CT-guided percutaneous screw fixation plus cementoplasty in the treatment of painful bone metastases with fractures or a high risk of pathological fracture

Effectiveness of RF ablation and cementoplasty in enhancing functional capacity in pelvic malignant bone metastases

PURPOSE

Pelvic and sacral bone metastases cause significant morbidity. The primary aim of the study is to thoroughly evaluate the increase in functional capacity resulting from combined RF ablation and cementoplasty surgery applied to malignant bone metastases of the pelvic bones.

METHODS

Twenty patients who underwent RF ablation and cementoplasty for malign pelvic bone and sacrum metastases between January 2014 and December 2021 were retrospectively identified. The inclusion criteria were having a life expectancy of more than 1 month, being > 18 years old, and having at least 1 month of follow-up. The Visual Anlogue Scale (VAS) pain, Karnofsky Performance Status (KP), and Musculoskelatal Tumor Society (MSTS) scores were calculated.

RESULTS

VAS pain values decreased, and KP values increased postoperatively (p = 0.006 and p = 0,013). There was no statistically significant increase in MSTS (p > 0.05). The correlation relationships between lesion filling ratio and VAS pain, KP, and MSTS scores were not statistically significant (p > 0.05). Cement leakage was observed in 5 patients (25.0%), and no symptoms related to this leakage were observed.

CONCLUSION

The pelvic region, given its close proximity to blood vessels, nerves, and joint areas, along with the distinct challenges associated with its surgery, requires separate evaluation. In studies evaluating applications in the isolated pelvic ring region, as in our study, functional gains have been most comprehensively assessed in this study, demonstrating that the procedure results in significant functional improvements.

Combined vertebroplasty and pedicle screw insertion for vertebral consolidation: feasibility and technical considerations

PURPOSE

To assess the feasibility and technical accuracy of performing pedicular screw placement combined with vertebroplasty in the radiological setting.

METHODS

Patients who underwent combined vertebroplasty and pedicle screw insertion under combined computed tomography and fluoroscopic guidance in 4 interventional radiology centers from 2018 to 2023 were retrospectively assessed. Patient demographics, vertebral lesion type, and procedural data were analyzed. Strict intra-pedicular screw positioning was considered as technical success. Pain score was assessed according to the Visual Analogue Scale before the procedure and in the 1-month follow-up consultation.

RESULTS

Fifty-seven patients (38 men and 19 women) with a mean age of 72.8 (SD = 11.4) years underwent a vertebroplasty associated with pedicular screw insertion for the treatment of traumatic fractures (29 patients) and neoplastic disease (28 patients). Screw placement accuracy assessed by post-procedure CT scan was 95.7% (89/93 inserted screws). A total of 93 pedicle screw placements (36 bi-pedicular and 21 unipedicular) in 32 lumbar, 22 thoracic, and 3 cervical levels were analyzed. Mean reported procedure time was 48.8 (SD = 14.7) min and average injected cement volume was 4.4 (SD = 0.9) mL. A mean VAS score decrease of 5 points was observed at 1-month follow-up (7.7, SD = 1.3 versus 2.7, SD = 1.7), p < .001.

CONCLUSION

Combining a vertebroplasty and pedicle screw insertion is technically viable in the radiological setting, with a high screw positioning accuracy of 95.7%.

Emerging Minimally Invasive Percutaneous Procedures for Periacetabular Osteolytic Metastases

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Periacetabular osteolytic skeletal metastases are frequently associated with pain and impaired ambulatory function. Minimally invasive techniques allow for the restoration of ambulation without interrupting critical systemic cancer therapy.

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The open surgical management of massive periacetabular osteolytic lesions, such as by curettage, internal fixation, or complex total hip reconstruction, is associated with blood loss, hospitalization, rehabilitation, and complications such as infection or delayed wound-healing.

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Minimally invasive percutaneous procedures have become increasingly popular for the management of periacetabular osteolytic metastases by interventional oncologists and orthopaedic surgeons before complex open surgical procedures are considered.

