Percutaneous Vertebral Augmentation Techniques in Osteoporotic and Traumatic Fractures.

Percutaneous vertebral augmentation/consolidation techniques are varied. These are vertebroplasty, kyphoplasty, and several methods with percutaneous introduction of an implant (associated or not with cement injection). They are proposed in painful osteoporotic vertebral fractures and traumatic fractures. The objectives are to consolidate the fracture and, if possible, to restore the height of the vertebral body to reduce vertebral and regional kyphosis. Stabilization of the fracture leads to a reduction in pain and thus restores the spinal support function as quickly as possible, which is particularly important in the elderly. The effectiveness of these interventions on fracture pain was challenged once by two randomized trials comparing vertebroplasty to a sham intervention. Since then, many other randomized studies in support of vertebroplasty efficacy have been published. International recommendations reserve vertebroplasty for medical treatment failures on pain, but earlier positioning may be debatable if the objective is to limit kyphotic deformity or even reexpand the vertebral body. Recent data suggest that in osteoporotic fracture, the degree of kyphosis reduction achieved by kyphoplasty and percutaneous implant techniques, compared with vertebroplasty, is not sufficient to justify the additional cost and the use of a somewhat longer and traumatic procedure. In young patients with acute traumatic fractures and a significant kyphotic angle, kyphoplasty and percutaneous implant techniques are preferred to vertebroplasty, as in these cases a deformity reduction has a significant positive impact on the clinical outcome.

Vertebroplasty and interventional radiology procedures for bone metastases.

Advances in cancer treatments have lengthened the survival of patients with bone metastases. Optimal control of the symptoms and prevention of the complications associated with bone metastases improve quality of life. Achieving these goals increasingly involves interventional radiology procedures. These include bone consolidation and analgesic techniques such as cementoplasty (vertebroplasty at the spine); percutaneous implantation of screws, metallic reinforcement devices, or intraosseous implants; and tumor destruction using thermal methods (radiofrequency and cryotherapy), chemicals (alcohol), and drugs (chemoembolization), which have fewer indications. Here, these techniques and their indications are reviewed.

An open-label, prospective, observational study of the efficacy of bisphosphonate therapy for painful osteoid osteoma.

OBJECTIVES: To assess the efficacy of bisphosphonate therapy on bone pain in patients with osteoid osteoma (OO) (main objective), and to describe bisphosphonate-induced changes in nidus mineralisation and regional bone-marrow oedema (BMO). METHODS: A prospective, observational study was conducted from 2011 to 2014. Patients with risk factors for complications of percutaneous or surgical ablation or recurrence after ablation, were offered once monthly intravenous bisphosphonate treatment until significant pain alleviation was achieved. RESULTS: We included 23 patients. The first two patients received pamidronate and the next 21 zoledronic acid (mean, 2.95 infusions per patient). Bisphosphonate therapy was successful in 19 patients (83%), whose mean pain visual analogue scale score decreased by 76.7%; this pain-relieving effect persisted in 17 patients (74%) with a mean follow-up time of 36 months. Computed tomography (CT) demonstrated a mean nidus density increase of 177.7% (p = 0.001). By magnetic resonance imaging (MRI), mean decreases were 38.4% for BMO surface area and 30.3% for signal intensity (p = 0.001 and p = 0.000, respectively). CONCLUSIONS: In 17/23 patients with painful OO managed conservatively with bisphosphonates, long-term final success was achieved. Bisphosphonates may accelerate the spontaneous healing of OO. KEY POINTS: • 19/23 patients with OO managed with bisphosphonates experienced significant pain relief • Pain relief was sustained in 17/23 patients, mean follow-up of 36 months • CT demonstrated a significant increase in nidus mineralisation • MRI demonstrated a significant decrease in bone marrow oedema • Bisphosphonate therapy may accelerate the spontaneous healing of OO.

Is pain duration associated with morphologic changes of osteoid osteomas at CT?

PURPOSE: To assess the morphologic changes of osteoid osteomas on computed tomographic (CT) scans in association with pain duration. MATERIALS AND METHODS: Institutional review board approval was obtained. Informed consent was waived. From January 2008 to December 2012, 235 patients were treated with interstitial laser ablation at the Hôpital Lariboisière. Ninety-six patients with histopathologically proven osteoid osteomas, complete clinical files, and CT data were studied retrospectively. The following variables were assessed: age, sex, bone location, bone segment, location of the osteoid osteoma in relation to the native cortex, nidus area, nidus calcification area and attenuation at CT, and nidus mineralization ratio (percentage of the calcification area over the total nidus area). Analysis of variance, Kaplan-Meier method, and Cox multivariate regression model were used for statistical analyses. RESULTS: The study sample consisted of 96 patients, 68 of whom were male (71%) and 28 of whom were female (29%) (ratio of male to female patients, 2.4:1). Mean age ± standard deviation was 22.2 years ± 10.4 (range, 4-54 years; median, 18.5 years). The patients' age and nidus mineralization ratio increased significantly with pain duration (hazard ratio, 0.975 [P = .031] and 0.193 [P = .007], respectively). No significant association was found between pain duration and other variables, including the nidus area. In long bones, diaphyseal osteoid osteomas were significantly less mineralized than those in other locations (P = .009). CONCLUSION: The nidus mineralization ratio of osteoid osteomas increases significantly with pain duration and may be a marker of tumor age. Diaphyseal osteoid osteomas demonstrate a lower ratio of nidus mineralization. At the onset of symptoms, older patients experience pain for a longer period before treatment.

