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Infective endocarditis can have peri-annular spread and involve the valvular annulus and adjacent cardiac structures, leading to tissue necrosis and peri-annular abscess. This process may cause pseudoaneurysm formation and other rare and potentially life-threatening complications, so their identification and correct diagnosis are crucial. We describe a case of an 81-year-old woman, with a history of aortic valve replacement and worsening of symptoms, that presents at the imaging a pseudoaneurysm of the aortic root complicated at the same time by 2 life-threatening conditions: fistulization in the Right Ventricular Outflow Tract (RVOT) and the compression of Right Coronary Artery (RCA). This case underlines the importance of imaging, especially Coronary Computed Tomography Angiography (CCTA), in the diagnosis and follow-up of infective endocarditis and its complications, especially in a patient not eligible for surgery.

As an alternative treatment to immediate surgical repair, endotracheal stent placement has been recently proposed in cases of iatrogenic tracheal damages.We report a case of a 91-year-old male who developed sudden subcutaneous emphysema during a total laryngectomy for laryngeal carcinoma. A tracheal tear at the distal third of the posterior tracheal wall was endoscopically assessed about 2 cm above the carina; CT confirmed the breach approximately 4 cm in length with associated pneumomediastinum and bilateral pneumothorax. Two covered self-expandable metal stents were then coaxially released under fluoroscopic control to cover the defect, restoring the tracheal integrity and leading to a normal thoracic appearance at CT and X-ray after 72 hours. Keywords: Iatrogenic tracheal rupture, Pneumomediastinum, Self-expandable metal stent

Vertebroplasty and kyphoplasty are minimally invasive techniques applied for the treatment of vertebral fractures. Since not all vertebral compression fractures are the same, a tailored-based approach is necessary for optimum efficacy and safety results. Nowadays, different cements and materials are proposed as alternatives to the original poly-methylmethacrylate aiming to overcome the limitations and the risks governing its use. Both techniques are governed by high efficacy and low complication rates; multilevel treatment in a single session has been shown to be feasible with no compromise of the technique's safety and efficacy. The purpose of this article is to describe the basic concepts of spinal augmentation by means of vertebroplasty and kyphoplasty. The current status and future of cements used will be defined. Controversies upon issues concerning both techniques will be addressed. Finally, the necessity for a tailored-based approach applying different techniques for different fractures will be addressed.

The thoracolumbar junction and lumbosacral segment are the portions of the spinal column most prone to acute traumatic fractures. Multiple classifications and injury severity score systems have been published to standardize the management of patients, establishing stable/unstable and surgical/nonsurgical fractures. In the past, patients could be treated only by surgical stabilization or conservative methods. The latter implied bed rest, long immobilization periods, prolonged drugs therapies, and, at worst, the evolution of kyphosis. Percutaneous mini-invasive treatments have been developed to improve the quality of life of patients affected by stable fractures, by rapidly recovering mobility and preventing deformity of the spinal column. These approaches, based on assisted techniques, imply the placement of different types of expandable bone implant systems. We discuss the treatment of vertebral fractures, focusing on percutaneous procedures and analyzing indications, contraindications, and outcomes of patients affected by vertebral nonosteoporotic/nonneoplastic but traumatic fractures.

Low back pain is an extremely common pathology affecting a great share of the population, in particular, young adults. Many structures can be responsible for pain such as intervertebral discs, facet joints, nerve roots, and sacroiliac joints. This review paper focuses on disc pathology and the percutaneous procedures available to date for its treatment. For each option, we will assess the indications, technical aspects, advantages, and complications, as well as outcomes reported in the literature and new emerging trends in the field.

A comprehensive description of the literature regarding interspinous process devices (IPD) mainly focused on comparison with conservative treatment and surgical decompression for the treatment of degenerative lumbar spinal stenosis. Recent meta-analysis and articles are listed in the present article in order to establish IPD pros and cons.

It is estimated that each year around 5% of all cancer patients develop metastases to the spine. In these patients, pain is the most cardinal symptom. The treatment of bone metastases is determined by a multidisciplinary team where the interventional radiologist is increasingly taking on a crucial role. Open surgery is not frequently used for treatment of bone metastases, owing to its morbidity and the often short life span of the patients. Surgical indications include a fracture with associated a neurologic compromise or high risk of developing pathologic fracture, which could result in neurological damage. Percutaneous cryoablation and thermoablation procedures are the therapeutic choices with a good efficacy in the treatment of painful metastatic lesions refractory to traditional therapies. These ablative methods can also be performed in combination with percutaneous cementoplasty to support and stabilisation for metastases in weight-bearing bones at risk for pathologic fracture.

Interventional radiology provides local management of bone metastases (BM) with a palliative intent in most cases, or with a curative intent in selected patients. Its role has rapidly expanded in the last decade, offering new treatment solutions often in combination with surgery, radiation therapy and medical treatments. The aim of the present paper is to increase awareness, acceptance and adoption of interventional radiology procedures for the treatment of BM; and to present the joint position of the Italian College of Musculoskeletal Radiology and the Italian College of Interventional Radiology.

Interventional radiology is based on minimally invasive procedures that allow diagnosis and percutaneous treatment of diseases in almost all organ systems. Such procedures have many benefits, but they also contribute significantly to collective radiation dose. In this regard, effective dose (E) is a convenient quantity to estimate patients’ stochastic radiation risk. However, E cannot be accurately evaluated immediately. In the present study, we aimed to estimate the E value in 15 selected interventional procedures. The estimation was based on dose area product (DAP) measurements and used case-specific conversion coefficients. The E values ranged from 3.3 to 69.9 mSv, depending on the kind of procedure. This wide range was mainly due to the broad variation in DAP values, which in turn depend on the details of how the procedures are performed. This suggests that to ensure valid comparative studies and universal reference levels, all interventional procedures should be well classified.

