Percutaneous vertebroplasty with acrylic cement in the treatment of a Langerhans cell vertebral histiocytosis

Benign Bone Tumors Beyond Osteoid Osteoma: Percutaneous Minimally Invasive Image-Guided Interventions

Painful benign bone tumors often adversely influence quality of life primarily due to skeletal-related events such as unremittable pain, pathologic fracture, neurologic deficit, as well as skeletal growth disturbance. Substantial advances in percutaneous minimally invasive interventions for treatment of painful benign bone tumors beyond osteoid osteoma have been established as safe, efficacious, and durable treatments to achieve definitive cure. This article details the available armamentarium and most recent advances in minimally invasive percutaneous interventions and the role of radiologists for the management of patients with benign bone tumors beyond osteoid osteoma.

Spinal Langerhans cell histiocytosis with cord compression and neurological deficits: A case report

INTRODUCTION AND IMPORTANCE

Langerhans cell histiocytosis (LCH) is a rare idiopathic disease that uncommonly affect the spine in adults.

CASE PRESENTATION

In this report, we presented a rare adult case of symptomatic spinal LCH with asymptomatic systemic involvement. She was a 46-year-old previously healthy lady who presented with subacute thoracic sensory level, urine retention, constipation, and pyramidal paraplegia. Her magnetic resonance imaging (MRI) of the spine revealed T6 compression fracture with an epidural mass compressing the cord.

CLINICAL DISCUSSION

Sellar MRI showed pituitary gland enlargement with hyperintense signal in the posterior lobe. Positron emission tomography (PET)/computed tomography (CT) scan showed an increased uptake in the right parotid gland uptake and renal cortex, indicating systemic involvement.

CONCLUSION

Surgical excision, decompression, and screw fixation were performed, and the patient improved. The prognosis is usually good in patients with solitary spinal LCH.

Benign Bone Tumors: State of the Art in Minimally Invasive Percutaneous Interventions

Painful benign bone tumors most commonly affect pediatric patients and young adults. They may be associated with skeletal-related events such as intractable pain, pathologic fracture, neurologic deficit as a consequence of nerve or spinal cord compression, as well as growth disturbance. Consequently, they often result in diminished activity and adversely affect quality of life. There have been substantial recent advances in percutaneous minimally invasive image-guided interventions for treatment of painful benign bone tumors including thermal ablation (radiofrequency ablation, cryoablation, microwave ablation, laser photocoagulation, and high-intensity focused US ablation), chemical (alcohol) ablation, cementoplasty, and intralesional injections. The safety, efficacy, and durability of such interventions have been established in the recent literature and as such, the role of musculoskeletal interventional radiologists in the care of patients with benign bone lesions has substantially expanded. The treatment goal of minimally invasive musculoskeletal interventions in patients with benign bone tumors is to achieve definitive cure. The authors detail the most recent advances and available armamentarium in minimally invasive image-guided percutaneous interventions with curative intent for the management of benign bone tumors. ^© RSNA, 2022.

Benign Spine Lesions: Advances in Techniques for Minimally Invasive Percutaneous Treatment

Minimally invasive percutaneous imaging-guided techniques have been shown to be safe and effective for the treatment of benign tumors of the spine. Techniques available include a variety of tumor ablation technologies, including radiofrequency ablation, cryoablation, microwave ablation, alcohol ablation, and laser photocoagulation. Vertebral augmentation may be performed after ablation as part of the same procedure for fracture stabilization or prevention. Typically, the treatment goal in benign spine lesions is definitive cure. Painful benign spine lesions commonly encountered in daily practice include osteoid osteoma, osteoblastoma, vertebral hemangioma, aneurysmal bone cyst, Paget disease, and subacute/chronic Schmorl node. This review discusses the most recent advancement and use of minimally invasive percutaneous therapeutic options for the management of benign spine lesions.

[Vertebroplasty--state of the art]

BACKGROUND

Percutaneous vertebroplasty (PVP) using PMMA (polymethyl methacrylate) was first described in 1987 by Gallibert and Deramond for the treatment of vertebral body instability in patients with aggressive forms of vertebral hemangioma. Other types of painful osteolytic bone lesions, such as osteoporotic vertebral fractures and vertebral metastasis are in the meantime more commonly treated using this method.