Long-term results of percutaneous resection and interstitial laser ablation of osteoid osteomas.

To evaluate the efficiency and complication rate of two percutaneous treatments of osteoid osteomas, percutaneous trephine resection (PR) and interstitial laser ablation (ILA). Ethical review board was obtained for the retrospective study. One hundred and 26 patients were treated by PR (n = 26) or ILA (n = 100) under CT, with a median follow-up of 113 months for the PR group and 47 months for the ILA group. In the group treated by PR, the clinical success rate was 96% at 6-month and 95% at 24-month follow-up, with 12% (3/26) transient complications (one meralgia, two skin burns). One patient experienced immediate failure, and none had delayed failure. In the group treated by ILA, the clinical success rate was 96% at 6-month and 94% at 24-month follow-up, with 4% (4/100) transient complications (one common fibular nerve contusion, one hematoma, one infection and one tendinitis). Four ILA procedures were repeated, one because of initial failure and three because of recurrence (at 6.5, 15 and 32 months). Two were successful and two failed again. Failure was more frequent (p = 0.0094) in patients less than 18 years old, and in lesions with a nidus size of 12 mm or larger (p = 0.0022).

Percutaneous biopsy of osteoid osteomas prior to percutaneous treatment using two different biopsy needles.

Biopsy is usually performed as the first step in percutaneous treatment of osteoid osteomas prior to laser photocoagulation. At our institution, 117 patients with a presumed diagnosis of osteoid osteoma had a trephine biopsy before a percutaneous laser photocoagulation. Biopsies were made using two different types of needles. A Bonopty biopsy needle (14-gauge cannula, 16-gauge trephine needle; Radi Medical Systems, Uppsala, Sweden) was used in 65 patients, and a Laurane biopsy needle (11-gauge cannula, 12.5-gauge trephine needle; Laurane Medical, Saint-Arnoult, France) in 43 patients. Overall biopsy results were positive for osteoid osteoma in 83 (70.9%) of the 117 cases. The Laurane needle provided a significantly higher positive rate (81.4%) than the Bonopty needle (66.1%; p < 0.05). This difference was not due to the size of the nidus, which was similar in the two groups (p < 0.05) and may be an effect of differences in needle caliber (12.5 vs. 14 gauge) as well as differences in needle design. The rate of positive biopsy results obtained in the present series with the Laurane biopsy needle is, to our knowledge, the highest rate reported in series dealing with percutaneous radiofrequency ablation and laser photocoagulation of osteoid osteomas.

CT-guided percutaneous laser photocoagulation of osteoid osteomas of the hands and feet.

Percutaneous local ablation of osteoid osteoma has largely replaced surgery, except in the small bones of the hands and feet. The objective of this study was to describe the technical specificities and results of computed tomography (CT)-guided percutaneous laser photocoagulation in 15 patients with osteoid osteomas of the hands and feet. We retrospectively examined the medical charts of the 15 patients who were treated with CT-guided percutaneous laser photocoagulation therapy at our institution between 1994 and 2004. The 15 patients had a mean age of 24.33 years. None of them had received any prior surgical or percutaneous treatment for the osteoid osteoma. The follow-up period was 24 to 96 months (mean, 49.93). The pain resolved completely within 1 week. Fourteen patients remained symptom-free throughout the follow-up period; the remaining patient experienced a recurrence of pain after 24 months, underwent a second laser photocoagulation procedure, and was symptom-free at last follow-up 45 months later. No adverse events related to the procedure or to the location of the tumor in the hand or the foot were recorded. CT-guided percutaneous laser photocoagulation is an alternative to surgery for the treatment of osteoid osteomas of the hands and feet.

Vertebroplasty at L5 with a transiliac transpedicular approach in a patient with osteogenesis imperfecta: technical note.