Vertebral compression fractures (VCFs) may result in a kyphotic deformity which can cause potential systemic complications secondary to respiratory and gastrointestinal dysfunction. The use of implants in the spine for VCF treatment represents a paradigm shift away from cement injection on its own, aiming to combine the analgesic and stabilizing effect of injecting cement into the vertebral body with vertebral height restoration and kyphotic angle correction. Spine implants which can be used for VCF treatment include stents, jacks, PEEK cages and fracture reduction systems. Lumbar spinal stenosis (LSS) with neurogenic intermittent claudication is one of the most commonly occurring spinal conditions, usually affecting people older than 50, which can cause disability and a reducted quality of life. Percutaneous interspinous spacers for the relief of symptoms caused by spinal stenosis can be used in patients who are not surgical candidates. The purpose of this article is to describe the basic concepts of spinal implantation in patients with VCF or spinal stenosis. The role of biomechanics and the different types of implants will be described. Controversies concerning techniques and products will be addressed. Finally, the necessity for an individually tailored approach for the use of different implants in different cases and anatomic locations will be emphasized.

Patients affected by rheumatic conditions frequently present with spine degeneration and vertebral compression fractures, mainly related to the long-term therapies with glucocorticosteroids. A mini-invasive approach provided by interventional radiology techniques, especially vertebroplasty, plays a relevant role in the pain management of these patients; vertebroplasty represents the symptomatic treatment of fracture pain, so patients must always be included in a specific therapeutic workup of the rheumatic condition. This article describes patient selection criteria, technique, and outcomes of vertebroplasty in patients affected by rheumatic disease and secondary osteoporosis caused by glucocorticosteroids.

Radiofrequency procedures have been used for treating various chronic pain conditions for decades. These minimally invasive percutaneous treatments employ an alternating electrical current with oscillating radiofrequency wavelengths to eliminate or alter pain signals from the targeted site. The aim of the continuous radiofrequency procedure is to increase the temperature sufficiently to create an irreversible thermal lesion on nerve fibres and thus permanently interrupt pain signals. The pulsed radiofrequency procedure utilises short pulses of radiofrequency current with intervals of longer pauses to avert a temperature increase to the level of permanent tissue damage. The goal of these pulses is to alter the processing of pain signals, but to avoid relevant structural damage to nerve fibres, as seen in the continuous radiofrequency procedure. The pulse-dose radiofrequency procedure is a technical improvement of the pulsed radiofrequency technique in which the delivery mode of the current is adapted. During the pulse-dose radiofrequency procedure thermal damage is avoided. In addition, the amplitude and width of the consecutive pulses are kept the same. The method ensures that each delivered pulse keeps the same characteristics and therefore the dose is similar between patients. The current review outlines the pulse-dose radiofrequency procedure and presents our institution’s chronic pain management studies.

Morton’s neuroma (MN) is a leading cause of disability. The purpose of this study was to investigate the effectiveness of radiofrequency (RF) in patients with chronic pain refractory to conservative therapies. Between September 2012 and December 2016, RF was performed on 52 patients. A sterile RF needle probe (22G, 5-cm needle with 10-mm electrode active tip) was inserted between the toes into the intermetatarsal space at the center of the lesion. Potential complications of the intervention and post-procedure care were examined. All patients provided written, informed consent. All percutaneous procedures were performed with the NeuroTherm® NT1100 (Neurotherm Inc., M.) device and using ultrasound guidance (Philips IU22). Continuous RF was performed with one cycle of 90 s and with the probe tip maintaining a temperature of 85 °C (impedance 95–210 mΩ). Mean VAS score before the procedures was 9.0 ± 0.6. A reduction of pain intensity was achieved after 1 week by RF (mean VAS scores 3.7 ± 0.9; p

Low back pain (LBP) is a major problem to public health. Approximately 60 to 80 % of the US population experience back pain at some point of their life [1]. Internal disc disruption (IDD) is an important cause of LBP, accounting for 28 to 43 % of the patients with LBP [2, 3].

Primary spinal tumors are relatively rare, estimated around 10% of all cancers interesting spine [1]. The spine is instead the most common site of metastasis in patients with cancer: up to 70% of cancer patients develop secondary spinal disease [2]. New cases of spinal tumors are detected in North America with a rate of incidence near to 18000 patients/year [3].

Aim The purpose of our study was to investigate the role of intra-articular pulse-dose radiofrequency in management of painful hallux valgus refractory to conservative therapies. Method Between November 2010 and April 2012, 51 patients (15 male, 36 female) with a median age of 71.4 years were included in our clinical trial. Under fluoroscopic guidance we introduced a 22 gauge 10 cm length cannula by a percutaneous access in the first metatarsophalangeal joint and its tip was placed intra-articularly. After removing the spindle, a radiofrequency needle with a 5 mm active tip was introduced. The following parameters were used: 1200 pulses at high voltage (45 V) with 20 msec duration followed by 480 msec silent phases. Results A great reduction in pain intensity was documented at 1 week, 1 month and 3 months after procedures. Pain intensity increased between 5 and 8 months after treatments, so we performed a second procedure in all patients between 7 months and 9 months since the first treatment. Also in this case we obtained a great reduction of pain intensity in the first 3 months after the procedure. Pain intensity returned at preprocedural values after 9 months after second procedure. No complications were observed. Conclusion Our experience shows pulse-dose radiofrequency is a safe, repeatable and effective technique for managing patients with symptomatic hallux valgus in the short and medium term. Pulse-dose radiofrequency may improve pain control and quality of life in patients with hallux valgus refractory to conservative therapies.

Low back pain is one of the most common causes of seeking medical attention in industrialized western countries. End plate degenerative changes in the acute phase, formally referred to as Modic type I, represent a specific cause. The aim of this study is to evaluate the effectiveness of vertebral augmentation with calcium sulfate and hydroxyapatite resorbable cement in patients with low back pain resistant to conservative treatment whose origin can be recognized in Modic type I changes. From February 2009 to October 2013, 1,124 patients with low back pain without radicular symptoms underwent physical and imaging evaluation. Stringent inclusion criteria elected 218 to vertebral augmentation with resorbable cement. Follow-up period was 1 year. One hundred seventy-two (79 %) patients improved quickly during the first 4 weeks after treatment. Forty-two (19 %) patients showed a more gradual improvement over the first 6 months, and at 1 year, their pain level did not differ from that of the previous group. In both groups, pain did not resolved completely, but patients showed significant improvement in their daily life activities. Two (1 %) patients did not show any improvement. Two (1 %) patients died for other reasons. There were no complications related to the procedures. Vertebroplasty with bioactive resorbable bone cement seems to be an effective therapeutic option for patients with low back pain resistant to conservative treatment whose origin could be recognized in Modic type I end plate degenerative changes.

