Deep learning-based identification of spine growth potential on EOS radiographs.

OBJECTIVES: To develop an automatic computer-based method that can help clinicians in assessing spine growth potential based on EOS radiographs. METHODS: We developed a deep learning-based (DL) algorithm that can mimic the human judgment process to automatically determine spine growth potential and the Risser sign based on full-length spine EOS radiographs. A total of 3383 EOS cases were collected and used for the training and test of the algorithm. Subsequently, the completed DL algorithm underwent clinical validation on an additional 440 cases and was compared to the evaluations of four clinicians. RESULTS: Regarding the Risser sign, the weighted kappa value of our DL algorithm was 0.933, while that of the four clinicians ranged from 0.909 to 0.930. In the assessment of spine growth potential, the kappa value of our DL algorithm was 0.944, while the kappa values of the four clinicians were 0.916, 0.934, 0.911, and 0.920, respectively. Furthermore, our DL algorithm obtained a slightly higher accuracy (0.973) and Youden index (0.952) compared to the best values achieved by the four clinicians. In addition, the speed of our DL algorithm was 15.2 ± 0.3 s/40 cases, much faster than the inference speeds of the clinicians, ranging from 177.2 ± 28.0 s/40 cases to 241.2 ± 64.1 s/40 cases. CONCLUSIONS: Our algorithm demonstrated comparable or even better performance compared to clinicians in assessing spine growth potential. This stable, efficient, and convenient algorithm seems to be a promising approach to assist doctors in clinical practice and deserves further study. CLINICAL RELEVANCE STATEMENT: This method has the ability to quickly ascertain the spine growth potential based on EOS radiographs, and it holds promise to provide assistance to busy doctors in certain clinical scenarios. KEY POINTS: • In the clinic, there is no available computer-based method that can automatically assess spine growth potential. • We developed a deep learning-based method that could automatically ascertain spine growth potential. • Compared with the results of the clinicians, our algorithm got comparable results.

Robotic navigation during spine surgery: an update of literature.

INTRODUCTION: The application of robotic navigation during spine surgery has advanced rapidly over the past two decades, especially in the last 5 years. Robotic systems in spine surgery may offer potential advantages for both patients and surgeons. This article serves as an update to our previous review and explores the current status of spine surgery robots in clinical settings. AREAS COVERED: We evaluated the literature published from 2020 to 2022 on the outcomes of robotics-assisted spine surgery, including accuracy and its influencing factors, radiation exposure, and follow-up results. EXPERT OPINION: The application of robotics in spine surgery has driven spine surgery into a new era of precision treatment through a form of artificial intelligence assistance that compensates for the limitations of human abilities. Modularized robot configurations, intelligent alignment and planning incorporating multimodal images, efficient and simple human - machine interaction, accurate surgical status monitoring, and safe control strategies are the main technical features for the development of orthopedic surgical robots. The use of robotics-assisted decompression, osteotomies, and decision-making warrants further study. Future investigations should focus on patients' needs while continuing to explore in-depth medical - industrial collaborative development innovations that improve the overall utilization of artificial intelligence and sophistication in disease treatment.

Real-time automatic prediction of treatment response to transcatheter arterial chemoembolization in patients with hepatocellular carcinoma using deep learning based on digital subtraction angiography videos.

