Interventional Spine

Patrick, Browaeys, MD
Nicolas, Amoretti, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

To describe and analyse the outcome of a new method of spondylolysis treatment which consists of a direct trans-isthmic fixation, realized under CT and fluoroscopic guidance and under local anaesthesia.

Methods & Materials

Prospective study including 10 patients (4 males & 6 females, mean age 57) between Jan 2007 and Jan 2008. Inclusion criteria were: a)bilateral L5-S1 spondylolysis with grade 1 or 2 associated spondylolisthesis; b) refractory pain to medical therapy and paraisthmic infiltration under CT guidance; c) orthopedic surgical indication for classic osteosynthesis.
Visual Analogic Score (VAS) for pain and Oswestry Disability Index (ODI) for daily activity were measured by an independent evaluator before the procedure, at 1, 3, 6, 12 and 24 months after the procedure.
Technique itself consists of an isotropic CT acquisition of the lumbar spine (GE Lightview 8 rows MSCT, GE Healthcare, Milwaukee, MI, USA). Under surgical conditions of aseptia and local anaesthesia, a 20-Gauge Shiba needle is first inserted on each side through the spondylolysis under fluoroscopic guidance, and after planification of the entry point and trajectory based on multiplanar reformation of the CT acquisition. Transfixition of the spondylolysis by the needle is assessed by iterative CT acquisition. A 13-Gauge Trocar t’AM (Thiebaud, France) is then inserted over the Shiba needle whom hub has been removed. Rotation motion is prefered over hammer for the trocar progression, up to the pedicle. A Kirschner wire is then inserted within the trocar and anchored to the pedicle. Trocar is withdrawn, and a 4mm self-drilling self-tapping Asnis IV screw (Stryker, Switzerland) is positioned over the K-wire. The length of the screw is calculated after the isthmus morphology using the CT acquisition. Fixation of the screw within the isthmus is done under fluoroscopic guidance and iterative CT acquisition to check its optimal placement and avoidance of nervous structures or intracanal cortical disruption. K-wire is finally withdrawn and a final CT acquisition is performed to confirm correct positioning of the screws.

Results

Bilateral minimally invasive percutaneous spondylolysis was successful in each patient. A total of 20 screws were placed (2 by patient)
Average procedure time was 50 minutes.
Patients were hospitalized for a total of 48h and instructed to return to full activity immediately after discharge.
No complication was observed during the procedure. There was no significant bleeding. No infection occurred during the immediate post intervention period nor during the 2 years follow-up.
No screw disruption nor displacement were observed during the 2 years follow-up.
The VAS for pain decreased from 7.8 +/- 1.7 before the procedure to 1.9 +/- 1.2 after the procedure (p<0.001). Post-procedure VAS were unchanged at 1, 3, 6, 12 and 24 months.
The ODI for daily activity decreased from 62.3 +/- 17.2% before the procedure to 15.1 +/- 6% after the procedure (p<0.001). Post-procedure ODI were also unchanged at 1, 3, 6, 12 and 24 months.

Conclusion

Trans-isthmic fixation under CT and fluoroscopic guidance appears to be a safe and effective therapeutic procedure for L5-S1 spondylolysis with low-grade spondylolisthesis.
To our knowledge, this technique has never been described.
We think that this procedure might improve patient care in this specific indication, by minimizing post-operative disability compared to classic open surgery, both because of absence of soft tissue injury and avoidance of general anaesthesia. It could also significantly reduce the overall treatment cost, with a limited hospitalisation time and a lighter procedure when compared to classic surgery.

General Spine

Christopher, E, Buckle, MD
Raghid, Kikano, MD, Non ASSR Member
Jordan, Prager, MD, Non ASSR Member
Saaid, Mojthaedi, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

While neuroforaminal stenosis is an important cause of sciatica that can be identified on MRI, estimates of the severity of foraminal stenosis vary widely between raters. Hence, there is a need for a consistent, reliable method of grading the degree of neuroformainal stenosis. While several scales have been developed for this purpose, to our knowledge there have been no studies that have directly compared the reliability of these scales using the same raters. The purpose of this study was to compare the interrater consistency and agreement of these scales in assessing the severity of neuroforaminal stenosis

Methods & Materials

4 raters with different levels of experience â

Interventional Spine

Alessandro, Cianfoni, MD
Guido, Bertolini, PhD, Non ASSR Member
Alessandro, Marrocu, PhD, Non ASSR Member
Giuseppe, Bonaldi, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

To assess the safety, feasibility, and effectiveness of posterior vertebral arch cement augmentation in preventing delayed spinous processesâ

Interventional Spine

Jonathan, A, Flug, MD, MBA
Ann, Hanford, RN, Non ASSR Member
A Orlando, Ortiz, MD, MBA, Non ASSR Member

Paper/Non-Mentor

Purpose

The purpose of this study is to compare the average cost per hospitalization of inpatients who have undergone vertebral augmentation in the fluoroscopy suite compared to those who had the procedure in the operating room.

