Vertebroplasty and kyphoplasty: friends or foes?

Differentiation of benign versus malignant indistinguishable vertebral compression fractures by different machine learning with MRI-based radiomic features

OBJECTIVES

To explore an optimal machine learning (ML) model trained on MRI-based radiomic features to differentiate benign from malignant indistinguishable vertebral compression fractures (VCFs).

METHODS

This retrospective study included patients within 6 weeks of back pain (non-traumatic) who underwent MRI and were diagnosed with benign and malignant indistinguishable VCFs. The two cohorts were retrospectively recruited from the Affiliated Hospital of Qingdao University (QUH) and Qinghai Red Cross Hospital (QRCH). Three hundred seventy-six participants from QUH were divided into the training (n = 263) and validation (n = 113) cohort based on the date of MRI examination. One hundred three participants from QRCH were used to evaluate the external generalizability of our prediction models. A total of 1045 radiomic features were extracted from each region of interest (ROI) and used to establish the models. The prediction models were established based on 7 different classifiers.

RESULTS

These models showed favorable efficacy in differentiating benign from malignant indistinguishable VCFs. However, our Gaussian naïve Bayes (GNB) model attained higher AUC and accuracy (0.86, 87.61%) than the other classifiers in validation cohort. It also remains the high accuracy and sensitivity for the external test cohort.

CONCLUSIONS

Our GNB model performed better than the other models in the present study, suggesting that it may be more useful for differentiating indistinguishable benign form malignant VCFs.

KEY POINTS

• The differential diagnosis of benign and malignant indistinguishable VCFs based on MRI is rather difficult for spine surgeons or radiologists. • Our ML models facilitate the differential diagnosis of benign and malignant indistinguishable VCFs with improved diagnostic efficacy. • Our GNB model had the high accuracy and sensitivity for clinical application.

Long-term outcome of treatment of vertebral body hemangiomas with direct ethanol injection and short-segment stabilization

BACKGROUND

Vertebral body hemangiomas with myelopathy are difficult to manage.

OBJECTIVE

The objective of this study was to evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented short-segment fusion in vertebral hemangioma (VH) with myelopathy and long-term outcome (>24 months).

CLINICAL MATERIALS AND METHODS

This prospective study included symptomatic VH with cord compression with myelopathy. Pathologic fractures and deformity or multilevel pathologies were excluded from the study. Surgery consisted of intraoperative bilateral pedicular absolute alcohol (<1% hydrated ethyl alcohol) injection, laminectomy, and cord decompression at the level of pathology followed by a short-segment instrumented fusion using pedicle screws.

RESULTS

The study included 33 patients (mean 26.9±13.2, range: 10-68 years, 18 females). The clinical features of the study were myelopathy in all patients (5 paraplegic), sphincter involvement (13), and mid back or lower back pain (7). The preoperative American Spinal Injury Association (ASIA) scores were A (7), B (11), C (6), D (8), and E (1). Majority of the patients had single vertebral involvement (30) and three patients had multiple-level involvement. Six patients underwent surgery earlier (one underwent alcohol embolization). The mean surgical time was 124±39 minutes, and the average blood loss was 274±80 cc. The mean amount of absolute alcohol injected was 14.6±5.7 cc (two patients required 20 and 25 cc). Immediate embolization was achieved in all patients, allowing laminectomy and easy removal of soft-tissue hemangioma. Post surgery, one patient had transient deterioration, and the condition of the rest of the patients improved (sphincters improved in nine patients) at a follow-up ranging 28-103 months (mean 47.6±22.3). Follow-up ASIA scores were E (26), D (4), B (2), and C (1). All patients showed evidence of bone sclerosis and relief of cord compression on follow-up imaging.

CONCLUSIONS

This is the largest study in literature showing excellent improvement, low reoperation rates after ethanol embolization, and short-segment fixation.

Posterior surgical treatment of ankylosing spondylitis with spinal tuberculosis: A case series and long-term follow-up

This retrospective cohort study aimed to evaluate the clinical outcomes of posterior surgical treatment of ankylosing spondylitis (AS) with spinal tuberculosis (STB). This was a retrospective study including 12 patients treated between January 2004 and April 2014 for AS with STB at our department. All patients underwent 1-stage posterior internal fixation, debridement, and bone fusion. The patients were evaluated based on the American Spinal Injury Association (ASIA), kyphotic Cobb angle, and the visual analog score (VAS). All patients were followed up for an average of 42.7 ± 13.2 months after surgery and bone fusion was achieved 6.8 ± 1.3 months. According to ASIA, 2 cases were rated as Grade D, 10 cases were Grade E at last follow-up. The average preoperative Cobb angle was 26.7 ± 7.6° (range 15-36) and the average postoperative Cobb angle was 7.8 ± 1.2° (range 6-9). The mean latest follow-up Cobb angle was 9.1 ± 1.0° (range 6-10). Compared with the average preoperative Cobb angle, there were significant differences regarding the kyphotic Cobb angle measured postoperatively and at final follow-up (P < .05). The VAS significantly was considerably improved between the preoperative and the last clinical visits. These positive results demonstrate that 1-stage surgical treatment for AS with STB by posterior debridement, fusion, and instrumentation can be an effective and feasible treatment method for this specific condition. It should be noted that it is necessary to carry out antiosteoporosis treatment and perform long-segmental instrumentation in order to obtain spinal stabilization.

