T2 shine-through phenomena in diffusion-weighted MR imaging of lumbar discs after oxygen–ozone discolysis: a randomized, double-blind trial with steroid and O2–O3 discolysis versus steroid only

Effectiveness of intradiscal ozone injections for treating pain following herniated lumbar disc: A systematic review and meta-analysis

BACKGROUND

Low back pain and sciatica caused by herniated lumbar discs (HLDs) are common complaints among patients visiting pain clinics. Among the various therapeutic methods, intradiscal ozone injections have emerged as an effective alternative or additional treatment option for HLDs.

OBJECTIVE

This meta-analysis aimed to investigate the effectiveness of intradiscal ozone injections in the treatment of HLDs.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Scopus databases for relevant studies published until January 25, 2024. We included studies that investigated the efficacy of intradiscal ozone injections in patients with HLDs. We evaluated the methodological quality of individual studies using the Cochrane Collaboration tool.

RESULTS

At ⩾ 6 months after treatment, the therapeutic effect of intradiscal ozone injections in patients with HLDs was greater than that of steroid injections (treatment success rate, 6 months: odds ratio = 3.95, 95% confidence interval [CI] [2.44, 6.39], P< 0.01) or conventional medications (changes in the Visual Analog Scale [VAS], 6 months: standardized mean difference [SMD] = 1.65, 95% CI [1.08, 2.22], P< 0.01; 12 months: SMD = 1.52, 95% CI [0.96, 2.08], P< 0.01) but similar to that of microdiscectomy (changes in VAS, 18 months: SMD =-0.05, 95% CI [-0.67, 0.57], P= 0.87). At < 6 months after treatment, the reduction in the VAS score after intradiscal ozone injections was higher than that after steroid injections (changes in VAS, 1 month: SMD = 2.53, 95% CI [1.84, 3.21], P< 0.01).

CONCLUSION

Intradiscal ozone injections may be a useful therapeutic tool in patients with HLDs. Compared with other conventional treatment methods such as steroid injections and oral medications, intradiscal ozone injection has great long-term (⩾ 6 months) effectiveness.

The clinical efficacy of ozone combined with steroid in the treatment of discogenic low back pain: a randomized, double-blinded clinical study

Objective

This randomized double-blinded clinical study is to investigate the clinical efficacy of per-paravertebral disk ozone injection combined with steroids in the treatment of patients with chronic discogenic low back pain (CDLBP).

Methods

Group A (N = 60) received a per-paravertebral injection of a steroid mixture of 10 mL with pure oxygen 20 mL, while group B (N = 60) received a per-paravertebral injection of a steroid mixture of 10 mL combined with ozone 20 mL (30 μg/mL). Injections were administered once a week for 3 weeks, with a follow-up of 6 months. Clinical outcomes were assessed at week 1, month 3, and month 6 with the help of Visual Analog Scale (VAS) scores and Macnab efficacy evaluation.

Results

The VAS score of both group A (1.65 vs. 6.87, p = 0.000) and group B (1.25 vs. 6.85, p = 0.000) at week 1 was significantly reduced compared to baseline. The effect was sustained at the 3- and 6-month follow-up periods (p < 0.05). Group B had significantly lower VAS scores at month 3 (1.53 vs. 3.82, p = 0.000) and month 6 (2.80 vs. 5.05, p = 0.000) compared to group A, respectively. Based on Macnab criteria, 95 and 96.7% of patients in groups A and B had good rates "excellent plus good" at week 1, respectively. Good rates were significantly higher in group B at month 3 (91.7 vs. 78.3%, p = 0.041) and month 6 (85.0 vs. 68.3%, p = 0.031) compared to group A, respectively. No serious adverse events were noted in both groups.

Conclusion

Per-paravertebral injection of steroid and ozone combination resulted in better relief of CDLBP compared to pure oxygen plus steroid.

Clinical Trial Registration

ChiCTR2100044434 https://www.chictr.org.cn/showproj.html?proj=121571.

