Paravertebral Approach Research Articles

Percutaneous core needle biopsy for paraaortic retroperitoneal lesions: impact of size and location on diagnostic accuracy of CT-guided biopsy and feasibility of ultrasound guidance

AimTo evaluate the safety and efficacy of computed tomography (CT)-guided core needle biopsy (CNB) for paraaortic retroperitoneal lesions, identify factors affecting false-negative results, and explore the feasibility of alternative CT-guided and ultrasound-guided approaches for challenging anatomical regions. Materials and methodsThis single-institution retrospective study included 317 consecutive patients who underwent CNB for paraaortic retroperitoneal lesions. A total of 345 biopsies were performed using 18-gauge cutting needles under CT or ultrasound guidance. Diagnostic accuracy was calculated based on biopsy and follow-up results, and univariate analysis was performed to identify predictors of false-negative CT-guided biopsies. ResultsOf the 332 CT-guided biopsies, 203 targeted lateral aortic lesions. The standard posterior paravertebral approach was commonly used; complex cases requiring alternative CT or ultrasound-guided approaches involved pre-aortocaval or inter-aortocaval lesions. In CT-guided biopsies, 5 of the 30 lesions in these regions were accessed via trans-caval, trans-pedicle, or trans-disc approaches. All 13 ultrasound-guided biopsies were performed with anterior access except for 2 cases. Malignant lymphoma and nodal metastasis were the most common pathologic findings. Overall sensitivity, specificity, and accuracy were 96.7%, 100%, and 97%, respectively. Neither lesion size nor location predicted false-negative CT-guided biopsies, with similar accuracy for lesions ≤15 mm (98.4%) and >15 mm (96.9%). Major bleeding occurred in two CT-guided biopsies (0.6%). ConclusionCT-guided CNB demonstrated high diagnostic accuracy across all lesion locations, particularly with the standard posterior paravertebral approach. For more challenging pre-aortocaval or inter-aortocaval lesions, alternative CT-guided posterior or ultrasound-guided anterior approaches may help overcome anatomical constrains and expand percutaneous options.

Studies on Echostructural Pattern of Urinary System in Adult Female Goats

Background: Ultrasonography is a second most commonly used diagnostic imaging technique in veterinary practice after radiography. The ultrasonographic examination of clinically healthy animals provides relevant information about anatomical location, echo texture, size and shape of organs. In the present study, the echo-structural pattern of urinary system of adult female goats were evaluated to find the normal structural pattern of various constituents of urinary system. Methods: B-mode ultrasonographic study of urinary system was performed in 20 healthy adult female Jamunapari goats. Mean±S.E. values of body weight and age of selected animals were 27.49±0.79 kg and 2.77±0.10 years, respectively. All twenty animals were subjected to sonographic examination after clipping the hairs from desired sites to scan the various organs of urinary system in standing position under physical restraint without using any anesthetic agent. The values of various clinico-physiological parameters including rectal temperature, heart rate, respiration rate, colour of mucous membranes were recorded to examine the health status prior to sonography. The left and right kidneys were scanned from right dorsal flank by paravertebral approach using a transcutaneous micro-convex probe at 5 MHz and a convex probe at 2.8-6 MHz frequency. A dual frequency (5-9 MHz) micro-curved array cavity probe was used to scan bladder and urethra per rectally. The renal parenchyma in healthy goats was distinctly divided into hypoechoic outer cortex and anechoic inner medulla. The hyperechoic renal sinus complex was present in center of the kidney and renal pelvis was anechoic. The renal capsule was seen as hyperechoic fine line surrounding the renal parenchyma. Pulsed wave renal color doppler ultrasound was performed in 3 healthy goats with the aim to generate reference images of renal vasculature. Result: The Mean±SE values of renal length, renal height, horizontal diameter of renal sinus, vertical diameter of renal sinus and diameter of renal pelvis for right kidney were 6.11±0.09, 3.26±0.08, 3.01±0.11, 1.32±0.03, 1.05±0.03, respectively while for left kidney these values were 6.02±0.09 and 3.35±0.07, 2.67±0.12, 1.14±0.06, 1.10±0.07 cm. The ureters could not be visualized in any of the goats. The distended bladder was seen as anechoic circular structure surrounded by a smooth echogenic wall with a mean thickness of 1.65±0.06 mm. No significant difference was observed in the measurements of both kidneys except in dimensions of renal sinus. Positive correlation was found between renal size and body weight of goats. It was concluded that ultrasound is an easy, rapid and non-invasive method to evaluate echotexture and morphometry of structures of urinary system.

