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MRI - Crohn's disease and small bowel

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MRI of Crohn’s disease has the main advantage over CT in that patients who are typically young, are not exposed to the effects of radiation that occurs with CT, which up until now has been the main imaging modality of inflammatory bowel disease (IBD).

Preparation for an MRI examination is an overnight fast and drinking an oral dye over a period of 2 hours. The scan takes approximately 1 hour, with injections of intravenous buscopan performed (to temporarily halt normal bowel motion in order to obtain the clearest images) as well as intravenous contrast in order to assess for bowel inflammatory changes at the time of initial diagnosis, assessment of any changes to therapy in patients with small bowel disease, as well as any of its complications. Furthermore, MRI is the modality of choice in pregnant women.

After the MRI scan, patients can eat and drink normally and resume normal activity. The report will then be interpreted by our radiologists and then sent to the patient's referring doctor.

MRI of small bowel showing thickened bowel characteristic of Crohn's disease

As of March 1, 2015 MRI scans for Crohn's disease that are eligible for the Medicare rebate referred by Specialists are bulk billed at Melbourne Radiology Clinic.


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Adult MRI Series 4 - Scan of Knee

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The advent of MRI heralded a new era in musculoskeletal imaging and sounded the end of the routineuse of invasive imaging tests, such as arthrography. Non invasive MRI is now the routine modality of choice in investigating most joints. Specifically in relation to the knee, MRI has the ability to visualise normal and pathological conditions of menisci, ligaments, joint capsule, tendons, cartilage, subchondral bone marrow oedema and intra-articular bodies.

One of the most common clinical scenarios in the clinical and imaging assessment of knee trauma is the integrity of the meniscus and whether a tear is present that may warrant arthroscopic debridement. Other important consequences of trauma includes instability, with the anterior cruciate ligament (ACL) the most important stabiliser. The ACL is typically completely torn when injured and often occurs inconjunction with other ligament injuries, as well as meniscal tears and chondral defects. An isolated tear of the ACL is often a straightforward clinical diagnosis, however with concomitant injury of other structures, pain inhibition frequently precludes an adequate clinical examination, in which case either MRI or and/or arthroscopic assessment are required.


Figure 7 & 8. MRI of Knee.

Figure 7. Sagittal MRI of the knee in a patient presenting with instability following a twisting injury demonstrates mid substance rupture of the anterior cruciate ligament (arrow).

Figure 8. Sagittal MRI of the knee in a 54 year old male following a twisting injury reveals hyperintense (bright) signal in keeping with fluid, extending to the undersurface of the posterior horn of the medial meniscus, in keeping with a tear.


MBS item description

Referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of knee following acute knee trauma for a patient 16 years or older with:

  • inability to extend the knee suggesting the possibility of acute meniscal tear; or
  • clinical findings suggesting anterior cruciate ligament tear

MRI scans that are eligible for the Medicare rebate referred by GPs are bulk billed at Melbourne Radiology Clinic.

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Adult MRI Series 3 - Cervical Spine for Suspected Trauma

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Following an episode of significant trauma, the supporting structures of the cervical spine often require definitive imaging. CT reliably excludes most fractures, however suffers from the inability to evaluate many acute types of disc injury, as well as any neurological injury.

MRI is an important adjunct to CT and in fact, the two tests are complimentary, as the strength in CT is to exclude osseous injury and the role of MRI is to exclude disc, ligament and neurological (spinal nerve and spinal cord) injury. MRI can even show small osseous contusions (“bone bruises”) that are typically CT occult and though not unstable, may account for unexplained pain following a normal CT examination. In the context of neurological symptoms following trauma, MRI is considered mandatory.


Figure 5 & 6. MRI of Cervical Spine  of patients presenting with suspected trauma.

Figure 5. Sagittal T2 fat saturated sequence demonstrates following a motor vehicle accident demonstrates isolated disruption of the anterior longitudinal ligament (ALL) at the C7/T1 level.

Figure 6. Sagittal T2 fat saturated sequence status post hyperflexion injury of the spine demonstrates abnormal hyperintense signal within the supraspinous and interspinous ligaments of the upper cervical spine (arrow) consistent with sprain injury..


MBS item description

Referral by a medical practitioner (excluding a specialist or consultant physician) for a MRI scan of spine for a patient 16 years or older for suspected:

  • cervical spine trauma

MRI scans that are eligible for the Medicare rebate referred by GPs are bulk billed at Melbourne Radiology Clinic.