The aim of our study was to evaluate the effectiveness of osteointegrable strontium-hydroxyapatite (Sr-HA) bone cement in the treatment of thoracolumbar traumatic vertebral fractures by percutaneous vertebroplasty (VTP).We treated 35 patients [29 (82.85 %) men, 6 (17.14 %) women, mean age 34.05 ± 8.36 years (range 21-54 years)] with single type A1.1 and A1.2 thoracolumbar traumatic vertebral fracture without endospecal bone fragments. Pain intensity was evaluated before and at 1 day; 1 week; and 1, 6, and 12 months after VTP by a 10-point visual analog scale (VAS) score (0 = no pain, 10 = unbearable pain). Physical status and quality of life were evaluated by Oswestry Disability Index (ODI) questionnaire before and 1, 6, and 12 months after VTP.Procedural technical success was achieved in all patients with no deaths observed during follow-up. In three patients (8.57 %), postprocedural CT showed cement leakages: one intradiscal and two in venous plexus. No adjacent vertebral body fractures nor intrasomatic recollapse was detected. The VAS and ODI scores showed a statistically significant reduction 1 week after procedure (P value0.0001) with a progressive statistically significant reduction during follow-up (P value0.0001). Twenty-three patients (65.71 %) assigned a value of 0 to the VAS scale at 1 year after treatment.Strontium-hydroxyapatite bone cement is an effective and safe bone filler in percutaneous vertebroplasty with low leakage rate and absence of major complications when performed by a skilled equipe. It allows an immediate and long-lasting stabilization with a significant pain reduction and quality of life improvement.

The purpose of this retrospective observational study was to demonstrate the efficacy of a percutaneous screws system in the treatment of lumbar pain caused by high-level disc degeneration combined with facet joint hypertrophy and canal stenosis especially in the L5-S1 levels.Thirty-eight patients (25 males, 13 females, mean age 63 years) with lumbar pain and/or neuralgia-claudication were treated with interpeduncular dynamic screws. Diagnosis was based on clinical\medical history evaluation and X-ray, CT, and MR examinations. All patients completed the visual analogic scale (VAS) for evaluation of clinical efficacy and pain measurement both before and after (1 month and after 2 years) the procedure. Patients also were given the Oswestry disability index (ODI) before and after treatment. The area of the neuroforamina also was measured.Thirty-eight intervertebral spaces were treated. The VAS pain scale showed a reduction of pain symptoms at 1 month and after 2 years (VAS pre 8.7 ± 1.1; after 1 month 5.1 ± 2.2; after 2 years 6.5 ± 2.1; p = 0.001). ODI also showed improvement (pre 56.7 ± 18.6 %; after 1 month: 31.9 ± 26.3%; after 2 years: 42 ± 24.2 %, p = 0.001). The study showed a widening of the neuroforaminal area of 15.5 % in the right neuroforamen and 17 % in the left ones (right foraminal area pre 0.94 mm(2), post 1.08 mm(2); left foramina area pre 0.95 mm(2), post 1.11 mm(2)). In addition, the spinal canal area displayed a statistically significant reduction (pre = 1.97 and post = 2.23; p0.0001).Our study indicates that patients treated with dynamic screws have VAS pain reduction as well as ODI improvement. Moreover, we found a statistically significant widening of the neuroforaminal area.

Inhaled corticosteroids (ICS) are established as first-line therapy for persistent asthma in children. Fluticasone propionate (FP) has been used because it has equivalent efficacy when used at half-dose of older-generation ICS and has a comparable safety profile. However, concerns persist about the potential risk of adverse effects of long-term FP therapy on childhood growth, bone, adrenal function and immune system. To evaluate the potential adverse effects of FP, we analyzed growth, glucidic metabolism, hypothalamic-pituitary-adrenal axis, bone metabolism, bone mass density and immune system in a cohort of 19 children (average 102±18 months), with asthma who were in treatment with FP (average duration: 14 months, range: 11–17 months). Of these, 11 children homogenous for control of asthma symptoms, and compliance to therapy, were selected for a prospective study during which they were treated with FP250 mg/day for further 6 months (total period of treatment average duration: 22 months, range: 18–23 months). In all children, no alterations of growth, glucidic metabolism, hypothalamic-pituitary-adrenal axis, bone metabolism, bone mass density, immune system nor severe exacerbation of the disease were observed. Our study, showing that FP was able to control the symptoms of asthma and confirming the lack of systemic side effects at the recommended doses, supports its long-term use in children with asthma.

Purpose Evaluation of the efficacy of the Falena® and Aperius™ PerCLID™ interspinous devices in the treatment of degenerative lumbar spinal stenosis with neurogenic intermittent claudication refractory to conservative treatment. Materials and methods We retrospectively analyzed data from 24 patients (20 male and 4 female patients; 61 ± 7 years old), treated with an implantation of the AperiusTM PerCLID™ system, and from 35 patients (29 male and 6 female patients; 65 ± 9 years old) treated with the Falena® interspinous device. Patient pain intensity was evaluated by a 10-point visual analog scale (VAS), with a score (ranging from 0 = no pain to 10 = unbearable pain) that was collected before the procedure, at baseline; and at months 1, 6 and 12 after the interventional procedure. The assessment of quality of life (QOL) impairment was evaluated by the Oswestry Disability Index (ODI) questionnaire, which was administered beforehand at baseline; and at months 1, 6 and 12 after the interventional procedure. The vertebral canal area was measured by magnetic resonance imaging (MRI) scans before the treatment and at the one-year follow-up. Results All patients completed the study with no complications. Both the Falena group and Aperius group of surgery patients showed a statistically significant reduction of their VAS and ODI scores at the 6- and 12-month follow-up ( p Conclusions The implantation of Falena® and Aperius™ PerCLID™ interspinous devices is an effective and safe procedure, in the medium term.

