Optimization of b value in diffusion-weighted MRI for the differential diagnosis of benign and malignant vertebral fractures

Objective The objective was to explore the optimal b value in diffusion-weighted imaging (DWI) of MRI for differential diagnosis of benign and malignant vertebral fractures. Materials and Methods Thirty-four consecutive patients with vertebral compression fractures underwent sagittal diffusion-weighted imaging (DWI) with different b values. The group included 14 patients with 18 benign vertebral fractures due to osteoporosis and/or trauma and 20 patients with 27 malignant vertebral fractures due to malignancy. The quality of the images was analyzed qualitatively on a three-point scale and quantitatively by measurement of the signal-to-noise ratio (SNR). Apparent diffusion coefficient (ADC) values were also calculated. Results Smaller b values correlated with better DW image quality. We found significant differences in the qualitative points values among the DW images with different b values (F = 302.18, p < 0.001). The mean SNR of the images ranged from 21.75 ± 3.64 at a b value of 0 s/mm² to 5.31 ± 3.17 at a b value of 800 s/mm². The SNR of DWI with a b value of 300 s/mm² (18.62 ± 2.47) was significantly different from that with other b values (p < 0.01). The mean combined ADC values of malignant fractures were significantly lower than those of benign ones on DWI with a b value of 300 s/mm² (t = 9.097, p < 0.01). Four cases of benign vertebral fractures were misdiagnosed as being malignant when b values of 0 s/mm² and 100 s/mm² were used. Conclusions When DWI with multiple b values is used to differentiate benign from malignant vertebral compression fractures, b values within the range of around 300 s/mm² are recommended, taking into account both SNR and diffusion weighting of water molecules.     

Percutaneous vertebroplasty in the management of vertebral osteoporotic fractures. Short-term,mid-term and long-term follow-up of 285 patients

Objectives  To evaluate the short-term, mid-term and long-term follow-up of 285 patients who had undergone percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture (VCF) in our department from 2003 to 2006, and, particularly, to analyse our data on the safety and the usefulness of PVP for durable pain reduction, mobility improvement and the need for analgesic drugs. Materials and methods  Follow-up analysis was made through a questionnaire completed by the patients before and after PVP (1 week, 1 year and 3 years). The results are reported by subdivision of patients into groups (by gender, age and number of treated vertebrae), with special reference to pain management, drug administration and quality of life. Results  All patients (285) were followed up for 1 week, 186 for 12 months, and 68 patients were followed up for 3 years. One week after PVP all patients reported normal ambulation (with or without pain), and more than 95% were able to perform activities of daily living (ADL) either without pain or with mild pain. There was no difference in pain relief between the genders after 1 week’s follow up, but after 3 years better analgesia results were observed in women. There was no statistically significant difference in the visual analogue scale (VAS) values before PVP between age groups (P = 0.7) and gender (P = 0.4); Patients younger than 75 years had better outcomes than did older ones (>75 years) at 1 week and 1 year follow up. Patients also reported significant reduction in drug therapy for pain. Conclusions  PVP is a safe and useful procedure for the treatment of vertebral osteoporotic fractures. It produces enduring pain reduction, improves patients’ mobility and decreases the need for analgesic drugs.     

CT-guided percutaneous vertebroplasty in the therapy of vertebral compression fractures

The purpose of this study was to determine the efficacy and safety of CT-guided percutaneous vertebroplasty in the treatment of vertebral compression fractures. The primary objectives were pain reduction and bone-cement leakage during a long-term follow-up in patients with osteoporotic vertebral compression fractures. CT-guided percutaneous vertebroplasty was carried out in 61 patients (mean age 71.4 years; range 42–83; female ratio: 73.8%) with vertebral compression fractures. Treatment was carried out on an outpatient basis. Pain, bone-cement leakage and complications were monitored and recorded. The mean follow-up time was 19.8 months (range 3–52). Paired comparison procedures were used for the analysis of the results, which showed that all patients had a significant reduction of pain. The mean visual-analogue scale (VAS) before treatment was 8.8 points (range 6.5–9.8 points). The mean VAS score after treatment was significantly reduced to 2.6 points (range 1.5–4.1 points; p<0.01). No clinical or neurological complications were documented. Minor and asymptomatic bone-cement leakage was observed in 54% of the cases. Percutaneous vertebroplasty is an efficient and safe interventional procedure which rapidly improves the mobility and quality of life of patients with vertebral compression fractures. CT-guidance is a reasonable upgrade in the treatment procedure which reduces the amount of bone-cement leakage.T.J. Vogl and D. Proschek contributed equally to this work.     

