Vertebroplasty as a Treatment for Primary Benign or Metastatic Cervical Spine Lesions: Up to One Year of Follow-up.

This paper illustrates the validity of vertebroplasty (VP) in patients with primary benign or metastatic lesion in the cervical spine. From January 2006 to December 2007, ten consecutive patients were treated with VP for a total of ten vertebral bodies: two symptomatic vertebral haemangiomas at C5 and C4.3, multiple myeloma at C2 (two cases) and one case at C4, five patients with vertebral metastasis from breast or lung cancer at C2, C4 (three cases) and C5. All the patients complained of pain resistant to continuous medical management. All procedures were performed under general anaesthesia by anterolateral approach under CT or fluoroscopy control with manual dislocation of the carotid axis. A transoral approach under fluoroscopy was performed to treat the C2 lesion. Bone biopsy was never performed. VP was performed to prevent fracture after implantation of a double discal prothesis in two patients. For patients with multiple myeloma, VP was performed to prevent new vertebral fracture. VP was performed before of radiotherapy in three patients with metastasis, and just after radiotherapy in two. Two metastatic patients were lost at one year follow-up due to death from systematic diffusion. Results were evaluated on the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODS). A successful outcome was observed with a complete resolution or partial reduction of pain in 90% of patients 24-72 hours after VP. At 12 months follow-up, we recorded a reduction of four points in the VAS evaluation and a 45% reduction in the ODS score. No extravertebral vascular or discal cement leakage was observed. At 12 months, X-ray follow-up showed a stable result. Percutaneous treatment with VP for benign or malignant cervical spine lesions is a valuable, mini-invasive and quick method that allows a complete and enduring resolution of painful vertebral symptoms without fracture of the adjacent or distal vertebral bodies.

Medical therapy and multilevel vertebroplasty in osteoporosis: when and why.

Vertebroplasty (VP) is a mini-invasive percutaneous technique for the treatment of symptomatic, vertebral body fracture (VBF) caused by porotic or other diseases and its outcome has now been demonstrated by many trials. Beyond the results of these trials on the efficacy and safety of VP, the real problem for patients with osteoporotic and non-osteoporotic vertebral fractures is the risk of new fractures to adjacent or distant vertebra following VP that is reported to range from 10% to 30%. It is still unclear whether this is related to the natural history of the underlying disease (osteoporotic and non-osteoporotic diseases) or to the treatment, especially when a single vertebral fracture in an osteoporotic patient is highly predictive of future fractures. To prevent new fractures to adjacent or distant vertebra following VP in porotic patients multiple non-pharmacologic interventions are recommended (diet with vitamin D or calcium supplements, smoking cessation, exercise) in addition to a specific medical therapy to block the activation of osteoclast cells responsible for bone resorption, and to re-establish correct bone remodeling. These drugs include anti-catabolic drugs: bisphosphonate, oestrogen hormone, and anabolic drugs: PTH analogues and strontium ranelate. Bisphosphonate are the most commonly used compounds to treat postmenopausal osteoporosis. However, medical treatment appears to be too slow to prevent the natural history of patients with VBF. One session multilevel VP could be performed to prevent vertebral refracture risk in porotic or non-porotic patients with recurrent VBFs also after the first VP even if there is not a true vertebral collapse. Even if there are no limits to how many body levels can be treated in one session, European and American guidelines suggest doing no more than three body levels in the same session to reduce patient discomfort, and to prevent peri-procedural anesthesiologic problems, like uncontrolled fat-embolism, cement leakage, and pulmonary embolism, that could be increased. How many vertebrae could be treated in same session could be analyzed beforehand based on MDCT vertebral morphology and trabecular structure, or on MRI-signal changes. Added to medical therapy, multilevel VP can be performed in selected cases to treat VBF related to osteoporosis, preventing fractures or refracture without any further thrombo-embolic or fat uncontrolled embolism peri or post-procedural complications.

Endovascular treatment of a fusiform cerebral aneurysm by stenting alone. Two case reports and literature review.