The purpose of this study was to evaluate the effectiveness of a new pedicle screw-based posterior dynamic stabilization device PDS Percudyn System™ Anchor and Stabilizer (Interventional Spine Inc., Irvine, CA) as alternative minimally invasive treatment for patients with lumbar spine stenosis. Twenty-four consecutive patients (8 women, 16 men; mean age 61.8 yr) with lumbar spinal stenosis underwent implantation of the minimally invasive pedicle screw-based device for posterior dynamic stabilization. Inclusion criteria were lumbar stenosis without signs of instability, resistant to conservative treatment, and eligible to traditional surgical posterior decompression. Twenty patients (83 %) progressively improved during the 1-year follow-up. Four (17 %) patients did not show any improvement and opted for surgical posterior decompression. For both responder and nonresponder patients, no device-related complications were reported. Minimally invasive PDS Percudyn System™ has effectively improved the clinical setting of 83 % of highly selected patients treated, delaying the need for traditional surgical therapy.

The aim of the study was to evaluate the efficacy of an injectable and partly absorbable calcium bone cement (CERAMENT™, Bone Support, Sweden) in the treatment of osteoporotic or traumatic vertebral fractures by percutaneous vertebroplasty.From March 2009 to October 2010 an open, prospective study in two centres was performed. 33 patients with symptomatic vertebral fractures were enrolled. Patients were included based on evaluation by X-ray, CT, and MRI. Clinical evaluation by Visual Analogue Scale (VAS, 0-10) and Oswestry Disability index test (ODI, 0-100 %) was performed before the operation as well as 1, 6 and 12 months after the procedure. Radiology assessment post-procedure was carried out by X-ray, CT, and MRI at 1, 6 and 12 months post-op. Intake of analgesic medications pre- and post-procedure was monitored.66 vertebral bodies underwent percutaneous vertebroplasty. VAS score demonstrated a significant decrease from 8.61 (SD 19.8) pre-operatively to 2.48 (SD 2.36) at 1 month. The score was 2.76 (SD 2.68) at 6 months and 1.36 (SD 1.33) at the latest follow up. ODI score dropped significantly from 58.86 pre-op to 26.94 at 6 months and further down to 7.61 at 12 months. No re-fractures or adjacent level fractures were reported.Data show that CERAMENT can be a substitute of PMMA in the treatment of osteoporotic and traumatic vertebral fractures, especially in young patients.

This study aimed to evaluate long-term stabilizing healing effectiveness and influence on adjacent intact vertebral bodies of a new injectable partly resorbable calcium sulfate (60 wt.%)/hydroxyapatite (40 wt.%) bone substitute employed in vertebral augmentation of osteoporotic collapses.From April 2009 to April 2011, 80 patients underwent vertebral augmentation. Patient enrolment criteria are as follows: age more than 20 years; symptomatic osteoporotic vertebral compression fracture from low energy trauma encompassing level T5 to L1 and classified as A1.1 to A1.2 according to the AO classification system; vertebral height compression within 0-75% compared to the posterior (dorsal) wall; client history confirming the age of the compression fracture to be within at least 4 weeks; and patients who are able to understand the procedure and participate in the study. Preoperative and postoperative imaging studies consisted of computed tomography, plain X-ray, dual X-ray absorptiometry scanning, and magnetic resonance. Pain intensity has been evaluated by an 11-point visual analog scale (VAS), and physical and quality of life compromise assessments have been evaluated by Oswestry Disability Questionnaire (ODI). All procedures have been performed fluoroscopically guided by left unilateral approach under local anesthesia and mild sedation.VAS-based pain trend over 12-month follow-up has shown a statistical significant (p 0.001) decrease, starting from 7.68 (SD 1.83) preoperatively with an immediate first day decrease at 3.51 (SD 2.16) and 0.96 (SD 0.93) at 12 months. The ODI score dropped significantly from 54.78% to 20.12% at 6 months. None device-related complication has been reported. In no case, a new incidental adjacent fracture has been reported.Data show how this injectable partly resorbable ceramic cement could be a nontoxic and lower stiffness alternative to polymethylmethacrylate for immediate and long-term stabilization of osteoporotic collapsed vertebral bodies.

To assess the ablative effectiveness, the oncological and cosmetic efficacy of image-guided percutaneous cryoablation in the treatment of single breast nodules with subclinical dimensions after identification with ultrasonography (US), mammography, magnetic resonance (MRI) and characterization by vacuum assisted biopsy.Fifteen women with a mean age of 73 ± 5 years (range 64-82 years) and lesion diameter of 8 ± 4 mm were undergoing cryotherapy technology with a single probe under US-guidance associated with intra-procedural lymph-node mapping and excision of the sentinel node. All the patients underwent surgical resection (lumpectomy) from 30 to 45 days after the percutaneous ablation.The iceball size generated by the cryoprobe during the procedure at minus 40°C was 16 × 41 mm. In 14 of the 15 patients was observed a complete necrosis of the cryo-ablated lesion both in post-procedural MRI follow-up and anatomo-pathological evaluation after surgical resection. In one case there was a residual disease in post-procedural MRI and postoperative histological examination, probably justified by an incorrect positioning of the probe.The percutaneous cryoablation as a "minimally invasive" technique can provide excellent oncological and cosmetic results on selected cases handled by experienced operators by using the tested devices.

This study was designed to evaluate the efficacy of the blunt-tipped curved injection needle (BCN) AVAflex (Care Fusion) for vertebral augmentation in cases of Kummel's disease.We performed 25 vertebral augmentation procedures on 25 consecutive patients (11 men/14 women; mean age, 67 years) with Kummel's disease using the blunt-tipped curved injection needle with PMMA cement. We performed all 25 procedures by unipedicular left approach with patients in prone position under local anesthesia and mild sedation. In all cases, an intravertebral cleft was evident on preprocedural imaging. We evaluated pain intensities by Visual Analogic Scale (VAS) before and at first day, 6 months, and 1 year after procedure.In all cases the curved injection cannula permitted the filling of the clefts and surrounding cancellous bone without any complication. A significant reduction of kyphotic deformities of the treated vertebral bodies was evident. A significance decrease in VAS values at 1 year also was evident (mean decrease 7.2). At plain dynamic postprocedural X-rays checks, there was no sign of pathologic intravertebral motion as evidence of optimal stabilization.BCN AVAflex is a safe and effective device for targeted vertebral augmentation in cases of Kummel's disease. Its distinctive characteristic is the curved injection cannula, which enables targeting the cement injection to areas far off the trajectory of the straight access cannula, thus providing excellent cement spread throughout the entire volume of vertebral body.

