Electrochemotherapy in Aggressive Hemangioma of the Spine: A Case Series and Narrative Literature Review.

(1) Background: this case series and literature review aims to evaluate the efficacy and safety of electrochemotherapy in the management of aggressive spinal hemangiomas, presenting two distinct cases. (2) Methods: we present two cases of spinal aggressive hemangioma which were refractory to conventional treatments and underwent electrochemotherapy. Case 1 involves a 50-year-old female who presented with an aggressive spinal hemangioma of L1, who previously underwent various treatments including surgery, radio-chemotherapy, and arterial embolization. Case 2 describes a 16-year-old female with a T12 vertebral hemangioma, previously treated with surgery and stabilization, who faced limitations in treatment options due to her young age and the location of the hemangioma. (3) Results: in Case 1, electrochemotherapy with bleomycin was administered following the failure of previous treatments and resulted in the reduction of the lesion size and improvement in clinical symptoms. In Case 2, electrochemotherapy was chosen due to the risks associated with other treatments and was completed without any adverse events. Both cases demonstrated the potential of electrochemotherapy as a viable treatment option for spinal hemangiomas, especially in complex or recurrent cases. (4) Conclusions: electrochemotherapy with bleomycin is a promising treatment for aggressive spinal hemangiomas when conventional therapies are not feasible or have failed. Further research is needed to establish definitive protocols and long-term outcomes of electrochemotherapy in spinal hemangioma management.

Transpedicular Contrast-enhanced CT-guided biopsy of the body and dens of the axis avoiding the trans-oral approach: Technical report and literature review.

This technical report illustrates the technique to perform computed tomography (CT)-guided bone biopsies in the body and dens of the axis (C2 vertebra) through a posterior transpedicular approach with the use of preoperative contrast-enhanced scans to highlight the course of the vertebral artery. The technique is presented through two exemplification cases: a pediatric patient with osteoblastoma and secondary aneurysmal bone cyst and one adult patient with melanoma metastasis. This case highlights the potential of the CT-guided posterolateral/transpedicular approach for performing safe and effective biopsies in the body and dens of C2, even in pediatric patients.

Aneurysmal bone cyst: Is selective arterial embolization effective as curettage and bone grafting?

INTRODUCTION: Aneurysmal bone cyst (ABC) is a lytic benign bone lesion representing about 1% of all primary bone tumors. Method to treat ABC's have developed over time. The standard of care cure for ABC has been curettage with or without bone grafting of the defect but is burdened by recurrence rates of approximately 25%-31%. Based on the assumption that ABCs usually supplied by one or more pathological feeding arteries, selective arterial embolization has been described as an adjuvant preoperative procedure to reduce intra-operative hemorrhage, and as primary treatment for lesions in difficult surgical access. In the current study, we therefore asked whether (1) a single or a repeat selective arterial embolization (SAE) for treating ABCs would produce comparable healing rates compared with curettage and bone grafting; (2) evaluated the relationship of recurrence in relation to the site of the cyst, the age, and gender of the patients; and (3) the two techniques differ in term of long-term complication. MATERIAL AND METHODS: We retrospectively reviewed 265 patients who underwent curettage and bone grafting or SAE performed at our institute from 1994 to 2018. The diagnosis of ABC was always established with percutaneous CT-guided biopsy or open biopsy. Patients were followed clinically with plain radiographs or CT scan at 3, 6, 9, and 12 months then annually in the absence of symptoms. Treatment success was determined evaluating pre- and postprocedural imaging according to Chang classification. RESULTS: Two hundred and nineteen were treated with curettage and bone grafting (curettage group), and 46 with SAE Group. Of the 219 patients treated with Curettage and bone grafting (curettage group), 165 out of 219 (75.3%) experienced bone healing, while local recurrence was observed in 54 cases (24.7%) after 12 months on average (range: 3-120 months) from surgery. After the first SAE, bone ossification was seen in 27 (58.7%), without needing any further treatment. Eleven recurred patients were treated with SAE (four patients need two while seven need three SAE to heal), and eight patients with curettage and bone grafting. Thirty-eight out of 46 (82%) patients experienced bone ossification regardless the number of SAE. The overall rate of local recurrence for all patients was 26.7%. SAE group presented a lower complication rate (6%) where two patients experienced skin necrosis, and one limb-length discrepancies (2% of all cohort). DISCUSSION: The use of SAE is an attractive option to treat ABC as it combines on one hand a lower complication rate than curettage and bone grafting, on the other it can be carried out in case of nonresectable ABCs, significantly reducing the size of viable ABC lesions, fostering bone remodeling and mineralization, and most importantly, significantly improving the patient's quality of life.