BACKGROUND: Transcatheter arterial chemoembolization (TACE) is the mainstay of therapy for intermediate-stage hepatocellular carcinoma (HCC); yet its efficacy varies between patients with the same tumor stage. Accurate prediction of TACE response remains a major concern to avoid overtreatment. Thus, we aimed to develop and validate an artificial intelligence system for real-time automatic prediction of TACE response in HCC patients based on digital subtraction angiography (DSA) videos via a deep learning approach. METHODS: This retrospective cohort study included a total of 605 patients with intermediate-stage HCC who received TACE as their initial therapy. A fully automated framework (i.e., DSA-Net) contained a U-net model for automatic tumor segmentation (Model 1) and a ResNet model for the prediction of treatment response to the first TACE (Model 2). The two models were trained in 360 patients, internally validated in 124 patients, and externally validated in 121 patients. Dice coefficient and receiver operating characteristic curves were used to evaluate the performance of Models 1 and 2, respectively. RESULTS: Model 1 yielded a Dice coefficient of 0.75 (95% confidence interval [CI]: 0.73-0.78) and 0.73 (95% CI: 0.71-0.75) for the internal validation and external validation cohorts, respectively. Integrating the DSA videos, segmentation results, and clinical variables (mainly demographics and liver function parameters), Model 2 predicted treatment response to first TACE with an accuracy of 78.2% (95%CI: 74.2-82.3), sensitivity of 77.6% (95%CI: 70.7-84.0), and specificity of 78.7% (95%CI: 72.9-84.1) for the internal validation cohort, and accuracy of 75.1% (95% CI: 73.1-81.7), sensitivity of 50.5% (95%CI: 40.0-61.5), and specificity of 83.5% (95%CI: 79.2-87.7) for the external validation cohort. Kaplan-Meier curves showed a significant difference in progression-free survival between the responders and non-responders divided by Model 2 (p = 0.002). CONCLUSIONS: Our multi-task deep learning framework provided a real-time effective approach for decoding DSA videos and can offer clinical-decision support for TACE treatment in intermediate-stage HCC patients in real-world settings.

Learning curves of robot-assisted pedicle screw fixations based on the cumulative sum test.

BACKGROUND: In robot-assisted (RA) spine surgery, the relationship between the surgical outcome and the learning curve remains to be evaluated. AIM: To analyze the learning curve of RA pedicle screw fixation (PSF) through fitting the operation time curve based on the cumulative summation method. METHODS: RA PSFs that were initially completed by two surgeons at the Beijing Jishuitan Hospital from July 2016 to March 2019 were analyzed retrospectively. Based on the cumulative sum of the operation time, the learning curves of the two surgeons were drawn and fit to polynomial curves. The learning curve was divided into the early and late stages according to the shape of the fitted curve. The operation time and screw accuracy were compared between the stages. RESULTS: The turning point of the learning curves from Surgeons A and B appeared in the 18th and 17th cases, respectively. The operation time [150 (128, 188) min vs 120 (105, 150) min, P = 0.002] and the screw accuracy (87.50% vs 96.30%, P = 0.026) of RA surgeries performed by Surgeon A were significantly improved after he completed 18 cases. In the case of Surgeon B, the operation time (177.35 ± 28.18 min vs 150.00 ± 34.64 min, P = 0.024) was significantly reduced, and the screw accuracy (91.18% vs 96.15%, P = 0.475) was slightly improved after the surgeon completed 17 RA surgeries. CONCLUSION: After completing 17 to 18 cases of RA PSFs, surgeons can pass the learning phase of RA technology. The operation time is reduced afterward, and the screw accuracy shows a trend of improvement.

Comparison of Outcomes between Robot-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion and Oblique Lumbar Interbody Fusion in Single-Level Lumbar Spondylolisthesis.

