Non-discogenic low back pain treated with oxygen-ozone: outcome in selected applications

Low back pain and sciatica are highly debilitating conditions affecting all socioeconomic groups at an increasingly early age. They are caused by different often concomitant spinal disorders: disc or facet joint disease, spondylolysis (with or without listhesis), vertebral body and interapophyseal arthrosis, spinal stenosis, radicular and synovial cysts and, more rarely, infections and primary or metastatic cancer. Treatment of low back pain and/or sciatica requires an accurate diagnosis based on thorough history-taking and physical examination followed by appropriate imaging tests, namely computed tomography, and/or magnetic resonance scans in addition to standard and morphodynamics X-rays of the spine. In recent years, several reports have demonstrated the utility of oxygen-ozone therapy in reducing the size of herniated discs. The present study reports on the outcome of oxygen-ozone treatment in 576 patients with non-discogenic low back pain caused by degenerative disease of the posterior vertebral compartment (facet synovitis, Baastrup syndrome, spondylolysis and spondylolisthesis, facet degeneration).

Revascularized giant aneurysm of the anterior communicating artery after surgery and embolization, occluded by placement of a Leo+Baby intracranial stent. A case report

Balt (Montmorency, France) recently manufactured the Leo+Baby dedicated intracranial stent for arteries with a calibre between 1.5 and 3.10 mm. We describe a patient with a partially thrombosed giant sacciform aneurysm of the anterior communicating artery treated without success by surgery and coil embolization subsequently occluded by placement of a Leo+Baby stent (Balt, Montmorency, France). A 56-year-old man presented with a giant aneurysm in the anterior communicating artery region. Following successive surgical intervention and embolization procedures the patient was referred to us with a revascularized aneurysm measuring 15×9×8 cm. To stabilize the endovascular occlusion a combined treatment was scheduled with coil embolization and stent deployment after dual antiplatelet therapy started five days before the interventional procedure. Treatment was undertaken two weeks later under general anaesthesia and total heparinization. A microcatheter was inserted into the aneurysmal sac and four metal coils were released for a total of 61cm obtaining almost complete occlusion of the aneurysm from the circulation. A Leo+Baby stent (2.5×18 mm) was subsequently deployed across the aneurysm neck. At follow-up angiography two months later the aneurysm appeared substantially excluded from the arterial circulation except for a small portion in the neck. Six months later, four months after suspending antiplatelet therapy, follow-up angiography disclosed the complete exclusion of the aneurysm from the circulation. Deployment of the new ministent through the same microcatheter used to release the coils made the interventional procedure simpler and faster.

Management of unruptured brain aneurysms: retrospective analysis of a single centre experience

Embolization is very effective in preventing bleeding of unruptured aneurysms with lower rates of mortality and morbidity than surgical treatment. Neurosurgery remains, however, a good alternative. This retrospective analysis examined data stored the digital database of Bellaria Hospital Radiology Department, evaluating patients, treatments and devices used as well as outcomes and complications. Therapy should be tailored to each individual case to offer each patient the best treatment. Out of 265 unruptured intracranial aneurysms detected, 182 were treated by embolization. 16 cases presented complications (12 only radiologically found); severe clinical consequences occurred in 3%: one ischaemia and five haemorrhages. Conservative treatment was adopted in 21 patients. Long-term follow-up is mandatory as aneurysms could increase their size and develop an irregular morphology in ten years' time. Endovascular embolization is a very effective treatment with positive outcomes in the majority of cases and a percentage of retreatments of 8%. In order to increase the number of successful cases, a multidisciplinary cooperation with neurosurgeons is strongly recommended.

Complications in the treatment of intracranial aneurysms with silk stents: an analysis of 30 consecutive patients

Flow-diverting stents (Silk and PED) have radically changed the approach to intracranial aneurysm treatment from the use of endosaccular materials to use of an extraaneurysmal endoluminal device. However, much debate surrounds the most appropriate indications for the use of FD stents and the problems raised by several possible complications.We analysed our technical difficulties and the early (less than ten days after treatment) and late complications encountered in 30 aneurysms treated comprising 13 giant lesions, 12 large, five with maximum diameters <10 mm and one blister-like aneurysm. In our experience the primary indications for the use of FD stents can be the symptomatic intracavernous giant aneurysms. Although the extracavernous carotid siphon aneurysms have major risk of bleeding, FD stents are indicated clearly explaining the risks to the patient in case of severe mass effect. There is a very complex assessment for aneurysms of the vertebrobasilar circulation.