Methods & Materials

Institutional review board approval was obtained for the study. 89 patients were retrospectively identified using billing data between April of 2008 and September of 2010 who were admitted to our institution with a diagnosis of vertebral fracture (ICD-9 codes 733.13, 805.2, & 805.4) and underwent vertebral augmentation during their hospitalization (ICD-9 codes 81.65 & 81.66). At our institution, one interventional Neuroradiologist performs vertebral augmentation in the fluoroscopy suite. The remaining credentialed physicians perform these procedures in the operating room. The location of the procedure was assumed based on the surgeon of record. The two cohorts were compared based on length of stay, total cost of the admission, and daily cost of the admission. A one-tailed T-Test was used to compare the findings.

Results

39 patients were identified who had vertebral augmentation performed in the fluoroscopy suite during their hospitalization with an average of 81.7 years. 70% were female. 25 patients were identified who had vertebral augmentation performed in the operating room during their hospitalization with an average age of 80.7 years. 65% were female. The average length of stay was not statistically different between the two groups. The average total cost per hospitalization was $26,074 in the group who had vertebral augmentation in the fluoroscopy suite compared to $32,078 for the group who had vertebral augmentation in the operating room. The average cost per day was $2,041 compared to $2,452. These findings were statistically significant.

Conclusion

Our findings suggest that vertebral augmentation performed on the inpatient population in the fluoroscopy suite is significantly cheaper than when it is performed in the operating room, without affecting length of stay for the hospitalization.

References/Financial Disclosures

1. Mathis JM, Ortiz OO, Zoarski GH. Vertebroplasty versus kyphoplasty: a comparison and contrast. AJNR Am J Neuroradiol 2004;25:840â

Interventional Spine

H., Paul, Hatten, Jr., M.D.

Paper/Non-Mentor

Purpose

In medicine, treatment algorithms and procedural methods continuously evolve in response to technology, reimbursement, clinical knowledge, site of service and patient preference. These dynamics provide opportunity for physicians most willing and technically prepared to recognize and serve as leaders in this evolution. Acute vertebral compression fractures (VCFs) are often treated with vertebral augmentation. Consideration of procedural forecasts and related opportunities, spine radiologists are positioned to serve as procedure advocates and first line "primary care" providers for osteoporosis patients & patients with tumors involving vertebral bodies.

Methods & Materials

Market research data are available for current and future trends in interventional procedures. Categorical evaluation of procedure type, procedural volume, site of service, physician discipline are provided and used to evaluate market potential and trends. Analysis of these data is used to forecast volumes of both kyphoplasty & vertebroplasty procedures by spine surgeons and spine radiologists for both procedures.

Results

Market research estimates 193,000 osteoporotic and oncology VCF minimally invasive procedures will be performed in 2010 in USA with an expected 4 year compounded annual growth rate (CAGR) of 7%.(1) Spine radiologists (neuroradiologists, interventional neuroradiologists, interventional radiologists) have performed the majority of vertebroplasties (58.2% in 2008).(2) Spine surgeons have dominated the kyphoplasty market (72.8% in 2008)(2) due primarily to targeted marketing of balloon kyphoplasty. iData Research, Inc. forecasts spine radiologists will acquire 53% of the growth estimated to occur in vertebroplasty & kyphoplasty by 2014 (Figure 1).

Conclusion

Given 700,000 VCFs occur annually in the US and a shift in VCF procedures away from spine surgeons, spine radiologists are uniquely positioned to dominate an existing U.S. market for osteoporotic and oncology VCFS of $460 million, which represents over $2 billion dollars in site of service and physician provider fees, based on current reimbursement. Educating the referral community, patients, payors and administrators to recent (Klazen et al and Wardlaw et al) and extensive historical evidence demonstrating clinical significance of these procedures is an opportunity to enlighten both referring physicians as well as spine surgeons no longer interested in performing these procedures. The surgical community has shown an unwillingness to defend vertebroplasty and kyphoplasty procedures. Spine radiologists must fill this void, to avoid payors heightened scrutiny of these procedures putting future reimbursement at risk. The spine radiology community is well positioned to treat these patients (in some cases as â

Interventional Spine

francisco, aparisi rodriguez, MD PhD.
maria pilar, aparisi rodriguez, md, Non ASSR Member

Paper/Non-Mentor

Purpose

I´m looking for a good tool in the lumbalgia treatment .

