Jaume Pomés

Effect of vertebroplasty on pain relief, quality of life, and the incidence of new vertebral fractures: A 12-month randomized follow-up, controlled trial

Uncertainty regarding the benefits of vertebroplasty (VP) for the treatment of acute osteoporotic vertebral fractures has recently arisen. A prospective, controlled, randomized single‐center trial (ClinicalTrials.gov registration number NCT00994032) was designed to compare the effects of VP versus conservative treatment on the quality of life and pain in patients with painful osteoporotic vertebral fractures, new fractures and secondary adverse effects were also analyzed during a 12‐month follow‐up period. A total of 125 patients were randomly assigned to receive conservative treatment or VP. The primary end point was to compare the evolution of the quality of life (Quality of Life Questionnaire of the European Foundation for Osteoporosis [Qualeffo‐41] and pain (Visual Analogue Scale [VAS]) during a 12 month follow‐up. Secondary outcomes included comparison of analgesic consumption, clinical complications, and radiological vertebral fractures at the same time points. Both arms showed significant improvement in VAS scores at all time points, with greater improvement (p = 0.035) in the VP group at the 2‐month follow‐up. Significant improvement in Qualeffo total score was seen in the VP group throughout the study, whereas this was not seen in the conservative treatment arm until the 6‐month follow‐up. VP treatment was associated with a significantly increased incidence of vertebral fractures (odds ratio [OR], 2 · 78; 95% confidence interval [CI], 1.02–7.62, p = 0.0462). VP and conservative treatment are both associated with significant improvement in pain and quality of life in patients with painful osteoporotic vertebral fractures over a 1‐year follow‐up period. VP achieved faster pain relief with significant improvement in the pain score at the 2‐month follow‐up but was associated with a higher incidence in vertebral fractures.

No Clinical or Electrophysiologic Evidence of Nerve Injury after Intraneural Injection during Sciatic Popliteal Block

Background: Intraneural injection during nerve-stimulator–guided sciatic block at the popliteal fossa may be a common occurrence. Although intraneural injections have not resulted in clinically detectable neurologic injury in small studies in human subjects, intraneural injections result in postinjection inflammation in animal models. This study used clinical, imaging, and electrophysiologic measures to evaluate the occurrence of any subclinical neurologic injury in patients with intraneural injection during sciatic popliteal block. Methods: Twenty patients undergoing popliteal block were enrolled; 17 patients completed the study protocol. After tibial nerve response was achieved by nerve stimulation (0.3–0.5 mA; 2 Hz; 0.1 ms), 20 ml mixture of mepivacaine (1.25%) and radiopaque contrast (2 ml) were injected. Location and spread of the injectant were assessed by ultrasound measurements of the sciatic nerve area before and after injection, and by computed tomography. In addition to clinical neurologic evaluations, serial electrophysiologic studies (nerve conduction and late response studies using predefined criteria) were performed at baseline and at 1 week and 3 weeks after the block for signs of subclinical neurologic dysfunction. Results: Sixteen injections (94%, 95% CI: 71–100%) met criteria for an intraneural injection. Postinjection nerve area on ultrasound increased by 45% (95% CI: 29–58%), P < 0.001. Computed tomography demonstrated fascicular separation in 70% (95% CI: 44–90%), air within the nerve in 29% (95% CI: 10–56%), contrast along bifurcations in 65% (95% CI: 38–86%), and concentric contrast layers in 100% (95% CI: 84–100%). Neither clinical nor electrophysiologic studies detected neurologic dysfunction indicating injury to the nerve. Conclusions: Nerve-stimulator–guided sciatic block at the popliteal fossa often results in intraneural injection that may not lead to clinical or electrophysiologic nerve injury.

Intraneural Injection during Anterior Approach for Sciatic Nerve Block

To the Editor:—We read with interest the case report by Sala-Blanch et al. The authors describe an unorthodox but interesting treatment for patients undergoing continuous sciatic nerve block that raises several concerns. In short, using computed tomographic imaging without clear clinical indication, the authors documented that nerve stimulator–guided needle placement during sciatic nerve block through the anterior approach resulted in an intraneural needle placement. The authors then inserted the catheter and administered local anesthetics. Conventional wisdom suggests that intraneural needle placement and catheter insertion should be avoided because intraneural application of local anesthetics has been shown to result in neurologic injury in animal models. However, despite the documented intraneural needle and catheter placement—although it is not clear whether the stimulating needle lies between fascia and epineurium or between epineurium and perineurium—the patients did not have neurologic injury. Therefore, this case report suggests that not all intraneural injections lead to neurologic injury. It also suggests that nerve stimulators may not be reliable in avoiding intraneural needle or catheter placement. Finally, a better definition of what constitutes an intraneural versus an intraepineural sheath injection during blockade of peripheral nerves and plexuses is needed for more meaningful discussion of this matter. Some experts may view the patient treatment in report by Sala-Blanch et al. unusual or even potentially hazardous. However, their findings should be welcomed because they clearly pose some important questions. At the least, they suggest that future research should continue to focus on developing more reliable and objective tools of nerve localization and injection monitoring techniques to help avoid intraneural injection and reduce the risk of consequent neurologic injury. In any case, it is recommended to withdraw the needle or the catheter if one has any doubt that its position is too close to the nerve, for the safety of regional anesthesia.