Imaging of metabolic bone disease

Osteoporosis is the most important metabolic bone disease, with a wide distribution among the elderly. It is characterized by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. Identify bone weakening with an appropriate and accurate use of diagnostic imaging is of critical importance in the diagnosis and follow-up of osteoporotic patients. The aim of this review is to evaluate the detection rates of the different imaging modalities in the evaluation of bone strength, in the assessment of fracture risk and in the management of fragility fractures. (www.actabiomedica.it)

Magnetic Resonance Imaging in degenerative disease of the lumbar spine: Fat Saturation technique and contrast medium

Purpose: To examine both anterior and posterior elements of the lumbar spine in patients with low back pain using MRI T2-weighted sequences with Fat Saturation (FS) and contrast enhanced T1-weighted sequences with FS.Materials and methods: Two thousand eight hundred and twenty (2820) patients (1628 male, 1192 female, mean age 54) presenting low back pain underwent MRI standard examination (Sagittal T1w TSE and T2w TSE, axial T1 SE) with the addition of sagittal and axial T2w Fat Sat (FS) sequences. Among all the patients, 987 (35%) have been studied adding Contrast Enhanced (CE) T1w FS sequences after administration of contrast medium. Results: Among 987 patients studied with contrast medium, we found: active-inflammatory intervertebral osteochondrosis in 646 (65%) patients; degenerative-inflammatory changes in facet joints (facet joint effusion, synovitis, synovial cysts) in 462 (47%); spondylolysis in 69 (7%); degenerative-inflammatory changes of the flava, interspinous and supraspinous ligaments in 245 (25%); inflammatory changes of posterior perispinal muscles in 84 (8%) patients. Conclusions: In patients with suspected no-disc-related low back pain, the implementation of T2w FS and CE T1w FS sequences to the standard MR protocol could allow a better identification of degenerative-inflammatory changes more likely associated to the pain. (www.actabiomedica.it)

Weight-bearing MRI of the knee: a review of advantages and limits

Standard knee imaging with MRI is usually performed with patient in recumbent position under non-weight-bearing conditions. Recently, magnetic resonance imaging systems to scan the knee joint under weight bearing conditions has been proposed as an approach to improve the clinical utility of musculoskeletal MRI. Imaging under loading can be useful to understand the natural motion behavior of the knee joint and to identify conditions that are challenging to diagnose by using standard position. We reviewed the literature on weight-bearing MR imaging of the knee to describe the current state of use of such MRI technologies, evaluating the advantages and the potential limitations of these technologies.

Diagnostic imaging and intervention of the musculoskeletal system: state of the art

The study of the musculoskeletal system has always been one of the most important application for diagnostic imaging in radiology (1-4).

Acute and overuse elbow trauma: radio-orthopaedics overview

Summary. The correct management of acute, subacute and overuse-related elbow pathologies represents a challenging diagnostic and therapeutic problem. While major trauma frequently requires a rapid surgical intervention, subluxation and minor trauma allow taking more time for diagnostics and planning the correct elective treatment after careful clinical and radiological investigation. In these conditions, communication between orthopaedic surgeon and radiologist allow to create a detailed radiology report, tailored to the patient’s and surgeon’s needs and optimal to plan proper management. Imaging technique as X-Ray, CT, US, MRI, CTA and MRA all belong to the radiologist’s portfolio in elbow diagnostics. Detailed knowledge of elbow pathology and its classification and of the possibilities and limits of each imaging technique is of crucial importance to reach the correct diagnosis efficiently. The aim of this review is to present the most frequent elbow pathologies and suggest a suitable diagnostic approach for each of them. (www.actabiomedica.it)

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures. (www.actabiomedica.it)

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study

BACKGROUND AND AIM

The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal.

METHODS

Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment.

RESULTS

In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly.

CONCLUSIONS

Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.

