RESUMO
PURPOSE: The aim of this study was to evaluate treatment efficacy of percutaneous injection of hydroxyapatite-osteoconductive-cement in patients with spinal aneurysmal bone cysts. MATERIALS AND METHODS: The study was designed as a retrospective observational clinical study. We included patients who were diagnosed with of spinal aneurysmal bone cyst, at our institution between 2013 and 2020, and treated with percutaneous injection of osteoconductive cement: "Cerament"® (BONESUPPORT AB, Lund, Sweden). Typical clinical and radiological features of the ABCs treatment and follow-up were investigated. RESULTS: Our study included nine patients, two children and seven adults. Three different types of approaches were applied: (single pedicle approach in 3 patients; double pedicle approach in 2 patients; while in the remaining cases, a multiple access approach was used. VAS score decreased from 8.5 ± 0.5 before treatment to 4.1 ± 0.9 at 6-months-follow up. All of the patients reacted well to treatment, with none neurological complications, complete loss of pain and achieved osteosclerosis as radiological marker of treatment success. CONCLUSION: Treatment of symptomatic spinal ABC's with hydroxyapatite cement is effective to achieve complete pain reduction and sclerosis.
Assuntos
Cistos Ósseos Aneurismáticos , Adulto , Criança , Humanos , Cistos Ósseos Aneurismáticos/diagnóstico por imagem , Cistos Ósseos Aneurismáticos/terapia , Cistos Ósseos Aneurismáticos/complicações , Estudos Retrospectivos , Hidroxiapatitas/uso terapêutico , Resultado do Tratamento , Dor/tratamento farmacológico , Cimentos Ósseos/uso terapêuticoAssuntos
Fixação de Fratura/métodos , Procedimentos Cirúrgicos Minimamente Invasivos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/cirurgia , Vertebroplastia/métodos , Fixação de Fratura/instrumentação , Humanos , Imageamento por Ressonância Magnética , Qualidade de Vida , Fraturas da Coluna Vertebral/classificaçãoRESUMO
The management of low back pain should always start with a conservative approach; however, when it fails, intervention is required and at that moment the most appropriate choice remains unclear. Before invasive surgery, minimally invasive techniques can be adopted. In European trials and in a trans-Canadian clinical trial 03 ozone has been used successfully. In total over 50,000 patients have been treated safely. Ozone is a gas normally present in the atmosphere with potent oxidizing power; it has been used for percutaneous intradiscal injection combined with oxygen (O2O3) at very low concentrations for 15 years in Europe. The main indication is back pain with or without radicular pain but without motor deficits, which is refractory to 4-6 weeks of conservative therapies. Its mechanism of action on the disc is mechanical (volume reduction by subtle dehydration of the nucleus pulposis) and antinflammatory. The intradiscal ozone injection is performed with a thin needle (18-22 gauge) image guided by computed tomography or angiofluoroscopy and is usually complimented by periganglionic injection of corticosteroids and anesthetics. This combination gives immediate pain relief and allows time for the ozone to act. It is a cost-effective procedure that presents a very low complication rate (0.1%). The radicular pain is resolved before the back pain does, as is seen with microdiscectomy. Peer-reviewed publications of large randomized trials, case series, and meta analysis from large samples of patients have demonstrated the procedure to be safe and effective in the short and the long terms, with benefits recognized up to 10 years after treatment. We aim to review the principles of action of O2O3 and report the injection techniques, complications, and short- and long-term outcomes.
Assuntos
Dor Lombar/tratamento farmacológico , Oxigênio/administração & dosagem , Ozônio/administração & dosagem , Combinação de Medicamentos , Humanos , Injeções Intralesionais/métodos , Deslocamento do Disco Intervertebral/complicações , Dor Lombar/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Arachnoid cysts are extra-cerebral, intra-arachnoidal cerebrospinal fluid collections - the most frequent congenital developmental intracranial cystic lesions. They are often diagnosed incidentally during imaging exams acquired for different reasons, and are usually asymptomatic. Rare complications are post-traumatic rupture with consequent subdural haematomas. Spontaneous bleeding should be acknowledged as a rare but possible complication of this benign lesion. We report on the case of a patient presenting with a giant arachnoid cyst extending to the left frontal, temporal and parietal lobes associated with acute subdural haematoma without history of trauma.