Role of Apparent Diffusion Coefficient in Evaluating Degeneration of the Intervertebral Disc: A Narrative Review

Degeneration of the lumbar intervertebral disc is the most common cause of lower back pain. It is directly related to daily activities, mechanical stress, and other biological factors. We use imaging modalities to assess the degree of disc degeneration, out of which magnetic resonance imaging (MRI) is the most popular non-invasive modality. It is believed that early changes in disc degeneration are due to the biochemical events in the disc and can be evaluated by sequences in MRI involving the diffusion of water molecules. The apparent diffusion coefficient (ADC) is one such sequence that captures the signals based on the diffusion of water molecules. Ten articles were chosen from PubMed and Google Scholar using the MeSH terms 'lumbar spine degeneration' and 'apparent diffusion coefficient'. This review article has summarized various studies intending to gain a better understanding of the biochemical events leading to the development of disc degeneration. This study has also gathered the role of various sequences in MRI that can quantitatively assess disc degeneration.

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial

BACKGROUND CONTEXT

Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.

PURPOSE

To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.

STUDY DESIGN / SETTING

Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.

PATIENT SAMPLE

Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.

OUTCOME MEASURES

Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.

METHODS

Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.

RESULTS

In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.

CONCLUSIONS

Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

O2-O3 chemodiscolysis: How much, how long? Retrospective outcome evaluation of different treatment sessions in partially-responder patients

PURPOSE

To retrospectively evaluate the clinical and instrumental outcome of different treatment sessions of oxygen-ozone (O₂-O₃) chemodiscolysis in patients with lumbar disc herniation.

METHODS

We evaluated 73 patients partially responders to a single session of oxygen-ozone (O₂-O₃) chemodiscolysis and submitted to multiple injections sessions. All patients completed a pre- and post-treatment clinical (VAS and modified McNab score) and instrumental MRI follow-up. Imaging evaluation included assessment of intervertebral disc area (IDA). Pre- and post-treatment differences were compared to evaluate differences in variation between groups. Correlation analysis was used to evaluate the relationship between morphological and clinical parameters.

RESULTS

Based on the type and number of treatments performed, patients were divided into three groups: Group A) patients submitted to an additional periradicular anaesthetic/steroid injection; Group B) patients submitted to an additional session of intradiscal O₂-O₃ injection; Group C) patients submitted to two further sessions of intradiscal O₂-O₃ injection.The results showed an improvement of pain scores in all groups, and a smaller disc area change in group B. Comparing the differences between pre- and post-treatment features among the three different groups of patients, we did not find any statistically significant difference. Correlation analysis did not show any statistically significant correlation between the morphological changes of the intervertebral disc and the clinical output scores.

CONCLUSIONS

In our retrospective observation of partially responder patients, multiple intradiscal ozone injections were not associated with a higher disc shrinkage nor superior clinical outcome compared to a single intradiscal O₂-O₃ application with an additional periradicular injection session.

Diagnostic Role of Magnetic Resonance Imaging in Low Back Pain Caused by Vertebral Endplate Degeneration

Low back pain (LBP) is a common health issue worldwide with a huge economic burden on healthcare systems. In the United States alone, the cost is estimated to be $100 billion each year. Intervertebral disc degeneration is considered one of the primary causes of LBP. Moreover, the critical role of the vertebral endplates in disc degeneration and LBP is becoming apparent. Endplate abnormalities are closely correlated with disc degeneration and pain in the lumbar spine. Imaging modalities such as plain film radiography, computed tomography, and fluoroscopy are helpful but not very effective in detecting the causes behind LBP. Magnetic resonance imaging (MRI) can be used to acquire high-quality three-dimensional images of the lumbar spine without using ionizing radiation. Therefore, it is increasingly being used to diagnose spinal disorders. However, according to the American College of Radiology, current referral and justification guidelines for MRI are not sufficiently clear to guide clinical practice. This review aimed to evaluate the role of MRI in diagnosing LBP by considering the correlative contributions of vertebral endplates. The findings of the review indicate that MRI allows for fine evaluations of endplate morphology, endplate defects, diffusion and perfusion properties of the endplate, and Modic changes. Changes in these characteristics of the endplate were found to be closely correlated with disc degeneration and LBP. The collective evidence from the literature suggests that MRI may be the imaging modality of choice for patients suffering from LBP. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 3.

