Radiographic Control Research Articles

4:12 PMAbstract No. 385 - Pain palliation and radiographic local control of spinal metastases with percutaneous radiofrequency ablation and vertebral augmentation

4:12 PMAbstract No. 385 - Pain palliation and radiographic local control of spinal metastases with percutaneous radiofrequency ablation and vertebral augmentation

Initial radiographic tumor control is similar following single or multi-fractionated stereotactic radiosurgery for jugular paragangliomas

ObjectiveTo evaluate radiographic tumor control and treatment-related toxicity in glomus jugulare tumors treated with stereotactic radiosurgery (SRS). Study designRetrospective chart review. SettingTertiary academic referral center. PatientsGlomus jugulare tumors treated with SRS between 1998 and 2014 were identified. The data analysis only included patients with at least 18months of post-treatment follow up (FU). InterventionPatients were treated with either single fraction or fractionated SRS. Main outcome measurePatient demographics and tumor characteristics were assessed. Radiographic control was determined by comparing pre and post treatment MRI, and was categorized as no change, regression, or progression. ResultsEighteen patients were treated with SRS, and 14 met inclusion criteria. Median age at treatment was 55years (range 35–79), and 71.4% of patients were female. 5 patients (35.7%) received single fraction SRS (dose range 15–18Gy), and 9 (64.3%) fractionated therapy (dose 3–7Gy×3–15 fractions). Median tumor volume was 3.78cm3 (range 1.15–30.6). Median FU was 28.8months (range 18.6–56.1), with a mean of 31.7months. At their last recorded MRI, 7 patients (50%) had tumor stability, 6 (42.9%) had improvement, and 1 (7.1%) had progression. Disease improvement and progression rates in the single fraction group were 40% and 0%, and in the multiple-fraction group, 44.4% and 11.1%, respectively. There was no statistically significant difference in disease improvement (p=0.88) or progression (p=0.48) rates between groups (unpaired t-test). ConclusionsAt a median follow up of 28months, both single fraction and fractionated SRS appear to have comparable radiographic tumor control outcomes and toxicity profiles.

Acetabular Development Following Salter’s Innominate Osteotomy for the Treatment of Developmental Dysplasia of the Hip: Long Term Follow-Up

Aim: To investigate the long term results of the patients followed till the skeletal maturity and treated with Salter innominate osteotomy. Patients and Methods: 85 hips of 63 patients whom were operated by the same surgeon between the years 1985 and 1991 were evaluated retrospectively. 34 hips of 25 patients who did not have enough follow-up or did not reach skeletal maturity at their last radiographic control were excluded from the study. So, 51 hips of 38 patients were included into our study. Mean age of the patients at the time of operation was 3 years 2 months (1.5 - 11 years), mean follow-up time was 16 years 6 months (10 - 23 years) and mean age at the last control was 19 years 7 months (15 - 27 years). Results: The overall clinical results were favorable (excellent or good) in 48 hips (94.1%) according to the modified McKay clinical evaluation scale. Avascular necrosis was evaluated with the Kalamchi-McEven classification at the last follow up and 45 hips (88.2%) had no avascular necrosis. The radiographic results were assessed by the Severin classification system and 10 hips (19.6%) were stage 1a; 10 hips (19.6%) were stage 1b; and 30 hips (58.8%) were stage 2. Upon the analysis of our radiographic results according to Stulberg classification system, we found out that only 2 (3.9%) of our patients were Stulberg stage 5, whereas 36 cases (70.6%) were Stulberg stage 1 and 2 (spherical congruency). According to Croft’s classification of hips for degenerative changes, 36 (70.6%) patients were stage 0; 6 (11.8%) patients were stage 1; 5 (9.8%) patients were stage 2 and 4 patients (8.7%) were stage 3. Conclusion: When appropriate soft tissue balance is provided, the complications of Salter Innominate Osteotomy are decreased and thus, it provides an excellent functional and radiological result.

Maxillary Incisor with Internal Resorption: Endodontic and Restorative Management.

