Lower Extremity Paralysis After Radiofrequency Ablation of Vertebral Metastases

Interventional and Non-interventional Medical Rehabilitation Approaches to Axial Spine Pain in Vertebral Metastatic Disease

As targeted therapies help patients with advanced cancer live longer, interventions for management of axial spine pain will become more common. Unfortunately, the indications for and safety of these procedures have been relatively unexplored compared with non-cancer adults. This review focuses on the following aspects of axial spine pain management in patients with vertebral metastatic disease: (1) pathophysiology and symptoms of cancer- and non-cancer-related spine pain; (2) safety and efficacy of non-interventional rehabilitation approaches to treat this pain; (3) considerations for interventional pain approaches to acute and chronic pain in patients with vertebral metastatic disease. This review also summarizes gaps in the literature and describes specific cases in which the described interventions have been applied.

Comparison of the postoperative pain change and spinal stenosis rate between percutaneous vertebroplasty combined with radiofrequency ablation and with 125I particle implantation in the treatment of metastatic spinal cord compression: A retrospective study

Background context

Metastatic spinal cord compression (MSCC) seriously affects the survival rate.

Objective

The therapeutic effects of two treatment strategies for MSCC: percutaneous vertebroplasty (PVP) combined with radiofrequency ablation (RFA) and PVP combined with ¹²⁵I particle implantation, were compared.

Study design

Retrospective study.

Patient sample

40 patients with MSCC were divided into two groups: 19 cases in the RFA group and 21 cases in the ¹²⁵I group.

Method

All patients were accessed to determine the differences in pain, which was evaluated using the visual analog scale (VAS) at 1 week, 1 month, and 3 months after the operation, and spinal stenosis rates (SSRs), which were measured at 1 and 3 months after the operation, between the two groups.

Results

The VAS scores and SSRs at baseline were comparable between the RFA group and the ¹²⁵I group (7.19 ​± ​2.07 vs 7.42 ​± ​1.95, 37.7% ​± ​11.2% vs 41.1% ​± ​11.4%). The VAS scores and SSRs at 1 month and 3 months after the operation were significantly reduced in both groups, compared with those at baseline. The VAS scores and SSRs in the ¹²⁵I group were lower than those in the RFA group at 3 months after the operation (1.09 ​± ​0.97 vs 1.75 ​± ​1.06 p ​= ​0.048 and 12.3% ​± ​6.4% vs 18.1% ​± ​10.1% p ​= ​0.034), while the VAS scores at 1 week after the operation in the RFA group were lower than those in the ¹²⁵I group (4.39 ​± ​1.34 vs 5.05 ​± ​1.82 p ​= ​0.049).

Conclusion

PVP combined with RFA has a slight advantage in relieving pain in the short term, while PVP combined with ¹²⁵I particle implantation may have a better effect in the relieving pain and decreasing the SSRs at 3 months after the operation.

Safety of Thermosensor Insertion in the Midline of the Spinal Canal Anterior to the Dura: A Cadaveric Study

OBJECTIVE

To evaluate the safety of the insertion of a blunt-tip thermosensor inside the anterior epidural space using the trans-osseous route in the dorsal spine and the double oblique trans-foraminal approach in the lumbar spine.

MATERIALS AND METHODS

A total of 10 attempts were made on a 91 years old human specimen. Thermosensors were inserted under fluoroscopic guidance in the anterior part of the spinal canal using various oblique angulations. Surgical dissection was then performed to identify the position of the thermosensor and look for any injury to the dural sac or the spinal cord/cauda equina.

RESULTS

Nine thermosensors could be deployed successfully in the anterior part of the spinal canal from Th8 to L5 while one attempt (L5 level) failed due to a technical issue on the coaxial needle. On anteroposterior projection, the tip of thermosensor relative to the midline was classified as centered in 5 cases, overcrossing in 3 cases and undercrossing in 1 case. At surgical dissection, the tip of the thermosensor was epidural posterior to the posterior longitudinal ligament in 8 cases and anterior to the longitudinal ligament in 1 case (the undercrossing case). There were 3 tears to the dura, all in the overcrossing group. There was no case of injury to the spinal cord/cauda equina.

CONCLUSION

Insertion of a thin blunt-tip thermosensor with optimal angulation leads to an epidural post-ligamentous position on the midline without damage to the dural sac. The blunt-tip did not prevent from dural tearing should the insertion overcross the midline.

Iatrogenic neurological injury after radiofrequency ablation and epidural steroid injections: illustrative cases

BACKGROUND

Neck pain is often chronic and disabling. Cervical facet joint injections and epidural steroid injections are frequently used to manage chronic neck pain and cervicogenic headaches. While minimal side effects are commonly associated with these treatments, severe complications are exceedingly rare.

OBSERVATIONS

The authors report 4 cases of iatrogenic neurological injury after radiofrequency ablation (RFA) and epidural steroid injections. One patient experienced left shoulder, scapular, and arm pain with left arm and hand weakness that developed immediately after RFA for chronic neck pain. Electromyography/nerve conduction velocity (EMG/NCV) studies confirmed denervation changes in the left C8–T1 distribution. Three patients complained of numbness and weakness of the hands immediately after an interlaminar cervical epidural block. One of these patients underwent EMG/NCV that confirmed denervation changes occurring in the left C8–T1 distribution.