Assuntos
Cistos Aracnóideos/complicações , Cistos Aracnóideos/diagnóstico por imagem , Hematoma Subdural Agudo/diagnóstico por imagem , Hematoma Subdural Agudo/etiologia , Idoso , Cistos Aracnóideos/cirurgia , Diagnóstico Diferencial , Hematoma Subdural Agudo/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Ruptura Espontânea , Tomografia Computadorizada por Raios XRESUMO
Radicular lumbar back pain is an important public health problem not yet benefiting from a unequivocal treatment approach. Medical and physical therapies represent the first solution; however, when these fail, the second therapeutic step is still controversial and mini-invasive treatments may play an important role. In these cases oxygen-ozone therapy has been proved to be a very safe and effective option that is widely used with different modalities. This paper, by reviewing oxygen-ozone therapy literature data, aims to describe the rationale of oxygen-ozone therapy for the treatment of lumbar disk herniations, propose an effective procedural technique and clarify patient selection criteria; furthermore, complications and follow-up management are also considered.
Assuntos
Quimiólise do Disco Intervertebral/métodos , Deslocamento do Disco Intervertebral/terapia , Vértebras Lombares , Oxigênio/uso terapêutico , Ozônio/uso terapêutico , Feminino , Humanos , Quimiólise do Disco Intervertebral/efeitos adversos , Dor Lombar/etiologia , Dor Lombar/terapia , Masculino , Pessoa de Meia-Idade , Oxigênio/efeitos adversos , Ozônio/efeitos adversos , Seleção de Pacientes , Cirurgia Assistida por Computador , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
INTRODUCTION: This study aimed to determine changes in size of lumbar spinal canal and related articular structures, during dynamic MR scans acquired in symptomatic patients standing upright using a new open MR system. METHODS: Forty patients (mean age 58.4 years) affected by lumbar back pain associated with claudication, referring symptoms since more than 6 months. No one underwent to previous spine surgery. MR scans were performed with a novel open 0.5-T scanner, patient supine and upright (90°). Lumbar lordotic angle, flavum ligament thickness, herniated discs, spinal canal area, spinal canal and dural sac antero-posterior diameters, and spinal alignment were measured and compared in both supine and upright positions. Mean scanning time was 43 min. RESULTS: All the considered parameters showed a statistically significant difference, except for lumbar lordotic angle. Mean percentage differences moving from supine to upright were +3.9 % for lumbar lordotic angle, +15 % for flavum ligament thickness, +16.2 % for sagittal disc bulge, -10.8 % for dural sac diameter, -13.1 % for spinal canal diameter, and -15.8 % for spinal canal area. In supine position, no patient presented with spondylolisthesis; moving to upright position, four patients showed spondylolisthesis (grade I). CONCLUSION: Dynamic MR is a valuable diagnostic exam to analyze the structures involved in lumbar back pain due to spinal canal stenosis and spondylolisthesis; in supine position, relevant factors can be underestimated or hidden, becoming appreciable only patient standing upright. In this series, flavum ligament thickening presented a role comparable to disc bulge for narrowing of lumbar spinal canal.
Assuntos
Aumento da Imagem/métodos , Claudicação Intermitente/diagnóstico por imagem , Vértebras Lombares/diagnóstico por imagem , Síndromes de Compressão Nervosa/diagnóstico por imagem , Neuroimagem/métodos , Posicionamento do Paciente/métodos , Estenose Espinal/diagnóstico por imagem , Adulto , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , SíndromeRESUMO
Vertebral cementoplasty is a well-known mini-invasive treatment to obtain pain relief in patients affected by vertebral porotic fractures, primary or secondary spine lesions and spine trauma through intrametameric cement injection. Two major categories of treatment are included within the term vertebral cementoplasty: the first is vertebroplasty in which a simple cement injection in the vertebral body is performed; the second is assisted technique in which a device is positioned inside the metamer before the cement injection to restore vertebral height and allow a better cement distribution, reducing the kyphotic deformity of the spine, trying to obtain an almost normal spine biomechanics. We will describe the most advanced techniques and indications of vertebral cementoplasty, having recently expanded the field of applications to not only patients with porotic fractures but also spine tumours and trauma.
