CT-guided transforaminal cervical and lumbar epidural injections.

Transforaminal injections are widely used. Serious complications including strokes and paraplegia have been reported after transforaminal injections of corticosteroids, and the Afssaps (2011) has issued a warning about their use [1]. The needle must be positioned in the posterior aspect of foramen, and its correct placement validated by an injection of contrast product. It is preferable to choose cortivazol (Altim(®)) as the corticoid for injection. This procedure is simple, reproducible, and durably effective in 60 to 70% of cases. Complications and adverse effects are rare but potentially serious: allergies, blood pressure surge, vasovagal syncope, transient exacerbation of pain, infection, stroke, and paraplegia. The aim of this course is to stress the need for rigor - in the indication, the technical performance of the procedure, and the overall management of the patient.

[Percutaneous vertebroplasty -- the role of osseous phlebography]. / Die perkutane Vertebroplastie -- Rolle der ossären Phlebographie.

PURPOSE: To evaluate the usefulness of osseous phlebography preceding percutaneous vertebroplasty. MATERIALS AND METHODS: Seventy-five patients with painful osteoporotic (57) or malignant (18) vertebral fractures were treated by percutaneous vertebroplasty under fluoroscopic control. Prior to cement injection, osseous phlebography was performed, with 247 phlebographic studies included in the retrospective correlation with radiographic and CT images. Clinical results were assessed by standardized questionnaire. RESULTS: In 69/75 (92 %) patients, pain and mobility improved and medication needed for pain control decreased significantly after vertebroplasty. Two clinically apparent complications occurred. The results of osseous phlebography prompted correction of the needle position in 34/247 (14 %) of the procedures and cancellation of the cement injection in 19/247 (8 %). No complications occurred related to osseous phlebography. CT was superior to conventional radiography in detecting extra-osseous cement leakage (106/247 by CT vs. 63/247 by conventional radiography). The cement leakage was asymptomatic in 104/106 (98 %) cases for the duration of follow-up. DISCUSSION: Osseous phlebography prior to percutaneous vertebroplasty had a significant impact on the procedure in our retrospective study and was able to predict the cement distribution in the majority of cases. However, phlebography was unable to foresee and therefore prevent 2 clinically relevant complications. Complications related to phlebography did not occur.

[Lenticulostriate aneurysms. Radioclinical study]. / Anévrysme des artères lenticulostriées. Etude radioclinique à propos de quatre observations et revue de la littérature.

The authors report four cases of aneurysm of the lenticulostriate arteries, three idiopathic and one with underlying MoyaMoya disease. This unusual pathology, which often affects young patients, is revealed by a meningeal syndrome and sometimes focal neurological signs. The bleeding is highlighted by a CT scan without contrast injection, even by MRI, these examinations making it possible to evaluate its repercussion. Arteriography or MRA show the aneurysm and eliminate vascular malformation. According to literature (15 cases published) and our experience, considering the difficulty of a surgical or endovascular approach, morbidity and the frequency of spontaneous thromboses, it seems that a conservative management is justified after a negative etiologic check-up and under radio-clinical monitoring.

[Percutaneous vertebroplasty]. / Perkutane Vertebroplastie.

PURPOSE: To describe the procedure of percutaneous vertebroplasty and to present our first clinical results of patients treated for benign or malignant painful vertebral body disease. MATERIAL AND METHODS: We performed percutaneous vertebroplasty in 31 painful lesions of the spine. Liquid bone cement was injected into the affected vertebral body using fluoroscopic guidance through a bilateral transpedicular approach. Etiology of the bone disease was assessed by biopsy. Pain intensity was assessed before and 1 week after the procedure by standardized catalogue. RESULTS: Percutaneous vertebroplasty was performed in 17 thoracic and in 14 lumbar spine bodies of benign (n = 23) or malignant (n = 8) disease; no clinically relevant complications occurred. All patients reported significant pain relief 1 week after the intervention. One week after treatment, patients were pain-free in 15/31 vertebral bodies, and reported mild residual pain not necessitating narcotic medication in 16/31 cases. CONCLUSION: In accordance with the literature, percutaneous vertebroplasty proved to be a highly effective, minimal invasive interventional procedure to treat severely painful bone lesions of benign and malignant origin.

Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty.

OBJECTIVE: To assess the immediate and long-term efficacy and safety of percutaneous vertebroplasty with polymethylmethacrylate (PMMA) for the treatment of refractory pain resulting from osteoporotic vertebral fractures. METHODS: A retrospective, open study of percutaneous vertebroplasty (PV) was conducted with long-term follow-up. PV with PMMA was carried out between 1990 and 1996 in 40 patients with symptomatic osteoporotic vertebral fracture(s) that had not responded to maximum medical therapy. In 1997, each patient was asked to come back to our institution for a physical and spinal X-ray examination. Efficacy was assessed by changes over time in pain on Huskisson's visual analogue scale (VAS). RESULTS: Thirty-four vertebrae treated by PV in 25 patients were evaluated with long-term follow-up. The mean duration of follow-up was 48 months (range 12-84 months). Pain assessed by the VAS significantly (P<0.05) decreased from a mean of 80 mm+/-16 (S.D.) before PV to 37+/-24 mm after 1 month and 34+/-28 mm at the time of maximal follow-up. There was no severe complication related to this treatment, and no progression of vertebral deformity in any of the injected vertebrae. However, there was a slight but significantly increased risk of vertebral fracture in the vicinity of a cemented vertebra (odds ratio 2.27, 95% confidence interval 1.1-4.56). The odds ratio of a vertebral fracture in the vicinity of an uncemented fractured vertebra was 1.44 (0.82-2.55). CONCLUSION: PV appears to be a safe and useful procedure for the treatment of focal back pain secondary to osteoporotic vertebral fracture when conservative treatment has failed.

Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results.

Percutaneous vertebroplasty with acrylic cement consists of injecting polymethylmethacrylate into vertebral bodies destabilized by osseous lesions. The aim is to obtain an analgesic effect by reinforcing lesions of the spine. The major indications are vertebral angiomas, osteoporotic vertebral crush syndromes, and malignant spinal tumors. The clinically significant complications occur predominantly in patients with spinal metastatics, but in the great majority of cases they resolve with medical treatment.

[Percutaneous vertebral surgery. Technics and indications]. / Vertébroplasties percutanées. Technique et indications.

Percutaneous vertebroplasty is a technique of interventional radiology, which allows to fulfill pathologic vertebral body with acrylic cement. This method is used to strengthen the vertebral body and reduce pain in some diseases involving the vertebra. Main indications are spine angiomas, metastases and osteoporosis. The vertebroplasty is realised under neuroleptanalgesia for cervical spine antero lateral way is used. For thoracic or lumbar vertebra, the way of approach is usually transpedicular; but in some cases, this approach is not possible: osteolysis of the pedicle, surgical osteosynthesis; in such cases, a postero lateral approach is realized. Technical incidents are not rare, but are usually asymptomatic. More frequent are venous filling with cement; the veins involved can be intra spinal (vertebral plexus) or paraspinal. Instead of this frequency pulmonary embolism in direct relation with the vertebroplasty where not reported. Extravasation in intervertebral disk or soft tissue can also be observed. This last incident can be in relation with the way of the needle or with a cortical rupture. Local complications are rare: rate of neurological deficit or infection is under 0.5%. Radicular pain is observed in 3.7% of cases. These complications are in close relation with the radiological involvement of the vertebra: cortical disruption, heterogeneous Lysis of the vertebral body. The frequency of complications is 1.3% in osteoporosis, 2.5% in spine angiomas and 10% in metastatic disease. Indications concern lesion involving the vertebral body: symptomatic spine angiomas; painful osteoporotic fractures after medical treatment or in patients with a high risk of decubitus complications; in metastatic disease, vertebroplasty is a way to consolidate the vertebral body and release pain. It can be usefull in recurrent pain after chemotherapy and/or radiotherapy, and also in unstable vertebra to obtain a stabilization before radiotherapic or chemotherapic treatment isolated or in combination with surgical osteosynthesis.

Percutaneous Vertebroplasty.

Percutaneous vertebroplasty (PVP) with acrylic cement [polymethylmethacrylate (PMMA)]consists of injecting PMMA into vertebral bodies weakened by osseous lesions. The aim of PVP with PMMA is to obtain an antalgic effect by consolidation in destructive lesions of the spine. There are three major indications: vertebral angiomas, osteoporotic vertebral crush syndromes, and malignant vertebral tumors. Indications in vertebral angiomas only concern patients with aggressive clinical signs (severe pain or nervous compression) and/or aggressive radiological signs. Indications in osteoporotic vertebral crush syndromes only concern patients suffering from back pain related to one or two adjacent vertebral collapses resistant to medical treatment for several weeks. Indications in malignant vertebral tumors only concern patients suffering from severe back pain related to a destruction of the vertebral body, not involving the major part of the cortical bone. Complications of PVP occur essentially in patients with vertebral metastasis. In the great majority of cases, these complications heal under medical treatment. In patients with osteoporotic vertebral crush syndromes or vertebral angiomas, the complications are represented by the increase or onset of radiculalgias (in less than 1%), which disappear after local anesthetic injection.

Intracerebral stenosing arteriopathies. Contribution of three radiological techniques to the diagnosis.

Fifty-one patients with intracerebral stenosing arteriopathy were studied by computerized tomography (CT), magnetic resonance imaging (MRI) and cerebral arteriography. Clinical symptoms were varied, included impaired cognitive functions, progressive neurological deficit, headache and vomiting, and were sometimes not suggestives of the diagnosis. CT scans of the brain were normal in 25 percent of the cases or they were not probative because of various and non-specific abnormalities (hypodensity of various types or haemorrhagic hyperdensity). MRI always showed abnormalities but in many cases the lesions observed on T2-weighted images consisted of non-specific focal areas of high-intensity signal in the white matter. High-intensity signals in both white matter and cortex seemed to be more suggestive of the diagnosis. In this as in other studies, arteriography therefore remains the reference examination for stenosing arteriopathies. Inflammatory, infectious and atheromatous processes are the main causes of these arterial lesions. The aetiological value of radiological examinations is poor, and in most cases the morphology and distribution of the lesions does not point to any specific origin. However, herpes zoster arteritis usually affects the proximal segments of the anterior and middle cerebral arteries and spares the carotid siphon.

[Acute neurologic complications of rubella]. / Complications neurologiques aiguës de la rubéole.

Two cases of rubella with neurological complications are reported. In one case an extensive atypical polyradiculoneuritis was associated with a late albumino-cytologic dissociation. The other presented as a transverse myelitis with meningitis and radiculitis. In neither case was an history of contagion or recent vaccination elicited, and no eruption appeared in either patient. Clinical onset was sudden, with an acute meningitis followed several days later by neurological deficits. The course was marked by successive phases of early rapid deterioration, stabilization and slow regression over several months. Sequelae were minimal. Diagnosis was based on a sharp fall in the ratio of serum/CSF levels of specific antibodies to the rubeola virus. This was sure evidence of the presence of intrathecal synthesis of specific antibodies.