Joint injection is a useful tool in the diagnosis of intra-articular pathology that may improve diagnostic performance of computed tomography (CT) and magnetic resonance (MR) imaging. Historically, conventional arthrography under fluoroscopy was the first method to be used to image indirectly the intra-articular soft tissues, but with the advent of CT, CT arthrography offered better soft tissue depiction. The development of conventional MR allowed even better visualization of soft tissues, and in the early 1990s, MR arthrography surpassed CT arthrography in popularity. Joint injections may also be performed for therapeutic reasons with different drugs, such as corticosteroids, anesthetics, or hyaluronic acid, which have been shown to provide pain relief in various circumstances. In this article, the technical principles for joint injection of the shoulder, knee, elbow, hip, ankle, and wrist, used for therapeutic or diagnostic reasons, are discussed. Indications, expected benefits, and risks are also analyzed.

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.

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.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.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.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.

Body composition (BC) assessment is indispensable to evaluate nutritional status and thus health, both at the population and individual level, and to assess the efficacy of primary and secondary preventive nutritional strategies. Changes in BC, including the regional distribution of body fat, largely occur during pubertal transition, with marked differences between genders. They may, however, also occur in the elderly, who experience significant changes in the ratio between body fat and muscle with aging. The development and implementation of more sophisticated techniques (e.g. BC assessment at the molecular and atomic levels) could provide a major contribution to determining BC at different levels. This review discusses the application of dual-energy X-ray absorptiometry (DXA) on BC determination, given that DXA has the potential to provide overall and regional assessment of BC in terms of fat, lean mass and bone. DXA is widely used in many clinical settings primarily diagnosis osteoporosis. This article describes the use of whole-body DXA in assessing BC in patients with chronic diseases (e.g. metabolic syndrome) as well as in different sport activities to evaluate the effects of exercise.

The photocurrent generation of nanometric Ge droplets has been investigated by using electrochemical measurements. Dots have been grown by annealing Ge layers of different nominal thicknesses (ranging from 0.5 to 5 nm) deposited on clean SiO2 surface at room temperature. The photocurrent signals for the largest dots show features, which can be ascribed to the Ge nanocrystals direct electronic transitions. Only in the case of 0.5 nm Ge film a broad and intense feature at 2.4 eV has been observed while the peaks at higher energy result to be dramatically reduced. Since this last sample is characterized by (5±1) nm nanodots size (the smallest among the measured samples) the appearance of this broad band in the photocurrent active spectrum can be ascribed to quantum confinement effect.

A retrospective study was conducted in 179 consecutive patients (48 males, 131 females; mean age: 72.0 +/- 8.59 years; range: 51-93) with single symptomatic acute amyelic osteoporotic vertebral fracture presenting between September 2004 and September 2005 to the Santa Lucia Foundation in Rome, Italy. Vertebral fractures usually become manifest due to pain which can be debilitating. Treatment depends on the presence or absence of spinal cord involvement. In the first case, surgical stabilization is mandatory. In the second case, treatment may be performed either by conservative medical therapy (CMT) or percutaneous vertebroplasty (PVT). The aim of this study was to evaluate the effectiveness, costs and cost-effectiveness of percutaneous vertebroplasty. After 2 weeks of analgesic therapy, 153 patients presented refractory pain and were offered treatment by PVT. A total of 58 patients accepted and underwent PVT (PVT group), while 95 refused and underwent conservative medical therapy (CMT group). Follow-up was performed by specialist consults, spine radiography and MRI and a self-assessment questionnaire evaluating pain using a Visual Analogue Scale (VAS) and function using an ambulation and an Activities of Daily Living (ADL) scale. A 12-month follow-up was obtained in 86 of 95 (90.5%) CMT group patients and 54 of 58 (93.1%) PVT group patients. Significant reduction of VAS and improvement of ambulation and ADL was observed in both groups at 1 week and 3 and 12 months (P0.05; Wilcoxon signed rank test), however, these results were significantly superior in the PVT group at 1 week and 3 months (P0.05; Mann-Whitney U test). Average cost per patient at 1 week and 3 and 12 months were respectively 755.49 +/- 661.96, 3791.95 +/- 3341.97 and 4299.55 +/- 3211.53 euros (CMT group) and 3311.35 +/- 0.32, 3745.30 +/- 3.59 and 4101.05 +/- 755.41 euros (PVT group). PVT resulted significantly more cost-effective than CMT with regards to the three scales at 1 week (P0.05; Mann-Whitney U test). At 3 months PVT was more cost-effective than CMT with regards to the three scales, however, the difference was significant only with regards to ambulation. No significant differences in cost-effectiveness where found between the two groups at 12 months. PVT should be considered the treatment of first choice in symptomatic acute amyelic osteoporotic vertebral fractures with refractory pain after a short period of analgesic therapy.

The aim of this study was to assess the effectiveness and safety of percutaneous vertebroplasty, a new technique for the treatment of vertebral pain deriving from fracture or gross osteolytic lesion due to multiple myeloma spinal involvement.Spinal osteolytic lesions are frequently associated with hematologic malignancies due to primary localization of disease (multiple myeloma and rarely lymphoma) or secondary effect of intensive corticosteroid therapy.We treated 64 patients (34 males, 30 females; mean age 71.4+/-9.6 y) with pain refractory to conventional medical therapy (analgesics, bed-rest, bracing with orthopedic devices for more than 3 wk) localized in spine, in the absence of neurologic signs.This treatment generated swift pain relief associated with an evident augmentation in vertebral resistance. Average preprocedural pain level for all patients was reported to be 8.04+/-1.4 whereas average pain level at 1 and 6 months follow-up period was 1.82+/-1.84 and 1.92+/-1.68, respectively. Although preprocedure and postprocedure demonstrated a statistically significant reduction in numeric pain scores (P0.01), the pain level at 1 and 6 months was not considered statistically significant. No procedure-related complications were observed in either leakages of polymethylmethacrylate in the epidural or foraminal area or in complications of pulmonary embolism for venous plexus involvement.Vertebroplasty is widely considered as an alternative, effective, simple, and safe technique in the treatment of neoplastic vertebral localizations consequent to hematologic malignancies. The same injection of polymethylmethacrylate can be executed before radiation therapy treatment, synergizing its delayed analgesic action to pain, after failure or in the case of local recurrences.

