Vertebroplastia percutânea para fraturas tumorais. 15 anos de experîência de uma estrutura multidisciplinar e revisão de literatura / Percutaneous Verteboplasty for tumoral fractures. 15 years experience of a multidisciplinary support and review of the literature

O tratamento da dor do paciente oncológico necessita de um acesso multidisciplinar. Se considerarmos metastases ósseas, mielomamúltiplo e linfoma, os procedimentos percutâneos como a vertebroplastia podem gerar um alívio rápido da dor. Entretanto,a vertebroplastia percutânea deve ser colocada de maneira a não retardar o tratamento sistêmico ou outras modalidades detratamento. Neste artigo, descrevemos nossos 15 anos de experiência com a colaboração de uma equipe multidisciplinar, atravésde revisão da literatura e pontos especiais da vertebroplastia percutânea para fraturas tumorais da coluna vertebral...

The pain management in oncologic patients requires a multidisciplinary approach. Considering bone metastases, multiplemyeloma and lymphoma, percutaneous procedures like vertebroplasty can provide rapid pain relief. However, percutaneousvertebroplasty must be placed in order to not delay systemic therapy or other modalities of treatment. In this article, we describedour 15 years’ experience in collaborating with a multidisciplinary team, reviewing literature and special issues percutaneousvertebroplasty for spinal tumoral fractures...

Tomografia computadorizada combinada à técnica de fluoroscopia para procedimentos percutaneous complexos da coluna vertebral / Combined cone beam computed tomography and fluoroscopy techniques for challenging percutaneous spine procedures

Transpedicular approaches for spine procedures are currently employed in biopsies and vertebroplasties (VT), and frequentlyperformed with computed tomography (CT) or fluoroscopy for image guidance. The fluoroscopy is not always reliable in termsof visualization if the pedicle is very small or destroyed by osteolytic lesions. CT is more precise in these situations but needleprogression is not visualized in dynamic view. We describe 3 cases where the anatomic landmarks were not well visualized innormal fluoroscopy and transpedicular needle implantation was achieved with a combined C-arm cone beam CT acquisition(CBCT), known as XperCT, and fluoroscopic overlay guidance, namely XperGuide.

Delayed but Complete Response following Oral Temozolomide Treatment in Melanoma Leptomeningeal Carcinomatosis.

Isolated leptomeningeal recurrence of melanoma is rare, occurring in 2% of patients with central nervous system involvement secondary to melanoma. The optimal treatment of leptomeningeal carcinomatosis (LMC) in melanoma has not yet been determined and remains a major challenge. We report a melanoma patient who presented with isolated LMC in the form of a new-onset weakness of the lower limbs, paresthesia of the left hand and foot, lumbago and headache. A lumbar puncture and spinal MRI confirmed LMC. The patient was treated with temozolomide 75 mg/m(2)/day on a 4 weeks on/2 weeks off schedule. After an initial transient clinical deterioration, the patient showed a complete radiological response as well as a dramatic improvement in quality of life. The encouraging clinical response reported here suggests that dose-intensified temozolomide might have significant activity in the treatment of leptomeningeal dissemination of melanoma and may be a valid treatment option for patients who have not been previously exposed to this agent. Moreover, this treatment regimen is extremely well tolerated and obviates the need for repeated intrathecal administrations of chemotherapeutic agents, which are often not well tolerated by patients who have significant co-morbidities due to their disease. As illustrated in this case, response to temozolomide may occur in a delayed manner, highlighting the importance of following temozolomide treatment long enough before determining that it is inefficient in a given patient.

Standards of practice: quality assurance guidelines for percutaneous treatments of intervertebral discs.

