RPS 1009b - Spine and bone

Purpose:

To report our clinical experience of CT-guidance fixation of pelvic ring traumatic fractures, evaluating screw placement accuracy, safety, complications, and clinical outcome.

Methods and materials:

All consecutive patients who beneficiated from a CT-guided fixation of a sacroiliac or acetabular fracture in our radiology department after a high energy trauma from 11/2016-11/2018 were included. All procedures were realised under general anaesthesia with dual CT and fluoroscopic guidance by two experienced interventional radiologists. Treated fractures, unstable reduced posterior pelvic ring disruptions, with or without sacroiliac disjunction (TILE B or C), and minimally displaced acetabular fractures were minimally displaced. The primary outcome was screw placement accuracy. Secondary endpoints were patient radiation exposure, procedure time, complications, clinical functional score (MAJEED score), and pain scale evaluation (VAS) during a follow-up period from 4-30 months.

Results:

32 patients were included (mean age 46 years) and 62 screws were placed. Screw placement was correct in 28/31 patients (87.5%, missing data of one patient). 2 patients presented with persistent pain after fixation due to a screw conflict. In both cases, screws were removed by an interventional radiologist after fracture consolidation, resolving the pain. The mean procedure time was 67 minutes and the mean patient radiation exposure was 965mGy cm. No major complications occurred. The mean follow up was 13 months. The mean postoperative MAJEED score was 84/100 and the mean pain score was 1.6/10.

Conclusion:

This technique is an effective and safe procedure in undisplaced or minimally displaced pelvic fractures, allowing both accurate fixation and minimally invasiveness. The possibility of percutaneous removal allows resolution of any eventual unsatisfying screw positioning in a minimally invasive way.

Limitations:

The retrospective design.

Ethics committee approval

Informed consent was obtained.

Funding:

No funding was received for this work.

Purpose:

To explore how O2-O3 chemiodiscolysis affects the biomechanics of the spine and the functional spinal unit and whether it accelerates lumbar spine degeneration.

Methods and materials:

A total of 100 patients treated with an O2-O3 mixture, either periganglionic or intradiscal, 6 years before our study underwent MRI examination. An evaluation of the success rate was performed on both groups on the basis of the modifications of lumbar spine biomechanics, using well-defined markers of spine degeneration. Comparisons were made between the patients treated with the percutaneous O2-O3 intradiscal injection and the paraganglionic O2-O3 injection was used as a control group.

Results:

Both treatments showed a significant reduction of disc height (p<0.05), although only the intradiscal injection obtained the decrease of disc area and protrusion (p<0.05). Similarly, in the periganglionic injection, the Pfirrman and Modic score markers of lumbar spine degeneration increased (p<0.05), whereas in the intradiscal injection they remained stable (p>0.05).

Conclusion:

Biomechanical properties of the spine are not affected after the intradiscal injection of O2-O3. This study demonstrates that chemiodiscolysis, restoring the natural loads along the FSU, does not exacerbate lumbar spine degeneration.

Conversely, periganglionic injection, acting as a symptomatic treatment, does not delay lumbar spine degeneration.

Limitations:

Although in the paraganglionic injection, we did not directly obtain any shrinkage of the disc, a protruded disc naturally reduces its own extrusion due to the dehydration of the NP.

Ethics committee approval

Approval of our medical ethical committee and informed consent was obtained.

Funding:

No funding was received for this work.

Purpose:

To evaluate image quality and confidence for planning of periradicular infiltrations using virtually lowered tube currents and in-house developed statistical iterative reconstruction (IR) for multi-detector computed tomography (MDCT).

Methods and materials:

20 patients (54.9±13.1 years) underwent MDCT for planning purposes of periradicular infiltrations at the lumbosacral spine (120 kVp/100 mAs). Planning scans were simulated as if they were performed at 50% (D50), 10% (D10), 5% (D5), and 1% (D1) of the tube current of original scanning. Image reconstruction was achieved with two levels of IR (A: similar in appearance to clinical reconstructions and B: ten times stronger noise reduction). Two readers (R1/R2) performed image evaluation including confidence for intervention planning (scoring: 1-high, 2-intermediate, and 3-low confidence).

Results:

Level A of IR was favourable regarding overall image quality, artefacts, image contrast, and nerve root depiction, with preserved good scores down to D10 scans. The confidence for planning was not significantly different (p>0.05) between scans with tube currents virtually lowered down to 10% and original-dose scans when using level A of IR (R1: 1.2 ± 0.4, R2: 1.1 ± 0.3). Inter-reader agreement for planning confidence was good (Cohen’s kappa: 0.62-1.00).