A comparison of the motor effects and analgesic efficacy following lumbar plexus block combined with sciatic nerve block or epidural in dogs undergoing tibial plateau leveling osteotomy

ObjectiveTo compare motor effects and analgesic efficacy following an ultrasound-guided lateral approach to lumbar plexus blockade at L7 and sciatic nerve blockade (LPSNB) against epidural injection in dogs undergoing tibial plateau leveling osteotomy (TPLO). Study designProspective, randomized, blinded clinical trial. AnimalsA total of 27 healthy adult dogs undergoing unilateral TPLO surgery. MethodsDogs were allocated to either LPSNB (bupivacaine 2 mg kg–1, 0.75%) or epidural (morphine PF 0.1 mg kg–1 and bupivacaine 0.5 mg kg–1, 0.75%). Other aspects of clinical management were identical, including anesthetic drug protocol, area of presurgical clipping and bladder care. Time to perform the block, response to surgical stimuli, pain scores, rescue analgesia, time to stand and walk, motor score and time to first urination were recorded. One evaluator, unaware of treatment status, performed all evaluations. Student’s t-test or Mann–Whitney U test was used to compare continuous variables between groups, and Fisher’s exact test for categorical variables. ResultsMedian (range) times to stand and walk were shorter for LPSNB [60 (40–120) minutes and 90 (60–150) minutes, respectively, p = 0.003] than for epidural [150 (120–240) minutes and 180 (120–360) minutes, respectively, p = 0.006]. Four dogs required rescue intraoperatively (three in epidural group, one in LPSNB group, p = 0.438). Pain scores over the 24 hour evaluation period were similar, and not significantly different, for each group. Time to spontaneous urination [LPSNB, 330 (240–360) minutes; epidural, 300 (120–1440) minutes, p = 1.0] did not differ between groups. Conclusions and clinical relevanceAn ultrasound-guided lateral paravertebral approach to the lumbar plexus within the psoas compartment at L7, combined with sciatic nerve blockade, allows faster return to normal motor function, with similar pain control and impact on urination when compared with epidural in dogs after TPLO surgery.

Clinical Efficacy and Imaging Observation of Three Surgical Approaches in Treatment of Thoracolumbar Fractures.

To observe the efficacy and imaging of surgical treatment of thoracolumbar fractures via the paravertebral muscle space approach. A retrospective analysis was conducted on patients with thoracolumbar fractures receiving surgery in Baoding First Central Hospital from January 2019 to December 2020. According to different surgical approaches, they were divided into paravertebral approach group, posterior median approach group and minimally invasive percutaneous approach group. They received surgery via the paravertebral muscle space approach, posterior median approach and minimally invasive percutaneous approach, respectively. Statistically significant differences were found in surgical duration, intraoperative bleeding volume, intraoperative fluoroscopy frequency, postoperative drainage volume and hospital stay among the three groups. One year after surgery, the VAS, ADL and JOA scores of the paravertebral approach group and the minimally invasive percutaneous approach group had statistically significant differences from the posterior median approach group (P < 0.05). For the surgical treatment of thoracolumbar fractures, the clinical efficacy of the paravertebral muscle space approach is superior to that of the traditional posterior median approach, and the clinical efficacy of the minimally invasive percutaneous approach is similar to that of the posterior median approach. All the three approaches can effectively improve the postoperative function and pain symptoms of patients without increasing the incidence of complications. Compared with the posterior median approach, the surgery via the paravertebral muscle space and minimally invasive percutaneous approaches presents shorter surgical duration, less bleeding and shorter hospital stay, which is more conducive to postoperative recovery of patients.

Feasibility and efficacy of spinal microtubular technique for resection of lumbar dumbbell-shaped tumors.

