Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative lumbar kyphoscoliosis patients: an innovative preliminary study.

BACKGROUND: The aim of this study is to introduce a new method of percutaneous endoscopic decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative kyphoscoliosis patients without instability or those who with multiple comorbidities. Decompression alone using endoscope for kyphoscoliosis patient is technical demanding and may result in unnecessary bone destruction leading to further instability. The O-arm/StealthStation system is popular for its ability to provide automated registration with intraoperative, postpositioning computed tomography (CT) which results in superior accuracy in spine surgery. METHODS: In this study, we presented four cases. All patients were over seventy years old female with variable degrees of kyphoscoliosis and multiple comorbidities who could not endure major spine fusion surgery. Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation were successfully performed. Patients' demographics, image study parameters, and outcome measurements including pre- and post-operative serial Visual analog scale (VAS), and Oswestry Disability Index (ODI) were well documented. The follow-up time was 1 year. RESULTS: Pre- and post-operative MRI showed average dural sac cross sectional area (DSCSA) improved from 81.62 (range 67.34-89.07) to 153.27 (range 127.96-189.73). Preoperative neurological symptoms including radicular leg pain improved postoperatively. The mean ODI (%) were 85 (range 82.5-90) at initial visit, 35.875 (range 25-51) at 1 month post-operatively, 26.875 (range 22.5-35) at 6 months post-operatively and 22.5 (range 17.5-30) at 12 months post-operatively (p < 0.05). The mean VAS score were 9 (range 8-10) at initial visit, 2.25 (range 2-3) at 1 month post-operatively, 1.75 (range 1-2) at 6 months post-operatively and 0.25 (range 0-1) at 12 months post-operatively (p < 0.05). There was no surgery-related complication. CONCLUSIONS: To the best of our knowledge, this is the first preliminary study of percutaneous endoscopic laminotomy under O-arm navigation with successful outcomes. The innovative technique may serve as a promising solution in treating spinal stenosis patients with lumbar kyphoscoliosis and multiple comorbidities.

Effectiveness of Teriparatide for Spine Fusion in Osteoporotic Patient: A Systematic Review and Meta-Analysis of Comparative Studies.

OBJECTIVE: Our goal was to assess teriparatide's (TP) effectiveness in improving radiographic and functional outcomes after spinal fusion surgery. This meta-analysis included randomized controlled trials (RCTs) and comparative cohort studies. The findings provide valuable insights and guidance for surgeons treating osteoporotic patients undergoing spinal fusion surgery. METHODS: We conducted a systematic review to assess TP's efficacy in spinal fusion surgery for osteoporosis. Through thorough selection, data extraction, and quality assessment, we employed network meta-analysis to evaluate radiographic outcomes (fusion rate, screw loosening, vertebral fracture) and changes in bone mineral density measured by Hounsfield units. Functional outcomes were assessed using the Oswestry Disability Index scales. Our study aims to comprehensively understand TP's impact and effectiveness in spinal fusion surgery. RESULTS: A total of 868 patients were included in the analysis. All patients underwent thoracolumbar internal fixation fusion surgery and were divided into following 2 groups: the TP treatment group and the control group. The results revealed significant differences in radiological outcomes. The fusion rate showed a significant difference, as well as screw loosening, and bone mineral density measured in Hounsfield units. However, there was no significant difference in vertebral fracture. The TP group demonstrated favorable effects with statistical significance. In terms of functional outcomes, there was no significant difference in the assessment of Oswestry Disability Index scores between the 2 treatment groups. CONCLUSIONS: The meta-analysis demonstrated that the TP group exhibited significantly better outcomes, particularly in radiological measures, when compared to the control group. The use of TP in spinal fusion surgery shows promise in reducing postoperative complications and providing overall benefits.

Anterior Bone Loss after Cervical Baguera C Disc versus Bryan Disc Arthroplasty.