Conclusion:

MDCT for lumbosacral periradicular infiltrations may be conducted with tube currents lowered down to 10% of the standard dose (equal to 10 mAs) without limitations in planning confidence.

Limitations:

Evaluations were performed for procedure planning only and not for the sequential scans acquired during the intervention. The time needed for image reconstructions using IR can be long, hampering direct implementation into the clinical setting.

Ethics committee approval

This retrospective study was approved by the IRB.

Funding:

University of Pennsylvania Research Foundation and Philips Healthcare.

Purpose:

To assess annular fibers anisotropy through the intervertebral disc FA map to select patients suffering from low back pain of lumbar disc origin and who may benefit from intradiscal oxygen-ozone injection.

Methods and materials:

A total of 75 patients suffering from low back pain were selected. Before treatment, they underwent MR examination on a 3T, with a standard protocol of conventional sequences (T2, T2 fat-sat, and T1 FSE) and one additional DTI sequence for assessing respectively lumbar disc pathology and the fractional anisotropy (FA) map of the involved intervertebral disc. Discography of the involved disc was also obtained under CT guidance in order to confirm MRI reports. Patients were randomly assigned into two groups. One control group (20 men, 16 women) underwent intraforaminal injection of steroids and anaesthetics. The remaining 39 patients in the study group (18 men, 21 women) underwent the same treatment with the addition of an intradiscal oxygen-ozone (O2-O3) injection. An ODI questionnaire was administered before and after the treatment. Results were compared with a χ2, t-test, and regression analysis.

Results:

In cases of annular fissure without herniation or disc extrusion, O2-O3 intradiscal injection therapy was successful in 41% of the study group patients compared to 27.5% of the control group patients (P<0.01). The ODI questionnaire showed a significant improvement of symptoms in both groups (P<0.01). FA disc map values positively correlated with the annular fissuration and the positive outcome.

Conclusion:

An FA disc map congruous with a rupture of annular fibres could be considered as a predictive sign of a response to oxygen-ozone lumbar intradiscal injection and should be included in the preoperative study.

Limitations:

n/a

Ethics committee approval

Ethical approval was obtained by our medical committee.

Funding:

No funding was received for this work.

Purpose:

To evaluate the feasibility and effectiveness of the SpineJack® intravertebral implant in the treatment of pathological vertebral fractures in cancer patients. The primary aim of the treatment was pain palliation and recovery of the height of the vertebral body.

Methods and materials:

21 patients (10 men and 11 women, median age 62) with fractures of 24 vertebral metastases underwent CT fluoroscopy-guided percutaneous vertebral augmentation by bi-peduncular expandable SpineJack® insertion followed by vertebroplasty. 7 patients underwent MW ablation immediately before the osteosynthesis. We analysed the feasibility and complications of the procedure, the decrease in pain using a visual analogue scale (VAS), and the restoration of the anterior and middle height of the vertebral body, before and 1 week after the procedures. Patients were followed up for 14 months (range from 3-25 months).

Results:

The procedure was technically successful in all treated vertebrae. Bone cement leakage occurred in 12 cases, but no symptoms were reported. No signs of root irritation or neurological deficit were observed. VAS score decreased from 7.1 (range, 4-8.7) to 1.2 (range, 0-3). The anterior and middle height of the vertebral body reduced in all patients with a deformity reduction and improvement of column stability.

Conclusion:

This preliminary result suggests that the SpineJack ® procedure in vertebral pathological fractures is safe and effective, provides immediate benefits in terms of pain relief, functional recovery, and vertebral height restoration, with a rapid return to self-sufficiency.

Limitations:

The small sample of patients and the short follow-up don't permit establishing the exact role of this approach in the treatment of patients with vertebral fractures of spinal metastases.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To retrospectively evaluate clinical and radiological results of ablative procedures of focal benign bone lesions performed with a magnetic resonance-guided focused ultrasound surgery (MRgFUS) equipment.

Methods and materials:

We retrospectively evaluated patients who underwent MRgFUS treatment on painful and symptomatic benign bone lesions from February 2012-October 2019. Patients were considered eligible for the procedure if the lesion was on the bone surface, i.e. accessible from the ultrasound beam, and if there were no contraindications to MRI. We evaluated the success rate in terms of clinical and imaging results, complications, and relapse rates.

