Percutaneous Sacroplasty with or without Radiofrequency Ablation for Treatment of Painful Sacral Metastases

Radiofrequency sacroplasty as a pain treatment for symptomatic sacral destruction due to prostate metastasis: a case report and a review of the literature

In progressive malignant diseases such as prostate cancer, metastatic bone destruction is a frequent cause of chronic, debilitating pain. Pathological fractures of the sacrum can lead to complete immobility in patients. Cement augmentation of the sacrum has proven effective in treating sacral insufficiency fractures, resulting in significant pain reduction and improved mobility. In recent years, this technique has also been applied to pathological fractures of the sacrum. We present a case of successful treatment of prostate cancer-induced sacral bone infiltration and destruction using advanced radiofrequency sacroplasty. Literature reports describe individual cases of sacral bone destruction, where cement augmentation using various methods has led to substantial pain relief and improved overall outcomes.

Sacroplasty with or without screw fixation for sacral metastatic tumors

Introduction

Cementation (sacroplasty) with or without ablation has been shown to improve pain and function for patients with sacral metastatic disease. Percutaneous screw fixation with sacroplasty (PSFS) may provide superior outcomes in select patients.

Methods

Thirty patients with sacral metastases who underwent sacroplasty with or without ablation and screw fixation at a single institution were retrospectively reviewed. Patients were compared based on treatment (PSFS or sacroplasty alone) and fracture status (pathological or impending) with an ANCOVA. Traumatic fractures were excluded. Patients were followed for 4.4 months on average (range, 2 weeks to 36.5 months). Functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score. The rate of secondary procedures as well as changes in narcotic usage were noted.

Results

Patients with pathological fractures who underwent PSFS demonstrated increased postoperative MSTS scores compared to those who underwent sacroplasty (51% ± 19 versus 25% ± 13, p = 0.005). Patients with impending pathological fractures who underwent PSFS did not demonstrate statistically significant increased postoperative MSTS scores compared to those who underwent sacroplasty alone (38% ± 17 versus 32% ± 12, p = 0.72).

Discussion

PSFS may provide additional benefit for patients with pathological fractures, while sacroplasty alone may be sufficient for those with impending pathologic fractures secondary to sacral metastatic disease. This study was limited by its retrospective design and sample size; however, the results may aid in treatment indications for sacral metastases and guide further research Level of Evidence Level III, Therapeutic Study.

Perfecting the pour: A novel co-axial technique with sequential injections for optimising cement delivery during sacroplasty

BACKGROUND

Percutaneous sacroplasty is an effective treatment for painful sacral fractures and tumours, however there is no accepted optimal technique for performing this procedure. This study investigated a novel approach to sacroplasty combining co-axial sacral access, sequential cement injections and hypothermic cement manipulation to improve cement delivery.

METHODS

This retrospective study analysed 11 patients who underwent co-axial sacroplasty between April 2023 and March 2024 for treatment of painful insufficiency fractures (n = 5) or malignant sacral tumours (n = 6). All cases were performed using biplane fluoroscopy with conebeam CT navigation for planning and monitoring percutaneous access. Procedural details, technical outcomes, and clinical outcomes including Numerical Rating Scale (NRS) pain and analgesic utilisation on a six-point scale were analysed pre-procedure and at follow-up.

RESULTS

Technical success of was achieved in all cases using this technique. The mean injected cement volume was 20.5 ± 6.4 ml. Median pre-procedural NRS pain scores of 8 (IQR 7.25-8) significantly decreased to 0 (IQR, 0-0.25) at follow-up (p <.01). The median preprocedural analgesic utilisation score reduced from 3 (IQR, 2-3) to 0 (IQR, 0-2.5) at follow-up (p <.01). Cement leakage occurred during two cases without associated adverse clinical sequelae. There were no major adverse events.

CONCLUSION

Co-axial sequential injection sacroplasty is a safe and effective technique which allows facilitates controlled delivery of cement. Improved control of cement delivery, including around high-risk structures for cement leakage, offers a potential safety advantage over conventional sacroplasty techniques. Further research comparing technical and clinical outcomes to conventional techniques is warranted.

Exploring the Efficacy of Combining Radiofrequency Thermal Ablation or Microwave Ablation with Vertebroplasty for Pain Control and Disease Management in Metastatic Bone Disease-A Systematic Review

BACKGROUND

Interventional radiology techniques have become pivotal in recent years in managing metastatic bone disease, which frequently results in skeletal complications such as fractures and severe pain. Thermoablative methods like radiofrequency ablation (RFA) and microwave ablation (MWA), when combined with vertebroplasty (VP), are proving increasingly beneficial for these patients.

METHODS

The search was independently conducted by two radiologists on MEDLINE databases, using specified strings up to April 2024. Methodological quality was assessed using PRISMA guidelines. Studies meeting inclusion criteria investigated thermoablation techniques (RFA and/or MWA) combined with VP, focusing on pain management and disease control outcomes in adults.

RESULTS

Among 147 results, 42 articles met the criteria, with varied prospective and retrospective designs and sample sizes averaging 49 patients, predominantly involving RFA (30 studies), MWA (11 studies), and one comparative study. Our review highlights significant pain reduction, effective local tumor control, and favorable safety of combined RFA or MWA with VP, supporting its potential in managing vertebral pathologies and warranting further clinical integration.

CONCLUSIONS

The combined treatment of RFA/MWA with VP demonstrates significant pain reduction and local tumor control, with a rapid onset of analgesic effect. These findings support its crucial role in clinical practice for managing vertebral metastases.

Analgesic efficacy and safety of percutaneous thermal ablation plus cementoplasty for painful bone metastases: a systematic review and meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis of publications to evaluate the analgesic efficacy and safety of percutaneous thermal ablation (PTA) plus percutaneous cementoplasty (PCP) (PTA + PCP) for painful bone metastases.

METHODS

We searched PubMed, Cochrane Library and Embase for articles published up to October 2022. Outcomes were a 10-point pain scale, morphine equivalents daily dose (MEDD) and complications. A subgroup confined to spinal bone metastases was analyzed.

RESULTS

Twenty-one articles were selected for the analysis. The 21 selected articles involved a total of 661 cases. The pooled pain scales at pre-PTA + PCP, 1 day, 1 week and 1-, 3-, and 6 months post-PTA + PCP were 7.60 (95% confidence interval [CI], 7.26-7.95, I2 = 89%), 3.30 (95% CI, 2.25-4.82, I2 = 98%), 2.58 (95% CI, 1.99-3.35, I2 = 94%), 2.02 (95% CI, 1.50-2.71, I2 = 93%), 1.78 (95% CI, 1.26-2.53, I2 = 95%), and 1.62 (95% CI, 1.14-2.31, I2 = 88%), and in the subgroup, 7.97 (95% CI, 7.45-8.52, I2 = 86%), 3.01 (95% CI, 1.43-6.33, I2 = 98%), 2.95 (95% CI, 1.93-4.51, I2 = 95%), 2.34 (95% CI, 1.82-3.01, I2 = 68%), 2.18 (95% CI, 1.57-3.03, I2 = 78%), and 2.01 (95% CI, 1.16-3.48, I2 = 86%). Mean MEDD decreased up to 3 months post-PTA + PCP in 4 articles. The overall pooled major complication rate was 4% (95% CI, 2-6%, I2 = 2%).

CONCLUSIONS

The updated systematic review and meta-analysis indicates that PTA + PCP for painful bone metastases is safe, and can lead to rapid and sustained pain reduction.