Objectives: The objectives of this study were to identify the risk factors and incidence of anterior bone loss (ABL) after Baguera C cervical disc arthroplasty (CDA) and identify whether design differences in artificial discs affect ABL. Methods: In this retrospective radiological review of patients who underwent single-level Baguera C CDA in a medical center, the extent of ABL and the following radiological parameters were recorded: global and segmental alignment angle, lordotic angle (or functional spinal unit angle), shell angle, global range of motion (ROM), and ROM of the index level. ABL at the index level was grade 0-2. Grade 0 was defined as no remodeling, grade 1 as spur disappearance or mild change in body contour, and grade 2 as obvious bone regression with Baguera C Disc exposure. Results: Combining grade 1 and grade 2, ABL was found in 56 upper adjacent vertebrae and 52 lower adjacent vertebrae of the 77 patients. Only 18 patients (23.4%) had no ABL. Shell angle differed significantly between ABL grades of both the upper and lower adjacent level: 0.0° in grade 0 and 1 ABL vs. 2.0° in grade 2 ABL of the upper adjacent level (p < 0.05); and 0.0° in grade 0 and 1 ABL vs. 3.5° in grade 2 ABL of the lower adjacent level (p < 0.05). A female predominance of ABL was found. Hybrid surgery and artificial disc size were also related to ABL. Conclusions: ABL is more common in Baguera C Disc arthroplasty than Bryan Disc arthroplasty. Larger shell angle was related to ABL after CDA with Baguera C Discs, which may indicate that shell angle is pivotal in determining the incidence of ABL after CDA. Females had more ABL with Baguera C Disc arthroplasty; this might be related to shorter endplate lengths as well as a smaller endplate-implant mismatch.

Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation based on image analysis and clinical findings: A retrospective review of 345 cases.

The effect of spinal anatomical anomalies on the efficacy of percutaneous endoscopic lumbar discectomy (PELD) for disc herniation repair is unclear. This retrospective review aims to assess the safety and effectiveness of PELD for treating L5-S1 disc herniation with a range of characteristics and to determine the prevalence of lumbosacral transitional vertebrae (LSTV) anatomical anomalies to facilitate pre-surgical planning. From July 2005 to June 2019, 345 patients with L5-S1 disc herniations were treated with PELD. The primary outcome was 1-year postoperative visual analogue scale scores for low back and lower limb pain. The secondary outcomes included the surgical approach used, lumbosacral bony anomalies, presence of a ruptured disc or severely calcified disc, pediatric lumbar disc herniation, recurrent disc herniation management, and the long-term outcome. visual analogue scale scores for most patients were significantly improved after surgery. The prevalence of LSTVs was 4.05% (14/345 patients) in lumbar sacralization and 7.53% (26/345 patients) in sacral lumbarization. The prevalence of ruptured and severely calcified discs was 18.55% (64/345) and 5.79% (20/345), respectively. The prevalence of pediatric lumbar disc herniation was 2.02% (7/345). The recurrence rate was 4.34% (15/345). Two durotomy cases without sequelae and 8 cases of lower limb dysesthesia lasting longer than 3 months postoperatively were reported. PELD is safe and effective for treating L5-S1 disc herniation, including cases complicated by calcified lumbar disc herniation, disc rupture with migration, and the presence of LSTV. Appropriate imaging is essential to identify case-specific factors, including the prevalent LSTV anatomical anomalies, before surgery.

Using the Countermovement Jump Metrics to Assess Dynamic Eccentric Strength: A Preliminary Study.

Background: This study aimed to determine the validity and reliability of the countermovement jump (CMJ) as a dynamic eccentric (Ecc) strength test. Methods: Thirty-three college male student-athletes were recruited to participate in this study. The participants first performed CMJs with the second consisting of one repetition maximum back squat (1RM-BS) test. CMJ and 1RM-BS tests were performed on twin force plates. Results: The CMJ had significant correlations with the Ecc peak force (EccPF), and Ecc mean force (EccMF) of 1RM-BS, respectively (r = 0.61−0.69). Moreover, all parameters had a coefficient of variation (CV) < 10%. The intraclass correlation coefficient (ICC) values were moderate to excellent for each metric using the CMJ (0.94−0.97). The 1RM-BS and CMJ EccPF, EccMF Bland-Altman bias estimate variance ratio is 1.31−1.67, showing a moderate-large correlation in the Bland-Altman plot. Conclusions: CMJ ECC phase kinetics were associated with the 1RM-BS EccPF and EccMF. The CMJ can be an alternative tool for eccentric dynamic strength assessment.

Effect of Acute Judo Training on Countermovement Jump Performance and Perceived Fatigue among Collegiate Athletes.