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Adult MRI Series 2 - Cervical Spine Radiculopathy

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Patients presenting with arm pain may present with mixed clinical signs that can make it difficult to distinguish whether the pain is local in its origin or indeed arising from the cervical spine. In these clinical scenarios, an MRI of the cervical spine reliably demonstrates any intervertebral disc pathology compressing nerves, as well as any lesion within or surrounding the spinal cord that has potential to account for the patient's symptoms.

The most frequent diagnosis encountered on MRI is that of a disc herniation resulting in direct compression of a spinal nerve. When this corresponds with the clinical findings, for example matching the dermatomal distribution with the patient’s symptoms, then the diagnostic specificity and sensitivity of MRI is high.

MRI is the main modality utilised in the assessment of cervical radiculopathy, particularly fluid sensitive sequences, known as T2 weighted imaging, which have the ability to visualise bone, disc, ligaments, cerebrospinal fluid, spinal nerves and the cord.

MRI serves as a roadmap for performing any proposed intervention, including radiological guided injections (typically a CT guided foraminal injection of corticosteroid) that may assist in the relief of patient’s symptoms, should the patient not respond to conservative measures. An injection can be particularly useful in the acute setting where the patient is experiencing severe and unrelenting pain.


Figure 3 & 4. MRI of Cervical Spine  of patients presenting with radiculopathy.

Figure 3. Sagittal T2 weighted (fluid sensitive) sequence of the cervical spine demonstrates a C5/6 disc bulge contacting the spinal cord (arrow) in a patient presenting with radiculopathy.

Figure 4. Axial CT intervention image demonstrates a spinal needle in the right C5/6 neural foramen (arrow) in order to alleviate the patient’s symptoms of right sided C6 radiculopathy.


MBS item description

Referral by a medical practitioner (excluding a specialist or consultant physician) for a MRI scan of spinefor a patient 16 years or older for:

  • cervical radiculopathy

MRI scans that are eligible for the Medicare rebate referred by GPs are bulk billed at Melbourne Radiology Clinic.

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Adult MRI Series 1 - Head and Brain

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From a historical perspective, the main clinical utility of MRI has been its strength in superior resolution of neurological soft tissues, far more than that is able to be seen with Computed Tomography (CT). MRI easily distinguishes grey from white matter, excludes focal intracerebral (or intra-axial) lesions from extra-axial lesions and can perform angiography of the circle of Willis without the need for contrast.

Common conditions requiring MRI evaluation include demyelination disorders such as multiple sclerosis (MS), primary and secondary tumours, strokes, aneurysms and infections. All these may result in a positive clinical history of headaches and/or seizures, making MRI the imaging modality of choice.

CT is the main imaging modality used in the context of trauma as it is widely available and reliably demonstrates haemorrhage from normal cerebral tissue. The main disadvantage of CT is the use of ionising radiation.


Figure 1 and Figure 2 - MRI of Head and Brain

Figure 1. Coronal post contrast MRI of the brain in a patient presenting with a headache demonstrates an enhancing mass of the right lateral ventricle (arrow) that was pathologically confirmed to be a primary brain tumour, in this instance a central neurocytoma.

Figure 2. Sagittal post contrast MRI of the brain in a patient with a history of melanoma and new onset of seizures demonstrates an enhancing lesion (arrow) in keeping with a solitary metastasis.


MBS item description

Referral by a medical practitioner (excluding a specialist or consultant physician) for a MRI scan of head for a patient 16 years or older for:

  • unexplained seizure(s)
  • unexplained chronic headache with suspected intracranial pathology

MRI scans that are eligible for the Medicare rebate referred by GPs are bulk billed at Melbourne Radiology Clinic.

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MRI - Fingers and Toes

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It is not surprising that as MR image quality has improved and scan times have become shorter, the applications of this modality have increased, such that even smaller body parts are now routinely imaged. Finger tendon, ligament and joint injuries can be elegantly depicted, as can normal anatomical structures (figure 1).

Though such injuries have historically been evaluated with the combination of an X-ray and ultrasound, MRI has the advantage of simultaneously visualising both bone and soft tissues. Similarly, toe injuries can be demonstrated (figures 2 & 3), arthritis, blood vessel and nerve abnormalities, as well as soft tissue and bone tumours (1,2).

Axial and saggital MRI of middle finger

Figure 1. (A) Axial and (B) sagittal MRI of the middle finger demonstrates an area of bright signal (arrow) consistent with focal disruption of the central slip of the extensor tendon at the level of the proximal interphalangeal joint.

(A) Long and (B) short axis MRI of the great toe reveals changes of early osteoarthritis including small bone spurs (arrows), bone marrow oedema and ligament attenuation

Figure 2. (A) Long and (B) short axis MRI of the great toe reveals changes of early osteoarthritis including small bone spurs (arrows), bone marrow oedema and ligament attenuation.

