Influence of Blood Pressure on Acute Cervical Spinal Cord Injury Without Fracture and Dislocation: Results From a Retrospective Analysis.

OBJECTIVE: The objective of this study was to investigate the influence of blood pressure on the severity and functional recovery of patients with acute cervical spinal cord injury (SCI) without fracture and dislocation. METHODS: A retrospective case control study analyzed the data of 40 patients admitted to our orthopedics department (Beijing Tiantan Hospital, Capital Medical University) from January 2013 to February 2021. They were diagnosed as acute cervical SCI without fracture and dislocation. Gender, age, height, weight, history of hypertension, postinjury American Spinal Injury Association grade, postinjury modified Japanese Orthopaedic Association (mJOA) score, postoperative mJOA score, 1-year follow-up mJOA score, preoperative mean arterial pressure (MAP), intramedullary T2 hyperintensity, and hyponatremia were collected. The patients were divided into groups and subgroups based on their history of hypertension and preoperative MAP. The effects of history of hypertension and preoperative MAP on the incidence of T2 hyperintensity, hyponatremia, the improvement rate of the postoperative mJOA and 1-year follow-up mJOA scores were analyzed. RESULTS: Patients with history of hypertension had a lower incidence of intramedullary T2 hyperintensity than patients without history of hypertension (P < 0.05). Patients with history of hypertension and patients with a higher preoperative MAP had better neurological recovery at 1 year of follow-up (P < 0.05). CONCLUSIONS: Blood pressure has great influence on acute cervical SCI without fracture and dislocation. Maintaining a higher preoperative MAP is advantageous for better recovery after SCI. Attention should be paid to the dynamic management of blood pressure to avoid the adverse effects of hypotension after SCI.

A Web-Based Calculator to Predict Early Death Among Patients With Bone Metastasis Using Machine Learning Techniques: Development and Validation Study.

BACKGROUND: Patients with bone metastasis often experience a significantly limited survival time, and a life expectancy of <3 months is generally regarded as a contraindication for extensive invasive surgeries. In this context, the accurate prediction of survival becomes very important since it serves as a crucial guide in making clinical decisions. OBJECTIVE: This study aimed to develop a machine learning-based web calculator that can provide an accurate assessment of the likelihood of early death among patients with bone metastasis. METHODS: This study analyzed a large cohort of 118,227 patients diagnosed with bone metastasis between 2010 and 2019 using the data obtained from a national cancer database. The entire cohort of patients was randomly split 9:1 into a training group (n=106,492) and a validation group (n=11,735). Six approaches-logistic regression, extreme gradient boosting machine, decision tree, random forest, neural network, and gradient boosting machine-were implemented in this study. The performance of these approaches was evaluated using 11 measures, and each approach was ranked based on its performance in each measure. Patients (n=332) from a teaching hospital were used as the external validation group, and external validation was performed using the optimal model. RESULTS: In the entire cohort, a substantial proportion of patients (43,305/118,227, 36.63%) experienced early death. Among the different approaches evaluated, the gradient boosting machine exhibited the highest score of prediction performance (54 points), followed by the neural network (52 points) and extreme gradient boosting machine (50 points). The gradient boosting machine demonstrated a favorable discrimination ability, with an area under the curve of 0.858 (95% CI 0.851-0.865). In addition, the calibration slope was 1.02, and the intercept-in-large value was -0.02, indicating good calibration of the model. Patients were divided into 2 risk groups using a threshold of 37% based on the gradient boosting machine. Patients in the high-risk group (3105/4315, 71.96%) were found to be 4.5 times more likely to experience early death compared with those in the low-risk group (1159/7420, 15.62%). External validation of the model demonstrated a high area under the curve of 0.847 (95% CI 0.798-0.895), indicating its robust performance. The model developed by the gradient boosting machine has been deployed on the internet as a calculator. CONCLUSIONS: This study develops a machine learning-based calculator to assess the probability of early death among patients with bone metastasis. The calculator has the potential to guide clinical decision-making and improve the care of patients with bone metastasis by identifying those at a higher risk of early death.

Accurate Differentiation of Spinal Tuberculosis and Spinal Metastases Using MR-Based Deep Learning Algorithms.

