Eugenio Rimondi

Percutaneous CT-guided biopsy of the spine: results of 430 biopsies

Biopsies of lesions in the spine are often challenging procedures with significant risk of complications. CT-guided needle biopsies could lower these risks but uncertainties still exist about the diagnostic accuracy. Aim of this retrospective study was to evaluate the diagnostic accuracy of CT-guided needle biopsies for bone lesions of the spine. We retrieved the results of 430 core needle biopsies carried out over the past fifteen years at the authors’ institute and examined the results obtained. Of the 430 biopsies performed, in 401 cases the right diagnosis was made with the first CT-guided needle biopsy (93.3% accuracy rate). Highest accuracy rates were obtained in primary and secondary malignant lesions. Most false negative results were found in cervical lesions and in benign, pseudotumoral, inflammatory, and systemic pathologies. There were only 9 complications (5 transient paresis, 4 haematomas that resolved spontaneously) that had no influence on the treatment strategy, nor on the patient’s outcome. In conclusion we can assert that this technique is reliable and safe and should be considered the gold standard in biopsies of the spine.

Meniscal Allograft Transplantation Without Bone Plugs A 3-Year Minimum Follow-up Study

Background: Meniscal allograft transplantation is a viable option for subtotally meniscectomized and totally meniscectomized symptomatic patients and potentially results in pain relief and increased function. Hypothesis: The use of a single tibial tunnel arthroscopic technique without bone plugs will reduce symptoms (pain) and improve knee function at a minimum 3-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Thirty-two meniscal transplantations (16 medial, 16 lateral; 23 men, 9 women) were prospectively evaluated at a minimum of 36 months (mean, 40.4 ± 6.90 months; range, 36-66 months) after surgery. The average age at the time of surgery was 35.6 ± 10.3 years (range, 15-55 years). The transplantation was performed using an arthroscopic bone plug–free technique with a single tibial tunnel plus “all-inside” meniscal sutures. The anterior meniscal horn was sutured to the capsule. Follow-up included a visual analog scale (VAS) score for knee pain and subjective and objective International Knee Documentation Committee (IKDC), Lysholm, Tegner, and SF-36 scores. All patients underwent radiographic and magnetic resonance imaging (MRI) evaluation of the involved knee before the surgery and at the final follow-up. The MRI outcomes were evaluated with the modified Yulish score. Results: Regarding clinical evaluation, there was a significant improvement in scores at follow-up compared with preoperatively: the VAS score decreased from 70.6 ± 21.7 to 25.2 ± 22.7 (P < .0001), the SF-36 physical component score increased from 37.31 ± 7.2 to 49.69 ± 8.3 (P < .0001), the SF-36 mental component score increased from 49.69 ± 10.8 to 53.53 ± 7.5 (P = .0032), the Tegner activity score increased from 3 (range, 3-5) to 5 (range, 3-6) (P < .0121), the Lysholm score increased from 59.78 ± 18.25 to 84.84 ± 14.4 (P < .0001), the subjective IKDC score increased from 47.44 ± 20.60 to 77.20 ± 15.57 (P < .0001), and the objective IKDC score changed from 1 A, 21 B, 6 C, and 4 D to 22 A, 9 B, and 1 C (P < .0001). No significant difference was found in this study between patients who received medial allografts and patients who received lateral allografts. There was no significant difference between outcomes of patients with isolated and combined procedures. The MRI findings showed 69% extruded allografts (8 medial and 14 lateral). In detail, we found 50% of the medial allografts and 87% of the lateral allografts extruded. No significant difference in clinical outcomes and modified Yulish score was found between patients with extruded allografts and with in situ allografts. The MRI results also showed a significant decrease of the modified Yulish score from baseline to 3-year minimum follow-up (P < .0001 for femur and P < .0001 for tibia). Only one patient underwent arthroscopic selective meniscectomy because of a medial posterior horn retear of the graft. One patient developed lack of flexion and underwent an arthroscopic arthrolysis. These 2 patients did not draw benefit from allografting and therefore were considered failures. In all remaining cases (94%), meniscal allograft transplantation was able to reduce symptoms (pain measured by VAS) and improve knee function (as measured by IKDC and Lysholm scores). Conclusion: This study found that a single tibial tunnel arthroscopic technique without bone plugs for meniscal allograft transplantation significantly reduced pain and improved knee function in 94% of patients at a minimum 3-year follow-up.