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Minimally invasive procedures may include various methods of cancer ablation and reinforcement techniques. Minimally invasive procedures may entail cancer ablation, polymethylmethacrylate (PMMA) cement reinforcement, balloon osteoplasty, percutaneous screw fixation, or combinations of the aforementioned techniques (e.g., ablation-osteoplasty-reinforcement-internal fixation [AORIF]).

Percutaneous CT-Guided Microwave Ablation Combined with Pedicle Screw Fixation Followed by Vertebroplasty (MASFVA): Initial Experience of a Minimally Invasive Treatment of Vertebral Metastases with Extension to the Vertebral Pedicle

(1) Background: The aim of this study was to retrospectively evaluate the safety and efficacy of a combined CT-guided percutaneous microwave ablation (MWA) and pedicle screw fixation followed by vertebroplasty (MASFVA) for the treatment and stabilization of painful vertebral metastases with vertebral pedicle involvement. (2) Methods: from January 2013 to January 2017 11 patients with 16 vertebral metastatic lesions (7 men and 5 women; mean age, 65 ± 11 years) with vertebral metastases underwent CT-guided microwave ablation and screw fixation followed by vertebroplasty (MASFVA). Technical success, complication rate, pain evaluation using a visual analogue scale (VAS), Oswestry Disability Index (ODI) and local tumor control were examined. (3) Results: Technical success rate was 100%. No procedure-related major complications occurred. VAS score decreased from 6.8 ± 0.7 to 0.6 ± 0.6. ODI score decreased from 3.1 ± 0.7 to 1.2 ± 0.4. All patients could walk independently without neurological complication after one week from the procedure. No new bone fractures or local disease recurrence occurred during a median follow-up of 12 months. (4) Conclusions: Our results suggest that MWA and percutaneous pedicle screw fixation followed by vertebroplasty for the treatment of painful vertebral metastases is a safe and effective procedure for painful vertebral metastases with vertebral pedicle involvement, allowing pain relief and local tumor control.

Emerging Indications for Interventional Oncology: Expert Discussion on New Locoregional Treatments

Interventional oncology (IO) employs image-guided techniques to perform minimally invasive procedures, providing lower-risk alternatives to many traditional medical and surgical therapies for cancer patients. Since its advent, due to rapidly evolving research development, its role has expanded to encompass the diagnosis and treatment of diseases across multiple body systems. In detail, interventional oncology is expanding its role across a wide spectrum of disease sites, offering a potential cure, control, or palliative care for many types of cancer patients. Due to its widespread use, a comprehensive review of the new indications for locoregional procedures is mandatory. This article summarizes the expert discussion and report from the "MIOLive Meet SIO" (Society of Interventional Oncology) session during the last MIOLive 2022 (Mediterranean Interventional Oncology Live) congress held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions. The aim of this paper is to provide an updated review of the new techniques and devices available for innovative indications not only to residents and fellows but also to colleagues approaching locoregional treatments.

Combination of Percutaneous Screw Fixation and Cementoplasty for Lytic Bone Metastases: Feasibility, Safety and Clinical Outcomes

OBJECTIVE

To evaluate feasibility, safety and efficacy of a combination of screw fixation and cementoplasty for pathologic bone fracture.

METHODS

In this single-center prospective study, all consecutive percutaneous screw fixations under assisted CT guidance for palliation and fracture treatment of pathologic bone fracture were reviewed from July 2019 to February 2021. The primary outcome measure was the procedures' technical success, defined as the correct placement of the screw(s), without any complications. Secondary outcome measures were the safety, the procedures' early analgesic effects and impacts on quality of life at 4 weeks.

RESULTS

Technical success was achieved in 11/11 procedures (100%) among 11 patients. No major complications attributable to the procedure were noted. The mean pain scored significantly decreased at the initial follow-up: 8.0 ± 2.7 versus 1.6 ± 2.5 (p < 0.05). Opioid doses were statistically lower after procedure: 70.9 ± 37 versus 48.2 ± 46 mg/day (p < 0.05). The mean EQ5D score had significantly increased by the early post-procedure consultation: 42.5 ± 13.6 vs 63.6 ± 10.3 (p < 0.05).

