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BackgroundThe treatment of severe osteoporotic vertebral compression fractures (VCFs) with middle-column (MC) involvement, high fragmentation, large cleft and/or pedicular fracture is challenging. Minimally invasive 'stent-screw-assisted internal fixation' (SAIF) can reduce the fracture, reconstruct the vertebral body (VB) and fix it to the posterior elements.ObjectiveTo assess feasibility, safety, technical and clinical outcome of the SAIF technique in patients with severe osteoporotic VCFs.Methods80 treated vertebrae were analyzed retrospectively. Severe VCFs were characterized by advanced collapse (Genant grade 3), a high degree of osseous fragmentation (McCormack grade 2 and 3), burst morphology with MC injury, pediculo-somatic junction fracture, and/or large osteonecrotic cleft. VB reconstruction was evaluated on postprocedure radiographs and CT scans by two independent raters. Clinical and radiological follow-ups were performed at 1 and 6 months.ResultsSAIF was performed at 28 thoracic and 52 lumbar levels in 73 patients. One transient neurological complication occurred. VB reconstruction was satisfactory in 98.8% of levels (inter-rater reliability 96%, κ=1). Follow-up at 1 month was available for 78/80 levels and at 6 months or later (range 6–24, mean 7.9 months) for 73/80 levels. Significant improvement in the Visual Analog Scale score was noted at 1 and 6 months after treatment (pConclusionsSAIF is a minimally invasive, safe, and effective treatment for patients with severe osteoporotic VCFs with MC involvement.

ObjectivesTo describe a new technique to obtain minimally invasive but efficient vertebral body (VB) reconstruction, augmentation, and stabilization in severe osteoporotic and neoplastic fractures, combining two pre-existing procedures. The implant of vertebral body stents (VBS) is followed by insertion of percutaneous, fenestrated, cement-augmented pedicular screws that act as anchors to the posterior elements for the cement/stent complex. The screws reduce the risk of stent mobilization in a non-intact VB cortical shell and bridge middle column and pedicular fractures. This procedure results in a 360° non-fusion form of vertebral internal fixation that may empower vertebral augmentation and potentially avoid corpectomy in challenging fractures.Procedure detailsThis report provides step-by-step procedural details, rationale, and proposed indications for this procedure. The procedure is entirely percutaneous under fluoroscopic guidance. Through transpedicular trocars the VBS are inserted, balloon-expanded and implanted in the VB. Over k-wire exchange the transpedicular screws are inserted inside the lumen of the stents and cement is injected through the screws to augment the stents and fuse the screws to the stents.ApplicationsThis technique may find appropriate applications for the most severe osteoporotic fractures with large clefts, high-degree fragmentation and collapse, middle column and pedicular involvement, and in extensive neoplastic lytic lesions.ConclusionsStent-Screw-Assisted Internal Fixation (SAIF) might represent a minimally invasive option to obtain VB reconstruction and restoration of axial load capability in severe osteoporotic and neoplastic fractures, potentially obviating the need for more invasive surgical interventions in situations that would pose significant challenges to standard vertebroplasty or balloon kyphoplasty.

BackgroundExtensive lytic lesions of the vertebral body (VB) increase risk of fracture and instability and require stabilization of the anterior column. Vertebral augmentation is an accepted treatment option, but when osteolysis has extensively destroyed the VB cortical boundaries (a condition herein defined as ‘extreme osteolysis’), the risk of cement leakage and/or insufficient filling is high. Vertebral body stents (VBSs) might allow partial restoration of VB height, cement containment, and reinforcement, but their use in extreme osteolysis has not been investigated.ObjectiveTo assess retrospectively the feasibility and safety of VBS augmentation in patients with ‘extreme osteolysis’ of the VB.MethodsWe retrospectively analyzed 41 treated vertebrae (from T1 to L5). VB reconstruction was assessed on postprocedure CT images and rated on a qualitative 4-point scale (poor-fair-good-excellent). Clinical and radiological follow-up was performed at 1 month and thereafter at intervals in accordance with oncological protocols.ResultsVBS augmentation was performed at 12 lumbar and 29 thoracic levels, with bilateral VBS in 23/41. VB reconstruction was judged satisfactory (good or excellent) in 37/41 (90%) of levels. Bilateral VBS received higher scores than unilateral (p=0.057, Pearson’s X2). We observed no periprocedural complications. Cement leaks (epidural or foraminal) occurred at 5/41 levels (12.2%) without clinical consequences. Follow-up data were available for 27/29 patients, extending beyond 6 months for 20 patients (7–28 months, mean 15.3 months). VBS implant stability was observed in 40/41 cases (97.5%).ConclusionsOur results support the use of VBS as a minimally invasive, safe and effective option for reconstructing the anterior column in prominent VB osteolysis.