Integration of focal vibration and intra-articular oxygen-ozone therapy in rehabilitation of painful knee osteoarthritis

OBJECTIVE

To examine the pain-reducing effects of intra-articular oxygen-ozone (O₂O₃) injections and mechanical focal vibration (mFV) versus O₂O₃ injections alone in patients with knee osteoarthritis.

METHODS

Patients with chronic pain (>6 weeks) due to knee osteoarthritis (II-III on the Kellgren-Lawrence scale) were consecutively enrolled and divided into two groups: O₂O₃ (n = 25) and O₂O₃-mFV (n = 24). The visual analog scale (VAS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Medical Research Council (MRC) Manual Muscle Testing scale were administered at baseline (before treatment), after 3 weeks of treatment, and 1 month after the end of treatment. Patients received three once-weekly intra-articular injections of O₂O₃ into the knee (20 mL O₃, 20 μg/mL). The O₂O₃-mFV group also underwent nine sessions of mFV (three sessions per week).

RESULTS

The VAS score, KOOS, and MRC score were significantly better in the O₂O₃-mFV than O₂O₃ group. The within-group analysis showed that all scores improved over time compared with baseline and were maintained even 1 month after treatment. No adverse events occurred.

CONCLUSION

An integrated rehabilitation protocol involving O₂O₃ injections and mFV for 3 weeks reduces pain, increases autonomy in daily life activities, and strengthens the quadriceps femoris.

Oxygen-Ozone Therapy in the Rehabilitation Field: State of the Art on Mechanisms of Action, Safety and Effectiveness in Patients with Musculoskeletal Disorders

In recent years, the interest in oxygen–ozone (O₂O₃) therapy application has considerably increased in the field of rehabilitation. Despite its widespread use in common clinical practice, the biochemical effects of O₂O₃ are still far from being understood, although its chemical properties seem to play a pivotal role in exerting its positive effects on different pathological conditions. Indeed, the effectiveness of O₂O₃ therapy might be partly due to the moderate oxidative stress produced by O₃ interactions with biological components. O₂O₃ therapy is widely used as an adjuvant therapeutic option in several pathological conditions characterized by chronic inflammatory processes and immune over-activation, and most musculoskeletal disorders share these pathophysiological processes. The present comprehensive review depicts the state-of-the-art on the mechanisms of action, safety and effectiveness of O₂O₃ therapy in the complex scenario of the management of musculoskeletal disorders. Taken together, our findings suggest that O₂O₃ therapy seems to reduce pain and improve functioning in patients affected by low back pain and knee osteoarthritis, as reported by several studies in the literature. However, to date, further studies are warranted to clearly investigate the therapeutic effects of this promising therapy on other musculoskeletal disorders in the field of rehabilitation.

Apparent diffusion coefficient magnetic resonance imaging (ADC-MRI) in the axillary breast cancer lymph node metastasis detection: a narrative review

The presence of axillary lymph nodes metastases in breast cancer is the most significant prognostic factor, with a great impact on morbidity, disease-related survival and management of oncological therapies; for this reason, adequate imaging evaluation is strictly necessary. Physical examination is not enough sensitive to assess breast cancer nodal status; axillary ultrasonography (US) is commonly used to detect suspected or occult nodal metastasis, providing exclusively morphological evaluation, with low sensitivity and positive predictive value. Currently, sentinel lymph node biopsy (SLNB) and/or axillary dissection are the milestone for the diagnostic assessment of axillary lymph node metastases, although its related morbidity. The impact of magnetic resonance imaging (MRI) in the detection of nodal metastases has been widely investigated, as it continues to represent the most promising imaging modality in the breast cancer management. In particular, diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) values represent additional reliable non-contrast sequences, able to improve the diagnostic accuracy of breast cancer MRI evaluation. Several studies largely demonstrated the usefulness of implementing DWI/ADC MRI in the characterization of breast lesions. Herein, in the light of our clinical experience, we perform a review of the literature regarding the diagnostic performance and accuracy of ADC value as potential pre-operative tool to define metastatic involvement of nodal structures in breast cancer patients. For the purpose of this review, PubMed, Web of Science, and SCOPUS electronic databases were searched with different combinations of "axillary lymph node", "breast cancer", "MRI/ADC", "breast MRI" keywords. All original articles, reviews and metanalyses were included.