Radiofrequency thermoablation of primary non-spinal osteoid osteoma: optimization of the procedure

Osteoid osteoma is a small benign tumor that requires treatment due to the intense pain it causes. Surgical therapy has been the ablative technique of choice after a failure of medical therapy. Recently, numerous less invasive, alternative procedures have been proposed: drill trepanation with or without ethanol injections, cryoablation, and thermoablation with laser or radiofrequency. The aim of this review is to retrospectively assess the effect of radiofrequency (RF) thermoablation in the treatment of primary non-spinal osteoid osteoma. From June 2001 to July 2003, we treated 106 patients affected by osteoid osteoma with RF thermoablation. Five patients with spinal osteoid osteoma and four with a previously treated osteoma were excluded from the study. In this paper, we assess the results obtained in a selected group of 97 primary non-spinal osteoid osteoma. The lesions were predominantly in the metaphysics of the femur. Central nidus calcifications were frequent and there was no prevalence for which side they occurred. Primary success was achieved in 82 patients (85%), while we obtained secondary success in 15 patients (15%). In two patients (2%), pain persisted between the two treatments and failed to be resolved, even after the second treatment; therefore, surgical excision was performed and complete resolution was obtained. No complications were reported. In conclusion, our results confirm that the treatment of choice for non-spinal osteoid osteoma is RF thermoablation, offering several advantages over ablative techniques.

Palliative therapy for osteosarcoma.

Despite advances in diagnostic imaging, the evolution of neoadjuvant chemotherapy and the refinements in limb-salvage surgery, the progression-free survival rate remains poor for patients with metastatic, recurrent or unresectable osteosaroma. Different therapeutic strategies for these subgroups of patients have been employed to control disease and prolong survival. Treatment options are limited and controversial, including systemic and localized therapies. Surgical resection, whenever feasible, is still the standard treatment in advanced osteosarcoma. The role of chemotherapy is unclear while the use of radiotherapy, embolization and thermal ablation is increasing. New therapeutic experimental approaches and novel target therapies are needed to improve the outcome of these subgroups of patients.

Prevalence of thoracolumbar vertebral fractures on multidetector CT: Underreporting by radiologists

OBJECTIVE To evaluate the prevalence of osteoporotic vertebral fractures in patients undergoing multidetector computed tomography (MDCT) of the chest and/or abdomen. MATERIALS AND METHODS 323 consecutive patients (196 males, 127 females) with a mean age of 62.6 years (range 20-88) who had undergone chest and/or abdominal MDCT were evaluated. Sagittal reformats of the spine obtained from thin section datasets were reviewed by two radiologists and assessed for vertebral fractures. Morphometric analysis using electronic calipers was performed on vertebral bodies which appeared abnormal upon visual inspection. A vertebral body height loss of 15% or more was considered a fracture and graded as mild (15-24%), moderate (25-49%) or severe (more than 50%). Official radiology reports were reviewed and whether the vertebral fractures had been reported or not was noted. RESULTS 31 out of 323 patients (9.5%) had at least 1 vertebral fracture and 7 of those patients had multiple fractures for a total of 41 fractures. Morphometric grading revealed 10 mild, 16 moderate and 15 severe fractures. Prevalence was higher in women (14.1%) than men (6.6%) and increased with patients age with a 17.1% prevalence in post-menopausal women. Only 6 out 41 vertebral fractures (14.6%) had been noted in the radiology final report while the remaining 35 (85.45) had not. CONCLUSION although vertebral fractures represent frequent incidental findings on multidetector CT studies and may be easily identified on sagittal reformats, they are often underreported by radiologists, most likely because of unawareness of their clinical importance.

Selective embolization with N-butyl cyanoacrylate for metastatic bone disease.

