Medial branch neurotomy in low back pain.

INTRODUCTION: This study aimed to assess the effectiveness of pulsed radiofrequency medial branch dorsal ramus neurotomy in patients with facet joint syndrome. METHODS: From January 2008 to April 2010, 92 patients with facet joint syndrome diagnosed by strict inclusion criteria and controlled diagnostic blocks undergone medial branch neurotomy. We did not exclude patients with failed back surgery syndrome (FBSS). Electrodes (20G) with 5-mm active tip were placed under fluoroscopy guide parallel to medial branch. Patients were followed up by physical examination and by Visual Analog Scale and Oswestry Disability Index at 1, 6, and 12 months. RESULTS: In all cases, pain improvement was statistically significant and so quality of life. Three non-FBSS patients had to undergo a second neurotomy because of non-satisfactory pain decrease. Complications were reported in no case. CONCLUSIONS: Medial branch radiofrequency neurotomy has confirmed its well-established effectiveness in pain and quality of life improvement as long as strict inclusion criteria be fulfilled and nerve ablation be accomplished by parallel electrode positioning. This statement can be extended also to FBSS patients.

Metabolic and clinical assessment of efficacy of cryoablation therapy on skeletal masses by 18F-FDG positron emission tomography/computed tomography (PET/CT) and visual analogue scale (VAS): initial experience.

Various therapy modalities have been proposed as standard treatments in management of bone metastases. Radiation therapy remains the standard of care for patients with localized bone pain, but up to 30% of them do not experience notable pain relief. Percutaneous cryoablation is a minimally invasive technique that induces necrosis by alternately freezing and thawing a target tissue. This technique is successfully used to treat a variety of malignant and benign diseases in different sites. (18)F-FDG positron emission tomography/computed tomography ((18)F-FDG PET/CT) is a single technique of imaging that provides in a "single step" both morphological and metabolic features of neoplastic lesions of the bone. The aim of this study was to evaluate the efficacy of the cryosurgical technique on secondary musculoskeletal masses according to semi-quantitative PET analysis and clinical-test evaluation with the visual analogue scale (VAS). We enrolled 20 patients with painful bone lesions (score pain that exceeded 4 on the VAS) that were non-responsive to treatment; one lesion per patient was treated. All patients underwent a PET-CT evaluation before and 8 weeks after cryotherapy; maximum standardized uptake value (SUV(max)) was measured before and after treatment for metabolic assessment of response to therapy. After treatment, 18 patients (90%) showed considerable reduction in SUV(max) value (>50%) suggestive of response to treatment; only 2 patients did not show meaningful reduction in metabolic activity. Our preliminary study demonstrates that quantitative analysis provided by PET correlates with response to cryoablation therapy as assessed by CT data and clinical VAS evaluation.

Kummel disease treatment by unipedicular vertebral augmentation using curved injection cannula.

PURPOSE: This study was designed to evaluate the efficacy of the blunt-tipped curved injection needle (BCN) AVAflex (Care Fusion) for vertebral augmentation in cases of Kummel's disease. METHODS: We performed 25 vertebral augmentation procedures on 25 consecutive patients (11 men/14 women; mean age, 67 years) with Kummel's disease using the blunt-tipped curved injection needle with PMMA cement. We performed all 25 procedures by unipedicular left approach with patients in prone position under local anesthesia and mild sedation. In all cases, an intravertebral cleft was evident on preprocedural imaging. We evaluated pain intensities by Visual Analogic Scale (VAS) before and at first day, 6 months, and 1 year after procedure. RESULTS: In all cases the curved injection cannula permitted the filling of the clefts and surrounding cancellous bone without any complication. A significant reduction of kyphotic deformities of the treated vertebral bodies was evident. A significance decrease in VAS values at 1 year also was evident (mean decrease 7.2). At plain dynamic postprocedural X-rays checks, there was no sign of pathologic intravertebral motion as evidence of optimal stabilization. CONCLUSIONS: BCN AVAflex is a safe and effective device for targeted vertebral augmentation in cases of Kummel's disease. Its distinctive characteristic is the curved injection cannula, which enables targeting the cement injection to areas far off the trajectory of the straight access cannula, thus providing excellent cement spread throughout the entire volume of vertebral body.

Percutaneous vertebroplasty: the radiologist's point of view.

