Intraoperative scrub nurse turnover in orthopaedic surgery procedures: An opportunity for improved operating room efficiency.

BACKGROUND: Scrub nurses play a crucial role in facilitating orthopaedic surgeries, and thus intraoperative scrub nurse turnover may disrupt the workflow of the surgical team and prolong duration of surgery (DOS). The purpose of this study was to quantify the impact of intraoperative scrub nurse turnover on operative time of orthopaedic surgeries lasting less than 3h in duration. METHODS: Prospectively collected databases from two institutions were retrospectively queried to identify all orthopaedic procedures of maximum mean duration of 180min from March 4th, 2018 to August 31st, 2022. Cases were divided into two groups, those with scrub nurse turnover and those without. Propensity score matching was conducted to match groups by surgeon, hospital, patient age, gender, and ASA classification. Unpaired t-tests were used to compare mean DOS for each surgical procedure. Average treatment effect on treated (ATET) with 95% confidence intervals (CIs) were calculated. RESULTS: Scrub nurse turnover significantly prolonged DOS for both bone forearm facture open reduction and internal fixation (ORIF) (ATET=21.08, p=0.001), ankle ORIF (ATET=21.26, p<0.001), clavicle ORIF (ATET=16.16, p=0.028), femur intramedullary nail (ATET=11.52, p=0.003), rotator cuff repair (ATET=16.88, p<0.001), partial discectomy (ATET=10.52, p=0.001), total knee arthroplasty (TKA) (ATET=5.69, p<0.001), anterior total hip arthroplasty (THA) (ATET=8.80, p<0.001), lateral THA (ATET=7.02, p<0.001), and uncemented hip hemiarthroplasty (ATET=16.79, p=0.049). CONCLUSION: Intraoperative scrub nurse turnover significantly prolongs surgical times in orthopaedic surgeries lasting up to 3h in duration. This highlights the importance of developing strategies to prevent intraoperative scrub nurse turnover to improve OR efficiency and decrease healthcare costs.

Thickness and design features of clinical cranial implants-what should automated methods strive to replicate?

PURPOSE: New deep learning and statistical shape modelling approaches aim to automate the design process for patient-specific cranial implants, as highlighted by the MICCAI AutoImplant Challenges. To ensure applicability, it is important to determine if the training data used in developing these algorithms represent the geometry of implants designed for clinical use. METHODS: Calavera Surgical Design provided a dataset of 206 post-craniectomy skull geometries and their clinically used implants. The MUG500+ dataset includes 29 post-craniectomy skull geometries and implants designed for automating design. For both implant and skull shapes, the inner and outer cortical surfaces were segmented, and the thickness between them was measured. For the implants, a 'rim' was defined that transitions from the repaired defect to the surrounding skull. For unilateral defect cases, skull implants were mirrored to the contra-lateral side and thickness differences were quantified. RESULTS: The average thickness of the clinically used implants was 6.0 ± 0.5 mm, which approximates the thickness on the contra-lateral side of the skull (relative difference of -0.3 ± 1.4 mm). The average thickness of the MUG500+ implants was 2.9 ± 1.0 mm, significantly thinner than the intact skull thickness (relative difference of 2.9 ± 1.2 mm). Rim transitions in the clinical implants (average width of 8.3 ± 3.4 mm) were used to cap and create a smooth boundary with the skull. CONCLUSIONS: For implant modelers or manufacturers, this shape analysis quantified differences of cranial implants (thickness, rim width, surface area, and volume) to help guide future automated design algorithms. After skull completion, a thicker implant can be more versatile for cases involving muscle hollowing or thin skulls, and wider rims can smooth over the defect margins to provide more stability. For clinicians, the differing measurements and implant designs can help inform the options available for their patient specific treatment.

Measuring 3D facial displacement of increasing smile expressions.

