few sips of water up to an hour prior to the procedure.    On the day of the procedure, wear loose comfortable clothing.  Arrange for a designated driver to drive you home post-procedure.

During:

An IV is started and an antibiotic administered pre-procedure.   You are escorted to a fluoroscopy suite where the procedure is performed.   You lie on your stomach and conscious sedation is administered intravenously. After sterile prep of your back, a local anesthetic is administered. Under fluoroscopy, two needles are placed – one through each pedicle of the fractured vertebral body – and the balloon device deployed followed by the “cement”. The needles are then removed and adhesive bandages are placed over the puncture sites.  For one level, the procedure time is approximately 45 minutes.   For two or three levels, the procedure time is approximately 60 to 90 minutes.

After:

Depending on how quickly you recover from the sedation post-procedure, recovery is one to two hours. You may experience complete pain relief; however, some pain may return after 12 to 24 hours.  The immediate pain relief may be due to the long-acting local anesthetic.   A 50% pain relief post-procedure is considered a success. Arrange for a designated driver to drive you home post-procedure. During your first night home, we prefer that you are not alone and have an adult with you. You are required to schedule a consultation with us two to three weeks post procedure, so that we may assess your progress.

For more information, visit: Society of Interventional Radiology/Patient Center

Pain Management

Our board certified musculoskeletal and interventional radiologists perform highly effective, minimally invasive pain management procedures using image guidance. These image-guided therapies treat conditions that might require surgery in a comfortable outpatient setting. Because of their training and skill, our radiologists perform your procedure quickly and accurately. Treatments are obtained only by referral from your physician. Pain management injections and procedures are ordered by your physician for diagnosis and/or therapeutic treatment of pain in most joints of the body and in all areas of the spine (lumbar). In some cases, the spinal injection procedure will be used in combination with other imaging exams, such as CT.

Before your exam, a technologist will contact you with specific instructions for your procedure. Please note that, due to the effects of some medications, you will need to have someone drive you home after the exam. Our technologist will give you information and instructions on potential after-effects from the local anesthetic and medications used with your procedure. The total appointment time for most of our procedures is 30 to 60 minutes.

Injections for Joint Pain

A joint injection may be considered for patients with symptoms such as arthritis, injury or mechanical stress, leading to hip, buttock, leg or low back pain. The injection can help relieve the pain as well as help diagnose the direct cause of pain. Injections involve injecting medicine directly into the joint.

 Diagnostic: By placing numbing medicine into the joint, the amount of immediate pain relief experienced will help confirm or deny the joint as a source of pain. If complete pain relief is achieved while the joint is numb, it means this joint is likely to be the source of pain.

 Pain Relief: Along with the numbing medication, steroid Depo-Medrol is also injected into these joints to reduce inflammation, which can often provide long-term pain relief.

Before:

A technologist will contact you with specific instructions. Please note that, due to the effects of some medications, you may need to have someone drive you home after the exam.

During:

You will lie on the exam table and the skin over the injection site is sanitized. The physician numbs a small area of skin with an anesthetic (a numbing medicine). You may feel a sting that will last for a few seconds. The physician uses x-ray guidance (fluoroscopy) or ultrasound to direct a tiny needle into the joint. Several drops of contrast dye are then injected to confirm that only the medicine reaches the joint. A small mixture of anesthetic and steroid Depo-Medrol are then slowly injected into the joint. The injection itself only takes a few minutes, but the overall procedure usually takes between 30 and 60 minutes.

After:

After the joint injection procedure, you will remain resting on the table for a few minutes, and then be asked to move the area of usual discomfort to try to trigger the related pain. You may or may not obtain pain relief in the first few hours after the injection, depending upon whether the joint that was injected is the main source of your pain. On occasion, you may feel numb or experience a slightly weak or odd feeling in the leg for a few hours after the injection. On the day of the injection, you are advised to avoid driving and doing any strenuous activities.

On the day after the procedure, you may return to your regular activities. When the pain has improved, it is advisable to start regular exercise and activities in moderation. Even if the pain relief is significant, it is still important to increase activities gradually over one to two weeks to avoid recurrence of pain. Injections are also commonly coupled with other treatments (medications, physical therapy, etc.) in an attempt either to maximize the benefit or prolong the effects. If the area is uncomfortable in the first two to three days after the injection, applying ice or a cold pack to the general area of the injection site will typically provide pain relief.

Epidural Steroid Injections

Lake Medical Imaging offers only L-spine epidurals. An epidural steroid injection is a minimally invasive procedure that can help relieve neck, arm, back, and leg pain caused by inflamed spinal nerves due to spinal stenosis or disc herniation. Medicines are delivered to the epidural space, which is a fat-filled area between the bone and the protective sac of the spinal nerves. Pain relief may last for several days or even years. The goal is to reduce pain, so that you may resume normal activities and a physical therapy program.

A steroid injection includes both a corticosteroid and an anesthetic numbing agent. The drugs are delivered into the epidural space of the spine, which is the area between the bony vertebra and the protective dura sac surrounding the spinal nerves and cord.

Before:

If you take blood thinning medication (Coumadin, Plavix, etc.), you may need to stop taking it several days before the procedure. Discuss any medications with your doctors, including the one who prescribed the medication and the doctor who will perform the injection.

The procedure is usually performed in an outpatient center using x-ray fluoroscopy. Arrange to have someone drive you to and from the center the day of the injection.

During:

The procedure may last between 15 and 45 minutes, followed by a recovery period. You will lie on an x-ray table. Local anesthetic is used to numb the treatment area, so discomfort is minimal throughout the procedure. In order to provide feedback to the physician, you remain awake and aware during the procedure.

With the aid of an x-ray fluoroscope, the doctor directs a hollow needle through the skin and between the bony vertebrae into the epidural space. Fluoroscopy allows the doctor to watch the needle in real-time on the x-ray monitor, ensuring that the needle goes to the desired location. Some discomfort occurs, but it’s more common to feel pressure rather than pain.

You will be monitored for 20 minutes to ensure that you are not experiencing numbness, tingling or full loss of sensation from the waist down. If any of the aforementioned symptoms occurs, you will be required to remain in-office – between two to five hours – until the effects wear off.

After:

You should be able to walk around immediately after the procedure. Rarely, a temporary leg weakness or numbness may occur, so someone should drive you home. You should be able to ­­­­­­­­­­­resume your full activities the next day. Soreness around the injection site may be relieved by using ice and taking a mild pain reliever, such as Tylenol.

You may notice a slight increase in pain, numbness, or weakness as the numbing medicine wears off and before the corticosteroid starts to take effect, which could be three to four days.

Sacroiliac Joint Injections

The sacroiliac joint, located in the lower spine above the tailbone, is the largest joint in the spine. Inflammation of the sacroiliac joint can cause low back and buttock pain. Using CT, local anesthetic and steroid medication are injected into the sacroiliac joint. If pain is relieved, it could mean the joint is the pain generator.

Before: Stop taking all blood thinning medication.

During:

The injection site is sanitized and draped. Skin-numbing medication is injected into and around the procedure site. CT guidance is used during the procedure to guide the needle into the proper position. CT injections will include an anesthetic and a steroid.

After:

You will be discharged home with written instructions. The area around the injection site will feel numb. Relief from typical symptoms may last for six hours following the injection.

Nerve Root Blocks are done under CT guidance.