Percutaneous treatments are used in the therapy of small- to medium-sized hernias of intervertebral discs to reduce the intradiscal pressure in the nucleus and theoretically create space for the herniated fragment to implode inward, thus reducing pain and improving mobility and quality of life. These techniques involve the percutaneous removal of the nucleus pulposus by using a variety of chemical, thermal, or mechanical techniques and consist of removal of all or part of nucleus pulposus to induce more rapid healing of the abnormal lumbar disc. These guidelines are written to be used in quality improvement programs for assessing fluoroscopy- and/or computed tomography-guided percutaneous intervertebral disc ablative techniques.

Investigation of subcellular acidic compartments using alpha-aminophosphonate 31P nuclear magnetic resonance probes.

The 31P nuclear magnetic resonance (NMR) characteristics, toxicity, and cellular penetration of five linear or cyclic alpha-aminophosphonate highly sensitive pH probes were investigated in Dictyostelium discoideum cells and isolated rat hearts and were compared with three phosphonic acid derivatives. The line width broadening at pH approximately pK(a), which was satisfactorily modelized for all compounds, was significantly limited in biological milieu for the new markers, affording a four- to sixfold better accuracy in pH determination. Cellular uptake or washout of nontoxic concentrations (< 15 mM) of alpha-aminophosphonates occurred by rapid passive permeation, whereas standard probes required a much slower fluid-phase pinocytosis and transport processes that could ultimately lead to trapping. Using mild concentrations (< 4 mM) three alpha-aminophosphonates having 6 < pK(a) < 7 allowed an easy and simultaneous 31P NMR determination of cytosolic, acidic, and extracellular compartments in anoxic-reoxygenated or starving D. discoideum.

Percutaneous cementoplasty in multiple myeloma: a valuable adjunct for pain control and ambulation maintenance.

GOALS OF WORK: Bone pain and functional impairment are major concerns for multiple myeloma (MM) patients. The goal of this study was to better define the role of percutaneous cementoplasty (PC) in improving their quality of life. MATERIALS AND METHODS: This retrospective analysis included 28 consecutive heavily pretreated MM patients managed at our institution between 1996 and 2002. They underwent a total of 34 PC procedures for the treatment of 117 vertebrae and 2 iliac sites and were evaluated at 1 month. MAIN RESULTS: Significant pain reduction of >50% was obtained after 83% of the procedures, with a mean visual analogous score decreasing from 7.48/10 to 2.1/10 (p < 0.001). It resulted in a complete interruption of opiate analgesic consumption after 59.3% of the procedures, with a mean decrease of 70.4% in the opiate dose. Functional impairment was evaluated with the Eastern Cooperative Oncology Group (ECOG) performance status scale, with mean scores improving from 1.9 to 0.86 after the procedures (p = 0.001). There was no major complication. CONCLUSION: PC is a safe, feasible, and efficient approach for the treatment of bone pain and disability in MM patients.

Percutaneous vertebroplasty: preliminary experiences with rotational acquisitions and 3D reconstructions for therapy control.

Percutaneous vertebroplasty (PVP) is carried out under fluoroscopic control in most centers. The exclusion of implant leakage and the assessment of implant distribution might be difficult to assess based on two-dimensional radiographic projection images only. We evaluated the feasibility of performing a follow-up examination after PVP with rotational acquisitions and volumetric reconstructions in the angio suite. Twenty consecutive patients underwent standard PVP procedures under fluoroscopic control. Immediate postprocedure evaluation of the implant distribution in the angio suite (BV 3000; Philips, The Netherlands) was performed using rotational acquisitions (typical parameters for the image acquisition included a 17-cm field-of-view, 200 acquired images for a total angular range of 180 degrees ). Postprocessing of acquired volumetric datasets included multiplanar reconstruction (MPR), maximum intensity projection (MIP), and volume rendering technique (VRT) images that were displayed as two-dimensional slabs or as entire three-dimensional volumes. Image evaluation included lesion and implant assessment with special attention given to implant leakage. Findings from rotational acquisitions were compared to findings from postinterventional CT. The time to perform and to postprocess the rotational acquisitions was in all cases less then 10 min. Assessment of implant distribution after PVP using rotational image acquisition methods and volumetric reconstructions was possible in all patients. Cement distribution and potential leakage sites were visualized best on MIP images presented as slabs. From a total of 33 detected leakages with CT, 30 could be correctly detected by rotational image acquisition. Rotational image acquisitions and volumetric reconstruction methods provided a fast method to control radiographically the result of PVP in our cases.