METHODICAL INNOVATIONS

Within the last few years, this technique has become widely accepted and it is proposed for osteolytic bone lesions in areas that are more difficult to approach surgically, e.g., the pelvis and sacrum.

EFFICACY

Rapid pain relief and resulting stability have conferred an important role upon osteoplasty especially in palliative tumor-treatment for patients with shortened expected life spans. In addition, combined treatment of painful osteolytic metastases with image-guided thermoablation and percutaneous cement injection has been shown to be a safe palliative modality in the therapy of nonresectable tumors.

Eosinophilic granuloma of the sacrum treated with radiation therapy: a case report

BACKGROUND CONTEXT

Eosinophilic granulomas (EGs) of the sacrum have been reported in fewer than 10 patients. Treatment algorithms for these tumors remain poorly defined; there are no reports of treating solitary sacral EG with radiation therapy (RT).

PURPOSE

This study aimed to describe the presentation, treatment, and outcome of sacral EG in an adult patient with intractable pain and radiculopathy, treated in a novel fashion with RT.

STUDY DESIGN/SETTING

The study design was a case report from a tertiary cancer referral center.

METHODS

Patient records, imaging, and pathology were reviewed.

RESULTS

A 35-year-old man received 20 Gy of radiation to his S1 EG lesion. He subsequently developed vertebra plana of S1 causing symptomatic L5-S1 stenosis, but 15 months after RT treatment was free of pain or tumor recurrence.

CONCLUSION

Radiation therapy is an effective treatment option for sacral EG causing severe axial pain and neural impingement.

Vertebroplasty

Percutaneous vertebroplasty has become widely accepted as a safe and effective minimally invasive procedure for the treatment of painful vertebral body compression fractures refractory to medical therapy. In this article, the authors review the indications and contraindications for vertebroplasty, principles of appropriate patient selection, useful techniques to achieve optimal outcomes, and the potential risks and complications of the procedure.

Percutaneous vertebroplasty for Langerhans cell histiocytosis of the lumbar spine in an adult: Case report and review of the literature

Langerhans cell histiocytosis (LCH) is extremely rare in the lumbar spine of adults. The radiological features typically manifest as vertebral tumors. The exact etiology of LCH remains unknown. Langerhans cells may cause local or systemic effects. The most frequent sites of these bony lesions are the skull, femur, mandible, pelvis and spine. To date, only 3 spinal LCH cases treated by percutaneous vertebroplasty (PVP) have been reported. The present study reports a case of LCH of the fourth lumbar vertebra (L4) in a 51-year-old male with a 10-day history of low back pain, limited waist motion and right lower limb numbness. The patient was treated using PVP. The use of PVP for treating LCH of the spine was successful. The present study provides an up-to-date literature overview of LCH.

Percutaneous cementoplasty

Cementoplasty includes percutaneous procedures like vertebroplasty, kyphoplasty, osteoplasty, and sacroplasty. Bone packing with cement aims to treat or prevent vertebral and extraspinal pathological fractures and relieve pain in patients with osteoporosis and bone metastases. The authors outline the accepted and newer indications for patient selection and present the fundamentals of image-guided lesion access and cement injection. Practitioners should evaluate each patient carefully and have a thorough knowledge of the anatomy, the technique, the expected outcomes, and the potential complications. Detailed informed consent and multidisciplinary decision making are recommended. Understanding of the particular advantages and limitations of the various modern filler materials is also crucial for a successful and uncomplicated procedure. Future developments include new mechanical devices for effective restoration of vertebral height, as well as the introduction of osteoconductive and osteoinductive cements that will be able to promote more physiological bone healing.

Safety and feasibility of percutaneous vertebroplasty with radioactive (153)Sm PMMA in an animal model

PURPOSE

We investigated the safety and feasibility of the combination of samarium-153-ethylenediamine tetramethylene phosphonate ((153)Sm-EDTMP)-incorporated bone cement (BC) with percutaneous vertebroplasty (PVP) in dogs.

METHODS AND MATERIALS

(153)Sm-EDTMP-incorporated BC was prepared by combining solid (153)Sm-EDTMP and polymethylmethacrylate (PMMA) immediately before PVP. It was then injected into the vertebrae of four healthy mongrel dogs (two males and two females) by PVP under CT guidance. Each dog was subjected to five PVP sessions at a (153)Sm-EDTMP dose of 30-70 mCi. The suppressive effect of local injection of (153)Sm-EDTMP on the hematopoietic system was evaluated through counting of peripheral blood cells. Distribution of (153)Sm-EDTMP-incorporated BC and the status of tissues adjacent to injected vertebrae were evaluated with SPECT, CT and MRI. Histopathology was carried out to assess the influence of PVP on the vertebra and adjacent tissues at the microscopic level.