Radiological Follow-up of New Compression Fractures Following Percutaneous Vertebroplasty

The purpose of the present study was to ascertain chronological changes in the analgesic effects of percutaneous vertebroplasty (PVP) on osteoporotic vertebral compression factures and to radiologically follow new compression fractures after PVP. Seventy-six patients (206 vertebral bodies) were followed radiologically for a mean of 11.5 months. A visual analog scale (VAS; 0–10) was used to assess pain severity, and frontal and lateral plain radiographs of the thoracic and lumbar vertebrae were taken 1–3 days and 1, 4, 10, and 22 months after PVP. The average VAS score was 7.2 ± 2.0 (mean pain score ± standard deviation) before PVP, 2.5 ± 2.3 at 1–3 days after PVP, 2.2 ± 2.3 at 1 month, 1.9 ± 2.2 at 4 months, 1.8 ± 2.4 at 10 months, and 1.0 ± 0.2 at 22 months. A new compression fracture was confirmed in 56 vertebral bodies in 28 patients (36.8%), affecting 38 adjacent vertebral bodies (67.8%), 17 nonadjacent vertebral bodies (30.4%), and 1 treated vertebral body (1.8%). A new compression fracture occurred within 1 week of PVP in 2 vertebral bodies (3.6%), between 1 week and 1 month after PVP in 22 (39.3%), between 1 and 3 months in 12 (21.4%), between 3 and 6 months in 12 (21.4%), and after more than 6 months in 8 (14.3%). PVP was highly effective in relieving the pain associated with osteoporosis-induced vertebral compression fractures, and this analgesia was long lasting. Radiological follow-up observation revealed new compression fractures in about one-third of patients. More than half of these new compression fractures occurred in adjacent vertebral bodies within 3 months of PVP.     

Outcome of long-axis percutaneous sacroplasty for the treatment of sacral insufficiency fractures

Our aim was to assess the clinical outcome of patients who were subjected to long-axis sacroplasty for the treatment of sacral insufficiency fractures. Nineteen patients with unilateral (n = 3) or bilateral (n = 16) sacral fractures were involved. Under local anaesthesia, each patient was subjected to CT-guided sacroplasty using the long-axis approach through a single entry point. An average of 6 ml of polymethylmethacrylate (PMMA) was delivered along the path of each sacral fracture. For each individual patient, the Visual Analogue pain Scale (VAS) before sacroplasty and at 1, 4, 24 and 48 weeks after the procedure was obtained. Furthermore, the use of analgesics (narcotic/non-narcotic) along with the evolution of post-interventional patient mobility before and after sacroplasty was also recorded. The mean pre-procedure VAS was 8 ± 1.9 (range, 2 to 10). This rapidly and significantly (P < 0.001) declined in the first week after the procedure (mean 4 ± 1.4; range, 1 to 7) followed by a gradual and significant (P < 0.001) decrease along the rest of the follow-up period at 4 weeks (mean 3 ± 1.1; range, 1 to 5), 24 weeks (mean 2.2 ± 1.1; range, 1 to 5) and 48 weeks (mean 1.6 ± 1.1; range, 1 to 5). Eleven (58%) patients were under narcotic analgesia before sacroplasty, whereas 8 (42%) patients were using non-narcotics. Corresponding values after the procedure were 2/19 (10%; narcotic, one of them was on reserve) and 10/19 (53%; non-narcotic). The remaining 7 (37%) patients did not address post-procedure analgesic use. The evolution of post-interventional mobility was favourable in the study group as they revealed a significant improvement in their mobility point scale (P < 0.001). Long-axis percutaneous sacroplasty is a suitable, minimally invasive treatment option for patients who present with sacral insufficiency fractures. More studies with larger patient numbers are needed to explore any unrecognised limitations of this therapeutic approach.     

