Palliative pain relief and safety of percutaneous radiofrequency ablation combined with cement injection for bone metastasis

Complication avoidance, rehabilitation, pain therapy and palliative care for patients with metastatic spine tumors: WFNS spine committee recommendations

OBJECTIVE

This review aims to formulate the most current, evidence-based recommendations regarding complication avoidance, rehabilitation, pain therapy and palliative care for patients with metastatic spine tumors.

METHODS

A systematic literature search in PubMed and MEDLINE, and was performed from 2013 to 2023 using the search terms "complications" + "spine metastases", "spine metastases" + + "rehabilitation", "spine metastases" + "pain therapy" + "palliative care". Screening criteria resulted in 35, 15 and 56 studies respectively that were analyzed. Using the Delphi method and two rounds of voting at two separate international meetings, nine members of the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated nine final consensus statements.

RESULTS

Preoperative assessment for complications following surgery in patients with metastatic spine tumors should include estimation of Karnofsky score, site of primary tumor, number of spinal and visceral metastasis, ASA score and preoperative Hb (Hemoglobin) value. Complication risk factors are age > 65 years, preoperative ASA score of 3 and 4 and greater operative blood loss. Pain management using WHO analgesic concept and early mobilization are needed, starting with non-opioids, weak opioids followed by strong opioids. Morphine is the first choice for moderate to severe pain whereas IV-PCA may be used for severe breakthrough pain with monitoring. Use of bisphosphonates is considered in cases of non-localized pain and not accessible radiation therapy.

CONCLUSIONS

These nine final consensus statements provide current, evidence-based guidelines on complication avoidance, rehabilitation, pain therapy and palliative care for patients with spinal metastases.

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.

Image-Guided Energy Ablation for Palliation of Painful Bony Metastases-A Systematic Review

PURPOSE

To analyze the effectiveness of image-guided energy ablation techniques with and without concurrent therapies in providing palliative pain relief in patients with bone metastases.

MATERIALS AND METHODS

Ovid Embase, Ovid Medline, and Pubmed were searched from inception to April 14, 2023, using search terms related to bone lesions and MeSH terms regarding ablation therapy. English peer-reviewed primary articles were included that reported pain scores following image-guided energy-based ablation of bone metastases. Exclusion criteria included nonpalliative treatment, pain scores associated with specific treatment modalities not reported, and nonmetastatic bone lesions. Mean percentage reduction in pain score was calculated.

RESULTS

Of the 1,396 studies screened, 54 were included. All but 1 study demonstrated decreased pain scores at final follow-up. Mean reductions in pain scores at final follow-up were 49% for radiofrequency (RF) ablation, 58% for RF ablation and adjunct, 54% for cryoablation (CA), 72% for cryoablation and adjunct (CA-A), 48% for microwave ablation (MWA), 81% for microwave ablation and adjunct (MWA-A), and 64% for high-intensity focused ultrasound (US). Postprocedural adverse event rates were 4.9% for RF ablation, 34.8% for RF ablation and adjunct, 9.6% for CA, 12.0% for CA-A, 48.9% for MWA, 33.5% for MWA-A, and 17.0% for high-intensity focused US.

CONCLUSIONS

Image-guided energy ablation demonstrated consistently strong reduction in pain across all modalities, with variable postprocedural adverse event rates. Owing to heterogeneity of included studies, quantitative analysis was not appropriate. Future primary research should focus on creating consistent prospective studies with established statistical power, explicit documentation, and comparison with other techniques.

Supportive care interventions in metastatic bone disease: scoping review

BACKGROUND

Patients with secondary metastatic involvement of the musculoskeletal system due to primary cancers are a rapidly growing population with significant risks for health-related end-of-life morbidities. In particular, bone metastases or metastatic bone disease (MBD) imparts significant adversity to remaining quality of life. No rigorous review of clinical trials on the use of supportive care interventions for MBD has been conducted. The objective of this review was to examine the characteristics of supportive care interventions for MBD and critically appraise study designs, key findings, and quality of evidence of the research.

METHODS

We searched for published clinical trials, systematic reviews and meta-analyses in PubMED, CINAHL and Google Scholar for articles published between September 2017 and September 2022. Some examples of Medical Subject Headings terms were: 'secondary neoplasm', 'metastatic bone disease', 'palliative care' and 'supportive care intervention'. Quality of published evidence was evaluated based on treatment types and study design.