RESULTS

PVP was done successfully, and all dogs exhibited normal behavior and stable physical signs after procedures. (153)Sm-EDTMP-incorporated BC was concentrated mainly in target vertebrae, and the peripheral blood cells remained within normal range. The spinal cord and tissues around BC did not exhibit signs of injury even when the dosage of (153)Sm-EDTMP increased from 30 mCi to 70 mCi.

CONCLUSION

A dose lower than 70 mCi of (153)Sm is safe when it was injected into vertebrae. (153)Sm-EDTMP-incorporated BC did not influence the effect of PVP. This means might strengthen anti-tumor activity locally for vertebra with osseous metastasis without damaging adjacent tissues.

Percutaneous vertebroplasty for eosinophilic granuloma of the cervical spine in a child

We report a case of eosinophilic granuloma at the fourth cervical vertebra in a 10-year-old girl presenting with a 1-month history of cervical pain and stiffness. This lesion was histologically diagnosed by needle biopsy and then treated by percutaneous vertebroplasty. After the procedure, the cervical pain and stiffness resolved rapidly. The height of the vertebral body remained stable without further collapse over a 6-month follow-up period.

Current concepts and techniques in percutaneous vertebroplasty

Percutaneous vertebroplasty is a safe and effective alternative for the treatment of many different types of painful vertebral lesions, including osteoporotic compression fractures,hemangiomas, or malignancy-induced pathologic vertebral fractures. Medical therapy often is limited to pain control and immobilization. Because surgery is contraindicated frequently in patients who have osteoporotic compression fractures, and because patients who have widespread metastatic disease often are not surgical candidates, vertebroplasty may be the only practical option. In experienced hands and with appropriately selected patients, percutaneous vertebroplasty is a safe, inexpensive, and highly efficacious procedure; however, because of the potential for devastating complications, all efforts must be made to optimize patient safety.

Kyphoplasty versus vertebroplasty to increase vertebral body height: a cadaveric study

PURPOSE

To prospectively compare the vertebral height restoration achieved with kyphoplasty and vertebroplasty in fresh cadavers by using multi-detector row computed tomography (CT).

MATERIALS AND METHODS

Institutional review board approval was not required because the donors had registered in and consented to an anatomic gift program prior to their death. Thirty-seven vertebrae were harvested from four donated cadavers of elderly female individuals (mean age, 82 years; age range at death, 73-87 years). The vertebrae were dissected free of the surrounding muscles and imaged with multi-detector row CT. Compression fractures were induced, and the vertebrae were again imaged. The vertebrae were randomized to be treated with kyphoplasty (n = 19) or vertebroplasty (n = 18) and were then imaged at multi-detector row CT. The anterior, central, and posterior vertebral body heights and wedge angles were measured in the midsagittal plane of the reformatted images. The amount of cement injected was determined by weighing the vertebrae before and after treatment. The statistical significance of changes in vertebral body height, wedge angle, and weight with the two treatment techniques was evaluated with the independent t test or Mann-Whitney U test.

RESULTS

The increase in vertebral height was greater with kyphoplasty than with vertebroplasty (5.1 mm vs 2.3 mm, respectively; P < .05). The original vertebral height was restored in 93% of vertebrae with kyphoplasty and in 82% with vertebroplasty (P < .05). There was a greater decrease in wedge angle with kyphoplasty than with vertebroplasty (3.1 degrees vs 1.6 degrees, respectively); however, this difference was not significant (P > .05). There was no significant difference in the amount of cement injected with kyphoplasty and vertebroplasty (P > .05).

CONCLUSION

Kyphoplasty increased vertebral body height more than vertebroplasty in this model of acutely created fractures in fresh cadaver specimens.