Predictive value of brain perfusion SPECT for ketamine response in hyperalgesic fibromyalgia

Purpose Ketamine has been used successfully in various proportions of fibromyalgia (FM) patients. However, the response to this specific treatment remains largely unpredictable. We evaluated brain SPECT perfusion before treatment with ketamine, using voxel-based analysis. The objective was to determine the predictive value of brain SPECT for ketamine response. Methods Seventeen women with FM (48 ± 11 years; ACR criteria) were enrolled in the study. Brain SPECT was performed before any change was made in therapy in the pain care unit. We considered that a patient was a good responder to ketamine if the VAS score for pain decreased by at least 50% after treatment. A voxel-by-voxel group analysis was performed using SPM2, in comparison to a group of ten healthy women matched for age. Results The VAS score for pain was 81.8 ± 4.2 before ketamine and 31.8 ± 27.1 after ketamine. Eleven patients were considered “good responders” to ketamine. Responder and non-responder subgroups were similar in terms of pain intensity before ketamine. In comparison to responding patients and healthy subjects, non-responding patients exhibited a significant reduction in bilateral perfusion of the medial frontal gyrus. This cluster of hypoperfusion was highly predictive of non-response to ketamine (positive predictive value 100%, negative predictive value 91%). Conclusion Brain perfusion SPECT may predict response to ketamine in hyperalgesic FM patients.     

Height gain of vertebral bodies and stabilization of vertebral geometry over one year after vertebroplasty of osteoporotic vertebral fractures

The height gain of vertebral bodies after vertebroplasty and geometrical stability was evaluated over a one-year period. Osteoporotic fractures were treated with vertebroplasty. The vertebral geometry and disc spaces were analysed using reformatted computed tomography (CT) images: heights of the anterior, posterior, and lateral vertebral walls, disc spaces, endplate angles, and minimal endplate distances. Vertebrae were assigned to group I [severe compression (anterior height/posterior height) <0.75] and group II (moderate compression index >0.75). A total of 102 vertebral bodies in 40 patients (12 men, 28 women, age 70.3 ± 9.5) were treated with vertebroplasty and prospectively followed for 12 months. Group I showed a greater benefit compared with group II with respect to anterior height gain (+2.1 ± 1.9 vs +0.7 ± 1.6 mm, P < 0.001), reduction of endplate angle (−3.6 ± 4.2 vs −0.8 ± 2.3°, P < 0.001), and compression index (+0.09 ± 0.11 vs +0.01 ± 0.06, P < 0.001). At one-year follow-up, group I demonstrated preserved anterior height gain (+1.5 ± 2.8 mm, P < 0.015) and improved endplate angle (−3.4 ± 4.9°, P < 0.001). In group II, the vertebral heights returned to and were fixed at the pre-interventional levels. Vertebroplasty provided vertebral height gain over one year, particularly in cases with severe compression. Vertebrae with moderate compression were fixed and stabilized at the pre-treatment level over one year.     

Glucosamine sulfate effect on the degenerated patellar cartilage: preliminary findings by pharmacokinetic magnetic resonance modeling

Normal and degenerated cartilages have different magnetic resonance (MR) capillary permeability (K^trans) and interstitial interchangeable volume (v_e). Our hypothesis was that glucosamine sulfate treatment modifies these neovascularity abnormalities in osteoarthritis. Sixteen patients with patella degeneration, randomly distributed into glucosamine or control groups, underwent two 1.5-Tesla dynamic contrast-enhanced MR imaging studies (treatment initiation and after 6 months). The pain visual analog scale (VAS) and American Knee Society (AKS) score were used. A two-compartment pharmacokinetic model was used. Percentages of variations (postreatment-pretreatment/pretreatment) were compared (t-test for independent data). In the glucosamine group, pain and functional outcomes statistically improved (VAS: 7.3 ± 1.1 to 3.6 ± 1.3, p < 0.001; AKS: 18.6 ± 6.9 to 42.9 ± 2.7, p < 0.01). Glucosamine significantly increased K^trans at 6 months (−54.4 ± 21.2% vs 126.7 ± 56.9%, p < 0.001, control vs glucosamine). In conclusion, glucosamine sulfate decreases pain while improving functional outcome in patients with cartilage degeneration. Glucosamine sulfate increases K^trans, allowing its proposal as a surrogate imaging biomarker after 6 months of treatment.     