Pelvic osteoplasty in osteolytic metastases: technical approach under fluoroscopic guidance and early clinical results.

PURPOSE: To describe a new fluoroscopically guided technique for osteoplasty (or cementoplasty) of the superior and inferior pubic rami and ischial tuberosities and to provide information about the access routes and initial results on pain management after this technique. MATERIALS AND METHODS: Twenty-three lytic metastases of the superior and inferior pubic rami and ischial tuberosities were treated in 14 consecutive patients. Percutaneous access of the bones was performed under fluoroscopy. All patients had pain refractory to radiation and narcotic therapy and were unsuitable candidates for surgery according to multidisciplinary consensus. RESULTS: Technical success was achieved in all cases. Clinically, effective pain relief was obtained in 92% of patients. One intraarticular asymptomatic minor complication and one major complication resulting from leakage near the pudendal nerve were observed. The latter was subsequently treated by radiofrequency ablation. CONCLUSION: Pelvic osteoplasty appears to be a safe and highly effective palliative therapy for painful osteolytic malignant bone metastases.

Percutaneous vertebroplasty in octogenarians: results and follow-up.

OBJECTIVES: To determine pain relief, performance status, morbidity, and mortality associated with percutaneous vertebroplasty for spinal pain in patients aged 80 years and older. DESIGN: Prospective, descriptive, third-party independent interview, clinical audit. SETTING: University Hospital, Geneva, Switzerland. PARTICIPANTS: Patients aged 80 years and older who underwent vertebroplasty between August 1997 and August 2004 because of vertebral fractures from osteoporotic or malignant etiologies. METHODS: Primary outcome measures were verbal rating scale (VRS) (0--no pain, 5--intolerable) and Eastern Cooperative Oncology Group (ECOG) performance status scale (0--normal activity, 4--unable to get out of bed) before and after procedure. Patients were interviewed 8 to 35 months post treatment (mean 25), independently assessed for pain relief, analgesic consumption, and overall satisfaction by using the American Society of Anesthesiologists (ASA) Outcome Measures questionnaire. RESULTS: Mean VRS scores significantly decreased from 4.86 +/- 0.64 to 2.39 +/- 1.14 (P < 0.05), and mean ECOG performance scores improved from 1.87 +/- 0.97 to 1.29 +/- 1.06 (P < 0.05) after treatment. When patients were analyzed by etiology (group 1--cancer; group 2--osteoporosis), both groups significantly reduced their VRS (P < 0.05); however, only group I significantly improved their performance (P < 0.05; P = 0.334, respectively). Nine patients answered the ASA questionnaire (18 deceased, 1 demented, 1 lost to follow-up) and reported an improvement in their ability to perform daily tasks. No early or late complications were observed; none of the deaths were procedure-related. CONCLUSIONS: Percutaneous vertebroplasty is a safe, minimally invasive, well-tolerated analgesic procedure among octogenarians suffering from spinal pain, permitting increased activities of daily living. Pain reduction is significant regardless of the etiology; performance scores are significantly improved in cancer pain.

Percutaneous vertebroplasty through a transdiscal access route after lumbar transpedicular instrumentation.