Purpose: To explore the application of deep learning (DL) methods based on T2 sagittal MR images for discriminating between spinal tuberculosis (STB) and spinal metastases (SM). Patients and Methods: A total of 121 patients with histologically confirmed STB and SM across four institutions were retrospectively analyzed. Data from two institutions were used for developing deep learning models and internal validation, while the remaining institutions' data were used for external testing. Utilizing MVITV2, EfficientNet-B3, ResNet101, and ResNet34 as backbone networks, we developed four distinct DL models and evaluated their diagnostic performance based on metrics such as accuracy (ACC), area under the receiver operating characteristic curve (AUC), F1 score, and confusion matrix. Furthermore, the external test images were blindly evaluated by two spine surgeons with different levels of experience. We also used Gradient-Class Activation Maps to visualize the high-dimensional features of different DL models. Results: For the internal validation set, MVITV2 outperformed other models with an accuracy of 98.7%, F1 score of 98.6%, and AUC of 0.98. Other models followed in this order: EfficientNet-B3 (ACC: 96.1%, F1 score: 95.9%, AUC: 0.99), ResNet101 (ACC: 85.5%, F1 score: 84.8%, AUC: 0.90), and ResNet34 (ACC: 81.6%, F1 score: 80.7%, AUC: 0.85). For the external test set, MVITV2 again performed excellently with an accuracy of 91.9%, F1 score of 91.5%, and an AUC of 0.95. EfficientNet-B3 came second (ACC: 85.9, F1 score: 91.5%, AUC: 0.91), followed by ResNet101 (ACC:80.8, F1 score: 80.0%, AUC: 0.87) and ResNet34 (ACC: 78.8, F1 score: 77.9%, AUC: 0.86). Additionally, the diagnostic accuracy of the less experienced spine surgeon was 73.7%, while that of the more experienced surgeon was 88.9%. Conclusion: Deep learning based on T2WI sagittal images can help discriminate between STB and SM, and can achieve a level of diagnostic performance comparable with that produced by experienced spine surgeons.

The Temporal and Spatial Changes of Autophagy and PI3K Isoforms in Different Neural Cells After Hypoxia/Reoxygenation Injury.

There are limited therapeutic options for patient with traumatic spinal cord injury (SCI). Phosphoinositide 3-kinase family (PI3Ks) are the key molecules for regulating cell autophagy, which is a possible way of treating SCI. As we know, PI3K family are composed of eight isoforms, which are distributed into three classes. While the role of PI3Ks in regulating autophagy is controversial and the effects may be in a cell-specific manner. Different isoforms do not distribute in neural cells consistently and it is not clear how the PI3K isoforms regulate and interact with autophagy. Therefore, we explored the distributions and expression of different PI3K isoforms in two key neural cells (PC12 cells and astrocytes). The results showed that the expression of LC3II/I and p62, which are the markers of autophagy, changed in different patterns in PC12 cells and astrocytes after hypoxia/reoxygenation injury (H/R). Furthermore, the mRNA level of eight PI3K isoforms did not change in the same way, and even for the same isoform the mRNA activities are different between PC12 cells and astrocytes. What is more, the results of western blot of PI3K isoforms after H/R were inconsistent with the relevant mRNA. Based on this study, the therapeutic effects of regulating autophagy on SCI are not confirmed definitely, and its molecular mechanisms may be related with different temporal and spatial patterns of activation and distributions of PI3K isoforms.

Differential diagnosis of benign and malignant vertebral compression fractures: Comparison and correlation of radiomics and deep learning frameworks based on spinal CT and clinical characteristics.

PURPOSE: Differentiating benign from malignant vertebral compression fractures (VCFs) is a diagnostic dilemma in clinical practice. To improve the accuracy and efficiency of diagnosis, we evaluated the performance of deep learning and radiomics methods based on computed tomography (CT) and clinical characteristics in differentiating between Osteoporosis VCFs (OVCFs) and malignant VCFs (MVCFs). METHODS: We enrolled a total of 280 patients (155 with OVCFs and 125 with MVCFs) and randomly divided them into a training set (80%, n = 224) and a validation set (20%, n = 56). We developed three predictive models: a deep learning (DL) model, a radiomics (Rad) model, and a combined DL_Rad model, using CT and clinical characteristics data. The Inception_V3 served as the backbone of the DL model. The input data for the DL_Rad model consisted of the combined features of Rad and DCNN features. We calculated the receiver operating characteristic curve, area under the curve (AUC), and accuracy (ACC) to assess the performance of the models. Additionally, we calculated the correlation between Rad features and DCNN features. RESULTS: For the training set, the DL_Rad model achieved the best results, with an AUC of 0.99 and ACC of 0.99, followed by the Rad model (AUC: 0.99, ACC: 0.97) and DL model (AUC: 0.99, ACC: 0.94). For the validation set, the DL_Rad model (with an AUC of 0.97 and ACC of 0.93) outperformed the Rad model (with an AUC: 0.93 and ACC: 0.91) and the DL model (with an AUC: 0.89 and ACC: 0.88). Rad features achieved better classifier performance than the DCNN features, and their general correlations were weak. CONCLUSIONS: The Deep learnig model, Radiomics model, and Deep learning Radiomics model achieved promising results in discriminating MVCFs from OVCFs, and the DL_Rad model performed the best.

A Modified Unilateral Extrapedicular Approach Applied to Percutaneous Kyphoplasty to Treat Lumbar Osteoporotic Vertebral Compression Fracture: A Retrospective Analysis.