This study focused on the effect of acute Judo training on countermovement jump (CMJ) performance and perceived fatigue among a group of highly trained collegiate judo athletes. Twenty male judo athletes participated in this study (age: 20.65 ± 1.22 years, weight: 84.17 ± 28.45 kg). Participants were assessed for CMJperformance changes before, immediately after (0 h), 12 h after, and 24 h after judo training (JT) using unloaded CMJ(CMJunloaded) and loaded CMJ(CMJloaded). All the jumps were performed on a force plate, and the force-time curves were collected for further analysis. Respondents' perceptions were evaluated using the modified rating of perceived exertion (mRPE) before, after (0 h), 12 h, and 24 h after JT. CMJparameters were analyzed at four measured points using a one-way repeated analysis of variance. Effect sizes (ES) and percentage changes before versus 24 h after JT were calculated for comparison. Associations between the CMJparameters and mRPE were analyzed using the Pearson product-moment correlation. The ratio of flight time to contact time significantly decreased, whereas the eccentric duration, concentric duration, and total duration significantly increased (p < 0.05) in both CMJs 24 h after JT. Compared with CMJunloaded, CMJloaded had a significantly lower (p < 0.05) flight time, jump height, peak velocity, and peak power. The mRPE and CMJloaded peak velocity showed moderate- to high-level negative correlation results both 0 and 24 h after training (r = -0.543, p < 0.05; r = -0.479, p < 0.05). In this study, we only observed the effect of fatigue on the neuromuscular (NM) system 24 h after JT. CMJloaded height may help to better determine fatigue state compared with CMJunloaded. According to the results, the neuromuscular effects of fatigue were not observed until 24 h after a single high-intensity training. Therefore, when arranging high-intensity special training or strength and conditioning training, one should reduce the volume of training appropriately to avoid fatigue accumulation and reduce the risk of sports injuries.

Triboelectric behaviour of selected MOFs in contact with metals.

MOFs have been effectively used to magnify the triboelectric charge of polymers. However, so far the individual triboelectric properties and charge transfer mechanisms of MOFs haven't been reported. Triboelectric property investigation for selected MOFs show that the main mechanism for MOF triboelectrification in contact with metals is electron transfer.

Percutaneous Endoscopic Surgery Alone to Treat Severe Infectious Spondylodiscitis in the Thoracolumbar Spine: A Reparative Mechanism of Spontaneous Spinal Arthrodesis.

BACKGROUND: Infective spondylodiscitis has been treated solely with antibiotics based on the pathogen identified. Surgical intervention was used in cases of unidentified pathogens, failed antibiotic treatment, neurological deficit, or instability. The standard surgical procedure was debridement and interbody fusion with a bone graft through the anterior approach, followed by posterior instrumentation. Recently, percutaneous endoscopic surgery has been proven to be safe and effective for treating infectious spondylodiscitis. The results of endoscopy surgery treatment alone for infectious spondylodiscitis with severe bony destruction were analyzed in this study. OBJECTIVE: To describe the clinical and radiological outcomes in patients with infectious spondylodiscitis and severe bony destruction, who were treated with minimally invasive endoscopic surgery alone. STUDY DESIGN: Retrospective observational study (Institutional Review Board: CMUH 105-REC2-101). SETTING: An inpatient surgery center. METHODS: The study included 24 patients with infectious spondylodiscitis and severe bony destruction treated with endoscopy surgery. The patients were treated according to the endoscopic surgical protocol and were followed up for at least 5 years. A retrospective chart review was conducted to evaluate the locations, symptoms and signs, comorbidity, pain scale, and functional outcome. Laboratory data, such as erythrocyte sedimentation rate and C-reactive protein level, and clinical outcomes, including the pain scale, visual analogue scale, and functional score of Oswestry disability index, were recorded. All patients underwent a preoperative magnetic resonance imaging (MRI) scan and were carefully reviewed and classified based on the severity, including endplate erosion, bone edema (low T1, high T2), loss of vertebral height, paravertebral inflammation, paravertebral abscess, and epidural abscess. All patients underwent a plain film follow-up at 3, 6, 9, 12, and 18 months after surgery and computed tomography at 12 months postoperatively. RESULTS: The comorbidities of patients were categorized according to the Charlson Comorbidity Index. The results revealed 10 lesions on the thoracic or upper lumbar spine (between T10 and L3) and 14 on the lower lumbar spine (between L3 and S1). Bone destruction as a result of severe infection and loss of disc height was observed in most cases. During the final follow-up, no significant changes were observed in the sagittal alignment, and a kyphotic angle change of less than 10° was observed in 20 cases. Syndesmophyte formation along the anterior longitudinal ligament (ALL), paravertebral syndesmophyte formation, intervertebral bony fusion, and bony ankylosis of the facet joints in the form of osteophyte formation and fusion were noted. No posterior instrumentation surgery was performed for instability in our case series. LIMITATIONS: This was a retrospective observational clinical case series with small sample size. CONCLUSIONS: A trend of spontaneous spinal arthrodesis, including syndesmophyte formation along the ALL, paravertebral ligaments, direct intervertebral bone growth, and bony ankylosis of the facet joint were observed after a minimally invasive endoscopy treatment for infectious spondylodiscitis. The stability of the 3 columns resulted in segmental stability, which prevented the progression of the kyphotic deformity. Percutaneous endoscopic surgery is safe and effective for treating infectious spondylodiscitis even in patients with severe bony destruction.