RESULTS

After reviewing 572 publications, 13 articles were included in the final review and evaluation including seven clinical trials, two trial protocols and four systematic reviews. Feasible interventions included enhanced palliative care consultation, palliative radiotherapy and alternative medicines. Interventions addressed primary endpoints of fatigue (N=4, 31%), pain (N=3, 23%) or cancer-related symptoms (N=3, 23%) with patient-reported outcome instruments. No interventions reported on fracture complications or endpoints, specifically. The quality of most studies was moderate to strong.

CONCLUSION

Supportive care interventions for MBD are feasible and the impact is measurable via patient-reported outcome measures. While the evidence for interventions was moderate to strong, there are very few specific controlled trials for skeletal-related events and impacts of social determinants of health. Further clinical trials are needed to define supportive care interventions for MBD that demonstrate reduced risk of fracture and that mitigate the reduced quality of life when negative musculoskeletal outcomes arise.

Analgesic efficacy and safety of percutaneous thermal ablation plus cementoplasty for painful bone metastases: a systematic review and meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis of publications to evaluate the analgesic efficacy and safety of percutaneous thermal ablation (PTA) plus percutaneous cementoplasty (PCP) (PTA + PCP) for painful bone metastases.

METHODS

We searched PubMed, Cochrane Library and Embase for articles published up to October 2022. Outcomes were a 10-point pain scale, morphine equivalents daily dose (MEDD) and complications. A subgroup confined to spinal bone metastases was analyzed.

RESULTS

Twenty-one articles were selected for the analysis. The 21 selected articles involved a total of 661 cases. The pooled pain scales at pre-PTA + PCP, 1 day, 1 week and 1-, 3-, and 6 months post-PTA + PCP were 7.60 (95% confidence interval [CI], 7.26-7.95, I2 = 89%), 3.30 (95% CI, 2.25-4.82, I2 = 98%), 2.58 (95% CI, 1.99-3.35, I2 = 94%), 2.02 (95% CI, 1.50-2.71, I2 = 93%), 1.78 (95% CI, 1.26-2.53, I2 = 95%), and 1.62 (95% CI, 1.14-2.31, I2 = 88%), and in the subgroup, 7.97 (95% CI, 7.45-8.52, I2 = 86%), 3.01 (95% CI, 1.43-6.33, I2 = 98%), 2.95 (95% CI, 1.93-4.51, I2 = 95%), 2.34 (95% CI, 1.82-3.01, I2 = 68%), 2.18 (95% CI, 1.57-3.03, I2 = 78%), and 2.01 (95% CI, 1.16-3.48, I2 = 86%). Mean MEDD decreased up to 3 months post-PTA + PCP in 4 articles. The overall pooled major complication rate was 4% (95% CI, 2-6%, I2 = 2%).

CONCLUSIONS

The updated systematic review and meta-analysis indicates that PTA + PCP for painful bone metastases is safe, and can lead to rapid and sustained pain reduction.

Pain Relief and Safety of Microwave Ablation Combined with Percutaneous Vertebroplasty for Vertebral Metastasis: A Pilot Study

BACKGROUND

 We investigate the pain relief and safety of microwave ablation (MWA) combined with percutaneous vertebroplasty (PVP) in the treatment of metastatic vertebral tumors.

METHODS

 This prospective pilot study enrolled patients with metastatic vertebral tumors treated between January 2018 and October 2019. The participants were randomized to the PVP and MWA + PVP groups. Clinical parameters, pain visual analog scale (VAS), analgesic use scores (AUS), and quality-of-life score (QLS) were compared between groups.

RESULTS

 Sixty-seven participants were enrolled (PVP: n = 35; MWA + PVP: n = 32). There were no differences in bone cement injection volume, extravasation, and X-ray exposure time between the two groups (p > 0.05), but treatment costs were higher for the MWA + PVP group (26,418 ± 194 vs. 15,606 ± 148 yuan; p < 0.05). There were no significant improvements in VAS from baseline to 24 hours, 72 hours, 7 days, 1 month, and 3 months in the two groups (p > 0.05); at 6 and 12 months after the operation, the improvement from baseline was significant in the two groups (p < 0.05). The VAS was lower at 6 months (2.7 ± 0.7 vs. 3.2 ± 0.7) and 12 months (3.5 ± 0.8 vs. 4.0 ± 0.7) in the MWA + PVP group (both p < 0.01 vs. PVP). The AUS and QLS were improved with PVP at 6 and 12 months (p < 0.05) and with MWA + PVP at 12 months (p < 0.05). The AUS was lower at 6 and 12 months in the MWA + PVP group (p < 0.05 vs. PVP).