BACKGROUND: In recent years, many extrapedicular puncture methods have been applied to percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures (OVCFs). However, these techniques were generally complex and had the risk of some puncture-related complications, which greatly limited the wide applications in PKP. Finding a safer and more feasible extrapedicular puncture method was rather important. OBJECTIVES: To evaluate the treatment effect of modified unilateral extrapedicular PKP in patients with lumbar OVCFs clinically and radiologically. STUDY DESIGN: Retrospective study. SETTING: Department of Orthopedic Surgery, an affiliated hospital of a medical university. METHODS: Patients who were treated by modified unilateral extrapedicular PKP in our institution, from January 2020 to March 2021, were retrospectively enrolled. The degree of pain relief and functional recovery were evaluated by the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI), respectively. Radiologic results were assessed including anterior vertebral height (AVH) and kyphotic angle. In addition, volumetric analysis was performed to evaluate bone cement distribution. And the intraoperative data and complications were also recorded. RESULTS: A total of 48 patients with lumbar OVCFs were successfully treated by modified unilateral extrapedicular PKP. All patients experienced a significant decrease in VAS and ODI scores after surgery (P < 0.01) and maintained the statistical significance until the last follow-up (P < 0.01), as well as significant AVH restoration (P < 0.01) and kyphotic angle correction (P < 0.01) compared with preoperative corresponding values. Volumetric analysis showed that all cases of bone cement diffused across the midline of the vertebral body (VB), in which 43 patients (89.6%) presented optimal contralateral distribution with good or excellent bone cement spread. In addition, 8 patients (16.7%) experienced asymptomatic cement leakage, and no other severe complications, such as injuries to segmental lumbar arteries and nerve roots, were found. LIMITATIONS: A noncontrol study with a small patient population and short follow-up duration. CONCLUSIONS: Modified unilateral extrapedicular PKP, in which the puncture trajectory was advanced through the bottom of Kambin's triangle to or across the midline of VB for proper bilateral cement distribution, greatly alleviated back pain and restored the morphology of fractured vertebrae. It seemed to be a safe and effective alternative applied to treat lumbar OVCFs with appropriate patient selection.

Identification of Origin for Spinal Metastases from MR Images: Comparison Between Radiomics and Deep Learning Methods.

OBJECTIVE: To determine whether spinal metastatic lesions originated from lung cancer or from other cancers based on spinal contrast-enhanced T1 (CET1) magnetic resonance (MR) images analyzed using radiomics (RAD) and deep learning (DL) methods. METHODS: We recruited and retrospectively reviewed 173 patients diagnosed with spinal metastases at two different centers between July 2018 and June 2021. Of these, 68 involved lung cancer and 105 were other types of cancer. They were assigned to an internal cohort of 149 patients, randomly divided into a training set and a validation set, and to an external cohort of 24 patients. All patients underwent CET1-MR imaging before surgery or biopsy. We developed two predictive algorithms: a DL model and a RAD model. We compared performance between models, and against human radiological assessment, via accuracy (ACC) and receiver operating characteristic (ROC) analyses. Furthermore, we analyzed the correlation between RAD and DL features. RESULTS: The DL model outperformed RAD model across the board, with ACC/ area under the receiver operating characteristic curve (AUC) values of 0.93/0.94 (DL) versus 0.84/0.93 (RAD) when applied to the training set from the internal cohort, 0.74/0.76 versus 0.72/0.75 when applied to the validation set, and 0.72/0.76 versus 0.69/0.72 when applied to the external test cohort. For the validation set, it also outperformed expert radiological assessment (ACC: 0.65, AUC: 0.68). We only found weak correlations between DL and RAD features. CONCLUSION: The DL algorithm successfully identified the origin of spinal metastases from pre-operative CET1-MR images, outperforming both RAD models and expert assessment by trained radiologists.

Evidence-based guideline for the prevention and management of perioperative infection.

BACKGROUND: We have updated the guideline for preventing and managing perioperative infection in China, given the global issues with antimicrobial resistance and the need to optimize antimicrobial usage and improve hospital infection control levels. METHODS: We conducted a comprehensive evaluation of the evidence for prevention and management of perioperative infection, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Revisions were made to the guidelines in response to feedback from the experts. RESULTS: There were 17 questions prepared, for which 37 recommendations were made. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the meta-analysis results, recommendations were graded using the Delphi method to generate useful information. CONCLUSIONS: This guideline provides evidence to perioperative antimicrobial prophylaxis that increased the rational use of prophylactic antimicrobial use, with substantial improvement in the risk-benefit trade-off.

Evaluation of Adjacent Segment With Pre-Existing Degeneration Using the Cerebrospinal Fluid Occlusion Sign on MRI Before Posterior Lumbar Fusion: A Multi-Center Observational Cohort Study.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To evaluate whether pre-existing adjacent spinal canal stenosis (SCS) is associated with short-term outcomes after lumbar fusion surgery. METHODS: We included patients with lumbar spinal stenosis treated surgically between July 2015 and December 2017 at 4 centers. All patients had the same pathology, with L4-S1 as the culprit sections. Patients were divided into 2 groups based on the cerebrospinal fluid occlusion sign on MRI at the adjacent L3/4 level. Patients without SCS (grade 0) and with mild SCS (grade 1) were classified into the non-stenosis (NS) and mild stenosis (MS) groups, respectively. All patients underwent PLIF and completed at least 1-year follow-up. The incidence of adjacent segment degeneration (ASDeg) and clinical outcomes were compared between the 2 groups. RESULTS: A total of 308 patients (NS, 156; MS, 152) met the inclusion criteria. The incidence of ASDeg in the NS group (n = 40, 25.6%) was significantly lower than that in the MS group (n = 74, 48.7%; P < .001). The most frequent type of ASDeg in the 2 groups was the SCS-aggravated type. No significant difference was observed in adjacent segment disease incidence between the 2 groups (P = .243). The NS group had better outcomes according to the clinical function scores (P < .05). CONCLUSIONS: The cerebrospinal fluid occlusion sign on MRI is valuable for evaluating the adjacent segment with pre-existing degeneration. Patients with mild SCS in adjacent segments were more likely to have ASDeg, and the most frequent type of ASDeg was the SCS-aggravated type at early follow-up.

