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Kumar N, Lee EXY, Hui SJ, Kumar L, Jonathan Tan JH, Ashokka B. Does Patient Blood Management Affect Outcomes in Metastatic Spine Tumour Surgery? A Review of Current Concepts. Global Spine J 2024:21925682231167096. [PMID: 38453667 DOI: 10.1177/21925682231167096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE The spine is the most common site of metastases, associated with decreased quality of life. Increase in metastatic spine tumour surgery (MSTS) has caused us to focus on the management of blood, as blood loss is a significant morbidity in these patients. However, blood transfusion is also not without its own risks, and hence this led to blood conservation strategies and implementation of a concept of patient blood management (PBM) in clinical practise focusing on these patients. METHODS A narrative review was conducted and all studies that were related to blood management in metastatic spine disease as well as PBM surrounding this condition were included. RESULTS A total of 64 studies were included in this review. We discussed a new concept of patient blood management in patients undergoing MSTS, with stratification to pre-operative and intra-operative factors, as well as anaesthesia and surgical considerations. The studies show that PBM and reduction in blood transfusion allows for reduced readmission rates, lower risks associated with blood transfusion, and lower morbidity for patients undergoing MSTS. CONCLUSION Through this review, we highlight various pre-operative and intra-operative methods in the surgical and anaesthesia domains that can help with PBM. It is an important concept with the significant amount of blood loss expected from MSTS. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
| | | | - Si Jian Hui
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Laranya Kumar
- Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Jiong Hao Jonathan Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
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Makishima J, Yamamoto S, Yata S, Takasugi S, Kamata Y, Tanishima S, Fujii S. Efficacy of Subtraction Computed Tomography Arteriography During Preoperative Embolization in Spinal Tumors. Yonago Acta Med 2024; 67:61-67. [PMID: 38371281 PMCID: PMC10867234 DOI: 10.33160/yam.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/25/2023] [Indexed: 02/20/2024]
Abstract
Background This study aimed to evaluate the efficacy of subtraction computed tomography arteriography (s-CTA) during preoperative embolization in spinal tumors. Methods The study analyzed 17 vertebrae in 13 patients who underwent preoperative embolization before spinal fixation surgery for malignant spinal tumors to decrease blood loss at our hospital from 2019 to 2021. Their ages ranged from 56 to 88 years (average, 73.5 years). Metastatic bone tumors were most common, including five cases originating as lung carcinomas and three as renal cancers. After digital subtraction angiography of selected tumor-feeding arteries and non-subtraction CTA (ns-CTA) were performed, s-CTA was conducted using data obtained from both procedures. A clarity score of the boundary between the normal bone and tumor was derived for each patient, which was then classified into four grades (good, 3 points; fair, 2 points; faint, 1 point; poor, 0 points) by two experienced radiologists, followed by a comparison between the s-CTA and ns-CTA groups using the Wilcoxon signed-rank test. Results Clarity scores were significantly higher in the s-CTA group than in the ns-CTA group (P < 0.001). The agreement of Cohen's coefficients between the two radiologists was κ = 0.724 in s-CTA scoring and κ = 0.622 in ns-CTA scoring, which were moderately matched. Seven arteries were not embolized due to insufficient tumor contrast enhancement and their poor relation to the surgical invasion zone. No complications were observed during or after embolization. Conclusion S-CTA successfully distinguished between tumor and normal bone and may help avoid unnecessary embolization.