CONCLUSION

Combination of percutaneous screw fixation and cementoplasty for pathologic bone fracture is feasible and safe. It is efficient to reduce pain, decrease the consumption of opioids and improve the quality of life at 4 weeks after the procedure.

Interventional Radiology in the Management of Metastases and Bone Tumors

Interventional Radiology (IR) has experienced an exponential growth in recent years. Technological advances of the last decades have made it possible to use new treatments on a larger scale, with good results in terms of safety and effectiveness. In musculoskeletal field, painful bone metastases are the most common target of IR palliative treatments; however, in selected cases of bone metastases, IR may play a curative role, also in combination with other techniques (surgery, radiation and oncology therapies, etc.). Primary malignant bone tumors are extremely rare compared with secondary bone lesions: osteosarcoma, Ewing sarcoma, and chondrosarcoma are the most common; however, the role of interventional radiology in this fiels is marginal. In this review, the main techniques used in interventional radiology were examined, and advantages and limitations illustrated. Techniques of ablation (Radiofrequency, Microwaves, Cryoablation as also magnetic resonance imaging-guided high-intensity focused ultrasound), embolization, and Cementoplasty will be described. The techniques of ablation work by destruction of pathological tissue by thermal energy (by an increase of temperature up to 90 °C with the exception of the Cryoablation that works by freezing the tissue up to -40 °C). Embolization creates an ischemic necrosis by the occlusion of the arterial vessels that feed the tumor. Finally, cementoplasty has the aim of strengthening bone segment weakened by the growth of pathological tissue through the injection of cement. The results of the treatments performed so far were also assessed and presented focused the attention on the management of bone metastasis.

Revision balloon kyphoplasty and vertebra-pediculoplasty using cannulated screws for osteoporotic vertebral fractures with cement dislodgement following conventional balloon kyphoplasty

We report the usefulness of revision balloon kyphoplasty (re-BKP) and vertebra-pediculoplasty using cannulated screws (VPCS) for osteoporotic vertebral fractures (OVF) following cement dislodgement of conventional BKP. Between 2015 and 2020, three patients with OVF developed symptomatic cement dislodgement following BKP and underwent re-BKP. All three patients showed a loose cemented mass and spinal instability. Balloon inflation was performed in the gap between the loosened cemented mass and the remaining cortical bone rim, and this extended gap was filled with cement. To prevent re-dislodgement of the cement mass, a cannulated screw was inserted into the cemented mass through the pedicle. All patients achieved early pain relief, and improved vertebral stability of the fractured vertebra and all related symptoms, with no perioperative complications. Re-BKP and VPCS are innovative concepts and could be an effective minimally invasive treatment for OVF following cement dislodgement of conventional BKP treatment.

Interventional Palliation of Painful Extraspinal Musculoskeletal Metastases

The musculoskeletal system is commonly involved by metastases, and skeletal-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a result of nerve compression often adversely affect patient's quality of life. There have been substantial advances in percutaneous minimally invasive musculoskeletal oncologic interventions for the management of patients with musculoskeletal metastases including thermal ablations, cementation with or without osseous reinforcement via implants, osteosynthesis, neurolysis, and palliative injections which are progressively incorporated in clinical practice. These interventions are performed, in conjunction with or supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesics, to achieve durable pain palliation, local tumor control, or cure. This article reviews minimally invasive percutaneous image-guided musculoskeletal oncologic interventions for the management of patients with extraspinal musculoskeletal metastases.

Joint-sparing Reconstruction for Extensive Periacetabular Metastases: Literature Review and a Novel Minimally Invasive Surgical Technique

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Metastasis accounts for nearly half of pathologic acetabular reconstructions.

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Increasing use of combined percutaneous ablation, cementoplasty, and osteosynthesis.

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Harrington or MAC classification may lead to overtreatment of acetabular lesions.