Computed Tomography-Guided Endoscopic Surgery in Lumbar Disc Herniation With High-grade Migration: A Retrospective, Comparative Study.

BACKGROUND: Symptomatic herniated intervertebral discs are debilitating. However, surgical management poses a significant challenge for endoscopic spine surgeons, especially in high-grade migrated lesions. OBJECTIVES: This study aimed to  assess the surgical and clinical outcomes after applying a computed tomography navigated percutaneous endoscopic lumbar discectomy. STUDY DESIGN: The data of patients with high-grade lumbar disc migration who underwent percutaneous endoscopic lumbar discectomy at our spine center were retrospectively collected and analyzed from November 2017 to May 2019. The patients were divided into 2 groups based on different workflows, with group O who underwent percutaneous endoscopic lumbar discectomy with computed-tomography navigation (O-arm), and group C who underwent conventional fluoroscopic guidance (C-arm). SETTING: Twenty-one (n = 21) patients were enrolled with data fully documented. There were 9 patients in group O (n = 9) and 12 patients in group C (n = 12). METHODS: An intraoperative 3-dimensional image was obtained using the O-arm device (O-arm®, Medtronic, Inc., Louisville, CO, United States) after patient positioning in group O, and enable multiplanar visualization during exploring the entry point, trajectory, orientation, and finally discectomy. In group C, conventional imaging scanner intensifier (C-arm) was used during the procedure. RESULTS: The operative time (99.4 ± 40.7 vs 86.9 ± 47.9 minutes, P = .129), blood loss (11.1 ± 15.7 vs 6.7 ± 8.2 mL, P = .602), and hospital stay (2.9 ± 0.3 vs 2.8 ± 0.6 days, P = .552) were similar between the 2 groups. However, group O showed more reduction in the pain and faster functional recovery immediately after the surgery (Visual Analog Score [VAS]: -9 vs -6.7, P =.277; Oswestry Disability Index [ODI]: -53.2% vs -29.1%, P = 0.006) and during the one-year follow-up (VAS: -8.1 vs -7.3, P =.604; ODI: -56.7% vs -40.1%, P = .053) compared with group C. LIMITATIONS: The retrospective nature of the study design, the small population size, and the shorter period of follow-up required further study. CONCLUSIONS: Computed tomography-navigated percutaneous endoscopic surgery is safe and effective for lumbar disc herniation with high-grade migration, and enhance early functional recovery even compared with conventional fluoroscopic guidance.

Efficacy of percutaneous endoscopic lumbar discectomy for pediatric lumbar disc herniation and degeneration on magnetic resonance imaging: case series and literature review.

OBJECTIVE: Pediatric lumbar disc herniation (LDH), although uncommon, causes significant pain, discomfort, and sometimes disability. We examined the efficacy of percutaneous endoscopic lumbar discectomy (PELD) for pediatric LDH and the degree of lumbar disc degeneration at 1 year after PELD. METHODS: We retrospectively reviewed the data of pediatric patients with LDH who underwent PELD from December 2007 to July 2018. The patients' symptoms, physical examination findings, clinical images, visual analog scale (VAS) scores, Oswestry Disability Index (ODI), and perioperative results (blood loss, length of hospital stay, and complications) were obtained from the medical records. Lumbar disc degeneration was graded using the modified Pfirrmann grading system at the 1-year postoperative magnetic resonance imaging (MRI) examination. RESULTS: Six boys and four girls who underwent PELD were evaluated. The patients' mean age was 15.6 years (range, 13-17 years). The mean VAS score for low back pain, mean VAS score for lower limb pain, and mean ODI preoperatively and 1 year postoperatively were 6.2 and 0.3, 6.9 and 0.5, and 20 and 0.1, respectively. MRI showed significant disc degeneration after PELD. CONCLUSIONS: Treating pediatric LDH with PELD is safe and effective. It relieves pain and reduces disability. However, lumbar disc degeneration still occurs.

Rapid Fabrication of Biocomposites by Encapsulating Enzymes into Zn-MOF-74 via a Mild Water-Based Approach.

