Advances in the clinical research of the minimally invasive treatment for the posterior edge of vertebral-body defects by spinal metastases

Prognostic analysis of percutaneous vertebroplasty (PVP) combined with 125I implantation on lumbosacral vertebral osteoblastic metastases

OBJECTIVE

Lumbosacral vertebral osteoblastic metastasis is treated with percutaneous vertebroplasty (PVP) combined with 125I seed implantation and PVP alone. Compared to PVP alone, we evaluated the effects of combination therapy with PVP and 125I seed implantation on pain, physical condition, and survival and evaluated the clinical value of PVP combined with 125I particle implantation.

METHODS

We retrospectively analyzed 62 patients with lumbosacral vertebral osseous metastases treated at our hospital between 2016 and 2019. All the patients met the inclusion criteria for 125I implantation, and they were randomly divided into a combined treatment group and a pure PVP surgery group. The visual analog pain scale (VAS), Karnofsky Performance Status (KPS), and survival time were recorded at different time points, including preoperative, postoperative 1 day, 1 month, 3 months, 6 months, 12 months, and 36 months in each group. The variation in clinical indicators and differences between the groups were analyzed using SPSS version 20.0. Correlations between different variables were analyzed using the nonparametric Spearman's rank test. The Kaplan-Meier method was used to estimate the relationship between survival time and KPS score, VAS score, or primary tumor progression, and survival differences were analyzed using the log-rank test. Multivariate analyses were performed using a stepwise Cox proportional hazards model to identify independent prognostic factors.

RESULTS

Compared to the PVP treatment group, the pain level in the combined treatment group was significantly reduced (P = 0.000), and the patient's physical condition in the combination treatment group significantly improved. Kaplan-Meier analysis showed that the survival rate of the PVP group was significantly lower than that of the combination group (P = 0.038). We also found that the median survival of patients in both groups significantly increased with an increase in the KPS score (14 months vs. 33 months) (P = 0.020). Patients with more than three transfer sections had significantly lower survival rates than those with one or two segments of the section (P = 0.001). Further, Cox regression analysis showed that age (P = 0.002), the spinal segment for spinal metastasis (P = 0.000), and primary tumor growth rate (P = 0.005) were independent factors that affected the long-term survival of patients with lumbosacral vertebral osseous metastases.

CONCLUSIONS

PVP combined 125I seeds implantation surgery demonstrated superior effectiveness compared to PVP surgery alone in treating lumbosacral vertebral osseous metastases, which had feasibility in the clinical operation. Preoperative KPS score, spine transfer section, and primary tumor growth rate were closely related to the survival of patients with lumbosacral vertebral osteoblastic metastasis. Age, spinal segment for spinal metastasis, and primary tumor growth can serve as prognostic indicators and guide clinical treatment.

Percutaneous mesh-container-plasty versus percutaneous kyphoplasty in the treatment of malignant thoracolumbar compression fractures: a retrospective cohort study

OBJECTIVE

This study aimed to compare the clinical and radiological results of percutaneous mesh-container-plasty versus percutaneous kyphoplasty in the treatment of malignant thoracolumbar compression fractures.

METHODS

Patients with malignant thoracolumbar compression fractures treated in a single tertiary care center between January 2011 and December 2020 were retrospectively reviewed and included in the study. Ninety-four patients who were diagnosed by pathological biopsy were divided into 2 groups according to the type of surgical treatment: the percutaneous kyphoplasty group (50 patients: 24 male, 26 female; mean age=73.02 ± 7.79 years) and the percutaneous mesh-container-plasty group (44 patients: 21 male, 23 female; mean age=74.68 ± 7.88 years). The epidemiological data, surgical outcomes, and clinical and radiological features were compared between the 2 groups. Cement leakage, height restoration, deformity correction, and cement distribution were calculated from the radiographs. The visual analog scale, Oswestry disability index, Karnofsky performance scale scores, and short-form 36 health survey domains role physi cal and bodily pain were calculated preoperatively, immediately, and 1 year postoperatively.

RESULTS

The visual analog scale score improved from 5 (range=4-6) preoperatively to 2 (range=2-3) immediately postoperatively in the percutaneous kyphoplasty group and from 5 (range=4-6) preoperatively to 2 (range=2-2) immediately postoperatively in the percutane ous mesh-container-plasty group; there was a significant difference between the 2 groups (P=.018). Although Oswestry disability index, Karnofsky performance scale, short-form 36 health survey domains bodily pain and role physical significantly improved in both groups after surgery compared to the preoperative period, there was no significant difference between the 2 groups (P > .05). The mean cost in the percutaneous kyphoplasty group was lower than that in the percutaneous mesh-container-plasty group (5563 ± 439 vs. 6569 ± 344 thousand dollars, P < .05). There was no difference between the cement volume in the 2 groups, and cement distribution in the percutaneous mesh-container-plasty group was higher than that in the percutaneous kyphoplasty group (44.30% ± 10.25% vs. 32.54% ± 11.76%, P < .05). Cement leakage was found to be lesser in the percutaneous mesh-container-plasty group (7/44) than in the percutane ous kyphoplasty group (18/50, P < .05). There were no statistically significant differences in the recovery of vertebral body height and improvement of segmental kyphosis between the 2 groups (P > .05).

CONCLUSION

Percutaneous kyphoplasty and percutaneous mesh-container-plasty both have significant abilities in functional recovery, height restoration, and segment kyphosis improvement in treating malignant thoracolumbar compression fractures. Percutaneous mesh container-plasty may be better able to relieve pain, inhibit cement leakage, and improve cement distribution than percutaneous kypho plasty. However, percutaneous mesh-container-plasty requires a relatively longer procedure and is more expensive than percutaneous kyphoplasty.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

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.

