Palliative Treatment of Multiple Level Painful Vertebral Metastases Employing O-Arm, Navigated Radiofrequency Ablation and Augmentation

Mario Carvi Nievas*

Department of Neurosurgery, Hufeland Klinikum GmbH, Germany

*Corresponding Author: Mario Carvi Nievas, Department of Neurosurgery, Hufeland Klinikum GmbH, Germany.

Received: June 27, 2023; Published: July 24, 2023

Abstract

Purpose: The aim of this study was to evaluate the benefit of the palliative treatment of multiple level painful vertebral metastases employing O-Arm navigated radiofrequency ablation (RFA) and augmentation.

Methods: Over a period of two years, the author of this paper additionally treated his patients with painful vertebral metastases on more than one level, using an O-Arm device and a navigator, to perform radiofrequency ablations with additional augmentation. In a few cases without obvious instabilities and if necessary, small microsurgical decompressions were also performed. The clinical effectiveness of this treatment was analysed by examining: 1) pain relief (standard 10-point visual analogue scale (VAS)), 2) follow up of the neurological condition and 3) procedure related morbidity (surgical bleeding, infections, and wound disorders). Radiological evaluations included: 1) MRI calculated percentage of tumour infiltration area on involved vertebra; 2) CT assessed morphological changes and the percentage cemented of the treated vertebra.

Results: Sixteen patients with painful metastases involving two to four levels were palliative treated during this period. Twelve patients had previously been irradiated and submitted to chemotherapy. All of them presented pain on more than one level. The mean age of the patients was 56 years (range 36 to 72); the mean time of onset of pain was 4 months; the surgeries lasted an average of 74 minutes. No neurological deterioration was observed in any of the treated patients. The mean VAS score decreased from a preoperative score of 8.3 to 3.2 at patient discharge (p ‹ .001), and 4.1 (p ‹ .001) 1 month later.

The mean percentage of vertebral bodies infiltrated by the tumor on MRI was 52% and the mean percentage of cemented vertebral bodies observed on computed tomography images was 46%. A good individual anatomical-radiological overlap between both areas was confirmed. In the postoperative period, a clear reduction in the use of narcotic drugs was observed. Pain relief was not related to the percentage of vertebral cementation, suggesting that thermal injury was the main mechanism involved in its resolution. In only one case there was a leakage of cement into the spinal canal, which was detected during the operation and immediately removed. One month later, no delayed radiological changes (new tumor growth, cement-induced tumor displacements, or vertebral instability) were found.

Conclusion: The palliative use of radiofrequency ablation and augmentation procedures coupled with intraoperative navigation performed with an O-Arm, reported several benefits in all patients treated with multiple-level vertebral metastases. These allowed to improve the accuracy of the procedures, achieve a prompt resolution of the pain suffered by the patients and reduce the time of surgical and X-ray exposure, with a very low complication rate.

Keywords: Radiofrequency Ablation and Augmentation; Multilevel Vertebral Painful Metastases; O-Arm Intra-Operative Targeted Navigation