A 34-year-old female patient reported with a chief complaint of cervical erosion and discoloration of upper maxillary central incisor with the history of trauma a week before. The patient said the tooth showed a pink spot on the crown at the cervical area 36 hours after the trauma, with no symptoms. Few days before she observed the erosion of the enamel at the same area, since it become a cavity in the next days. Radiographic examination showed the presence of an internal resorption at the crown,starting from the pulp chamber [Table/Fig-1]. No symptoms, no mobility, no pain on percussion were present and the vitality of the tooth were maintained (positive response to cold test). Prior to commencement of the procedure, treatment modality, cost benefit and risk were explained to the patient and appropriate consent was taken. [Table/Fig-1]: Initial radiograph with evidence of IRR at the crown. Local anaesthesia was administered. Enamel and dentine around the lesion were removed [Table/Fig-2] and a cervical restoration with composite resine was planned. At the same time the palatine access cavity was open with a diamond bur and all pulpal tissue was removed using Endoflare Ni-Ti rotary file (MicroMega, Besancon, France) and hand stainless-steel K files n.10 and n.15. The canal was irrigated with 5% sodium hypochlorite (NaOCl) to control the bleeding and to dissolve residual pulp tissue. So the restoration with composite resin (Filtek Supreme XTE, 3M Espe, Seefeld, Germany) of the coronal perforation was done, respecting all the protocols for adhesion. An intraoperative radiographic control of the restoration was done after removal of the rubber dam clamp, in order to control the fitting of the restoration [Table/Fig-3]. Then the rubber dam was replaced and root canal treatment was continued with the Revo-S Ni-Ti system (MicroMega, Besancon, France): all the sequence was done using SC1, SC2 and SC: the root canal was prepared at 25/.06. All the steps were done in presence of abundant irrigation with 5% NaOCl and 17% EDTA solutions. Irrigating solutions were frequently replaced. At the end of the treatment NaOCl was activated for 4 minutes using the Endo Activator(MailleferSimit Dental, Baillagues, Switzerland) and the whole root canal was filled with Calcium hydroxide (MM Paste, MicroMega, Besancon, France). A temporary restoration of the access cavity was placed and a radiograph was taken for control [Table/Fig-4]. [Table/Fig-5] shows the restored tooth immediately at the end of the treatment. [Table/Fig-2]: Intraoral view of the incisor after cleaning of coronal resoprtion with high- and low-speed burs: the root canal is visible through the cavity. [Table/Fig-3]: Radiographic control of composite resin restoration of the cervical cavity [Table/Fig-4]: Radiographic control of the temporary filling with Calcium hydroxide after initial treatment and removal of whole pulp tissue. [Table/Fig-5]: Aspect of the tooth after restoration with composite resin. The patient was recalled three weeks later for a second visit: no symptoms were present and the root canal treatment was finished. The root canal was irrigated with the copious amount of 5% NaOCl and the shaping was completed with Revo-S Apical 30 and 35 (MicroMega, Besancon, France). After verifying the complete removal of the Calcium hydroxide with the aid of the operating microscope, the final rinse with activated 5% NaOCl was done and the root canal was dried with paper points. The root canal obturation was done with the continuous wave technique [Table/Fig-6]: sealing of the apical third with warm gutta-percha compacted by the System B Heat source (Sybron Endo, Orange, CA, USA) and the MM Seal (MicroMega, Besancon, France) as sealer; backfilling obtained using Obtura II syringe (Spartan, Fenton, MO, USA). The patient was recalled one week later for the final obturation of the access cavity with composite resin (Filtek Supreme XTE, 3M Espe, Seefeld, Germany). [Table/Fig-6]: Radiographic control after obturation of the root canal. Radiographs were taken after two months [Table/Fig-7], after six months [Table/Fig-8] and after 12 months [Table/Fig-9]. The last control was done after two years [Table/Fig-10,​,11].11]. The tooth was asymptomatic and completely healed. No apical and peri-radicular lesions or signs of new resorption were visible. [Table/Fig-7]: A 2 months recall radiograph. [Table/Fig-8]: A 6 months recall radiograph. [Table/Fig-9]: A 12 months recall radiograph. [Table/Fig-10]: A 24 months recall radiograph. [Table/Fig-11]: Clinical and healthy aspect of the tooth after 24 months recall.