Is diabetes the risk factor for poor neurological recovery after cervical spine surgery? A review of the literature.

The poor prognosis of cervical spine surgery is mainly manifested as poor neurological recovery and the presence of new upper extremity dysfunction that promotes significant psychological and physiological burdens on patients. Many factors influence the prognosis of cervical spine surgery, including the age of patients, the time and mode of surgery, and the surgical technique used. However, in clinical studies, it has been observed that patients with diabetes have a higher probability of poor prognosis after surgery. Therefore, we review the pathophysiology of diabetic neuropathies and discuss its impact on cervical nerve system function, especially in cervical nerve roots and upper limb peripheral nerve conduction.

Effects of hanger reflex on the cervical muscular activation and function: A surface electromyography assessment.

Introduction: Cervical muscular dysfunction is closely associated with disorders and neuromuscular diseases of the cervical spine, and the hanger reflex (HR) has the potential to become a rehabilitation method. The muscular electrophysiology mechanism of HR is unclear. This study aims to identify the impacts of HR on cervical rotators' myoelectrical activity and function. Methods: We designed a self-control clinical trial, and asymptomatic volunteers were continuously included from 1 September 2021 to 30 April 2022 in our department. Rotation tasks were performed on both sides under each of the situations: no HR, unilateral HR, and bilateral HR. Surface electromyography (SEMG) was used to detect the myoelectrical activity of agonistic splenius capitis (SPL), upper trapezius (UTr), and sternocleidomastoid (SCM). The co-contraction ratio (CCR) during rotation tasks was calculated. Correlation analyses and multiple linear regression were performed. Results: Finally, 90 subjects were enrolled (power >90%). The adjusted EMG value (aEMG) of SPL UTr, SCM, and rotating CCR under the unilateral HR and bilateral HR were higher than no HR; the aEMG of SPL and rotating CCR under the bilateral HR were higher than the unilateral HR. Multiple linear regression showed that HR pattern and age were the independent affecting factors for the aEMG of SPL (p < 0.001, p < 0.001), UTr (p < 0.001, p < 0.001), and SCM (p < 0.001, p < 0.001); BMI was an independent affecting factor for the aEMG of SPL (p < 0.001) and SCM (p < 0.001); HR pattern was the only affecting factor for CCR (p < 0.001). Conclusion: HR can increase the cervical rotators' myoelectrical activities and rotating CCR, and the effects of bilateral HR are greater than unilateral HR, suggesting that bilateral HR has a greater clinical potential to become a rehabilitation method for treating cervical neuromuscular disorders.

New Insights into the Regulatory Role of Ferroptosis in Ankylosing Spondylitis via Consensus Clustering of Ferroptosis-Related Genes and Weighted Gene Co-Expression Network Analysis.

Background: The pathogenesis of ankylosing spondylitis (AS) remains undetermined. Ferroptosis is a newly discovered form of regulated cell death involved in multiple autoimmune diseases. Currently, there are no reports on the connection between ferroptosis and AS. Methods: AS samples from the Gene Expression Omnibus were divided into two subgroups using consensus clustering of ferroptosis-related genes (FRGs). Weighted gene co-expression network analysis (WGCNA) of the intergroup differentially expressed genes (DEGs) and protein-protein interaction (PPI) analysis of the key module were used to screen out hub genes. A multifactor regulatory network was then constructed based on hub genes. Results: The 52 AS patients in dataset GSE73754 were divided into cluster 1 (n = 24) and cluster 2 (n = 28). DEGs were mainly enriched in pathways related to mitochondria, ubiquitin, and neurodegeneration. Candidate hub genes, screened by PPI and WGCNA, were intersected. Subsequently, 12 overlapping genes were identified as definitive hub genes. A multifactor interaction network with 45 nodes and 150 edges was generated, comprising the 12 hub genes and 32 non-coding RNAs. Conclusions: AS can be divided into two subtypes according to FRG expression. Ferroptosis might play a regulatory role in AS. Tailoring treatment according to the ferroptosis status of AS patients can be a promising direction.

A Comparison Between Modified Unilateral Extrapedicular and Bilateral Transpedicular Percutaneous Kyphoplasty in the Treatment of Lumbar Osteoporotic Vertebral Compression Fracture.