Follow-up of pain processing recovery after ketamine in hyperalgesic fibromyalgia patients using brain perfusion ECD-SPECT

Purpose The aim of this study was to determine whether the follow-up of pain processing recovery in hyperalgesic fibromyalgia (FM) could be objectively evaluated with brain perfusion ethyl cysteinate dimer single photon computerized tomography (ECD-SPECT) after administration of ketamine. Materials and methods We enrolled 17 hyperalgesic FM women patients (48.5 ± 11 years, range 25–63). After treatment with subcutaneous ketamine, 11 patients were considered as “good responders”, with a decrease in pain intensity, evaluated by visual analog scale (VAS), greater than 50%. On the other hand, six patients were considered as “poor responders”. A voxel-based analysis of regional cerebral blood flow (rCBF) was conducted (p _voxel < 0.001uc), in the two subgroups of patients, before and after treatment, in comparison to a group of ten healthy subjects, matched for age and gender. Results In comparison to baseline brain SPECT, midbrain rCBF showed a greater increase after ketamine in the responder group than in the nonresponder group (p _cluster = 0.016c). In agreement with the clinical response, the change in midbrain rCBF after ketamine was highly correlated with the reduction of VAS pain score (r = 0.7182; p = 0.0041). Conclusion This prospective study suggests that blockade of facilitatory descending modulation of pain with ketamine can be evaluated in the periaqueductal grey with brain perfusion SPECT.     

Measurement of spinal canal narrowing,interpedicular widening,and vertebral compression in spinal burst fractures: plain radiographs versus multidetector computed tomography

Objective  To assess the reliability of measurements of spinal canal narrowing, vertebral body compression, and interpedicular widening in burst fractures in radiography compared with multidetector computed tomography (MDCT). Materials and methods  Patients who had confirmed acute vertebral burst fractures over an interval of 34 months underwent both MDCT and radiography. Measurements of spinal canal narrowing, vertebral body compression, and interpedicular widening from MDCT and radiography were compared. Results  The 108 patients (30 female, 78 male, aged 16–79 years, mean 39 years) had 121 burst fractures. Eleven patients had multiple fractures, of which seven were not contiguous. Measurements showed a strong positive correlation between radiography and MDCT (Spearman’s rank sum test: spinal canal narrowing k = 0.50–0.82, vertebral compression k = 0.55–0.72, and interpedicular widening k = 0.81–0.91, all P < 0.05), except for the cervical spine (k = −0.50 to 0.61, with all P > 0.25) and for interpedicular widening in the thoracic spine (k = 0.35, P = 0.115). The average difference in measurements between the modalities was 3 mm or fewer. Conclusion  Radiography demonstrates interpedicular widening, spinal canal narrowing and vertebral compression with acceptable precision, with the exception of those of the cervical spine.     

CT-guided vertebroplasty: analysis of technical results, extraosseous cement leakages, and complications in 500 procedures