Extended Tumor Control after Dendritic Cell Vaccination with Low-Dose Cyclophosphamide as Adjuvant Treatment in Patients with Malignant Pleural Mesothelioma.

We demonstrated previously that autologous tumor lysate-pulsed dendritic cell-based immunotherapy in patients with malignant pleural mesothelioma is feasible, well-tolerated, and capable of inducing immunologic responses against tumor cells. In our murine model, we found that reduction of regulatory T cells with metronomic cyclophosphamide increased the efficacy of immunotherapy. To assess the decrease in number of peripheral blood regulatory T cells during combination therapy of low-dose cyclophosphamide and dendritic cell immunotherapy and determine the induction of immunologic responses with this treatment in patients with mesothelioma. Ten patients with malignant pleural mesothelioma received metronomic cyclophosphamide and dendritic cell-based immunotherapy. During the treatment, peripheral blood mononuclear cells were analyzed for regulatory T cells and immunologic responses. Administration of dendritic cells pulsed with autologous tumor lysate combined with cyclophosphamide in patients with mesothelioma was safe, the only side effect being moderate fever. Dendritic cell vaccination combined with cyclophosphamide resulted in radiographic disease control in 8 of the 10 patients. Overall survival was promising, with 7 out of 10 patients having a survival of greater than or equal to 24 months and two patients still alive after 50 and 66 months. Low-dose cyclophosphamide reduced the percentage of regulatory T cells of total CD4 cells in peripheral blood from 9.43 (range, 4.34-26.10) to 4.51 (range, 0.27-10.30) after 7 days of cyclophosphamide treatment (P = 0.02). Consolidation therapy with autologous tumor lysate-pulsed dendritic cell-based therapy and simultaneously reducing the tumor-induced immune suppression is well-tolerated and shows signs of clinical activity in patients with mesothelioma. Clinical trial registered with www.clinicaltrials.gov (NCT 01241682).

Radiographic Local Control of Spinal Metastases with Percutaneous Radiofrequency Ablation and Vertebral Augmentation.

Combination radiofrequency ablation and vertebral augmentation is an emerging minimally invasive therapy for patients with metastatic spine disease who have not responded to or have contraindications to radiation therapy. The purpose of this study was to evaluate the rate of radiographic local control of spinal metastases treated with combination radiofrequency ablation and vertebral augmentation. We retrospectively reviewed our tumor ablation database for all patients who underwent radiofrequency ablation and vertebral augmentation of spinal metastases between April 2012 and July 2014. Tumors treated in conjunction with radiation therapy were excluded. Tumor characteristics, procedural details, and complications were recorded. Posttreatment imaging was reviewed for radiographic evidence of tumor progression. Fifty-five tumors met study inclusion criteria. Radiographic local tumor control rates were 89% (41/46) at 3 months, 74% (26/35) at 6 months, and 70% (21/30) at 1 year after treatment. Clinical follow-up was available in 93% (51/55) of cases. The median duration of clinical follow-up was 34 weeks (interquartile range, 15-89 weeks), during which no complications were reported and no patients had clinical evidence of metastatic spinal cord compression at the treated levels. Combination radiofrequency ablation and vertebral augmentation appears to be an effective treatment for achieving local control of spinal metastases. A prospective clinical trial is now needed to replicate these results.

Rimozione chirurgica di un calcolo nel tratto anteriore del dotto di Wharton

ObjectivesThe aim of this study is to describe the case of a patient undergoing oral surgical removal of a calcified nodule from the anterior Wharton's duct. Materials and methodsA patient with salivary stones localized in the Wharton's duct, two fragments of total length between 1.5 and 2 cm, was surgically treated. A sialodochoplasty after calculi removal was performed. Results and conclusionsAfter clinical controls at 7 days after surgery and at 3-6 months, 1-3-5 years, as well as radiographic control at 5 years, a good healing process and a complete resolution of the pathological condition were assessed.

Clinical outcome of vertebral compression fracture after single fraction spine radiosurgery for spinal metastases.