OBJECTIVE: To compare the safety and effectiveness of robot-assisted minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF) and oblique lumbar interbody fusion (OLIF) for the treatment of single-level lumbar degenerative spondylolisthesis (LDS). METHODS: This is a retrospective study. Between April 2018 and April 2020, a total of 61 patients with single-level lumbar degenerative spondylolisthesis and treated with robot-assisted OLIF (28 cases, 16 females, 12 males, mean age 50.4 years) or robot-assisted Mis-TLIF (33 cases, 18 females, 15 males, mean age 53.6 years) were enrolled and evaluated. All the pedicle screws were implanted percutaneously assisted by the TiRobot system. Surgical data included the operation time, blood loss, and length of postoperative hospital stay. The clinical and functional outcomes included Oswestry Disability Index (ODI), Visual Analog scores (VAS) for back and leg pain, complication, and patient's satisfaction. Radiographic outcomes include pedicle screw accuracy, fusion status, and disc height. These data were collected before surgery, at 1 week, 3 months, 6 months, and 12 months postoperatively. RESULTS: There were no significantly different results in preoperative measurement between the two groups. There was significantly less blood loss (142.4 ± 89.4 vs 291.5 ± 72.3 mL, P < 0.01), shorter hospital stays (3.2 ± 1.8 vs 4.2 ± 2.5 days, P < 0.01), and longer operative time (164.9 ± 56.0 vs 121.5 ± 48.2 min, P < 0.01) in OLIF group compared with Mis-TLIF group. The postoperative VAS scores and ODI scores in both groups were significantly improved compared with preoperative data (P < 0.05). VAS scores for back pain were significantly lower in OLIF group than Mis-TLIF group at 1 week (2.8 ± 1.2 vs 3.5 ± 1.6, P < 0.05) and 3 months postoperatively (1.6 ± 1.0 vs 2.1 ± 1.1, P < 0.05), but there was no significant difference at further follow-ups. ODI score was also significantly lower in OLIF group than Mis-TLIF group at 3 months postoperatively (22.3 ± 10.0 vs 26.1 ± 12.8, P < 0.05). There was no significant difference in the proportion of clinically acceptable screws between the two groups (97.3% vs 96.2%, P = 0.90). At 1 year, the OLIF group had a higher interbody fusion rate compared with Mis-TLIF group (96.0% vs 87%, P < 0.01). Disc height was significantly higher in the OLIF group than Mis-TLIF group (12.4 ± 3.2 vs 11.2 ± 1.3 mm, P < 0.01). Satisfaction rates at 1 year exceeded 90% in both groups and there was no significant difference (92.6% for OLIF vs 91.2% for Mis-TLIF, P = 0.263). CONCLUSION: Robot-assisted OLIF and Mis-TLIF both have similar good clinical outcomes, but OLIF has the additional benefits of less blood loss, less postoperative hospital stays, higher disc height, and higher fusion rates. Robots are an effective tool for minimally invasive spine surgery.

Robot-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Spondylolisthesis.

OBJECTIVE: To compare the clinical efficacy between robot-assisted minimally invasive transforaminal lumbar interbody fusion (robot-assisted MIS-TLIF) and traditional open TLIF surgery in the treatment of lumbar spondylolisthesis. METHODS: According to the inclusion and exclusion criteria, 48 cases with lumbar spondylolisthesis who received surgical treatment from June 2016 to December 2017 in the spinal surgery department of Beijing Jishuitan Hospital were analyzed in this study, including 23 patients who received robot-assisted MIS-TLIF and 25 patients who received traditional open TLIF surgery. The two groups were compared in terms of pedicle screw accuracy evaluated by Gertzbein-Robbins classification on postoperative computed tomography (CT), operation time, blood loss, postoperative drainage, hospitalization, time to independent ambulation, low back pain evaluated by visual analog scale (VAS), lumbar function evaluated by Oswestry Disability Index (ODI), paraspinal muscles atrophy on magnetic resonance imaging (MRI), and complications. RESULTS: Postoperative CT showed that the rate of Grade A screws in the robot-assisted MIS-TLIF group was significantly more than that in the open surgery group (χ2 = 4.698, P = 0.025). Compared with the open surgery group, the robot-assisted MIS-TLIF group had significantly less intraoperative blood loss, less postoperative drainage, shorter hospitalization, shorter time to independent ambulation, and lower VAS at 3 days post-operation (P < 0.05). However, the duration of surgery was longer. The VAS of the robot-assisted MIS-TLIF group decreased from 6.9 ± 1.8 at pre-operation to 2.1 ± 0.8 at post-operation, 1.8 ± 0.7 at 6-month follow-up and 1.6 ± 0.5 at 2-year follow-up. The VAS of the open surgery group decreased from 6.5 ± 1.7 at pre-operation to 3.7 ± 2.1 at post-operation, 2.1 ± 0.6 at 6-month follow-up and 1.9 ± 0.5 at 2-year follow-up. The ODI of the robot-assisted MIS-TLIF group decreased from 57.8% ± 8.9% at pre-operation to 18.6% ± 4.7% at post-operation, 15.7% ± 3.9% at 6-month follow-up and 14.6% ± 3.7% at 2-year follow-up. The ODI of the open surgery group decreased from 56.9% ± 8.8% at pre-operation to 20.8% ± 5.1% at post-operation, 17.3% ± 4.2% at 6-month follow-up and 16.5% ± 3.8% at 2-year follow-up. Paraspinal muscle cross-sectional area in 2-year follow-up in patients of the open surgery group decreased significantly compared to patients of robotic-assisted MIS-TLIF group (P = 0.016). CONCLUSION: In the treatment of lumbar spondylolisthesis, robot-assisted MIS-TLIF may lead to more precise pedicle screw placement, less intraoperative blood loss, less postoperative drainage, less postoperative pain, quicker recovery, and less paraspinal muscle atrophy than traditional open surgery.