Basic embolization techniques: tips and tricks

Good knowledge of the various approaches of embolization of peripheral bleedings and different embolic materials available is of paramount importance for successful and safe embolization. We review and illustrate the main endovascular and percutaneous techniques used for embolization, along with the characteristics of the different embolic materials, and the potential complications.

Predictive factors of volumetric reduction in lumbar disc herniation treated by O2-O3 chemiodiscolysis

Purpose:

Aim of this study is to assess the effectiveness of O₂-O₃ percutaneous chemiodiscolysis by evaluating volumetric changes in lumbar disc herniation on magnetic resonance imaging, in order to identify possible pre-treatment factors affecting such changes

Methods:

Between January 2014 and December 2017, a total of 87 patients with low back pain and 103 lumbar disc herniations with MRI confirmation were considered for O₂-O₃ chemiodiscolysis. The volume of each herniated disc was determined before and after the treatment.

Results:

Multiple linear regression analysis showed a strong correlation between post-treatment LDH volume percent change and both pre-treatment LDH volume and pre-treatment EQ-VAS (p<0.05), while age showed only a weak positive correlation with post-treatment LDH volume percent change (p<0.1). No association was found for other factors, such as sex and herniation disc level.

Conclusions:

In conclusion, age, baseline LDH volume and self-assessed disease severity score could represent three easy accessible outcome predictive parameters to consider when intradiscal O₂-O₃ chemiodiscolysis is envisaged. Better results after intradiscal O₂-O₃ chemiodiscolysis were obtained in older patients with higher pre-treatment LDH volume and low-moderate pre-treatment EQ-VAS. (www.actabiomedica.it)

Diagnostic and interventional management of infective spine diseases

Spondylodiscitis (SD) is one of the main causes of back pain. Although the low mortality, high morbidity is related to spondilodiscitys, leading spine instability, chronic pain or neurological deficit. Diagnostic imaging plays a primary role in diagnosing spondylodiscitis. However different accuracy is highlighted by different diagnostic tool, depending also on timing of disease which represents a cardinal element for the phenotypic manifestation of the disease, beyond spatial resolution and tissue characterization proper of specific modality imaging. Conventional Radiology (CR), Computed Tomography (CT) and MRI (Magnetic Resonance Imaging) all have proven to be of primary importance in the approach to spondylodiscitis, although magnetic resonance imaging has demonstrated the greatest advantage in identifying the disease from its earliest stages, demonstrating high sensitivity and specificity (92% and 96%, respectively). This review focus on the role of different imaging modality in the approach to the spondylodiscitis, also addressing the role of interventional radiology that is pivotal not only for a diagnosis of certainty through biopsy, but also for a minimally-invasive treatment of paravertebral abscesses spondylodiscitis-related. (www.actabiomedica.it)

Diagnostic and interventional radiology: an update

NOT PRESENT.

Clinical utility of Dual Energy Computed Tomography in gout: current concepts and applications

Gout is the most common inflammatory arthritis and is increasing in prevalence and incidence in many countries worldwide. Dual Energy Computed Tomography (DECT) has a high diagnostic accuracy in established gout, but its diagnostic sensitivity is low in subjects with recent-onset gout. A meta-analysis of 17 studies showed a pooled sensitivity and specificity of 0.85 and 0.88, respectively. DECT is a useful diagnostic tool for patients with contraindications for joint aspiration or for those who refuse joint aspiration. This article aims to give an up to date review and summary of existing literature on the role and accuracy of DECT in the imaging of gout. (www.actabiomedica.it)