Vertebral compression fracture (VCF) occurs after stereotactic body radiation therapy (SBRT) for spine metastasis. Recently, single fraction radiosurgery (sfSRS) is used more frequently. The aim of this study is to determine the clinical outcome of VCF after sfSRS. Spinal instability neoplastic score (SINS) criteria were used to retrospectively score 143 consecutive vertebral segments in 79 patients treated with SRS. Follow-up MRI, pain, and neurologic assessments obtained every 3-6months. Pain also scored at 7, 14, and 30days after sfSRS. Follow up was 16±18months ±SD, range 3-78. Long-term radiographic control occurred in 94% of cases. Pain improvement resulted within 7days in 100% of cases with severe pain and sustained long-term in 95%. VCF occurred in 21% of segments: 30% were de novo VCF. The overall 1year fracture free probability (1yFFP) was 76%. Pre-existing VCF resulted in higher probability to progress: 1yFFP 90 versus 60%. Symptoms presented in 6% of cases with de novo VCF and 39% with progressive. The former were treated with vertebral augmentation (VA), the latter with open surgery. Surgery/VA prior to SRS did not change risk of progressive VCF. Univariate but not multivariate analysis identified histology (colorectal), pre-existing VCF, and pain (severe) as significant predictors of VCF. In conclusion, sfSRS compares favourably to SBRT for radiographic and pain control with similar VCF risk. Patients with pre-existing VCF have a higher probability to progress, become symptomatic, and require surgery. These results may help discussing risk and benefits with patients undergoing sfSRS for spinal metastasis and developing new treatment algorithms.

A novel tool for continuous fracture aftercare – Clinical feasibility and first results of a new telemetric gait analysis insole

Weight bearing after lower extremity fractures still remains a highly controversial issue. Even in ankle fractures, the most common lower extremity injury no standard aftercare protocol has been established. Average non weight bearing times range from 0 to 7 weeks, with standardised, radiological healing controls at fixed time intervals. Recent literature calls for patient-adapted aftercare protocols based on individual fracture and load scenarios. We show the clinical feasibility and first results of a new, insole embedded gait analysis tool for continuous monitoring of gait, load and activity.Ten patients were monitored with a new, independent gait analysis insole for up to 3 months postoperatively. Strict 20kg partial weight bearing was ordered for 6 weeks. Overall activity, load spectrum, ground reaction forces, clinical scoring and general health data were recorded and correlated. Statistical analysis with power analysis, t-test and Spearman correlation was performed.Only one patient completely adhered to the set weight bearing limit. Average time in minutes over the limit was 374min. Based on the parameters load, activity, gait time over 20kg weight bearing and maximum ground reaction force high and low performers were defined after 3 weeks. Significant difference in time to painless full weight bearing between high and low performers was shown. Correlation analysis revealed a significant correlation between weight bearing and clinical scoring as well as pain (American Orthopaedic Foot and Ankle Society (AOFAS) Score rs=0.74; Olerud–Molander Score rs=0.93; VAS pain rs=−0.95).Early, continuous gait analysis is able to define aftercare performers with significant differences in time to full painless weight bearing where clinical or radiographic controls could not. Patient compliance to standardised weight bearing limits and protocols is low. Highly individual rehabilitation patterns were seen in all patients. Aftercare protocols should be adjusted to real-time patient conditions, rather than fixed intervals and limits. With a real-time measuring device high performers could be identified and influenced towards optimal healing conditions early, while low performers are recognised and missing healing influences could be corrected according to patient condition.