Minimally invasive surgical resection of lumbar dumbbell-shaped tumors is rarely reported. We retrospectively collected clinical data of lumbar dumbbell-shaped tumors treated with the spinal microtubular technique to evaluate the feasibility, complications and efficacy of the surgical methods. From September 2013 to August 2021, clinical data of patients with lumbar dumbbell-shaped tumors that underwent paravertebral approach and micro-tubular tumorectomy (PAMT) were collected; neurological function was assessed using the pain visual analog scale (VAS) and the Japanese Orthopaedic Association (JOA) score. A total of 46 patients that underwent PAMT were included in this study. In all patients, total resection of the tumor was performed at one stage (100%). The median follow-up period was 27.5 months (P25, P75: 16.5- 57 months). Symptoms such as pain or lower extremity weakness were significantly relieved in 46 patients. The postoperative VAS score and JOA score were significantly higher compared with preoperative scores (p <0.001), and the patients had no tumor recurrence or spinal instability. According to the Eden classification, there were 7 cases of type I, 8 cases of type II, 15 cases of type III, and 16 cases of type IV. In the comparison of the improvement of VAS score at 12 months after PAMT, there were significant differences among different types of tumors (H =15.756, p =0.001); type I was better than type III (Z =2.768, p =0.029) and type IV (Z =2.763, p =0.029), and type II was also better than type III (Z =2.679, p =0.037) and type IV (Z =2.708, p =0.034). With respect to estimated blood loss (Z =-3.041, p =0.013) and postoperative hospital stays (Z =-3.003, p =0.014), type IV was less than type III; and type IV was also less than type II about operation time (Z =-2.653, p =0.040). In small lumbar dumbbell-shaped tumors, PAMT is indicated for Eden types I-IV and different pathological types of tumors, and can achieve complete resection of the tumor (GTR) in one stage with a good prognosis.

Results of surgical treatment of the thoracic spinal nerve tumors: a retrospective analysis

Objective. To analyze clinical and morphological features of neurogenic hourglass tumors in the thoracic spine and their impact on outcomes of treatment through posterior surgical approaches.Material and Methods. The results of surgical treatment of 295 patients with tumors growing from the nerve roots of the thoracic spinal cord were studied. In 63 (21 %) of them, tumors of the spinal nerves were diagnosed. The vast majority of neoplasms were represented by Grade 1 neuromas – in 57 (90 %) patients, Grade 1 neurofibromas were found in 3 (5 %) patients, and High-grade malignant tumors – in 3 (5 %). Intracanal neoplasms were found in 42 (66.7 %) cases and intraextravertebral (hourglass) – in 21 (33.3 %).Results. Microsurgical removal of tumor was performed using two types of low-traumatic surgical approaches: 1) posterior median approach – in 56 (89.0 %) cases, of which hemilaminectomy was performed in 36 (64.4%) cases, interlaminectomy – in 15 (26.8 %) cases, and laminectomy – in 5 (8.1 %) cases; 2) paravertebral approach – in 7 (11.0 %) out of 63 cases with partial facetotomy or facetectomy and resection of part of the head and upper or lower edge of the rib at the same level. Tumors were removed totally in 56 (88.9 %) patients and subtotally – in 7 (11.1%). Intracanal tumors were removed totally in 40 (95.2 %) patients. A similar totality was achieved in removal of 16 (76.2 %) of hourglass neurinomas. Surgical interventions performed in the early postoperative period improved the functional state of patients: the Karnofsky Performance Scale (KPS) index increased from 70–80 to 90 %, the VAS pain score decreased from 5–6 to 2 points. Good clinical outcomes were achieved in 42 (66.7 %) patients, satisfactory – in 17 (27.0 %), and unsatisfactory – in 6 (6.3 %). Twenty nine patients had symptoms of myelopathy, complete regression of which occurred in 3 (10.3 %) cases, partial – in 9 (34.6 %), in 13 (50.0 %) cases they remained at the preoperative level, and in 4 (15.4 %) – worsened.Conclusion. The use of modern neurointroscopy, microsurgical techniques and low-traumatic posterior surgical approaches for resection of tumors of the spinal nerve roots in the thoracic spine provides good clinical outcomes of treatment in the early postoperative period. The existing hourglass tumor in the thoracic spine reduces the likelihood of its total removal when performing a low-traumatic posterior approach.