PURPOSE To evaluate the clinical and imaging effect of selective embolization using N-butyl cyanoacrylate (NBCA) as palliation for bone metastases. MATERIALS AND METHODS The procedures and effect of 309 embolizations performed in 243 patients were retrospectively analyzed; 56 patients had repeat embolization at the same location at 1-3 months; 197 patients had embolization for progressive bone metastases after radiation therapy. The mean tumor diameter before embolization was 7.8 cm (range 5-30 cm). In all patients, embolizations were performed under local anesthesia through transfemoral catheterization using NBCA in 33% ethiodized oil. The technical success of embolization was evaluated by angiography after completion of the procedure. The clinical and imaging effect was evaluated at follow-up examinations with a pain score scale and use of analgesics, hypoattenuating areas, tumor size, and ossification. RESULTS In all 309 embolizations, postprocedural angiography showed complete occlusion of metastatic blood supply and greater than 80% devascularization of the lesions. Greater than 50% reduction of pain score and analgesic doses was achieved in 97% of procedures. The mean duration of pain relief was 8.1 months (range 1-12 months). The mean maximal tumor diameter after embolization was 5.5 cm (range 2-20 cm). Variable ossification appeared in 65 patients. Postembolization syndrome, ischemic pain at the site of embolization, paresthesias, skin breakdown, and subcutaneous necrosis were observed in 87 patients. CONCLUSIONS Selective embolization with NBCA is a safe and effective palliative treatment for metastatic bone lesions of various primary cancers; pain relief is temporary.

Post traumatic myositis ossificans: Sonographic findings

The aim of this paper is to describe the sonographic (US) features of post traumatic myositis ossificans (PTMO).

Conservative treatment of spontaneous osteonecrosis of the knee in the early stage: Pulsed electromagnetic fields therapy

BACKGROUND HYPOTHESIS pulsed electromagnetic fields treatment might improve symptoms in the early stage of spontaneous osteonecrosis of the knee. METHODS Twenty-eight patients (19M/9F, age 49.8±16.4 years) suffering from symptomatic (pain) Koshino stage I spontaneous osteonecrosis of the knee, confirmed by magnetic resonance imaging (MRI) were treated with local pulsed electromagnetic fields therapy (6 h daily for 90 days). Clinical evaluation: baseline, 6- and 24-month follow-up by VAS for pain, knee society score (KSS), Tegner and EQ-5D scales. MRI evaluation: baseline and 6-month follow-up, measuring bone marrow lesions areas and grading these lesions by WORMS score. Failures: patients undergoing knee arthroplasty. RESULTS Pain significantly reduced at 6 months (from 73.2±20.7 to 29.6±21.3, p<0.0001), which remained almost unchanged at final follow-up (27.0±25.1). KSS significantly increased in first 6 months (from 34.0±13.3 to 76.1±15.9, p<0.0001) and was slightly reduced at final follow-up (72.5±13.5, p=0.0044). Tegner median level increased from baseline to 6-month follow-up (1(1-1) and 3(3-4), respectively, p<0.0001) and remained stable. EQ-5D improved significantly throughout the 24 months (0.32±0.33, baseline; 0.74±0.23, 6-month follow-up (p<0.0001); 0.86±0.15, 24-month follow-up (p=0.0071)). MRI evaluation: significant reduction of total WORMS mean score (p<0.0001) and mean femoral bone marrow lesions area (p<0.05). This area reduction was present in 85% and was correlated to WORMS grading both for femur, tibia and total joint (p<0.05). Four failures (14.3%) at 24-month follow-up. CONCLUSIONS Pulsed electromagnetic fields stimulation significantly reduced knee pain and necrosis area in Koshino stage I spontaneous osteonecrosis of the knee already in the first 6 months, preserving 86% of knees from prosthetic surgery at 24-month follow-up. No correlation was found between MRI and clinical scores. LEVEL OF EVIDENCE Level IV; case series.