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Know indications for joint-sparing reconstruction; consider use in select patients.

Classically, patients with advanced lytic disease of the acetabulum secondary to metastatic bone disease are treated with complex arthroplasty reconstruction techniques. Advancements in percutaneous techniques have extended the indications for safer, minimally invasive procedures for patients with periacetabular metastasis without the need for complex hip replacement and the complications that follow it. The purpose of this report is to revisit the management of this group of patients and provide indications for an alternative minimally invasive joint-sparing technique. We describe a novel technique using a combination of percutaneous cryoablation, cementoplasty and two-screw fixation. With careful consideration of indications, excellent functional and oncologic outcomes one year after surgery is possible without the need for additional procedures.

Computer-Assisted Surgical Navigation for Primary and Metastatic Bone Malignancy of the Pelvis: Current Evidence and Future Directions

Computer-assisted navigation and robotic surgery have gained popularity in the treatment of pelvic bone malignancies, given the complexity of the bony pelvis, the proximity of numerous vital structures, and the historical challenges of pelvic bone tumor surgery. Initial interest was on enhancing the accuracy in sarcoma resection by improving the quality of surgical margins and decreasing the incidence of local recurrences. Several studies have shown an association between intraoperative navigation and increased incidence of negative margin bone resection, but long-term outcomes of navigation in pelvic bone tumor resection have yet to be established. Historically, mechanical stabilization of pelvic bone metastases has been limited to Harrington-type total hip arthroplasty for disabling periacetabular disease, but more recently, computer-assisted surgery has been employed for minimally invasive percutaneous fixation and stabilization; although still in its incipient stages, this procedure is potentially appealing for treating patients with bone metastases to the pelvis. The authors review the literature on navigation for the treatment of primary and metastatic tumors of the pelvic bone and discuss the best practices and limitations of these techniques.

Bone Metastases: State of the Art in Minimally Invasive Interventional Oncology

Bone is the third most common site involved by cancer metastases, and skeleton-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a consequence of nerve or spinal cord compression often affect patients' functional independence and quality of life unfavorably. The annual medical-economic burden related to bone metastases is a substantial component of the total direct medical cost estimated by the National Institutes of Health. There have been substantial recent advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions for the management of patients with osseous metastatic disease. These advances include thermal ablation, cementation with or without osseous reinforcement with implants, osteosynthesis, thermal and chemical neurolyses, and palliative injections, which are progressively incorporated into the management paradigm for such patients. These interventions are performed in conjunction with or are supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesic agents to achieve durable pain palliation, local tumor control, or cure, and they provide a robust armamentarium for interventional radiologists to achieve safe and effective treatment in a multidisciplinary setting. In addition, these procedures are shifting the patient management paradigm in modern-era practice. The authors detail the state of the art in minimally invasive percutaneous image-guided musculoskeletal oncologic interventions and the role of radiologists in managing patients with skeletal metastases. ^©RSNA, 2021.

Prophylactic Percutaneous Consolidation of Large Osteolytic Tumors of the Pelvic Ring Using Fixation by Internal Cemented Screws

Purpose To evaluate the efficacy, durability, and safety of percutaneous fixation by internal cemented screw (FICS) for prophylactic consolidation of impending pathologic fractures of the pelvic ring. Materials and Methods In this single-institute retrospective study, patients with large, minimally symptomatic to asymptomatic osteolytic tumors of the pelvic ring that were treated with percutaneous cone-beam CT-guided FICS procedures were included (January 2014 to May 2019). Follow-up cross-section imaging and clinical reports were reviewed for procedural complications and assessment of the long-term consolidation efficacy on the basis of the development of pathologic fracture or need for additional surgical intervention. All continuous variables were expressed as a mean with standard deviation, and dichotomous variables were expressed as frequencies and percentages. Results Fifty consecutive patients (mean age, 60 years ± 12; 27 men) underwent prophylactic FICS for consolidation of 54 osteolytic tumors (mean size, 51 mm ± 21.5; range, 30-114 mm). Local tumor destruction was performed in association with FICS in 38 patients (76%) using percutaneous thermal and/or radiation therapy. Follow-up exceeded a year in 35 patients (70%), with mean follow-up of 22 months ± 18 (range, 1-67 months). Long-term consolidation efficacy was 98% (49 of 50), with the development of a pathologic fracture in only one patient 20 months after FICS. Procedural complications were limited to two patients with self-resolving hematoma, one patient with inflammatory sciatic pain, and one patient with focal pain at the ischial tuberosity. Conclusion Percutaneous FICS provides a safe and durable minimally invasive treatment for the prevention of pathologic fractures of the pelvic ring. Keywords: Interventional-MSK, Percutaneous, Skeletal-Axial, Metastases, Oncology Supplemental material is available for this article. © RSNA, 2020.