CONCLUSION

 MWA combined with PVP might be a safe and effective palliative treatment for pain from metastatic vertebral tumors.

Treatment progress of spinal metastatic cancer: a powerful tool for improving the quality of life of the patients

Spinal metastasis is a common secondary malignant tumor of the bone, often resulting in spinal cord and nerve root compression, leading to obvious pain and related compression symptoms. This condition has a high incidence and mortality rate. The treatment approach for most patients with spinal metastasis is primarily palliative. Consultation with a multidisciplinary team is widely accepted as a comprehensive treatment approach for patients with spinal metastases. With advancements in research and technology, the evaluation and treatment of spinal metastatic cancer are continuously evolving. This study provides an overview of surgical treatment, minimally invasive treatment, and radiotherapy for spinal metastatic cancer and also analyzes the clinical effects, advantages, and current limitations associated with various treatment approaches.

Microwave ablation versus radiofrequency ablation for treating spinal metastases

BACKGROUND

This study aimed to compare the clinical efficacy and safety of microwave ablation (MWA) and radiofrequency ablation (RFA) for the treatment of spinal metastases.

METHODS

A literature search was performed using the PubMed, Web of Science, and Cochrane Library databases according to the PRISMA statement (as of September 20, 2022). Two independent investigators screened articles based on the inclusion and exclusion criteria and included studies with primary outcomes of pain relief, tumor control, and complications. Article quality was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool.

RESULTS

Sixteen articles were finally included in this study, including 630 patients with spinal metastases, with ages ranging from 51.4 to 71.3 years. Of these, 393 (62.4%) underwent MWA and 237 (37.6%) underwent RFA. After MWA and RFA treatment, visual analog scale scores significantly decreased, and the local tumor control rates were all above 80%. Complications were reported in 27.4% of patients treated with MWA compared with 10.9% of patients treated with RFA.

CONCLUSION

The results of this systematic review suggest that MWA alone or in combination with surgery and RFA in combination with other modalities may improve pain caused by primary tumor metastasis to the spine, and MWA alone or in combination with surgery may have better local tumor control. However, MWA appears to result in more major complications than RFA in combination with other treatment modalities.

Risk factors for pulmonary cement embolism after percutaneous vertebroplasty and radiofrequency ablation for spinal metastases

Objective

Pulmonary cement embolism is a rare but underestimated complication of vertebroplasty due to the relative lack of study and examination. This study aims to investigate the incidence of pulmonary cement embolism in patients with spinal metastasis who undergo PVP with RFA and to analyze the relative risk factors.

Methods

A total of 47 patients were retrospectively included and classified into pulmonary cement embolism (PCE) group and non-pulmonary cement embolism (NPCE) group by comparing pre- and postoperative pulmonary CT scan images. The demographic and clinical information of the patients was obtained. Demographic data in the two groups were compared using the chi-square test for qualitative data and the unpaired t test for quantitative data. Multiple logistic regression analysis was used to identify risk factors related to pulmonary cement embolism.

Results

Pulmonary cement embolism was detected in 11 patients (23.4%), and all patients were asymptomatic and followed up regularly. Risk analysis showed that multiple segments (≥3, p=0.022), thoracic vertebrae (p=0.0008), and unipedicular puncture approach (p=0.0059) were risk factors for pulmonary cement embolism. There was a high incidence of pulmonary cement embolism if bone cement leaked into the para vertebral venous plexus in the thoracic vertebra (p<0.0001). Vein leakage of cement was related to the integrity of the vertebral cortex.

Conclusion

The number of involved vertebrae, lesion location, and puncture approach are independent risk factors for pulmonary cement embolism. There was a high incidence of pulmonary cement embolism if bone cement leaked into the para vertebral venous plexus in the thoracic vertebra. Surgeons should consider these factors when formulating therapeutic strategies.