LESSONS

Spine surgeons and pain management specialists should be aware of neurological injuries that may occur after cervical RFA and epidural steroid injections, especially after a multilevel cervical procedure and with severe cervical spinal stenosis. EMG/NCV studies plays an important role in detecting and localizing neurological injury and in differentiating from conditions that mimic cervical root injuries, including brachial plexus trauma due to positioning and Parsonage-Turner syndrome.

Radiofrequency ablation and balloon kyphoplasty for palliation of painful spinal metastases

PURPOSE

This study was designed with an aim to assess the safety and early postoperative outcomes of the combined Radiofrequency ablation (RFA) and Balloon Kyphoplasty (BKP) used for the treatment of painful neoplastic spinal lesions palliatively.

PATIENTS AND METHODS

Between December 2015 and December 2018, 60 patients (35 men and 25 women) with spinal metastases were operated using RFA and BKP at our institution. Transpedicular biopsy was performed in all cases. Patients' demographics, lesion characteristics, concurrent palliative therapies and complications were recorded. All patients were clinically (Pain score VAS 0-10) and radiologically evaluated pre- and postoperatively. Retrospective analysis of data for this cohort was performed.

RESULTS

Seventy-five painful spinal metastases (46 in the lumbar spine and 29 in the thoracic region) in 60 patients were operated [transpedicular RFA alone in 5 lesions, and in combination with BKP in 70 lesions (93%)]. The mean pre-procedure and post-procedure VAS for back pain was 7.2/10 and 2.7/10, respectively (p value = 0.0001). No neurological complications related to RFA were found and no cement extravasation into the spinal canal was observed. In two patients, asymptomatic leaks into the needle track, in two patients into draining veins and in one patient into the disk space were detected.

CONCLUSION

Combined RFA and BKP appears to be a safe, practical, effective and reproducible palliative treatment for painful spinal osteolytic metastasis. In carefully indicated cases, it relieves pain and maintains stability in a minimal invasive way without adding significant surgical trauma or complications.

Complications of Percutaneous Radiofrequency Ablation of Spinal Osseous Metastases: An 8-Year Single-Center Experience

OBJECTIVE. The purpose of this article was to evaluate the complication rate of percutaneous radiofrequency ablation of spinal osseous metastases. MATERIALS AND METHODS. This retrospective HIPAA-compliant study reviewed complications of radiofrequency ablation combined with vertebral augmentation performed on 266 tumors in 166 consecutive patients for management of vertebral metastases between January 2012 and August 2019. Common Terminology Criteria for Adverse Events (CTCAE) was used to categorize complications as major (grade 3-4) or minor (grade 1-2). Local tumor control rate as well as pain palliation effects evaluated by the Brief Pain Inventory scores determined 1 week, 1 month, 3 months, and 6 months after treatment were documented. Wilcoxon signed rank and Mann-Whitney U tests were used for statistical analysis. RESULTS. Among 266 treated tumors, the total complication rate was 3.0% (8/266), the major complication rate was 0.4% (1/266), and the minor complication rate was 2.6% (7/266). The single major (CTCAE grade 3) periprocedural complication was characterized by lower extremity weakness, difficulty in urination, and lack of erection as a result of spinal cord venous infarct. The seven minor complications included four cases of periprocedural transient radicular pain (CTCAE grade 2) requiring transforaminal steroid injections, one case of delayed secondary vertebral body fracture (CTCAE grade 2) requiring analgesics, and two cases of asymptomatic spinal cord edema on routine follow-up imaging (CTCAE grade 1). The local tumor control rate was 78.9%. There were statistically significant pain palliation effects at all postprocedural time intervals (p < .001 for all). CONCLUSION. Radiofrequency ablation of spinal osseous metastases is safe with a 3.0% rate of complications.

Transosseous Temperature Monitoring of the Anterior Epidural Space during Thermal Ablation in the Thoracic Spine

PURPOSE

To present the technique of combined temperature monitoring and hydrodissection of the anterior epidural space during thermal ablation in the thoracic spine.

MATERIALS AND METHODS

Data from 8 patients were retrieved retrospectively with thoracic spinal metastases located near the posterior wall of the vertebral body. Thermal ablation was performed with temperature monitoring and hydrodissection of the anterior epidural space.

RESULTS

Technical success, defined as a fulfilled ablation protocol without changes of the temperature of the epidural space below 10°/above 45° that could not be controlled by active hydrodissection, was 100%. The mean time to deploy the thermosensor was 19.5 ± 4.8 min (range 13-35). There was one post-operative transient intercostal neuralgia. No spinal cord or nerve root injuries arose. Two local recurrences occurred at a mean follow-up of 20 ± 9 months.

CONCLUSION

Transosseous temperature monitoring of the anterior epidural space in the thoracic spine is a feasible technique and seems safe.

Vertebral Metastases: Minimally Invasive Percutaneous Thermal Ablation

This article provides a step-by-step guide for minimally invasive percutaneous image-guided thermal ablation for treatment of vertebral metastases. Such interventions have proved safe and effective in management of selected patients with spinal metastases primarily to achieve pain palliation and local tumor control. Particular attention to patient selection guidelines, details of procedure techniques, thermal protection, adequacy of treatment, recognition and management of potential complications, and post-ablation imaging are essential for improved patient outcomes.