A minimally invasive treatment for lumbar disc herniation: DiscoGel® chemonucleolysis in patients unresponsive to chemonucleolysis with oxygen-ozone

A multitude of therapies is available to treat disc herniation, ranging from conservative methods (medication and physical therapy) to minimally invasive (percutaneous) treatments and surgery. O₂-O₃ chemonucleolysis (O₂-O₃ therapy) is one of the minimally invasive treatments with the best cost/benefit ratio and lowest complication rate. Another substance recently made available exploiting the chemical properties of pure ethanol is DiscoGel®, a radiopaque gelified ethanol more viscous than absolute alcohol 8,9. The present study aimed to assess the therapeutic outcome of DiscoGel® chemonucleolysis in patients with lumbar disc herniation unresponsive to O₂-O₃ therapy. Thirty-two patients aged between 20 and 79 years were treated by DiscoGel® chemonucleolysis between December 2008 and January 2010. The treatment was successful (improvement in pain) in 24 out of 32 patients. DiscoGel® is safe and easy to handle and there were no complications related to product diffusivity outside the treatment site. The therapeutic success rate of DiscoGel® chemonucleolysis in patients unresponsive to O₂-O₃ therapy was satisfactory. Among other methods used to treat lumbar disc herniation, DiscoGel® chemonucleolysis can be deemed an intermediate procedure bridging conservative medical treatments and surgery.

Staged treatment of a blood blister-like aneurysm with stent-assisted coiling followed by flow diverter in-stent insertion. A case report

Blood blister-like aneurysms (BBLA) are rare lesions sometimes difficult to recognize and in most cases associated with diffuse subarachnoid haemorrhage and severe clinical conditions. BBLA are life-threatening because they tend to enlarge rapidly and to rebleed, and no consensus has so far been reached on the best management strategy. We describe a patient with a BBLA in the right ICA treated successful by a two-stage embolization procedure first with coils and an open cell stent (Neuroform 3) and later by further coil placement and insertion of a flow-diverting stent (Silk).

Treatment of intracranial aneurysms using flow-diverting silk stents (BALT): a single centre experience

The Silk stent (Balt, Montmorency, France) is a retractable device designed to achieve curative reconstruction of the parent artery associated with an intracranial aneurysm. We present our initial experience with the Silk flow-diverting stent in the management and follow-up of 25 patients presenting with intracranial aneurysms.Twenty-five patients (age range, 34-81 years; 24 female) were treated with the Silk flow-diverting device. Aneurysms ranged in size from small (5), large (10) and giant (10) and included wide-necked aneurysms, multiple, nonsaccular, and recurrent intracranial aneurysms. Nine aneurysms were treated for headache, 14 for mass effect. None presented with haemorrhage. All patients were pretreated with dual antiplatelet medications for at least 72 hours before surgery and continued taking both agents for at least three months after treatment. A total of 25 Silk stents were used. Control MR angiography and/or CT angiography was typically performed prior to discharge and at one, three, six and 12 months post treatment. A follow-up digital subtraction angiogram was performed between six and 19 months post treatment.Complete angiographic occlusion or subtotal occlusion was achieved in 15 patients in a time frame from three days to 12 months. Three deaths and one major complication were encountered during the study period. Two patients, all with cavernous giant aneurysms, experienced transient exacerbations of preexisting cranial neuropathies and headache after the Silk treatment. Both were treated with corticosteroids, and symptoms resolved completely within a month.In our experience the Silk stent has proven to be a valuable tool in the endovascular treatment of intracranial giant partially thrombosed aneurysms and aneurysms of the internal carotid artery cavernous segment presenting with mass effect. The time of complete occlusion of the aneurysms and the risk of the bleeding is currently not predictable.