SURG-07A MULTI-INSTITUTIONAL EXPERIENCE ON LASER THERMAL ABLATION AS TREATMENT FOR CORPUS CALLOSAL GLIOBLASOTMAS

INTRODUCTION: Surgical management of glioblastomas involving the corpus callosum is of particular challenge. Accordingly, patients afflicted with this disease entity exhibit poor survival relative to other forms of glioblastomas. The development of minimally invasive, stereotactic laser thermal ablation now offers a new surgical option against this disease. METHODS: We present a multi-institutional experience (Cleveland Clinic, University of California San Diego, University Hospital-Case Medical Center) in the treatment of glioblastoma that involve the corpus callosum. Radiographic control, peri-operative morbidities, time of hospitalization, and overall survival were examined. RESULTS: All 16 patients harbored histologically confirmed diagnosis of glioblastoma. Five patients were newly diagnosed and underwent ablation before TMZ/RT while the remaining 10 patients were treated after TMZ/RT failure. The median age of the cohort is 52 (range: 29-68), with a median KPS of 80 (range 60-100). Three patients suffered transient post-operative hemiparesis. The average length of hospital stay was 3.3 days (range: 1-11 days). 13 of the 16 patients underwent subsequent chemotherapy treatment. No tumor growth was observed within the region of thermal ablation in any of the treated patient. The median survival of the cohort has not been reached. Eleven of the treated patients (69%) survived > 3 months – the reported median survival for corpus callosal glioblastoma patients without surgical resection. The overall survival for these 11 patients ranged 5 to 35 months. CONCLUSIONS: Glioblastoma involving the corpus callosum can be safely treated through laser thermal ablation. Our multi-institutional experience provides evidence in support of safety and suggest potential efficacy in select patients.

Local Control Rates of Metastatic Renal Cell Carcinoma (RCC) to Thoracic, Abdominal, and Soft Tissue Lesions Using Stereotactic Body Radiotherapy (SBRT)

Background and purposeWe report the radiographic response rate of SBRT compared to conventional fractionated radiotherapy (CF-EBRT) for thoracic, abdominal, skin and soft tissue RCC lesions treated at our institution.Material and methodsFifty three lesions where included in the study (36 SBRT, 17 CF-EBRT), treated from 2004 to 2014 at our institution. We included patients that had thoracic, skin & soft tissue (SST), and abdominal metastases of histologically confirmed RCC. The most common SBRT fractionation was 50 Gy in 5 fractions.ResultsThe median time of follow-up was 16 months (range 3–97 months). Median BED was 216.67 (range 66.67–460.0) for SBRT, and 60 (range 46.67–100.83) for CF-EBRT. Median radiographic local control rates at 12, 24, and 36 months were 100, 93.41, and 93.41 % for lesions treated with SBRT versus 62.02, 35.27 and 35.27 % for those treated with CF-EBRT (p < 0.001). Predictive factors for radiographic local control under univariate analysis included BED ≥ 100 Gy (HR, 0.048; 95 % CI, 0.006–0.382; p = 0.005), dose per fraction ≥ 9 Gy (HR, 0.631; 95 % CI, 0.429–0.931; p = 0.021), and gender (HR, 0.254; 95 % CI, 0.066–0.978; p = 0.048). Under multivariate analysis, there were no significant predictors for local control. Toxicity rates were low and equivalent in both groups, with no grade 4 or 5 side effects reported.ConclusionsSBRT is safe and effective for the treatment of RCC metastases to thoracic, abdominal and integumentary soft tissues. Radiographic response rates were greater and more durable using SBRT compared to CF-EBRT. Further prospective trials are needed to evaluate efficacy and safety of SBRT for RCC metastases.

Clinical and radiographic outcome of a treat-to-target strategy using methotrexate and intra-articular glucocorticoids with or without adalimumab induction: a 2-year investigator-initiated, double-blinded, randomised, controlled trial (OPERA)

ObjectivesTo study clinical and radiographic outcomes after withdrawing 1 year's adalimumab induction therapy for early rheumatoid arthritis (eRA) added to a methotrexate and intra-articular triamcinolone hexacetonide treat-to-target strategy (NCT00660647).MethodsDisease-modifying antirheumatic...

A Novel Minimally Invasive Technique for Treatment of Unicameral Bone Cysts.