The AJNR published a game changing manuscript in 1997. A group composed mostly of neurointerventionalists described the use of polymethylmethacrylate in painful osteoporotic vertebral compression fractures.1 Soon thereafter, this then nascent technique began to flourish throughout many parts of the world. Since its inception, the JNIS has published content covering all aspects of neurointervention, including spine intervention; the first issue featured an article prospectively evaluating pain and functional outcomes after vertebroplasty.2 Over the years, JNIS has featured a variety of articles that advanced our knowledge and improved the capability of percutaneous approaches to treat spinal lesions, for example, in cancer patients.3 4 Moreover, the manuscripts have promoted understanding of the capabilities of percutaneous approaches to treating extra-spinal locations, for example, sacroplasty,5 6 acetabuloplasty,7 and even calcaneoplasty.8 JNIS has been receiving an ever-increasing number of high-quality manuscript submissions. This was very apparent during the most acute period of the COVID-19 pandemic.9 Topics related to mechanical spine have been a critical part of that growth. This commentary will highlight that subject matter—important spine articles from the last few years. Driven by clinical results, the number of patients treated with cement augmentation increased year over year from the time of the seminal Jensen AJNR paper. The simultaneous 2009 publication of two blinded studies in the NEJM raised some questions regarding the effectiveness of vertebroplasty over a sham procedure. Subsequent randomized control trials demonstrated vertebroplasty provided improved patient outcomes compared with sham procedures. These results have been extensively discussed in JNIS and other venues.10 The scientific discourse and conflicting results have impacted patient …

A 20-year-old man presented with a 6-month history of progressive weakness in the right hand. Neurological examination showed a bilateral weakness of hand muscles more pronounced in the right hand, slight scapula winging and no sensory disturbances. Nerve conduction studies showed motor conduction blocks in the median and ulnar nerves bilaterally (figure 1), with normal sensory conduction studies, suggesting a motor multifocal neuropathy (MMN). Somatosensory evoked potentials from …

Introduction/purpose Aim of this education exhibit is to offer an overview on image guided sympathetic blocks, focusing on specific indications and techniques, through the use of Fluoroscopy and/or CT imaging guidance, at each level of blockade. Materials and Methods Sympathetic blocks are used for diagnostic, prognostic and therapeutic purposes for painful and other conditions associated with sympathetic system dysfunctions. Main indications for sympathetic blockade are: Complex regional pain syndrome (CRPS), phantom limb pain, central pain, hyperhydrosis, acute pancreatitis, and abdominal viscera cancer pain. Stellate ganglion blocks are utilized for painful and non-painful conditions related to sympathetic dysfunctions of head, neck and upper extremities. Thoracic sympathetic blocks are utilized for CRPS, postoperative analgesia, pain from fractured ribs, therapeutic control of hyperhydrosis of the upper limbs and torso, liver capsule pain after blunt trauma, acute postherpetic neuralgia, and premature ventricular contractions. Coeliac plexus blocks are utilized in pain due to intra-abdominal cancer, stemming from organs innervated by coeliac plexus. Lumbar sympathetic blocks are utilized for CPRS of the lower extremities, herpes zoster, amputation stump pain and inoperable peripheral vascular vasospastic diseases of the lower limb. Superior hypogastric blocks are utilized for pelvic pain, and pelvic organs cancer pain (uterus, cervix, bladder, prostate, urethra, testes and ovaries). Impar ganglion blocks are utilized in coccydynia. Results The sympathetic nervous system has been implicated in numerous pain syndromes including neuropathic, vascular and visceral pain. In relation to this, in order to determine the sympathetic role in the transmission of pain and to manage these algic syndromes, sympathetic ganglia are targeted for local anesthetic blocks, for diagnostic, prognostic, and therapeutic purposes, balanced in a more complex pain treatment strategy, in the treatment of CRPS and other pain conditions. Safe and precise performance of these blocks requires knowledge of the loco-regional anatomy, accurate imaging guidance, and rigorous technique. Elements of relevant fluoroscopic and cross sectional anatomy, as well as procedural technique elements are discussed and displayed. Conclusion This educational exhibit summarizes the indications, the anatomy and the techniques, under Fluoroscopy or CT guidance, for the sympathetic blocks. Competing interests None.