A 70-year-old man with a painful vertebral metastasis was treated with combined percutaneous cryoablation and vertebroplasty therapy (CVT) in one session. The patient was suffering from diffuse visceral metastasized cholangiocarcinoma. After several weeks of back pain, magnetic resonance imaging documented a single L2 bone metastasis. In consultation with the oncologists, palliative combined CVT was administered with the aim of obtaining pain relief and bone stabilization. In our experience this combined treatment is safe and effective for immediate pain relief in painful bone metastases when other standard palliative treatments have failed.

Classical trigeminal neuralgia (CTN) is treated predominantly by pharmacotherapy but side effects and unsuccessful occurs. The current study was carried out to evaluate the therapeutic effect of combination of pharmacotherapy and lidocaine block. Thirteen patients with CTN managed with pharmacotherapy were recruited and assigned either to no additional treatment (Group I) or to additional analgesic block (Group II). The primary endpoint was the reduction in the frequency of pain episodes in a month assessed at 30 and 90 days. Comparisons of measurements of pain, general health and depression scales were secondary endpoints. The results from the follow-up visits at 30 and 90 days showed the Group II to have larger reduction in the frequency of pain and exhibited a bigger improvement in the scores of the pain, general health and depression scales. The results from this preliminary study suggest a clinical benefit of the combination of pharmacotherapy and lidocaine block. A neuralgia clássica do trigêmio (NTC) é tratada predominantemente por drogas, porém efeitos colaterais e falhas terapêuticas ocorrem. Avaliamos o efeito terapêutico da combinação entre farmacoterapia e bloqueio analgésico utilizando a lidocaína. Treze pacientes portadores de NTC tratados com farmacoterapia foram divididos em dois grupos: Grupo I pacientes que mantiveram somente tratamento medicamentos e Grupo II pacientes que associaram bloqueio anestésico. O objetivo primário do estudo foi à redução da freqüência da dor 30 e 90 dias após o bloqueio. Secundariamente avaliamos o impacto sobre as escalas de depressão, dor e qualidade de vida. O grupo II teve uma redução significativa na freqüência da dor e uma melhora nos escores de qualidade de vida, dor e escala de depressão. Os resultados sugerem um benefício clinico da combinação de farmacoterapia e bloqueio anestésico no tratamento da NTC.

Vertebroplasty (VP) is a percutaneous mini-invasive technique developed in the late 1980s as antalgic and stabilizing treatment in patients affected by symptomatic vertebral fracture due to porotic disease, traumatic injury and primary or secondary vertebral spine tumors. The technique consists of a simple metameric injection of an inert cement (poly-methyl-methacrylate, PMMA), through a needle by trans-peduncular, parapeduncular or trans-somatic approach obtaining a vertebral augmentation and stabilization effect associated with pain relief. The technique is simple and fast, and should be performed under fluoroscopy or CT guidance in order to obtain a good result with low complication rate. The aim of this paper is to illustrate the utility of VP, the indications-contraindications criteria, how to technically perform the technique using imaging guidance, and the results and complications of this treatment in patients affected by symptomatic vertebral compression fracture.

Aim To assess the efficiency of pulse-dose radiofrequency (PDRF) in the management of chronic pain in patients with trapezio-metacarpal osteoarthritis (OA). Methods Seventy-five patients with trapezio-metacarpal OA were treated with the PDRF between October 2011 and September 2013. A 22-gauge cannula with a 5-cm length was introduced with percutaneous access in the lateral region of the affected trapezio-metacarpal joint. The PDRF procedure was performed with 1200 pulses at 45 V and 20 msec duration, followed by a 480 msec silent phase. The follow-up visits were performed at 1 month, 3 and 6 months after the PDRF procedure. All patients underwent a second treatment between 7 and 9 months after the first PDRF procedure with a new follow-up scheme at 1, 3, 6 and 9 months. Results Mean visual analogue scale (VAS) scores before the procedures was 8.5 ± 1.1. A great reduction in pain intensity was reported at 3 months after the PDRF procedure (mean VAS scores 3.1 ± 0.9, P

The purpose of this work has been to dosimetrically investigate four fluoroscopically guided interventions: the percutaneous vertebroplasty (PVP), the percutaneous disc decompression (PDD), the radiofrequency medial branch neurolysis (RF) (hereafter named spine procedures), and the endovascular treatment for the critical limb ischemia (CLI). The X‐ray equipment used was a Philips Integris Allura Xper FD20 imaging system provided with a dose‐area product (DAP) meter. The parameters investigated were: maximum skin dose (MSD), air kerma (Ka,r), DAP, and fluoroscopy time (FT). In order to measure the maximum skin dose, we employed a system based on MOSFET detectors. Before using the system on patients, a calibration factor Fc and correction factors for energy (CkV) and field size (CFD) dependence were determined. Ka,r, DAP, and FT were extrapolated from the X‐ray equipment. The analysis was carried out on 40 patients, 10 for each procedure. The average fluoroscopy time and DAP values were compared with the reference levels (RLs) proposed in literature. Finally, the correlations between MSD, FT, Ka,r, and DAP values, as well as between DAP and FT values, were studied in terms of Pearson's product‐moment coefficients for spine procedures only. An Fc value of 0.20 and a very low dependence of CFD on field size were found. A third‐order polynomial function was chosen for CkV. The mean values of MSD ranged from 2.3 to 10.8 cGy for CLI and PVP, respectively. For these procedures, the DAP and FT values were within the proposed RL values. The statistical analysis showed little correlation between the investigated parameters. The interventional procedures investigated were found to be both safe with regard to deterministic effects and optimized for stochastic ones. In the spine procedures, the observed correlations indicated that the estimation of MSD from Ka,r or DAP was not accurate and a direct measure of MSD is therefore recommended. PACS number: 87

The Schmorl node represents displacement of intervertebral disc tissue into the vertebral body. Both Schmorl nodes and degenerative disc disease are common in the human spine. We performed a retrospective study, for the period from January 2003 to February 2005, evaluating 23 patients affected by painful Schmorl nodes, who underwent in our department percutaneous transpedicular injection of polymethylmethacrylate (vertebroplasty) in order to solve their back pain not responsive to medical and physical management. Eighteen patients reported improvement of the back pain and no one reported a worsening of symptoms. Improvement was swift and persistent in reducing symptoms. Painful Schmorl nodes, refractory to medical or physical therapy, should be considered as a new indication within those vertebral lesions adequately treatable utilizing Vertebroplasty procedure.