The use of flow-diverting stents in the treatment of giant cerebral aneurysms: preliminary results

The treatment of giant cerebral aneurysms has always been a challenge for neurosurgeons and neuroradiologists. Flow-diverting stents (Silk; Pipeline Embolization Device) are new endovascular devices introduced for the treatment of intracranial aneurysms without release of intrasaccular coils. They are tubular bimetallic endoluminal devices with low porosity. We have employed these stents in the Neuroradiology Unit of Bellaria Hospital (Bologna, Italy) since the end of 2008, treating nine patients with giant carotid cerebral aneurysms using nine Silk stents as soon as the device obtained the CE mark. All patients were pretreated with dual antiplatelet medications before surgery. The Silk stents were deployed through a 4F Balt introducer, which ensured an uneventful and very quick procedure. Control CT angiography or MR angiography was typically performed at discharge and one, three, six and 12 months after treatment. Post-treatment results were: four complete occlusions, three near complete occlusions (residual neck flow) with reduced volume of the aneurysm and two more than 50% reduction of intra-aneurysmal flow. A fatal hemorrhagic complication occurred in one patient, probably due to the antiplatelet treatment. The Silk stent seems a very interesting curative device to treat giant aneurysms with preservation of the parent artery and small adjacent branches. Technical improvements will certainly reduce the thrombogenic effect with the related risks.

3T MRI in the Evaluation of Brain Aneurysms Treated with Flow-Diverting Stents: Preliminary Experience

Deployment of stents across the neck of intracranial aneurysms to isolate the lesion from the circulation is a recently introduced endovascular treatment. These devices are known as flow-diverting stents because the stent mesh design drastically slows the blood flow within the aneurysm sac, thereby stimulating thrombus formation. Treated aneurysms require close follow-up monitoring using an effective minimally invasive method. We devised a dedicated follow-up protocol using a high field strength magnetic resonance system (MR) with gadolinium administration to monitor 11 patients treated by insertion of flow-diverting stents. Findings were compared with the results of a reference imaging procedure (CT angiography). MR accurately demonstrated patency of the stent lumen and monitored the evolution of the aneurysmal sac in all patients. Gadolinium administration proved essential in two patients to depict the complete exclusion of the flow within the aneurysmal sac.

Ruptured “Occult” Aneurysm Disclosed by Three-Dimensional Angiographic Reconstructions

Rotational angiographic sequences and their three-dimensional reconstructions have led to major improvements in angiographic diagnostics, especially in the study of brain aneurysms. Reconstructions accurately depict the morphology of the aneurysm, namely any wall irregularities and the possible origin of arterial branches from the aneurysmal sac, and display the aneurysm on multiple spatial planes, measuring its different diameters and ratios (particularly the dome to neck ratio). Lastly, three-dimensional angiographic reconstructions will sometimes disclose ruptured or intact aneurysms not depicted by digital subtraction angiography. A 43-year-old woman was admitted to the emergency room of Maggiore Hospital, Bologna Local Health Trust, presenting severe headache, confusion and nuchal rigidity. Emergency CT scan disclosed cisternal subarachnoid haemorrhage. Subsequent 3D sequences revealed an aneurysm of the left carotid artery siphon. This occult aneurysm found in our patient had been masked by the overlying infundibular origin of the posterior communicating artery. This prevented detection of the lesion not only in standard oblique anteroposterior, craniocaudal and lateral sequences but also in the rotational sequence. Identification of the aneurysm in our patient was the result of the diagnostic strategy adopted. When cisternal subarachnoid haemorrhage is detected, our protocol routinely includes a rotational angiographic sequence centred on the anterior circulation and on the posterior circulation when the standard examination fails to depict the course of all the vessels or when the features of subarachnoid haemorrhage strongly suggest aneurysm rupture in that anatomical location. Three-dimensional angiographic reconstructions are extremely useful not only to characterize brain aneurysms, but also to disclose ruptured occult aneurysms and additional zero grade lesions.

Treatment of carotid siphon aneurysms with a microcell stent. A case report

SUMMARY

The treatment of giant, large, multiple or wide-necked carotid siphon aneurysms has always represented a challenge for neurosurgeons and neuroradiologists. Very recently the use of stents with tiny holes has been proposed by two companies: Balt Silk Stent in Europe and Pipeline in America. We have used the Silk stent on a few patients and describe our first case who now has an eleven month follow-up. The carotid siphon presented three converging aneurysms sharing a very large common neck. The Silk stent (Balt Extrusion, Montmorency, France) was deployed through a 4F Balt introducer. The procedure was uneventful and very quick. As soon as the stent was positioned contrast medium stagnation was displayed within the aneurysm. The patient's post-operative course was normal and she was discharged three days later in good health.