Management of unicameral bone cysts (UBC) remain controversial. These cysts seldom heal spontaneously or even after pathological fracture. Sometimes these cysts can be very large and incredibly troublesome to the patient. Various treatments exist with variable success rates. We present our experience of treating these lesions by continuous drainage. Over a seven year period, six patients with unicameral bone cysts were treated by inserting a modified drain into the wall of the cyst. The aim of surgery was to place the drain in a dependent area of the cyst, through the cortex allowing for continuous drainage. This was achieved through a small incision under radiographic control. A cement restrictor (usually used for femoral canal plugging during total hip replacements) was modified and inserted to prevent closure of the drain site. A redivac drain was passed through the plug into the cyst. The drain was left in place for a week to establish an epithelialized pathway which hopefully would remain patent, into the subcutaneous tissues, after the drain had been removed. There were four males and two females in the group and the age range was 6 -12 years. Four of the lesions were in the upper humerus, one in the proximal femur and the other one in the proximal tibia. Healing was rated according to the modified Neer classification. Grade 1 (healed) and Grade 2 (healed with defect) was defined as excellent outcome. Persistent /Recurrent cysts (Grade 3 and 4) were noted as unsatisfactory. Five cases were completely healed. Only one had a further fracture and there were no recurrent fractures. All the patients reported complete comfort and they all were able to re-engage in recreational activities without restriction. We think that reducing the intra-medullary pressure in these lesions will lead to healing. We report a safe and minimally invasive technique for the management of UBC.

Pre-clinical evaluation of a minimally invasive laryngeal pacemaker system in mini-pig.

Microlaryngoscopic enlargement techniques have been the standard treatment for bilateral vocal fold paralysis (BVFP) for decades. Laryngeal pacing is a promising alternative treatment based on the electrostimulation of the posterior cricoarytenoid (PCA) muscle. This paper reports on the results of a pre-clinical study aiming to evaluate this method. Eight Göttingen mini-pigs were implanted with a laryngeal pacemaker (LP) implant prototype and with two LP electrodes, one in each PCA muscle. The 6-week follow-up included endoscopic stimulation controls in general anaesthesia and radiographic controls of electrode integrity and position stability. Stimulation parameters for optimal glottal opening were evaluated via videolaryngoscopy. Histopathology was performed upon conclusion of the study. 7/8 (87.5 %) animals were successfully implanted with the LP implant prototype and two LP electrodes. In general, stimulation was effectively delivered and correlated with the expected PCA muscle activation. 2/14 (14.3 %) electrodes dislocated and 1/14 (7.1 %) electrode tip broke. The LP system used in this experiment to induce vocal fold abduction by means of selective functional electrical stimulation of the PCA showed promising results. It may be a valid alternative to the current golden standard for BVFP treatment. Clinical studies are needed to confirm the medical relevance of the LP.

The National Lung Screening Trial Premise of Null and Chest Radiography Equivalence Is Open to Question.

Lung cancer screening guidelines are based on the National Lung Screening Trial (NLST) that used chest radiographic control subjects on the premise of the reported mortality equivalence in chest radiography versus unscreened persons in the NLST-eligible subgroup of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. The purpose of this article is to discuss concerns regarding the validity of the NLST premise of chest radiography and null screening equivalence. Anomalous findings combined with the failure of CT trials using unscreened control subjects to replicate the benefits of the NLST open to question the validity of this premise.

Reverse shoulder prosthesis to treat complex proximal humeral fractures in the elderly patients: results after 10-year experience.

The aim of this study is to report the clinical and radiological results of reverse total shoulder arthroplasty (rTSA) in elderly patients who have been treated for complex humeral fractures. From January 2005 to December 2014, we have implanted rTSA for proximal humeral fractures in 95 patients (80 women, 15 men) about 75 years old on average (range 62-95 years). All rates and results on intraoperative and postoperative complications have been collected in a specific database. In all cases we have used a modular implant prosthesis (Lima Corporate, San Daniele del Friuli, Italy). The prosthesis was implanted cementless in 92 cases. Because of the presence of a high percentage of comorbidities in the elderly patients, we have retrospectively analyzed the necessity of a secondary hospitalization, from a week to a 6-month time after the discharge, due to general health problems and specific postoperative shoulder complications. The mean follow-up was 5 years (range 1-9 years) for 70 of 95 patients, 50 of whom had adequate radiographic controls. None of 95 patients has required a reoperation or a hospitalization for general health problems from 1 week to 6 months postoperative. No early or late infection of prosthesis has been observed. There were seven cases of perioperative complications, three humeral vertical bone fissuring, two glenoid fractures and two cases of deltoid muscle damage. We have had three cases of postoperative hematoma and one case of ulnar nerve neuropathy. The mean constant score was 85.4, and the mean simple shoulder test was 7.4. We have observed a grade 1 scapular notching in 15 cases (30 %). In the remaining 35 reviewed cases, there was no notching. Peri-articular heterotopic ossifications were found in 11 cases (22 %). Reverse shoulder prosthesis in complex humeral fractures in the elderly can be considered as a reliable surgical procedure, which leads to very good clinical and radiological results in case of cementless prosthesis, as well.