Unraveling the enigma of Adamkiewicz: exploring the prevalence, anatomical variability, and clinical impact in spinal embolization procedures for bone metastases.

BACKGROUND: The artery of Adamkiewicz (AKA) is vital for spinal cord blood supply. Its role in embolization procedures for bone metastases can cause serious complications. We explored its prevalence, anatomical variation, and effect on spinal embolization using N-butyl cyanoacrylate (NBCA) in patients with bone metastases. PURPOSE: To understand the impact and variability of AKA in spinal embolizations in cases of bone metastases to reduce complications and improve patient outcomes. MATERIAL AND METHODS: We examined data from 454 patients who underwent spinal embolization with NBCA between 2009 and 2018. The presence, anastomoses, and tumor features of AKA were assessed via pre-procedure imaging and angiography. Complications were classified per the CIRSE Classification System. RESULTS: AKA was found in 22.8% of patients, predominantly left-sided and originating from T8 to L1. Direct and indirect anastomoses were present in 66.6% and 33.4% of patients, respectively. Extra-compartmental invasion was linked with direct anastomosis (P = 0.004). High-grade complications were rare but included one instance of bilateral lower limb paralysis. Partial embolization was necessary in 22.8% of cases due to AKA. CONCLUSION: The study underscores the need for rigorous preoperative evaluation of AKA origin and anastomoses in patients undergoing spinal embolization for bone metastases. Given the significant presence of AKA and related anastomoses, especially with renal extra-compartmental tumors, caution is advised to reduce complications and optimize patient outcomes. Further research is required for best practice guidelines involving bone metastases and AKA.

The New Ice Age of Musculoskeletal Intervention: Role of Percutaneous Cryoablation in Bone and Soft Tissue Tumors.

In the rapidly evolving field of interventional oncology, minimally invasive methods, including CT-guided cryoablation, play an increasingly important role in tumor treatment, notably in bone and soft tissue cancers. Cryoablation works using compressed gas-filled probes to freeze tumor cells to temperatures below -20 °C, exploiting the Joule-Thompson effect. This cooling causes cell destruction by forming intracellular ice crystals and disrupting blood flow through endothelial cell damage, leading to local ischemia and devascularization. Coupling this with CT technology enables precise tumor targeting, preserving healthy surrounding tissues and decreasing postoperative complications. This review reports the most important literature on CT-guided cryoablation's application in musculoskeletal oncology, including sarcoma, bone metastases, and bone and soft tissue benign primary tumors, reporting on the success rate, recurrence rate, complications, and technical aspects to maximize success for cryoablation in the musculoskeletal system.

Palliative Arterial Embolization for Metastases of the Sternum.

BACKGROUND: To investigate the safety and efficacy of palliative arterial embolization for metastases of the sternum. MATERIALS AND METHODS: This study included 10 consecutive patients (5 M, 5 F; mean age 58.1; range 37-70) with metastases of the sternum from different primary tumors, treated with palliative arterial embolization using NBCA-Lipiodol between January 2007 and June 2022. Four patients received a second embolization at the same site, for a total of 14 embolizations. Data on technical and clinical success, as well as changes in tumor size, were collected. All embolization-related complications were evaluated according to the CIRSE classification system for complications. RESULTS: Post-embolization angiography showed occlusion of more than 90% of the pathological feeding vessels in all procedures. Pain score and analgesic drug consumption were reduced by 50% in all 10 patients (100%, p < 0.05). The mean duration of pain relief was 9.5 months (range 8 to 12 months, p < 0.05). Metastatic tumor size was reduced from a mean of 71.5 cm3 (range 41.6 to 90.3 cm3) pre-embolization to a mean of 67.9 cm3 (range 38.5 to 86.1 cm3) at the 12-month follow-up (p < 0.05). None of the patients experienced embolization-related complications. CONCLUSION: Arterial embolization is safe and effective as a palliative treatment for patients with metastases of the sternum who did not benefit from radiation therapy or experienced recurrence in symptoms.

CT-guided Pulsed Radiofrequency Combined with Steroid Injection for Sciatica from Herniated Disk: A Randomized Trial.