Risk Factors of Unsatisfactory Robot-Assisted Pedicle Screw Placement: A Case-Control Study.

OBJECTIVE: To identify potential risk factors of unsatisfactory screw position during robot-assisted pedicle screw fixation. METHODS: A retrospective analysis of robot-assisted pedicle screw fixation performed in Beijing Jishuitan Hospital from March 2018 to March 2019 was conducted. Research data was collected from the medical record and imaging systems. Univariate tests were performed on the potential risk factors (patient's characteristics and surgical factors) of unsatisfactory screw position during robot-assisted pedicle screw fixation. For statistically significant variables in univariate tests, a logistic regression test was used to identify independent risk factors for unsatisfactory screw position. RESULTS: A total of 780 pedicle screws placed in 163 robot-assisted surgeries were analyzed. The rate of perfect screw positions was 93.08%, and the unsatisfactory rate was 6.92%. In patients with severe obesity (body mass index ≥ 30 kg/m2) (odds ratio [OR], 2.459; 95% confidence interval [CI], 1.199-5.044; p = 0.014), osteoporosis (T ≤ -2.5) (OR, 1.857; 95% CI, 1.046-3.295; p = 0.034), and the segments 3 levels away from the tracker (OR, 2.216; 95% CI, 1.119-4.387; p = 0.022), robot-assisted pedicle screw placement has a higher risk of screw malposition. CONCLUSION: During robot-assisted pedicle screw placement for patients with severe obesity, osteoporosis, and segments 3 levels away from the tracker, vigilance should be maintained during surgery to avoid postoperative complications due to unsatisfactory screw position.

Correction to: Intrathecal Epigallocatechin Gallate Treatment Improves Functional Recovery After Spinal Cord Injury by Upregulating the Expression of BDNF and GDNF.

Since the publication of our article [1] it has come to our attention that there was an error in Figure 4 in which the bottom left immunochemistry panel Control/Bax was a duplication of the bottom right immunohistochemistry panel EGCG/GDNF in Figure 3.

Robot-assisted direct repair of spondylolysis: A case report.

INTRODUCTION: Direct repair of the pars defect in lumbar spondylolysis is an effective surgical procedure, but it is technically challenging. We assessed the feasibility of a new robotic system for intralaminar screw fixation of spondylolysis. PATIENT CONCERNS: A 26-year-old man complained about frequent low back pain after failed conservative treatments. DIAGNOSIS: The lumbar computed tomography images demonstrated the presence of bilateral spondylolysis at the L5 level, with no spondylolisthesis. INTERVENTIONS: We performed one surgery of direct intralaminar screw fixation under the guidance of the TiRobot system. The trajectory of the screw was planned based on intraoperative 3-dimensional radiographic images. Then, the robotic arm spontaneously moved to guide the guide wires and screw insertion. OUTCOMES: Bilateral L5 intralaminar screws were safely and accurately placed. No intraoperative complications occurred. Postoperative computed tomography showed good radiological results, without cortical perforation. CONCLUSION: We report the first case of robot-assisted direct intralaminar screw fixation for spondylolysis using the TiRobot system. Robotic guidance for direct repair of spondylolysis could be feasible.

Robotic navigation during spine surgery.