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Affiliation(s)
- Jun Makishima
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shuichi Yamamoto
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shinsaku Yata
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shohei Takasugi
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Yuji Kamata
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shinji Tanishima
- Division of Orthopedic Surgery, Department of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shinya Fujii
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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Qiao R, Ma R, Zhang X, Lun D, Li R, Hu Y. Comparison of intraoperative blood loss and perioperative complications between preoperative embolization and nonembolization combined with spinal tumor surgeries: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:4272-4296. [PMID: 37661228 DOI: 10.1007/s00586-023-07898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The present study aimed to comparatively evaluate intraoperative blood loss (IBL) and perioperative complications between preoperative embolization (PE) and nonembolization (NE) combined with spinal tumor surgeries as well as to determine the subgroup of spinal tumor surgeries suitable for PE. METHODS A systematic search in PubMed and EMBASE and an additional search by reference lists of the retrieved studies were undertaken by two reviewers. The mean IBL and perioperative complication rate were employed as the effect size in the general quantitative synthesis through direct calculation. Meta-analysis was performed using standardized mean difference (SMD) and weighted mean difference (WMD) of IBL and the odds ratio (OR) of complications. Heterogeneity was assessed using the I2 statistic. RESULTS The reviewers selected 17 published studies for the general quantitative synthesis and meta-analyses. The mean IBL of spinal tumor surgeries was 1786.3 mL in the NE group and 1716.4 mL in the PE group. The mean IBL between the two groups was similar. The pooled WMD and SMD of IBL in spinal tumor surgeries was 324.15 mL (95% CI 89.50-1640.9, p = 0.007) and 0.398 (95% CI 0.114-0.682, p = 0.006), respectively. The reduction of the PE group compared with the NE group for the rates of major complications and major hemorrhagic complications were 7.80% and 5.71%, respectively. The risk of PE-related complications in the PE group was only 1.53% more than in the PE group. The pooled OR of major complications in spinal tumor surgeries was 1.426 (95% CI 0.760-2.674; p = 0.269). CONCLUSIONS PE may be suitable for spinal tumor surgeries and some subgroups. From the perspective of complications, PE may also be a feasible option for spinal tumor surgeries.
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Affiliation(s)
- Ruiqi Qiao
- Department of Bone and Soft Tissue Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, 300000, MD, China
| | - Rongxing Ma
- Graduate School, Tianjin Medical University, Tianjin, China
| | | | - Dengxing Lun
- Department of Bone Oncology, Weifang People's Hospital, Weifang, China
| | - Ruifeng Li
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Yongcheng Hu
- Department of Bone and Soft Tissue Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, 300000, MD, China.
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Motov S, Stengel F, Ringel F, Bozinov O, Stienen MN. Current state of preoperative embolization for spinal metastasis - A survey by the EANS spine section. BRAIN & SPINE 2023; 3:102712. [PMID: 38021014 PMCID: PMC10668085 DOI: 10.1016/j.bas.2023.102712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023]
Abstract
Introduction Preoperative embolization (PE) for spinal metastasis can be used to reduce tumor blood supply in selected patients. The decision whether and when to perform PE varies largely among spine surgeons and centers. Research question The aim was to understand the current decision-making process in European spine centers. Material and methods The European Association of Neurosurgical Societies (EANS) spine section designed a 13-item online survey. It was distributed to neurosurgical residents and board-certified neurosurgeons between 7th of February and May 5, 2023. Results We analyzed 120 survey responses. Most participants were board-certified neurosurgeons (71%) or residents (26%) in university hospitals (76%). Routinely performed PE was stated not a common practice in 62%. Of those using PE, 25% indicated to perform it in selected cases requiring vertebral body replacement. Reasons for not performing PE included lack of time (44%), unclear benefits (25%), no significant bleeding without PE (19%), and significant bleeding despite PE (8%). Most participants opted for PE < 24h before surgery, but in a separate anesthesia (54%). More experienced participants were more likely to observe reduced blood loss (BL) after PE (p = 0.014). The most common reported complications were neurological deterioration due to spinal cord infarction (n = 15) and swelling due to tumor necrosis (n = 13). Discussion and conclusions PE is still not a routine among European spine surgeons and is considered mostly for elective cases with hypervascularized tumors scheduled in a separate anesthesia <24h before tumor resection. Most participants noted reduced intraoperative BL, but also a risk of procedure-related complications.