BACKGROUND: Following paralysis, facial reanimation surgery can restore movement by nerve and/or muscle transfer within the face. The subtleties of lip and cheek movements during smiling are important aspects in assessing reanimation. This study quantifies average 3D movement vectors of the face during smiling based on the diverse Binghamton University 3D facial expression database to yield normative measures of lip and cheek movement. METHODS: The analysis was conducted on 100 subjects with 3D facial scans in a neutral and 4 increasing smile intensities, as well as associated labeled 3D landmark points. Each subject set of 3D scans was rigidly registered to measure average displacement vectors (distance, azimuth, and elevation) between the neutral and happy expressions. RESULTS: The average lip commissure displacement was found to be 9.2, 11.4, 13.5, and 16.0 mm for increasing smile levels 1-4, respectively. Similarly, the average commissure azimuth angle across all 4 smile levels is ∼44 ± 21 degrees, and the average elevation angle across all 4 smile levels is ∼37 ± 15 degrees. The maximum cheek displacement from the neutral expression was 4.5, 5.7, 6.8, and 7.9 mm for the smile levels 1-4, respectively. The average cheek movement azimuth angle is outward (increasing 1-13 degrees), and the elevation angle is upward (increasing 51-59 degrees) from the face. CONCLUSIONS: These data quantifying 3D lip and cheek smile displacements improve the understanding of facial movement and may be applicable to future assessment/planning of facial reanimation surgeries.

Modeling and measuring average nasal asymmetry by dorsum midline and nose tip lateral deviation.

In rhinoplasty and nasal reconstruction, achieving symmetry is critical for optimal patient outcomes and reducing re-operation rates. Assessing nasal asymmetry is challenging, both pre- and intra-operatively, if based on only a surgeons' visual perception to assess and adjust the small distances important to cosmesis (<2-3 mm). To measure nasal symmetry, we first developed an algorithm to analyze lateral nasal deviation on facial three-dimensional (3D) scans captured by external surface scanning. In this, nasal deviation is measured by first registering a 3D facial scan to orthogonal axes in order to remove tilt. The lateral position of the nasal midline is then found across transverse planes along the dorsum and nasal tip regions by probing midpoints 1 and 2 mm back from the local maximum projection. The nasal deviation measurement algorithm was validated on a simulated asymmetrical nose model with known nasal deviation. Simulated deviations were applied to the symmetrical average nose using an exponential twist away from the face, with control of the maximum deviation and degree of curvature. Modeled deviations were evaluated with the algorithm at clinically negligible (0.02-0.06 mm) average differences and for small lateral deviations (1-5 mm). Nasal deviation using the algorithms was then measured for the 100 multi-ethnic subjects in the Binghamton University 3D Facial Expression database. Average values for maximum lateral deviation, deviation across the whole nose, and deviation at the nose tip were measured to provide context to deviation measurements in surgical planning. This research presents a new nasal assessment tool that can be useful in improving symmetry in rhinoplasty and reconstruction.

Biomechanical analysis of anterior ring fixation of the ramus in type C pelvis fractures.

PURPOSE: This biomechanical study compared the stability of four different ramus fracture fixation methods for Type C pelvic ring injuries in the absence of posterior fixation. METHODS: A 5-mm vertical osteotomy of the mid-superior and inferior pubic ramus was created in 12 synthetic pelvic models. Four surgical constructs were compared: (1) two-pin AIIS external fixation, (2) 3.5-mm reconstruction plating, (3) bicortical, fully threaded 3.5-mm, and (4) 6.5-mm pubic ramus screws. Specimens were tested in a simulated one-legged stance on a hemiarthroplasty implant in three stages: (1) no applied load, (2) application of the loading fixture preload to the sacrum (6N), and (3) following six cycles of a 250N load. Stability was assessed based on resultant displacement of the fracture sites at the superior ramus and the anterior sacroiliac joint. RESULTS: The bicortical, fully threaded 6.5-mm pubic ramus screw provided the most stable ramus fracture fixation (0.5 ± 0.4 mm) displacement under load and was the only construct to finish testing without gross posterior pelvic disruption. Plate constructs finished the final loading stage with only a small increase (3.1 ± 2.3 mm) in ramus fracture gap size, but had significant displacement at the SI joint (>20 mm). 3.5-mm screw constructs had 1.6 ± 0.7 mm of ramus displacement in the preload stage, but had complete posterior pelvic disruption (>20 mm) that prevented further testing. External fixation was unstable at the ramus and sacroiliac sites in the initial setup. CONCLUSIONS: The bicortical, fully threaded 6.5-mm pubic ramus screw was the only anterior fixation construct tested that controlled motion at both the anterior and posterior pelvic rings in the absence of posterior fixation.