Interspinous Device Implant and Sopraspinous Ligament Removal: An Alternative Approach for Low Back Pain Syndrome Persistence: Our Experience after 2 Years

Introduction Low-back pain syndrome is, up to date, one of the most common cause of inability, especially for young-adult people. In 20% of cases, patients have a degenerative disc disease associated with radiculopathy due to neuroforamen diameter reduction and lumbar soft-stenosis. Interspinous devices were extensively used in the treatment of this pathology, with different outcomes. Material and Methods An observational study was conducted comparing the interspinous device implant only, according to the standard technique, versus the devices implant together with a supraspinous ligament removal. Since April 2012, 81 patients with low-back pain and foraminal “soft” stenosis were enrolled and divided into two groups, homogeneous for age, sex, and disease severity (clinically and instrumentally assessed). Before surgery, all patients were subjected to medical therapy for at least 6 months without any clinical benefit. A total of 39 patients (group A, control) underwent interspinous devices implant only, according to the standard technique and 42 patients (group B) underwent device implant and supraspinous ligament removal. A clinical follow-up was performed at month 1, 3, 6, 12, and 24 by mean of visual analog scale (VAS), neurogenic claudication outcome score (NCOS), and Oswestry low back pain disability questionnaire (OLBPDQ). A radiographic control was obtained at month 1 and 6 (dynamic radiographic studies included). A MRI was done at month 6. The data were analyzed by mean of the Kaplan–Meier curve (results yielding a p value &lt; 0.05 were considered statistically significant). Results Until month 12, slight differences in VAS, NCOS, and OLBPDQ values were noticed between the two groups, but these scores was significantly higher in group B at month 24. Furthermore, radiographic evaluation showed a more significant neural foramina height recovery (mean value: 23 ± 3% vs. 41 ± 3%, respectively, in groups A and B). Although the supraspinous ligament is removed, there is not iatrogenic instability risk, because the device produces an immediate mechanical stability and a consequent intervertebral fusion. At follow-up there were no “fixation failure” and none patient underwent revision surgery. The standard technique provides the intraspinous ligament incision only and the devices positioning in the space between the spinous processes. In our opinion, this approach represents only a partial approach. Although the device implant is useful for radiculopathy resolution, usually low back could decrease, but in many cases only at the beginning. In fact the device may produce a supraspinous ligament extreme elongation, through to the intervertebral distraction. The nociceptors are abnormally stimulated and the back pain can reappear or in some cases persist. Conclusion This approach is able to definitively resolve both radiculopathy and low-back pain. This is an effective technique in terms of safety and efficacy, capable to provide a structural and functional correction, without back pain persistence risk, due to supraspinous ligament extreme elongation.

Pneumomediastino en cão yorkshire – relato de caso

The pneumomediastinum is a rare disease in the veterinary medical routine and is defined as the presence of free air in the mediastinum. It can occur spontaneously or due to trauma. The disease tends to be benign, but it is extremely important to identify its primary cause by means of physical examination and imaging tests. In this study, a Yorkshire-bred male was referred to the medical clinic with subcutaneous emphysema in the chest and neck areas. Since there were no obvious signs of clinical pain or dyspnea, a thoracic radiography was performed, in which the pneumomediastinum was identified. After conservative treatment, the patient returned for new radiographic control and medical discharge. Due to the rare and self-limiting nature of this condition, careful assessment is needed to prevent possible complications, which can vary according to the etiology or triggering factor.