Morton's neuroma (MN) is a frequent cause of metatarsalgia. The aim of our study was to evaluate the efficacy of neuroma alcohol-sclerosing therapy (NAST) under US guide in MN after a 10-month follow-up. Forty intermetatarsal neuromas underwent alcohol-sclerosing therapy after sonographic evaluation of their dimensions and echotexture. After subcutaneous anesthesia, a sclerosing solution composed of anesthetic (carbocaine-adrenaline 70%) and ethylic alcohol (30%) was injected inside the mass under US guidance. The procedure was repeated at intervals of 15 days until the resolution of the symptoms. A total or partial symptomatic relief was obtained in 36 cases (90%). No procedure-related complications were observed. Transitory plantar pain, due to the flogistic reaction induced by the sclerosing solution, occurred in 6 cases (15%). The 10-month follow-up revealed a 20-30% mass volume reduction and an adiposus-like change in echotexture. In the 4 cases (10%) of therapeutic failure, the preliminary sonography demonstrated a hypoechoic echotexture with a strong US beam attenuation corresponding to a highly fibrous neuroma after surgical resection. The NAST is a feasible and cost-efficient procedure with high rates of therapeutic success.

Magnetic resonance (MR) imaging has improved the possibility of evaluating musculoskeletal structures thus gaining an important role in the diagnosis and treatment of foot and ankle pathologies. In this review, the normal and pathological images of the ankle and foot obtained using MR techniques are presented and discussed. The high soft-tissue contrast resolution and the multiplanar sections of MRI allow the imaging of contiguous tissues where small contrast differences exist, such as ligamentous and tendinous injuries or impingement syndromes. The spatial resolution with high sensitivity for bone signal changes offers an early detection of osseous abnormalities such as stress fractures or osteonecrosis. Here it is specified possibilities and limitations of MRI in the diabetic foot: this technique is superior to nuclear medicine and computed tomography (CT), however it is unable to distinguish between neuro arthropathy and infection.

The principal criterion for resectability of pancreatic carcinoma is the assessment of vascular involvement. In a prospective evaluation the ability of Spiral CT Angiography (CTA) to detect vascular involvement in 50 patients with pancreatic carcinoma, was proved; DSA was performed later in all patients. In 20 patients, without vascular involvement, a complete concordance was obtained. Of 30 patients with vascular involvement, there was complete concordance between CTA and angiography in 22 patients and discordance in 8 patients. CTA was superior in 2 cases with periadventitial infiltration and in 5 patients with splenoportal confluence thrombosis. DSA was superior in 1 case with infiltration of the superior mesenteric vein. After surgical evaluation, sensitivity of CTA and DSA was 97% and 77%, respectively, and the negative predictive values were 95% and 74%. As compared to DSA, CTA is more rapid and less invasive and can be considered the modality of choice for preoperative work-up of pancreatic neoplasm.

Knee osteoarthritis (OA) is a leading cause of disability in the elderly. The purpose of this study was to investigate the effectiveness of pulse-dose radiofrequency (PDRF) in patients with chronic pain refractory to conservative therapies.Between January 2011 and November 2012, PDRF was performed on 40 patients. A 20-gauge cannula, 10 cm in length, was introduced in the antero-lateral region of the interested knee, and its tip was placed in the joint space under fluoroscopic guidance. After the spindle was removed, an RF needle with a 10-mm "active tip" was introduced. PDRF was performed with 1,200 pulses at high voltage (45 V) with 20-ms duration followed by a 480-ms silent phase.Mean VAS scores before the procedures was 6.8 ± 0.8. A great decrease of pain intensity was achieved 1 week after PDRF (mean VAS scores 1.8 ± 0.4 [p0.05]) with stabilization of painful symptomatology in the following months and excellent results 1 year after treatment (mean VAS scores 2.3 ± 0.6 after 12 months [p0.05]). Western Ontario and McMaster Universities Index of Osteoarthritis scores showed improved quality of life in all patients at 6 months (p0.05) and at 1 year (p0.05) after PDRF. No patients developed complications.This study successfully investigated the effectiveness of PDRF in patients with chronic pain unresponsive to conservative therapies. PDRF seems to be an effective and reliable technique for palliative management of chronic pain in patients with knee OA.

The Amplatz Thrombectomy Device (ATD) is a percutaneous, rotational thrombectomy catheter, capable of recirculating and homogenizing the thrombus in order to obtain mechanical clot dissolution. The authors present their experience with mechanical thrombectomy with the ATD in eight cases of ilio-caval thrombosis. Under temporary caval filter protection, the ATD was introduced through the right transjugular approach (in one patient this was used in combination with the right femoral approach) and activated for a time ranging from 90 to 180 s. Complete clearing of thrombotic material in the treated venous segments was achieved in six cases (75 %), partial success was obtained in one case (12.5 %) and failure occurred in one patient (12.5 %). One patient developed a recurrence of venous iliac thrombosis 1 week after the procedure and postphlebitic syndrome 6 months after the first episode of deep venous thrombosis, and one patient died from acute myocardial infarction, unrelated to thrombectomy session, after 3 days. A negative clinical and radiological follow-up at 3, 6, 12 and 24 months was obtained in the remaining six patients. If a fresh free-floating ilio-caval clot must be removed immediately, the ATD can be effective under temporary filter protection.