Assuntos
Cementoplastia/métodos , Fraturas por Compressão/terapia , Humanos , Doenças da Coluna Vertebral/terapia , Fraturas da Coluna Vertebral/terapiaRESUMO
The spine is a frequent localization of primary tumours or metastasis involving posterior arch, pedicles and vertebra body, and often causing unsustainable pain. The management of spinal metastasis remains complex, including medical therapy (corticosteroids, chemotherapy), radiotherapy and surgical treatment, or the recent percutaneous mini-invasive approach. The target of all these treatments is to improve the quality of life of patients affected by this type of lesion. Diagnosis of spinal metastasis and then its treatment should be based on the combination of different elements: clinical evaluation, CT, MRI and nuclear medicine patterns, considering the age of the patient, known primary tumour, location of the lesions, single/multiple lesions, pattern of morphology (border, matrix, expansile character, soft tissue extension), density or signal intensity, oncologic instability and expectancy of life. The percutaneous mini-invasive approach for patients affected by secondary lesions involving the spine has as treatment goal of: (1) pain relief improving the quality of life; (2) stability treatment re-establishing the spinal biomechanics, alterated by bone destruction or deformity, preventing pathological fracture; and (3) an anti-neoplastic effect. The aim of this paper is to provide a comprehensive diagnostic and percutaneous approach to the bone metastatic spine lesions, identifying which metamer should be treated to improve patient quality of life, showing the importance of a multi-disciplinary approach to this problem.
Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Metástase Neoplásica/terapia , Neoplasias da Coluna Vertebral/secundário , Neoplasias da Coluna Vertebral/cirurgia , Terapia Combinada , Humanos , Fraturas da Coluna Vertebral/etiologia , Neoplasias da Coluna Vertebral/diagnóstico por imagemRESUMO
Vertebroplasty (VP) is a percutaneous mini-invasive technique developed in the late 1980s as antalgic and stabilizing treatment in patients affected by symptomatic vertebral fracture due to porotic disease, traumatic injury and primary or secondary vertebral spine tumors. The technique consists of a simple metameric injection of an inert cement (poly-methyl-methacrylate, PMMA), through a needle by trans-peduncular, parapeduncular or trans-somatic approach obtaining a vertebral augmentation and stabilization effect associated with pain relief. The technique is simple and fast, and should be performed under fluoroscopy or CT guidance in order to obtain a good result with low complication rate. The aim of this paper is to illustrate the utility of VP, the indications-contraindications criteria, how to technically perform the technique using imaging guidance, and the results and complications of this treatment in patients affected by symptomatic vertebral compression fracture.
Assuntos
Cementoplastia/métodos , Fraturas por Compressão/diagnóstico por imagem , Fraturas por Compressão/terapia , Fraturas por Osteoporose/diagnóstico por imagem , Fraturas por Osteoporose/terapia , Radiografia Intervencionista , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/terapia , Fluoroscopia , Humanos , Imageamento por Ressonância Magnética , Medição da Dor , Polimetil Metacrilato/uso terapêutico , Tomografia Computadorizada por Raios XRESUMO
This study assessed the one-year clinical and radiographic outcomes, in terms of pain-relief, vertebral re-fracture and complications, after vertebroplasty (VP) using a new osteoconductive cement (calcium triglyceride bone cement - Kryptonite™ bone cement, Doctors Research Group Inc., Southbury, CT, USA) to treat osteoporotic vertebral compression fractures. Sixteen consecutive osteoporotic patients (12 women and four men, mean age 68+/-10.5) were treated with VP using Kryptonite™ bone cement for a total of 20 vertebral fractures. All the patients complained of a pain syndrome resistant to medical therapy and all procedures were performed under fluoroscopy control with neuroleptoanalgesia using a monopedicular approach in 12 patients and bipedicular approach in four patients. All patients were studied by MR and MDCT and were evaluated with the visual analogue scale (VAS) and the Oswestry disability index (ODI) before treatment and at one and 12 months after the procedure. A successful outcome was observed in 80% of patients, with a complete resolution of pain. Differences in pre and post treatment VAS and ODI at one-year follow-up were significant (P<0.0001). We observed a disk and venous leakage in 66% of patients but only in one case did an asymptomatic pulmonary embolism occur during cement injection. Two cases of vertebral re-fractures at distant metamers were observed during follow-up. VP using Kryptonite bone cement is a helpful procedure that allows complete and long-lasting resolution of painful vertebral symptoms. The cost of the material is very high and the rate of disk and venous leakage is too high compared to standard cement.