BACKGROUND CONTEXT: Transpedicular vertebroplasty is an effective procedure to reduce pain and stabilize osteoporotic vertebral fractures. It is, however, difficult to perform after transpedicular instrumentation because the pedicle screws are in the way. PURPOSE: To determine if vertebroplasty can be performed in patients who have previously undergone osteosynthesis pedicle-screw fixation. STUDY DESIGN: We postulate that an alternate transdiscal route can be used in cases with instrumentation in order to successfully perform vertebroplasty. METHODS: We report the case of a 73-year-old male patient presenting with a fresh osteoporotic fracture of L2 and L3 6 weeks after having undergone a dorsal operative stabilization between L3 and L5. RESULTS: Vertebroplasty was performed using a transdiscal descending approach to treat the two adjacent vertebral levels. The patient reported a 50% decrease in pain and was able to walk with a stick at 3 months. At late follow-up at 18 months his walking had further improved and he experienced only sporadic lumbar pain. CONCLUSIONS: Vertebroplasty can be performed in patients having previously undergone transpedicular instrumentation. The transdiscal route represents such a new approach.

Combined use of electrolytically and mechanically detachable platinum coils for endovascular treatment of cerebral aneurysms--technical note.

The combined use of Guglielmi detachable coils (GDCs) and newly developed mechanically detachable platinum coils (Detach Coil System: DCS) was evaluated for the endovascular treatment of 10 patients with cerebral aneurysms. The number and total length of detachable coils placed into the aneurysms, the detaching time for each coil, and any technical problems were recorded and evaluated. Sixty GDCs and 60 DCSs were used. The detachment time for the DCS (mean 21 seconds) was faster than that for the GDC (mean 2 minutes 35 seconds). One DCS moved inside the aneurysm during the mechanical detachment maneuver, but was successfully placed. Neither detachment system influenced the behavior of the other system during coil implantation. The DCS includes a useful J-shape coil, whereas the GDC can be detached safely in fragile aneurysms. The DCS is also cheaper. The coil systems complemented one another and the combination optimized cost and operating time.

Conformity of carotid stents with vascular anatomy: evaluation in carotid models.

BACKGROUND AND PURPOSE: Conformity between self-expanding Wallstents and vascular anatomy is limited. Because of a lack of longitudinal flexibility, straightening effects on vascular curves occur and may result in stent-induced kinking. Our purpose was to evaluate the conformity of self-expanding stents with the course and endoluminal surface of silicone models of the normal human carotid artery. METHODS: Five different types of self-expanding carotid stents were implanted into simplified pulsatile perfused silicone models of the carotid bifurcation. The models embody elastic properties of the vessel wall similar to those of normal human arteries. All stents had the same nominal diameter and length and bridged the external carotid artery origin as well as a consecutive curve at the initial segment of the internal carotid artery. Conventional radiographs of the model were compared before and after stent placement to record changes of shape and course of the silicone artery. Dehiscences between stent filaments and arterial wall were measured on digital subtraction angiograms of the model. RESULTS: Implantation of braided Wallstents or the Expander with continuous filaments induced considerable straightening effects on the bifurcation angle, as well as on the curves of the internal carotid artery. Segmented designs of modular nitinol stents complied better with vascular tortuosity and showed improved adaption between stent and the endoluminal surface of the model. CONCLUSION: Model experiments show that segmented nitinol stents improve the conformity between the prosthesis and vascular anatomy, and confirm new carotid stent concepts as an alternative to the Wallstent.

Percutaneous vertebroplasty in metastatic disease: transpedicular access and treatment of lysed pedicles--initial experience.

For the treatment of lytic disease involving the pedicles of vertebrae in patients with metastatic disease, the authors performed percutaneous vertebroplasty by using an access route via the lysed pedicle. Fifty-one pedicles were treated in 32 consecutive patients. In all cases, a radiologically satisfactory filling of both the affected pedicle and the vertebral body was achieved. Clinically effective pain relief was obtained in 24 (75%) of 32 patients, and no clinical complications were observed.

Transarterial approach for selective intravenous coil embolization of a benign dural arteriovenous fistula. Case report.