[Potential uses of color Doppler in periskeletal soft tissue neoplasms]

Integrated imaging plays a fundamental role in the study of periskeletal soft tissue tumors, for both diagnosis and treatment planning. The steady and progressive technologic progress of color Doppler US equipment now permits the integration of conventional morphostructural parameters with the biofunctional data of lesion flow patterns and relative qualitative features. To assess color Doppler capabilities in differentiating benign from malignant soft tissue tumors, we reviewed the B-mode and color Doppler findings of 43 consecutive patients with a palpable periskeletal soft tissue mass. All patients were examined with a real time unit (Ultramark 9 HDI), with a broadband (5-10 MHz) linear transducer operating at 6.5 MHz for Doppler measurements. The PRF was set at 1500 to 800 Hz with 70% color gain; a 100 Hz wall filter was used. We kept the color box in the area of interest as small as possible to keep the frame rate high; pulsed Doppler studies were performed with a small sample volume and 2000 Hz PRF. The following signs were considered: morphostructural features; the presence/absence of color signals; the (peripheral/internal) site of vascular branches, their caliber and course; the number of afferent vascular poles; resistance index. As a rule, malignant masses tend to differ from benign masses for the presence of multiple vascular afferent branches, especially if they have an irregular pattern and caliber, and for the variability of the resistance index measured in different parts of the same mass. Further examinations, performed with second level imaging (CT and MRI) and microhistologic tests, respectively after biopsy and surgical resection, confirmed the high predictive value of color Doppler US, with only 1 false negative and 2 false positives; color Doppler sensitivity and specificity were 94.7% and 91.6%, respectively, which are higher values than those obtained with US alone (63% and 66.6%). Therefore, we believe that color Doppler US can be systematically applied to the study of periskeletal soft tissue masses, integrating conventional US for the correct selection of the patients to be submitted to second level investigations.

[Magnetic resonance in the evaluation of lesions of the posterior tibial tendons]

Posterior tibial tendon (PTT) tears are the most common cause of unilateral flatfoot in adults. It is a chronic pathologic condition with a degenerative inflammatory character which usually affects middle-aged or elderly women, with no history of trauma. PTT tears occur more rarely in young patients, after an acute traumatic event. Clinically, PTT tears present with pain along the tendon, increased by weight bearing, swelling and functional limitation. PTT tears are surgically classified in three types: with tendon hypertrophy, with tendon atrophy and with complete tendon tear. The three different anatomicosurgical patterns require different therapeutic approaches. This work was aimed at investigating MR capabilities in recognizing the direct and indirect signs of PTT tears, assessing MR sensitivity in different types of tears. Fourteen patients with clinically suspected PTT tears and 10 control patients underwent MRI of the ankle (0.5 T, GE Vectra) following a study protocol including SE T1-weighted and FSE T2-weighted scans acquired on the axial and sagittal planes. In all patients, the transverse diameter, the shape and the section surface of the lesions were calculated on the axial planes at different levels; all these parameters were compared with those of the adjacent tendons, i.e., flexor longus ditae and flexor hallucis. Moreover, the probable presence was investigated of intratendineous signal intensity changes, of peritendineous synovial fluid and of indirect signs of PTT tear, i.e., the lack of longitudinal talonavicular alignment and the bulging of the medial navicular tubercle. According to MR results, the 14 patients were subdivided into 8 patients with type-I tears, 2 with type-II tears and 4 patients with type-III tears. The measures of healthy and injured tendons were in substantial agreement: in fewer cases, agreement was found also between symptomatic and control patients with intratendineous signal changes. Thus, the specificity of the two parameters was reduced. Finally, such indirect signs of PTT tear as a hypertrophic navicular tubercle and the lack of longitudinal talonavicular alignment exhibited good specificity, but sensitivity was barely sufficient. MR diagnoses were confirmed at surgery in 6 patients with type-II and type-III tears. In conclusion, MRI appears to be a suitable modality for recognizing and classifying PTT tears and a useful tool for the treatment and follow-up of these patients.