Dynamic MRI in the evaluation of the spine: state of the art

Introduction: Degenerative disease of the spine is a generic term encompassing a wide range of different disease processes, which leads to spinal instability; traumatic/neoplastic events can accelerate this aging process. Therefore, the dynamic nature of the spine and its mobility across multiple segments is difficult to depict with any single imaging modality. Methods: A review of PubMed databases for articles published about kMRI in patients with cervical and lumbar spinal desease was performed. We focused on the physiopathological changes in the transition from supine to upright position in spine instability. Discussion: Until a few years ago, X-ray was the only imaging modality for the spine in the upright position. Of the imaging techniques currently available, MRI provides the greatest range of information and the most accurate delineation of soft-tissue and osseous structures. Conventional MRI examinations of the spine usually are performed in supine position, in functional rest, but the lumbar spine instability is often shown only by upright standing. This can result in negative findings, even in the presence of symptoms. Regardless, the final result is distorted. To overcome this limitation, Kinetic MRI (kMRI) can image patients in a weight-bearing position and in flexed and extended positions, thus revealing abnormalities that are missed by traditional MRI studies. Conclusion: Despite some limitations, the upright MRI can be a complementary investigation to the traditional methods when there are negative results in conventional MRI in symptomatic patients or when surgical therapy is scheduled. (www.actabiomedica.it)

Radiofrequency ablation of osteoid osteoma

Osteoid osteoma is a benign bone neoplasm with a reported incidence of 2-3% among all bone primary tumors. Although it is a small and benign lesion, it is often cause of patient complaint and discomfort. It is generally characterized by a long lasting, unremitting pain that typically exacerbates at night, often leading to sleep deprivation and functional limitation of the skeletal segment involved, with a significant reduction of patient daily life activities and consequent worsening of the overall quality of life. Over decades, complete surgical resection has represented the only curative treatment for symptomatic patients. In the last years, new percutaneous ablation techniques, especially radiofrequency ablation, have been reported to be a safe and effective alternative to classical surgery, with a low complication and recurrence rate, and a significant reduction in hospitalization cost and duration. The aim of this article is to provide an overview about the radiofrequency thermal ablation procedure in the treatment of osteoid osteoma. (www.actabiomedica.it)

Talar fractures: radiological and CT evaluation and classification systems

Introduction: The talus is the second largest bone of the foot. It is fundamental to ensure normal ankle-foot movements as it connects the leg and the foot. Talar fractures are usually due to high energy traumas (road accidents, high level falls). They are not common as they account for 3-5% of ankle and foot fractures and 0.85% of all body fractures. However, talar fractures not correctly diagnosed and treated can lead to avascular necrosis of the astragalus, pseudoarthrosis, early osteoarthrisis and ankle instability, declining the quality of life of patients. Methods: A PubMed search was performed using the terms “talus” “talus AND radiology”, “talar fractures”, and “talar fractures classification”, selecting articles published in the last 98 years. We selected articles about pre-treatment and post-surgery talar fractures diagnostic imaging. We also selected articles about talar fractures complications and traumatic talar dislocations. Case reports have not been included. Aim of the work: to describe radiological evaluations, classification systems, and biomechanical patterns involved in talar fractures. Also we will briefly describe talar fractures complications and treatment option and strategies. Conclusions: This work suggests a radiological approach aimed to classify talar fractures and guide treatment strategies, improving patient outcomes. (www.actabiomedica.it)

Developments in the management of bone metastases with interventional radiology

Interventional radiology has known an exponential growth in the last years. Technological advances of the last decades, have made it possible to use new treatments on a larger scale, with safe and effective results. They could be considered as palliative treatments for painful lesions but also curative procedures, as single treatment or specially in combination with other techniques (surgery, radiation and oncology therapies, etc.). The main diffuse techniques are those of thermal ablation that destroy the target lesion through the heat; however there are also endovascular therapies that destroy the target tissue thanks to devascularization. Finally the is also the possibility to stabilize pathological fractures or impending fractures. In this paper all the most diffuse and effective techniques are reviewed and also a discussion of the main indications is done, with an analisys of the success and complications rates. (www.actabiomedica.it)

Imaging of pediatric foot disorders

Infants and children undergo imaging studies to evaluate a wide variety of congenital and acquired disorders. Imaging protocols have to consider the patient’s comfort, level of anxiety, and smaller size. The first imaging study is usually made with plain radiographs. The routine radiographic examination of the foot includes the anteroposterior (AP), lateral, and oblique projections. Magnetic Resonance Imaging (RMI) provides excellent anatomic detail of cartilage, vasculature and soft tissue thanks to superior soft tissue contrast and spatial resolution, so is valuable in many cases. According to the clinical and objective signs, guided by the radiographs images, we can be oriented to perform Computed Tomography (CT), CT imaging or MRI imaging. CT imaging is useful to observe the bones but it has the disadvantage of using radiation and doesn’t adequately define the bone’s non-ossified portions. On the contrary, MRI imaging is very useful in identifying the cartilaginous parts and vascular and soft tissues, thanks to its superior contrast and spatial resolution. Finally, it is important to orientate the diagnostic process keeping in mind the clinical sign of the patient and to use the most appropriate diagnostic technique. (www.actabiomedica.it)

Magnetic Resonance Imaging correlates of benign and malignant alterations of the spinal bone marrow