The aim of this study was to analyze the technical results, the extraosseous cement leakages, and the complications in our first 500 vertebroplasty procedures. Patients with osteoporotic vertebral compression fractures or osteolytic lesions caused by malignant tumors were treated with CT-guided vertebroplasty. The technical results were documented with CT, and the extraosseous cement leakages and periinterventional clinical complications were analyzed as well as secondary fractures during follow-up. Since 2002, 500 vertebroplasty procedures have been performed on 251 patients (82 male, 169 female, age 71.5 ± 9.8 years) suffering from osteoporotic compression fractures (n = 217) and/or malignant tumour infiltration (n = 34). The number of vertebrae treated per patient was 1.96 ± 1.29 (range 1–10); the numbers of interventions per patient and interventions per vertebra were 1.33 ± 0.75 (range 1–6) and 1.01 ± 0.10, respectively. The amount of PMMA cement was 4.5 ± 1.9 ml and decreased during the 5-year period of investigation. The procedure-related 30-day mortality was 0.4% (1 of 251 patients) due to pulmonary embolism in this case. The procedure-related morbidity was 2.8% (7/251), including one acute coronary syndrome beginning 12 h after the procedure and one missing patellar reflex in a patients with a cement leak near the neuroformen because of osteolytic destruction of the respective pedicle. Additionally, one patient developed a medullary conus syndrome after a fall during the night after vertebroplasty, two patients reached an inadequate depth of conscious sedation, and two cases had additional fractures (one pedicle fracture, one rib fracture). The overall CT-based cement leak rate was 55.4% and included leakages predominantly into intervertebral disc spaces (25.2%), epidural vein plexus (16.0%), through the posterior wall (2.6%), into the neuroforamen (1.6%), into paravertebral vessels (7.2%), and combinations of these and others. During follow-up (15.2 ± 13.4 months) the secondary fracture rate was 17.1%, including comparable numbers for vertebrae at adjacent and distant levels. The presence of intradiscal cement leaks was not associated with increased adjacent fracture rates. CT-guided vertebroplasty is safe and effective for treatment of vertebral compression fractures. CT-fluoroscopy provides an excellent control of the posterior vertebral wall. The number of cement leakages alone is not directly associated with clinical complications. However, even small volumes of pulmonary PMMA embolism might be responsible for the fatal outcome in cases with underlying cardiopulmonary insufficiency.     

Radiofrequency Ablation Therapy Combined with Cementoplasty for Painful Bone Metastases: Initial Experience

The purpose of this study was to assess the efficacy and safety of percutaneous radiofrequency (RF) ablation therapy combined with cementoplasty under computed tomography and fluoroscopic guidance for painful bone metastases. Seventeen adult patients with 23 painful bone metastases underwent RF ablation therapy combined with cementoplasty during a 2-year period. The mean tumor size was 52 × 40 × 59 mm. Initial pain relief, reduction of analgesics, duration of pain relief, recurrence rate of pain, survival rate, and complications were analyzed. The technical success rate was 100%. Initial pain relief was achieved in 100% of patients (n = 17). The mean VAS scores dropped from 63 to 24 (p < 0.001) (n = 8). Analgesic reduction was achieved in 41% (7 out of 17 patients). The mean duration of pain relief was 7.3 months (median: 6 months). Pain recurred in three patients (17.6%) from 2 weeks to 3 months. Eight patients died and 8 patients are still alive (a patient was lost to follow-up). The one-year survival rate was 40% (observation period: 1–30 months). No major complications occurred, but one patient treated with this combined therapy broke his right femur 2 days later. There was transient local pain in most cases, and a hematoma in the psoas muscle (n = 1) and a hematoma at the puncture site (n = 1) occurred as minor complications. Percutaneous RF ablation therapy combined with cementoplasty for painful bone metastases is effective and safe, in particular, for bulky tumors extending to extraosseous regions. A comparison with cementoplasty or RF ablation alone and their long-term efficacies is needed.     

Use of FDG-PET in differentiating benign from malignant compression fractures

Objective The objective was to evaluate the use of fluorodeoxyglucose positron emission tomography (FDG-PET) in differentiating benign from malignant compression fractures. Patients and methods In a retrospective analysis, we identified 33 patients with 43 compression fractures who underwent FDG-PET. On FDG-PET the uptake pattern was recorded qualitatively and semiquantitatively and fractures were categorized as benign or malignant. Standardized uptake values (SUV) were obtained. MRI, CT, and biopsy results as well as clinical follow-up for 1–3 years served as standards of reference. The Student’s t test was used to determine whether there was a statistically significant difference between the SUV for benign and malignant compression fractures. Results There were 14 malignant and 29 benign compression fractures, including 5 acute benign fractures. On FDG-PET, 5 benign fractures were falsely classified as malignant (false-positive). Three of these patients underwent prior treatment with bone marrow-stimulating agents. There were two false-negative results. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FDG-PET in differentiating benign from malignant compression fractures were 86%, 83%, 84%, 71%, and 92% respectively. The difference between SUV values of benign and malignant fractures was statistically significant (1.9 ± 0.97 for benign and 3.9 ± 1.52 for malignant fractures, p < 0.001). SUV of benign acute and chronic fractures were not statistically significant. Conclusion Fluorodeoxyglucose positron emission tomography is useful in differentiating benign from malignant compression fractures. Therapy with bone marrow-stimulating agents can mimic malignant involvement.     