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Affiliation(s)
- Stefan Motov
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Felix Stengel
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Florian Ringel
- University Hospital Mainz & Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Martin N. Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
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Wu LC, Hsieh YY, Chen IC, Chiang CJ. Life-threatening perioperative complications among older adults with spinal metastases: An analysis based on a nationwide inpatient sample of the US. J Geriatr Oncol 2023; 14:101597. [PMID: 37542948 DOI: 10.1016/j.jgo.2023.101597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/20/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION We aimed to investigate the prognostic determinants of life-threatening and fatal complications in patients <80 and ≥ 20 years of age and those ≥80 years who were undergoing surgery for spinal metastases. MATERIALS AND METHODS Based on data between 2005 and 2018 extracted from National Inpatient Sample as the largest longitudinal hospital inpatient databases in the United States, statistical analyses were performed to identify prognostic factors (age, sex, household income, insurance status, major comorbidities, primary site of malignancy, types of surgery, surgical approaches, types of hospital admission, and hospital-related characteristics) for major and fatal perioperative complications among older adult patients. RESULTS A total of 31,925 patients aged ≥ 20y who were undergoing surgery for spinal metastasis were identified (< 80 y: n = 28,448; ≥ 80 y: n = 35,37). After adjustment, age ≥80 y was significantly associated with greater risk of perioperative cardiac arrest (adjusted odds ratio [aOR]: 1.34, 95% confidence interval [CI]: 1.03-1.73) and acute kidney injury (AKI) (aOR: 1.23, 95% CI: 1.07-1.41) but lower risk of venous thromboembolic event (VTE) (aOR: 0.80, 95% CI: 0.66-0.96) than <80y. Factors predicting life-threatening complications among patients ≥ 80y were: male sex (<80 y: aOR = 1.14; ≥ 80 y: aOR = 1.35), higher score on Charlson Comorbidity Index (CCI) (80 y, aOR = 1.21-2.67; ≥ 80 y: aOR = 1.25-2.55), open surgery (<80 y: aOR = 1.24; ≥ 80 y: aOR = 1.35), and greater Metastatic Spinal Tumor Frailty Index (MSTFI) (<80 y: aOR = 2.48-10.03; ≥ 80 y: aOR = 2.69-11.21). Among patients <80y, factors predicting life-threatening complications were: male sex, Black race, greater CCI score, primary tumor at kidney, hematologic cancer, other/unspecified primary site, certain surgical procedures, open surgery, greater MSTFI, emergent admission, and low hospital volume. DISCUSSION This study identifies a list of independent risk factors for the presence of life-threatening complications among patients <80 and ≥ 80y who were undergoing surgery for spinal metastasis. The findings contribute to the development of clinical strategies for the surgical management of spinal metastasis, especially for octogenarians, and lower the risk of unfavorable inpatient outcomes.
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Affiliation(s)
- Lien-Chen Wu
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan; Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan
| | - Yueh-Ying Hsieh
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - IChun Chen
- Hospice and Home care of Snohomish County, Providence Health & services, Washington 98203, USA
| | - Chang-Jung Chiang
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan.
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Maddy K, Trenchfield D, Destine H, Waiters V, Nwatu D, Lucke-Wold B. Spinal tumor embolization: benefit for surgical resection. BOHR INTERNATIONAL JOURNAL OF NEUROLOGY AND NEUROSCIENCE 2023; 1:71-80. [PMID: 37576947 PMCID: PMC10421648 DOI: 10.54646/bijnn.2023.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
The embolization of hypervascular spinal tumors preoperatively has shown to be a worthwhile adjunctive procedure to minimize the elevated risks associated with surgical resection, such as intraoperative blood loss and its associated complications. Resection of these hypervascular tumors is necessary for local tumor control, reduction in patient-reported pain, improved neurological functioning, and spinal stability. This adjunctive procedure has been associated with improved surgical outcomes and easier facilitation of surgical resection. As such, we provide a review of the current literature examining the employment of this technique. Specifically, this article (a) reviews the techniques of embolization, with anatomical considerations of the arterial framework of the spinal network; (b) relativizes and outlines the post-embolization management of spinal tumor resection; (c) provides a critical outlook on the reported benefit of preoperative embolization before surgical resection with support from clinical studies in the literature; and (d) discusses the efficacy and reliability of provocative testing and post-procedural management and follow-up. Ultimately, a thorough and updated review of preoperative spinal tumor embolization and its clinical benefits will summarize the current fund of knowledge and encourage future research toward continued improvements in patient outcomes for those needing to undergo surgical resection of spinal lesions.