Background and aim of the work: Bone marrow (BM) abnormalities in the spine are a common, sometimes unexpected, finding on Magnetic Resonance Imaging (MRI), which is the most sensitive imaging modality to evaluate the marrow, and their interpretation can be difficult for the unexperienced radiologist. In this review, the MRI appearance of normal age-related BM changes, as well as the imaging features of benign and malignant diseases, are presented. Discussion: A large variety of BM signal alterations has been identified and described, including normal variants, BM reconversion, degenerative changes, infections, spondyloarthritis and osteonecrosis, trauma, neoplastic lesions (both primary or metastatic), post-radiation and chemotherapy sequelae. Conclusions: Knowledge of normal age-related BM appearance, normal variants and patterns of involvement in focal and diffuse bone diseases is essential, together with clinical and laboratory data, to narrow the list of the possible differential diagnoses. The radiologist should be familiar with these signal changes, as they can sometimes be discovered incidentally. In this context, it is equally important not to attribute pathological significance to benign alterations and to promptly detect signs of malignant diseases. (www.actabiomedica.it)

[Kyphoplasty and vertebroplasty for spinal trauma]

CLINICAL ISSUE

Minimally invasive treatment of spinal fractures.

STANDARD TREATMENT PROCEDURES

Conservative treatment versus spinal surgery.

TREATMENT INNOVATIONS

Minimally invasive stabilization techniques, such as percutaneous (assisted) cementoplasty have been introduced as new procedures.

DIAGNOSTIC WORK-UP

Magnetic resonance imaging (MRI), X‑rays and computed tomography (CT) are the imaging techniques of first choice. The most important questions concern recent fractures, instability and indications for minimally invasive treatment.

PERFORMANCE

Vertebroplasty and kyphoplasty are established methods for the treatment of patients with osteoporosis.

ACHIEVEMENTS

Cementoplasty techniques are promising treatment options for traumatic spinal injuries.

PRACTICAL RECOMMENDATIONS

The application of the techniques should best be carried out in individual cases within the framework of prospective controlled studies.

What's new in vertebral cementoplasty?

Vertebral cementoplasty is a well-known mini-invasive treatment to obtain pain relief in patients affected by vertebral porotic fractures, primary or secondary spine lesions and spine trauma through intrametameric cement injection. Two major categories of treatment are included within the term vertebral cementoplasty: the first is vertebroplasty in which a simple cement injection in the vertebral body is performed; the second is assisted technique in which a device is positioned inside the metamer before the cement injection to restore vertebral height and allow a better cement distribution, reducing the kyphotic deformity of the spine, trying to obtain an almost normal spine biomechanics. We will describe the most advanced techniques and indications of vertebral cementoplasty, having recently expanded the field of applications to not only patients with porotic fractures but also spine tumours and trauma.

Vertebroplasty for vertebral hemangioma in children: a report of two cases with 2-year follow-up

PURPOSE

To describe two cases of a dorsal vertebral hemangioma diagnosed in a 12- and 14-year-old child successfully treated with vertebroplasty.

METHOD

Cases reports.

RESULTS

Two cases of aggressive vertebral hemangiomas were diagnosed and treated in two independent institutions. Percutaneous vertebroplasty was then decided. Bipedicular vertebroplasty was performed under general anesthesia, under biplanar fluoroscopic guidance. The injection of acrylic cement filled the entire vertebral body without significant leakage. At last follow-up, the clinical and radiographic outcome was very good. In one patient, last control radiographs showed a gap between the end plates and the cement, spinal growth seemed to have resumed.

CONCLUSION

Vertebral hemangioma is rare in pediatric patients, and its diagnosis requires meticulous and regular clinical examinations and a combination of imaging studies, particularly an MRI and a CT scan, which can assess the aggressiveness of the lesion. Vertebroplasty seems to be an effective and safe treatment of this benign tumor in children with stable outcome at 2-year follow-up. Spinal growth may resume despite the aggressiveness of both the tumor and the treatment.

Update of vertebral cementoplasty in porotic patients

Vertebroplasty (VP) is a percutaneous mini-invasive technique developed in the late 1980s as antalgic and stabilizing treatment in patients affected by symptomatic vertebral fracture due to porotic disease, traumatic injury and primary or secondary vertebral spine tumors. The technique consists of a simple metameric injection of an inert cement (poly-methyl-methacrylate, PMMA), through a needle by trans-peduncular, parapeduncular or trans-somatic approach obtaining a vertebral augmentation and stabilization effect associated with pain relief. The technique is simple and fast, and should be performed under fluoroscopy or CT guidance in order to obtain a good result with low complication rate. The aim of this paper is to illustrate the utility of VP, the indications-contraindications criteria, how to technically perform the technique using imaging guidance, and the results and complications of this treatment in patients affected by symptomatic vertebral compression fracture.