Comparison of the Clinical Efficacy of Transforaminal Endoscopy and Microtubular Technology for the Treatment of Lumbar Dumbbell-Shaped Tumors.

ObjectiveTo analyze differences in feasibility and efficacy between the paravertebral approach and microtubular tumorectomy (PAMT) or percutaneous transforaminal endoscopic tumorectomy (PTET) for the treatment of lumbar dumbbell-shaped tumors. MethodsClinical data of dumbbell-shaped lumbar tumors in patients treated with PAMT or PTET in our hospital between June 2015 and November 2020 were retrospectively analyzed. The gross total resection (GTR) rate, operation time, estimated blood loss, postoperative hospital stay (PHS), postoperative neurological function, and spinal stability were compared between the 2 surgical methods. Neurological improvement was assessed using the pain visual analogue scale (VAS) and the Japanese Orthopaedic Association (JOA) score. ResultsFifteen cases of GTR (93.8%) and 1 case of subtotal resection were included in the PTET group, whilst all 18 patients in the PAMT group achieved GTR. There was no significant difference in the GTR rate, operation time, and PHS between the PAMT and PTET groups. The estimated blood loss was significantly lower in the PTET group than in the PAMT group. At the last follow-up, there was no significant difference in the VAS or JOA scores between PTET and PAMT. No tumor recurrence or spinal instability was observed in either group during the follow-up period. ConclusionBoth PAMT and PTET can achieve Eden type III-IV lumbar 1-stage tumor resection without additional spinal internal fixation due to reduced muscle, ligament, and facet joint damage. No lumbar instability and tumor recurrence occurred, and neurological function was improved.

Splanchnic nerve neurolysis via the transdiscal approach under fluoroscopic guidance: a retrospective study.

BackgroundNeurolytic celiac plexus block (NCPB) is a typical treatment for severe epigastric cancer pain, but the therapeutic effect is often affected by the variation of local anatomical structures induced by the tumor. Greater and lesser splanchnic nerve neurolysis (SNN) had similar effects to the NCPB, and was recently performed with a paravertebral approach under the image guidance, or with the transdiscal approach under the guidance of computed tomography. This study observed the feasibility and safety of SNN via a transdiscal approach under fluoroscopic guidance.MethodsThe follow-up records of 34 patients with epigastric cancer pain who underwent the splanchnic nerve block via the T11-12 transdiscal approach under fluoroscopic guidance were investigated retrospectively. The numerical rating scale (NRS), the patient satisfaction scale (PSS) and quality of life (QOL) of the patient, the dose of morphine consumed, and the occurrence and severity of adverse events were recorded preoperatively and 1 day, 1 week, 1 month, and 2 months after surgery.ResultsCompared with the preoperative scores, the NRS scores and daily morphine consumption decreased and the QOL and PSS scores increased at each postoperative time point (P < 0.001). No patients experienced serious complications.ConclusionsSNN via the transdiscal approach under flouroscopic guidance was an effective, safe, and easy operation for epigastric cancer pain, with fewer complications.

Comparison of analgesic efficacy of the conventional approach and mid-transverse process to pleura approach of the paravertebral block in video-assisted thoracoscopy surgeries: A randomised controlled trial.

Background and Aims:The paravertebral block (PVB) is an effective alternative to thoracic epidural analgesia for post-operative analgesia in thoracic surgeries. Despite the use of ultrasound in PVB, the search for a safer approach continues. This study was conducted to compare the analgesic efficacy of conventional and mid-transverse process to the pleura (MTP) approach of the PVB.Methods:Forty patients aged between 18-60 years, posted for video-assisted thoracoscopic surgery, were enroled for this study. Patients were randomised into two groups using a random number table, and group allocation was done by the sealed opaque envelope method. One group received PVB by conventional approach (group CP). In contrast, patients in the other group (group MP) received PVB by the mid-transverse process to pleura (MTP) approach before induction of general anaesthesia under ultrasound guidance. The study's primary aim was to compare analgesic consumption in the first 24 hours. Secondary aims were comparing the Visual Analogue Scale (VAS) score, block performance time, dermatomal spread, haemodynamic parameters such as heart rate (HR), oxygen saturation (SpO2), and non-invasive blood pressure (NIBP), patient satisfaction scores, and complications observed. Data were analysed using Statistical Package for the Social Sciences version 23.Results:Demographic parameters, block performance time, and dermatomal distribution were comparable in both groups. We did not find any statistical difference in the analgesic consumption in the first 24 hours (P = 0.38), VAS at rest or on movement, complication rates, and patient satisfaction scores between the groups.Conclusion:The MTP approach of the PVB is as effective as the conventional thoracic paravertebral approach for post-operative analgesia in video-assisted thoracoscopic surgeries.