A zinc-based metal organic framework, Zn-MOF-74, which has a unique one-dimensional (1D) channel and nanoscale aperture size, was rapidly obtained in 10 min using a de novo mild water-based system at room temperature, which is an example of green and sustainable chemistry. First, catalase (CAT) enzyme was encapsulated into Zn-MOF-74 (denoted as CAT@Zn-MOF-74), and comparative assays of biocatalysis, size-selective protection, and framework-confined effects were investigated. Electron microscopy and powder X-ray diffraction were used for characterization, while electrophoresis and confocal microscopy confirmed the immobilization of CAT molecules inside the single hexagonal MOF crystals at loading of ∼15 wt %. Furthermore, the CAT@Zn-MOF-74 hybrid was exposed to a denaturing reagent (urea) and proteolytic conditions (proteinase K) to evaluate its efficacy. The encapsulated CAT maintained its catalytic activity in the decomposition of hydrogen peroxide (H2O2), even when exposed to 0.05 M urea and proteinase K, yielding an apparent observed rate constant (kobs) of 6.0 × 10-2 and 6.6 × 10-2 s-1, respectively. In contrast, free CAT exhibited sharply decreased activity under these conditions. Additionally, the bioactivity of CAT@Zn-MOF-74 for H2O2 decomposition was over three times better than that of the biocomposites based on zeolitic imidazolate framework 90 (ZIF-90) owing to the nanometer-scaled apertures, 1D channel, and less confinement effects in Zn-MOF-74 crystallites. To demonstrate the general applicability of this strategy, another enzyme, α-chymotrypsin (CHT), was also encapsulated in Zn-MOF-74 (denoted as CHT@Zn-MOF-74) for action against a substrate larger than H2O2. In particular, CHT@Zn-MOF-74 demonstrated a biological function in the hydrolysis of l-phenylalanine p-nitroanilide (HPNA), the activity of ZIF-90-encapsulated CHT was undetectable due to aperture size limitations. Thus, we not only present a rapid eco-friendly approach for Zn-MOF-74 synthesis but also demonstrate the broader feasibility of enzyme encapsulation in MOFs, which may help to meet the increasing demand for their industrial applications.

Adjacent segment disease following Dynesys stabilization for lumbar disorders: A case series of mid- and long-term follow-ups.

BACKGROUND: Radiologic adjacent segment degeneration (ASDeg) can occur after spinal surgery. Adjacent segment disease (ASDis) is defined as the development of new clinical symptoms corresponding to radiographic changes adjacent to the level of previous spinal surgery. Greater pre-existing ASDeg is generally considered to result in more severe ASDis; nonetheless, whether the ASDeg status before index surgery influences the postoperative risk of revision surgery due to ASDis warrants investigation. AIM: To identify possible risk factors for ASDis and verify the concept that greater preexisting ASDeg leads to more severe ASDis. METHODS: Data from 212 patients who underwent posterior decompression with Dynesys stabilization from January 2006 to June 2016 were retrospectively analyzed. Patients who underwent surgery for ASDis were categorized as group A (n = 13), whereas those who did not were classified as group B (n = 199). Survival analysis and Cox proportional hazards models were used to compare the modified Pfirrmann grade, University of California-Los Angeles grade, body mass index, number of Dynesys-instrumented levels, and age. RESULTS: The mean time of reoperation was 7.22 (1.65-11.84) years in group A, and the mean follow-up period was 6.09 (0.10-12.76) years in group B. No significant difference in reoperation risk was observed: Modified Pfirrmann grade 3 vs 4 (P = 0.53) or 4 vs 5 (P = 0.46) for the upper adjacent disc, University of California-Los Angeles grade 2 vs 3 for the upper adjacent segment (P = 0.66), age of < 60 vs > 60 years (P = 0.9), body mass index < 25 vs > 25 kg/m2 (P = 0.3), and sex (P = 0.8). CONCLUSION: Greater preexisting upper ASDeg was not associated with a higher rate of reoperation for ASDis after Dynesys surgery. Being overweight tended to increase reoperation risk after Dynesys surgery for ASDis.

3D Real-Time Image-Guided Navigation Spine Corpectomy with Ultrasonic Bone Cutter: Technical Note.

BACKGROUND: Surgical interventions for congenital scoliosis are challenging for spine surgeons. The coordination of 3-dimensional (3D), real-time, image-guided navigation with an ultrasonic bone cutter allows surgeons to localize the affected area of the spine accurately and remove the lesion without damaging soft tissue structures. The goal of this technical paper is to report a previously undescribed method of hemivertebrectomy that combines 3D, real-time, image-guided navigation and an ultrasonic bone cutter. We highlight the feasibility and safety of this method in spinal surgery. METHODS: Three patients with congenital scoliosis were treated with this technique. We present three illustrative cases comprising hemivertebrectomies for congenital scoliosis. Intraoperative photos demonstrating the technique are also provided. RESULTS: All surgeries were completed without complications. The hemivertebrae were completely removed, and marked correction of congenital scoliosis was noted. CONCLUSIONS: We believe that the combination of 3D, real-time image navigation and an ultrasonic bone cutter improves hemivertebrectomy by increasing accuracy and avoiding dura laceration, major organ damage, or potential vessel damage.

