Vertebral Augmentation: Is It Time to Get Past the Pain? A Consensus Statement from the Sardinia Spine and Stroke Congress.

Vertebral augmentation has been used to treat painful vertebral compression fractures and metastatic lesions in millions of patients around the world. An international group of subject matter experts have considered the evidence, including but not limited to mortality. These considerations led them to ask whether it is appropriate to allow the subjective measure of pain to so dominate the clinical decision of whether to proceed with augmentation. The discussions that ensued are related below.

Spine Intervention-An Update on Injectable Biomaterials.

Back pain is the second most common reason for primary-care physician visits after the common cold. New understanding of the spine pathophysiology and biomechanics led to the development of novel injectable biomaterials to treat those pain generators. Although not all biomaterials are currently ready for common use, there is significant interest by the medical community to invest time, resources, and energy to optimize these injectables. This review introduces basic concepts and advancements in the field of bioinjectables tailored for the vertebral body. Also, we highlight advances in injectable biomaterials which were presented at the Groupe de Recherche Interdisciplinaire sur les Biomatériaux Ostéoarticulaires Injectables (GRIBOI) (Interdisciplinary Research Society for Injectable Osteoarticular Biomaterials) meeting in March 2018 in Los Angeles, CA. Indeed, multidisciplinary translational research and international meetings such as GRIBOI bring together scientists and clinicians with different backgrounds/expertise to discuss injectable biomaterials innovations tailored for the interventional pain management field.

ISASS Policy Statement 2022: Literature Review of Intraosseous Basivertebral Nerve Ablation.

The index 2020 ISASS Guideline Statement "Intraosseous Ablation of the Basivertebral Nerve for the Relief of Chronic Low Back Pain" was generated in response to growing requests for background, supporting literature, evidence, as well as proper coding for intraosseous basivertebral nerve ablation. Since the guideline was published, the American Medical Association has added Current Procedural Terminology category I codes for basivertebral nerve ablation: 64628 and 64629. Additionally, the has recognized a need for greater specificity in differentiating various types of low back pain and has designatedthe International Classification of Diseases, 10th revision, Clinical Modification code M54.51, vertebrogenic low back pain, to ensure correct diagnosis. The timing of these additions provides an opportunity to refresh the ISASS Guideline to ensure proper diagnosis and procedural coding and to update the supporting literature and evidence.

CT-Guided Percutaneous Vertebroplasty for Vertebral Non-union Following Posterior Fixation: A Preliminary Retrospective Study.

PURPOSE: Traumatic thoracolumbar vertebral fractures are frequently treated with posterior fixation (PF) and vertebral augmentation. Sometimes, it is deemed too risky to offer vertebral augmentation under fluoroscopic guidance alone. Adjuvant CT/fluoroscopy-guided percutaneous vertebroplasty (PVP) could be offered in certain scenarios. The aim was to evaluate feasibility, safety and effectiveness of PVP in patients presenting with vertebral non-union (VNU) following PF performed without concomitant vertebral augmentation. MATERIALS AND METHODS: All patients treated in our institution with PVP between July 2015 and July 2020 were retrospectively reviewed. Patients treated with CT/fluoroscopy-guided PVP under local anesthesia for symptomatic VNU following PF were selected. Three criteria were established to assess cement distribution, considering vertebral filling of: (1) fracture cleft, (2) anterior two-thirds of the vertebral body, (3) from superior to inferior endplates. Numeric pain rating scale (NPRS) assessing grade of discomfort (0 = no pain; 10 = worst pain) and complications were evaluated before and 1 month after PVP. RESULTS: Ten patients were identified (mean age 53 ± 12y). Mean time between PF and PVP was 9.6 [2-35] months. Two patients required further cement injection with a second PVP. Eight patients had satisfactory vertebral filling according to the three criteria. Mean NPRS reduction was 2.7(-42%, p < 0.05). No significant complications occurred. CONCLUSIONS: Combined CT/fluoroscopy guidance seems a useful tool to perform PVP in VNU following PF, even in presence of orthopedic metalwork. Interventional radiologists may help in these scenarios, performing an adjuvant PVP under local anesthesia. In this small series, the procedure seems safe and effective and could be taken in consideration as alternative to revision surgery.

Long-term consequences of a prolonged febrile seizure in a dual pathology model.