INTRODUCTION: Vertebral compression fractures (VCFs), usually caused by osteoporosis, is a disabling pathology associated with back pain, low quality of life and high costs. We report a retrospective study of 852 patients who underwent Percutaneous Vertebroplasty (PVP) in our department, for treatment of refractory back pain caused by osteoporotic vertebral fractures. OBJECTIVES: To evaluate the safety and the helpfulness of the PVP in vertebral osteoporotic fractures treatment and, particularly on durable pain reduction, mobility improvement and analgesic drugs need. MATERIALS AND METHODS: Follow-up analysis was made through a questionnaire filled by the patients before and after PVP (1-6 months), designed to measure pain, ambulation capacity, ability to perform activities of daily living (ADL) and analgesic drugs administration. RESULTS: A statistically significant difference between visual analogue scale (VAS) values before and after treatment has been observed. No difference between VAS values were observed at 1 and 6 months post-treatment period. The treated vertebrae number did not influence post-treatment VAS values during all the follow-up. Ambulation capacity and the ability to perform ADL have been improved following PVP. Patients also reported significant reduction in administration of medications after PVP. CONCLUSIONS: PVP is a safe and useful procedure in painful osteoporotic VCFs treatment, able to reduce pain, improve patients mobility and decrease analgesic drugs need.

Diagnostic and therapeutic joint injections.

Joint injection is a useful tool in the diagnosis of intra-articular pathology that may improve diagnostic performance of computed tomography (CT) and magnetic resonance (MR) imaging. Historically, conventional arthrography under fluoroscopy was the first method to be used to image indirectly the intra-articular soft tissues, but with the advent of CT, CT arthrography offered better soft tissue depiction. The development of conventional MR allowed even better visualization of soft tissues, and in the early 1990s, MR arthrography surpassed CT arthrography in popularity. Joint injections may also be performed for therapeutic reasons with different drugs, such as corticosteroids, anesthetics, or hyaluronic acid, which have been shown to provide pain relief in various circumstances. In this article, the technical principles for joint injection of the shoulder, knee, elbow, hip, ankle, and wrist, used for therapeutic or diagnostic reasons, are discussed. Indications, expected benefits, and risks are also analyzed.

Percutaneous vertebroplasty in the management of vertebral osteoporotic fractures. Short-term, mid-term and long-term follow-up of 285 patients.

OBJECTIVES: To evaluate the short-term, mid-term and long-term follow-up of 285 patients who had undergone percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture (VCF) in our department from 2003 to 2006, and, particularly, to analyse our data on the safety and the usefulness of PVP for durable pain reduction, mobility improvement and the need for analgesic drugs. MATERIALS AND METHODS: Follow-up analysis was made through a questionnaire completed by the patients before and after PVP (1 week, 1 year and 3 years). The results are reported by subdivision of patients into groups (by gender, age and number of treated vertebrae), with special reference to pain management, drug administration and quality of life. RESULTS: All patients (285) were followed up for 1 week, 186 for 12 months, and 68 patients were followed up for 3 years. One week after PVP all patients reported normal ambulation (with or without pain), and more than 95% were able to perform activities of daily living (ADL) either without pain or with mild pain. There was no difference in pain relief between the genders after 1 week's follow up, but after 3 years better analgesia results were observed in women. There was no statistically significant difference in the visual analogue scale (VAS) values before PVP between age groups (P = 0.7) and gender (P = 0.4); Patients younger than 75 years had better outcomes than did older ones (>75 years) at 1 week and 1 year follow up. Patients also reported significant reduction in drug therapy for pain. CONCLUSIONS: PVP is a safe and useful procedure for the treatment of vertebral osteoporotic fractures. It produces enduring pain reduction, improves patients' mobility and decreases the need for analgesic drugs.

Hospital organization and importance of an interventional radiology inpatient admitting service: Italian single-center 3-year experience.

In June 2005 a Complex Operating Unit of Interventional Radiology (COUIR), consisting of an outpatient visit service, an inpatient admitting service with four beds, and a day-hospital service with four beds was installed at our department. Between June 2005 and May 2008, 1772 and 861 well-screened elective patients were admitted to the inpatient ward of the COUIR and to the Internal Medicine Unit (IMU) or Surgery Unit (SU) of our hospital, respectively, and treated with IR procedures. For elective patients admitted to the COUIR's inpatient ward, hospital stays were significantly shorter and differences between reimbursements and costs were significantly higher for almost all IR procedures compared to those for patients admitted to the IMU and SU (Student's t-test for unpaired data, p < 0.05). The results of the 3-year activity show that the activation of a COUIR with an inpatient admitting service, and the better organization of the patient pathway that came with it, evidenced more efficient use of resources, with the possibility for the hospital to save money and obtain positive margins (differences between reimbursements and costs). During 3 years of activity, the inpatient admitting service of our COUIR yielded a positive difference between reimbursements and effective costs of 1,009,095.35 euros. The creation of an inpatient IR service and the admission of well-screened elective patients allowed short hospitalization times, reduction of waiting lists, and a positive economic outcome.