Selective arterial embolisation for bone tumours: experience of 454 cases

PurposeThe authors present the experience of a single institution with selective arterial embolisation for primary and metastatic bone tumours.Materials and methodsA total of 365 patients were treated with 454 embolisation procedures from December 2002 to April 2010. Embolisation was the primary treatment for benign bone tumours, adjuvant treatment to surgery for benign and malignant bone tumours and palliative treatment for bone sarcomas and metastases. Indications for repeat embolisation included pain or imaging evidence of progressive disease: 105 patients had repeat embolisation at the same location at an interval of 1–3 months; 260 patients had one embolisation, 78 had two and 29 had three or more. In all patients, N-2-butyl cyanoacrylate (NBCA) in 33% lipiodol was the embolic agent used.ResultsA total of 419 of the 454 embolisations (93%) were technically successful. In 35 cases, embolisation was not feasible because of poor lesion vascularisation (21 patients with bone metastases and two with aneurysmal bone cysts), origin of the Adamkiewicz artery in the embolisation field (four patients with bone metastases and one with aneurysmal bone cyst), atheromatosis and arteriosclerosis (five patients with bone metastases) and anatomical and technical problems such as small-calibre vessels, many branches and acute vessel angles (two patients with bone metastases). A clinical response was achieved in 406 of the 419 procedures (97%), and no response in 13 procedures in patients with pelvis and sacrum tumours. Complications included postembolisation syndrome in 81 patients (22%), transient paraesthesias in 41 (11%), skin breakdown and subcutaneous necrosis at the shoulder and pelvis in five (1.4%) and paresis of the sciatic nerve in one (0.3%).ConclusionsWe recommend embolisation as primary or palliative treatment or an adjunct to surgery for tumours of variable histology. Strict adherence to the principles of transcatheter embolisation is important. Arteries feeding the tumour and collaterals must be evaluated carefully and catheterised superselectively to protect the normal tissues. NBCA is considered the most appropriate embolic agent for small-vessel occlusion without major complications.RiassuntoObiettivoScopo del nostro lavoro è presentare l’esperienza di una singola istituzione nell’embolizzazione arteriosa selettiva dei tumori primitivi e delle metastasi dell’apparato muscolo-scheletrico.Materiali e metodiTrecentosessantacinque pazienti sono stati sottoposti a 454 embolizzazioni da dicembre 2002 a aprile 2010. L’embolizzazione è stata usata come trattamento primario per pseudo-tumori e tumori benigni, con significato adiuvante nel trattamento dei tumori maligni e nelle forme benigne e con significato palliativo nel trattamento dei sarcomi dell’osso e delle lesioni metastatiche. Il dolore e l’evidenza all’imaging di una progressione di malattia era l’indicazione per la ripetizione dell’embolizzazione; 105 hanno ripetuto l’embolizzazione nella stessa sede, ad intervallo di 1–3 mesi; 260 pazienti sono stati sottoposti ad una sola embolizzazione, 78 pazienti a due embolizzazioni e 29 pazienti a tre o più embolizzazioni. In tutti è stato usato come unico agente embolizzante l’N-2-butil-Cianoacrilato (NBCA) diluito con lipiodol al 33%.RisultatiQuattrocentodiccianove embolizzazioni (93%) sono state portate a termine con successo. Si è ottenuta risposta clinica in 406 procedure (97%) e nessuna risposta in 13 procedure in pazienti con tumori del bacino e del sacro. In 35 pazienti non è stata eseguita alcuna embolizzazione: in 21 pazienti con metastasi e in 2 con cisti aneurismatiche per scarsa vascolarizzazione; in 4 con metastasi ossea ed in 1 con cisti aneurismatica per la presenza di arteria di Adamkiewicz nella vascolarizzazione della lesione; in 5 pazienti con metastasi ossee per problemi steno-ostruttivi su base ateromasica; in 2 pazienti con metastasi per problemi tecnici legati al calibro dei vasi. Per quanto riguarda le complicazioni, in 81 pazienti (22%) è stata osservata una sindrome post-embolica, in 41 pazienti (11%) paresi transitoria, in cinque pazienti (1,4%) necrosi cutanea e sottocutanea di spala e pelvi, e in un paziente (0,3%) è stata riscontrata una paresi transitoria del nervo sciatico.ConclusioniRaccomandiamo l’embolizzazione per tumori ossei di varia istologia come trattamento primario, adiuvante o palliativo. È fondamentale un rigorosa adesione ai principi delle tecniche di embolizzazione. I vasi afferenti alla lesione vanno attentamente valutati e cateterizzati in maniera altamente selettiva al fine di proteggere i tessuti non lesionali. L’NBCA è, a nostro avviso, l’agente embolizzante più adatto per l’occlusione di piccoli vasi in assenza di complicanze maggiori, ma richiede buona esperienza da parte degli operatori.