Introduction: Potential complications associated with screw malposition may result in neurological deficits or vascular injuries. Spine surgery has significantly developed under the assistance of technological progress. The advantages of applying robotic technology in spine surgery include the possibility of improving screw accuracy, reducing complications, decreasing fluoroscopy use.Areas covered: We critically evaluated the current literature on the radiographic and clinical outcomes of robotic-assisted spine surgery, including accuracy, radiation exposure, operative time, and complication rates.Expert opinion: Robotic-assisted spine surgery shows promising results and has the potentials for further investigations. The robot-assisted spine surgery is appeared to be more accurate in pedicle screw placement than the free-hand technique. In general, the robot-assisted technique is associated with shorter radiation exposure time but longer operative time than free-hand technique. For higher accuracy of robotic-assisted spine surgery, technical advancement and high-quality researches are needed. Artificial intelligent technology, decompression function, and higher accuracy are the directions for the development of robotic-assisted spine surgery.

Comparison of Superior-Level Facet Joint Violations Between Robot-Assisted Percutaneous Pedicle Screw Placement and Conventional Open Fluoroscopic-Guided Pedicle Screw Placement.

OBJECTIVE: To compare the superior-level facet joint violations (FJV) between robot-assisted (RA) percutaneous pedicle screw placement and conventional open fluoroscopic-guided (FG) pedicle screw placement in a prospective cohort study. METHODS: This was a prospective cohort study without randomization. One-hundred patients scheduled to undergo RA (n = 50) or FG (n = 50) transforaminal lumbar interbody fusion were included from February 2016 to May 2018. The grade of FJV, the distance between pedicle screws and the corresponding proximal facet joint, and intra-pedicle accuracy of the top screw were evaluated based on postoperative CT scan. Patient demographics, perioperative outcomes, and radiation exposure were recorded and compared. Perioperative outcomes include surgical time, intraoperative blood loss, postoperative length of stay, conversion, and revision surgeries. RESULTS: Of the 100 screws in the RA group, 4 violated the proximal facet joint, while 26 of 100 in the FG group had FJV (P = 0.000). In the RA group, 3 and 1 screws were classified as grade 1 and 2, respectively. Of the 26 FJV screws in the FG group, 17 screws were scored as grade 1, 6 screws were grade 2, and 3 screws were grade 3. Significantly more severe FJV were noted in the FG group than in the RA group (P = 0.000). There was a statistically significant difference between RA and FG for overall violation grade (0.05 vs 0.38, P = 0.000). The average distance of pedicle screws from facet joints in the RA group (4.16 ± 2.60 mm) was larger than that in the FG group (1.92 ± 1.55 mm; P = 0.000). For intra-pedicle accuracy, the rate of perfect screw position was greater in the RA group than in the FG group (85% vs 71%; P = 0.017). No statistically significant difference was found between the clinically acceptable screws between groups (P = 0.279). The radiation dose was higher in the FG group (30.3 ± 11.3 vs 65.3 ± 28.3 µSv; P = 0.000). The operative time in the RA group was significantly longer (184.7 ± 54.3 vs 117.8 ± 36.9 min; P = 0.000). CONCLUSIONS: Compared to the open FG technique, minimally invasive RA spine surgery was associated with fewer proximal facet joint violations, larger facet to screw distance, and higher intra-pedicle accuracy.

Comparison of the One-Time Accuracy of Simulated Freehand and Navigation Simulated Pedicle Screw Insertion.

OBJECTIVE: To compare one-time accuracy rate between simulated freehand (SFH) and navigation simulated (NS) pedicle screw insertion, assuming no second chance to correct screws. METHODS: A simulated, comparative, cross-sectional study was conducted on 69 patients undergoing lumbar spine surgery. An intraoperative registration system captured the planned point of entry and trajectory of pedicle screws for both SFH under direct visualization and NS under navigation-aided visualization. Pedicle screw insertion was simulated for each captured image (370 screws) using Surgimap. Rajasekaran's method helped evaluate the point of entry accuracy and trajectory. RESULTS: Accuracy rate was better for the NS method (97.8%) than for the SFH method (63.8%). Of 370 screws in the SFH group, 134 penetrated the cortex, with 31 resulting in >4 mm penetration. Of 370 screws in the NS group, 8 penetrated the cortex, <4 mm penetration. Of 134 misplaced screws in the SFH group, 64 were due to error in the point of entry, 63 were due to error in the trajectory angle, and 7 were due to both errors. Of 8 errors in the NS group, 7 were due to the point of entry. CONCLUSIONS: Intraoperative navigation had significantly better one-time accuracy of pedicle screw insertion than freehand insertion and should be used to avoid injury to the pedicle and surrounding tissue from screw reinsertion.

