Cancer Treatment Today » Orthopedic

Epidural Injections – pro

admin — Sun, 02 Sep 2012 15:00:32 +0000

ODG recommends epidural injections only in the acute phase of pain and specifically does NOT recommend a series of three. Epidural injections were subject of a TEC assessment, which concluded: ….The average magnitude of effect is small, and the generalizability of the observation is limited by the small number of studies, limited to highly selected patient populations, the few techniques and doses studied, and variable comparison treatments….Their routine use for these indications is not recommended (Level B, Class I–III evidence).
Data on use of epidural steroid injections to treat cervical radicular pain are inadequate to make any recommendation (Level U).

ODG, Back Pain

Armon C, Argoff CE, Samuels J, Backonja MM, Therapeutics and Technology Assessment Subcommittee of the American. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007 Mar 6;68(10):723-9. [27 references]

PLDD, Percutaneous Laser Disc Decompression – pro

admin — Sun, 02 Sep 2012 14:59:37 +0000

The percutaneous laser discectomy is a procedure which consists of passing a side firing laser probe into specific regions of a lumbar or cervical disc under X-Ray visualization. The lasery is then directed at the “degenerate” tissues, with the purported effect to reduce inflammation in the disc and to reduce pressure upon nerves passing over the disc protrusion.

A recent review(Schenk et al) states that the success rates in the larger studies varied from 75% (95% confidence interval [CI], 69%–81%)17 to 87% (95% CI, 80%–94%). The definition of “successful outcome” varied strongly between the different studies, depending on the outcome measures used. The duration of follow-up ranged from 310 to 8412 months. Because of insufficient improvement of symptoms or recurrent herniation, 4.4%20 to 25% of patients received additional surgical treatment. In most cases, surgery revealed the presence of free fragments in the spinal canal.

I quote teh conclusion of this review: “No randomized, controlled trials were available. Almost all trials were case series, with a relatively low strength of evidence. Furthermore, the sample size in most trials was relatively small, resulting in broad 95% CIs that made interpretation of success rates difficult. Generalization of the results into general practice remains difficult, because of the different inclusion and exclusion criteria, laser types, and outcome measures used and the large variation in duration of follow-up. These individual differences impair the mutual comparability of the studies and, more important, limit the possibilities for a valid comparison to studies evaluating the outcome of conventional surgical treatment for lumbar disk herniation.

Despite the fact that PLDD has been around for almost 20 years, scientific proof of its efficacy still remains relatively poor, though the potential medical and economic benefits of PLDD are too high to justify discarding it as experimental or ineffective on the sole basis of insufficient scientific proof. Well-designed research of sufficient scientific strength, comparing PLDD to both conventional surgery and conservative management of lumbar disk herniation, is needed to determine whether PLDD deserves a prominent place in the treatment arsenal for lumbar disk herniation. ”

The PLDD method has not been subjected to ar igorous designed trila and reported success rates are poorly defined. Pain control is a notoriously poor predictor of success in back conditions. There are no ongoing US trials but there is a comparative trail ongoing in England, Current Controlled Trials ISRCTN25884790.

B. Schenk et al, Percutaneous Laser Disk Decompression: A Review of the Literature American Journal of Neuroradiology 27:232-235, January 2006

Gibson JN, Grant IC, Waddell G. Surgery for lumbar disc prolapse (Cochrane review). Cochrane Database Syst Rev. 2000;(3):CD001350.

Patrick A Brouwer et al, Effectiveness of percutaneous laser disc decompression versus conventional open discectomy in the treatment of lumbar disc herniation; design of a prospective randomized controlled trial BMC Musculoskeletal Disorders 2009, 10:49

Intra-arterial(IA) chemotherapy for peripheral osteosarcoma – pro

admin — Sun, 02 Sep 2012 14:58:49 +0000

Local control of osteosarcoma primarily is a surgical problem, but histologic response to neoadjuvant therapy is the single most important prognostic factor for long-term survival in nonmetastatic osteosarcoma of the extremity.IA therapy might be able to provide better guidance but this is not proven. Currently, doxorubicin, cisplatin, high-dose methotrexate with leucovorin rescue and ifosfamide are considered the most active agents against osteosarcoma.

IA cisplatin is not standard of care. It is not NCCN recommended. Instead, NCCN on Bone-C,1 recommends for fits-line: docetaxel/gemcitabine, cisplatin and doxorubicine, MAP, doxirubine/cisplatin/ifosfamide/high-dose methotrexate, ifosfamide/cisplatin/epirubicin.

Radiofrequency coagulation for osteoblastic osteoma – pro

admin — Sun, 02 Sep 2012 14:57:50 +0000

Osteoid osteoma is a benign osteoblastic tumor. The literature suggests a history of resolving pain and healing of the lesions, but the course can be variable. The course of this disease is unpredictable and protracted, with intervals of resolution of pain that sometimes last 6-15 years. Initial treatment of osteoid osteoma remains non-operative, with medications consisting of aspirin or other NSAIDs. There is a variety of operative approaches. Surgical intervention is generally indicated for patients whose pain is unresponsive to medical therapy, patients who cannot tolerate prolonged use of NSAIDs, and those who are not amenable to activity restrictions.