Diagnostic and interventional radiology fundamentals of synovial pathology

The synovial membrane is a specialized mesenchymal tissue that lines the diarthrodial joints surfaces, bursae, and tendon sheaths of the body. This article aims to provide an overview of the fundamentals of synovial tissue, with particular regard to the imaging findings of the main pathologic processes that can affect the synovia and the role of image-guided interventions. (www.actabiomedica.it)

Ultrasonography for oxygen-ozone therapy in musculoskeletal diseases

Over the years, infiltrative oxygen-ozone therapy has shown clinical benefits in several musculoskeletal disorders, due to its potential analgesic, anti-inflammatory, antioxidant and immunomodulatory effect. Ultrasonography is a safe, non-invasive imaging, easily available, and has the additional advantage of being real time for imaging and image-guided procedures of the musculoskeletal system. This review explains the numerous promising ways in which ultrasonography can be useful in oxygen-ozone therapeutic practices for musculoskeletal disorders, in order to improve safety and accuracy of treatment.

Assessment of lumbar disc herniaton using fractional anisotropy in diffusion tensor imaging along with conventional T2-weighted imaging

OBJECTIVE

To assess the usefulness of diffusion tensor imaging and its fractional anisotropy map along with conventional T2-weighted imaging in evaluating the anisotropic water diffusion variations of annulus fibres involved in herniation disc pathology.

MATERIALS AND METHODS

Seventy-five patients with previous medical ethics committee approval and informed consent experiencing low back pain were selected for this prospective randomised blinded trial. Lumbar disc fractional anisotropy maps were obtained acquiring diffusion tensor sequences on a 3T machine. The matrix of nucleus pulposus and structures of annulus fibres were analysed using fractional anisotropy textural features to highlight any presence of lumbar disc herniation. Observer variability and reliability between two neuroradiologists were evaluated. The χ² test, two-tailed t test and linear regression analysis were used to focus differences in patients' demographic data and magnetic resonance imaging findings.

RESULTS

Annular fissures with extrusions were identified using diffusion tensor imaging in 10 out of 17 discs (study group) previously assessed as bulging discs using conventional magnetic resonance imaging. Eighteen extrusions out of 39 (study group) disc levels were identified on diffusion tensor imaging compared to eight extrusions highlighted on T2-weighted imaging (P < 0.01). All eight (study group) disc extrusions evaluated on T2-weighted imaging showed annular fissures on diffusion tensor imaging. Seven out of 14 (study group) protrusions highlighted on T2-weighted imaging had no annular fissures on diffusion tensor imaging; thirty-six disc levels in the control group had no evidence of annular fissures on diffusion tensor imaging (P > 0.01).

CONCLUSIONS

The addition of diffusion tensor imaging sequences and fractional anisotropy mapping to a conventional magnetic resonance imaging protocol could be useful in detecting annular fissures and lumbar disc herniation.

Evaluation of intervertebral disc using T2 mapping sequences in patients undergoing O2-O3 chemiodiscolysis: an instrumental study with clinical correlation

PURPOSE

To assess the MRI modifications of the intervertebral disc (IVD) treated by chemiodiscolysis using T2 mapping sequences.

METHODS

Thirty sciatica patients (17 males, 13 females, mean age 47.52 years) were enrolled for percutaneous CT-guided O₂-O₃ chemiodiscolysis treatment. As a control group, we enrolled 30 patients who were treated by CT-guided periradicular injections. All patients were submitted to clinical (using VAS and Oswestry Disability index (ODI)) and imaging studies to evaluate the intervertebral disc area (IDA) and T2 mapping values of the IVD before and at 1-month follow-up.

