Stefano Marcia

Percutaneous vertebroplasty in multiple myeloma vertebral involvement

Study Design and Objective The aim of this study was to assess the effectiveness and safety of percutaneous vertebroplasty, a new technique for the treatment of vertebral pain deriving from fracture or gross osteolytic lesion due to multiple myeloma spinal involvement. Summary of Background Data Spinal osteolytic lesions are frequently associated with hematologic malignancies due to primary localization of disease (multiple myeloma and rarely lymphoma) or secondary effect of intensive corticosteroid therapy. Methods We treated 64 patients (34 males, 30 females; mean age 71.4±9.6 y) with pain refractory to conventional medical therapy (analgesics, bed-rest, bracing with orthopedic devices for more than 3 wk) localized in spine, in the absence of neurologic signs. Results This treatment generated swift pain relief associated with an evident augmentation in vertebral resistance. Average preprocedural pain level for all patients was reported to be 8.04±1.4 whereas average pain level at 1 and 6 months follow-up period was 1.82±1.84 and 1.92±1.68, respectively. Although preprocedure and postprocedure demonstrated a statistically significant reduction in numeric pain scores (P<0.01), the pain level at 1 and 6 months was not considered statistically significant. No procedure-related complications were observed in either leakages of polymethylmethacrylate in the epidural or foraminal area or in complications of pulmonary embolism for venous plexus involvement. Conclusions Vertebroplasty is widely considered as an alternative, effective, simple, and safe technique in the treatment of neoplastic vertebral localizations consequent to hematologic malignancies. The same injection of polymethylmethacrylate can be executed before radiation therapy treatment, synergizing its delayed analgesic action to pain, after failure or in the case of local recurrences.

Percutaneous vertebroplasty: Multi-centric results from EVEREST experience in large cohort of patients

PURPOSE The purpose of this study was to prospectively evaluate results and complications of percutaneous vertebroplasty (PV) performed in 6 different Italian Centres belonging to the European VErtebroplasty RESearch Team (E.VE.RES.T) in a large series of patients. MATERIALS AND METHODS Follow-up was obtained in 4547 patients (3211 females and 1336 males; mean age 70.2 years) that underwent PV for a total of 13.437 treated vertebrae. Procedures were performed by using fluoroscopic guidance or combined CT-fluoroscopic guidance. All patients underwent PV in local anaesthesia except for second cervical vertebrae treated with a trans-oral approach that required general anaesthesia. RESULTS 4004 out of 4547 (88.0%) patients reported significant pain relief (difference>or=2 point in pain evaluated with an 11-point visual analogue scale; p<0.0001) within 48 h: an average of 7.7 ± 0.4 dropped to 1.8 ± 0.6 in the osteoporotic patients; 8.3 ± 0.4 to 2.4 ± 0.4 in metastases; 8.3 ± 0.4 to 1.7 ± 1.0 in myeloma; 6.2 ± 3.5 to 0.3 ± 0.2 in angioma and 7.4 ± 0.4 to 1.4 ± 0.9 in trauma. 430 osteoporotic patients (13%) were retreated for a subsequent fracture; in 302/430 patients (70.2%), the new fracture occurred in the contiguous vertebra. No major neurologic complications were reported and the most frequent minor complication was venous leakage (20.5%). CONCLUSIONS This large series of patients confirms that percutaneous vertebroplasty is an effective and safe procedure in the treatment of vertebral fractures. Best results are obtained in the treatment of myeloma and trauma.

Assisted techniques for vertebral cementoplasty: Why should we do it?

Assisted techniques (AT) for vertebral cementoplasty include multiple mini-invasive percutaneous systems in which vertebral augmentation is obtained through mechanical devices with the aim to reach the best vertebral height restoration. As an evolution of the vertebroplasty, the rationale of the AT-treatment is to combine the analgesic and stability effect of cement injection with the restoration of a physiological height for the collapsed vertebral body. Reduction of the vertebral body kyphotic deformity, considering the target of normal spine biomechanics, could improve all systemic potential complications evident in patient with vertebral compression fracture (VCF). Main indications for AT are related to fractures in fragile vertebral osseous matrix and non-osteoporotic vertebral lesions due to spine metastasis or trauma. Many companies developed different systems for AT having the same target but different working cannula, different vertebral height restoration system and costs. Aim of this review is to discuss about vertebral cementoplasty procedures and techniques, considering patient inclusion and exclusion criteria as well as all related minor and/or major interventional complications.

Percutaneous stabilization of lumbar spine: a literature review and new options in treating spine pain

Vertebral fracture (VF) is a common condition with >160,000 patients affected every year in North America and most of them with affected lumbar vertebrae. The management of VF is well known and defined by many protocols related to associated clinical neurological symptoms, especially in case of the presence or absence of myelopathy or radicular deficit. In this article, we will explore the percutaneous stabilization of the lumbar spine by showing the newest approaches for this condition.