Introduction/purpose Aim of this educational exhibit is to offer an overview on neuroradiological armamentarium in the minimally invasive percutaneous image-guided procedures on cervical spine. Materials and Methods Spinal neuro-interventional radiology offers a wide variety of percutaneous procedures for tissue diagnosis, draianage of fluid collections, pain management, diagnostic and therapeutic blocks, radiofrequency ablations, disc procedures, osteoporotic and neoplastic vertebral fractures treatment. Procedures under fluoroscopy and/or CT guidance, with different approaches (anterior, lateral, posterior, transmaxillary, and trans-oral), will be shown, and indications, relevant anatomy, procedural techniques will be outlined. -Anterior approach: Under fluoroscopic or CT guidance, it is used to access: Disc spaces: for biopsy, discography, percutaneous disc decompression; Vertebral bodies: from C4 to C7, for biopsy, cement vertebral augmentation, percutaneous tumor ablation; Stellate ganglion: for diagnostic, prognostic and therapeutic blocks in painful and non-painful conditions related to sympathetic dysfunctions of head, neck and upper extremities -Lateral approach: Under fluoroscopic or CT guidance, it is used to access: Central canal at C1-C2 for CSF collection or myelography; Neuroforamina C3-C8: for diagnostic, prognostic and therapeutic blocks in radicular pain; Zygoapophyseal joints: for diagnostic, prognostic and therapeutic blocks in facet-related pain; Median branch nerves: for diagnostic and prognostic blocks in facet-related pain -Posterior approach: Under fluoroscopic or CT guidance, it is used to access: Interlaminar space: for epidural blocksPosterior bony elements: for bone biopsies and cementoplasty; C1 lateral masses: for bone biopsies and cementoplasty; C1 and C2 neuroforamina: for diagnostic, prognostic and therapeutic blocks in radicular pain; C1-C2 joint: for diagnostic, prognostic and therapeutic blocks; Zygoapophyseal joints: for diagnostic, prognostic and therapeutic blocks in facet-related pain; Radiofrequency median branch denervation: for pain management of facet-related pain; Radiofrequency transverse occipital nerve denervation: for pain management of occipital neuralgia -Transmaxillary approach: Under CT guidance, it is used to access: C1 and C2 anterior bony elements: for biopsy, cement vertebral augmentation, percutaneous tumor ablation -Transoral approach: Under fluoroscopic guidance, it is used to access: C1-C3 anterior bony elements: for biopsy, cement vertebral augmentation, percutaneous tumor ablation. Results A wide variety of image-guided cervical spine procedures are illustrated, with their different approaches. Fluoroscopic or CT guidance can be chosen on the basis of personal preference, anatomical features, type of approach, and specific procedure to be performed. Percutaneous image-guided procedures on the cervical spine require thorough knowledge of loco-regional anatomy, precise and reliable imaging guidance, and rigorous technique, due to the complex, delicate, and vital anatomical environment, to avoid serious complications. Elements of relevant fluoroscopic and cross sectional anatomy, as well as procedural technique elements are discussed and displayed. Conclusion This educational exhibit illustrates a wide variety of percutaneous image-guided accesses to the cervical spine, utilized for diagnostic and therapeutic purposes, their indications, the anatomy and the techniques, under Fluoroscopy or CT guidance. Competing interests None.