Transarterial particulate embolization is indicated for benign intracranial dural arteriovenous fistulas (DAVFs) that have no dangerous venous reflux. This treatment, however, does not cure these lesions. In this case report the authors describe a spontaneously occurring DAVF that was treated by implanting coils through a transarterial microcatheter into the affected venous channel. The channel was separate from the normal dural sinuses. The pathological architecture of the fistula and the usefulness of this approach are discussed.

Radicular pain after vertebroplasty: compression or irritation of the nerve root? Initial experience with the "cooling system".

STUDY DESIGN: During vertebroplasty (VP), polymethylmethacrylate (PMMA) may leak into the posterior epidural venus plexus, provoking symptoms ranging from radicular pain to medullar compression. OBJECTIVES: To propose and test the feasibility of a procedure (cooling system) to prevent radicular irritation caused by foraminal PMMA leakage. SUMMARY OF BACKGROUND DATA: Foraminal leak of PMMA, as observed during VP, may lead to radiculalgia. Several mechanisms of nerve root irritation have been proposed. Considering heat or local chemical irritation has led us to treat immediately by local periradicular irrigation with a cooling liquid. METHODS: Four consecutive patients with observed foraminal leakage were treated by local fluid injection. Immediately after observation of a foraminal leak, a 20-gauge Chiba needle was positioned to reach the foramen. Ten cubic centimeters of lidocaine (0.2%) was followed by 100-200 cc of pressurized saline perfusion within 10-20 minutes (cooling system). RESULTS: In all patients with foraminal leakage, no radicular pain existed after application of the cooling system. No complications were observed with its use. CONCLUSION: In presence of a foraminal leakage, the immediate application of a cooling irrigation may protect the root from injury, which is explained by the hypothesis that the main mechanism of injury may be more related to heat or chemical irritation of the nerve than compression.

Cervical sympathetic block to reverse delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The purpose of the present study was to evaluate the feasibility and safety of a locoregional cervical sympathetic block to improve cerebral perfusion in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage. METHODS: Nine consecutive patients with symptoms of delayed ischemic deficits, induced by angiographically confirmed cerebral vasospasm, were treated with the injection of locoregional anesthesia to block the ascending cervical sympathetic chain at the level of the superior cervical ganglion. Neurological status was recorded before and after the procedure, and cerebral angiography was performed before and after the procedure. RESULTS: No complications occurred in this short series. The procedure appeared to be simple and safe. Horner's signs appeared within 12+/-0.1 minutes and lasted for an average of 6.3+/-4 hours. In all patients, improved cerebral perfusion was detected at the confirmatory angiography but without change in vessel caliber. One patient died of the complications of the initial hemorrhage, and 2 died of the consequences of the severe vasospasm despite maximal medical treatment. In all the other cases, the neurological status promptly returned to normal within 48 hours after the locoregional treatment. CONCLUSIONS: Patients with mild to moderate symptoms seem to benefit greatly from transient ipsilateral cervical sympathetic block. This simple technique may be helpful when used as an adjunct to the standard therapy to improve cerebral perfusion.

Artificial cerebral aneurysm model for medical testing, training, and research.

Artificial models of cerebral aneurysms for medical training and testing of medical devices were constructed from corrosion casts of the main cerebral arteries of a human specimen. Three aneurysms with a variety of shapes were simulated at typical locations. Rigid and soft models were made of silicone using the "lost wax" technique. The transparent silicone models were anatomically accurate and reproducible copies of human vascular casts. These models could be connected in a closed circuit that used an electric pump to simulate pulsatile flow. Endovascular procedures and surgical clip application were performed under fluoroscopic or direct visual control. Surgical clipping, endoluminal coil manipulation, and consecutive hemodynamic changes were visualized by digital subtraction angiography and direct observation. The model provides trainee surgeons with an understanding of clinical conditions. New medical devices, such as platinum coils, would be experimentally implanted in the model under stable conditions. These anatomically accurate and reproducible models of cerebral vasculature and aneurysms are valuable for medical testing, training, and research.