Percutaneous vertebroplasty: An update

Percutaneous vertebroplasty is an imaging-guided interventional technique in which surgical polymethylmethacrylate is injected via a large bore needle into a painful compressed vertebral body. This technique is safe and effective, and provides increased strength and pain relief in vertebrae weakened by bone diseases. Among the current indications for vertebroplasty are intractable nonradicular pain caused by compression fractures due to osteoporosis, myeloma, metastasis, and aggressive vertebral hemangioma. Contraindications include bleeding disorder, unstable fracture, and lack of definable vertebral collapse. The preprocedural evaluation, technique, complications, and expected results of performing this procedure are also reviewed.

Percutaneous vertebroplasty: history, technique and current perspectives

Percutaneous vertebroplasty is a safe and efficacious technique for the treatment of persistent pain from a fractured vertebral body. Injection of cement into the vertebral body is made after insertion of a large-bore needle, frequently by a trans-pedicular approach. Vertebroplasty is most commonly used to treat painful osteoporotic fracture resistant to conservative therapy, but may be helpful in other conditions such as malignant collapse. NICE guidelines are now available for this procedure, which is relatively new in the UK, but has been performed for more than 15 years in continental Europe.

[Percutaneous vertebroplasty (pv): indications, contraindications, and technique]

PURPOSE

Percutaneous vertebroplasty (pv) is a worldwide increasingly performed interventional therapeutic procedure. This article addresses indications, patient preparation, technical requirements and approach as well as possible complications of percutaneous vertebroplasty.

TECHNIQUE

Percutaneous vertebroplasty is a technique consisting in an injection of bone cement into a vertebral body under imaging guidance. This procedure is performed to relief pain and support the mechanical stability in partially collapsed vertebral bodies.

RESULTS

In the management of spinal compression fractures secondary to osteoporosis, myeloma, osteolytic metastases and aggressive hemangiomas, percutaneous vertebroplasty yields analgesic effect, and provides additional fortification in weakened segments of the vertebral column. Contraindications include major bleeding disorders, radicular pain and pain caused by compression of the myelon.

DISCUSSION

Percutaneous vertebroplasty results in prompt pain relief and rapid rehabilitation. In experienced hands, using correct technique, pv is a safe and effective procedure for treating pain, caused either by osteoporotic or malignant vertebral compression fractures.

Optimizing patient selection in percutaneous vertebroplasty

Percutaneous vertebroplasty has emerged as an effective technique for treatment of painful vertebral compression fractures (VCFs) caused by osteoporosis, malignancy, and some benign bone tumors. In selecting appropriate patients for vertebroplasty, it is important to distinguish the pain caused by VCF from other numerous causes of back pain. Careful adherence to clinical and imaging selection criteria is crucial to procedural success.

Kyphoplasty in the treatment of osteolytic vertebral compression fractures as a result of multiple myeloma

PURPOSE

We prospectively evaluated the safety and efficacy of kyphoplasty in the treatment of osteolytic vertebral compression fractures resulting from multiple myeloma. The principle symptoms in multiple myeloma result from bone destruction, especially the spine. Kyphoplasty is a new technique that involves the introduction of inflatable bone tamps (IBT) into the vertebral body. The purpose of the IBT is to restore the vertebral body back toward its original height, while creating a cavity that can be filled with highly viscous bone cement.

PATIENTS AND METHODS

Fifty-five consecutive kyphoplasty procedures were performed in 18 patients with osteolytic vertebral compression fractures resulting from multiple myeloma. Cement leakage and any complications were recorded. Early objective analysis was made by comparing preoperative and latest Short Form 36 Health Survey scores. Height restoration was estimated by measuring vertebral height on lateral radiographs.

RESULTS

The mean age of patients was 63.5 years, mean duration of symptoms was 11 months, and mean follow-up was 7.4 months. There were no major complications related directly to use of this technique. On average, 34% of height lost at the time of fracture was restored. Asymptomatic cement leakage occurred at two (4%) of 55 levels. Significant improvement in SF36 scores occurred for Bodily Pain (23.2 to 55.4, P =.0008), Physical Function (21.3 to 50.6, P =.0010), Vitality (31.3 to 47.5, P =.010), and Social Functioning (40.6 to 64.8, P =.014).

CONCLUSION

Kyphoplasty was efficacious in the treatment of osteolytic vertebral compression fractures resulting from multiple myeloma. Kyphoplasty is associated with early clinical improvement of pain and function as well as some restoration of vertebral body height.

Minimally invasive options for the treatment of osteoporotic vertebral compression fractures

The recent introduction of vertebroplasty and kyphoplasty provide minimally invasive methods to alleviate symptoms from vertebral fractures. While both methods are successful in addressing fracture related pain, only the kyphoplasty can partially restore structural alignment and height.