RESULTS

In the study group, pre-treatment IDA mean values were 20.47 ± 1.62 cm², with significant reduction at the follow-up (P < 0.05). Mean pre-treatment T2 relaxation time values were 38.80 ± 4.51 ms, 44.05 ± 0.91 ms, and 45.45 ± 14.11 ms for anterior annulus fibrosus, nucleus pulposus (NP), and posterior annulus fibrosus, respectively, with significant increase at the level of the NP (P < 0.05) at the follow-up. Mean pre-treatment ODI and VAS scores were 21.5 ± 10.6 and 8.5 ± 0.57, with significant improvement at the post-treatment follow-up (P < 0.05). In the control group, despite clinical improvement, we did not find significant IVA reduction nor significant T2 values change after treatment. Correlation analysis of T2 mapping relaxation time values showed significant correlation of NP T2 mapping value with both the reduction of IDA (0.81, P < 0.001) and the improvement of VAS and ODI scores (0.86, P < 0.001) at 1 month. In the control group, we did not find any statistically significant correlation.

CONCLUSIONS

T2 mapping may be a useful indicator to predict disc shrinkage and the clinical response to CT-guided O₂-O₃ injection.

Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis

BACKGROUND

Evaluate the comparative effectiveness of treatment strategies for patients with pain due to lumbar disc prolapse (LDP).

METHODS

PubMed, EMBASE, and the Cochrane Database were searched through September 2017. Randomized controlled trials on LDP reporting on pain intensity and/or global pain effects which compared included treatments head-to-head, against placebo, and/or against conventional care were included. Study data were independently double-extracted and data on patient traits and outcomes were collected. Risk of bias was assessed using the Cochrane risk of bias tool. Separate Bayesian network meta-analyses were undertaken to synthesize direct and indirect, short-term and long-term outcomes, summarized as odds ratios (OR) or weighted mean differences (WMD) with 95% credible intervals (CI) as well as surface under the cumulative ranking curve (SUCRA) values.

RESULTS

58 studies in global effects and 74 studies in pain intensity analysis were included. Thirty-eight (65.5%) of these studies reported a possible elevated risk of bias. Autonomic drugs and transforminal epidural steroid injections (TESIs) had the highest SUCRA scores at short-term follow up (86.7 and 83.5 respectively), while Cytokines/Immunomodulators and TESI had the highest SUCRA values at long-term-follow-up in the global effect's analysis (86.6 and 80.9 respectively). Caudal steroid injections and TESIs had the highest SUCRA scores at short-term follow up (79.4 and 75.9 respectively), while at long-term follow-up biological agents and manipulation had the highest SUCRA scores (86.4 and 68.5 respectively) for pain intensity. Some treatments had few studies and/or no associated placebo-controlled trials. Studies often did not report on co-interventions, systematically differed, and reported an overall elevated risk of bias.

CONCLUSION

No treatment stands out as superior when compared on multiple outcomes and time periods but TESIs show promise as an effective short-term treatment. High quality studies are needed to confirm many nodes of this network meta-analysis.

High-resolution magnetic resonance imaging at 3T of pituitary gland: advantages and pitfalls

Magnetic resonance imaging (MRI) is the primary imaging tool for the evaluation of pituitary gland pathology. In the last decades, MRI with high-field scanners has become widely used in clinical practice, leading to significant improvements in image quality mainly thanks to a superior spatial resolution and signal intensity. Moreover, several advanced functional MRI sequences have been implemented for pituitary imaging, providing valuable information in diagnostic and presurgical planning of pituitary adenomas. Higher field strength presents however some technical pitfalls to be aware of. The purpose of this article is to review the state of the art of high-resolution MRI of the pituitary gland at 3 Tesla (3T), with a particular focus on the main benefits and the possible limitations of higher field imaging.

Application of ozone therapy in interventional medicine

Ozone therapy has been gradually accepted by doctors in various fields because it has been safe, convenient, and inexpensive since the twentieth century. It has been used in the treatment of various diseases with satisfactory results, especially in the application of interventional surgery. For lumbar disc herniation, knee osteoarthritis, tissue ischemia-reperfusion after revascularization, stroke, and cancer, ozone therapy can improve the efficacy of interventional surgery and reduce postoperative acute and chronic complications. Prospects of ozone therapy in interventional therapy and the underlying mechanisms of efficacy need further exploration.