Gene delivery to the spinal cord using MRI-guided focused ultrasound.

Non-invasive gene delivery across the blood-spinal cord barrier (BSCB) remains a challenge for treatment of spinal cord injury and disease. Here, we demonstrate the use of magnetic resonance image-guided focused ultrasound (MRIgFUS) to mediate non-surgical gene delivery to the spinal cord using self-complementary adeno-associated virus serotype 9 (scAAV9). scAAV9 encoding green fluorescent protein (GFP) was injected intravenously in rats at three dosages: 4 × 10(8), 2 × 10(9) and 7 × 10(9) vector genomes per gram (VG g(-1)). MRIgFUS allowed for transient, targeted permeabilization of the BSCB through the interaction of focused ultrasound (FUS) with systemically injected Definity lipid-shelled microbubbles. Viral delivery at 2 × 10(9) and 7 × 10(9) VG g(-1) leads to robust GFP expression in FUS-targeted regions of the spinal cord. At a dose of 2 × 10(9) VG g(-1), GFP expression was found in 36% of oligodendrocytes, and in 87% of neurons in FUS-treated areas. FUS applications to the spinal cord could address a long-term goal of gene therapy: delivering vectors from the circulation to diseased areas in a non-invasive manner.

An optimized process flow for rapid segmentation of cortical bones of the craniofacial skeleton using the level-set method.

Accurate representation of skeletal structures is essential for quantifying structural integrity, for developing accurate models, for improving patient-specific implant design and in image-guided surgery applications. The complex morphology of thin cortical structures of the craniofacial skeleton (CFS) represents a significant challenge with respect to accurate bony segmentation. This technical study presents optimized processing steps to segment the three-dimensional (3D) geometry of thin cortical bone structures from CT images. In this procedure, anoisotropic filtering and a connected components scheme were utilized to isolate and enhance the internal boundaries between craniofacial cortical and trabecular bone. Subsequently, the shell-like nature of cortical bone was exploited using boundary-tracking level-set methods with optimized parameters determined from large-scale sensitivity analysis. The process was applied to clinical CT images acquired from two cadaveric CFSs. The accuracy of the automated segmentations was determined based on their volumetric concurrencies with visually optimized manual segmentations, without statistical appraisal. The full CFSs demonstrated volumetric concurrencies of 0.904 and 0.719; accuracy increased to concurrencies of 0.936 and 0.846 when considering only the maxillary region. The highly automated approach presented here is able to segment the cortical shell and trabecular boundaries of the CFS in clinical CT images. The results indicate that initial scan resolution and cortical-trabecular bone contrast may impact performance. Future application of these steps to larger data sets will enable the determination of the method's sensitivity to differences in image quality and CFS morphology.

Local treatment of mixed osteolytic/osteoblastic spinal metastases: is photodynamic therapy effective?