BACKGROUND: Few researchers have verified the clinical efficacy and safety of the modified unilateral extrapedicular approach (mUEP) applied to the percutaneous kyphoplasty (PKP) in comparative studies with other puncture techniques. Compared with the bilateral transpedicular approach (BTP), whether mUEP PKP is a preferred treatment for lumbar osteoporotic vertebral compression fracture (OVCF) remains unclear. METHODS: Patients treated by PKP for single-level lumbar OVCF in our institution from September 2019 to December 2020 were retrospectively enrolled. Patients were grouped according to the puncture techniques. Clinical and radiologic outcomes were evaluated preoperatively, postoperatively, and at follow-up. The clinical evaluation was performed by using visual analog scale for pain relief and Oswestry Disability Index for health status. Radiologic measurements contained anterior vertebral height, kyphotic angle, and bone cement distribution. RESULTS: In total, 76 patients with a mean follow-up duration of 16.6 months were enrolled, including 34 patients in the mUEP PK group and 42 patients in the BTP PKP group. In the mUEP group, operation time, fluoroscopy times, and injected cement volume were significantly less than that in the BTP group (P < 0.01). Both visual analog scale and Oswestry Disability Index scores of all patients decreased significantly after surgery (P < 0.01), with no significant differences between the 2 groups at each follow-up. Both mUEP PKP and BTP PKP showed significant anterior height restoration and kyphotic angle correction (P < 0.01), with no significant differences between the 2 groups at each follow-up. Meanwhile, the mUEP PKP reduced the incidence of intraspinal cement leakage (P < 0.05), and no facet joint violation was found in mUEP PKP. CONCLUSIONS: mUEP PKP could be clinically and radiographically equivalent to BTP PKP. However, it has advantages in reducing operation time and fluoroscopy times, lowering the risk of intraspinal cement leakage, and preventing the presence of facet joint violation. Compared with BTP PKP, the mUEP PKP seems to be an effective and alternative puncture technique for the treatment of lumbar OVCF after appropriate patient selection.

Depression and anxiety in cervical degenerative disc disease: Who are susceptible?

Background: Pre-operative depression and anxiety are associated with poorer patient-reported outcomes following cervical spine surgery. Identification of and interventions for these disorders are key to preventing related negative effects. However, most spine surgeons do not routinely evaluate mental health disorders. Few studies have investigated which patients with cervical degenerative disc diseases (CDDD) are susceptible to depression and anxiety. Objective: To determine the factors associated with depression and anxiety in patients with CDDD. Methods: Three hundred twelve patients with CDDD were recruited in this cross-sectional case-control study. Patients underwent a structured interview to acquire demographic and clinical characteristic information, which included the Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA), and Visual Analog Scale (VAS) for neck/arm pain. Depression and anxiety were evaluated using the Zung Self-Rating Depression and Anxiety Scales. Univariate and multivariate logistic regression analyses were used to identify factors associated with depression and anxiety. Results: Of all patients, 102 (32.7%) had depression and 92 (29.5%) had anxiety. Two hundred six (66.0%) patients with neither depression nor anxiety were defined as the control group. Univariate analysis indicated that gender, educational level, occupation type, Charlson comorbidity index, symptom duration, symptomatology, surgery history, NDI, mJOA, VAS-neck, and VAS-arm scores were associated with depression and anxiety (except for symptom duration for anxiety). Multivariate logistic regression analysis indicated that females [odds ratio (OR) 1.81, 95% confidence interval (CI) 1.01-3.23], physical work (OR 2.06, 95% CI 1.16-3.65), poor mJOA score (ORmoderate 2.67, 95% CI 1.40-5.07; ORsevere 7.63, 95% CI 3.85-15.11), and high VAS-neck score (OR 1.24, 95% CI 1.11-1.39) were independent risk factors for depression. Physical work (OR 1.84, 95% CI 1.01-3.35), poor mJOA score (ORmoderate 2.66, 95% CI 1.33-5.33; ORsevere 9.26, 95% CI 4.52-18.99), and high VAS-neck score (OR 1.34, 95% CI 1.19-1.51) were independent risk factors for anxiety. Conclusion: Approximately one-third of patients with CDDD had depression or anxiety. Patients who engaged in heavy work and had severe symptoms (poor mJOA and high VAS-neck scores) are susceptible to depression and anxiety. Additionally, female patients are susceptible to depression. Our findings may help identify CDDD patients with depression and anxiety in clinical practice.

A Rare Manifestation of a Presumed Non-Osteophilic Brain Neoplasm: Extensive Axial Skeletal Metastases From Glioblastoma With Primitive Neuronal Components.