Efficacy of One-stage Paravertebral Approach using a Micro-Tubular Technique in Treating Thoracic Dumbbell Tumors.

ObjectiveThe aim of the present study was to investigate the feasibility and efficacy of one‐stage surgical resection of thoracic dumbbell tumors using a paravertebral approach and a micro‐tubular technique.MethodsClinical data of thoracic dumbbell tumors resected using a paravertebral approach and a micro‐tubular technique (14 mm, non‐expandable type) in the Department of Neurosurgery at our hospital from July 2014 to July 2019 were retrospectively analyzed. Tumors were found between T1 and T12 vertebrae. Operation time, blood loss, hospitalization, recovery of neurological function, complications, the Japanese Orthopaedic Association (JOA) score, and the visual analogue scale (VAS) score were used to evaluate clinical efficacy.ResultsIn all 31 cases, tumors were completely resected in one operation, with a mean blood loss of 53.23 ± 33.08 mL (20–150 mL) and a mean operation time of 95.16 ± 20.31 min (60–180 min). According to the Eden classification, there were four type II cases, 16 type III cases, and 11 type IV cases. The incidence of tumors in the lower thoracic segment (T8–T12) was 51.6% (16/31 cases), while the incidences in the upper thoracic segment (T1–T4) and middle segment (T5–T8) were 25.8% (8/31 cases) and 22.6% (7/31 cases), respectively. Pathological diagnoses were schwannoma (n = 22), gangliocytoma (n = 4), metastatic tumor (n = 2), neurofibroma (n = 1), granuloma (n = 1), and lipoma (n = 1). After surgery, symptoms were relieved in all patients. VAS and JOA scores significantly improved (P < 0.001). There was no pleural or lung injury, and there were no complications, such as cerebrospinal fluid leakage. The average follow‐up duration was 29 months (13–59 months), during which time no tumor recurrence or spinal instability occurred. The group of Eden type II tumors had lower JOA scores at 12 months postoperatively, longer operation times, and more estimated blood loss compared with other groups (P < 0.05). There were no significant influences on VAS scores at 12 months postoperatively and postoperative hospital stay from the different types of tumors.ConclusionThe paravertebral approach with a micro‐tubular technique is a safe and effective minimally invasive surgical approach for thoracic dumbbell tumors that allows one‐stage tumor resection using a single incision. Using this approach significantly reduces intraoperative blood loss and postoperative complications, shortens hospital stay, and reduces the rates of postoperative spinal instability.

Computed Tomography-Guided Percutaneous Radiofrequency Ablation of the Splanchnic Nerves as a Single Treatment for Pain Reduction in Patients with Pancreatic Cancer.

The aim of this paper is to prospectively evaluate the efficacy and safety of percutaneous computed tomography (CT)-guided radiofrequency (RF) neurolysis of splanchnic nerves as a single treatment for pain reduction in patients with pancreatic cancer. Patients with pancreatic ductal adenocarcinoma suffering from abdominal pain refractory to conservative medication who underwent CT-guided neurolysis of splanchnic nerves by means of continuous radiofrequency were prospectively evaluated for pain and analgesics reduction as well as for survival. In all patients, percutaneous neurolysis was performed with a bilateral retrocrural paravertebral approach at T12 level using a 20 Gauge RF blunt curved cannula with a 1cm active tip electrode. Self-reported pain scores were assessed before and at the last follow-up using a pain inventory with numeric visual scale (NVS) units. The mean patient age was 65.4 ± 10.8 years (male-female: 19-11). The mean pain score prior to RF neurolysis of splanchnic nerves was 9.0 NVS units; this score was reduced to 2.9, 3.1, 3.6, 3.8, and 3.9 NVS units at 1 week, 1, 3, 6, and 12 months respectively (p < 0.001). Significantly reduced analgesic usage was reported in 28/30 patients. Two grade I complications were reported according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system. According to the results of the present study, solely performed computed tomography-guided radiofrequency neurolysis of splanchnic nerves can be considered a safe and efficacious single-session technique for pain palliation in patients with pancreatic ductal adenocarcinoma suffering from abdominal pain refractory to conservative medication. Although effective in pain reduction the technique seems to have no effect upon survival improvement.