Assessment of coronary flow reserve by sestamibi imaging in patients with typical chest pain and normal coronary arteries

Purpose We assessed coronary flow reserve (CFR) by sestamibi imaging in patients with typical chest pain, positive exercise stress test and normal coronary vessels. Methods Thirty-five patients with typical chest pain and normal angiogram and 12 control subjects with atypical chest pain underwent dipyridamole/rest ^99mTc-sestamibi imaging. Myocardial blood flow (MBF) was estimated by measuring first transit counts in the pulmonary artery and myocardial counts from SPECT images. Estimated CFR was expressed as the ratio of stress to rest MBF. Rest MBF and CFR were corrected for rate–pressure product (RPP) and expressed as normalised MBF (MBF_n) and normalised CFR (CFR_n). Coronary vascular resistances (CVR) were calculated as the ratio between mean arterial pressure and estimated MBF. Results At rest, estimated MBF and MBF_n were lower in controls than in patients (0.98 ± 0.4 vs 1.30 ± 0.3 counts/pixel/s and 1.14 ± 0.5 vs 1.64 ± 0.6 counts/pixel/s, respectively, both p < 0.02). Stress MBF was not different between controls and patients (2.34 ± 0.8 vs 2.01 ± 0.7 counts/pixel/s, p=NS). Estimated CFR was 2.40 ± 0.3 in controls and 1.54 ± 0.3 in patients (p < 0.0001). After correction for the RPP, CFR_n was still higher in controls than in patients (2.1 ± 0.5 vs 1.29 ± 0.5, p < 0.0001). At baseline, CVR values were lower (p < 0.01) in patients than in controls. Dipyridamole-induced changes in CVR were greater (p < 0.0001) in controls (−63%) than in patients (−35%). In the overall study population, a significant correlation between dipyridamole-induced changes in CVR and CFR was observed (r = −0.88, p < 0.0001). Conclusion SPECT might represent a useful non-invasive method for assessing coronary vascular function in patients with angina and a normal coronary angiogram.     

Chronic medial knee pain without history of prior trauma: correlation of pain at rest and during exercise using bone scintigraphy and MR imaging

Objective  The objective of this study was to correlate chronic medial knee pain at rest and during exercise with bone scintigraphic uptake, bone marrow edema pattern (BMEP), cartilage lesions, meniscal tears, and collateral ligament pathologies on magnetic resonance MR imaging (MRI). Materials and methods  Fifty consecutive patients with chronic medial knee pain seen at our institute were included in our study. Pain level at rest and during exercise was assessed using a visual analog scale (VAS). On MR images, BMEP volume was measured, and the integrity of femoro-tibial cartilage, medial meniscus, and medial collateral ligament (MCL) were assessed. Semiquantitative scintigraphic tracer uptake was measured. Multivariate linear regression analysis was performed. Results  At the day of examination, 40 patients reported medial knee pain at rest, 49 when climbing stairs (at rest mean VAS 33 mm, range 0–80 mm; climbing stairs mean VAS, 60 mm, range 20–100 mm). Bone scintigraphy showed increased tracer uptake in 36 patients (uptake factor, average 3.7, range 2.4–18.0). MRI showed BMEP in 31 studies (mean volume, 4,070 mm³; range, 1,200–39,200 mm³). All patients with BMEP had abnormal bone scintigraphy. Ten percent of patients with pain at rest and 8% of patients with pain during exercise showed no BMEP but tracer uptake in scintigraphy. Tracer uptake and signal change around MCL predicted pain at rest significantly (tracer uptake p = 0.004; MCL signal changes p = 0.002). Only MCL signal changes predicted pain during exercise significantly (p = 0.001). Conclusion  In chronic medial knee pain, increased tracer uptake in bone scintigraphy is more sensitive for medial knee pain than BMEP on MRI. Pain levels at rest and during exercise correlate with signal changes in and around the MCL.     