Background Evidence regarding effective nonsurgical management of sciatica remains limited. Purpose To determine a difference in effectiveness between combined pulsed radiofrequency (PRF) and transforaminal epidural steroid injection (TFESI) treatment versus TFESI alone for sciatic pain due to lumbar disk herniation. Materials and Methods This prospective multicenter double-blind randomized clinical trial was conducted between February 2017 and September 2019 in participants with sciatica due to lumbar disk herniation lasting 12 weeks or longer that was not responsive to conservative treatment. Study participants were randomly assigned to undergo one CT-guided treatment with combined PRF and TFESI (n = 174) or TFESI alone (n = 177). The primary outcome was leg pain severity, as assessed with the numeric rating scale (NRS) (range, 0-10) at weeks 1 and 52 after treatment. Secondary outcomes included Roland-Morris Disability Questionnaire (RMDQ) score (range, 0-24) and Oswestry Disability Index (ODI) score (range, 0-100). Outcomes were analyzed according to the intention-to-treat principle via linear regression. Results Mean age of the 351 participants (223 men) was 55 years ± 16 (SD). At baseline, NRS was 8.1 ± 1.1 in the PRF and TFESI group and 7.9 ± 1.1 in the TFESI group. NRS was 3.2 ± 0.2 in the PRF and TFESI group and 5.4 ± 0.2 in the TFESI group (average treatment effect, 2.3; 95% CI: 1.9, 2.8; P < .001) at week 1 and 1.0 ± 0.2 and 3.9 ± 0.2 (average treatment effect, 3.0; 95% CI: 2.4, 3.5; P < .001), respectively, at week 52. At week 52, the average treatment effect was 11.0 (95% CI: 6.4, 15.6; P < .001) for ODI and 2.9 (95% CI: 1.6, 4.3; P < .001) for RMDQ, favoring the combined PRF and TFSEI group. Adverse events were reported in 6% (10 of 167) of participants in the PRF and TFESI group and in 3% (six of 176) of participants in the TFESI group (eight participants did not complete follow-up questionnaires). No severe adverse events occurred. Conclusion In the treatment of sciatica caused by lumbar disk herniation, pulsed radiofrequency combined with transforaminal epidural steroid injection is more effective for pain relief and disability improvement than steroid injection alone. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Jennings in this issue.

Preoperative Arterial Embolization for Heterotopic Ossification of the Hip.

PURPOSE: To investigate the efficacy and safety of preoperative arterial embolization for neurogenic heterotopic ossification (NHO) of the hip. MATERIALS AND METHODS: This single-center retrospective study reviewed outcomes in 16 consecutive patients who had surgical resection of NHO of the hip: 8 of whom underwent preoperative arterial embolization and 8 of whom did not. Both patient cohorts had similar baseline characteristics. A mean of 2.62 ± 1.9 arteries per patient, including the gluteal, lateral circumflex femoral, and deep circumflex iliac branches, were embolized using an n-butyl cyanoacrylate (NBCA)-ethiodized oil mixture. Data from both cohorts regarding intraoperative blood loss, volume of blood transfused, complications, and duration of hospitalization were compared. RESULTS: A mean of 2.6 ± 1.9 arteries were embolized with NBCA-ethiodized oil, mainly the gluteal arteries, lateral circumflex femoral artery, and deep circumflex iliac artery. In the embolization group, mean intraoperative blood loss was 875 mL ± 320, mean number of units of blood used was 0.5 ± 0.7, and mean number of days of hospitalization was 6.4 days ± 1.6. In the control group, mean intraoperative blood loss was 1,350 mL ± 120, mean number of units of blood used was 2 ± 1.1, and average number of days of hospitalization was 11.5 days ± 1.4. The embolization group had a mean reduction in blood loss of 40.7% (P = 0.035), reduction in units of blood administered of 75% (P = 0.021), and reduction in days of hospitalization of 44.7% (P = 0.014). No procedural complications were recorded. CONCLUSIONS: Preoperative arterial embolization is effective and safe in reducing intraoperative blood loss, number of hospitalization days, and need for blood transfusions in surgical resection of NHO of the hip.

Current concepts in the diagnosis and treatment of adhesive capsulitis: role of diagnostic imaging and ultrasound-guided interventional procedures.

Adhesive capsulitis is a common cause of painful shoulder, characterized by pain and restricted range of motion of the glenohumeral joint. With a well-known clinical presentation, and an increasing understanding of its clinical and radiologic features, early diagnosis of adhesive capsulitis is becoming a reality. Although often treated conservatively, for refractory cases arthroscopic release and open capsulotomy have been the only therapeutic option for a long time. Therefore, in the last years, a particular effort was put into the development of novel minimal-invasive techniques capable of pain relief and functional range improvement of the glenohumeral joint. The purpose of this literature review is to report the main updates on diagnosis and treatment for adhesive capsulitis with a focus on imaging diagnosis techniques and novel minimally invasive ultrasound-guided treatments. Results showed that ultrasound-guided procedures come with a high success rate in terms of pain reduction and improved range of motion, thus making the ultrasound a unique tool capable of giving the operator real-time diagnostic information confirming the clinical suspicion, and subsequently performing an interventional procedure.

