Matteo Mammucari

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 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.

Future directions in percutaneous vertebroplasty

The first percutaneous vertebroplasty, used to treat a painful cervical haemangioma, was performed by a French team in 1984 and reported in the literature in 1987. This technique has rapidly become the standard of care for treatment of medically refractory painful vertebral compression fractures. Vertebral fractures usually become evident because of pain of varying intensity that reduces the patient’s quality of life, producing functional limitations, depression, disability, height loss, spinal instability and kyphotic deformity associated with impaired lung capacity. Many diseases may underlie vertebral compression fractures, such as osteoporosis, trauma, neoplasms and haemangioma. Vertebroplasty, as derived from our experience and a review of the literature data, has more than 70%–90% effectiveness for short-term pain reduction and return to activity. The aim of this paper was to describe the state of the art of this spinal interventional radiology procedure and to examine the future directions of percutaneous vertebroplasty.RiassuntoLa prima vertebroplastica percutanea è stata condotta da un gruppo francese nel 1984, e riportata in letteratura nel 1987, per il trattamento di un emangioma doloroso cervicale. Questa tecnica è rapidamente diventata di riferimento nella gestione di fratture vertebrali compressive dolorose non trattabili conservativamente. Le fratture vertebrali vengono generalmente diagnosticate in relazione alla marcata algia, di vario grado, lamentata dal paziente, che determina riduzione della qualitá della vita, limitazione funzionale, depressione, disabilitá, riduzione in altezza, instabilitá spinale e deformitá cifotica associata a compromissione respiratoria. Tra le molteplici cause alla base delle fratture vertebrali si riconoscono l’osteoporosi, i traumi, le neoplasie e gli emangiomi. La vertebroplastica, in relazione a quanto derivato dalla nostra esperienza e dai dati presenti in letteratura, presenta una efficacia di oltre il 70%–90% nella riduzione del dolore a breve termine con pronta ripresa delle attivitá quotidiane. Lo scopo di questo lavoro è descrivere lo stato dell’arte di questa procedura di radiologia interventistica spinale e di esaminare le future direzioni della vertebroplastica percutanea.

Answers to letter regarding our paper, “Medial branch neurotomy in low back pain” by Dr. S. Masala et al.

Dear Sir, We have read the comments about our work, and we are inclined to believe that all the matter has arisen from the term “pulsed” referred to radiofrequency, which appears twice in the Abstract and Introduction, that is a misnomer. We did not employ pulses of radiofrequency alternating current but single 70-s lasting shots of continuous radiofrequency alternating current for each lesion. As clearly described in the Technique section, we never mentioned any “pulse” there, what we produced were six contiguous lesions by heating tissues at 80°C for 70 s thus accomplishing an 8–9 mm wide 20 mm long whole lesion by moving the electrode tip in the described fashion. All the considerations about physics, histologic effect and clinical effectiveness of pulsed radiofrequency have been rightly expressed by you. This solves also the other related drawn criticisms. Concerning the follow-up, we examined the patients at 1 week, but according to our general experience, we opted not to trust in their reports on pain relief at so close time interval because of the possible interference of unpredictable confounding factors. However matter stands, pain relief was immediate without a significant peak effect. Our intention was not to study the cost ineffectiveness of the controlled diagnostic blocks, that has been well established in literature as you mention, but simply to obtain such highly selected patient population on which test the effectiveness of our technique. Alcoholization has been mentioned only for knowledge of a possible alternative treatment modality, proven ineffective, without deep examination.