BACKGROUND: Glioblastoma multiforme (GBM) is the most common malignant tumor of the central nervous system. GBM with primitive neuronal component (GBM-PNC) is an aggressive variant identified in 0.5% of GBMs. Extracranial metastasis from GBM-PNC is a rare and challenging situation. METHODS: A special case of early-onset GBM with systemic bone metastasis was enrolled. Clinical data, including patient characteristics, disease course, and serial radiological images were retrieved and analyzed. Tumor tissues were obtained by surgical resections and were made into formalin-fixed paraffin-embedded sections. Histopathological examinations and genetic testing were performed for both the primary and metastatic tumor specimens. RESULTS: A 20-year-old man suffered from GBM with acute intratumoral hemorrhage of the left temporal lobe. He was treated by gross total resection and chemoradiotherapy following the Stupp protocol. Seven months later, he returned with a five-week history of progressive neck pain and unsteady gait. The radiographic examinations identified vertebral collapse at C4 and C6. Similar osteolytic lesions were also observed at the thoracolumbar spine, pelvic, and left femur. Anterior spondylectomy of C4 and C6 was performed. The resected vertebral bodies were infiltrated with greyish, soft, and ill-defined tumor tissue. One month later, he developed mechanical low-back pain and paraplegia caused by thoracolumbar metastases. Another spine surgery was performed, including T10 total en-bloc spondylectomy, T7-9, L2-3, and L5-S1 laminectomy. After the operation, the patient's neurological function and spinal stability remained stable. However, he finally succumbed to the rapidly increased tumor burden and died 15 months from onset because of cachexia and multiple organ failure. In addition to typical GBM morphology, the histological examinations identified monomorphic small-round cells with positive immunohistochemical staining of synaptophysin and CD99, indicating the coexistence of PNC. The next-generation sequencing detected pathogenic mutations in TP53 and DNMT3A. Based on above findings, a confirmed diagnosis of systemic metastases from GBM-PNC (IDH-wild type, WHO grade IV) was made. CONCLUSIONS: The present case highlights the occurrence and severity of extensive axial skeletal metastases from GBM-PNC. This rare variant of GBM requires aggressive multimodal treatment including surgery and chemoradiotherapy targeting PNC. The pathological screening of PNC is recommended in patients with early-onset GBM and intratumoral hemorrhage. Surgery for spinal metastasis is appropriate in patients with chemoradioresistance and relatively good general status, with the objectives of restoring spinal stability and relieving spinal cord compression.

Insulin-like growth factor 1 promotes neurological functional recovery after spinal cord injury through inhibition of autophagy via the PI3K/Akt/mTOR signaling pathway.

Spinal cord injury (SCI) is a serious trauma; however, the mechanisms underlying the role of insulin-like growth factor 1 (IGF-1) in autophagy following SCI remain to be elucidated. The present study aimed to investigate the therapeutic effect of IGF-1 on SCI and to determine whether IGF-1 regulates autophagy via the PI3K/Akt/mTOR signaling pathway. SH-SY5Y neuroblastoma cells were assigned to the H2O2, IGF-1 and control groups to investigate subsequent neuron injury in vitro. An MTT assay was performed to evaluate cell survival. In addition, Sprague-Dawley rats were randomly assigned to SCI, SCI + IGF-1 and sham groups, and Basso-Beatlie-Bresnahan scores were assessed to determine rat neurological function. Western blotting was used to analyze the autophagy level and the activation of the PI3K/Akt/mTOR signaling pathway. Cell survival was increased significantly in the IGF-1 group compared with the control group in vitro (P<0.05). Furthermore, neurological function was improved in the SCI + IGF-1 group compared with the control group in vivo (P<0.05). The western blotting results further demonstrated that LC3II/LC3I expression was increased in the IGF-1 group compared with the sham group in vivo and compared with the control group in vitro (both P<0.05). In the SCI + IGF-1 group, the expression levels of PI3K, phosphorylated (p)-Akt and p-mTOR were higher compared with those in the sham and SCI groups in vivo (P<0.05). Moreover, in the IGF-1 group, the expression levels of p-Akt and p-mTOR were higher compared with the control and the H2O2 groups in vitro (P<0.05). Collectively, the results of the present study suggested that IGF-1 promoted functional recovery in rats following SCI through neuroprotective effects. Furthermore, the underlying mechanism may involve activation of the PI3K/Akt/mTOR signaling pathway, followed by inhibition of autophagy. However, further investigation into the association between IGF-1-regulated autophagy and the activation of different subtypes of PI3K is required.

Influence of volar margin of the lunate fossa fragment fixation on distal radius fracture outcomes: A retrospective series.