Results:

Our population included 71 patients (40 males, 31 females, mean age at the time of treatment 29±16). In the last few years, since 2012, we successfully treated 66 lesions (success rate 93.5%): 51 osteoid osteomas and 15 epiphyseal lesions (6 intraarticular osteoblastomas, 4 fibroangiomas, 1 subperiosteal chondroma, 1 mixofibroma, 2 chondroblastomas, and 1 GCT recurrence). Pain control was obtained in all cases with a fast and definitive relief. No complication from the percutaneous approach was recorded (complication rate 0%). The advantage in HIFU treatment was also shown by the imaging follow-up (up to over 2 years), with significant bone densification and no pathologic fracture after thermal ablation. In 5 patients, we reported clinical and radiological relapse (relapse rate 6.5%): 1 tug lesion, 3 osteoid osteomas, and 1 osteoblastoma. All the disease relapse cases occurred before 2017, probably related to limited technical experience.

Conclusion:

Our results confirm the validity of MRgFUS as the treatment of choice for benign superficial bone lesions because of its minimally invasive approach, high-profile of safety, and excellent effectiveness.

Limitations:

A limited number of patients and an operator with progressively increasing experience.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To compare the clinical outcome of CT and fluoroscopy-guided percutaneous vertebroplasty (PVP) in vertebral fractures with and without an intravertebral cleft.

Methods and materials:

All patients treated at our centre with PVP from 11/2014-11/2015 under CT and fluoroscopic guidance were reviewed. Inclusion criteria were the presence of painful thoracolumbar osteoporotic vertebral fractures (VAS>5 under antalgic medication) with MRI confirmation, graded type II or III according to Genant’s classification. Patients were divided into two groups according to the presence (group 2) of an intravertebral cleft (Kümmel disease) or not (group 1).

Exclusion criteria were medullary compression, acute infection, active haemorrhage, and malignant vertebral fractures.

Follow-up was done at day 1, months 1, 3, 6, and 1 year with a visual analogue scale (VAS) score for pain.

Results:

90 patients were included (mean age 79 years [70-92 years], 27 males and 63 females, 61 thoracic and 39 lumbar vertebral fractures).

50 patients (group 1) didn't have an intravertebral cleft before PVP, while 40 patients did (group 2).

Vertebral fractures with a cleft were significantly more painful at preoperatory (p<0.05). Both groups demonstrated significant improvement in VAS results at follow-up after PVP (p<0.05). Group 2 (cleft) presented a larger decrease in pain compared to group 1 (no cleft). Cement leakage into an intervertebral disc was observed in 25/90 cases (27.7%), significantly more frequent in patients without a cleft (20/50, 40%) than in patients with a cleft (5/40, 12.5%)(p<0.0006).

Conclusion:

Fractures with an intravertebral cleft are more painful that those without a cleft and receive greater clinical benefit from PVP, with a larger VAS decrease and less intervertebral disc cement leakage in comparison to the group of osteoporotic fractures without a cleft.

Limitations:

The retrospective design.

Ethics committee approval

IRB approval and informed consent was obtained.

Funding:

No funding was received for this work.

Purpose:

To review complications following thermal ablation and cryoablation of painful bone metastasis and discuss the risks and clinical presentation of each complication, as well as how to treat and potentially avoid complications.

Methods and materials:

We retrospectively evaluated 50 advanced cancer patients with painful bone metastasis (BM) treated by CT-guided percutaneous thermal ablation techniques (RFA, CA, or MWA) with palliative or curative intent in the last 4 years in our department. Curative treatment was performed to selected oligometastatic patients presenting with limited bone disease (<3 potentially treatable BM, each ≤3 cm in size). Patients with a painful bone metastasis (≥4/10 on a 0-10 VAS scale over the 24h) or higher risk of pathological fracture underwent palliative treatments.

Results:

Axial bones were involved in 21 patients (42%). CA was performed in 31 cases (62%), RFA in 11 patients (22%), and MW ablation in 8 cases (16%). Complications were observed in 4 patients out of 50 (8%). An intramuscular haematoma was detected in 1 lesion located in the sacral wing. In 1 patient, an abscess developed after CA of an acetabular lesion. A lumbar artery pseudoaneurysm was observed following CA of an L2 secondary lesion. In 1 case, subcutaneous emphysema after CA of an ischiatic lesion was detected. In all the patients, the complications were successfully managed.

Conclusion:

Percutaneous thermal ablation techniques are minimally invasive and a safe option in the management of BM. In our study, the low rate of complications observed is related to an appropriate patient selection made by a multidisciplinary team with 10-years experience in this field.

Limitations:

A small sample size.

Ethics committee approval

n/a

Funding:

No funding was received for this work.