Combined CT and fluoroscopic guidance of balloon kyphoplasty versus fluoroscopy-only procedures

Objective  To evaluate the performance of combined (computed tomography (CT) and fluoroscopic) guidance of balloon kyphoplasty in comparison to fluoroscopic guidance alone. Materials and methods  Forty-one kyphoplasties were performed between January 2005 and March 2006 according to two different protocols. Study group 1 consisted of 20 consecutive patients with 20 balloon kyphoplasty procedures under dual guidance (CT scan and fluoroscopy) for osteoporotic or traumatic vertebral fractures. Study group 2 consisted of 21 consecutive patients in whom kyphoplasty was performed with fluoroscopy alone. Visualization of the pedicles, the final of the balloon position, and cement distribution were evaluated(1—poor, 2—intermediate, 3—good). Results  Combined use of CT and fluoroscopy (group 1) was superior in identifying the pedicles (100% versus 66.7%, p = 0.009) and balloon placement (100% versus 71.4%, p = 0.02) but not in monitoring of cement distribution within the vertebral body (100% versus 90.5%, p = 0.49). The difference between the two groups was more pronounced in the thoracic spine than in the lumbar spine. Conclusion  CT/fluoroscopic guidance of kyphoplasty combines safe CT-guided insertion of the osteointroducers and balloons as well as fluoroscopic real-time monitoring of polymethylmethacrylate injection.     

Is 3T-MR Spectroscopy a Predictable Selection Tool in Prophylactic Vertebroplasty?

This study was designed to confirm relationships between decrease of bone mineral density and increase of marrow fat and to delineate, through MR spectroscopy, vertebral body at high risk for compression fracture onset to justify prophylactic vertebroplasty. We enrolled 127 women: 48 osteoporotic, 36 osteopenic, and 43 normal subjects, who underwent DXA and MR examination of spine. Then, we selected 48 patients with at least two acute osteoporotic vertebral fractures with interposed normal “sandwich” vertebrae; all patients underwent MR examination of spine. Significant statistical differences were found among “Fat Fraction” (FF) values in normal, osteopenic, and osteoporotic subjects: 59.8 ± 5.1%; 64.8 ± 4.4%; and 67.1 ± 3.3%. A mild, significant, negative correlation was observed between T-score and vertebral fat content (r = − 0.585; P = 0.0000). In the second part of the study, 9 new vertebral fractures were observed in 48 patients (19%): 6 were “sandwich” vertebrae (12.5%), and 3 were located in distant vertebral body. The mean FF in sandwich fractured vertebrae was 72.75 ± 1.95 compared with the FF of the nonfractured sandwich, and distant control vertebrae were 61.83 ± 3.42 and 61.42 ± 3.64. We found a significant statistical difference between fractured and nonfractured vertebrae (P < 0.001). The results of this study suggest that MR spectroscopy could be a reliable index to predict the risk of new compression vertebral fracture and could be used for vertebroplasty planning contributing to clarify the possibility to add prophylactic PVP to standard treatment.     

Percutaneous vertebroplasty for multiple myeloma of the cervical spine

Introduction  Spinal involvement is a common presentation of multiple myeloma (MM); however, the cervical spine is the least common site of myelomatous involvement. Few studies evaluate the results of percutaneous vertebroplasty (PV) in the treatment of MM of the spine. The purpose of this series is to report on the use of PV in the treatment of MM of the cervical spine and to review the literature. Materials and methods  From January 1994 to October 2007, four patients (three men and one woman; mean age, 45 years) who underwent five PV for painful MM in the cervical spine were retrospectively reviewed. The pain was estimated by the patient on a verbal analogic scale. Clinical follow-up was available for all patients (mean, 27.5 months; range, 1–96 months). Results  The mean volume of cement injected per vertebral body was 2.3 ± 0.8 mL (range, 1.0–4.0 mL) with a mean vertebral filling of 55.0 ± 12.0% (range, 40.0–75.0%). Analgesic efficacy was achieved in all patients. One patient had a spinal instability due to a progression of spinal deformity noted on follow-up radiographs, without clinical symptoms. Cement leakage was detected in three (60%) of the five treated vertebrae. There was no clinical complication. Conclusions  The present series suggests that PV for MM of the cervical spine is safe and effective for pain control; nonetheless, the detrimental impact of the disease on bone quality should prompt close radiological follow-up after PV owing to the risk of spinal instability.     