Clinical evidence suggests that febrile status epilepticus (SE) in children can lead to acute hippocampal injury and subsequent temporal lobe epilepsy. The contribution of febrile SE to the mechanisms underlying temporal lobe epilepsy are however poorly understood. A rat model of temporal lobe epilepsy following hyperthermic SE was previously established in our laboratory, wherein a focal cortical lesion induced at postnatal day 1 (P1), followed by a hyperthermic SE (more than 30 min) at P10, leads to hippocampal atrophy at P22 (dual pathology model) and spontaneous recurrent seizures (SRS) with mild visuospatial memory deficits in adult rats. The goal of this study was to identify the long term electrophysiological, anatomical and molecular changes in this model. Following hyperthermic SE, all cortically lesioned pups developed progressive SRS as adults, characterized by the onset of highly rhythmic activity in the hippocampus. A reduction of hippocampal volume on the side of the lesion preceded the SRS and was associated with a loss of hippocampal neurons, a marked decrease in pyramidal cell spine density, an increase in the hippocampal levels of NMDA receptor NR2A subunit, but no significant change in GABA receptors. These findings suggest that febrile SE in the abnormal brain leads to hippocampal injury that is followed by progressive network reorganization and molecular changes that contribute to the epileptogenesis as well as the observed memory deficits.

International Society for the Advancement of Spine Surgery Guideline-Intraosseous Ablation of the Basivertebral Nerve for the Relief of Chronic Low Back Pain.

This International Society for the Advancement of Spine Surgery guideline is generated to respond to growing requests for background, supporting literature and evidence, and proper coding for intraosseous ablation of the basivertebral nerve for chronic low back pain.

Republished: Parapedicular vertebral augmentation with polymethylmetacrylate for pedicle screw loosening.

A 71-year-old man who had a L1/S1 posterior fusion revision surgery complained of increasing back pain 5 weeks after the open surgical procedure. The pain was initially estimated at 9/10 on the visual analog scale (VAS) and thought to be related to a right-sided L2 screw loosening. A right parapedicular vertebroplasty was performed and polymethylmethacrylate cement was instilled around the right pedicle screw, filling the anterior two-thirds of the vertebral body. On postvertebroplasty day 1, the patient had significant improvement in his low back pain. The pain further decreased at 1 and 3 months after the intervention (2/10 on the VAS). Vertebroplasty is a minimally invasive, accessible, effective, and long lasting treatment for compression fractures. We believe that this technique could also be indicated to treat pain related to low grade screw loosening in properly selected patients.

ISASS Policy 2018-Vertebral Augmentation: Coverage Indications, Limitations, and/or Medical Necessity.

The ISASS Policy Statement on vertebral augmentation has the objectives to provide a background and an update with the latest clinical evidence for the international spine community. A SpineLine Panel Review (2010) appropriately recommended an exploration of "the seeming disconnect between the conclusions of … two [Level I] PRCT's and previous experience and data" regarding vertebral augmentation. ISASS responded by supporting a comprehensive meta-analysis to help frame a cogent historical analysis of vertebral augmentation. This ISASS Policy 2018 is based on a thorough literature search for relevant studies, including systematic reviews and meta-analyses, that are subjected to thorough quality appraisal for the purpose of informing public opinion and decision making. Given the abundance of high-quality information, ISASS can confidently advocate that there is strong support for vertebral augmentation in the treatment of symptomatic vertebral compression fractures.

Parapedicular vertebral augmentation with polymethylmetacrylate for pedicle screw loosening.

A 71-year-old man who had a L1/S1 posterior fusion revision surgery complained of increasing back pain 5 weeks after the open surgical procedure. The pain was initially estimated at 9/10 on the visual analog scale (VAS) and thought to be related to a right-sided L2 screw loosening. A right parapedicular vertebroplasty was performed and polymethylmethacrylate cement was instilled around the right pedicle screw, filling the anterior two-thirds of the vertebral body. On postvertebroplasty day 1, the patient had significant improvement in his low back pain. The pain further decreased at 1 and 3 months after the intervention (2/10 on the VAS). Vertebroplasty is a minimally invasive, accessible, effective, and long lasting treatment for compression fractures. We believe that this technique could also be indicated to treat pain related to low grade screw loosening in properly selected patients.