Current trends in mini-invasive management of spine metastases

The spine is a frequent localization of primary tumours or metastasis involving posterior arch, pedicles and vertebra body, and often causing unsustainable pain. The management of spinal metastasis remains complex, including medical therapy (corticosteroids, chemotherapy), radiotherapy and surgical treatment, or the recent percutaneous mini-invasive approach. The target of all these treatments is to improve the quality of life of patients affected by this type of lesion. Diagnosis of spinal metastasis and then its treatment should be based on the combination of different elements: clinical evaluation, CT, MRI and nuclear medicine patterns, considering the age of the patient, known primary tumour, location of the lesions, single/multiple lesions, pattern of morphology (border, matrix, expansile character, soft tissue extension), density or signal intensity, oncologic instability and expectancy of life. The percutaneous mini-invasive approach for patients affected by secondary lesions involving the spine has as treatment goal of: (1) pain relief improving the quality of life; (2) stability treatment re-establishing the spinal biomechanics, alterated by bone destruction or deformity, preventing pathological fracture; and (3) an anti-neoplastic effect. The aim of this paper is to provide a comprehensive diagnostic and percutaneous approach to the bone metastatic spine lesions, identifying which metamer should be treated to improve patient quality of life, showing the importance of a multi-disciplinary approach to this problem.

Vertebroplasty Using Calcium Triglyceride Bone Cement (Kryptonite™) for Vertebral Compression Fractures. A Single-Centre Preliminary Study of Outcomes at One-Year Follow-up

This study assessed the one-year clinical and radiographic outcomes, in terms of pain-relief, vertebral re-fracture and complications, after vertebroplasty (VP) using a new osteoconductive cement (calcium triglyceride bone cement - Kryptonite™ bone cement, Doctors Research Group Inc., Southbury, CT, USA) to treat osteoporotic vertebral compression fractures. Sixteen consecutive osteoporotic patients (12 women and four men, mean age 68+/-10.5) were treated with VP using Kryptonite™ bone cement for a total of 20 vertebral fractures. All the patients complained of a pain syndrome resistant to medical therapy and all procedures were performed under fluoroscopy control with neuroleptoanalgesia using a monopedicular approach in 12 patients and bipedicular approach in four patients. All patients were studied by MR and MDCT and were evaluated with the visual analogue scale (VAS) and the Oswestry disability index (ODI) before treatment and at one and 12 months after the procedure. A successful outcome was observed in 80% of patients, with a complete resolution of pain. Differences in pre and post treatment VAS and ODI at one-year follow-up were significant (P<0.0001). We observed a disk and venous leakage in 66% of patients but only in one case did an asymptomatic pulmonary embolism occur during cement injection. Two cases of vertebral re-fractures at distant metamers were observed during follow-up. VP using Kryptonite bone cement is a helpful procedure that allows complete and long-lasting resolution of painful vertebral symptoms. The cost of the material is very high and the rate of disk and venous leakage is too high compared to standard cement.

ACR appropriateness criteria management of vertebral compression fractures

This is an updated review of management of vertebral compression fracture for both benign osteoporotic and malignant causes. Vertebral compression fracture radiologic imaging evaluation is discussed. A literature review is provided of current indications for vertebral augmentation with percutaneous vertebroplasty and kyphoplasty as well as medical management. Limitations and potential benefits of these procedures are discussed. Variant tables describing various clinical situations are also provided to assist in determining appropriate use of these treatments for patient care. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to formulate recommendations for imaging or treatment.

Assisted techniques for vertebral cementoplasty: why should we do it?

Assisted techniques (AT) for vertebral cementoplasty include multiple mini-invasive percutaneous systems in which vertebral augmentation is obtained through mechanical devices with the aim to reach the best vertebral height restoration. As an evolution of the vertebroplasty, the rationale of the AT-treatment is to combine the analgesic and stability effect of cement injection with the restoration of a physiological height for the collapsed vertebral body. Reduction of the vertebral body kyphotic deformity, considering the target of normal spine biomechanics, could improve all systemic potential complications evident in patient with vertebral compression fracture (VCF). Main indications for AT are related to fractures in fragile vertebral osseous matrix and non-osteoporotic vertebral lesions due to spine metastasis or trauma. Many companies developed different systems for AT having the same target but different working cannula, different vertebral height restoration system and costs. Aim of this review is to discuss about vertebral cementoplasty procedures and techniques, considering patient inclusion and exclusion criteria as well as all related minor and/or major interventional complications.

