SPECT/CT and PET/CT for the Evaluation of Persistent or Recurrent Pain After Spine Surgery: A Systematic Review and Case Series.

OBJECTIVE: The differential diagnosis for postoperative back pain is broad, and conventional imaging modalities are not always conclusive. Therefore, we performed a systematic review of the literature and present case studies describing the use of single-photon emission CT (SPECT)/CT or positron emission tomography (PET)/CT in the diagnosis of back pain following spine surgery. METHODS: A systematic review was conducted according to PRISMA guidelines across 5 databases. Relevant keywords included PET/CT, bone SPECT/CT, and pseudarthrosis. The studies were assessed for diagnostic accuracy of the imaging technologies. RESULTS: A total of 2,444 studies were screened, 91 were selected for full-text review, and 21 were ultimately included. Six retrospective studies investigated the use of SPECT/CT with a total sample size of 309 patients. Two of these studies used SPECT/CT to predict screw loosening in over 50% of patients. Eight studies examined the use of 18-fluoride sodium fluoride (18F-NaF) PET/CT. Among these studies, measures of diagnostic accuracy varied but overall demonstrated the ability of 18F-NaF PET/CT to detect screw loosening and pseudarthrosis. Seven studies examined 18F-fluorodeoxyglucose (FDG) PET/CT and supported its utility in the diagnosis of postoperative infections in the spine. CONCLUSIONS: PET/CT and SPECT/CT are useful in the evaluation of postoperative pain of the spine, especially in patients for whom conventional imaging modalities yield inconclusive results. More diagnostic accuracy studies with strong reference standards are needed to compare hybrid imaging to conventional imaging.

Augmented Reality in Spine Surgery: A Narrative Review.

Augmented reality (AR) navigation refers to novel technologies that superimpose images, such as radiographs and navigation pathways, onto a view of the operative field. The development of AR navigation has focused on improving the safety and efficacy of neurosurgical and orthopedic procedures. In this review, the authors focus on 3 types of AR technology used in spine surgery: AR surgical navigation, microscope-mediated heads-up display, and AR head-mounted displays. Microscope AR and head-mounted displays offer the advantage of reducing attention shift and line-of-sight interruptions inherent in traditional navigation systems. With the U.S. Food and Drug Administration's recent clearance of the XVision AR system (Augmedics, Arlington Heights, IL), the adoption and refinement of AR technology by spine surgeons will only accelerate.

Endothelial/Mesenchymal Stem Cell Crosstalk Within Bioprinted Cocultures.

The development of viable tissue surrogates requires a vascular network that sustains cell metabolism and tissue development. The coculture of endothelial cells (ECs) and mesenchymal stem cells (MSCs), the two key players involved in blood vessel formation, has been heralded in tissue engineering (TE) as one of the most promising approaches for scaffold vascularization. However, MSCs may exert both proangiogenic and antiangiogenic role. Furthermore, it is unclear which cell type is responsible for the upregulation of angiogenic pathways observed in EC:MSC cocultures. There is disagreement on the proangiogenic action of MSCs, as they have also been shown to negatively affect the formation of capillary networks. To address these issues, we investigated the regulation of key angiogenic pathways in scaffolds hosting different EC:MSC ratios fabricated through extrusion-based bioprinting. Human ECs were cocultured with either rat or human MSCs, and the regulation of fundamental angiogenic and arteriogenic pathways was analyzed through DNA, gene, and protein expression. The use of a hybrid human/rat coculture system facilitated pinpointing each cell type role in the regulation of specific genes and showed that MSCs exert a dose-dependent inhibitory effect on the EC expression of angiogenic factors within the first 24 h. Within a week of coculture, MSCs exert a proangiogenic effect, as corroborated in human/human bioprinted cocultures. Interestingly, juxtacrine signaling promoted secretion of the angiogenic factor vascular endothelial growth factor in direct cocultures (EC and MSC co-encapsulated), while paracrine signaling encouraged secretion of the arteriogenic factor platelet-derived growth factor in indirect cocultures (adjacent bioprinting of EC-laden and MSC-laden scaffolds). Overall, the use of a bioprinted system to elucidate EC:MSC interplay allows rapid leveraging of the data for novel vascular TE applications. Despite the transitory negative effect early in the culture, MSC presence is necessary for the regulation of pathways involved in arteriogenesis. With further validation in vivo, this study provides a possible explanation to the controversial findings present in literature and shows how MSC effect on angiogenic pathway regulation mimics the dynamics of blood vessel formation reported in literature and normally occurring in vivo. Impact Statement The coculturing of endothelial cells (ECs) and mesenchymal stem cells (MSCs) holds great promise in tissue engineering for the development of prevascularized tissue constructs. Yet, different studies report conflicting results on the role of MSCs, which can either support or inhibit vasculature formation. Furthermore, it is unclear how each cell type modulates distinct pathways involved in angiogenesis when cocultured. Using bioprinted hybrid coculture systems, we show that MSCs have both a time- and dose-dependent effect on the gene and protein expression of key angiogenic and arteriogenic factors by ECs. These findings, obtained in translationally relevant setup, can readily inform the design of vascularized scaffolds.