Guideline for Thoracolumbar Pedicle Screw Placement Assisted by Orthopaedic Surgical Robot.

The pedicle screw placement procedure is the most commonly used technique for spinal fixation and can provide reliable three-column stabilization. Accurate screw placement is necessary in clinical practice. To avoid screw malposition, which may decrease the stiffness of the screw-rod construct or increase the likelihood of neural and vascular injuries, the surgeons must fully understand the regional anatomy. Deformities, such as scoliosis, kyphosis or congenital anomalies, may complicate the application of the pedicle screw placement technique and increase the chance of screw encroachments. Incidences of pedicle screw malposition vary in different districts and hospitals and with surgeons and techniques. Today, the minimally invasive spinal surgery is well developed. However, the narrow corridors and limited views for surgeons increase the difficulty of pedicle screw placement and the possibility of screw encroachment. Evidenced by previous studies, robotic surgery can provide accurate screw placement, especially in settings of spinal deformities, anatomical anomalies, and minimally invasive procedures. Based on the consensus of consultant specialists, the literature review and our local experiences, this guideline introduces the robotic system and describes the workflow of robot-assisted procedures and the precautions to take during procedures. This guideline aims to outline a standardized method for robotic surgery for thoracolumbar pedicle screw placement.

Guideline for Posterior Atlantoaxial Internal Fixation Assisted by Orthopaedic Surgical Robot.

Atlantoaxial transarticular facet screw fixation (Magerl technique) and C1 lateral mass screws combined with C2 pedicle screws fixation (Harms technique) are the most commonly used techniques for posterior internal fixation in the upper cervical spine. Upper cervical spinal surgery is a technically demanding and challenging procedure because of complicated anatomical structures and frequent occurrence of anomalies. Accurate insertion of screws allows for stable and secure internal fixation, which is necessary for both techniques. Traditional methods under fluoroscopic assistance in this region cannot meet the requirements of high levels of accuracy and security during the procedure. Robot-assisted spinal surgery can provide accurate and reliable guidance during the screw insertion, which is evidenced in the literature. As a recently developed technique, robot-assisted surgery is supposed to be performed by skilled surgeons who have received standard training for robotic surgery. The standardized upper cervical spinal surgery assisted by the robot system needs to be introduced to these surgeons. Based on the consensus of consultant specialists, the literature review, and our local experience, this guideline included the introduction of the robotic system, the workflow of robot-assisted procedures, and the precautions to take during procedures. This guideline aims to provide a standardization of the robotic surgery for posterior atlantoaxial internal fixation.

Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease.

OBJECTIVE: To compare the clinical accuracy and perioperative outcomes for pedicle screw placement in transforaminal lumbar interbody fusion (TLIF) between the robot-assisted (RA) technique and fluoroscopy-guided (FG) technique. METHODS: Seventy-seven patients scheduled to undergo RA (n = 43) and FG (n = 44) TLIF surgery were included. Patient demographics, radiographic accuracy, and perioperative outcomes were recorded and compared. The accuracy of pedicle screw placement was according to the Gertzbein and Robbins scale and facet joint violation. Perioperative outcomes mainly included operative time, radiation exposure, and revisions. RESULTS: Of the 176 screws in the RA group, 164 screws were grade A, and 9, 2, and 1 screws were grades B, C, and D, respectively. Of the 204 screws in the FG group, 175 screws were grade A, with 16 screws scored as grade B, 8 screws scored as grade C, 3 screws scored as grade D, and 2 screws scored as grade E. The rate of perfect screw position (grade A) was higher in the RA group than in the FG group (93.2% vs. 85.8%, respectively; P = 0.020). In the FG group, 191 screws (93.6%) were clinically acceptable (groups A and B), whereas more acceptable screw positions were achieved in the RA group (98.3%; P = 0.024). Fewer screws in the RA group violated the proximal facet joint (5 vs. 24 screws, respectively; P = 0.001). The radiation dose was lower in the RA group (25.9 ± 14.2 vs. 70.5 ± 27.3 µSv, respectively; P < 0.001). Two screws in the FG group required a revision, but no revision was required in the RA group. CONCLUSIONS: RA pedicle screw placement is an accurate and safe procedure in TLIF for lumbar degenerative disease.

