Worsening Retropulsion of Bony Fragments Following Image Guided Radiofrequency Ablation and Vertebroplasty

 

Percutaneous vertebroplasty is commonly indicated for the treatment of medically refractory vertebral body compression fractures. • Relative contraindications include disruption of the posterior vertebral body wall or tumor extension into the spinal canal. • Radiofrequency ablation (RFA) can be incorporated to improve pain outcomes. • Complications may arise even after reassuring post-operative imaging.

 

A 48-year-old female presented to her local ED with a chief complaint of acute low back pain. • CT scan did not reveal any apparent etiology of the back pain. • MRI of the spine demonstrated a pathological fracture of the L2 vertebral body and soft tissue protrusion into the ventral epidural space (Figures 1,2). • Malignancy suspicion was confirmed after lymph node and neck mass biopsies. • The patient underwent palliative radiofrequency ablation combined with vertebroplasty. • Two 11-gauge needles were advanced to the posterior aspect of the vertebral body, and the RFA was carried out. CASE PRESENTATION • Polymethylmethacrylate mixture (PMMA) was delivered under fluoroscopic guidance with good coverage and no significant extravasation (Figures 3,4). • Upon emergence from anesthesia, the patient reported severe low back pain. • Repeat MRI confirmed a collapse of L2 vertebrae and showed a larger epidural soft tissue tumor, causing moderate compression of the thecal sac and severe stenosis of bilateral L2 lateral recesses (Figures 5-7). • Ultimately, the patient went through an L2 laminectomy with image-guided T12-L4 instrumental fusion and ameliorated her symptoms.