(A) Short axis and (B) sagittal MRI of a benign soft tissue nerve tumour of the great toe (neurofibroma).

Figure 3. (A) Short axis and (B) sagittal MRI of a benign soft tissue nerve tumour of the great toe (neurofibroma).

 

References:

  1. Connell DA, Koulouris G, Thorn DA, Potter HG. Contrast-enhanced MR angiography of the hand. Radiographics 22(3):583-99, 2002
  2. Vilanova JC, Barceló J, Smirniotopoulos JG, Pérez-Andrés R, Villalón M, Miró J, Martin F, Capellades J, Ros PR. Hemangioma from head to toe: MR imaging with pathologic correlation. Radiographics 24(2):367-85, 2004
 
 

MRI and Ultrasound of the Achilles Tendon

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The Achilles tendon, also known as the tendo Achilles, tendo calcaneus or calcaneal tendon, is the longest tendon of the body, formed by the union of the lower aspect of the calf muscles (gastrocnemius, soleus and the variably present plantaris muscle).

The tendon inserts by way of a broad insertion on the calcaneus (heel bone) of the hindfoot. During development, the Achilles tendon is continuous with the broad flat tendon of the foot known as the plantar fascia (figure 1).

Normal MRI of the Achilles tendon (figure 1) and ultrasound of normal Achilles tendon

Figure 1. Normal MRI of the Achilles tendon demonstrates this to be a well defined hypointense (dark) structure (arrow) inserting onto the calcaneus, thereafter becoming continuous with the plantar fascia (arrow).

Figure 2: Ultrasound of a normal Achilles tendon depicts the multiple small fibrils that make up the tendon as alternating bright and dark lines (arrow). Note the calcaneal insertion.

As for any tendon, degeneration due to wear and tear may occur, known as tendinosis (incorrectly frequently referred to as tendinitis). Achilles tendinosis results in pain during activities such as running and may be seen in combination with degeneration of the plantar fascia (plantar fasciitis, or “heel spurs”) and strains of the calf muscles [1].

Most cases of tendinosis resolve with conservative therapy, which consists of exercises, eccentric strengthening, heel inserts and activity modification.

If severe, the tendinosis may not respond to such treatment, hence requiring injection therapy, using autologous blood, platelet rich plasma, autologous tenoctyes or polidocanol (figure 3).

Ultrasound guided polidocanol injection into the mid Achilles tendon

Figure 3: Ultrasound guided polidocanol injection into the mid Achilles tendon.

Initially, imaging with either an ultrasound (figure 2) or an MRI is performed in order to determine the degree and extent of the tendinosis, as well as the presence of any tears and surrounding inflammation (paratenonitis, retrocalcaneal and/or retroAchilles bursitis).

Achilles tendinosis typically involves the mid portion of the tendon (figure 4) and left untreated, may result in dramatic painful rupture (figure 5) with sudden loss of function, warranting surgery.

MRI of severe Achilles tendinosis

Figure 4: MRI of severe Achilles tendinosis is characterised by marked thickening, increased signal intensity (brightness) and areas of intrasubstance tearing of the tendon, placing the tendon at risk of full thickness rupture.

MRI of a patient, demonstrates a full thickness tear of the Achilles tendon

Figure 5: MRI of a patient suffering from severe pain following a jumping injury demonstrates a full thickness tear of the Achilles tendon, with recoiling of the tendon edges and haemorrhage in the surrounding soft tissues.

Less frequently, the tendinosis may involve the insertion of the Achilles onto the calcaneus (known as enthesopathy) and may be seen in conjunction with certain arthritic diseases, as well as increasing age (figure 6). In this instance, changes within the bone may be seen, such as fluid (oedema) and prominence of the calcaneus, known as Haglund’s deformity.

MRI of Achilles insertional tendinosis (enthesopathy)

Figure 6: MRI of Achilles insertional tendinosis (enthesopathy) is characterised by bone marrow oedema (arrow) of the calcaneus (heel bone), Haglund’s deformity, inflammation in the surrounding soft tissues (retrocalcaneal bursitis; arrow) and partial thickness insertional tendon tearing (arrow).

References

  1. Koulouris G, Ting AY, Jhamb A, Connell D, Kavanagh EC. Magnetic resonance imaging findings of injuries to the calf muscle complex. Skeletal Radiol (10):921-7, 2007
  2. Pavlov H, Heneghan MA, Hersh A, Goldman AB, Vigorita V. The Haglund syndrome: initial and differential diagnosis. Radiology. 1982 Jul;144(1):83-8.