Preliminary clinical and radiographic outcomes of proximal humeral fractures: comparison of ALPS and PHILOS plating in Asian patients in Taiwan.

BACKGROUND: Up to 20% of proximal humeral fractures need to be treated operatively. However, numerus complications were reported by using fixed angled locking plates. The ALPS Proximal Humerus Plating System is a new design implant with novel design features. The aim of this study was to compare the preliminary clinical outcomes and complications of proximal humeral fractures treated with either ALPS or the proximal humeral internal locking system (PHILOS) in Asian patients in Taiwan. METHODS: Between January 2016 and December 2018, 66 patients with displaced proximal humeral fractures were analyzed retrospectively, of whom 31 underwent ALPS implant treatment and 35 underwent PHILOS implant treatment. Intraoperative blood loss and operation time, postoperative Constant-Murley Shoulder Outcome (Constant-Murley) score, and complications variables were recorded for the comparison. All cases were regularly followed up for at least 1 year. RESULTS: The mean follow-up period was 400.8 days (range, 367-446 days). Union was achieved in 98.5% of patients (65/66). The ALPS group yielded similar radiologic and clinical outcomes to the PHILOS plating group for treating displaced proximal humeral fractures, including operation time, intraoperative blood loss, the Constant-Murley score, and varus malunion (P > 0.05, respectively). However, the incidence of total postoperative complications in the ALPS group was significantly lower than in the PHILOS group (P < 0.05). There was a trend of a lower complication rate of screws/pegs protrusion, avascular necrosis, subacromial impingement, postoperative infection, and reoperation in the ALPS group, although it was not statistically significant (P > 0.05, respectively). CONCLUSION: The ALPS group yielded similar radiologic and clinical outcomes to the PHILOS plating group for displaced proximal humeral fractures, but the ALPS group had a significantly lower total rate of complications. Therefore, ALPS may be a better option for treating proximal humeral fractures. Further larger clinical studies are needed to confirm the findings presented here. TRIAL REGISTRATION: Retrospective study.

Anterior bone loss after cervical Bryan disc arthroplasty: insight into the biomechanics following total disc replacement.

BACKGROUND CONTEXT: Cervical disc arthroplasty (CDA) is an innovative procedure launched in the early 2000s. Compared with anterior cervical discectomy and fusion, many studies show that CDA offers equivalent clinical outcomes while reducing secondary procedures and total cost. PURPOSE: We sought to determine the incidence of anterior bone loss after CDA and the related biomechanical effects. STUDY DESIGN/ SETTING: Retrospective chart review. PATIENT SAMPLE: Patients who underwent CDA with one level Bryan Disc (Medtronic SofamorDanek, Memphis, TN, USA) at one institution. OUTCOME MEASURES: Radiological measurements, including the extent of anterior bone loss, global alignment angle, shell angle, lordotic angle, mean degree of angle of the endplate with the horizontal line, global range of motion (ROM) and ROM of the index level were recorded. The grading of anterior bone loss of the index level was defined as Grade 0, no remodeling; Grade 1, spur disappearance or mild change in body contour; Grade 2, obvious bone regression with Bryan Disc exposure. METHODS: Anatomical measures and ROM were compared by grade of bone loss. RESULTS: Of the 121 patients included in the study, anterior bone loss was found in 53 (43.8%) on the upper adjacent level and 54 (44.6%) on the lower adjacent level. Twenty-nine patients (23.9%) had anterior bone loss in both levels. The majority of cases had Grade 1 anterior bone loss. Grade 2 bone loss was noted in the upper adjacent vertebra in only 5 patients and in 4 patients in the lower adjacent vertebra. Age, sex, operative level, and hybrid surgery had no effect on anterior bone loss. Most radiological assessments, including global alignment angle, lordotic angle, mean degree of angle of the endplate with the horizontal line, global ROM, and ROM of the index level, showed no correlation to anterior bone loss. Shell angle was found to be different in groups with or without remodeling in the upper adjacent level: 5.0 degreesin the Grade 0 group and 7.0 degrees in the Grade 1-2 group, p<.05. CONCLUSIONS: Many more patients than predicted had anterior bone loss. Increasing the shell angle of the artificial disc may increase the incidence of anterior bone loss after CDA. Further study of the biomechanics following CDA should help clarify the mechanisms at work.

Seizure After Percutaneous Endoscopic Surgery-Incidence, Risk Factors, Prevention, and Management.