Gastrointestinal 18F-FDG accumulation on PET without a corresponding CT abnormality is not an early indicator of cancer development

Focal gastrointestinal 2-deoxy-2-[¹⁸F]-fluoro-D-glucose (FDG) uptake can frequently be found on FDG-PET/CT even in patients without known gastrointestinal malignancy. The aim of this study was to evaluate whether increased gastrointestinal FDG uptake without CT correlate is an early indicator of patients developing gastrointestinal malignancies. A total of 1,006 patients without esophagogastric or anorectal malignancies underwent FDG-PET/CT. The esophagogastric junction, the stomach and the anorectum were evaluated for increased FDG uptake. Patients without elevated uptake were assigned to group A, patients with elevated uptake were allocated to group B. The SUVmax values of both groups were tested for significant differences using the U test. A follow-up of longer than 1 year (mean 853 ± 414 days) served as gold standard. A total of 460 patients had to be excluded based on insufficient follow-up data. For the remaining 546 patients the mean SUVmax was as follows: (a) esophagogastric junction, group A 3.1 ± 0.66, group B 4.0 ± 1.11, p < 0.01; (b) stomach, group A 2.8 ± 0.77, group B 4.1 ± 1.33, p < 0.01; (c) rectal ampulla, group A 2.8 ± 0.83, group B 3.9 ± 1.49, p < 0.01; (d) anal canal, group A 2.7 ± 0.55, group B 3.9 ± 1.59, p < 0.01. Only one patient developed gastric cancer. In the case of an unremarkable CT, elevated esophagogastric or anorectal FDG uptake does not predict cancer development and does not have to be investigated further.     

Safety and Efficacy of Sacroplasty for Sacral Fractures: A Systematic Review and Meta-Analysis

PurposeTo evaluate the safety and efficacy of sacroplasty for the treatment of osteoporotic and malignant sacral fractures by performing a systematic review and meta-analysis of existing literature.Materials and MethodsPubMed, Web of Science, and SCOPUS databases were searched from their inception until February 2018 for articles describing sacroplasty. Inclusion criteria were as follows: studies reporting > 5 patients, and pain assessment before and after the procedure recorded with visual analog scale (VAS). Demographic data, procedural details, technical success rates, VAS scores before and after the procedure, and procedural complications were recorded. A random-effects meta-analyses of the VAS pain score before the procedure, at 24–48 hours, at 6 months, and at 12 months were calculated.ResultsNineteen studies (18 case series and 1 cohort study) were identified consisting of 861 total patients (682 women and 167 men; mean age 73.89 ± 9.73 years). Patients underwent sacroplasty for the following indications: sacral insufficiency fractures secondary to osteoporosis (n = 664), malignancy (n = 167), and nonspecified sacral insufficiency fractures (n = 30). Technical and clinical successes were achieved in 98.9% (852/861) and 95.7% (623/651) of patients undergoing sacroplasty, respectively. The pooled major complication rate was 0.3%, with 3 patients requiring surgical decompression for cement leakage. Random-effects meta-analyses demonstrated statistically significant differences in the VAS pain level at preprocedure, 24–48 hours, 6 months, and 12 months, with cumulative pain scores of 8.32 ± 0.01, 3.55 ± 0.01, 1.48 ± 0.01, and 0.923 ± 0.01, respectively.ConclusionsSacroplasty appears safe and effective for pain relief in patients with osteoporotic or malignant sacral fractures, with statistically significant sustained improvement in VAS pain scores up to 12 months.