The present report describes the use of a modified transpedicular vertebroplasty approach via the iliac bone for treatment of a painful osteoporotic L5 vertebral body fracture in a 66-year-old woman with osteogenesis imperfecta. As a result of altered osseous morphology of the pelvic girdle and lumbosacral junction secondary to the patient's condition, vertebroplasty at L5 was successfully performed by entering the needle into the adjacent superomedial aspect of iliac bone before passing through the pedicle and then into the vertebral body. This modified vertebroplasty approach provides an interesting alternative for fractures involving the frequently less accessible lowermost lumbar vertebral body.

Complications of percutaneous vertebroplasty and their prevention.

Vertebroplasty is an efficient treatment of vertebral collapses of malignant or benign origin but also carries a risk of complications. Cement extravasation is a frequent occurrence in vertebroplasty. It is well tolerated in the large majority of cases but is also the main source of complications especially nerve root compression in case of cement leakage into the intervertebral foramen and pulmonary embolism of cement complicating venous cement leakage. Rate of these complications are much higher in malignant than in osteoporotic collapses. The risk of neurological complication also increases at the cervical level. In addition, incidence of new vertebral fractures in adjacent vertebrae may be increased by vertebroplasty. General reactions possibly due to a reflex reaction to intramedullary bone injection and fat embolism may also occur. This article reviews the safety measures to reduce the risk of cement extravasation including high quality permanent radiological guidance enabling early detection of cement extravasation, use of conscious sedation, bilateral transpedicular approach at the thoracic and lumbar levels, careful selection of the bone penetration site in order to make a single vertebral needle path, careful needle placement to avoid the risk of cortical breakthrough, use of a well-opacified and refrigerated cement with a toothpaste consistency.

Aneurysmal bone cysts in children: complications of fibrosing agent injection.

PURPOSE: To report complications of direct fibrosing agent injection in the treatment of aneurysmal bone cysts (ABCs) in children. MATERIALS AND METHODS: The authors retrospectively analyzed all cases of ABCs treated with direct fibrosing agent injection (Ethibloc; Ethnor Laboratories, Ethicon, Noderstedt, Germany) at Robert Debré Hospital since 1994. Histologic diagnosis was assigned by means of surgical biopsy findings prior to treatment. Treatment responses were categorized. Injection was administered with general anesthesia, computed tomographic guidance, and use of a 14- to 16-gauge needle. Contrast material was injected to determine presence of intracystic septa and verify absence of venous opacification. Amount of fibrosing agent injected corresponded to amount of contrast material necessary to fully opacify the cyst. Intraosseous needle track was obliterated with histoacryl injection. RESULTS: Fifteen patients were treated. Mean follow-up was 80 months; no patient was lost to follow-up. One patient experienced pulmonary embolus that necessitated a 7-day intensive care unit stay. Four patients experienced early aseptic fistulization after the first injection, which led to surgical débridement and curettage. Five patients had transient inflammatory reaction with mild 38 degrees C fever, which was controlled with analgesic and antiinflammatory drugs. Eleven patients did not require surgery, and results at latest follow-up were considered to indicate complete healing (type 1 results) in nine and incomplete healing (type 2 results) in two. For type 1 results: Six patients received one injection, two received two injections, and one received three injections. For type 2 results: one patient received one injection, and one received three injections. CONCLUSION: A high rate of major local and general complications was encountered with use of direct fibrosing agent injection; the technique has been abandoned for treatment of ABCs.

Percutaneous Biopsy of Musculoskeletal Lesions.

Percutaneous biopsy is a minimally invasive technique that yields a high diagnostic accuracy at a relatively low cost in musculoskeletal lesions, especially tumors and infection. In this article, technical refinements improving the results of percutaneous biopsy of musculoskeletal lesions are reviewed, especially the type of radiological guidance, the different biopsy needles available, and the technique of approach depending on the lesion site. Reported complications, results, and indications of musculoskeletal percutaneous biopsy are also discussed.

Percutaneous Biopsy of the Synovial Membrane.

Techniques of percutaneous synovial biopsy under fluoroscopic control of large joints of the limbs (other than the knee) may be useful in arthritis of undetermined etiology especially when infection is considered. Main technical refinements include adequate selection of an optimal approach and biopsy site using new imaging methods, use of a Tru-Cut(R) needle, and placement of the cutting window tangential to the joint surface, and selection of an optimal approach and biopsy site. Detailed technique of the synovial biopsy of hip, ankle, shoulder, and elbow joints is discussed.

Percutaneous Resection of Osteoid Osteomas.

Osteoid osteomas in almost all locations may be treated by percutaneous resection under CT scan guidance. The authors give their own experience with a series of 30 cases. The different techniques of percutaneous resection reported in the literature are reviewed. Advantages of the percutaneous resection are compared to those of classical surgery and other percutaneous techniques such as lesion destruction with thermocoagulation, photocoagulation, and intralesional injection of alcohol.