Percutaneous radiofrequency coagulation or ablation of the nidus is performed by using an electrode placed in the lesion, coupled with a radiofrequency generator that produces local tissue destruction by converting radiofrequency into heat. Complete or nearly complete relief of pain often occurs within 3 days. Patients are sent home on same day of surgery, and they have no limitations in weight bearing, though aggressive athletics are restricted for 2-3 months. Patients may then return to normal activities immediately or within 24-48 hours after surgery. For this reason, it is currently the favored procedure for osteoblstic osteoma. Pain resolves immediately, and limping resolves within 24 hours. Furthermore, this procedure requires only a small osseous access to allow insertion of the electrode; therefore, no substantial structural weakening of the bone occurs. Primary cure rates are 83-94%.

The main disadvantages of this procedure are recurrence or persistence of the osteoid osteoma and the lack of histologic verification. Recurrent lesions can be managed with repeat percutaneous radiofrequency ablation, but lesions should be confirmed histologically by means of needle biopsy before ablation. Cure with a second ablation procedure is approximately 100% and recurrence is very rare. Lesions that are resistant to percutaneous radiofrequency ablation can easily be treated with open surgery. Another complication is local skin burns.

I had not been able to find guidelines that recommend RFA or comparative studies of surgery versus RFA. However, the literature appears to support RFA as the lass invasive and somewhat preferable option. For example a recent article (Montanez-Heredia et al) says: “CT-guided radiofrequency ablation of osteoid osteoma is neither invasive nor damaging. It has achieved a high rate of pain relief with a small morbidity rate in this series. It can be carried out on a one-day clinic basis. In cases in the lower extremity, immediate full-weight bearing is allowed following the procedure. Open surgery should be used only for cases in which the diagnosis is uncertain, or when the lesion is located near an important neurovascular structure and cannot be removed completely

Motamedi D, Learch TJ, Ishimitsu DN, Motamedi K, Katz MD, Brien EW, et al. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics. Nov 2009;29(7):2127-41. [Medline].

Akhlaghpoor S, Aziz Ahari A, Ahmadi SA, Arjmand Shabestari A, Gohari Moghaddam K, Alinaghizadeh MR. Histological evaluation of drill fragments obtained during osteoid osteoma radiofrequency ablation. Skeletal Radiol. May 2010;39(5):451-5.

Volkmer D, Sichlau M, Rapp TB. The use of radiofrequency ablation in the treatment of musculoskeletal tumors. J Am Acad Orthop Surg. Dec 2009;17(12):737-43.

Rehnitz C, Sprengel SD, Lehner B, Ludwig K, Omlor G, Merle C, et al. CT-guided radiofrequency ablation of osteoid osteoma: correlation of clinical outcome and imaging features. Diagn Interv Radiol. Mar 8 2013

Elvira MONTAÑEZ-HEREDIA, José SERRANO-MONTILLA, María Luisa MERINO-RUIZ,

Francisco AMORES-RAMÍREZ, José VILLALOBOS-MARTÍN Osteoid osteoma : CT-guided radiofrequency ablation Acta Orthop. Belg., 2009, 75, 75-80

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Hyperbaric oxygen for osteonecrosis of the jaw – pro

admin — Sat, 01 Sep 2012 22:11:35 +0000

OsteonecroIs a well known complication of several medical interventions, such as radiation and biphosphonates. Osteonecrosis of the jaw is a known complication on of several medical interventions, such as radiation and biphosphonates. It had been described with Fosomax but began to be seen more frequently with the intravenous biphosphonates, such as Zometa. Conservative treatment is successful in approximately 50% of patients and consists of local rinses, antibiotics, and cessation of biphosphonates. Unfortunately some patients evidence progressive necrosis despite therapy and almost a half fail to completely heal. For this reason there is a great deal of interest in hyperbaric oxygen, as therapy that has shown effectiveness front nonhealing wounds of various types as well as for osteonecrosis caused by radiation. Unfortunately, for osteonecrosis after biphosphonate use, the supporting evidence remains case reports and case series A 2006 American Association of Oral and Maxillofacial Surgeons
Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws failed to recommend this therapy because of the lack of evidence.

REFERENCES:
Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD005005

Gesell, Laurie B. (Chair and editor) (2008). Hyperbaric Oxygen Therapy Indications. The Hyperbaric Oxygen Therapy Committee Report (12 ed.). Durham, NC: Undersea and Hyperbaric Medical Society. ISBN 0930406230.

Freiberger JJ. Utility of hyperbaric oxygen in treatment of bisphosphonate-related osteonecrosis of the jaws.J Oral Maxillofac Surg. 2009 May;67(5 Suppl):96-106.

Mustafa Erkan etal, Bisphosphonate-Related Osteonecrosis of the Jaw in Cancer Patients
and Hyperbaric Oxygen TherapyJOP. J Pancreas (Online) 2009 Sep 4; 10(5):579-580.

Van den Wyngaert T, Claeys T, Huizing MT, Vermorken JB, Fossion E.
Initial experience with conservative treatment in cancer patients with osteonecrosis of the jaw (ONJ) and predictors of outcome.Ann Oncol. 2009 Feb;20(2):331-6.

www.aaoms.org/docs/position_papers/osteonecrosis.pdf

Read the Layperson version here.