The widespread use of systemic and local therapies aimed at spinal metastatic lesions secondary to breast cancer has increased the incidence of mixed osteolytic/osteoblastic patterns of bony disease. The complex structure of these lesions requires novel therapeutic approaches to both reduce tumor burden and restore structural stability. In photodynamic therapy (PDT), a minimally invasive approach can be used to employ light to activate a photosensitizing agent that preferentially accumulates in tumor tissue, leading to cell toxicity and death. Previous work in an osteolytic rat model (MT-1) demonstrated that PDT effectively ablates tumor and improves vertebral structural properties. The aim of this study was to assess the efficacy of PDT in a rat model of mixed osteolytic/osteoblastic spinal metastases. Mixed spinal metastases were generated through intracardiac injection of Ace-1 canine prostate cancer cells into female athymic rats (day 0). A single PDT treatment was applied to lumbar vertebra L2 of tumor-bearing and healthy control rats (day 14). PDT-treated and untreated control rats were euthanized and excised spines imaged with µCT to assess bone quality (day 21). Spines were mechanically tested or histologically processed to assess mechanical integrity, tumor burden, and remodelling properties. Untreated tumor-bearing vertebrae showed large areas of osteolysis and areas of immature, new bone formation. The overall bone quality resulting from these lesions consisted of decreased structural properties but without a significant reduction in mechanical integrity. PDT was shown to significantly decrease tumor burden and osteoclastic activity, thereby improving vertebral bone structural properties. While non-tumor-bearing vertebrae exhibited significantly more new bone formation following PDT, the already heightened level of new bone formation in the mixed tumor-bearing vertebrae was not further increased. As such, the effect of PDT on mixed metastases may be more influenced by suppression of osteoclastic resorption as opposed to the triggering of new bone formation.

Sensitivity analysis of a validated subject-specific finite element model of the human craniofacial skeleton.

Developing a more complete understanding of the mechanical response of the craniofacial skeleton (CFS) to physiological loads is fundamental to improving treatment for traumatic injuries, reconstruction due to neoplasia, and deformities. Characterization of the biomechanics of the CFS is challenging due to its highly complex structure and heterogeneity, motivating the utilization of experimentally validated computational models. As such, the objective of this study was to develop, experimentally validate, and parametrically analyse a patient-specific finite element (FE) model of the CFS to elucidate a better understanding of the factors that are of intrinsic importance to the skeletal structural behaviour of the human CFS. An FE model of a cadaveric craniofacial skeleton was created from subject-specific computed tomography data. The model was validated based on bone strain measurements taken under simulated physiological-like loading through the masseter and temporalis muscles (which are responsible for the majority of craniofacial physiologic loading due to mastication). The baseline subject-specific model using locally defined cortical bone thicknesses produced the strongest correlation to the experimental data (r2 = 0.73). Large effects on strain patterns arising from small parametric changes in cortical thickness suggest that the very thin bony structures present in the CFS are crucial to characterizing the local load distribution in the CFS accurately.

Evaluating the ability of posterior elements to support new instrumentation for spinal fusion.

Posterior spinal plating devices have recently made a re-emergence as both stand-alone devices and for use in conjunction with anterior fusion. Yet, the structural integrity of the posterior elements to support loads throughout the spine and the impact of plating on posterior element strength has not been well characterized. This study aims to quantify the mechanical strength of the posterior elements (spinous processes/laminae) throughout the spine and to determine the effect of attaching posterior element plating systems on their ultimate load to failure. Vertebral levels from six cadaveric spines were grouped in pairs to account for varying geometries and sizes of the human posterior elements (a total of 59 levels in 5 groups). One sample from each pair was tested in its native state, and the complementary vertebra was tested via posterior plating. Posterior element plating caused moderate reductions in posterior element failure strength (15-24 percent) throughout the cervical, thoracic, and lumbar spine. Bone mineral density of the posterior elements had the most significant impact on ultimate load to failure (a decrease of 0.1 g/cm3, yields a 189N reduction in). The modest structural impact of posterior element plating motivates continued investigation into potential use of less invasive plating devices for posterior spinal fusion.

Image registration demonstrates the growth plate has a variable affect on vertebral strain.