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Affiliation(s)
- Krisna Maddy
- University of Miami Miller School of Medicine, Miami, FL, United States
| | | | - Henson Destine
- University of Miami Miller School of Medicine, Miami, FL, United States
| | | | - Daniel Nwatu
- University of Miami Miller School of Medicine, Miami, FL, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
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Spirollari E, Vazquez S, Das A, Wang R, Ampie L, Carpenter AB, Zeller S, Naftchi AF, Beaudreault C, Ming T, Thaker A, Vaserman G, Feldstein E, Dominguez JF, Kazim SF, Al-Mufti F, Houten JK, Kinon MD. Characteristics of Patients Selected for Surgical Treatment of Spinal Meningioma. World Neurosurg 2022; 165:e680-e688. [PMID: 35779754 DOI: 10.1016/j.wneu.2022.06.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Spinal meningiomas are benign extra-axial tumors that can present with neurological deficits. Treatment partly depends on the degree of disability as there is no agreed-upon patient selection algorithm at present. We aimed to elucidate general patient selection patterns in patients undergoing surgery for spinal meningioma. METHODS Data for patients with spinal tumors admitted between 2016 and 2019 were extracted from the U.S. Nationwide Inpatient Sample. We identified patients with a primary diagnosis of spinal meningioma (using International Classification of Disease, 10th revision codes) and divided them into surgical and nonsurgical treatment groups. Patient characteristics were evaluated for intergroup differences. RESULTS Of 6395 patients with spinal meningioma, 5845 (91.4%) underwent surgery. Advanced age, nonwhite race, obesity, diabetes mellitus, chronic renal failure, and anticoagulant/antiplatelet use were less prevalent in the surgical group (all P < 0.001). The only positive predictor of surgical treatment was elective admission status (odds ratio, 3.166; P < 0.001); negative predictors were low income, Medicaid insurance, anxiety, obesity, and plegia. Patients with bowel-bladder dysfunction, plegia, or radiculopathy were less likely to undergo surgical treatment. The surgery group was less likely to experience certain complications (deep vein thrombosis, P < 0.001; pulmonary embolism, P = 0.002). Increased total hospital charges were associated with nonwhite race, diabetes, depression, obesity, myelopathy, plegia, and surgery. CONCLUSIONS Patients treated surgically had a decreased incidence of complications, comorbidities, and Medicaid payer status. A pattern of increased utilization of health care resources and spending was also observed in the surgery group. The results indicate a potentially underserved population of patients with spinal meningioma.
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Affiliation(s)
| | - Sima Vazquez
- New York Medical College, Valhalla, New York, USA
| | - Ankita Das
- New York Medical College, Valhalla, New York, USA
| | - Richard Wang
- New York Medical College, Valhalla, New York, USA
| | - Leonel Ampie
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Austin B Carpenter
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Sabrina Zeller
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | | | | | - Tiffany Ming
- New York Medical College, Valhalla, New York, USA
| | - Akash Thaker
- New York Medical College, Valhalla, New York, USA
| | | | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - John K Houten
- Department of Neurosurgery, Maimonides Medical Center, Northwell School of Medicine, Brooklyn, New York, USA
| | - Merritt D Kinon
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Facchini G, Parmeggiani A, Peta G, Martella C, Gasbarrini A, Evangelisti G, Miceli M, Rossi G. The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2839-2851. [PMID: 34415449 DOI: 10.1007/s00586-021-06963-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Spinal bone tumors include a heterogeneous broad of primary or metastatic lesions that may present as incidental findings or manifest with painful symptoms and pathological fractures. Optimal management of spine bone lesions is often difficult and treatment algorithms are usually solidly based on surgery. We aimed to evaluate the contribution of trans-arterial embolization in this field, with particular attention to the procedure efficacy, technical difficulties and complications. METHODS We present a literature review on the role of trans-arterial embolization in the management of spinal bone tumors, both primary and metastatic, evaluating its contribution as preoperative treatment, palliative procedure and standalone curative strategy. RESULTS Trans-arterial embolization provides an important contribution to reducing surgery hemorrhagic risks, offering a better visualization of the operating field, and possibly increasing tumor susceptibility to chemotherapy or radiation therapy. Nonetheless, it plays an important part in pain palliation, with the unquestionable advantage of being easily repeatable in case of necessity. Its curative role as a standalone therapy is still subject of debate, and at the present time, satisfactory results have been recorded only in the treatment of aneurysmal bone cysts. CONCLUSION Percutaneous trans-arterial embolization has established as a highly useful minimally invasive procedure in the management of spinal bone lesions, particularly as adjuvant preoperative therapy and palliative treatment.
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Affiliation(s)
- Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Anna Parmeggiani
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy. .,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Giuliano Peta
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Claudia Martella
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gisberto Evangelisti
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Rossi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
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