PVP with or without microwave ablation for the treatment of painful spinal metastases from NSCLC: a retrospective case-control study

OBJECTIVE

To compare the clinical efficacy of percutaneous vertebroplasty (PVP) alone and microwave ablation (MWA) combined with PVP for the treatment of painful spinal metastases from non-small cell lung cancer (NSCLC).

METHODS

From October 2014 to October 2021, the data of 58 NSCLC patients with refractory painful spinal metastases (visual analog scale score ≥ 5) were retrospectively collected and analyzed. Patients in Group A (n = 30) and Group B (n = 28) received PVP alone and MWA combined with PVP, respectively. The primary endpoint was pain relief. The secondary endpoints were quality of life (QoL), local tumor progression (LTP), and complications.

RESULTS

The technical success rate was 100% in both groups. Patients in both groups showed similar pain relief at 1-12 weeks, but patients in Group B still showed sustained pain relief at 24 weeks compared to those in Group A (p = 0.03). The assessment of QoL showed similar changes. LTP (33.00% vs. 7.14%, p = 0.02) and cement leakage rates (40.00% vs. 7.14%, p = 0.03) were lower in Group B. The multivariate analysis demonstrated spinal metastases with a maximum diameter ≤ 3.0 cm (p = 0.027) and MWA combined with PVP (p = 0.028) were two independent protective factors for LTP. For cement leakage, spinal metastases with vertebral body compression (p = 0.019) was an independent risk factor, while MWA combined with PVP (p = 0.042) was an independent protective factor.

CONCLUSION

MWA combined with PVP for painful spinal metastases from NSCLC performed more sustained pain relief (>6 months) and ultimately improved QoL with lower LTP and cement leakage rates, compared to PVP alone.

Percutaneous-Reinforced Osteoplasty: A Review of Emerging Treatment Strategies for Bone Interventions

Percutaneous-reinforced osteoplasty is currently being investigated as a possible therapeutic procedure for fracture stabilization in high-risk patients, primarily in patients with bone metastases or osteoporosis. For these patients, a percutaneous approach, if structurally sound, can provide a viable method for treating bone fractures without the physiologic stress of anesthesia and open surgery. However, the low strength of fixation is a common limitation that requires further refinement in scaffold design and selection of materials, and may potentially benefit from tissue-engineering-based regenerative approaches. Scaffolds that have tissue regenerative properties and low inflammatory response promote rapid healing at the fracture site and are ideal for percutaneous applications. On the other hand, preclinical mechanical tests of fracture-repaired specimens provide key information on restoration strength and long-term stability and enable further design optimization. This review presents an overview of percutaneous-reinforced osteoplasty, emerging treatment strategies for bone repair, and basic concepts of in vitro mechanical characterization.

Minimally Invasive Interventional Procedures for Metastatic Bone Disease: A Comprehensive Review

Metastases are the main type of malignancy involving bone, which is the third most frequent site of metastatic carcinoma, after lung and liver. Skeletal-related events such as intractable pain, spinal cord compression, and pathologic fractures pose a serious burden on patients’ quality of life. For this reason, mini-invasive treatments for the management of bone metastases were developed with the goal of pain relief and functional status improvement. These techniques include embolization, thermal ablation, electrochemotherapy, cementoplasty, and MRI-guided high-intensity focused ultrasound. In order to achieve durable pain palliation and disease control, mini-invasive procedures are combined with chemotherapy, radiation therapy, surgery, or analgesics. The purpose of this review is to summarize the recently published literature regarding interventional radiology procedures in the treatment of cancer patients with bone metastases, focusing on the efficacy, complications, local disease control and recurrence rate.

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.

The Palliative Care in the Metastatic Spinal Tumors. A Systematic Review on the Radiotherapy and Surgical Perspective

Spine represents the most common site for metastatic disease involvement. Due to the close relationship between the spinal cord and critical structures, therapeutical management of metastatic spinal cord disease remains challenging. Spinal localization can lead to neurological sequelae, which can significantly affect the quality of life in patients with a limited life expectancy. The authors conducted a systematic literature review according to PRISMA guidelines in order to determine the impact of the most updated palliative care on spinal metastases. The initial literature search retrieved 2526 articles, manually screened based on detailed exclusion criteria. Finally, 65 studies met the inclusion criteria and were finally included in the systematic review. In the wide scenario of palliative care, nowadays, recent medical or surgical treatments represent valuable options for ameliorating pain and improving patients QoL in such this condition.