Dynamic MRI in the evaluation of the spine: state of the art

INTRODUCTION

Degenerative disease of the spine is a generic term encompassing a wide range of different disease processes, which leads to spinal instability; traumatic/neoplastic events can accelerate this aging process. Therefore, the dynamic nature of the spine and its mobility across multiple segments is difficult to depict with any single imaging modality.

METHODS

A review of PubMed databases for articles published about kMRI in patients with cervical and lumbar spinal desease was performed. We focused on the physiopathological changes in the transition from supine to upright position in spine instability.

DISCUSSION

Until a few years ago, X-ray was the only imaging modality for the spine in the upright position. Of the imaging techniques currently available, MRI provides the greatest range of information and the most accurate delineation of soft-tissue and osseous structures. Conventional MRI examinations of the spine usually are performed in supine position, in functional rest, but the lumbar spine instability is often shown only by upright standing. This can result in negative findings, even in the presence of symptoms. Regardless, the final result is distorted. To overcome this limitation, Kinetic MRI (kMRI) can image patients in a weight-bearing position and in flexed and extended positions, thus revealing abnormalities that are missed by traditional MRI studies.

CONCLUSION

Despite some limitations, the upright MRI can be a complementary investigation to the traditional methods when there are negative results in conventional MRI in symptomatic patients or when surgical therapy is scheduled.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study

BACKGROUND AND AIM

The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal.

METHODS

Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment.

RESULTS

In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly.

CONCLUSIONS

Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.

Developments in the management of bone metastases with interventional radiology

Interventional radiology has known an exponential growth in the last years. Technological advances of the last decades, have made it possible to use new treatments on a larger scale, with safe and effective results. They could be considered as palliative treatments for painful lesions but also curative procedures, as single treatment or specially in combination with other techniques (surgery, radiation and oncology therapies, etc.).The main diffuse techniques are those of thermal ablation that destroy the target lesion through the heat; however there are also endovascular therapies that destroy the target tissue thanks to devascularization. Finally the is also the possibility to stabilize pathological fractures or impending fractures. In this paper all the most diffuse and effective techniques are reviewed and also a discussion of the main indications is done, with an analisys of the success and complications rates.

MRI findings in lumbar spine following O2-O3 chemiodiscolysis: A long-term follow-up

Intradiscal O2-O3 injections are conventionally used as a minimally invasive treatment for lumbar disc herniation in patients not responding to conservative treatments. The aim of the present study is to report data of long-term imaging follow-up (3 years) of patients treated with intradiscal O2-O3 lumbar chemiodiscolysis. We evaluated the changes of disc volume and the modifications in disc appearance (in terms of disc degeneration) and endplate changes (according to Modic), comparing the results with a control group of patients. Our results showed a stable reduction of the disc herniation volume in patients treated compared with the control group, while we did not find statistically significant differences in terms of disc degeneration and endplate changes (Modic). We concluded that the O2-O3 discolysis, despite leading to a significant shrinkage of the disc herniation, does not involve - in the long term - biomechanical changes of the spine in terms of acceleration of the disc degeneration process in comparison with the natural course.

Imaging of post-operative spine in intervertebral disc pathology

This work is an imaging review of spine after surgery with special regard to imaging modality in intervertebral disc pathology. Advances in imaging technology can be evaluated. Depending on the clinical question is asked to the radiologist, it is possible to evaluate post-operative patients with conventional radiology (X-ray), computed tomography and magnetic resonance. Main indications for each technique are analysed. Imaging is important in the diagnosis of many forms of spine pathology and plays a fundamental role in evaluating post-surgical effects of treatments, according to the imaging method which is used, both on spine and on its surrounding tissues (intervertebral discs, spinal cord, muscles and vessels).

Rational approach, technique and selection criteria treating lumbar disk herniations by oxygen-ozone therapy

Radicular lumbar back pain is an important public health problem not yet benefiting from a unequivocal treatment approach. Medical and physical therapies represent the first solution; however, when these fail, the second therapeutic step is still controversial and mini-invasive treatments may play an important role. In these cases oxygen-ozone therapy has been proved to be a very safe and effective option that is widely used with different modalities. This paper, by reviewing oxygen-ozone therapy literature data, aims to describe the rationale of oxygen-ozone therapy for the treatment of lumbar disk herniations, propose an effective procedural technique and clarify patient selection criteria; furthermore, complications and follow-up management are also considered.