Cost-effectiveness of percutaneous vertebroplasty in osteoporotic vertebral fractures.

A retrospective study was conducted in 179 consecutive patients (48 males, 131 females; mean age: 72.0 +/- 8.59 years; range: 51-93) with single symptomatic acute amyelic osteoporotic vertebral fracture presenting between September 2004 and September 2005 to the Santa Lucia Foundation in Rome, Italy. Vertebral fractures usually become manifest due to pain which can be debilitating. Treatment depends on the presence or absence of spinal cord involvement. In the first case, surgical stabilization is mandatory. In the second case, treatment may be performed either by conservative medical therapy (CMT) or percutaneous vertebroplasty (PVT). The aim of this study was to evaluate the effectiveness, costs and cost-effectiveness of percutaneous vertebroplasty. After 2 weeks of analgesic therapy, 153 patients presented refractory pain and were offered treatment by PVT. A total of 58 patients accepted and underwent PVT (PVT group), while 95 refused and underwent conservative medical therapy (CMT group). Follow-up was performed by specialist consults, spine radiography and MRI and a self-assessment questionnaire evaluating pain using a Visual Analogue Scale (VAS) and function using an ambulation and an Activities of Daily Living (ADL) scale. A 12-month follow-up was obtained in 86 of 95 (90.5%) CMT group patients and 54 of 58 (93.1%) PVT group patients. Significant reduction of VAS and improvement of ambulation and ADL was observed in both groups at 1 week and 3 and 12 months (P < 0.05; Wilcoxon signed rank test), however, these results were significantly superior in the PVT group at 1 week and 3 months (P < 0.05; Mann-Whitney U test). Average cost per patient at 1 week and 3 and 12 months were respectively 755.49 +/- 661.96, 3791.95 +/- 3341.97 and 4299.55 +/- 3211.53 euros (CMT group) and 3311.35 +/- 0.32, 3745.30 +/- 3.59 and 4101.05 +/- 755.41 euros (PVT group). PVT resulted significantly more cost-effective than CMT with regards to the three scales at 1 week (P < 0.05; Mann-Whitney U test). At 3 months PVT was more cost-effective than CMT with regards to the three scales, however, the difference was significant only with regards to ambulation. No significant differences in cost-effectiveness where found between the two groups at 12 months. PVT should be considered the treatment of first choice in symptomatic acute amyelic osteoporotic vertebral fractures with refractory pain after a short period of analgesic therapy.

Percutaneous cryoablation and vertebroplasty: a case report.

A 70-year-old man with a painful vertebral metastasis was treated with combined percutaneous cryoablation and vertebroplasty therapy (CVT) in one session. The patient was suffering from diffuse visceral metastasized cholangiocarcinoma. After several weeks of back pain, magnetic resonance imaging documented a single L2 bone metastasis. In consultation with the oncologists, palliative combined CVT was administered with the aim of obtaining pain relief and bone stabilization. In our experience this combined treatment is safe and effective for immediate pain relief in painful bone metastases when other standard palliative treatments have failed.

Percutaneous combined therapy for painful sternal metastases: a radiofrequency thermal ablation (RFTA) and cementoplasty protocol.

BACKGROUND: Radiofrequency thermal ablation (RFTA) has recently been introduced for the treatment of painful bone metastases. We report the outcome of one combined protocol session of percutaneous RFTA and cementoplasty on a painful sternal breast cancer metastasis of a 66-year-old patient. PATIENTS AND METHODS: A sternal lesion was identified at a repeated CT scan during the oncological follow-up. Due to severe chest pain, the patient was treated percutaneously to obtain pain relief and bone stabilization. Percutaneous RFTA was performed using a 15-gauge needle electrode (MIRAS TX-120) coaxially introduced through a 13-gauge bone biopsy needle. The lesion was heated up to 80 degrees C for 3 minutes. A percutaneous injection of 1 cc polymethylmethacrylate in the central part of the lesion was performed immediately after the RFTA procedure. RESULTS: Immediate symptomatic improvement was documented. CONCLUSION: Combined percutaneous therapy showed feasibility and effectiveness and can be considered as an alternative for the treatment of painful bone metastases.