Embolisation of bone metastases from renal cancer.

PurposeThis study was done to evaluate embolisation for palliative and/or adjuvant treatment of bone metastases from renal cell carcinoma and discuss the clinical and imaging results.Materials and methodsWe retrospectively studied 107 patients with bone metastases from renal cell carcinoma treated from December 2002 to January 2011 with 163 embolisations using N-2-butyl cyanoacrylate (NBCA). Mean tumour diameter before embolisation was 8.8 cm and mean follow-up 4 years. Clinical and imaging effects of treatment were evaluated at follow-up examinations with a pain score scale, analgesic use, hypoattenuating areas, tumour size and ossification.ResultsA clinical response was achieved in 157 (96%) and no response in six embolisations of sacroiliac metastases. Mean duration of clinical response was 10 (range 1–12) months. Hypoattenuating areas resembling tumour necrosis were observed in all patients. Variable ossification appeared in 41 patients. Mean maximal tumour diameter after embolisation was 4.0 cm. One patient had intraprocedural tear of the left L3 artery and iliopsoas haemorrhage and was treated with occlusion of the bleeding vessel with NBCA. All patients had variable ischaemic pain that recovered completely within 2–4 days. Postembolisation syndrome was diagnosed after 15 embolisations (9.2%). Transient paraesthesias in the lower extremities were observed after 25 embolisations (25%) of pelvis and sacrum metastatic lesions.ConclusionsEmbolisation with NBCA is recommended as primary or palliative treatment of bone metastases from renal cell carcinoma. Strict adherence to the principles of transcatheter embolisation is important to avoid complications.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’embolizzazione come trattamento palliativo e/o adiuvante delle metastasi ossee da carcinoma a cellule renali e discuterne i risultati clinici e radiologici.Materiali e metodiAbbiamo studiato retrospettivamente 107 pazienti con metastasi da carcinoma renale trattati con 163 embolizzazioni con N-2-butil ciano-acrilato (NBCA) da dicembre 2002 a gennaio 2011. Il diametro medio tumorale prima dell’embolizzazione era di 8,8 cm. La media dei follow-up era di di 4 anni. Gli effetti clinici e radiologici sono stati valutati durante i successivi controlli con una scala di punteggio per il dolore, uso degli analgesici, aree di ipoattenuazione, dimensione del tumore ed ossificazione.RisultatiUna risposta clinica è stata ottenuta in 157 embolizzazioni (96%) mentre non è stata ottenuta alcuna risposta in 6 embolizzazioni di metastasi alla sacro-iliaca. La durata media della risposta clinica è stata di 10 mesi (da 1 a 12 mesi). Aree di ipoattenuazione associabili a necrosi tumorale sono state osservate in tutti i pazienti. Ossificazione variabile è stata osservata in 41 pazienti. La media dei diametri tumorali dopo l’embolizzazione è stata di 4,0 cm. Un paziente ha riportato, durante la procedura, una lesione dell’arteria sinistra di L3 ed emorragia nell’ileo-psoas, è stato trattato con occlusione del vaso sanguinante con NBCA. Tutti i pazienti hanno avuto un grado variabile di dolore ischemico che è completamente scomparso in un arco di 2–4 giorni. Dopo la procedura sono stati diagnosticati 15 casi (9,2%) di sindrome post-embolizzazione. Parestesie transitorie agli arti inferiori sono state osservate dopo 25 embolizzazioni (25%) di lesioni metastatiche al sacro ed alle pelvi.ConclusioniL’embolizzazione con NBCA è raccomandata come trattamento sia primario che palliativo delle metastasi ossee da carcinoma renale. Una rigorosa aderenza ai principi di embolizzazione attraverso catetere è importante per evitare complicazioni.