Complications of percutaneous image-guided screw fixation: An analysis of 94 consecutive patients

PURPOSE

The purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures.

MATERIALS AND METHODS

From July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (<24hours) and delayed (>24hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

RESULTS

A total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7±12.7 [SD] years; age range: 32-88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and>24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%).

CONCLUSION

The rate of per-procedural and early (within 24hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (>24hours).

Finite element models for fracture prevention in patients with metastatic bone disease. A literature review

Patients with bone metastases have an increased risk to sustain a pathological fracture as lytic metastatic lesions damage and weaken the bone. In order to prevent fractures, prophylactic treatment is advised for patients with a high fracture risk. Mechanical stabilization of the femur can be provided through femoroplasty, a minimally invasive procedure where bone cement is injected into the lesion, or through internal fixation with intra- or extramedullary implants. Clinicians face the task of determining whether or not prophylactic treatment is required and which treatment would be the most optimal. Finite element (FE) models are promising tools that could support this decision process. The aim of this paper is to provide an overview of the state-of-the-art in FE modeling for the treatment decision of metastatic bone lesions in the femur. First, we will summarize the clinical and mechanical results of femoroplasty as a prophylactic treatment method. Secondly, current FE models for fracture risk assessment of metastatic femurs will be reviewed and the remaining challenges for clinical implementation will be discussed. Thirdly, we will elaborate on the simulation of femoroplasty in FE models and discuss future opportunities. Femoroplasty has already proven to effectively relieve pain and improve functionality, but there remains uncertainty whether it provides sufficient mechanical strengthening to prevent pathological fractures. FE models could help to select appropriate candidates for whom femoroplasty provides sufficient increase in strength and to further improve the mechanical benefit by optimizing the locations for cement augmentation.

Stent screw-assisted internal fixation (SAIF): clinical report of a novel approach to stabilizing and internally fixating vertebrae destroyed by malignancy

OBJECTIVE

Severe lytic cancerous lesions of the spine are associated with significant morbidity and treatment challenges. Stabilization and restoration of the axial load capability of the vertebral body (VB) are important to prevent or arrest vertebral collapse. Percutaneous stent screw-assisted internal fixation (SAIF), which anchors a VB stent/cement complex with pedicular screws to the posterior vertebral elements, is a minimally invasive, image-guided, 360° internal fixation technique that can be utilized in this patient cohort. The purpose of this study was to assess the feasibility, safety, and stabilization efficacy of VB reconstruction via the SAIF technique in a cohort of patients with extensive lytic vertebral lesions, who were considered to have an unstable or potentially unstable spine according to the Spinal Instability Neoplastic Score (SINS).

METHODS

This study was a retrospective assessment of a prospectively maintained database of a consecutive series of patients with neoplastic extensive extracompartmental osteolysis (Tomita type 4-6) of the VB treated with the SAIF technique. VB reconstruction was assessed on postprocedure plain radiographs and CT by two independent raters. Technical and clinical complications were recorded. Clinical and imaging follow-ups were assessed.

