Ablation, consolidation and radiotherapy for the management of metastatic lesions of the spine: impact on the quality of life in a mid-term clinical and diagnostic follow-up in a pilot study

Radiofrequency Ablation in Vertebral Body Metastasis with and without Percutaneous Cement Augmentation: A Systematic Review Addressing the Need for SPINE Stability Evaluation

Vertebral body metastases (VBM) are one of the most frequent sites of bone metastasis, and their adequate therapeutic management still represents an insidious challenge for both oncologists and surgeons. A possible alternative treatment for VBM is radiofrequency ablation (RFA), a percutaneous technique in which an alternating current is delivered to the tumor lesion producing local heating and consequent necrosis. However, RFA alone could alter the biomechanics and microanatomy of the vertebral body, thus increasing the risk of post-procedure vertebral fractures and spine instability, and indeed the aim of the present study is to investigate the effects of RFA on spine stability. A systematic review according to PRISMA-P guidelines was performed, and 17 papers were selected for the systematic review. The results show how RFA is an effective, safe, and feasible alternative to conventional radiotherapy for the treatment of VBM without indication for surgery, but spine stability is a major issue in this context. Although exerting undeniable benefits on pain control and local tumor recurrence, RFA alone increases the risk of spine instability and consequent vertebral body fractures and collapses. Concomitant safe and feasible therapeutic strategies such as percutaneous vertebroplasty and kyphoplasty have shown synergic positive effects on back pain and improvement in spine stability.

Clinical analysis of percutaneous kyphoplasty for spinal metastases in older adults with comorbidities

INTRODUCTION

We aimed to investigate the clinical outcomes of percutaneous kyphoplasty (PKP) for spinal metastases in older adult patients with comorbidities.

MATERIALS AND METHODS

Ninety-two older adults (age ≥ 60 years) with spinal metastases who underwent 148 PKP procedures were retrospectively analyzed. Tokuhashi scores, Tomita scores, age-adjusted Charlson Comorbidity Index (aCCI) scores, and American Society of Anesthesiologists (ASA) scores were evaluated before the procedure. The visual analog scale (VAS), Oswestry Disability Index (ODI), vertebral body height (VBH), and quality of life (QoL) were used to assess the efficacy of the procedure. Clinical safety was evaluated based on periprocedural complications.

RESULTS

Tokuhashi scores and Tomita scores were 7.3 ± 4.0 and 5.8 ± 2.1, respectively. Excluding cancer-related factors, twelve patients (13.0%) had aCCI scores ≥4. Forty-three patients (46.7%) had ASA status ≥ III. Compared to preoperative status, average VAS scores, ODI scores, VBH variation, and QoL scores significantly improved at each follow-up examination point after PKP (p < 0.001). No major complications occurred, nor was there decompensation of comorbidities in the perioperative period. Seventeen segments (11.5%) of twelve patients (13.0%) suffered bone cement leakage. Among them, one patient suffered intercostal neuralgia cured by steroid injection, and the other patient suffered hyperesthesia, which disappeared after taking gabapentin (0.3 g, bid) for five weeks. Another minor complication of local hematoma occurred in one patient, which spontaneously resolved without surgical intervention.

DISCUSSION

PKP serves as a safe approach to provide significant pain relief, vertebral body height restoration, and QoL improvements for spinal metastases in older adults, independent of underlying disease.

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.

Cervical spine trauma: impact of different imaging classification systems in the clinical decision-making

Background and aim:

Considering the high rate of mortality and permanent disability related to vertebral traumas, an early and detailed diagnosis of the trauma and subsequently an immediate and effective intervention are crucial. Cervical vertebral injury classifications guide treatment choice through a severity grade based on radiological information. The purpose of the present study was to define which imaging classification system could provide the best morphological and clinical-surgical correlations for cervical spine traumas.