The combination of radiofrequency ablation and vertebroplasty shows advantages over single vertebroplasty in treating vertebral neoplastic lesions

OBJECTIVE

To investigate the safety and efficacy of the combination of radiofrequency ablation (RFA) and vertebroplasty versus single vertebroplasty in treating spinal metastases.

MATERIALS AND METHODS

The data of 35 patients with vertebral neoplastic lesions who received RFA combined with vertebroplasty (group A, 15 patients with 17 lesions) or single vertebroplasty (group B, 20 patients with 24 lesions) from March 2016 to June 2019 were retrospectively compared. The data of patients' Visual Analogue Scale (VAS) scores prior to the treatments, 1 week, 1 month, 3 months, and 6 months after the treatments, injected cement volume, ratios of cement leakage were compared between the two groups.

RESULTS

All procedures were successfully done without severe complications. The VAS scores in group A were decreased more rapidly 1 week after the treatments and remained more stable at 6 months than that in group B (P < 0.05). The cement injected in group A (5.95 ± 1.45 mL, range 4-9.5 mL) was significantly more than that in group B (4.09 ± 0.55 mL, range 3.1-5.5 mL) (P < 0.05). The ratio of vascular cement leakage in group A was significantly lower than that in group B (P < 0.05), while no statistical difference was found in the non-vascular cement leakage (P > 0.05).

CONCLUSIONS

Our study shows that the combination of RFA and vertebroplasty has a better analgesic effect with more injected cement and lower rates of venous cement leakage than single vertebroplasty.

What is the effectiveness of radiofrequency ablation in the management of patients with spinal metastases? A systematic review and meta-analysis

PURPOSE

Spinal metastases are indicative of progressive cancer which can lead to vertebral body fractures and spinal cord compression. Radiofrequency ablation (RFA) treatment is infrequently used in patients with refractory pain. The aim of this systematic review is to determine the clinical efficacy of RFA, with the scope of using it as front-line management of spinal metastases.

METHODS

Electronic databases were searched (to July 2020) for studies evaluating RFA treatment for spinal metastases in adults. Measured outcomes were pain (primary), disability, health-related quality of life (HRQOL), complications, tumour control and mortality. Study inclusion, data extraction and risk of bias using the ROBIN-I tool were assessed. Meta-analysis was conducted for pooled results with homogeneity, and narrative synthesis was conducted otherwise.

RESULTS

15 studies were included. RFA reduces pain scores at 3-5 weeks [standardised mean difference (SMD 2.24, 95% confidence intervals (CI) 1.55-2.93], 3-4 months (SMD 3.00, 95% CI 1.11-4.90) and 5-6 months (SMD 3.54, 95% CI 1.96-5.11). RFA is effective in reducing disability/improving HRQOL in the short-term but longer-term efficacy remains unclear. 13.2% cases reported local tumour control failure (2.5 months-5 year follow-up) whereas mortality was 23.6% (follow-up of up to 1 year).

CONCLUSION

Low quality evidence has proven RFA to be safe and effective in reducing pain and disability, especially in the short-term. RFA may be routinely implemented in all cases involving refractory pain or radiotherapy-resistant tumours but controlled trials are required to compare the efficacy of RFA to current frontline treatments. PROSPERO protocol registration number: CRD42020202377.

Role of radiofrequency ablation and cement injection for pain control in patients with spinal metastasis

Background

The study aimed to investigate the effects and reliability of simultaneous vertebroplasty and radiofrequency ablation or radiofrequency ablation applied alone for pain control in patients with painful spine metastasis, and to investigate the effect of preventing tumor spread in long-term follow-up.

Methods

Patients with painful vertebrae metastasis in the Afyonkarahisar Health Sciences University, Medical Faculty, Hospital Neurosurgery Clinic between 01.01.2015 and 01.06.2020 were recruited. They were divided into groups according to the surgical procedures applied. Group 1 included 26 patients who underwent radiofrequency ablation only, and group 2 included 40 patients who underwent vertebroplasty with radiofrequency ablation. Computed tomography and magnetic resonance imaging were performed in all patients pre-operation. The patients were followed for at least 6 months. Magnetic resonance imaging was performed at the end of the 6th month in neurologically stable patients. The metastatic lesion, pain, and quality of life were evaluated with Visual Analog Scale and Oswestry Disability Survey before and after the procedure.