Computer-assisted, minimally invasive transforaminal lumbar interbody fusion: One surgeon's learning curve A STROBE-compliant article.

Minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) is a challenging technique with a long learning curve. We combined computer-assisted navigation and MI TLIF (CAMISS TLIF) to treat lumbar degenerative disease. This study aimed to evaluate the learning curve associated with computer-assisted navigation MI spine surgery (CAMISS) and TLIF for the surgical treatment of lumbar degenerative disease. Seventy four consecutive patients with lumbar degenerative disease underwent CAMISS TLIF between March 2011 and May 2015; all surgeries were performed by a single surgeon. According to the plateau of the asymptote, the initial 25 patients constituted the early group and the remaining patients comprised the latter group. The clinical evaluation data included operative times, anesthesia times, intraoperative blood losses, days until ambulation, postoperative hospital stays, visual analog scale (VAS) leg and back pain scores, Oswestry disability index (ODI) values, Macnab outcome scale scores, complications, radiological outcomes, and rates of conversion to open surgery. The complexity of the cases increased over the series, but the complication rate decreased (12.00%-6.12%). There were significant differences between the early and late groups with respect to the average surgical times and durations of anesthesia, but no differences in intraoperative blood losses, days until ambulation, postoperative hospital stays, complication rate, VAS, ODI, Macnab outcome scale scores, or solid fusion rates. There was no need for conversion to open procedures in either group. Our study showed that a plateau asymptote for CAMISS TLIF was reached after 25 operations. The later patients experienced shorter operative times and anesthesia durations.

Computer-assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion May Be Better Than Open Surgery for Treating Degenerative Lumbar Disease.

STUDY DESIGN: This study was a retrospective review of prospectively collected clinical data. OBJECTIVE: To evaluate the clinical and radiologic outcomes of computer-assisted minimally invasive spine surgery transforaminal lumbar interbody fusion (CAMISS-TLIF) and open TLIF for the treatment of 1-level degenerative lumbar disease. SUMMARY OF BACKGROUND DATA: Minimally invasive TLIF is becoming increasingly popular; however, the limited space and high rate of hardware complications associated with this method are challenging to surgeons. Computer-assisted navigation has the potential to dynamically show the fine anatomic structures, which could theoretically facilitate minimally invasive spine procedures. METHODS: Sixty-one patients underwent 1-level TLIF procedures (30, CAMISS-TLIF; 31, open TLIF). The computer-assisted navigation system was used for CAMISS-TLIF, whereas conventional fluoroscopy was used for open TLIF. Demographic, operative, visual analog scale, and Oswestry disability index data were collected. Screw insertion was assessed by computed tomography, and radiologic fusion based on Bridwell grading was evaluated 2 years after surgery by independent investigators. RESULTS: The CAMISS-TLIF group had significantly less blood loss, postoperative drain, need for transfusion, and initial postoperative back pain; earlier rehabilitation; and shorter postoperative hospitalization than the open TLIF group, whereas CAMISS-TLIF took longer surgical time than open TLIF. However, no significant differences between the 2 groups in visual analog scale scores and Oswestry disability index were observed at 3 months, 1 year, and 2 years postoperatively. A total of 93.33% and 73.39% of screws in the CAMISS and open groups, respectively, had no pedicle perforation (P=0.016), and the fusion rate was similar in both groups (P=0.787). CONCLUSIONS: Computer-assisted navigation facilitated minimally invasive spine surgery-TLIF. CAMISS-TLIF was superior to open TLIF for treating 1-level degenerative lumbar disease, although it required longer operation time in the initial stage. CAMISS-TLIF showed several benefits compared with open TLIF, including less intraoperative blood loss, postoperative drainage, and pain; earlier rehabilitation; and shorter postoperative hospitalization.