Methods:

We retrospectively analyzed patients evaluated for cervical spine trauma at our Institution in the period 2015-2020. Information regarding the morphological examination (using CT and MRI), the neurological evaluation, and the therapeutic management were collected. C3-C7 fractures were classified according to the SLIC and AOSpine criteria; axial lesions were classified according to the modified AOSpine for the C1-C2 compartment and through the Roy-Camille and the Anderson D’Alonzo system for the odontoid process of the axis.

Results:

29 patients were included in the final study population. Nine patients with axial spine trauma and 21 with subaxial cervical spine trauma. A conservative approach was applied in 16 patients while nine patients underwent neurosurgery. Considering the therapeutical indications provided by the SLIC system, a 76.9% accordance was found for patients with a <4 score, while a 100% concordance was calculated for patients with a >4 score undergoing neurosurgery. Regarding the AOSspine classification, a 28.6% concordance was observed for patients classified group B being treated with a posterior neurosurgical approach, while for patients belonging to subgroup C, considered for anterior neurosurgical approach, a 66.7% accordance was calculated.

Conclusions:

The study demonstrated a better morphological correlation for the AOSpine classification in subaxial trauma and the AOSpine and Anderson D’Alonzo in axial trauma. The therapeutic indication found a better correlation in the SLIC classification for subaxial trauma and the Anderson D’Alonzo for axial ones. (www.actabiomedica.it)

Comparison of the clinical outcomes of percutaneous kyphoplasty for the management of osteolytic and osteoblastic-related metastatic vertebral lesions

OBJECTIVE

To retrospectively compare the clinical efficacy and safety of percutaneous kyphoplasty (PKP) for the management of osteolytic and osteoblastic-related metastatic vertebral lesions.

METHODS

A total of 117 patients with osteolytic (87 cases, 159 lesions, OL group) or osteoblastic-related (30 cases, 56 lesions, OB group) metastatic vertebral lesions underwent PKP. The clinical efficacy was assessed based on parameters including Visual Analog Scale (VAS), Oswestry Disability Index (ODI), vertebral body height (VBH) variation, and quality of life (QoL). Major and minor complications were systematically evaluated to assess the safety of the procedure.

RESULTS

No significant differences were found in the age, sex, or amount of bone cement between both groups (p>0.05). Compared with the OB group, the OL group was superior in operation duration (p<0.05) but was inferior in inflation pressure (p<0.05). Both groups experienced significant pain relief and improvement in the ODI, VBH, and QoL after PKP (p<0.05). The OB group had a better pain relief according to the VAS score but a poorer VBH restoration than the OL group throughout the follow-up period (p<0.05). No significant differences were observed in ODI and QoL between the two groups (p>0.05). The incidence of complications in the OL group was significantly higher than that in the OB group (p<0.05).

CONCLUSIONS

PKP can safely achieve pain relief, functional improvement, VBH restoration, and QoL improvement for patients with osteolytic or osteoblastic-related metastatic vertebral lesions. Patients with osteolytic metastatic vertebral lesions showed better VBH restoration and had a shorter operation time but experienced less pain relief and had a greater incidence of complications than patients with osteoblastic-related metastatic vertebral lesions after PKP.

Musculoskeletal Interventional Radiology in the Pediatric Population: State of the Art

Interventional radiology procedures have been proven to be as effective as traditional surgery but usually are characterized by lower morbidity rates. In this article, the most diffuse IR treatments for pediatric lesions are reviewed with the aim of describing main advantages and drawbacks. Ablation procedures (in particular RFA and MRgFUS) are widely used for the management of osteoid osteoma and osteoblastoma whereas intracystic injection of methylprednisolone acetate is performed for simple bone cysts. Sclerosing agents and where possible, selective arterial embolization are used for treatment of aneurysmal bone cysts and other vascular malformations. In the management of malignant muscoloskeletal tumors, the role interventional radiology is mainly represented by percutaneous biopsies, and by adiuvant selective embolizations in presence of hypervascular lesions to be submitted to surgery.