Results

The mean VAS score before the procedure was 8.3 ± 1.07 in the RFA group, and a statistically significant difference was observed in VAS scores at all post-procedural measurement time-points (p < 0.001). The pain scores decreased at a rate of 58.8 and 69.6% of patients showed significant improvements in the QoL in the RFA-only group. The mean VAS score was 7.44 ± 1.06 in group RFA + VP before the procedure; the difference in the mean VAS scores was statistically significant at all measurement time-points after the procedure (p < 0.001). The mean pre-treatment Oswestry Index (to assess the QoL) was 78.50% in the RFA + VP group, which improved to 14.2% after treatment.

Conclusion

Ablation + vertebroplasty performed to control palliative pain and prevent tumor spread in patients with painful vertebral metastasis is more successful than vertebroplasty performed alone.

10-Year Trends in the Surgical Management of Patients with Spinal Metastases: A Scoping Review

BACKGROUND

Spinal metastases are present in approximately 20% of patients with cancer, giving a risk for neurologic dysfunction and instability. In already frail patients, surgeons strive to improve quality of life. Our goal was to review a 10-year trend in the surgical management of spinal metastases.

METHODS

A scoping review was performed systematically using PubMed to assess trends in surgical treatment for spinal metastases. The search terms used were: metastas∗, "neoplasm metastasis"[Mesh], "Spine"[Mesh], spine, spinal, "vertebral column," "vertebral body," laser, robot, radiofrequency, screws, fixation, "separation surgery," corpectomy, vertebrectomy, spondylectomy, vertebroplasty, kyphoplasty, surgery, "open surgery," "mini open surgery," "minimally invasive surgery," endoscopy, thoracoscopy, corpectom∗, vertebrectom∗, spondylectom∗, "en bloc," and MIS. The variables of interest were neurologic improvement, tumor recurrence, reoperation, and overall survival.

RESULTS

A total of 2132 articles were found within the primary query. Fifty-six studies were selected for final review. The results were organized into main surgical practices: decompression, mechanical stabilization, and pain management. For separation surgery, clinical outcomes were overall 1-year survival, 40.7%-78.4%; recurrence rate, 4.3%-22%; reoperation, 5%; and complications, 5.4%-14%. For corpectomy, clinical outcomes were overall 1-year survival, 30%-92%; reoperation, 1.1%-50%; and recurrence rate, of 1.1%-28%. Complications and reoperations with spinal instrumentation were 0%-13.6% and 0%-15%, respectively. Cement augmentation achieved pain reduction rates of 56%-100%, neurologic improvement/stability 84%-100%, and complication rates 6%-56%. Laser achieved local tumor control rate of 71%-82% at 1 year follow-up, reoperation rate of 15%-31%, and complication rate of 5%-26%.

CONCLUSIONS

Minimally invasive techniques for decompression and stabilization seem to be the preferred method to surgically treat metastatic spine disease, with good outcomes. More research with high level of evidence is required to support the long-term outcomes of these approaches.

Percutaneous management of bone metastases: State of the art

Interventional radiology is playing an increasingly important role in the local treatment of bone metastases; this treatment is usually done with palliative intent, although in selected patients it can be done with curative intent. Two main groups of techniques are available. The first group, centered on bone consolidation, includes osteoplasty/vertebroplasty, in which polymethyl methacrylate (PMMA) is injected to reinforce the bone and relieve pain, and percutaneous osteosynthesis, in which fractures with nondisplaced or minimally bone fragments are fixed in place with screws. The second group centers on tumor ablation. tumor ablation refers to the destruction of tumor tissue by the instillation of alcohol or by other means. Thermoablation is the preferred technique in musculoskeletal tumors because it allows for greater control of ablation. Thermoablation can be done with radiofrequency, in which the application of a high frequency (450 Hz-600 Hz) alternating wave to the tumor-bone interface achieves high temperatures, resulting in coagulative necrosis. Another thermoablation technique uses microwaves, applying electromagnetic waves in an approximate range of 900 MHz-2450 MHz through an antenna that is placed directly in the core of the tumor, stimulating the movement of molecules to generate heat and thus resulting in coagulative necrosis. Cryoablation destroys tumor tissue by applying extreme cold. A more recent, noninvasive technique, magnetic resonance-guided focused ultrasound surgery (MRgFUS), focuses an ultrasound beam from a transducer placed on the patient's skin on the target lesion, where the waves' mechanical energy is converted into thermal energy (65 °C-85 °C). Treatment should be planned by a multidisciplinary team. Treatment can be done with curative or palliative intent. Once the patient is selected, a preprocedural workup should be done to determine the most appropriate technique based on a series of factors. During the procedure, protective measures must be taken and the patient must be closely monitored. After the procedure, patients must be followed up.