STUDY DESIGN: We postulate that osteoplasty of osteolytic metastases of the pelvic region performed by computed tomography (CT)-guided insertion of Kirschner wires into the lesions is effective and more feasible. OBJECTIVE: To determine whether osteoplasty of osteolytic metastases of the pelvic region can be performed by a more feasible lesion access, increasing patient compliance and reducing patient radiation exposure. SUMMARY OF BACKGROUND DATA: Treatment of osteolytic bone metastases is palliative and relies mainly on the elimination of pain. When pain is medically intractable, this can be effectively treated by osteoplasty. MATERIALS AND METHODS: A 61-year-old man with medically intractable pain from osteolytic lesions of the sacral ala and left iliac alum from pulmonary adenocarcinoma underwent osteoplasty. The lesions were accessed using Kirschner wires under CT guidance. Subsequently, under high-resolution fluoroscopic guidance, 13-G biopsy needles were advanced coaxially over the Kirschner wires and polymethyl methacrylate (PMMA) was injected into the lesions. RESULTS: No peri-procedural complications were observed. The patient experienced an immediate and substantial pain relief that was persistent during a 4-month follow-up. CONCLUSIONS: This technique is safe and effective and requires fewer CT scans, thus reducing the patient's radiation exposure. The shorter procedure correlates to a better patient tolerance.

Diagnostic imaging has become an essential tool for sports traumatology. Nowadays, modern techniques of diagnostic imaging can be applied to sports traumatology in pediatric and adolescent athletes for the process of diagnosis and follow-up. Diagnostic techniques, such as conventional radiology, ultrasounds (US), computed tomography (CT), and magnetic resonance imaging (MRI), can be useful during the healing process after a trauma has occurred, even before clinical examination may identify the same pathology. Imaging is now fundamental for early diagnosis and accurate prognosis when wondering the time that an athlete needs to return to his/her daily and agonistic sport activity. This chapter aims to highlight the different diagnostic techniques that are currently available, and the role that they play for the study of pediatric and adolescent athletes after they have suffered from a trauma.

This study was designed to demonstrate the feasibility and the reliability of microwave ablation (MWA) of epiphyseal osteoid osteomas (OO). From February to November 2012, 7 patients (4 males and 3 females; age range 16–30 years) with epiphyseal OOs were treated with MWA. The treatment was performed with 16 G antennas with a power of 20 W for 2 min. The OOs were approached by using coaxial needles inserted with hammer or with automatic drill. All patients underwent spinal anaesthesia, with posttreatment 6–8 h observation before discharging. We treated epiphyseal OOs placed away from nervous and vascular nontarget structures, located in: femoral head (n = 2), femoral lesser trochanter (n = 2), femoral neck (n = 2), and proximal tibial epiphysis (n = 1). CT was used to visualize the nidus and to insert the needle for thermal ablation and for postprocedure control. Technical success was considered the positioning of the antenna in the nidus, while the efficacy of treatment was clinically evaluated as the complete remission of pain after the procedure by using the visual analogue score (VAS). Follow-up was performed by using VAS score 1 day, 1 week, and 1, 3, and 6 months after the procedure, whereas MRI examination was performed immediately after the procedure, at 1 month, and in any case of recurrence. Complications were also recorded. All patients experienced resolution of the symptomatology (VAS = 0) in ~1 week until the last follow-up, with residual VAS

The purpose of this study is to describe the usefulness of 18F-FDG PET/CT scanning in the diagnosis and follow-up of stage 0 Charcot foot (CNO) and CNO outcomes when therapeutic options are driven by this image modality.We selected 25 out of 40 diabetic patients with an acute CNO, without any bone involvement at x-ray (stage 0 CNO). Diagnostic criteria were inflammatory clinical signs of the affected foot and skin temperature difference greater than 2°C compared with the contralateral foot (ΔT). All patients underwent x-ray, MRI, and 18F-FDG PET/CT scanning (expressed as standardized uptake value, SUVmax) at baseline (T0). All patients underwent another 18F-FDG PET/CT within 1 month after ΔT was less than 2°C [clinical recovery (T1)] and again every 3 months until SUVmax was less than 2 [final recovery (T2)]; at this time, MRI confirmed the end of the inflammatory condition.T0 ΔT was 3.04 ± 1.65°C. All patients showed T0 SUVmax of the affected foot higher than the contralateral one (3.83 ± 1.087 vs. 1.24 ± 0.3; P0.001). At clinical recovery (T1), defined by ΔT below 2°C, the inflammatory signs were no longer present (T0 vs. T1 ΔT = 3.04 ± 1.65 vs. 0.9 ± 0.55°C; P0.0001). At T1, SUVmax was unchanged from T0 (3.80 ± 1.69 vs. 3.83 ± 1.09; P = ns). At final recovery (T2), ΔT was 0.74 ± 0.29°C (similar to T1 ΔT), while the SUVmax dropped from T1 to T2 (3.8 ± 1.69 vs. 1.72 ± 0.52; P0.0001). Standard therapy was total contact cast and removable cast walker until T2 (15.12 ± 5.45 mo). No patient developed foot bone fractures nor had relapses during follow-up (21.75 ± 16.7 mo).PET/CT scan allows the quantification of the inflammatory process; therefore, it may drive clinical decisions in the management of acute CNO better than clinical criteria. None of our patients developed foot bone fractures or had relapses during follow-up driven by PET/CT scan.

The purpose of our study was to evaluate the efficacy of computed tomography (CT)-guided percutaneous pulse-dose radiofrequency (PDRF) for the treatment of chronic pain in patients with pudendal neuralgia (PN) unresponsive to conservative approaches.From March 2010 to January 2012, 30 patients with a diagnosis of PN were prospectively enrolled in the study, 18 women and 12 men (mean age 47 years). A 20-gauge cannula with a 10-cm length was placed under CT guide in the pudendal (Alcock's) canal. After the spindle was removed, a radiofrequency needle with a 5-mm active tip was introduced. The appropriate needle placement near the pudendal nerve, without an involvement of the vessels, was confirmed with an injection of 1-2 ml of contrast agent. PDRF was performed with 1,200 pulses at high voltage (45 V) with 20 ms duration followed by 480 ms silent phases.Twenty-six patients completed the study. Procedural success was achieved in all patients. Mean VAS scores before PDRF was 9 ± 0.7. Patients had a great improvement in pain intensity after 1 week by PDRF (mean VAS scores 3.8 ± 1.7, p0.05), with a stabilization of the symptomatology in the following months (mean VAS scores 1.5 ± 1.1 at 6 months by PDRF, p0.05) and excellent results after 1 year by the procedure (mean VAS scores 1.9 ± 0.7, p0.05).In our preliminary experience, CT-guided percutaneous PDRF should be recommended for treatment of PN because we evaluated the tolerability of this procedure with satisfactory and encouraging results.