BACKGROUND: Distal radius fractures accompanied by the volar margin of the lunate fossa (VMLF) lesions are often overlooked or inadequately reduced in clinical practice. AIM: To investigate the impact of VMLF fragment in distal radius fractures on the stability and function of the wrist joint. METHODS: This was a retrospective study of patients with distal radius fractures who underwent surgical treatment between January 2013 and December 2017. The patients were divided into two groups according to whether the VMLF fragments were fixed or not. X-rays and computed tomography were performed before surgery, immediately postoperatively, and at 1, 3, and 6 mo to measure the scapholunate angle, radiolunate angle, capitolunate angle, and effective radiolunate flexion (ERLF). The Mayo wrist score and disabilities of the arm, shoulder, and hand (DASH) score were determined at 1 year. RESULTS: Thirty-five patients were included. There were 15 males and 20 females. Their mean age was 52.5 ± 14.3 (range: 19-70) years. There were 38 wrists (17 on the left side, 15 on the right, and three bilateral; 16 in the fixed group, and 22 in the unfixed group). The interval between trauma and surgery was from 1 h to 1 mo. The incidence of postoperative wrist instability in the unfixed group (86.4%) was higher than in the fixed group (25.0%) (P ≤ 0.001). Ten patients had ERLF > 25° in the unfixed group and none in the fixed group (P = 0.019). The Mayo wrist score was 94 ± 5.7 in the fixed group and 68 ± 15.1 in the unfixed group (P < 0.001). The DASH score was 4.6 ± 2.5 in the fixed group and 28.5 ± 19.5 in the unfixed group (P < 0.001). CONCLUSION: Injuries of VMLF, even small fractures, might damage the radial-lunar ligament, leading to postoperative wrist instability, sagittal force line imbalance, and poor recovery of wrist joint function.

Clinical impact of 3-level anterior cervical decompression and fusion (ACDF) on the occipito-atlantoaxial complex: a retrospective study of patients who received a zero-profile anchored spacer versus cage-plate construct.

PURPOSE: To evaluate changes in the sagittal parameters of the occipito-atlantoaxial complex after three-level anterior cervical decompression and fusion (ACDF) and identify the influential factors by comparing ACDF with a zero-profile anchored spacer (ACDF-Z) versus a cage-plate construct (ACDF-P). METHODS: The cohort comprised 106 patients who underwent three-level contiguous ACDF-Z or ACDF-P for cervical radiculopathy and/or myelopathy. Standing, flexion, and extension radiographs of cervical spine were obtained preoperatively, and 3 and 12 months postoperatively. The assessed cervical sagittal parameters were the platform angle of the axis, Cobb angle, and range of motion (ROM) of C2⁃7, C0⁃1, and C1⁃2. RESULTS: In both the ACDF-Z and ACDF-P groups, the Cobb angle of the upper cervical spine decreased and the C0-1 ROM increased from preoperatively to 3 and 12 months postoperatively (P < 0.01). The alignment restoration was lost at 12 months compared with 3 months in the ACDF-Z group, but not in the ACDF-P group (P < 0.01). The ACDF-P group showed more loss of C2-7 ROM and more compensatory changes in C0-2 ROM than the ACDF-Z group (P < 0.05). CONCLUSION: The Cobb angle decreased and ROM increased significantly as compensatory changes of the atlantooccipital or atlantoaxial joint after both types of ACDF, which may accelerate degeneration. The zero-profile anchored spacer had less impact on the occipito-atlantoaxial complex but was worse at maintaining the alignment restoration, which were contrary to the cage-plate construct. Surgeons should be aware of the impact of multi-level ACDFs on the occipito-atlantoaxial complex.

The effect of cervical intervertebral disc degeneration on the motion path of instantaneous center of rotation at degenerated and adjacent segments: A finite element analysis.

BACKGROUND: The motion path of instantaneous center of rotation (ICR) is a crucial kinematic parameter to dynamically characterize cervical spine intervertebral patterns of motion; however, few studies have evaluated the effect of cervical disc degeneration (CDD) on ICR motion path. The purpose of this study was to investigate the effect of CDD on the ICR motion path of degenerated and adjacent segments. METHOD: A validated nonlinear three-dimensional finite element (FE) model of a healthy adult cervical spine was used. Progressive degeneration was simulated with six FE models by modifying intervertebral disc height and material properties, anterior osteophyte size, and degree of endplate sclerosis at the C5-C6 level. All models were subjected to a pure moment of 1 Nm and a compressive follower load of 73.6 N to simulate physical motion. ICR motion paths were compared among different models. RESULTS: The normal FE model results were consistent with those of previous studies. In degenerative models, average ICR motion paths shifted significantly anterior at the degenerated segment (ß = 0.27 mm; 95% CI: 0.22, 0.32) and posterior at the proximal adjacent segment (ß = -0.09 mm; 95% CI: -0.15, -0.02) than those of the normal model. CONCLUSION: CDD significantly affected ICR motion paths at the degenerated and proximal adjacent segments. The changes at adjacent segments may be a result of compensatory mechanisms to maintain the balance of the cervical spine. Surgical treatment planning should take into account the restoration of ICR motion path to normal. These findings could provide a basis for prosthesis design and clinical practice.

An Unrecognized Ligament and its Ossification in the Craniocervical Junction: Prevalence, Patient Characteristics, and Anatomic Evidence.