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.

Clinical Therapy of Metastatic Spinal Tumors

Metastatic spinal tumors (MST) have high rates of morbidity and mortality. MST can destroy the vertebral body or compress the nerve roots, resulting in an increased risk of pathological fractures and intractable pain. Here, we elaborately reviewed the currently available therapeutic options for MST according to the following four aspects: surgical management, minimally invasive therapy (MIT), radiation therapy, and systemic therapy. In particular, these aspects were classified and introduced to show their developmental process, clinical effects, advantages, and current limitations. Furthermore, with the improvement of treatment concepts and techniques, we discovered the prevalent trend toward the use of radiation therapy and MIT in clinic therapies. Finally, the future directions of these treatment options were discussed. We hoped that along with future advances and study will lead to the improvement of living standard and present status of treatment in patients with MST.

Percutaneous management of bone metastases: state of the art

Interventional radiology is playing an increasingly important role in the local treatment of bone metastases; this treatment is usually done with palliative intent, although in selected patients it can be done with curative intent. Two main groups of techniques are available. The first group, centered on bone consolidation, includes osteoplasty / vertebroplasty, in which polymethyl methacrylate (PMMA) is injected to reinforce the bone and relieve pain, and percutaneous osteosynthesis, in which fractures with nondisplaced or minimally bone fragments are fixed in place with screws. The second group centers on tumor ablation. Tumor ablation refers to the destruction of tumor tissue by the instillation of alcohol or by other means. Thermoablation is the preferred technique in musculoskeletal tumors because it allows for greater control of ablation. Thermoablation can be done with radiofrequency, in which the application of a high frequency (450 Hz-600Hz) alternating wave to the tumor-bone interface achieves high temperatures, resulting in coagulative necrosis. Another thermoablation technique uses microwaves, applying electromagnetic waves in an approximate range of 900MHz to 2450MHz through an antenna that is placed directly in the core of the tumor, stimulating the movement of molecules to generate heat and thus resulting in coagulative necrosis. Cryoablation destroys tumor tissue by applying extreme cold. A more recent, noninvasive technique, magnetic resonance-guided focused ultrasound surgery (MRgFUS), focuses an ultrasound beam from a transducer placed on the patient's skin on the target lesion, where the waves' mechanical energy is converted into thermal energy (65°C-85°C). Treatment should be planned by a multidisciplinary team. Treatment can be done with curative or palliative intent. Once the patient is selected, a preprocedural workup should be done to determine the most appropriate technique based on a series of factors. During the procedure, protective measures must be taken and the patient must be closely monitored. After the procedure, patients must be followed up.

Posterior Decompression Surgery and Radiofrequency Ablation Followed by Vertebroplasty in Spinal Metastases from Lung Cancer

Background

Spinal metastases can cause metastatic epidural spinal cord compression (MESCC), which can result in neurological dysfunction and impaired quality of life. This study investigated the safety and effectiveness of posterior decompression surgery and radiofrequency ablation followed by vertebroplasty in spinal metastasis from lung cancer.

Material/Methods

From June 2008 to September 2015, a retrospective analysis was conducted in 15 patients with spinal metastasis from lung cancer. All cases suffered MESCC and underwent posterior decompression surgery to relieve the compression of spinal cord, and had radiofrequency ablation followed by vertebroplasty. All patients received postoperative multidisciplinary therapy. The operative time, blood loss, complications, pain, neurologic deficit, quality of life, and survival were assessed preoperatively and postoperatively.