This paper illustrates two cases of stent-in-stenting treatment of unruptured, symptomatic, fusiform intracerebral aneurysms. Two unruptured symptomatic fusiform intracerebral aneurysms were treated by the stent-in-stent only technique. The first patient, a 35-year-old woman, had a partially thrombosed fusiform aneurysm in the left carotid siphon with the chief complaint of headache and left ophthalmoplegia. The second patient, a 60-year-old man, had a symptomatic fusiform aneurysm of the left V4 with recurrent transient ischemic attacks. No cervical trauma or infection was present in either patient. A CT, CTA and DSA were performed on hospital admission. Both patients were previously premedicated with Clopidrogel + ASA for five days before treatment. By DSA, both patients were treated under general anesthesia with a heparin protocol plus ASA (500mg) at stent placement. A double stent-in stent was placed in both patients. Post-intervention medical therapy was clopridogel and ASA for three months, then aspirin (100mg) daily for six months. CTA and DSA were performed at six and 12 months. Both stents were positioned without any difficulty and could be navigated within cerebral arteries without any exchange procedure, and thanks to their retractability, they were accurately positioned. No bleeding at post-treatment CT was noted. At 12 months follow-up, a complete disappearance of the aneurysm and preservation of the parent vessel was observed for both patients. No procedure-related complication occurred. No intra-stent stenosis or intimal hyperplasia was observed. Stenting for fusiform aneurysms is a safe procedure without complications. Medical therapy pre-post procedure associated with follow-up is necessary to prevent/establish the incidence of occlusion.

Vertebroplasty as treatment of aggressive and symptomatic vertebral hemangiomas: up to 4 years of follow-up.

INTRODUCTION: This study aimed to illustrate the validity of the treatment with vertebroplasty (VP) in patients with aggressive or symptomatic vertebral hemangioma (VH) with or without epidural extension. METHODS: From January 2003 to December 2007, 24 consecutive patients have been treated with VP, for a total of 36 vertebral bodies affected by VH: two cervical, ten dorsal, 24 lumbar. All the patients complained of a pain syndrome resistant to continuous medical medication; four of 24 patients also presented aggressive magnetic resonance features of the vertebral lesion and two patients showed also epidural extension. A unipedicular approach has been performed in 16 patients; a bipedicular approach has been performed in six, while for the cervical spine an anterior-lateral approach with manual dislocation of the carotid axis has always been performed. Bone biopsy was never done. All procedures have been carried out with local anesthesia, except for the treatment of the cervical hemangiomas which has always been performed under general anesthesia. Four vertebral bodies in the same session have been treated in one case. RESULTS: Results have been evaluated with the visual analog scale and the Oswestry Disability Index methods. In all the patients, in the following 24-72 h, a successful outcome has been observed with a complete resolution of pain symptom. Extravertebral vascular or discal cement leakage has been observed in four patients, without any onset of clinical radicular syndrome due to epidural diffusion. Clinical and radiological follow-up until 4 years has been performed in 12 patients and it showed stability of the treatment and absence of pain. CONCLUSIONS: Percutaneous treatment with VP for aggressive and symptomatic vertebral hemangiomas even with epidural extension is a valuable, mini-invasive, and quick method that allows a complete and enduring resolution of the painful vertebral symptoms without findings of fracture of a vertebral body adjacent or distant to the one treated.

Management of vertebral re-fractures after vertebroplasty in osteoporotic patients.

SUMMARY: This study illustrates the usefulness of vertebral biopsy in osteoporotic patients previously treated with vertebroplasty (VP) who present at follow-up with a new fracture in a vertebral soma adjacent or distant from the collapsed vertebral body. Five hundred and fifty patients with osteoporotic vertebral collapse underwent a minimally invasive treatment with vertebroplasty (VP) for a total of 980 vertebral bodies. The approach was unipedicular in 520 patients and bipedicular in 30. Only cases with unclear findings at MR or CT (23 patients) were scheduled for a vertebral biopsy before VP treatment. The biopsy results were positive for haematological disease in only eight patients. A vertebral biopsy was carried out during re-treatment with VP in all patients who presented a vertebral refracture in the three month follow-up at a site adjacent to or distant from the previously treated vertebra (21 patients). We have found new fractures of adjacent vertebrae in 15 patients and new fractures of distant vertebrae in 16 patients at three month follow-up examination. Five of the 31 cases (16%) of spinal refracture, where during vertebroplasty treatment a bone biopsy and a sternal medullary aspiration had been carried out, an anatomopathological response to multiple myeloma was responsible for the refracture. It is useful to perform a spinal bone biopsy during re-treatment of the vertebroplasty procedure to rule out multiple myeloma or other disease as the cause of the new collapse in patients with osteoporotic disease presenting a new vertebral fracture in an adjacent or distant site from the previously collapsed vertebral body.

Vertebroplasty and kyphoplasty: friends or foes?