RESULTS

Thirty-five patients with extensive osteolytic metastatic lesions of the VB underwent 36 SAIF procedures. SAIF was performed as a stand-alone procedure in 31/36 cases and was associated with posterior surgical fixation in 5/36 (4/5 with decompressive laminectomy). In 1 case an epidural cement leak required surgical decompression. VB reconstruction was categorized as satisfactory (excellent or good rating) by the two raters in 34/36 cases (94.5%) with an interrater reliability of 94.4% (Cohen's kappa of 0.8). Follow-up, ranging from 1 to 30 months, was available for 30/36 levels. Long-term follow-up (6-30 months, mean 11.5 months) was available for 16/36 levels. Stability during follow-up was noted in 29/30 cases.

CONCLUSIONS

SAIF provides 360° nonfusion internal fixation that stabilizes the VB in patients with extensive lytic lesions that would otherwise be challenging to treat.

Minimally Invasive Image-Guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) for Osteolytic Lesions in the Pelvis and Periarticular Regions of Weight-Bearing Bones

PURPOSE

To assess early outcome, safety, and complications of an alternative to open surgical treatments of osteolytic lesions in periarticular load-bearing bones.

MATERIALS AND METHODS

A single-center, prospective clinical cohort study of 26 lesions in 23 consecutive patients with painful osteolytic skeletal lesions was performed. Patients were followed for an average of 7 mo (1-18 mo). Lesions were targeted from the most intact bone via minimally invasive percutaneous approach for stable anchorage of internal fixation screws using fluoroscopic guidance. Cannulated screws served as universal portals for ablation, balloon osteoplasty, and delivery of bone cement in addition to internal fixation for cement anchoring and prophylactic stabilization of uninvolved bone.

RESULTS

There were 19 osteolytic lesions in the pelvis, 4 in the proximal femur, 2 in the proximal tibia, and 1 in the calcaneus. All defects were associated with severe pain or fractures. There were no conversions to open surgery and no infection or bleeding requiring transfusion, embolization, or additional procedures. There was significant improvement in visual analogue scale (VAS) pain score from 8.32 ± 1.70 to 2.36 ± 2.23, combined pain and functional ambulation score from 4.48 ± 2.84 to 7.28 ± 2.76, and Musculoskeletal Tumor Society score from 45% to 68% (P < .05).

CONCLUSIONS

Ablation, osteoplasty, reinforcement, and internal fixation is a safe and effective minimally invasive percutaneous image-guided treatment option for functional improvement or palliation of painful osteolytic lesions in the pelvis and periarticular loadbearing bones.

Cementoplasty of pelvic bone metastases: systematic assessment of lesion filling and other factors that could affect the clinical outcomes

OBJECTIVES

To evaluate lesion filling and other factors that could affect the clinical outcomes of cementoplasty for pelvic bone metastases.

METHODS

We retrospectively reviewed the files of 40 patients treated for 44 pelvic bone metastases, collected the parameters related to patients (pain relief evaluated on a visual analog scale, subsequent fractures, and need for surgery), lesions (size, cortical breach score, fracture, soft-tissue extension), and cementoplasty procedures (number of needles, volume of cement, percentage of lesion filling, cement leaks, residual acetabular roof defect), and performed a statistical analysis.

RESULTS

The lesions were on average 43.2 mm in diameter and the mean cortical breach score was 2.5 out of 6, with a pathological fracture in 14 lesions. The number of needles inserted was one in 32 out of 44, two in 10 out of 44, and three in 2 out of 44. On average, the volume of cement injected per lesion was 10.3 ml and the filling was 54.8%. Mild or moderate asymptomatic cement leakage occurred in 20 lesions (45.5%). The mean pain score was 84.2 mm before the procedure (with no correlation with lesion size, cortical breach score or fracture) and 45.6 mm at follow-up. The pain relief of 38.6 mm was statistically significant (p < 0.001) and did not correlate with the filling percentage. There were no fractures of the treated lesions at a mean follow-up of 355 days.

CONCLUSIONS

Cementoplasty of pelvic bone metastases appears effective for providing pain relief and may prevent subsequent fractures. We were unable to demonstrate a correlation between the lesion filling and the degree of pain relief.