References

1. Tokuhashi Y., et al. “Scoring system for the preoperative evaluation of metastatic spine tumor prognosis”. Spine 15 (1990): 1110-1113.
2. Tomita K., et al. “Surgical stategy for spinal metastases”. Spine 26 (2001): 298-306.
3. Barzilai O., et al. “State of the Art Treatment of Spinal Metastatic Disease”. Neurosurgery 82 (2018): 757-769.
4. Wagner A., et al. “Comprehensive surgical treatment strategy for spinal metastases”. Scientific Reports 11 (2021): 7988.
5. Tomasian A., et al. “Vertebral Metastases: Minimally Invasive Percutaneous Thermal Ablation”. Techniques in Vascular and Interventional Radiology 4 (2020): 100699.
6. Pusceddu C., et al. “The Role of a Navigational Radiofrequency Ablation Device and Concurrent Vertebral Augmentation for Treatment of Difficult-to-Reach Spinal Metastases”. Current Oncology 28 (2021): 4004-4015.
7. Cazzato RL., et al. “Percutaneous radiofrequency ablation of painful spinal metastasis: a systematic literature assessment of analgesia and safety”. International Journal of Hyperthermia 8 (2018): 1272-1281.
8. Cazzato RL., et al. “Low-power bipolar radiofrequency ablation and vertebral augmentation for the palliative treatment of spinal malignancies”. International Journal of Hyperthermia 8 (2018): 1282-1288.
9. Kam NM., et al. “Combined Vertebral Augmentation and Radiofrequency Ablation in the Management of Spinal Metastases: an Update”. Current Treatment Options in Oncology18 (2017): 74.
10. Aman MM., et al. “The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain”. Journal of Pain Research 14 (2021): 2139-2164.
11. Sayed D, et al. “Spinal Radiofrequency Ablation Combined with Cement Augmentation for Painful Spinal Vertebral Metastasis: A Single-Center Prospective Study”. Pain Physician5 (2019): E441-E449.
12. Anchala PR., et al. “Treatment of metastatic spinal lesions with a navigational bipolar radiofrequency ablation device: a multicenter retrospective study”. Pain Physician4 (2014) :317-327.
13. Greenwood TJ., et al. “Combined Ablation and Radiation Therapy of Spinal Metastases: A Novel Multimodality Treatment Approach”. Pain Physician6 (2015) :573-581.
14. Tomasian A., et al. “Simultaneous Bipedicular Radiofrequency Ablation Combined with Vertebral Augmentation for Local Tumor Control of Spinal Metastases”. AJNR American Journal of Neuroradiology 9 (2018): 1768-1773.
15. Wallace AN., et al. “Radiofrequency ablation and vertebral augmentation for palliation of painful spinal metastases”. Journal of Neuro-Oncology 1 (2015): 111-118.
16. Wallace AN., et al. “Radiographic Local Control of Spinal Metastases with Percutaneous Radiofrequency Ablation and Vertebral Augmentation”. American Journal of Neuroradiology 4 (2016): 759-765.
17. Tomasian A., et al. “Spine Microwave Ablation: Safety and Efficacy for Treatment of Vertebral Metastases”. American Journal of Neuroradiology 3 (2022): E9-E10.
18. Wallace AN., et al. “Use of Imaging in the Management of Metastatic Spine Disease with Percutaneous Ablation and Vertebral Augmentation”. American Journal of Roentgenology 2 (2015): 434-41.
19. Depreitere B., et al. “How good are the outcomes of instrumented debulking operations for symptomatic spinal metastases and how long do they stand? A subgroup analysis in the global spine tumor study group database”. Acta Neurochirurgica 162 (2020): 943-950.
20. Ringel F., et al. “Radiolucent Carbon Fiber-Reinforced Pedicle Screws for Treatment of Spinal Tumors: Advantages for Radiation Planning and Follow-Up Imaging”. World Neurosurgery 105 (2017): 294-301.
21. Hansen-Algenstaedt N., et al. “Comparison Between Minimally Invasive Surgery and Conventional Open Surgery for Patients With Spinal Metastasis: A Prospective Propensity Score-Matched Study”. Spine 42 (2017): 789-797.
22. Hamad A., et al. “Minimally invasive spinal surgery for the management of symptomatic spinal metastasis”. British Journal of Neurosurgery 31 (2017): 526-530.
23. Tomita K., et al. “Surgical strategy for spinal metastases”. Spine (Phila Pa 1976) 26 (2001): 298-306.
24. Kato S., et al. “Surgical Metastasectomy in the Spine: A Review Article”. The Oncologist 26 (2012): e1833-e1843.