PURPOSE: This paper aims to compare vertebroplasty and kyphoplasty by illustrating the two techniques, analysing the results and discussing the indications in relation to the type of fracture. MATERIALS AND METHODS: Vertebroplasty was performed on 805 vertebral bodies in 485 patients affected by osteoporosis (310), metastasis (160) and vertebral haemangioma (15). The approach was unipedicular in 365 patients and bipedicular in 120 patients. Biopsies were obtained in patients with no known primary cancer (75). Kyphoplasty was performed in 39 patients with Magerl type A1 and A3 fractures within 3 months from the trauma. A bipedicular approach was used in all cases. RESULTS: Outcomes were assessed on the basis of the visual analogue scale and the Oswestry Disability Index. In patients treated with vertebroplasty, success rates at 24-72 h were 90% for osteoporotic fractures, 100% for vertebral haemangiomas and 77% for metastatic fractures. Extravertebral vascular or discal leakage of cement occurred in 39 patients, but only two of them reported radicular pain due to epidural involvement. Osteoporotic patients developed new vertebral fractures at adjacent levels in 25 cases and at distal levels in 19 cases. In patients treated with kyphoplasty, pain relief was achieved within one month after treatment in 90% of cases. None of the patients wore orthotic braces after treatment, and no vertebral collapse was observed. CONCLUSIONS: Vertebroplasty and kyphoplasty are both useful in the management of vertebral pain. In light of our experience, vertebroplasty is better indicated for vertebral fractures due to osteoporosis, haemangioma or metastasis on account of its simplicity and minimal invasiveness. Kyphoplasty is suggested in acute traumatic fractures of type A1 and A3 according to Magerl, as it allows recovery of vertebral stability and a better distribution of the cement.

Posterior fossa arteriovenous pial fistula: diagnostic and endovascular therapeutic features. A case report.

Intracranial arteriovenous fistulas (AVFs) are rare vascular cerebral lesions composed of one or more cortical-pial arterial feeders directly connected with a single draining vein. They differ from the other AV malformations in that they lack a nidus and are located outside the dural leaflets. Because of high flow and pressure AVFs have a high risk of hemorrhage and if untreated cause death in up to 63% of cases. Treatment can be endovascular or microneurosurgical. We describe an infant with hydrocephalus and raised intracranial pressure and MRI findings of a single dilated venous vessel with a proximal varix in the perimedullary spaces confirmed by CT angiography and DSA that found a single artery-single vein fistula we successfully occluded with GDC coils.

Vertebroplasty in the treatment of spine disease.

SUMMARY: We report our experience in the treatment of thoracic and lumbosacral spinal pain due to vertebral bone fractures. This pathology can be related to osteoporosis but also to metastatic disease and less frequently vertebral haemangioma. From April 2001 through December 2004 we treated 238 patients for a total of 455 vertebral bodies. 175 patients had osteoporosis, 70 had metastasis and 13 had vertebral haemangioma. Sacroplasty was performed in six patients to obtain a cement filling of sacral metastasis. The procedures were mostly performed under fluoroscopy and only in cases of metastasis or sacroplasty was CT/fluoroscopy guidance preferred for optimal filling of the area of osteolysis. We evaluated the results at six and 18 months follow-up and analysed the incidence of new vertebral fractures, vascular and disk leakage and the incidence of major and minor complications. Biopsy was performed only in doubtful cases. We obtained different results considering the etiology of the disease. We obtained a 92% success rate at six months follow-up and 89% success at 18 months follow-up in osteoporosis, a 77% and 72% success rate at six and 18 months follow-up in metastastic patients, and no change at six and 18 months follow-up in patients with vertebral haemangioma in which the success rate was of 95%. We noted extravertebral leakage in 41% of vertebral bodies of which 31% were treated at the level of the vascular space and only 10% at the level of the disk space, and symptomatic in only two cases (acute compressive radiculitis, medically treated and resolved within a month). Six patients presented new fractures in the adjacent vertebral body and 30% had a partial recovery in the height of the vertebral body with kyphosis curve reduction. Vertebroplasty is a good technique to obtain spine pain relief and has a low incidence of side effects. Good quality equipment is important to obtain these results.

[Gadolinium-DTPA in the study of intracranial tumors in the adult]. / Apport du gadolinium-DTPA à l'étude des tumeurs intracrâniennes de l'adulte.

Thirty intracranial tumours were explored by MRI, using T1- and T2-weighted sequences, before and after intravenous injection of Gd-DTPA. Two-thirds of the intra-axial tumours were accurately detected on one section plane by MRI without Gd-DTPA, but in one quarter of the cases Gd-DTPA only delineated precisely the tumour. On the other hand, Gd-DTPA failed to detect certain tumours (benign gliomas) or showed only a small part of them (mixed grade gliomas), while they were detected by MRI without contrast injection. However, in such cases Gd-DTPA was useful for the stereotaxic biopsy of the tumour. Gd-DTPA appears of lesser interest in extra-axial tumours. Gd-DTPA is thus valuable for the neuroradiological diagnosis of brain tumours, particularly to evaluate the grade of gliomas and to confirm the diagnosis of recurrent growths.