Which Combination Treatment Is Better for Spinal Metastasis: Percutaneous Vertebroplasty With Radiofrequency Ablation, 125I Seed, Zoledronic Acid, or Radiotherapy?

BACKGROUND

Percutaneous vertebroplasty (PVP) can not only alleviate pain but also restore mechanical stability with injection of bone cement, whereas it exhibits a poor effect on antitumor activity. But through combinations with other therapies, it may be possible to achieve the maximum effect in clinical treatment. Thus, this study is designed to assess the clinical efficacy of PVP separately combined with 4 ways for spinal metastasis (SM) treatment.

STUDY QUESTION

Which combination treatment is better for spinal metastasis, percutaneous vertebroplasty with radiofrequency ablation, I seed, zoledronic acid or radiotherapy?

STUDY DESIGN

A total of 169 patients with SM were retrospectively recruited and randomly assigned to 4 groups to receive 4 different ways separately: 49 patients (group A) received PVP plus I seed, 51 (group B) received PVP plus radiofrequency ablation (RFA), 38 (group C) underwent PVP plus zoledronic acid (ZA), and 31 (group D) underwent PVP plus radiotherapy (RT).

MEASURES AND OUTCOMES

All of them underwent routine examinations before operation. Visual analog scale (VAS), World Health Organization (WHO) Pain Relief, and ODI were applied to evaluate pain relief and motor function.

RESULTS

PVP plus RT achieved the best efficacy in relieving pains, with the highest WHO Pain Relief (P < 0.05). The PVP plus RFA exhibited lowest ODI, suggesting the best outcome after treatment (P < 0.05). The PVP plus I showed the lowest VAS score, but it was the worst to improve the routine exercise ability and relieve pains from patients. The PVP plus ZA presented higher VAS and ODI (P < 0.05).

CONCLUSIONS

PVP combined with I seed exhibited the best clinical efficacy in terms of VAS, PVP combined with RT was the best choice in terms of WHO Pain Relief, and PVP combined with RFA showed the best effect in terms of ODI for the treatment of SM.

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

Purpose

To investigate the pain relief effect and safety of percutaneous radiofrequency ablation (RFA) with a multitined electrode combined with cement injection in patients with painful metastatic bone tumors.

Materials and methods

Sixteen patients with 34 osteolytic metastatic lesions were treated with RFA including 4 males and 12 females (age range 54-84). Thirteen patients with spinal metastases received additional cement injection. Medical imaging, a visual analog scale (VAS) and the EORTC QLQ-C30 were performed to evaluate the metastatic lesion, pain and quality of life, respectively, before and after RFA and at follow-ups.

Results

The RFA and/or vertebroplasty with cement injection were successful in all patients (100%). Except for one patient who had cement leakage, no intraprocedural complications occurred. After RFA, severe refractory pain was greatly relieved in all patients, with pretreatment VAS score of 8.1 ± 1.4 significantly reduced to 5.5 ± 1.1 at 24 h, 2.8 ± 0.6 at 1 week and 1.4 ± 0.8 at 6 months (P < 0.01). The EORTC QLQ-C30 scale at 1 month demonstrated significant improvement (P < 0.05) in the physical (P = 0.03) and emotion function (P = 0.003), global health status (P = 0.002), pain (P = 0.001) and insomnia (P = 0.002). The analgesics were reduced after the procedure and stopped 2 months later in all patients, with greatly improved quality of life and no apparent pain. Followed up for 6-12 months, all patients remained alive with no recurrence of pain. Palliative pain relief and safety of percutaneous radiofrequency ablation combined with cement injection for bone metastasis.

Conclusion

RFA with or without bone cement is safe and effective in the palliative treatment of pain caused by metastatic bone tumors.

Thermal effect of percutaneous radiofrequency ablation with a clustered electrode for vertebral tumors: In vitro and vivo experiments and clinical application

Purpose

To investigate effects and heat distribution of radiofrequency ablation (RFA) on vertebral tumors in vitro and in vivo swine experiments and its clinical application.

Materials and methods

RFA was performed on the swine spine in vitro and in vivo for 20 min at 90 °C at the electrode tip, and the temperature at the electrode tip and surrounding tissues were recorded. Clinical application of ablation combined with vertebroplasty was subsequently performed in 4 patients with spinal tumors.

Results

In the in vitro study, the mean temperature at the front and ventral wall of the spinal canal was 50.8 °C and 43.6 °C, respectively, at 20 mm significantly greater than 37.7 °C and 33.7 ± 1.7 °C, respectively, at 10 mm ablation depth. The coagulative necrosis area was significantly (P < 0.0001) greater at 20 mm depth than at 10 mm depth (mean 17.0 × 20.7 mm² vs. 14.2 × 16.6 mm²). In the in vivo experiment, the local temperature increased significantly (P < 0.05) from around 36 °C before ablation to over 41 °C at 20 min after ablation, with the temperature at the electrode tip (90.4 °C) and within the vertebral body (67.0 °C) significantly (P < 0.05) greater than at the posterior (41.9 °C) and lateral wall (41.8 °C). From 2 to 5 weeks, bone remodeling began. Clinically, all four patients had successful RFA and vertebroplasty, with no neurological deficits. The pain scores were significanlty (P < 0.05) improved before (4.5–10, mean 8.0) compared with at four weeks (0–1.8, mean 1.8).

Conclusion

The clustered electrode can be efficiently and safely applied in the treatment of spinal tumors without damaging the spinal cord and adjacent nerves by heat distribution.