25. Rieden K., et al. “The radiotherapeutic effect on bone metastases in relation to the frequency of metastases, sites of metastases and histology of the primary tumor”. Strahlentherapie und Onkologie 5 (1989): 380-385.
26. Adamietz IA., et al. “Palliative Radiotherapie“. In: Radioonkologie Klinik. Bamberg M, Molls M, Sack H (eds.). Zuckschwerdt W, Verlag GmbH (2009): 1065-1106.
27. Wu JS., et al. “Meta-analysis of dosefractionation radiotherapy trials for the palliation of painful bone metastases”. International Journal of Radiation Oncology, Biology, Physics 3 (2003): 594-605.
28. Chow E., et al. “Palliative radiotherapy trials for bone metastases: a systematic review”. Journal of Clinical Oncology 25 (2007): 1423-1436.
29. Ryu S., et al. “Image-guided and intensity-modulated radiosurgery for patients with spinal metastasis”. Cancer 97 (2003): 2013-2018.
30. “Cancer pain relief, with a guide to opiod availability”. World Health Organisation, Geneva (1996).
31. Greenlee RT., et al. “Cancer statistics”. CA Cancer Journal for Clinicians 50 (2000): 7-33.
32. Enkaoua EA., et al. “Vertebral metastases: a critical appreciation of the preoperative prognostic Tokuhashi score in a series of 71 cases”. Spine19 (1997): 2293-2298.
33. Patchell RA., et al. “Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial”. Lancet9486 (2005): 643-648.
34. Lemke DM., et al. “Metastatic compression fractures-vertebroplasty for pain control”. Journal of Neuroscience Nursing 35 (2003): 50-55.
35. Molloy S., et al. “The effect of vertebral body percentage fills on mechanical behavior during percutaneous vertebroplasty”. Spine14 (2003): 1549-1554.
36. Molloy S., et al. “Effect of cement volume and placement on mechanical-property restoration resulting from vertebroplasty”. American Journal of Neuroradiology 2 (2005): 401-404.
37. Garfin SR., et al. “New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures”. Spine14 (2001): 1511-1515.
38. Berenson J., et al. “Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial”. Lancet Oncology3 (2011): 225-235.
39. Anselmetti GC., et al. “Percutaneous vertebroplasty in multiple myeloma: prospective long-term follow-up in 106 consecutive patients”. CardioVascular and Interventional Radiology 1 (2012): 139-145.
40. Jurczyszyn A., et al. “Percutaneous Vertebroplasty for Pathological Vertebral Compression Fractures Secondary to Multiple Myeloma-Medium-Term and Long-Term Assessment of Pain Relief and Quality of Life”. Advances in Clinical and Experimental Medicine 4 (2015): 651-656.
41. McDonald RJ., et al. “Vertebroplasty in multiple myeloma: outcomes in a large patient series”. American Journal of Neuroradiology 4 (2008): 642-648.
42. Ringel F., et al. “Navigation, robotics, and intraoperative imaging in spinal surgery”. Advances and Technical Standards in Neurosurgery 41 (2014): 3-22.
43. Ryang YM., et al. “Learning curve of 3D fluoroscopy image-guided pedicle screw placement in the thoracolumbar spine”. The Spine Journal 15 (2015): 467-476. 
44. Tian NF., et al. “Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies”. European Spine Journal 20 (2011): 846-859. 
45. Rienmüller A., et al. “Accuracy of CT-navigated pedicle screw positioning in the cervical and upper thoracic region with and without prior anterior surgery and ventral plating”. The Bone and Joint Journal 99-b (2017): 1373-1380.
46. Banat M., et al. “The Role of Intraoperative Image Guidance Systems (Three-Dimensional C-arm versus O-arm) in Spinal Surgery: Results of a Single-Center Study”. World Neurosurgery 146 (2021): e817-e821.
47. Tomasian A., et al. “Complications of Percutaneous Radiofrequency Ablation of Spinal Osseous Metastases: An 8-Year Single-Center Experience”. American Journal of Roentgenology 6 (2021): 1607-1613.

Citation

Citation: Mario Carvi Nievas. “Palliative Treatment of Multiple Level Painful Vertebral Metastases Employing O-Arm, Navigated Radiofrequency Ablation and Augmentation". Acta Scientific Neurology 6.8 (2023): 30-40.

Copyright

Copyright: © 2023 Mario Carvi Nievas. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.