Magnetic resonance imaging in brachial plexus injury

Brachial plexus injury represents the most severe nerve injury of the extremities. While obstetric brachial plexus injury has showed a reduction in the number of cases due to the improvements in obstetric care, brachial plexus injury in the adult is an increasingly common clinical problem. The therapeutic measures depend on the pathologic condition and the location of the injury: Preganglionic avulsions are usually not amenable to surgical repair; function of some denervated muscles can be restored with nerve transfers from intercostals or accessory nerves and contralateral C7 transfer. Postganglionic avulsions are repaired with excision of the damaged segment and nerve autograft between nerve ends or followed up conservatively. Magnetic resonance imaging is the modality of choice for depicting the anatomy and pathology of the brachial plexus: It demonstrates the location of the nerve damage (crucial for optimal treatment planning), depicts the nerve continuity (with or without neuroma formation), or may show a completely disrupted/avulsed nerve, thereby aiding in nerve-injury grading for preoperative planning. Computed tomography myelography has the advantage of a higher spatial resolution in demonstration of nerve roots compared with MR myelography; however, it is invasive and shows some difficulties in the depiction of some pseudomeningoceles with little or no communication with the dural sac.

Atraumatic vertebral compression fractures: differential diagnosis between benign osteoporotic and malignant fractures by MRI

Atraumatic vertebral compression fractures are a common clinical problem, especially in elderly population. Metastases are the most frequent source of bone tumors, and the spine is a common site of metastatic disease; in case of cortical involvement or osteolysis, they may result in pathological compression fractures. Atraumatic compression fractures may result from other primary neoplasms of vertebrae and also from osteomyelitis, Paget's disease, hyperparathyroidism and other metabolic processes. Osteoporosis is a common source of vertebral compression fractures in elderly population, which may be indistinguishable from those of metastatic origin. The differentiation between osteoporotic compression fractures and malignant fracture is necessary to establish an appropriate staging and a therapeutic planning, especially in the acute and subacute stages. Anamnestic data about preexisting disease can be useful to individuate the potential cause of vertebral collapse. Plain radiography shows some difficulties in distinguishing whether the fracture represents a consequence of osteoporosis, a metastatic lesion or some other primary bone neoplasm. Computed tomography is one of the most suitable imaging techniques for the evaluation of bone structure and fragments and to establish the degree of cortical bone destruction; MR imaging (MRI) is the most helpful radiological investigation in order to provide the basis for the distinction between metastatic and acute osteoporotic compression fractures. The most relevant MRI findings to establish a differential diagnosis are described.

Rehabilitation and surgical management of ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease which, if untreated, may progress to severe damage of the spine with functional impairment, disability and poor quality of life. An increased mortality has been reported in AS patients compared to the general population. AS requires combined management (pharmacological and non-pharmacological) and advice by different health professionals. Even the pharmacological treatment in the last decade has dramatically changed the outcome, the severity of the disease might require a surgical approach for the hip involvement with total hip replacement, or the corrective spinal surgery. However, this surgery deserves some careful approaches since the complexity of the disease. Rehabilitation still represents a cornerstone of the global management of AS patients. The present review summarizes the state of art of surgical management of these two diseases.

Femoroacetabular impingement: role of imaging

The femoroacetabular impingement (FAI) is an impingement characterized by repetitive abutment between the femur and the acetabular rim during hip motion due to loss of joint clearance (Imam and Khanduja in Int Orthop 35(10):1427-1435, 2011; James et al. in AJR Am J Roentgenol 187(6):1412-1419, 2006). Femoroacetabular impingement (FAI) can be classified as either cam or pincer type, and it can be differentiated on the basis of a predominance of either a femoral or an acetabular abnormality (Pfirrmann et al. in Radiology 244(2):626, 2007; Ganz et al. in Clin Orthop Relat Res 466(2):264-272, 2008). In cases of cam FAI, the nonspherical shape of the femoral head at the femoral head-neck junction and reduced depth of the femoral waist lead to abutment of the femoral head-neck junction against the acetabular rim. In cases of pincer FAI, acetabular overcoverage limits the range of motion and leads to a conflict between the acetabulum and the femur. The most important role of preoperative MR evaluation in patients affected by FAI is the accurate assessment of the damage's extension.

Sacroplasty for symptomatic sacral hemangioma: a novel treatment approach. A case report

Painful vertebral body hemangiomas have been successfully treated with vertebroplasty and kyphoplasty. Sacral hemangiomas are uncommon and as such painful sacral hemangiomas are rare entities. We report what we believe is only the second successful treatment of a painful sacral hemangioma with CT-guided sacroplasty. A 56-year-old woman with a history of right-sided total hip arthroplasty and lipoma excision presented to her orthopedic surgeon with persistent right-sided low back pain which radiated into her buttock and right groin and hindered her ability to walk and perform her activities of daily living. MRIs of the thoracic spine, lumbar spine and pelvis showed numerous lesions with imaging characteristics consistent with multiple hemangiomas including a 2.2×2.1 cm lesion involving the right sacrum adjacent to the right S1 neural foramen. Conservative measures including rest, physical therapy, oral analgesics and right-sided sacroiliac joint steroid injection did not provide significant relief. Given her lack of improvement and the fact that her pain localized to the right sacrum, the patient underwent CT-guided sacroplasty for treatment of a painful right sacral hemangioma. Under CT fluoroscopic guidance, a 10 gauge introducer needle was advanced through the soft tissues of the back to the margin of the lesion. Biopsy was then performed and after appropriate preparation, cement was then introduced through the needle using a separate cement filler cannula. Appropriate filling of the right sacral hemangioma was visualized using intermittent CT fluoroscopy. After injection of approximately 2.5 cc of cement, it was felt that there was near complete filling of the right sacral hemangioma. With satisfactory achievement of cement filling, the procedure was terminated. Pathology from biopsy taken at the time of the procedure was consistent with hemangioma. Image-guided sacroplasty with well-defined endpoints is an effective, minimally invasive and safe procedure. Patients with painful sacral hemangiomas can be treated with this technique with no significant complications.