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MRI - Pectoralis Major Muscle Tear

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Sequential MRIs of the right pectoralis major muscle demonstrates an extensive partial thickness tear (arrows) commencing from the lower aspect of the muscle, almost involving its entire length.

An axial scan through the same area demonstrates fluid consistent with haemorrhage in the muscle defect. Importantly, the tendon inserting onto the humerus (orange arrow) is intact.

These injuries commonly occur during bench pressing, wrestling and football, with surgery required for extensive partial or full thickness tears if function and strength is to be preserved.

MRI is the best imaging modality that can determine the location and extent of the injury, as can ultrasound in experienced hands (1).

 

References:

  1. Connell DA, Sherman MF, Wickiewicz TL. Injuries of the pectoralis major muscle: evaluation with MR imaging. Radiology. 210(3):785-91, 1999
 
 

MRI - dGEMRIC Evaluation of Cartilage

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Delayed gadolinium enhanced Magnetic Resonance Imaging of cartilage (dGEMRIC) is a recent technique where an MRI scan dedicated to detecting early cartilage breakdown is performed. GAG (glycosaminoglycan) molecules are vital to the integrity of cartilage, maintaining water molecules within cartilage and therefore the tensile strength, so that it may perform its day to day function of resisting forces imparted upon a joint.

Breakdown of GAG molecules due to wear and tear is one of the early steps leading to the gradual development of osteoarthritis. Importantly, GAG loss is potentially reversible in its early stages. By injecting MRI contrast (gadolinium) into a patient, gadolinium is delivered into a patient’s joints. As both GAG molecules and gadolinium are negatively charged, gadolinium will penetrate articular cartilage in an inversely proportional manner to the GAG concentration; that is to say, the lower the GAG concentration (lesser negative charge) the more the negatively charged gadolinium will penetrate the cartilage, relative to areas of higher GAG concentration.  The greater negative charge of normal cartilage (higher GAG concentration) will repel gadolinium penetration.

Fortunately, the penetration of gadolinium into the cartilage is readily measured on dedicated MRI scans. Areas of greater gadolinium penetration into cartilage and therefore increased cartilage breakdown (due to GAG loss) may be color coded, so it can be appreciated readily whether a joint is heading along the osteoarthritis pathway (figure 1). The advantage of dGEMRIC imaging is that it can detect cartilage changes before conventional MRI. Conventional MRI relies on a detecting a discrete cartilage tear reaching a sufficient size so that it is visible, however this is currently inadequate in patients who are considering joint preservation surgery, as irreversible osteoarthritis at this point has usually occurred and the joint is usually beyond salvage. dGEMRIC scans can reliably detect whether GAG loss has occurred even before visible cartilage breakdown. This may spare patients complex and extensive reconstructive surgery, as any such surgery is bound to fail should GAG concentration fall below a critical point. Conversely, normal GAG levels reliably predict surgical success.

dGEMRIC scans are therefore useful in the assessment of patients with:

  • femoroactebular impingement patients considering pelvic reconstruction (periacetabular osteotomy) (1) and other congenital or developmental joint disorders that require regular follow up, such as Perthe’s disease of the hip (2), or slipped upper capital femoral epiphysis (3)
  • surgically treated cartilage defects (such as microfracture and autologous chondrocyte implantation techniques) that require follow up (4)
  • an injured joint, such as after patellar dislocation (5) and cruciate ligament tears (6, 7)
  • suspected early arthritis prior to the development of established arthritis on conventional X-Rays and MRI scans (8).
MRI - dgemeric evaluation of cartilage

Figure 1A. Routine MRI evaluation of the left hip demonstrates relatively normal cartilage thickness overlying the femoral head (arrows), with no areas of discrete breakdown or defect formation.
Figure 1B. dGEMRIC images through the same hip however demonstrate areas of advanced GAG loss, as indicated by the presence by white and yellow pixels overlying the articular cartilage. Normal GAG cartilage levels are indicated by shades of red. The patient is not a candidate for joint preserving surgery.