Interventional Techniques for the Ablation and Augmentation of Extraspinal Lytic Bone Metastases

In addition to being a major source of cancer-related pain, metastatic osseous lesions are frequently at risk for pathologic fracture and its accompanying morbidity. While bony metastases are commonly thought of as occurring within the vertebral column, over 80% are found outside the spine. Percutaneous interventional treatment options for nonspinal metastases offer a broad array of minimally invasive, image-guided procedures that are rapidly effective, reduce the need for opioids, and often work in complementary fashion with adjunct treatments in radiation oncology, orthopaedic surgery, and/or medical oncology. This article presents an approach to assess extraspinal metastases, reviews available interventional techniques in use today, and offers example cases as an introductory primer to the thought process used for selecting the appropriate interventional treatment.

Percutaneous screw-reinforced cement osteoplasty for palliation of postremission pain in larger lytic sacro-acetabular iliac cavities

We present 2 cases of palliative percutaneous screw fixation for refractory pain from periacetabular residual cavities, after clinical remission, from osteolytic iliac masses involving the cortices of the sacroiliac joint (SIJ). Two patients-1 with a treated 8 cm breast metastasis and another with a treated 14 cm plasmacytoma-were selected for osseous stabilization based on imaging criteria and physical signs of iliac deformability and SIJ dysfunction. Neither lesion exhibited active malignancy following systemic therapy or discrete fracture. Following computed tomography-guided screw fixation across the mass and SIJ, with surrounding cement osteoplasty, to reduce mechanical stress on abnormal bone, both patients reported pain resolution beyond 1-year. This technique may be a suitable palliation even for large treated pelvic metastastic cavities and in the absence of fracture.

Percutaneous restoration of bone continuity with screws and PMMA cement in an extensive destruction of the pelvis

We report a case of combined percutaneous screw placement and cementoplasty guided by CT and fluoroscopy in a 66-year-old man with extensive osteolytic destruction of the right iliac bone and sacral wing due to metastasic infiltrative vesical carcinoma. The medical condition was responsible for very limited and painful walking. Two perpendicular screws were inserted into the iliac bone and sacroiliac joint, and bone cement injection was used to anchor the screws and restore the mechanical continuity of the pelvis ring. This minimally invasive procedure allowed for significant and rapid resumption of painless walking.

Stent-screw-assisted internal fixation: the SAIF technique to augment severe osteoporotic and neoplastic vertebral body fractures

Objectives

To describe a new technique to obtain minimally invasive but efficient vertebral body (VB) reconstruction, augmentation, and stabilization in severe osteoporotic and neoplastic fractures, combining two pre-existing procedures. The implant of vertebral body stents (VBS) is followed by insertion of percutaneous, fenestrated, cement-augmented pedicular screws that act as anchors to the posterior elements for the cement/stent complex. The screws reduce the risk of stent mobilization in a non-intact VB cortical shell and bridge middle column and pedicular fractures. This procedure results in a 360° non-fusion form of vertebral internal fixation that may empower vertebral augmentation and potentially avoid corpectomy in challenging fractures.

Procedure details

This report provides step-by-step procedural details, rationale, and proposed indications for this procedure. The procedure is entirely percutaneous under fluoroscopic guidance. Through transpedicular trocars the VBS are inserted, balloon-expanded and implanted in the VB. Over k-wire exchange the transpedicular screws are inserted inside the lumen of the stents and cement is injected through the screws to augment the stents and fuse the screws to the stents.

Applications

This technique may find appropriate applications for the most severe osteoporotic fractures with large clefts, high-degree fragmentation and collapse, middle column and pedicular involvement, and in extensive neoplastic lytic lesions.

Conclusions

Stent-Screw-Assisted Internal Fixation (SAIF) might represent a minimally invasive option to obtain VB reconstruction and restoration of axial load capability in severe osteoporotic and neoplastic fractures, potentially obviating the need for more invasive surgical interventions in situations that would pose significant challenges to standard vertebroplasty or balloon kyphoplasty.

