Too close for comfort? Assessing the impact of thermoprotective techniques in image-guided ablation of musculoskeletal tumors

Abstract Purpose This study aims to evaluate complication rates following cryoablation and radiofrequency ablation of painful musculoskeletal tumors and to assess the impact of lesion proximity to critical structures and the role of passive and active thermoprotective strategies on procedural safety. Methods This retrospective, IRB-approved study included 364 percutaneous ablation procedures (100 cryoablation, 264 RFA) performed between January 2013 and August 2023. Patient demographics, lesion characteristics, procedural details, and thermoprotection techniques were analyzed. Lesion distances from critical structures (e.g., spinal cord, peripheral nerves, skin, viscera) were recorded pre- and postthermoprotection. Complications were classified using the Common Terminology Criteria for Adverse Events (CTCAE v5.0). Results The overall complication rates were 4% for cryoablation and 3.4% for RFA, with no procedure-related mortality. The most common complications for cryoablation were transient weakness and hypertensive urgency (2%, 1%), and for RFA were arrhythmia and nausea (1.1%, 0.8%). No complications occurred in patients who underwent RFA with active thermoprotection. Thermoprotective strategies increased the distance between lesions and adjacent vital structures, particularly in high-risk anatomical zones. Conclusions Both cryoablation and RFA are safe and effective for treating painful musculoskeletal tumors. Active thermoprotection significantly reduces complication risk, enabling safe ablation near critical structures. Lesion proximity alone should not be considered a contraindication when protective techniques are appropriately employed. These findings support routine prophylactic use of thermoprotection during thermal ablation procedures.