An Hourglass-Type Spinal Schwannoma Spreading to the Chest Treated with One-Stage Total Removal through Posterior Paravertebral Approach without Opening the Pleural Cavity (Clinical Observation)

The article describes the treatment of a 20-year-old patient with a spinal hourglass schwannoma (neurinoma) in the thoracic spine, growing from the right Th3 spinal root, spreading into the thoracic cavity and compressing the apex of the right lung. The introduction presents the frequency of occurrence of such neoplasms among all spinal cord tumors. Complaints, neurological symptoms, neoplasm diagnosis methods and its clinical and radiological manifestations are presented. The article describes stages and techniques of total surgical removal of the spinal hourglass schwannoma through the posterior paravertebral minimally invasive approach without opening the pleural cavity and with using neurophysiological monitoring of spinal cord function performed at the Neurosurgical Clinic of the Novosibirsk Research Institute of Traumatology and Orthopaedics named after Ya.L. Tsivyan. The data of histological examination and MRI control in the early postoperative period are presented. The follow-up was carried out at 6 and 12 months after surgical treatment. The publications describing the surgical treatment of paravertebral tumors through different approaches, the technique of their removal, possible complications and methods of their prevention are analyzed, and the classification according to Eden (1941), which characterizes the type of tumor growth, is presented.

A Technical Report on the Performance of Percutaneous Cryoneurolysis of Splanchnic Nerves for the Treatment of Refractory Abdominal Pain in Patients with Pancreatic Cancer: Initial Experience.

To report our preliminary results upon feasibility, efficacy and safety of percutaneous splanchnic nerves cryoneurolysis for the treatment of abdominal pain refractory to conservative medication in patients with pancreatic cancer MATERIALS METHODS: Institutional database research (retrospective review of prospectively collected data from April 2019 till August 2020) identified 5 patients with pancreatic cancer and pain refractory to conservative medication who underwent percutaneous cryoneurolysis of splanchnic nerves. In all patients, percutaneous cryoneurolysis was performed with posterolateral paravertebral approach using a 17 Gauge cryoprobe under computed tomography guidance and local anesthesia. Self-reported pain scores were assessed before and at the last follow-up using a pain inventory with visual analog scale (VAS) units. Mean patient age was 63.81years (male-female: 3-2). Mean pain score prior to cryoanalgesia of splanchnic nerves was 9.4 VAS units. This score was reduced to a mean value of 2.6, 2.6 and 3 VAS units at 1, 3 and 6months of follow-up, respectively. All patients reported significantly reduced analgesic usage. No complication was reported according to the CIRSE classification system. The mean procedure time was 44.4min (range 39-50min), including local anesthesia, cryoprobe(s) placement, ablation and post-procedural CT evaluation. Percutaneous cryoanalgesia of the splanchnic nerves is a minimally invasive, safe and effective procedure for pancreatic cancer pain relief. A larger, randomized trial is justified to substantiate these findings.

Clinical efficacy and prognostic factors of CT-guided 125I brachytherapy for the palliative treatment of retroperitoneal metastatic lymph nodes