CT-Guided Radiofrequency Thermal Ablation for the Treatment of Atypical, Early-Onset Osteoid Osteoma in Children Younger than 4 Years Old: Single-Institution Experience and Literature Review.

The aim of our study is to report our experience on CT-guided radiofrequency ablation (RFA) for osteoid osteoma (OO) in children under 4 years of age and to review the literature regarding this atypical, early onset of the disease. We retrospectively reviewed the clinical and radiological records of the patients treated with CT-guided RFA for OO at our institution (2006−2021), including those under 4 years of age. Data regarding technical success, clinical success, and biopsy diagnostic yield were collected. Moreover, we performed a literature review including previous articles on early-onset OO. We found only 12 patients that were under 4 years of age (12/842−1.4%) at the time of RFA treatment: 4 F and 8 M, mean age at the time of the treatment 35.3 months (range 22−46 months). The mean follow-up was 22.8 months (range 6−96 months). Technical success was achieved in all cases (12/12). In all patients (12/12), a complete remission of the pain symptoms was achieved at clinical follow-up controls. No recurrence of pain or complications were documented. The histopathological diagnosis was confirmed in 4 patients (4/12−33.3%). Moreover, we found another 9 articles in the literature with a main focus on early-onset OO (<4 years old), with a total of 12 patients included; 6 of those patients (6/12−50%) were treated with CT-guided RFA, with success reported 5 cases (5/6−83.3%). Our series of cases treated at a single institution, together with the existing data from the literature, confirms that CT-guided RFA is effective and safe for the treatment of osteoid osteoma, even in atypical, early onset in children under 4 years of age.

Reduction of Metal Artifacts Caused by Titanium Peduncular Screws in the Spine by Means of Monoenergetic Images and the Metal Artifact Reduction Software in Dual-Energy Computed Tomography.

Objectives: To evaluate the reduction of metal artifacts in patients with titanium peduncular screws in the spine using (1) conventional images (CI), (2) virtual monoenergetic reconstructions (VMRs), and (3) VMR + Metal Artifact Reduction Software (VMR + MARS), with dual-energy computed tomography (DECT). Materials and Methods: Twenty-four patients with titanium peduncular screws in the spine were studied using a 64-channel DECT. During the postprocessing phase, the CI, the VMRs from 100 to 140 keV, and the VMR at 140 keV + MARS were synthesized. All the images were considered, and a quantitative evaluation was performed measuring the attenuation values (in terms of Hounsfield Units) with region of interest, in correspondence with the most hyperdense and hypodense artifacts. All the values were then compared. A qualitative evaluation, in terms of image quality and extent of artifacts, was also performed by two radiologists. Results: In quantitative terms, the 140 keV + MARS reconstruction was able to significantly reduce both bright and dark metal artifacts, compared to CI and to VMRs. The VMR was capable of significantly reducing both dark and bright artifacts, compared to CI. In qualitative terms, the VMR at 140 keV proved to be the best, compared to CI and VMR + MARS images. Conclusions: The VMR + MARS image reduces metal artifacts from titanium peduncular screws more than VMRs alone and CI. Furthermore, the VMR can decrease metal artifacts from a quantitative and a qualitative point of view. Combining information from VMRs and VMR + MARS images could be the best way to solve the issue of metal artifacts on computed tomography images.

Prevalence and characteristics of diffuse idiopathic skeletal hyperostosis (DISH) in Italy.

PURPOSE: Diffuse idiopathic skeletal hyperostosis (DISH) is a benign condition characterized by ossification of the spine and prominent enthesopathies. Highly heterogeneous epidemiological figures have been reported in the literature, while in Italy the largest study has been conducted in 1992. The aim of our research is to contribute updated information about prevalence of DISH in Italy and to describe the clinical and radiographic characteristics associated with the disorder. MATERIAL AND METHODS: A retrospective review of lumbosacral spine, thoracic spine and pelvis radiographs was performed. Consecutive patients visiting the emergency department of our Institution over 3 years were enrolled. Presence of DISH was evaluated applying the Resnick and Niwayama criteria. Clinical and radiological features were also assessed. RESULTS: We included 1012 individuals (60.6% women), and DISH was present in 130 cases. The overall prevalence of DISH was 12.8% (95% CI 10.8-15.1), with higher figures in the male sample (16.8%) than in females (10.3%). In binary logistic regression adjusted for age, BMI (OR 1.50, p < 0.001) diabetes (OR 1.85, p = 0.003), hypertension (OR 2.04, p = 0.007) ischiopubic enthesopathy (OR 7.08, p < 0.001), iliac crest enthesopathy (OR 4.63, p < 0.001) and greater trochanter enthesopathy (OR 3.51, p < 0.001), were significantly associated with the condition. CONCLUSION: The prevalence of DISH observed in our study is consistent with previous literature, and we confirm that the disorder is more frequently retrieved in men and that it is associated with the presence of metabolic disorders and pelvic enthesopathy. Knowledge about the epidemiology and characteristics of DISH is needed to properly identify the condition.