Fluoroscopy and Cone-Beam CT-guided Fixation by Internal Cemented Screw for Pathologic Pelvic Fractures

Purpose To evaluate the safety and efficacy of palliative treatment of patients with pathologic pelvic by using fluoroscopy and cone-beam CT needle guidance software to perform percutaneous fixation by internal cemented screw (FICS). Materials and Methods This single-center study involved retrospective analysis of 100 consecutive patients with cancer with pathologic pelvic fractures managed with percutaneous FICS. Image guidance was performed with fluoroscopy and cone-beam CT needle guidance software. Pain palliative outcomes and opioid use after FICS were compared by means of paired-sample t test. Results A total of 107 percutaneous FICS procedures were performed from 2010 to 2017 to palliate 141 pathologic fractures in 100 patients (mean age, 65.0 years ± 17.6 [standard deviation; female age, 66.3 years ± 18.0; mean, 63.7 years ± 17.2]). Of 107 procedures, 104 (97.2%) were technically successful, with mean postprocedure hospitalization of 2 days ± 3. Complications occurred in 14 patients: focal pain at procedure site for longer than 48 hours (n = 5), hematoma (n = 3), progressive fracture despite fixation (n = 2), infection (n = 1), tumor track seeding (n = 1), and screw displacement (n = 2). In the 88 patients who completed early follow-up, mean numeric rating scale pain score was significantly improved at 6 weeks from 6.1 ± 2.5 to 2.1 ± 3.0 (P < .001). Opioid use was reduced at 6 weeks (preprocedure vs postprocedure, 91.3 g ± 121 vs 64.6 g ± 124, respectively; P = .04). Conclusion Fluoroscopy and cone-beam CT-guided percutaneous fixation of pathologic pelvis fractures by internal cemented screw is a safe and effective approach that can reduce pain and opioid use. © RSNA, 2018.

Percutaneous Fixation by Internal Cemented Screw for the Treatment of Unstable Osseous Disease in Cancer Patients

Interventional radiology expertise in image guidance has expanded the treatment options for cancer patients with unstable osseous disease. Percutaneous fixation by internal cemented screw (FICS) describes the technique by which the interventional radiologist stabilizes a fracture or impending fracture with the percutaneous placement of a cannulated screw that is locked in position by polymethyl methacrylate cement. The durable metallic screws provide added resistance to torque and tension stresses that complement the axial compression resistance of cement. Compared with cementoplasty alone, the procedure has been advanced as a more durable and precise technique for stabilization of osseous disease for certain disease presentations in cancer patients. The application of advanced image guidance techniques improves upon existing percutaneous surgical techniques to facilitate approaches that would otherwise prove quite challenging, particularly with stabilization of the pelvic flat bones. This article examines the applications of percutaneous FICS procedures for the treatment of unstable osseous disease in cancer patients. Indications, techniques, and follow-up care are reviewed. Case examples in which FICS can be performed in unstable pathology are detailed.

A practical guide for planning pelvic bone percutaneous interventions (biopsy, tumour ablation and cementoplasty)

Percutaneous approaches for pelvic bone procedures (bone biopsies, tumour ablation and cementoplasty) are multiple and less well systematised than for the spine or extremities. Among the different imaging techniques that can be used for guidance, computed tomography (CT) scan is the modality of choice because of the complex pelvic anatomy. In specific cases, such as cementoplasty where real-time evaluation is a determinant, a combination of CT and fluoroscopy is highly recommended. The objective of this article is to propose a systematic approach for image-guided pelvic bone procedures, as well as to provide some technical tips. We illustrate the article with multiple examples, and diagrams of the approaches and important structures to avoid to perform these procedures safely.

TEACHING POINTS

• Pelvic bone procedures are safe to perform if anatomical landmarks are recognised. • The safest approach varies depending on the pelvic level. • CT is the modality of choice for guiding pelvic percutaneous procedures. • Fluoroscopy is recommended when real-time monitoring is mandatory. • MRI can also be used for guiding pelvic percutaneous procedures.