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FIGURE 5 Seventy-eight-year-old man with metastatic lung cancer. The patient had a known posterior metastasis to the third cervical vertebrae that did not respond to radiotherapy. (A) Computed tomography scan prior to radiofrequency (RF) ablation shows osteolysis of the left lamina with an associated soft-tissue mass. (B) RF ablation was performed under conscious sedation without any neurological side effects due to the distance between the electrode and the cord and the presence of pulsating cerebrospinal fluid around the cord. The patient had pain relief from the treatment.

FIGURE 6 Seventy-five-year-old man with metastatic renal cell carcinoma. (A) Computed tomography (CT) image, with the patient prone, shows an osteolytic metastasis at the T-10 cos-tovertebral junction with soft tissue encroaching upon the spinal canal. (B) Due to the soft-tissue component causing mass effect, the possibility of radiofrequency (RF)-induced nerve damage was a concern. Prone CT image shows the remote thermocouple adjacent to the thecal sac (arrow) to monitor the temperature effects from the RF electrode that was placed into the lateral-most portion of the mass.

temperature elevations observed within the spinal canal, if the vertebral body cortex is intact and a cerebrospinal fluid (CSF) space exists between the mass and spinal canal (26). Despite the use of internally cooled electrodes at maximum output, significant elevation of temperatures in the epidural space did not occur in this experimental study. Ex vivo studies confirmed decreased heat transmission in cancellous bone and an insulative effect of cortical bone. Additional factors that more than likely account for the differences in heat distribution observed are local heat sinks from the rich epidural venous plexus and CSF pulsations.

Perfusion-mediated tissue cooling has been demonstrated as negatively influencing the extent of coagulation, which can be produced in in-vivo liver, and decrease of blood flow by mechanical or pharmacologic means can increase the diameter of coagulation necrosis. The clinical application of RFA to the vertebral body may be important in the future. Osseous meta-static disease commonly involves the spine and often leads to debilitating pain, surgical decompression, and paraplegia. If a less invasive means of treating local tumor burden were available, then surgical decompression may be avoided in some cases. Clearly in cases where there is preserved cancellous or better yet cortical bone between the lesion and the spine, a margin of safety will be provided. In patients with extensive osteolysis with no intact cortex between tumor and spinal cord or nerve roots, RF may not be an option due to potential thermal injury to adjacent neural tissue. Theoretically if a CSF space was present between tumor and neural tissue, RF could be applied without unwanted neurotoxicity (Fig. 5). The use of a remote temperature sensor (Fig. 6) may offer a prudent margin of safety because the procedure could be terminated if deleterious temperature rises are observed adjacent to nervous tissue (i.e., greater than 45°C). In addition to destroying local tumor with heat, combination strengthening procedures such as vertebroplasty can be done at the same sitting (Fig. 7). Anecdotally we have performed RF and vertebroplasty in several patients, and the results have been clinically beneficial. Upfront RFA may contract the tumor, enabling improved distribution of cement.

FIGURE 7 Fifty-seven-year-old man with metastatic renal cell carcinoma. The patient had an osteolytic metastasis in the fourth lumbar vertebral body that was irradiated one year earlier. The patient developed new back pain and a follow-up positron emission tomography scan and magnetic resonance imaging suggested tumor activity. (A) A prone computed tomography (CT) image shows the biopsy needle and central aspiration needle traversing the left L4 pedicle. On site cytopathology confirmed viable tumor. (B) A radiofrequency (RF) electrode was then placed through the outer sheath of the bone biopsy needle. (C) After the RF ablation cement was injected through a vertebroplasty needle under CT-fluoroscopy. (D) After 7 mL of cement, CT image confirms complete filling of the tumor cavity (a/row).This case illustrates the ability to diagnose, treat, and strengthen with a single oupatient procedure.

FIGURE 7 Fifty-seven-year-old man with metastatic renal cell carcinoma. The patient had an osteolytic metastasis in the fourth lumbar vertebral body that was irradiated one year earlier. The patient developed new back pain and a follow-up positron emission tomography scan and magnetic resonance imaging suggested tumor activity. (A) A prone computed tomography (CT) image shows the biopsy needle and central aspiration needle traversing the left L4 pedicle. On site cytopathology confirmed viable tumor. (B) A radiofrequency (RF) electrode was then placed through the outer sheath of the bone biopsy needle. (C) After the RF ablation cement was injected through a vertebroplasty needle under CT-fluoroscopy. (D) After 7 mL of cement, CT image confirms complete filling of the tumor cavity (a/row).This case illustrates the ability to diagnose, treat, and strengthen with a single oupatient procedure.

In summary, RFA is an exciting new treatment modality that can be safely applied to metastatic bone disease. Its synergy with other therapies and outpatient nature make it an attractive treatment option for this fragile group of patients. The precise role of RF in this group of patients is not clearly defined, and continued work is underway in the hope that it will benefit those patients who currently have no treatment options and succumb to their disease without adequate analgesia.

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Dealing With Back Pain

Dealing With Back Pain

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