BACKGROUND: In the craniocervical junction, the ligaments between the anterior foramen magnum and the anterior arch of the atlas are not well defined, and ossification of the ligaments in this region has rarely been reported. Characterizing the anatomy and ossification of these ligaments may help in the diagnosis and treatment of disorders in this region. QUESTIONS/PURPOSES: (1) What is the prevalence of an unrecognized ossification at the craniocervical junction in patients with cervical spine disorders, and what are the patient characteristics associated with this ossification? (2) Do patients with this ossification have a greater risk of ossification of other structures at the craniocervical junction or cervical spine? (3) Is there an unreported ligament at this ossified site? METHODS: We conducted a retrospective study of 578 hospitalized patients who underwent CT for cervical spine disorders between January 2016 and July 2020. Based on the inclusion criteria, 11% (66 of 578) were excluded because of a cervical or craniocervical tumor, deformity, infection, fracture or dislocation, or prior surgery, leaving 89% (512 of 578) for analysis. These 512 patients had diagnoses of cervical radiculopathy, cervical myelopathy, cervical spondylotic amyotrophy, cervical spinal cord injury without a radiographic abnormality, or axial neck pain. Their mean age was 57 years (range 22-90 years), and 60% of the patients were men. Patient characteristics including age, gender, and diagnosis were retrieved from a longitudinally maintained institutional database. CT images were used to assess the presence of a previously unrecognized ossification and ossification of other structures in the craniocervical junction and cervical spine, including the posterior longitudinal ligament, anterior longitudinal ligament, nuchal ligament, ligamentum flavum, transverse ligament, and apical ligament, as well as diffuse idiopathic skeletal hyperostosis (DISH). The association between these structures was also assessed. This unreported ossification was called the capped dens sign. It was defined and graded from 1 to 3. Grade 3 was defined as the typical capped dens sign. Cervical spine MRI was used to assess whether there was an unreported structure in the same region as where the capped dens sign was detected on CT images. In the database of a recent study, there were 33 patients younger than 41 years. Nine percent (three of 33) were excluded because they did not have cervical spine MRI. MRIs of the remaining 30 patients were assessed. Their mean age was 35 years (range 22-40 years), and 58% were men. All cervical spine CT images and MRIs were reviewed by one senior spine surgeon and one junior spine surgeon twice with a 2-week interval. Blinding was accomplished by removing identifying information from the radiographs and randomly assigning them to each examiner. Any discrepancy with respect to the grade of the capped dens sign was adjudicated by a third blinded senior spine surgeon. Intrarater and interrater reliabilities were assessed by calculating weighted kappa statistics. No ligament or membrane was reported at this site. MRI is not sensitive to identify thin tissue in this region, especially when severe degeneration has occurred. A cadaveric study was conducted to discover a potential ligament between the inferior margin of the foramen magnum and the anterior arch of the atlas, as prompted by the newly discovered ossification in the clinical analysis of this study. Six embalmed human cadaveric craniocervical regions (three male and three female cadavers; median age 56 years, range 45-78 years) were dissected by a senior anatomist and a senior anatomy technician. A mid-sagittal section of the craniocervical junction was created, allowing us to explore the interval between the anterior foramen magnum and anterior arch of the atlas. A histologic analysis was conducted in two of the six cadavers (a male cadaver, 45 years; and a female cadaver, 51 years). Slides were made with 4-µm sections and stained with hematoxylin and eosin. RESULTS: A novel capped dens sign was detected in 39% (198 of 512) of the patients and the most typical capped dens sign was detected in 19% (96 of 512) of patients. The prevalence of this sign was the highest in patients with cervical spondylotic amyotrophy (12 of 25 patients). The prevalence of ossification of the anterior longitudinal ligament, ligamentum nuchae, and apical ligament, as well as DISH, was higher in patients with a capped dens sign than in those without (p = 0.04, p < 0.001, p < 0.001, and p = 0.001, respectively). The capped dens sign was identified in 69% (18 of 26) of the patients with DISH. A thin and short band-like structure or osteophyte was detected on MRI in 87% (26 of 30), in the same region as the capped dens sign. In the cadaveric study, an unreported, distinct ligamentous structure was identified at this ossified site. It originated from the posterosuperior rim of the anterior arch of the atlas to the inferior margin of the foramen magnum, which we called the inter-atlanto-occipital ligament. It was found in all six dissected craniocervical junctions. The histologic analysis revealed dense connective tissue. CONCLUSION: More than one-third of the patients in this series demonstrated CT evidence of a previously unrecognized ossification in the craniocervical junction, which we called the capped dens sign. Anatomic evidence of this sign, which was a previously unidentified ligament, was also newly discovered in this region. This study was conducted among Asian patients and specimens. Further studies among diverse ethnic groups may be needed to generalize the results. An additional well-designed prospective study will be needed to provide further evidence regarding the potential pathophysiology and clinical relevance of the capped dens sign. Furthermore, the cadaveric analysis in this study was only a preliminary report of the ligament; further biomechanical research is needed to investigate its function. CLINICAL RELEVANCE: Knowledge of this novel ligament may improve the diagnosis and treatment of craniocervical stability and dislocation. Ossification of this ligament is correlated with age, cervical spondylotic amyotrophy, and DISH. We wonder whether patients with cervical degenerative disorders who also have a capped dens sign may be at risk for the formation of osteophytes of an uncovertebral joint, which may result in palsy of the upper limb muscles. The capped dens sign may be the craniocervical manifestation of DISH. This possible association between the capped dens sign and DISH should be considered when performing surgery on patients with the capped dens sign.