Anaesthetics, steroids and platelet-rich plasma (PRP) in ultrasound-guided musculoskeletal procedures

This review aims to evaluate the role of anaesthetics, steroids and platelet-rich plasma (PRP) employed with ultrasound-guided injection in the management of musculoskeletal pathology of the extremities. Ultrasound-guided injection represents an interesting and minimally invasive solution for the treatment of tendon and joint inflammatory or degenerative diseases. The availability of a variety of new drugs such as hyaluronic acid and PRP provides expansion of the indications and therapeutic possibilities. The clinical results obtained in terms of pain reduction and functional recovery suggest that the use of infiltrative procedures can be a good therapeutic alternative in degenerative and inflammatory joint diseases.

Thoracic spine trauma: advanced imaging modality

Technological advances in diagnostic imaging make the diagnosis of spinal trauma more accurate both in the acute and in the chronic settings. Improvements in medical care and in diagnostic imaging lead to an increasing prevalence of patients' surviving injuries. The management of these patients depends on early and appropriate radiological evaluation in the acute phase. The aim of this work was to review advanced imaging modalities employed to study thoracic spine and spinal cord in injured patients.

Does evaluator experience have an impact on the diagnosis of lumbar spine instability in dynamic MRI? Interobserver agreement study

OBJECTIVES

We aimed to evaluate interobserver agreement in the definition of spine instability among spine neuroradiologists with or without experience in dynamic magnetic resonance imaging (MRI).

MATERIAL AND METHODS

Two expert neuroradiologists and two residents retrospectively evaluated the pre-operative dynamic MRI examinations of patients with vertebral instability. Segmental motion, defined as excessive (more than 3 mm) translational motion from supine to upright, was investigated in 103 subjects (309 segments) using kinetic MRI. Radiographic parameters which can help indicate segmental instability include disc degeneration, facet joint osteoarthritis, and ligament flavum hypertrophy. These three radiographic parameters were simultaneously evaluated, and the combinations corresponding to significant segmental instability at each level were determined. The agreement among the neuroradiologists was calculated using the kappa coefficient. All patients had neurosurgical intervention to stabilize the spine.

RESULTS

Agreement was high among experienced and non-experienced neuroradiologists. Agreement was nearly perfect for spinal location of spinal instability.

CONCLUSIONS

This study demonstrates that the experience of the evaluator has a low impact on the assessment of spinal instability if correct classification is used. The interobserver agreement confirms the usefulness and safety of kinetic MRI in the correct diagnosis of spinal instability even by less experienced evaluators.

Magnetic resonance imaging (MRI) of the lumbar spine with dedicated G-scan machine in the upright position: a retrospective study and our experience in 10 years with 4305 patients

PURPOSE

To evaluate the pathological changes of the lumbar spine and the instability of the lumbar intervertebral joints observed in patients with low back pain, with the study of the transition from supine to orthostatic position through the use of dedicated MRI-G-scan machine.

MATERIALS AND METHODS

Within 10 years, 4305 patients, aged between 21 and 80 years old, with history of low back pain with or without sciatica, underwent MRI examinations in upright and in supine position. The open MRI-scanner used is Esaote G-scan, which enables the acquisition of images in supine and standing positions. The used sequences were sagittal T2-weighted FSE, T1-weighted SE and axial 3D HYCE. Patients were divided into two groups: "negatives", with no changes in the two positions (supine and upright), and "positives", with MRI modifications of imaging in upright position.

RESULTS

Orthostatic examination showed MRI changes in 2870 out of 4305 (66.6%) patients, including 1252 males and 1618 females.

CONCLUSIONS

The G-scan is useful to assess instability of the lumbar spine detecting hidden modifications of protrusions and/or herniated discs already present in the supine position. It is also helpful in assessing the presence or modification of spondylolisthesis and lumbar canal stenosis.