Results

Patients were followed from 6 to 56 months. The mean time of operation was 154±50 minutes and the mean blood loss was 210±90 mL. In the pre-operation analysis found the mean visual analogue scale (VAS) was 7.86±0.86. In the post-operation analysis at 3 months, the mean VAS score was 3.51±1.32. The VAS improved significantly (t=7.95, P<0.01). The Frankel grade was improved 1 grade or 2 grades in 14 patients when pre-operation was compared to post-operation. Only 1 patient kept Frankel grade D after surgery. Eight patients with sphincteric dysfunction preoperatively were improved after surgery. The EORTC QLQ-C30 score was 86.13±8.51 preoperatively and 52.21±13.28 postoperatively. The quality of life was improved significantly (t=11.8, P<0.01). The median survival time was 11 months.

Conclusions

Through posterior decompression surgery and radiofrequency ablation followed by vertebroplasty, the quality of life was improved significantly. This palliative treatment was effective and safe in spinal metastasis from lung cancer.

Current concepts in the surgical treatment of skeletal metastases

Symptomatic metastatic bone disease affects a large proportion of patients with malignant tumours and significantly impairs patients’ quality of life. There are still controversies regarding both surgical indications and methods, mainly because of the relatively few high-quality studies in this field. Generally, prosthetic reconstruction has been shown to result in fewer implant failures and should be preferred in patients with a good prognosis. Survival estimation tools should be used as part of preoperative planning. Adjuvant treatment, which relies on radiotherapy and inhibition of osteoclast function may also offer symptomatic relief and prevent implant failure. In this review we discuss the epidemiology, indications for surgery, preoperative planning, surgical techniques and adjuvant treatment of metastatic bone disease.

Analgesia of percutaneous thermal ablation plus cementoplasty for cancer bone metastases

Background

The purpose of this study was to review recent research related to the analgesic effect of ablation therapy combined with cementoplasty, as well as to identify the duration of analgesic effect and risk for cement leaks.

Methods

A systematic literature search using PubMed, Web of Science, and annual meeting proceedings of the oncology society and other organizations were conducted.

Results

Twelve retrospective studies met the inclusion criteria. Four of the studies included in the review assessed the changes immediately after treatment. Five studies were subjected to analyses of analgesic effect of combined percutaneous thermal ablation and Cementoplasty at 24 weeks after treatment. Incidences of leakage of bone cement during surgery were detected in 4 out of 12 studies. The change of mean pain scores at 1 days, at 1 week, and at 4 weeks, 12 weeks, and 24 weeks after treatment were -3.90 (95% CI: -4.80 to -3.00), -4.55 (95% CI:-5.46 to -3.64), -4.78 (95% CI: -5.70 to -3.86), -5.16 (95% CI: -6.39 to -3.92), and -5.91 (95% CI: -6.63 to -5.19). The relative risk of cement leakage was 0.10 (95% CI: -6.63 to -5.19).

Conclusions

Our systematic review suggested that thermal ablation combined with cementoplasty could be a safe and effective intervention for the management of bone metastases-induced pain.

The clinical efficacy of ultrasound-guided percutaneous microwave ablation for rib metastases with severe intractable pain: a preliminary clinical study

Purpose: To retrospectively evaluate the clinical efficacy of ultrasound-guided percutaneous microwave ablation (US-PMWA) for patients with rib metastases that caused severe intractable pain.

Materials and methods: From Jan 2016 to Apr 2018, 9 rib metastases from 7 solid tumor patients were treated with US-PMWA. The visual analogue scale (VAS), daily opiate intake doses, local tumor control and complications were recorded and analyzed.

Results: The follow-up period ranged from 6 to 33 months (median: 16 months). The procedures were successfully performed in all of the patients by one ablation. The ablation power ranged from 30 to 60 W, and the ablation time was 610.0±317.5 s. The mean preablation VAS pain score was 8.1±0.7, whereas the mean VAS pain score at 72 h postablation was 3.3±0.5 (P<0.001). All of the patients needed to apply oral and/or intravenous injection opiates to relieve severe intractable pain before ablation, with daily opiate intake doses of 61.4±30.8 mg. After ablation, five patients did not need to apply any opiate treatments 72 h after ablation, and only two patients needed oral opiates (daily opiate intake doses: 30 mg and 20 mg). Recurrence was detected in three lesions at 6, 11 and 9 months after ablation, with the maximum diameter observed being more than 4 cm. All of the patients were alive during the follow-up period. No minor or major complications occurred.

Conclusion: US-PMWA appears to be feasible, convenient, safe and effective in the palliative management of refractory pain caused by rib metastases. This treatment can improve the quality of life of patients and may also achieve promising local control of tumors.