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Extending the Arm of Augmentation Beyond the Neuroaxis
  1. Allan Brook
  1. Correspondence to Dr A Brook, Department of Radiology, Montefiore Medical Center, 111 east 210th St, Bronx, NY 10467, USA; abrook{at}

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This issue features an article on percutaneous acetabuloplasty.1 The authors of this manuscript are an experienced group of neurointerventionalists who have done extensive work in vertebral augmentation. At first pass, this article might appear distinct from many of its neighbors that deal with the variety of neurovascular conditions. On consideration, it is this observer's opinion that, in fact, this case series ideally represents an important component of the rich history of neurointerventional (NI) care.

The popular introduction of vertebral augmentation to the North American medical community occurred when neurointerventionalists published a seminal article in the AJNR.2 The subsequent literature on vertebral augmentation has been replete with multiple articles authored by NI specialists.3–5 In fact, the oft quoted multi-society position statement had critical input from members of our community.6

The international advent of percutaneous augmentation occurred in Europe in the early 1980s, and in the French language literature in 1987.7 This first lesion treated and the first series published was describing the percutaneous injection of polymethyl methacrylate (PMMA) into a hemangioma. The second unique fact is that the cervical spine was the first vertebral body blessed with percutaneous internal fixation. The trend was quickly adapted to osteoporosis, the more common etiology for insufficient bones. The natural evolution went caudally into the weight bearing lumbar spine and finally (about 16 years later; first reported in 2000)8 a revelation was made to treat the sacrum, a bone that offered unique challenges due to its inherent geometry. This also brought the procedure into the CT suite to help guide trajectories and avoid neurovascular structures and organs.

Interestingly, our European colleagues have long been more active in the use of these techniques to treat malignant compression fractures. Nonetheless, per above, while some of the early North American augmentation cases were malignant compression fractures, the majority of the experience and thus literature focused on the osteoporotic population.

Over time, an experience developed treating patients with malignant vertebral compression fractures. A variety of publications began to point to a better safety profile and higher level of effectiveness than was originally imagined.9–11 Indeed, the use of augmentation for management of malignant compression fractures has increased dramatically in the recent past.

In 1995, Cotton and colleagues12 suggested to extend the vertebroplasty technique to the acetabulum for the management of metastic osteolytic lesions. In recalling the earliest experiences in France, practitioners found benefit in percutaneous placement of PMMA in other sites. Following in the steps of our international colleagues, a US based literature emerged describing the use of percutaneous augmentation in non-traditional sites.13 14

Metastatic disease is the most common malignant disease of bone. Greater than half, of the 1.3 million cases of cancer, will develop skeletal metastases. Many of these, especially in weight bearing areas, present with pain or pathologic fractures.

The implicit message is clear; with oncologic patients surviving longer, the need for minimally invasive, relatively low risk, palliative treatments continues to increase. Even when systemic disease is advanced, local palliation remains an important component of advanced cancer care.

The group presenting this case series has been very active in the development of a variety of important concepts in vertebral augmentation. Embedded within the present group of authors are a radiation oncologist and neurointerventionalists. A review of this group's work highlights some of these emerging concepts. In 2008, they proposed a novel dosimetric analysis combining radioisotopes with traditional PMMA in a brachytherapy-type model for malignant compression fractures.15 In addition to themselves expanding on this work,16 17 other investigators have further developed these concepts.18–20 This parallels the vascular stroke pathway from intravenous to intra-arterial superselective deposition of medicines and newer devices.

Helping to pioneer the historical trend towards extra-vertebral augmentation described above, Hirsch et al have published several articles on the palliative placement of PMMA in non-vertebral sites.21 22

Recognizing the importance of communicating these results, this group published their initial case series on acetabuloplasty on a cohort of four patients.22 The present follow-through study is an important ‘next step’, including a larger cohort with meaningful statistical improvements in a variety of functional outcomes.

Since its inception, J NeuroInterv Surg has captured the NI imperative with a robust section on percutaneous spinal interventions. The inaugural volume of the journal featured an important article on functional outcomes after vertebroplasty.23 The September 2010 volume editor's selection was an analysis of this group's experience with malignant compression fractures.24 Moreover, the journal has featured comments on the evidentiary challenges of vertebral augmentation25 and technical specifics for the treatment of malignant compression fractures,26 among others.

Neurointervention is a field grounded in developing minimally invasive alternatives for operative lesions that ultimately improve the lives of the patients we serve. At its best, it provides alternatives where none may have existed before. In keeping with the best aspects of that care, this article on percutaneous acetabuloplasty helps move the treatment of oncologic patients forward.


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  • Linked article 004879.

  • Competing interests None.

  • Provenance and peer review Commissioned; not externally peer reviewed.

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