Novel use of propranolol for management of pain in children with vertebral hemangioma: report of two cases

INTRODUCTION

Vertebral hemangioma (VH) is an exceedingly rare neoplasm in pediatric population with less than 10 cases reported in the literature. It is usually asymptomatic in adults and diagnosed incidentally at radiographic investigations of other medical conditions. In this report, we describe two children who presented to our institution with severe back pain and were diagnosed with VH.

CASE REPORTS

Case 1 was an 8-year-old male with a pain score of 10 out of 10 at presentation. Clinical investigations eliminated the possibility of a neoplasm or infectious process and MRI findings were highly suggestive of an aggressive vertebral hemangioma. Case 2 was a 17-year-old female who presented with back pain radiating to shoulders. Her pain score was 4 out of 10 and she was diagnosed with vertebral hemangioma due to the specific findings on MRI studies.

DISCUSSION

Both patients received propranolol with a dose of 20 and 40 mg per day, respectively. They were free of pain at 2 months follow-up. There are different invasive treatment modalities for the management of VH, including vertebroplasty, kyphoplasty, radiotherapy, alcohol injection, embolization, and surgery. These methods have been used in adult patients for several years, but each of them has potential risks which make these options unsuitable for children.

CONCLUSION

Propranolol is a beta blocker which is safely used in the management of infantile hemangiomas. This is the first report demonstrating its efficacy in symptomatic treatment of childhood VH. The lesions did not show any regression, but the pain relief obtained was very significant under propranolol therapy.

Vertebroplasty in the treatment of symptomatic vertebral haemangiomas without neurological deficit

OBJECTIVE

To evaluate the effectiveness of vertebroplasty in symptomatic vertebral haemangiomas (VHs) with no neurological deficit, with or without features of aggressiveness in imaging studies.

METHODS

A retrospective study was conducted to review 31 consecutive patients with symptomatic VHs that underwent vertebroplasty procedures (13 males, 18 females; mean age, 57.5 years), for a total of 33 affected vertebral levels (range, T4-L5 levels). Pre procedure radiological examinations were reviewed. The presence of predominant soft tissue stroma on CT, low signals on T1W of MRI, epidural tissue, and cortical erosion are considered features of aggressiveness. The clinical effects were evaluated using the visual analogue scale (VAS) and modified Roland-Morris Disability Questionnaire (RDQ) at the pre and each postoperative follow-up time point (mean follow-up of 15.8 months).

RESULTS

Symptomatic VHs with no signs of aggressiveness were observed in 26 lesions and those with signs of aggressiveness in 7 lesions. Vertebroplasty was successfully performed under fluoroscopic guidance with a unipedicular approach in 16 levels, a bipedicular approach in 17 levels. VAS scores and RDQ scores were significantly improved after vertebroplasty (P < 0.001). Extraosseous cement leakage was observed in 4 patients without clinical complications.

CONCLUSIONS

Vertebroplasty is an optional treatment for symptomatic VHs with no neurological deficit.

KEY POINTS

• Vertebral haemangiomas with or without aggressive signs may cause pain. • Radiological signs of aggressiveness include evidence of lesions that contain less fat predominance, evidence of epidural soft tissue and evidence of cortical erosion. • Vertebroplasty provides effective treatment for symptomatic vertebral haemangiomas causing no neurological deficit.

Management of cement vertebroplasty in the treatment of vertebral hemangioma

BACKGROUND

The vertebral hemangiomas are benign vascular lesions occurring in spine. Although uncommon, symptomatic vertebral hemangiomas can be painful and can limit daily activities. A number of methods have been used in the treatment of symptomatic and aggressive vertebral hemangioma, but none of them is optimal. Treatment with cement vertebroplasty showed very good results. This study aims to illustrate the validity of the treatment with cement vertebroplasty in patients with painful vertebral hemangiomas.

PATIENTS AND METHODS

From January 2000 to January 2007, 24 patients were treated by percutaneous vertebroplasty because of hemangioma: 16 thoracic, 8 lumbar. There were 11 males and 13 females. The average age at the time of surgery was 48 years. All the patients complained of a pain syndrome resistant to continuing medication. All patients underwent X-ray examination, CT-scan and MR of the involved level preoperatively. A unipedicular approach under fluoroscopic guidance has been performed in all patients. All procedures have been carried out under the local anesthesia. The mean follow-up was 5.8 years.