References

  1. Cunningham T, Jessel R, eat al. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage to predict early failure of Bernese periacetabular osteotomy for hip dysplasia. J Bone Joint Surg Am 88(7):1540-8, 2006
  2. Zilkens C, Holstein A, et al. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage in the long-term follow-up after Perthes disease. J Pediatr Orthop 30(2):147-53, 2010
  3. Zilkens C, Miese F, et al. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), after slipped capital femoral epiphysis. Eur J Radiol 2010 May 24 . [Epub ahead of print]
  4. Vasiliadis HS, Danielson B, et al. Autologous chondrocyte implantation in cartilage lesions of the knee: long-term evaluation with magnetic resonance imaging and delayed gadolinium-enhanced magnetic resonance imaging technique. Am J Sports Med 38(5):943-9, 2010
  5. Watanabe A, Obata T, et al. Degeneration of patellar cartilage in patients with recurrent patellar dislocation following conservative treatment: evaluation with delayed gadolinium-enhanced magnetic resonance imaging of cartilage. Osteoarthritis Cartilage 17(12):1546-53, 2009
  6. Fleming BC, Oksendahl HL, et al. Delayed Gadolinium-Enhanced MR Imaging of Cartilage (dGEMRIC) following ACL injury. Osteoarthritis Cartilage 18(5):662-7, 2010
  7. Young AA, Stanwell P, et al. Glycosaminoglycan content of knee cartilage following posterior cruciate ligament rupture demonstrated by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC). A case report. J Bone Joint Surg Am 87(12):2763-7, 2005
  8. Williams A, Sharma L, et al. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage in knee osteoarthritis: findings at different radiographic stages of disease and relationship to malalignment. Arthritis Rheum. 2005 Nov;52(11):3528-35.

AFL Medical Officers Association Cartilage Injury Forum 6th July 2010

Download PDF of Presentation MRI Evaluation of Cartilage - Presentation  July 2010
Dr George Koulouris


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Last Updated ( Tuesday, 05 April 2011 21:35 )
 
 

MRI - Knee ACL Injury

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The Anterior Cruciate Ligament (ACL) is a major stabiliser of the knee joint, preventing the lower leg from slipping forward, away from the knee.

Injury to this ligament usually manifests as a full thickness tear and often requires surgical reconstruction, particularly if the affected individual wishes to participate in sporting activities.  

The normal ACL on MRI is a taut, thick dark structure that takes an oblique path through the knee joint (figure A).  A typical ACL tear is detected by the loss of the normal dark signal (figure B) and is replaced by bright signal on MRI (figure C).  Also, the ligament is absent where it arises from the femur, a finding known as the "empty notch sign". As the injury occurs due to a twisting injury, bone bruises may occur (figure D), with the bruises most commonly indicative of a pivot-shift mechanism of injury.  

ACL tears have a high association with meniscal injury, which can present with inability to straighten the knee - a "locked knee" (figure E).  This is due to a meniscal tear that is flipped from its expected position, preventing further movement of the two bones (femur and tibia) that comprise the knee joint.

Since 1 November 2013, GPs are able to request four new Magnetic Resonance Imaging (MRI) Medicare services for patients 16 years of age and over.
This includes 

  • Scan of knee following acute trauma for patients with inability to extend the knee suggesting the possibility of acute meniscal tear or clinical finding suggesting acute anterior cruciate ligament tear.

This enables GPs to refer adult patients (16 years and over) for an MRI examination of the knee to Melbourne Radiology Clinic based on the clinical indication shown above.

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Last Updated ( Wednesday, 26 February 2014 12:56 )
 
 

MRI - Shoulder

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AC Joint Injury

The acromioclavicular (AC) joint is a small joint of the outer aspect of the shoulder that is formed by the acromion and clavicle (collarbone). 

In this case, MRI demonstrates increased fluid (blue arrow) within the joint, which is also separated, consistent with the diagnosis of a grade two sprain. 

The coracoclavicular ligament (yellow arrows) acts as the main stabiliser of this joint and is of increased signal in this case in keeping with injury to this structure. 

AC joint injury usually occurs following a fall onto the outer point of the shoulder and in most cases can be treated without surgery. 

In the setting where the clavicle is completely offset from the acromion, surgical fixation is warranted in order to preserve function and to minimise pain in the long run.

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Last Updated ( Tuesday, 05 April 2011 00:11 )
 
 

MRI Lateral Epicondylitis ('tennis elbow')

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MRI of the elbow demonstrates increased signal intensity of the origin of the extensor carpi radialis brevis tendon, consistent with tendinosis (previously referred to as “tendinitis”) and thus the diagnosis of lateral epicondylitis, or “tennis elbow” (image 1).

Superimposed upon this, is the presence of a more focal area of increased signal, consistent with a large partial thickness tear (image 2).

Further image also demonstrates increased bone marrow signal secondary to increased fluid (image 3).

The tendon disease is also seen in the short axis views, again as an area of tendinosis (image 4) with the partial tear seen slightly lower on the subsequent slice (image 5).

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MEDICAL DISCLAIMER The Melbourne Radiology Clinic web site is not intended as a substitute for your own independent health professional’s advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition. Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second medical opinion.