Posterior reduction and monosegmental fusion with intraoperative three-dimensional navigation system in the treatment of high-grade developmental spondylolisthesis.

BACKGROUND: The treatment of high-grade developmental spondylolisthesis (HGDS) is still challenging and controversial. In this study, we investigated the efficacy of the posterior reduction and monosegmental fusion assisted by intraoperative three-dimensional (3D) navigation system in managing the HGDS. METHODS: Thirteen consecutive HGDS patients were treated with posterior decompression, reduction and monosegmental fusion of L5/S1, assisted by intraoperative 3D navigation system. The clinical and radiographic outcomes were evaluated, with a minimum follow-up of 2 years. The differences between the pre- and post-operative measures were statistically analyzed using a two-tailed, paired t-test. RESULTS: At most recent follow-up, 12 patients were pain-free. Only 1 patient had moderate pain. There were no permanent neurological complications or pseudarthrosis. The magnetic resonance imaging showed that there was no obvious disc degeneration in the adjacent segment. All radiographic parameters were improved. Mean slippage improved from 63.2% before surgery to 12.2% after surgery and 11.0% at latest follow-up. Lumbar lordosis changed from preoperative 34.9 ± 13.3° to postoperative 50.4 ± 9.9°, and 49.3 ± 7.8° at last follow-up. L5 incidence improved from 71.0 ± 11.3° to 54.0 ± 11.9° and did not change significantly at the last follow-up 53.1 ± 15.4°. While pelvic incidence remained unchanged, sacral slip significantly decreased from preoperative 32.7 ± 12.5° to postoperative 42.6 ± 9.8°and remained constant to the last follow-up 44.4 ± 6.9°. Pelvic tilt significantly decreased from 38.4 ± 12.5° to 30.9 ± 8.1° and remained unchanged at the last follow-up 28.1 ± 11.2°. CONCLUSIONS: Posterior reduction and monosegmental fusion of L5/S1 assisted by intraoperative 3D navigation are an effective technique for managing high-grade dysplastic spondylolisthesis. A complete reduction of local deformity and excellent correction of overall sagittal balance can be achieved.

Intrathecal epigallocatechin gallate treatment improves functional recovery after spinal cord injury by upregulating the expression of BDNF and GDNF.

This study aimed to investigate the therapeutic effects of epigallocatechin-3-gallate (EGCG) administered by subarachnoid injection following spinal cord injury (SCI) in rats and to explore the underlying mechanism. Sprague-Dawley rats were randomly divided into four groups of 12 as follows: a sham group (laminectomy only); a control group; a 10 mg/kg EGCG-treated group; and a 20 mg/kg EGCG-treated group. SCI was induced in the rats using the modified weight-drop method (10 g × 4 cm) at the T10 (10th thoracic vertebral) level. EGCG (10 or 20 mg/kg) or vehicle as control was administered by subarachnoid injection at lumbar level 4 immediately after SCI. Locomotor functional recovery was assessed during the four weeks post-operation using open-field locomotor tests and inclined-plane tests. At the end of the study, the segments of spinal cord encompassing the injury site were removed for histopathological analysis. Immunohistochemical and Western blot analyses were performed to observe the expression of: the B cell CLL/lymphoma-2 (Bcl-2), Bcl-2-associated X protein (Bax), brain-derived neurotrophic factor (BDNF) and glial cell line-derived neurotrophic factor (GDNF). The results showed that the EGCG-treated animals had significantly better recovery of locomotor function, less myelin loss, greater Bcl-2 expression and attenuated Bax expression. In addition, the EGCG treatment significantly increased the expression of BDNF and GDNF after SCI. These findings suggest that EGCG treatment can significantly improve locomotor recovery, and this neuroprotective effect may be related to the up-regulation of BDNF and GDNF, and the inhibition of apoptosis-related proteins. Therefore, EGCG may be a promising therapeutic agent for SCI.