Methods & Materials

After two-year period 93 patients treated by RF, by 122 procedures, which are distributed in 75 thermal, 35 pulsed and 12 mixed. The series includes patients with degenerative facet disease, some with spinal stenosis and patients with disc lesions

Results

The distribution of results shows that 90 patients had some improvement after the first session, leaving after this treatment session 3 patients. (2 Thermal and pulsed).
Of the patients who continued, 25% received more than one session. In these series have given up the treatment 2 patients., Both with multisession., This makes a total of four rejections. (4.3%).

The distribution of results shows that 90 patients had some improvement after the first session, leaving after this treatment session 3 patients. (2 Thermal and pulsed).
Of the patients who continued, 25% received more than one session. In these series have given up the treatment 2 patients., Both with multisession., This makes a total of four rejections. (4.3%).Figure 1, joint thermal RF , Figure 2 epidural pulsed RF, Figure 3, intradiscal pulsed RF.

Conclusion

The subjective assessment of the degree of pain by VAS scale, indicates that a degenerative disease which is close to 70% accept treatment as an acceptable solution to their problem, having seen some dramatic improvement results although not statistically significant.

The comparison of results between patients treated
by pulsed RF and thermal energy, showing no significant difference.

References/Financial Disclosures

Maarten van Kleef, MD, PhD,* Gerard A. M. Barendse, MD,* Alfons Kessels, MD,â

Interventional Spine

Jacob, E, Enterkin, MD
Alessandro, Cianfoni, MD, Non ASSR Member

Paper/Non-Mentor

Purpose

A new synthetic, non-resorbable, bioactive composite material, Cortossâ

General Spine

Thomas, C, Lee, MD
Ajit, Puri, MD, Non ASSR Member
Raymond, Y, Huang, MD/PhD, Non ASSR Member
Charles, H, Cho, MD/MBA, Non ASSR Member

Paper/Non-Mentor

Purpose

Discography by fluoroscopy can be technically challenging to seemingly impossible at some levels, particularly L5-S1 due to the narrow window of access created by the iliac crests and exiting nerve roots. Various methods for improving technical success have been described such as the use of curved needles. In this article we describe a method of performing discography with oblique axial CT to plan a path medial to the exiting nerve with retrospective analysis of whether this method would allow for successful disc access on previously unsuccessful discograms.

Methods & Materials

A three year search for studies containing the words discogram, diskogram, discography, and diskography at our institution was performed after IRB approval. For discograms which were not technically successful, an axial oblique CT image was retrospectively created on the disc that could not be accessed to determine if there were a direct line approach to the disc from the skin surface.

Results

Fourteen successive patients who had undergone discography from June 2009 to October 2010 were identified. Eight of the discograms were not completely technically successful due to failure to access of one of the discs; 7 of these were with fluoroscopic guidance and 1 with CT guidance. Failure was attributed to lack of bony access or radiculopathy due to a nerve root along the needle path. Axial oblique CT image was retrospectively created for all cases except for one for which axial oblique MRI was reformatted since there was no CT available. In all cases, a direct line of approach to the disc in question that avoided the bony structures and exiting nerve roots was possible.

Conclusion

An axial oblique CT image aligned with the disc at the time of discography allows for avoidance of the exiting nerve roots which can not be visualized by fluoroscopy. A future study will prove if the CT guided simultaneous placement of multiple needles at different angles and reduced kV and mAs settings with total radiation lower than a standard CT dose compares favorably with fluoro guided procedure time and radiation.

References/Financial Disclosures

No financial disclosures.

Interventional Spine

Bassem, Georgy, MD

Paper/Non-Mentor

Purpose

The purpose of this study is to evaluate the feasibility, safety and study cement leakage patterns in vertebroplasty performed for both osteoporotic and malignant vertebral compression fractures using ultraviscous cement injected by a hydrolic device, â

Interventional Spine

Louis, A, Gilula, MD, Professor of Radiology, Musculoskeletal Radiology

Paper/Non-Mentor

Purpose

Introduction
A prospective, randomized, controlled, multi-center percutaneous vertebroplasty (PVP) study was conducted to compare results achieved with PMMA to Cortoss®, a novel bioactive composite material for vertebral augmentation. In addition to safety and efficacy, subsequent fracture data was also collected. Following PVP with PMMA, the literature reports subsequent fracture rates as high as 44%; whereas the natural incidence following a first fracture is estimated at 15-20%. This abstract analyzes if T-score, Genantâ