Characterizing the biomechanical behavior of the vertebrae is important in understanding the impact of structural and material changes on spinal growth and fracture risk. The growth plate is critical for the normal development of the skeleton, with abnormalities leading to uneven maturation. Little is known about how growth plates affect the stress and strain experienced by the surrounding bone. Concentrated strain within the growth plate may influence mechanical cell signaling during development, lead to increased fracture risk at this site and may influence average bone strain measures. It is hypothesized that the growth plates and adjacent bony areas will take up a large amount of the strain within rat-tail vertebrae under axial compressive loading, leading to increased average bone strain measures. The sixth caudal vertebrae of 8 rnu/rnu rats were muCT scanned in both loaded (20-32 N axial compression) and unloaded configurations. Image registration was used to calculate strain in the bone due to the applied load by finding a spatial mapping between the two scans. In seven of the eight rats, the majority of the strain measured within their vertebrae was concentrated in the growth plates. Five of the specimens had growth plates that demonstrated rigid behavior in contrast to compliant growth plate behavior seen in the other three rats. The presence of a compliant growth plate led to higher average (-0.03 vs. -0.01) and maximum (-0.13 vs. -0.02) strains. The strain within the growth plate is important to consider when interpreting apparent tissue level biomechanical data commonly reported in the literature as this study suggests strains are not uniformly distributed with high concentrations in and around the growth plate. This strain distribution may provide insight into the mechanical signals that cells experience during the formation of new bone, with the higher strains near the growth plate signaling cells to lay down more bone, while also leading to increased risk of fracture in this region.

Radiological changes following second-line zoledronic acid treatment in breast cancer patients with bone metastases.

Initiation of bisphosphonate therapy in bisphosphonate-naïve patients is known to be associated with radiological changes such as increased bone density in both osteolytic and osteoblastic metastases. It is not known, however, whether switching from a second-generation bisphosphonate to a more potent agent is associated with similar changes. This study aimed to prospectively explore radiological changes, as assessed by thoracolumbar CT scanning, in patients switching from an early generation bisphosphonate (i.e., oral clodronate or intravenous pamidronate) to intravenous zoledronic acid. Patients with progressive bone metastases despite use of an earlier generation bisphosphonate were switched to zoledronic acid as part of a study to evaluate the palliative benefit of this intervention. Quantitative computed tomography (QCT) scanning of the thoracolumbar spine was carried out at baseline, and repeated 4 months after commencing zoledronic acid. The effect of this change of therapy was explored in terms of bone density, as well as volume of osteolytic and osteoblastic disease. Fifteen patients were assessed. Switching of bisphosphonate therapy was associated with a significant increase in bone density, and an increase in osteoblastic volume. There was an insignificant trend towards reduced osteolytic volume. In conclusion, switching from early generation bisphosphonates to a more potent agent is associated with radiological changes similar to those seen when commencing a bisphosphonate in treatment-naïve patients. This is consistent with the observed palliative benefit. The use of QCT may be of benefit in the monitoring of bone metastases.

Effects of bone density alterations on strain patterns in the pelvis: application of a finite element model.

Insufficiency fractures occur when physiological loads are applied to bone deficient in mechanical resistance. A better understanding of pelvic mechanics and the effect of bone density alterations could lead to improved diagnosis and treatment of insufficiency fractures. This study aimed to develop and validate a subject-specific three-dimensional (3D) finite element (FE) model of a pelvis, to analyse pelvic strains as a function of interior and cortical surface bone density, and to compare high strain regions with common insufficiency fracture sites. The FE model yielded strong agreement between experimental and model strains. By means of the response surface method, changes to cortical surface bone density using the FE model were found to have a 60 per cent greater influence compared with changes in interior bone density. A small interaction was also found to exist between surface and interior bone densities (< 3 per cent), and a non-linear effect of surface bone density on strain was observed. Areas with greater increases in average principal strains with reductions in density in the FE model corresponded to areas prone to insufficiency fracture. Owing to the influence of cortical surface bone density on strain, it may be considered a strong global (non-linear) indicator for insufficiency fracture risk.