BACKGROUND: Percutaneous endoscopic surgery is a popular surgery to treat lumbar spinal disorders. However, seizure after percutaneous endoscopic surgery is an unpredictable complication. The only prodromal sign for seizure currently known is neck pain. We reviewed the incidence of, and risk factors for, seizure during percutaneous endoscopic surgery and present the cases of 3 patients with seizure and our management. CASE DESCRIPTION: From October 2006 to March 2019, 3 of 816 patients (0.34%) with thoracic lumbar disorders who had undergone percutaneous endoscopic surgery experienced a seizure episode. The cases of those 3 patients were carefully reviewed. Studies of the risk factors for seizure after spinal procedures reported before June 13, 2019 were identified through a PubMed search. We found that infusion fluid containing cefazolin, the infusion rate, a prolonged operative time, the occurrence of a dural tear, and sevoflurane anesthesia might be associated with seizure, both described in the reported data and found in our experience. Three patients who experienced a seizure episode had had general anesthesia with sevoflurane, and the surgical approach used was interlaminar for a herniated disc in L5-S1. We noted a "red flag sign," namely an uncontrollable hypertension episode combined with a decreasing pulse rate, in all 3 patients who had experienced a seizure, which was not observed in the other patients. All 3 patients had received antihypertensive medication (labetalol) ≥3 times without response. CONCLUSION: Seizure after percutaneous endoscopic surgery is rare, but lethal. Although its cause remains unknown, all risk factors for seizure should be checked and corrected immediately when a red flag sign, uncontrolled hypertension, appears.

Trends and predictors of mortality in unstable pelvic ring fracture: a 10-year experience with a multidisciplinary institutional protocol.

Background: Pelvic ring fracture is often combined with other injuries and such patients are considered at high risk of mortality and complications. There is controversy regarding the gold standard protocol for the initial treatment of pelvic fracture. The aim of this study was to assess which risk factors could affect the outcome and to analyze survival using our multidisciplinary institutional protocol for traumatic pelvic ring fracture. Material and methods: This retrospective study reviewed patients who sustained an unstable pelvic ring fracture with Injury Severity Score (ISS) ≥ 5. All patients were admitted to the emergency department and registered in the Trauma Registry System of a level I trauma center from January 1, 2008, to December 31, 2017. The annular mortality rate after the application of our institutional protocol was analyzed. Patients with different systems of injury and treatments were compared, and regression analysis was performed to adjust for factors that could affect the rate of mortality and complications. Results: During the 10-year study period, there were 825 unstable pelvic ring injuries, with a mean ISS higher than that of other non-pelvic trauma cases. The annual mortality rate declined from 7.8 to 2.4% and the mean length of stay was 18.1 days. A multivariable analysis showed that unstable initial vital signs, such as systolic blood pressure < 90 mmHg (odds ratio [OR] 2.53; confidence interval [CI] 1.11-5.73), Glasgow Coma Scale < 9 (OR 3.87; CI 1.57-9.58), 24 > ISS > 15 (OR 4.84; CI 0.85-27.65), pulse rate < 50 (OR 11.54; CI 1.21-109.6), and diabetes mellitus (OR 3.18; CI 1.10-9.21) were associated with higher mortality. No other specific system in the high Abbreviated Injury Scale increased the rates of mortality or complications. Conclusion: Poor initial vital signs and Glasgow Coma Scale score, higher ISS score, and comorbidity of diabetes mellitus affect the mortality rate of patients with unstable pelvic ring fractures. No single system of injury was found to increase mortality in these patients. The mortality rate was reduced through institutional efforts toward the application of guidelines for the initial management of pelvic fracture.

New Strategy for Minimally Invasive Endoscopic Surgery to Treat Infectious Spondylodiscitis in the Thoracolumbar Spine.

BACKGROUND: Eradicating infection, protecting neurologic function, and maintaining structural alignment are the 3 objectives of treatment for infectious spondylodiscitis. For some patients, surgery may be necessary to achieve these goals; however, open surgeries are associated with high morbidity and mortality in elderly patients and those with multiple comorbidities. Endoscopic surgery provides a minimally invasive surgical option for obtaining a culture sample to aid identification of pathogens, while also providing a route for adequate decompression and drainage. The clinical results of this study were analyzed. OBJECTIVES: To evaluate the efficacy and safety of spinal endoscopic surgery, the basic characteristics of patients analyzed and their inflammatory markers, pain levels, and local kyphotic angles were recorded before surgery and at regular intervals after surgery. The patients' cultured pathogens and previous antibiotic treatments were also recorded and analyzed. STUDY DESIGN: Retrospective observational study (institutional review board: CMUH 105-REC2-101). SETTING: Inpatient surgery center. METHODS: From October 2006 to March 2017, of 508 patients who received spinal endoscopic surgery, 60 with infectious spondylodiscitis were treated using this new strategy. All 60 patients underwent plain film radiography and enhanced magnetic resonance imaging of the affected region to obtain evidence of infectious spondylodiscitis. The role of a computed tomography-guided biopsy and some indications for open surgery were replaced with endoscopic surgery. RESULTS: All the patients reported rapid pain relief after endoscopic surgery and antibiotic treatment. No significant changes in sagittal alignment were observed in final follow-up radiography images. Causative pathogens were identified in 34 patients (culture rate: 77.27%) without previous antibiotic treatment. The patients' erythrocyte sedimentation rates and C-reactive protein levels had decreased significantly 3 months after endoscopic surgery. Two patients (3.3%) experienced infection relapse following initial endoscopic surgery; both of them were efficiently resolved through a second round of endoscopic surgery. No surgery-related complications were observed and no open spinal surgery was required during the follow-up period. LIMITATIONS: This was a retrospective study; bias was unavoidable because of the single-center nature of the study design. CONCLUSIONS: Regarding the culture rate, recurrence rate, kyphotic change, and surgery-related complications, this new strategy for endoscopic surgery is safe and effective for treating infectious spondylodiscitis in the thoracic or lumbar spine and may be considered a new trend in treating diseases of this type. KEY WORDS: Spine, endoscopic, discectomy, spondylodiscitis, minimally invasive surgery.