Guía de práctica clínica en los sarcomas de partes blandas

Soft tissue sarcomas (STS) constitute a rare heterogeneous group of tumours that include a wide variety of histological subtypes, which require a multidisciplinary and, frequently specialized and complex management. Despite advances in our understanding of the pathophysiology of the disease, there are no consensus multidisciplinary recommendations about its diagnosis and treatment in our country. The objective of these guidelines is to provide practical therapeutic recommendations that may contribute to improve the therapeutic results of this disease in our environment. With this purpose, the Spanish Group for Research in Sarcomas (GEIS) held a meeting with a multidisciplinary group of experts for the study and management of sarcomas. The results of this meeting are compiled in this document, in which recommendations on diagnosis, treatment and monitoring of soft tissue sarcomas are included. In summary, these guidelines aim to facilitate the identification and management of STS for clinical practice in Spain.

Leiomyosarcoma of sacrum: imaging and histopathologic findings.

Abstract. A rare case of low-grade primary leiomyosarcoma of the sacrum is described in a young woman who suffered from pain in the right sacroiliac region. A lytic sacral mass was observed on conventional radiology and CT studies. Magnetic resonance imaging clearly showed Gd-DTPA enhancement in the entire mass demonstrating its hypervascularity, which was later confirmed by angiography. Histopathology and immunohistochemical results of biopsy and curettage of the lesion confirmed the diagnosis. We report on the features of a rare tumor entity through imaging and diagnostic methods.

Ultrasound View of Intraneural Injection

Presently we can identify signs to help guide the administration of anesthetic drugs in the intraneural tissue. Nevertheless, these signs remain loosely defined, or are too difficult to identify or interpret to be useful in forming the criteria that ensure we have performed an intraneural injection.

Computerized Tomographic Images of Intraneural Injection

In the early years of regional anesthesia, the nerve block technique was closely related to the injection of cocaine into the nerve, this behavior being known as “intraneural injection.” Thus, Victor Pauchet, in his book L’Anesthesie Regionale, defines what happens after an intended intraneural injection: “…A fusiform enlargement of the nerve ensues that disappears quickly. The injectate diffuses along both sides, that is why an intraneural injection can exit through the branches that leave the nerve close to the injection site….” These signs have recently been reconsidered as signs of intraneural injection.

Eficacia de la vertebroplastia en fracturas vertebrales crónicas sintomáticas debidas a osteoporosis. Estudio de 5 pacientes

BACKGROUND AND OBJECTIVE Percutaneous vertebroplasty (PVP) has been successfully used in the treatment of pain related to osteoporotic vertebral fractures refractory to medical therapy, especially in the treatment of acute factures. However, the effectiveness of this therapeutic approach in the treatment of painful chronic vertebral fractures is less clear. PATIENTS AND METHODS In this report we evaluate the short and long-term effectiveness in pain relief of PVP in a group of 5 patients with pain related to chronic osteoporotic vertebral fractures without bone marrow edema (BME) on magnetic resonance imaging (MRI). All patients were followed during one year, assessing analgesic use, pain evolution (on a 10-point visual analog scale [VAS]), new vertebral fractures and other clinical complications. Seven procedures were performed in the 5 patients. RESULTS All patients reported substantial improvement in back pain 2 weeks after the procedure, with a mean decrease of 53% in the VAS. However, one year after PVP most patients (4 out 5) worsened, achieving similar VAS scores to those obtained at baseline. No additional vertebral fractures or other clinical complications were observed. CONCLUSION The present cases suggest that the long-term effectiveness of PVP in the treatment of painful chronic vertebral fractures without BME on MRI is scarce.

Conferencia de consensoGuía de práctica clínica en los sarcomas de partes blandasSoft tissue sarcomas: clinical practice guidelines

Soft tissue sarcomas (STS) constitute a rare heterogeneous group of tumours that include a wide variety of histological subtypes, which require a multidisciplinary and, frequently specialized and complex management. Despite advances in our understanding of the pathophysiology of the disease, there are no consensus multidisciplinary recommendations about its diagnosis and treatment in our country. The objective of these guidelines is to provide practical therapeutic recommendations that may contribute to improve the therapeutic results of this disease in our environment. With this purpose, the Spanish Group for Research in Sarcomas (GEIS) held a meeting with a multidisciplinary group of experts for the study and management of sarcomas. The results of this meeting are compiled in this document, in which recommendations on diagnosis, treatment and monitoring of soft tissue sarcomas are included. In summary, these guidelines aim to facilitate the identification and management of STS for clinical practice in Spain.

Small bowel perforation due to ingested clam valve: imaging findings

A previously healthy 18-year-old woman was admitted to the Emergency Department with abdominal pain and nausea. Her past medical history was unremarkable. Physical examination revealed abdominal distress with peritoneal signs. Significant laboratory results were white blood cell count (WBC) of 11,800/μl, (77% of the total WBC were of polymorphonuclear type), hematocrit of 36% and hemoglobin levels of 11.2 g/dl. An abdominal plain film in upright position showed diffuse air-fluid levels. No other findings were detected. An abdominal ultrasonography found a high volume of ascites, and a large collection with echogenic “detritus” and septa, which lay anterior to the uterus. A CT study of the abdomen and pelvis showed bubbles of extraluminal gas, mesenteric inflammatory changes and a well-delineated radioopaque foreign body in the hypogastric area. This calcium-density foreign body seemed to be part of a clam valve (Figs 1, 2). Laparotomy was performed, and the surgeon found a sharp foreign body penetrating the serosa of the terminal ileum in the small bowel, with extensive peritoneal inflammatory changes. Resection of 20 small bowel centimeters with primary anastomosis was done. The final pathologic diagEur Radiol (2005) 15:189–190 DOI 10.1007/s00330-004-2400-7 L E T T E R T O T H E E D I T O R