Multicenter clinical and imaging evaluation of targeted radiofrequency ablation (t-RFA) and cement augmentation of neoplastic vertebral lesions

Background Treatment of spinal metastatic lesions by radiofrequency ablation (RFA) before cementation can potentially help in local tumor control and pain relief. This is often limited by access and tumor location. This study reports multicenter clinical and imaging outcomes following targeted RFA (t-RFA) and cement augmentation in neoplastic lesions of the spine. Material and methods A retrospective multicenter study of 49 patients with 72 painful vertebral lesions, evaluated for clinical and imaging outcomes following RFA and cement augmentation of spinal metastatic lesions, was undertaken. Visual Analogue Pain score (VAS) and Oswestry Disability Index (ODI) were obtained before and 2–4 weeks after treatment. Pre- and post-procedure imaging examinations including MRI and positron emission tomography (PET) were also evaluated. Results Mean ablation time was 3.7±2.5 min (range 0.92–15). Mean VAS scores decreased from 7.9±2.5 pre-procedure to 3.5±2.6 post-procedure (p<0.0001). Mean ODI scores improved from 34.9±18.3 to 21.6±13.8 post-procedure (p<0.0001). Post-contrast MRI resulted in a predictable pattern of decreased tumor volume and an enhancing rim. Metabolically active lesions in pre-procedure PET scans (n=10 levels) showed decreased fluorodeoxyglucose activity after ablation. Conclusions t-RFA followed by vertebral augmentation in malignant vertebral lesions resulted in significant pain reduction and functional status improvement, with no major complications. t-RFA permitted access to vertebral lesions and real-time accurate monitoring of the ablation zone temperature. Post-procedure MRI and PET examinations correlated with a favorable tumor response and helped to monitor tumor growth and the timing of adjuvant therapy.

Percutaneous Vertebroplasty and Kyphoplasty: Current Status, New Developments and Old Controversies

Vertebroplasty and kyphoplasty are minimally invasive techniques applied for the treatment of vertebral fractures. Since not all vertebral compression fractures are the same, a tailored-based approach is necessary for optimum efficacy and safety results. Nowadays, different cements and materials are proposed as alternatives to the original poly-methylmethacrylate aiming to overcome the limitations and the risks governing its use. Both techniques are governed by high efficacy and low complication rates; multilevel treatment in a single session has been shown to be feasible with no compromise of the technique’s safety and efficacy. The purpose of this article is to describe the basic concepts of spinal augmentation by means of vertebroplasty and kyphoplasty. The current status and future of cements used will be defined. Controversies upon issues concerning both techniques will be addressed. Finally, the necessity for a tailored-based approach applying different techniques for different fractures will be addressed.

Degenerative lumbar spinal stenosis treatment with Aperius™ PerCLID™ system and Falena® interspinous spacers: 1-year follow-up of clinical outcome and quality of life

Purpose Evaluation of the efficacy of the Falena® and Aperius™ PerCLID™ interspinous devices in the treatment of degenerative lumbar spinal stenosis with neurogenic intermittent claudication refractory to conservative treatment. Materials and methods We retrospectively analyzed data from 24 patients (20 male and 4 female patients; 61 ± 7 years old), treated with an implantation of the AperiusTM PerCLID™ system, and from 35 patients (29 male and 6 female patients; 65 ± 9 years old) treated with the Falena® interspinous device. Patient pain intensity was evaluated by a 10-point visual analog scale (VAS), with a score (ranging from 0 = no pain to 10 = unbearable pain) that was collected before the procedure, at baseline; and at months 1, 6 and 12 after the interventional procedure. The assessment of quality of life (QOL) impairment was evaluated by the Oswestry Disability Index (ODI) questionnaire, which was administered beforehand at baseline; and at months 1, 6 and 12 after the interventional procedure. The vertebral canal area was measured by magnetic resonance imaging (MRI) scans before the treatment and at the one-year follow-up. Results All patients completed the study with no complications. Both the Falena group and Aperius group of surgery patients showed a statistically significant reduction of their VAS and ODI scores at the 6- and 12-month follow-up (p < 0.0001). A statistically significant increase in the vertebral canal area was observed both in the group that received Falena (p < 0.0001) and in the group that received Aperius (p = 0.0003). At the 1-year follow-up, we observed that there was a higher increase of vertebral canal area in those patients whom were treated with the Falena device (p < 0.001). Conclusions The implantation of Falena® and Aperius™ PerCLID™ interspinous devices is an effective and safe procedure, in the medium term.

Interventions and Therapy in Rheumatology

Patients affected by rheumatic conditions frequently present with spine degeneration and vertebral compression fractures, mainly related to the long-term therapies with glucocorticosteroids. A mini-invasive approach provided by interventional radiology techniques, especially vertebroplasty, plays a relevant role in the pain management of these patients; vertebroplasty represents the symptomatic treatment of fracture pain, so patients must always be included in a specific therapeutic workup of the rheumatic condition. This article describes patient selection criteria, technique, and outcomes of vertebroplasty in patients affected by rheumatic disease and secondary osteoporosis caused by glucocorticosteroids.

Treatment of Facet Joints

Lumbar zygapophysial joints are also called “facet joints”. They are often cause of chronic back pain because of rich innervation of the articular structures. In 1933, Ghormley named the spectrum of symptoms arising from its pathological involvement as “facet joint syndrome” (FCS). FCS represents ≤15% of chronic pain in the lower back. It is characterized by joint pain which is usually insidious in its onset and which may derive from almost any structure in the zygapophysial joints (fibrous capsule, synovial membrane, hyaline cartilage, tendons, bone) due to mechanical or inflammatory stimulation of nociceptors. Standard treatments for pain in lumbar facet joints are mainly intra-articular injections of corticosteroids and radiofrequency denervation (RFD) of the medial branches which innervate the zygapophysial joint. We review here the anatomy and physiology of the lumbar zygapophysial joints as well as diagnostic tools and treatments.

Percutaneous management of bone metastases: state of the art, interventional strategies and joint position statement of the Italian College of MSK Radiology (ICoMSKR) and the Italian College of Interventional Radiology (ICIR)

Interventional radiology provides local management of bone metastases (BM) with a palliative intent in most cases, or with a curative intent in selected patients. Its role has rapidly expanded in the last decade, offering new treatment solutions often in combination with surgery, radiation therapy and medical treatments. The aim of the present paper is to increase awareness, acceptance and adoption of interventional radiology procedures for the treatment of BM; and to present the joint position of the Italian College of Musculoskeletal Radiology and the Italian College of Interventional Radiology.