Assuntos
Cimentos Ósseos , Óleo de Rícino , Polímeros , Compressão da Medula Espinal/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Vertebroplastia/métodos , Idoso , Idoso de 80 Anos ou mais , Óleo de Rícino/efeitos adversos , Óleo de Rícino/economia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas por Osteoporose/cirurgia , Dor/etiologia , Dor/cirurgia , Medição da Dor , Polímeros/efeitos adversos , Polímeros/economia , Complicações Pós-Operatórias/epidemiologia , Compressão da Medula Espinal/etiologia , Fraturas da Coluna Vertebral/complicações , Resultado do TratamentoRESUMO
Ependymoma has been described typically as an intramedullary tumour derived from ependymal cells with a predominance in women in the fifth decade of life. Pain is the most frequent symptom. Intradural extramedullary presentation is rarely described and almost always as a unique lesion. We describe a 53-year-old man with multi-segmental diffuse intradural extramedullary ependymoma with progressive lower leg hypoesthesia with regular motility. The patient's neurologic condition improved after surgery.
Assuntos
Ependimoma/patologia , Imageamento por Ressonância Magnética , Neoplasias da Medula Espinal/patologia , Medula Espinal/patologia , Descompressão Cirúrgica , Ependimoma/complicações , Ependimoma/cirurgia , Humanos , Hipestesia/etiologia , Hipestesia/cirurgia , Masculino , Pessoa de Meia-Idade , Medula Espinal/cirurgia , Neoplasias da Medula Espinal/complicações , Neoplasias da Medula Espinal/cirurgiaRESUMO
We present a case report of a 33-year-old woman with back pain for several months which was resistant to medical treatment. Thoracolumbar MRI and multidetector CT showed an aneurysmal bone cyst intersecting the body and pedicles of L5. Minimally invasive treatment was performed with percutaneous injection of osteoconductive cement (Cerament) to induce sclerosis and bone remodeling of the bone cyst lesion with an analgesic effect. Before treatment, spinal angiography was performed to exclude arterial afferents. No bone biopsy was done. Under general anesthesia and fluoroscopic guidance, a first vertebroplasty was performed by a bilateral transpedicular approach using the osteoconductive cement followed 2â months later by a second treatment with CT-fluoro-guided direct injection of Cerament. No complications occurred during the procedure. At 4 and 6â months follow-up the MRI/CT showed sclerotic bone remodeling of the walls of the aneurysmal cyst with clinical improvement.
Assuntos
Cimentos Ósseos/uso terapêutico , Cistos Ósseos Aneurismáticos/terapia , Injeções/métodos , Vertebroplastia/métodos , Adulto , Cistos Ósseos Aneurismáticos/diagnóstico por imagem , Feminino , Humanos , Vértebras Lombares/patologia , Radiografia , Resultado do TratamentoRESUMO
We present a case report of a 33-year-old woman with back pain for several months which was resistant to medical treatment. Thoracolumbar MRI and multidetector CT showed an aneurysmal bone cyst intersecting the body and pedicles of L5. Minimally invasive treatment was performed with percutaneous injection of osteoconductive cement (Cerament) to induce sclerosis and bone remodeling of the bone cyst lesion with an analgesic effect. Before treatment, spinal angiography was performed to exclude arterial afferents. No bone biopsy was done. Under general anesthesia and fluoroscopic guidance, a first vertebroplasty was performed by a bilateral transpedicular approach using the osteoconductive cement followed 2 months later by a second treatment with CT-fluoro-guided direct injection of Cerament. No complications occurred during the procedure. At 4 and 6 months follow-up the MRI/CT showed sclerotic bone remodeling of the walls of the aneurysmal cyst with clinical improvement.