BackgroundDue to the unique anatomical location of retroperitoneal metastatic lymph nodes, current treatment options are limited. This study was designed to explore the clinical efficacy and prognostic factors of CT-guided 125I brachytherapy for the treatment of retroperitoneal metastatic lymph nodes.MethodsWe retrospectively evaluated 92 patients received 125I brachytherapy for retroperitoneal metastatic lymph nodes. A layered Cox proportional hazards model was established to filter out the independent factors affecting local tumor progression-free survival (LTPFS).ResultsThe median LTPFS was 8 months. Metastatic lymph node with uniform density (p-0.009), clear boundaries (p-0.011), regular morphology (P < 0.001), and < 3 organs at risk of metastasis (p-0.020) were associated with better LTPFS. Necrotic lymph nodes (p < 0.001), fusion (p-0.003), and invasion of vessels visible on images (p < 0.001) were associated with poor LTPFS. Puncture path through abdominal wall or paravertebral approach were also associated with better LTPFS than a hepatic approach (P < 0.05). A maximum diameter ≤ 3 cm (P-0.031) or 3–5 cm (P-0.018) were also associated with significantly better LTPFS than a maximum diameter ≥ 5 cm. The Cox proportional hazards model suggested that lymph nodes invaded the large vessels visible on images, maximum diameter and puncture path were independent risk factors for LTPFS.ConclusionCT-guided 125I brachytherapy is an optional palliative treatment modality for retroperitoneal metastatic lymph nodes, which can provide high local control without severe complications. Better preoperative planning, intraoperative implementation, better choice of puncture path, and selection of appropriate tumor size are important factors that can improve the clinical efficacy of 125I brachytherapy for retroperitoneal metastatic lymph nodes.

Ozone mechanism of action on herniated disc: clinical and instrumental data abstract

PURPOSE: Recently, O2O3 has been successfully used in the treatment of Low Back Pain, reducing pain after the failure of other conservative treatments. Majority of LBP patients are affected by disc herniation (DH). O2O3 can stop pain caused by the Intervertebral Disc Degeneration (IDD), associated or not to extrusions of nucleus pulpous, causing inflammatory changes.&#x0D; Our primary purpose is to understand how ozone affects IDD.&#x0D; &#x0D; MATERIAL AND METHODS: Bilateral intramuscular O2O3 infiltrations, injected on the disk lesion with a paravertebral approach. An O2O3 mixture at a rate of 20 mcgr/mL was obtained by means of an ozone generator.&#x0D; &#x0D; RESULTS: A good reduction of pain and a significant improvement of life quality was obtained in patients with IDD treated with intramuscular infiltrations of O2O3.&#x0D; O2O3 therapy restricts production of pro-inflammatory substances from hernia, which are responsible for the painful symptoms and functional impairments.&#x0D; &#x0D; DISCUSSION: Contrary to popular knowledge, painful symptoms improvements are as a result of loss of bio-humoral inflammation factors and not the reduction of mechanical nerve pressure.&#x0D; &#x0D; CONCLUSION: The action of O2O3 is performed in a developed fibrous tissue in the disc herniation. This would prevent the production of pro inflammatory substances by the hernia itself, thus explaining the disappearance of the painful symptoms in the absence of volumetric&#x0D; reduction of the hernia. It is also shown by the persistence of the mechanical pressure on the nerve notwithstanding the disappearance of the inflammation and pain symptoms.

Usefulness of paravertebral approach for evaluation of descending thoracic aorta aneurysm.

Usefulness of paravertebral approach for evaluation of descending thoracic aorta aneurysm.

Minimally invasive decompression techniques for spinal cord stenosis

Lumbar spinal canal stenosis is frequently found among elderly patients and significantly limits their quality of life. Non-surgical therapy is an initial treatment option; however, it does not eliminate the underlying pathology. Surgical decompression of the spinal canal has now become the treatment of choice. Minimalization of surgical approach strategies with maintaining sufficient decompression of the spinal canal and avoiding disadvantages of macrosurgical techniques, monolateral paravertebral approach with bilateral intraspinal decompression, specific surgical techniques. Minimally invasive decompression techniques using a microscope or an endoscope are presented and different surgical strategies depending on both the extent (mono-, bi-, and multisegmental) and the location of the stenosis (intraspinal central, lateral recess, foraminal) are described. Minimally invasive microscopic or endoscopic decompression procedures enable sufficient widening of the spinal canal. Disadvantages of macrosurgical procedures (e. g., postoperative instability) can be avoided. The complication spectrum overlaps partially with that of macrosurgical interventions, albeit with significantly less marked severity. Subjective patient outcome is clearly improved. Referring to modern minimally invasive decompression procedures, surgery of lumbar spinal canal stenosis represents arational and logical treatment alternative, since causal treatment of the pathology is only possible with surgery.