Automated CT-based analysis to detect changes in the prevalence of lytic bone metastases from breast cancer.

The spinal column is the most frequent site of bone metastasis in patients with breast cancer. It is important to understand how the pattern of vertebral lesions may be affected by the introduction of modern cancer therapies. The purpose of this study was to characterize changes in the radiological appearance of spinal column metastases over the past decade using highly automated Computed Tomography (CT) based computational analysis methods. Two case series studies were performed using CT scans of patients with confirmed spinal metastases secondary to breast cancer: Cohort A with CT scans acquired between 1998 and 2001 and Cohort B with CT scans acquired between 2004 and 2007. Diseased vertebrae were classified as lytic, blastic, or mixed based on CT scan intensity through an automated 3D computer algorithm. The relative incidence of lytic vertebral metastases decreased in comparing Cohort B to Cohort A (12% vs. 49%) with a corresponding increase in mixed lesions (51% vs. 18%) Significant associations were found between the percentage of lytic lesions in number of diseased vertebrae measured per patient and lack of bisphosphonate use (RR = 2.6) and for membership in Cohort A vs. Cohort B (RR = 5.9). This work highlights a change in the CT appearance of vertebral metastases from breast cancer during the past decade toward a lower proportion of lytic disease. Observation of patient therapies suggests that differences in radiological assessment may be linked, at least in part, to bisphosphonate use. These findings have important implications for both clinical practice and research strategies involving vertebral metastases.

A biomechanical assessment of the coupling of torsion and tension in the human scapholunate ligament.

The mechanical behaviour of human scapholunate ligaments is not well described in the literature with regard to torsion. In this study, intact scapholunate specimens were mechanically tested in torsion to determine whether a simultaneous tensile load was generated. Human intact scapholunate specimens (n = 19) were harvested. The scaphoid and lunate bones were potted in square chambers using epoxy cement, while the interposing ligament remained exposed. Each specimen was mounted rigidly in a specially designed test jig and remained at a fixed axial length during all tests. Specimens were subjected to a torsional load regime that included cyclic preconditioning, ramp-up, stress relaxation, ramp-down, rest, and torsion to failure. Torque and axial tension were monitored simultaneously. The relationship between torsion and tension was determined. Graphs of torque versus tension were generated, from which outcome measures were extracted. Tests demonstrated a clear relationship between applied torsion and the resulting generation of tension for the ligament during ramp-up (torsion-to-tension ratio, 38.86 +/- 29.00 mm; linearity coefficient R2 = 0.89 +/- 0.15; n = 19), stress relaxation (torsion-to-tension ratio, 23.43 +/- 15.84 mm; R2 = 0.90 +/- 0.09; n = 16), and failure tests (torsion-to-tension ratio, 38.81 +/- 26.39mm; R2 = 0.77 +/- 0.20; n = 16). No statistically significant differences were detected between the torsion-to-tension ratios (p = 0.13) or between the linearity (R2) of the best-fit lines (p > 0.085). A strongly coupled linear relationship between torsion and tension for the scapholunate ligament was exhibited in all test phases. This may suggest interplay between these two parameters in the stabilization of the ligament during normal motion and for injury cascades.

Lateral compression fracture of the pelvis represents a heterogeneous group of complex 3D patterns of displacement.

Although clinical and radiological criteria exist to direct the non-operative and operative treatment of other types of pelvic injuries, none exist for lateral compression (LC) fractures. The purpose of this study is to describe the patterns of injury in LC fractures through quantitative 3D radiographic analysis. It is hypothesised that LC fractures represent a spectrum of injuries with a combination of translational and rotational displacements. CT data from 60 patients with unilateral lateral compression fractures were obtained. Quantification of translations and rotations of the fractures was performed using 3D visualisation software. Fractures initially diagnosed as LC actually represent a spectrum of displacement patterns, ranging from a minimally displaced hemipelvis to complex combinations of displacements. Fractures were grouped based on pattern of rotation and translation into 5 distinct groups. 3D analysis of displacement patterns demonstrated a complexity in LC fractures which may explain the variations seen in outcomes associated with this injury.