The Accuracy of 3D Printing Assistance in the Spinal Deformity Surgery.

BACKGROUND: The pedicle screw is one of the main tools used in spinal deformity correction surgery. Robotic and navigated surgeries are usually used, and they provide superior accuracy in pedicle screw placement than free-hand and fluoroscopy-guided techniques. However, their high cost and space limitation are problematic. We provide a new solution using 3D printing technology to facilitate spinal deformity surgery. METHODS: A workflow was developed to assist spinal deformity surgery using 3D printing technology. The trajectory and profile of pedicle screws were determined on the image system by the surgical team. The engineering team designed drill templates based on the bony surface anatomy and the trajectory of pedicle screws. Their effectiveness and safety were evaluated during a preoperative simulation surgery. The surgery consisted in making a pilot hole through the drill template on a computed tomography- (CT-) based, full-scale 3D spine model for every planned segment. Somatosensory evoke potential (SSEP) and motor evoke potential (MEP) were used for intraoperative neurophysiological monitoring. Postoperative CT was obtained 6 months after the correction surgery to confirm the screw accuracy. RESULTS: From July 2015 to November 2016, we performed 10 spinal deformity surgeries with 3D printing technology assistance. In total, 173 pedicle screws were implanted using drill templates. No notable change in SSEP and MEP or neurologic deficit was noted. Based on postoperative CT scans, the acceptable rate was 97.1% (168/173). We recorded twelve pedicle screws with medial breach, six with lateral breach, and five with inferior breach. Medial breach (12/23) was the main type of penetration. Lateral breach occurred mostly in the concave side (5/6). Most penetrations occurred above the T8 level (69.6%, 16/23). CONCLUSION: 3D printing technology provides an effective alternative for spinal deformity surgery when expensive medical equipment, such as intraoperative navigation and robotic systems, is unavailable.

Increased Risk for Hip Fractures among Patients with Cholangitis: A Nationwide Population-Based Study.

BACKGROUND: Cholangitis is the infectious disease involving the biliary tract, which may induce systemic inflammation. Bone loss is a well-known sequelae after systemic inflammatory disease, and one grave complication after osteoporosis is hip fracture. We want to know whether cholangitis can contribute to increased risk of hip fracture. METHODS: All the patients diagnosed with cholangitis since January 1, 2001, to December 31, 2009, were assessed. All the subjects with cancer history, traumatic accident, and previous fracture were excluded. We selected the controls without cholangitis and matched the controls to cholangitis patients by age, sex, osteoporosis, and the use of steroid for more than 30 days by approximately 1:4 ratio. RESULTS: There were 2735 subjects in the cholangitis cohort and 10915 in the noncholangitis cohort. There were 101 hip fractures in the cholangitis cohort with the incidence density of 7.58 per 1000 person-years. As for the noncholangitis cohort, 366 individuals suffered from hip fracture with the incidence density of 5.86 per 1000 person-years. The risk of hip fracture was higher in the cholangitis cohort with a 1.29-fold increased risk than the noncholangitis cohort (hazard ratio = 1.29, 95% confidence interval = 1.03-1.61). The association between cholangitis and the hip fracture was more prominent among subjects less than 65 years (hazard ratio = 2.65, 95% confidence interval =1.30-5.39) and the subjects without comorbidities (hazard ratio = 3.01, 95% confidence interval = 1.42-6.41). CONCLUSIONS: Cholangitis is associated with higher risk for hip fracture, especially among young subjects free from medical comorbidities.