RESULTS

In all the patients a successful outcome has been observed with a complete resolution of pain symptom. Extravertebral vascular cement leakage has been observed in 3 patients, without any clinical radicular syndrome onset due to the epidural diffusion. Clinical and radiological follow-up showed stability of the treatment and absence of pain in all patients.

CONCLUSION

Percutaneous treatment with vertebroplasty for symptomatic vertebral hemangiomas is a valuable, less-invasive, and a quick method that allows a complete and enduring resolution of the painful vertebral symptoms without findings of the vertebral body's fracture.

Vertebral Body Stenting System for the Treatment of Osteoporotic Vertebral Compression Fracture: Follow-up at 12 Months in 20 Cases

We describe our preliminary experience with the vertebral body stenting system (VBS) for the treatment of osteoporotic vertebral fracture or traumatic vertebral fracture showing our clinical results at 12 months follow-up. Twenty patients (16 women, four men, mean age 71 years): four with traumatic vertebral fracture (Magerl A1 fractures) and 16 with osteoporotic vertebral compression fracture (VCFs) resistant to conservative therapy, were treated by vertebral body stenting system (VBS) as follows: two at level T11, four at T12, one at L1, two at L2, five at L3 and six at L4. All patients were studied by MR (protocol: sagittal T1W, T2W and T2 STIR) and MDCT with MPR reconstructions. All procedures were performed under local anesthesia with fluoroscopy guidance and a bipeduncular approach. VBS, a new system of implantation of endovertebral stent used as an alternative to conventional vertebroplasty (VP), was implanted in all patients to restore the loss of height in the fractured vertebral body. A clinical and x-ray follow-up was performed at six and 12 months evaluating the result by VAS and ODS scale. New vertebral fractures at a distant level were observed in two cases and treated by VP. VBS was successful and led to an excellent outcome in all patients with clinical improvement stable at six months and one year follow-up. The height in the fractured vertebral body was increased in 12 of the 20 VCFs by an average of 1.5 mm. No vascular, extraforaminal or epidural leakage or other adverse events were observed. In the clinical 12 months follow-up we recorded a reduction of four scores in the VAS evaluation and a 40% reduction in the ODS score compared with the pre-treatment values. Endovertebral stents were stable at 12 months at x-ray control in 19/20 patients. No new vertebral fracture located in adjacent vertebrae were observed at 12 month follow-up. By using a stent, the VBS system reduces the collapsed vertebral body and offers good height restoration. The mechanical scaffold of the stent restores the height and at the same time offers a cavity for injection of highly viscous PMMA bone cement without increasing the rate of new vertebral fracture post-VP. A long-term follow-up is recommended.

Percutaneous vertebroplasty or kyphoplasty

Percutaneous vertebral augmentation techniques performed with vertebroplasty or kyphoplasty are safe and effective for the treatment of osteoporotic vertebral compression fractures, primary or secondary spine tumors, and selected traumatic fractures. This article compares the procedures and outlines their advantages and disadvantages. It concludes that vertebroplasty should be performed in most cases, but kyphoplasty is preferable in selected cases.

The role of kyphoplasty in the management of osteogenesis imperfecta: risk or benefit?

Kyphoplasty is a recognized treatment option in the management of symptomatic osteoporotic compression fractures, osteolytic vertebral metastases or haemangioma. To our knowledge, kyphoplasty with polymethylmethacrylate in a patient with type I osteogenesis imperfecta (OI) and a vertebral compression fracture has not been reported so far. We report on a 58-year-old patient with type I OI and a vertebral compression fracture at L2 with undislocated posterior vertebral wall and an additional older L1 fracture. Because of severe back pain resistant to conservative therapy over 5 months the indication for percutaneous kyphoplasty was made. Preoperative adjacent endplates of L2 were nearly parallel. Radiologically a minimal loss of height of the L2 vertebra was seen without adjacent fractures at 9 months follow-up. A slight increase of the preoperative kyphotic angle of overlying vertebrae L1 (8.7 degrees/10.3 degrees) and T12 (10.4 degrees/11.0 degrees) was apparent. The visual analogue scale showed decrease of low back pain from 10 to 2 allowing mobilization with a walking frame. Kyphoplasty constitutes a minimal invasive therapeutic alternative in the treatment of vertebral fractures in type I OI and pain, resistant to conservative treatment. Similar to the results of osteoporotic fractures the immediate reduction of pain and stabilization of the fracture in undislocated fragments can be achieved. No adjacent fractures occurred 9 months postoperatively after kyphoplasty in type I OI. Preoperative parallelism of the endplates seems to protect from adjacent fractures.