Intraoperative cone-beam CT for image-guided tibial plateau fracture reduction.

OBJECTIVES: A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C(3D)), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction. METHODS: Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique. RESULTS: CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions. CONCLUSION: This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C(3D) in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.

Quantitative characterization of metastatic disease in the spine. Part I. Semiautomated segmentation using atlas-based deformable registration and the level set method.

Quantitative assessment of metastatic disease in bone is often considered immeasurable and, as such, patients with skeletal metastases are often excluded from clinical trials. In order to effectively quantify the impact of metastatic tumor involvement in the spine, accurate segmentation of the vertebra is required. Manual segmentation can be accurate but involves extensive and time-consuming user interaction. Potential solutions to automating segmentation of metastatically involved vertebrae are demons deformable image registration and level set methods. The purpose of this study was to develop a semiautomated method to accurately segment tumor-bearing vertebrae using the aforementioned techniques. By maintaining morphology of an atlas, the demons-level set composite algorithm was able to accurately differentiate between trans-cortical tumors and surrounding soft tissue of identical intensity. The algorithm successfully segmented both the vertebral body and trabecular centrum of tumor-involved and healthy vertebrae. This work validates our approach as equivalent in accuracy to an experienced user.

Photodynamic therapy for the treatment of vertebral metastases in a rat model of human breast carcinoma.

The feasibility and efficacy of photodynamic therapy (PDT) for the treatment of vertebral metastases using a minimally invasive surgical technique adapted from vertebroplasty was evaluated in a rodent model. Initial validation included photosensitizer (benzoporphyrin-derivative monoacid-ring A) drug uptake studies and in vitro confirmation of PDT efficacy. Intracardiac injection of human MT-1 breast cancer cells was performed in athymic rats. In 63 rats that developed vertebral metastases 21 days post-inoculation, single treatment of PDT was performed using a parapedicular approach placing an optical fiber adjacent to targeted vertebrae. Two milligrams per kilogram of photosensitizer drug was administered intravenously followed by 150 mW of 690 nm light illumination at varying drug-light intervals and light energies. Histologic and immunohistochemical analysis was performed assessing treatment effect. Local tumor viability and growth was quantified by bioluminescence imaging pre and 48 h post-treatment. PDT demonstrated an ablative effect on vertebral metastases (light energies 25-150 J). The effect varied in proportion to light energy with the greatest anti-tumor effect observed at 150 J using a 3 h drug-light interval. 9/22 rodents in the 3 h drug-light interval developed hindlimb paralysis following treatment, consistent with drug uptake studies demonstrating an increase in spinal cord uptake 3h following drug administration. The observations of paralysis following treatment highlight the importance of closely defining the therapeutic window of treatment in safety and efficacy.

Cervical spine loading characteristics in a cadaveric C5 corpectomy model using a static and dynamic plate.

Anterior plates are used to increase the initial stability of anterior cervical spine fusions; however, plating has been suggested to cause graft stress shielding, leading to reduced fusion rates. The objectives of this study were to quantify the effects of graft size and plating (static versus dynamic) and the role of the posterior elements on load transmission in anterior cervical fusion. A C5 corpectomy was performed on six human cervical spines (C3-C7). An instrumented height-adjustable graft and dynamic cervical plate were used to measure axial load transmission. Each specimen underwent axial compressive testing with dynamic and static plate configurations, optimal and undersized graft heights, and posterior elements intact and removed. Dynamic plating allowed significantly more load transmission by the graft, particularly in the undersized graft configuration. The posterior elements play a significant role in load transmission.