Clinical Application of Diffusion Tensor Imaging for a Brachial Plexus Injury.

Brachial plexus injuries are commonly diagnosed clinically, as conventional imaging has a low sensitivity. In recent years, diffusion tensor imaging has established a clinical role in the study of the central nervous system and, while still presenting some limitations due to the technical complexity of the acquisition method, is showing promising results when applied to peripheral nerves. Moreover, deterministic fiber tracking with the Euler's method and multishell acquisition are two novel advances in the field which contribute to enhancing the reliability of the technique reducing the respiratory and inhomogeneity artifacts in this "magnetically complex" region, and better isolating the fibers in a heterogeneous territory. Here, we report a case of brachial plexus traumatic injury, a healthy reference subject, and details on the acquisition protocol of the reconstruction algorithm.

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.

Percutaneous CT-Guided Biopsy of the Craniovertebral Junction: Safety, Diagnostic Yield, and Technical Notes.

The craniovertebral junction defined as the occiput, the atlas, and the axis is a complex bony region that contains vital neural and vascular structures. We report the experience of a single academic institution regarding CT-guided biopsy of this skeletal region. We reviewed all of the CT-guided biopsies performed in our department, completed in the craniovertebral junction. We collected data in regard to biopsy procedures, patients' vital statistics, and histopathological diagnosis. In total, 16 patients (8M and 8F; mean age 52; range 16-86 years old) were included in this series. In eight patients, the lesions were located in the atlas vertebra (8/16-50%), in six patients in the axis (37.5%), and in two patients in the occiput (12.5%). No complications were observed during or after the procedures. All of the procedures were technically successful. The biopsy was diagnostic in 13/16 patients (81.3%): four metastatic lesions (25%-three breast and one prostate cancers), four multiple myeloma bone lesions (25%), three aneurismal bone cysts (18.8%), one aggressive hemangioma (6.3%), and one pseudogout (6.3%). Moreover, in two-thirds (66.6%) of non-diagnostic histological reports, malignancies were excluded. CT-guided percutaneous biopsy is a safe tool and allows obtaining a histological diagnosis, in most cases, even in the most delicate site of the human skeleton-the craniovertebral junction.

Iatrogenic Lesion of the Lateral Plantar Artery following Plantar Fasciotomy for Cavus Foot Correction - A Case Report.

Introduction: The aim of this study was to report a patient with a iatrogenic lesion of the lateral plantar artery following plantar fasciotomy (PF) for cavus foot correction, an extremely rare complication. Case Report: A 13-year-old male patient with bilateral cavus foot was surgically treated at the right foot. At 36 days follow-up, after plaster cast removal, a massive soft plantar bulge was located on the medial aspect of the foot. Once suture stiches removal was performed, a huge blood collection was evacuated, and active bleeding observed. Contrast-enhanced angio-CT revealed a lesion of the lateral plantar artery. A vascular suture was performed. At 5 months follow-up, the patient was pain-free in his foot. Conclusion: Despite a iatrogenic lesion of the plantar vascular structures following PF is extremely rare, it is a potential complication to consider. Meticulous attention to surgical technique and careful inspection of the foot the day after surgery, before patient discharge, are recommended.

Imaging of calcific tendinopathy in atypical sites by ultrasound and conventional radiography: A pictorial essay.

Calcific tendinopathy (CT) is a very common condition caused by the deposition of calcium hydroxyapatite crystals in tendons and it can be an incidental finding or associated with severe pain. CT can be easily detected by first level exams such as traditional radiography and ultrasound (US), which provide information on the site, extent and composition of the calcific formation. Classically, the most affected site is represented by the rotator cuff tendons, in particular the supraspinatus tendon. In this pictorial essay we illustrate various unusual localizations of CT detected by US and plain radiography, in order to provide an overview with the aim of preventing diagnostic delays and consequently CT complications.