Assuntos
Cistos Ósseos Aneurismáticos/diagnóstico , Cistos Ósseos Aneurismáticos/terapia , Sulfato de Cálcio/uso terapêutico , Durapatita/uso terapêutico , Dor Lombar/terapia , Adulto , Cimentos Ósseos/uso terapêutico , Cistos Ósseos Aneurismáticos/complicações , Combinação de Medicamentos , Feminino , Seguimentos , Humanos , Injeções Intralesionais , Injeções Espinhais , Dor Lombar/etiologia , Dor Lombar/fisiopatologia , Vértebras Lombares , Angiografia por Ressonância Magnética/métodos , Tomografia Computadorizada Multidetectores/métodos , Procedimentos Ortopédicos , Medição da Dor , Dor Intratável/etiologia , Dor Intratável/fisiopatologia , Dor Intratável/terapia , Medição de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Spine stability is the basic requirement to protect nervous structures and prevent the early deterioration of spinal components. All bony and soft spinal components contribute to stability, so any degenerative, traumatic or destructive lesion to any spinal structure gives rise to some degree of instability. Degenerative instability is considered a major cause of axial and radicular pain and is a frequent indication for surgery. Nevertheless the assessment of instability remains difficult in both clinical and imaging settings. All static imaging modalities, even conventional MR, the most accurate technique, are unreliable in assessing instability and chronic pain due to degenerative spine. Dynamic-positional MR is considered the most sophisticated imaging modality to evaluate abnormal spinal motion and instability. In spinal traumas, as multi-detector CT yields high-resolution reconstructions in every spatial plane, it will detect even the tiniest fractures revealing potentially unstable lesions, often avoid the routine use of MR. Nevertheless, MR remains the only modality that will directly and routinely assess soft tissue changes. Unfortunately the objectivity of MR in assessing the integrity of ligaments is not rigorously defined and its use in routine protocols to clear blunt spinal injuries remains controversial. There are no evidence-based guidelines currently available to assess the risk of spinal instability in the setting of neoplastic spinal disease, so predicting the risk of a pathological fracture or the timing of a collapse remains challenging even when the lesions are well-characterized by neuroimaging. Diagnostic difficulties lead to controversy in the choice of the best treatment in all forms of spinal instability.
Assuntos
Instabilidade Articular/fisiopatologia , Modelos Biológicos , Movimento , Músculo Esquelético/fisiopatologia , Doenças da Coluna Vertebral/fisiopatologia , Coluna Vertebral/fisiopatologia , Articulação Zigapofisária/fisiopatologia , Força Compressiva , Módulo de Elasticidade , Retroalimentação Fisiológica , Humanos , Resistência à Tração , Suporte de CargaRESUMO
Biomechanics, the application of mechanical principles to living organisms, helps us to understand how all the bony and soft spinal components contribute individually and together to ensure spinal stability, and how traumas, tumours and degenerative disorders exert destabilizing effects. Spine stability is the basic requirement to protect nervous structures and prevent the early mechanical deterioration of spinal components. The literature reports a number of biomechanical and clinical definitions of spinal stability, but a consensus definition is lacking. Any vertebra in each spinal motion segment, the smallest functional unit of the spine, can perform various combinations of the main and coupled movements during which a number of bony and soft restraints maintain spine stability. Bones, disks and ligaments contribute by playing a structural role and by acting as transducers through their mechanoreceptors. Mechanoreceptors send proprioceptive impulses to the central nervous system which coordinates muscle tone, movement and reflexes. Damage to any spinal structure gives rise to some degree of instability. Instability is classically considered as a global increase in the movements associated with the occurrence of back and/or nerve root pain. The assessment of spinal instability remains a major challenge for diagnostic imaging experts. Knowledge of biomechanics is essential in view of the increasing involvement of radiologists and neuroradiologists in spinal interventional procedures and the ongoing development of new techniques and devices. Bioengineers and surgeons are currently focusing on mobile stabilization systems. These systems represent a new frontier in the treatment of painful degenerative spine and aim to neutralize noxious forces, restore the normal function of spinal segments and protect the adjacent segments. This review discusses the current concepts of spine stability.