Transverse approach to the erector spinae block

Response to Dr Philip and Dr Kaushik  Krediet et al [1][1] compare several different paravertebral approaches. The erector spinae plane block is a new technique, and all approaches should...

An update on regional analgesia for rib fractures.

To provide an update on new strategies for pain management after rib fractures utilizing regional analgesia. Pain management for patients with rib fractures can be very challenging. Traditionally, intravenous patient-controlled analgesia (IVPCA) with opioids, epidural, and paravertebral blocks have been used. These techniques, however, may be contraindicated or have limited application in certain patient populations. Recently, ultrasound-guided myofascial plane blocks such as the erector spinae plane (ESP) block and the serratus anterior plane (SAP) block have emerged as alternatives; providing excellent analgesia with minimal side effects. These blocks have the flexibility to be employed in a wide variety of circumstances where epidural and paravertebral approaches may not be feasible such as in anticoagulated patients and in patients with vertebral fractures where positioning options are limited. Myofascial blocks are less invasive and allow for broader and earlier application (e.g. in the emergency department). Further research on myofascial plane blocks is a priority. Until recently, epidural, paravertebral, and intercostal blocks have been advocated as primary management techniques for pain associated with rib fractures. Newer myofascial plane blocks may play a key role in the future as part of alternative pain management strategies.

Paravertebral injections: techniques and indications

The paravertebral injections were first referred in 1989 by Dr. Cesare Verga [1], an italian orthopedist. He used them to treat disc herniation. We call them “classical paravertebral injections”. Later on, one colleague of him, Dr. Scuccimarra [2], used longer needles to inject ozone close to the foramen, under the hypothesis of improving the results, and he succeeded. They are known as “deep paravertebral injections”. Other techniques have been developed in order to improve the results, reduce the risks and shorten the treatment.[3-9]&#x0D; &#x0D; The classical paravertebral approach is done locating the upper part of the spinous process of the superior vertebrae involved in the disco-radicular conflict and injecting 2,5 cm to the left and right of the spinous process with a 0,8 x 40 mm needle an amount of 5-10 mL per point depending on the size of the patient. Some authors(63) have proved that using lower ozone concentration (10 µg/mL) can be as useful as standard concentration (20 µg/mL). Our advice is to use a 0,4 x 40 mm needle or thinner if available. Local, topic anesthesia or cryotherapy can be used to reduce the pain of the needle. Injection should be done slowly. Using local anesthesia in the muscle can reduce the effect of ozone injection. The “deep paravertebral injection” uses a similar procedure, but the distance from the middle line is narrower (1,5 cm for cervical and dorsal injection and 2 cm for lumbar injection) and it is necessary using longer needles (0,4 or 0,5 x 90 mm spinal needle) to be able to locate the posterior joints with the tip of the needle an inject periarticularly. The amount of ozone used is the same.&#x0D; &#x0D; It is also possible to inject over the laminae, close to the foramen, instead of around the facet joints, but risk of accidental dura or radicular puncture is greater (although without permanent side effects); this can be done for nerve root de-inflammation. Dr Verga modified his technique for cervical and dorsal disc herniation, narrowing the distance from the spinous process to 1,5 cm left and right, using shorter needles (25 or 30 mm) and decreasing the ozone volume per point to 3-7 mL. Dorsal approach uses the same technique as for cervical paravertebral injections.&#x0D; &#x0D; The classical paravertebral injection produce a relaxation in the muscle spam of the lumbar spine in low back pain. The deep paravertebral injection produce an anti-inflammatory effect that can reduce inflammation on the facet joint or nerve root, depending on the point of injection.&#x0D; &#x0D; Based on this empirical approach, and the publications that have already used them , the indications of these injections are:&#x0D; &#x0D; -Disc herniation [1-2]&#x0D; -Spondylolysis [10]&#x0D; -Spondylosis [11-14]&#x0D; -Lumbar spinal stenosis [7, 15]&#x0D; -Symptomatic treatment of facet joint disease [7]&#x0D; -Mechanical low back pain&#x0D; &#x0D; These injections may have side effects due to the technique itself, not the ozone, but we have few reports on anecdotal cases, most of them without aftermath.