Outcome of Direct Pulp Capping with Mineral Trioxide Aggregate: A Prospective Study

IntroductionThe aim of this experimental study was to assess the outcome of direct pulp capping with mineral trioxide aggregate (MTA) after complete excavation of caries in permanent dentition with a 2-visit treatment protocol. MethodsSixty-four teeth with deep carious lesions were consecutively selected. The mean age of the patients was 36.1 ± 15 years. An initial diagnosis of deep caries, with no irreversible pulp involvement, was made. Excavation of caries was performed under a rubber dam and operating microscope magnification. White MTA was applied, and a provisional restoration was placed. At the following appointment, positive sensibility testing and the MTA setting were confirmed. Bonded composite restorations were placed afterward. The patient was recalled at least 1 year after treatment for clinical and radiographic control. Outcome was described as success or failure. Success was defined as lack of complaints from the patient, positive reaction to cold testing, no sensitivity to percussion, and no widening of the periodontal ligament on the recall periapical radiograph. ResultsForty-six teeth (77.9%) were recalled after 3.6 years (standard deviation = 1.1 years). The overall success rate was 91.3%. The success rate in occlusal caries was 100% and 89.7% in proximal caries (difference = 10.3%; 95% confidence interval [CI], 8.5–89.1). The success rate in initial caries was 94.7% and 88.9% in secondary caries (difference = 5.8%; 95% CI, −48.1 to 59.7). The success rate in patients younger than 40 years was 100% and 80% in patients aged 40 years or older (difference = 20%; 95% CI, 4.2–35.8). ConclusionsDirect pulp capping with MTA after pulp exposure during excavation of deep caries could maintain pulp vitality in permanent teeth when a 2-visit treatment protocol is observed.

Is RCC truly radioresistant? Local control rates of metastatic renal cell carcinoma (RCC) to the lung using stereotactic radiotherapy (SBRT).

445 Background: The use of radiation therapy (RT) for renal cell carcinoma (RCC) is controversial because RCC has traditionally been considered to be “radioresistant”. Based on this concern, current studies have suggested the need for higher doses with conventional fractionation (CF) or the use of SBRT with RCC. The purpose of this study is to determine the efficacy of these modalities by comparing the radiographic and symptomatic local control (LC) rates in patients with metastatic RCC to the lung. Methods: We retrospectively analyzed the radiographic and symptomatic RT response in 27 consecutive RCC patients with 37 RCC lung lesions treated between 2005 to 2014. Twenty-six (70.2%) were treated with SBRT and eleven (29.8%) with CF. Only 9 patients (33.3%) had symptoms prior to RT. Median SBRT dose and fraction was 50 Gy (range 25-60) and 3 (range 1-6) versus CF 30 Gy (range 20-55) and 10 (range 5-22) respectively. Toxicity was evaluated by CTCAE 4.0. Results: Median follow up was 16 months (range 1-102). Rates of radiographic local control with SBRT and CF were 92.3% vs. 55.4% respectively (p=0.0016). Under univariate analysis, predictors for radiographic LR were gross tumor volume (GTV) &gt; 20 cc (p &lt; 0.0001), planned tumor volume (PTV) of &gt; 100 cc (p &lt; 0.0001), and biologic effective dose (BED) &lt; 70 Gy (p=0.0001). Subanalysis of CF demonstrated that a BED &lt; 54 Gy was also a strong predictor for LR (p=0.0012). Under multivariate analysis, PTV was a strong predictor for radiographic LR (odds ratio [OR] = 42.2, p=0.0492). For the 9 symptomatic patients, 3 of 4 (75%) patients in the CF arm and 4 of 5 (80%) in the SBRT arm experienced partial or complete symptomatic relief. The median time to relief of symptoms in the SBRT and CF arms were 0.5 and 2 months, respectively. All patients receiving CF had symptomatic LR compared to none in the SBRT arm (p=0.0124). One patient in the SBRT arm had grade 2 hiccups and one with grade 2 pneumonitis in the CF arm. There were no other grade 2 toxicities or higher. Conclusions: SBRT demonstrated an encouraging local control rate and was capable of safely providing symptomatic relief to patients. The traditional view of radioresistance in RCC may not apply in the era of SBRT.