Percutaneous Transpedicular Polymethylmethacrylate Vertebroplasty for the Treatment of Spinal Compression Fractures

OBJECTIVE

To assess the safety, feasibility, and clinical outcome of percutaneous transpedicular polymethylmethacrylate vertebroplasty (PTPV) for the treatment of spinal compression fractures causing refractory pain.

METHODS

We retrospectively reviewed a consecutive group of patients undergoing PTPV at our institution between April 1998 and January 2001. Outcome measures included analgesic requirements, ambulatory status, sleep comfort, and overall quality of life 2 weeks after the procedure.

RESULTS

A total of 97 patients (73 women and 24 men) underwent 258 PTPV procedures during 133 treatment sessions. The mean age was 76 years (range, 42–99 yr). The mean duration of follow-up was 14.7 months (range, 2–35 mo). Most of the patients had osteoporotic compression fractures, although some had osteolytic malignancies. Complete follow-up was obtained in 81 patients (84%). Narcotic and analgesic usage decreased in 63% of patients, increased in 7%, and remained the same in 30%. Ambulation and mobility were improved in 51%, worse in 1% and the same in 48%. One-half of the patients were able to sleep more comfortably after the procedure, whereas the other half remained the same. Most patients who reported no change in sleep or ambulation had experienced no impairment of these activities before PTPV. Overall, 74% of patients believed that PTPV significantly enhanced their quality of life and 26% reported no change. No patient was worse after PTPV. One patient with preexisting pneumonia died of respiratory failure after the procedure; another died of an acute stroke weeks later. One patient developed symptomatic pulmonary embolism of cement, and another developed transient quadriceps weakness from radiculopathy. Other complications were minor and infrequent. There were no infections.

CONCLUSION

PTPV provided significant relief in a high percentage of patients with refractory pain. PTPV is a safe and feasible treatment for patients with spinal compression fractures.

Pathology findings with acrylic implants

We report the pathological findings in cases of acrylic implants obtained by direct intratumoral injection of polymethyl-methacrylate (PMMA) and N-butyl-cyano-acrylate (NBCA). Direct intratumoral injection of acrylic implants was performed for a variety of primary and secondary bone lesions. These types of treatments have been used at our institution in the last 4 years for 40 vertebroplasty (PMMA) procedures and for nine bone lesions of other locations (PMMA, NBCA). Postmortem histology became available for 1 case of PMMA and for 5 cases with NBCA intratumoral acrylic implants. The pathological findings associated with PMMA and NBCA were evaluated and compared. PMMA exhibited a macroscopic and microscopic rim of tumor necrosis, 6 months after implantation. NBCA exhibited compressive effects on the nearby tumor tissue, however, without signs of significant necrosis outside the acrylic tumor cast. Tumor captured inside the acrylic cast showed extensive to near complete necrosis. Acrylic implants may lead to necrosis when injected directly in tumors. The necrotizing effect may extend beyond the limits of an implant in the case of PMMA. Such an extended effect of PMMA, when compared with NBCA, may be due to the variable toxicity of acrylic implants, including the different degrees of the exothermic reaction during polymerization.

Future directions. Augmentation of osteoporotic vertebral bodies

Because current medical and surgical treatments of vertebral body fractures are less than adequate, there is a need for interventions that decrease the likelihood of occurrence of these fractures and improve the treatment options once they have occurred. One such broad category of intervention involves the fortification or augmentation of the vertebral bodies. In addition to prophylactically stabilizing osteoporotic vertebral bodies at risk for fracture, augmentation of vertebral bodies that have already fractured may prove to be useful by reducing pain, improving function, and preventing further collapse and deformity. Vertebral body augmentation can also be used as an adjunct to fixation of internal hardware--for example, pedicle screws-in osteoporotic spines. A number of products are now available or are in clinical trials. The most promising products are injectable materials-polymethylmethacrylate or mineral bone cement. The early clinical results using polymethylmethacrylate in percutaneous vertebroplasty for fractured vertebral bodies and the results in vitro using an injectable mineral cement for vertebral body fortification are encouraging. Although the principle of vertebral body augmentation remains encouraging, data to support the widespread use of these techniques remain sparse, and the indications for their use should be more clearly defined.