Diagnosing Polypoidal Choroidal Vasculopathy Using Color Fundus Photography, Optical Coherence Tomography, and Optical Coherence Tomography Angiography.

PURPOSE: To compare the diagnostic accuracy of differentiating polypoidal choroidal vasculopathy (PCV) from exudative age-related macular degeneration (AMD), using color fundus photography (CFP), optical coherence tomography (OCT), and swept-source OCT angiography (SS-OCTA) without using indocyanine green angiography (ICGA). METHODS: Treatment-naive eyes with exudative AMD that underwent CFP, OCT, SS-OCTA, and ICGA imaging before treatment were identified. Images of each patient were categorized into two sets (set A, CFP + OCT; set B, CFP + SS-OCTA). In set B, both the en face and cross-sectional B scans were analyzed. Each set was reviewed by two graders, and it was determined whether the presumed diagnosis was PCV. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for the diagnosis of PCV were assessed for each set by comparing diagnoses that included ICGA. The number of polypoidal lesions in each set was calculated and compared to ICGA. RESULTS: A total of 94 eyes from 94 patients with AMD were included in the study, of which 66.0% were male, and the mean age was 71.8 ± 9.0 years. The PCV diagnosis rate using ICGA was 45.7%. The sensitivity was 0.88 for set A and 0.93 for set B, while the specificity was 0.94 for set A and 0.96 for set B. The AUC was 0.90 (95% confidence interval [CI], 0.83-0.97) for set A and 0.96 (95% CI, 0.90-1.00) for set B. Set A detected 1.28 ± 0.91 polypoidal lesions, while set B detected 1.47 ± 1.01; ICGA showed 1.51 ± 0.86. CONCLUSIONS: This study highlights that, without using ICGA, both CFP combined with OCT and CFP combined with SS-OCTA demonstrate high sensitivity, specificity, and AUC in diagnosing PCV. It is evident that SS-OCTA contributes to enhancing sensitivity, specificity, and AUC for PCV diagnosis.

Perifoveal Microvascular Changes following Internal Limiting Membrane Peeling Surgery for Epiretinal Membrane and Macular Hole.

INTRODUCTION: The aim of the study was to evaluate perifoveal microvasculature changes following pars plana vitrectomy with internal limiting membrane peeling for the epiretinal membrane (ERM) and macular hole (MH). METHODS: This retrospective study included 59 eyes from 59 patients. Subjects were divided into two groups: an ERM group (n = 43) and an MH group (n = 16) based on the initial diagnosis. Swept-source optical coherence tomography angiography (SS-OCTA) was performed in the macular area, pre- and postoperatively. Perifoveal microvascular changes were calculated using MATLAB from the 6 × 6 mm SS-OCTA images, excluding the foveal avascular zone. Pre- and postoperative perifoveal vessel densities (pfVDs) were separately analyzed in six sectors (superior, superotemporal, inferotemporal, inferior, inferonasal, and superonasal) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). The baseline characteristics and other clinical factors were compared between the ERM and MH groups. RESULTS: The postoperative best-corrected visual acuity significantly improved in both groups (p < 0.05). One year after surgery, the pfVD in the SCP of the ERM group significantly decreased in the inferotemporal sector (p = 0.049). The postoperative pfVD in the DCP of the MH group significantly decreased in temporal sectors (p < 0.05). The postoperative mean pfVD in the SCP in the MH group was significantly lower than that in the ERM group (p = 0.003). The presence of a dissociated optic nerve fiber layer (DONFL) was 75% in the MH group and 22% in the ERM group (p = 0.018). The correlation between the pfVD and DONFL was not statistically significant. CONCLUSION: Postoperative pfVD reduction in the temporal sector, a corresponding area in which DONFL is present after MH surgery, was significantly observed. After vitreoretinal surgery in MH patients, OCTA may serve as a useful tool for monitoring perifoveal microvascular changes, especially in temporal sectors.

Optical coherence tomography angiography biomarkers in a bi-monthly maintenance dosing aflibercept in patients with neovascular age-related macular degeneration.

PURPOSE: To evaluate the correlations between swept-source optical coherence tomography angiography (SS-OCTA) parameters and clinical outcomes in eyes with neovascular age-related macular degeneration (nAMD) administered a bimonthly intravitreal aflibercept regimen. METHODS: This prospective, single-arm, interventional study enrolled 33 patients with treatment-naïve nAMD. The eyes received three monthly aflibercept injections followed by five bi-monthly regimens (total 50 weeks). The structural parameters including central subfield thickness (CST) and 5 mm pigment epithelial detachment (PED) volume and microvascular parameters including macular neovascularization (MNV) area, vessel density (VD), and vessel length density (VLD) were recorded every before and 1 week after treatment. RESULTS: Patients who gained > 5 letters of best-corrected visual acuity (BCVA) from the baseline showed greater decreases in VD and VLD during the loading phase. Patients without recurrent or persistent fluid during the maintenance phase showed greater decreases in CST and 5 mm PED volume after the first injection. The decrease in mean VD during the loading phase was significantly correlated with the final BCVA (r = -0.820, p = 0.004). Moreover, the decrease in mean VLD during the loading phase was significantly correlated with the improvement in the final BCVA (r = -0.726, p = 0.017). CONCLUSIONS: The decrease in mean VD during the loading phase was significantly negatively correlated with the final BCVA at the last visit. The decrease in mean VLD during the loading phase, mean CST during the loading phase, and the improvement in final BCVA showed significant correlations. Therefore, early changes in OCTA microvascular and OCT structural parameters could help predict clinical outcomes in nAMD. TRIAL REGISTRATION: The trial was registered with the Clinical Research Information Service (CRIS), which joined the WHO International Clinical Trials Registry Platform (ICTRP) (Registration number: KCT0007375, Date of first trial registration: 10/06/2022).

Peripapillary microvasculature changes after vitrectomy in epiretinal membrane via swept-source OCT angiography.

PURPOSE: To evaluate the peripapillary microvasculature changes in patients with epiretinal membrane (ERM) following pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling using swept-source optical coherence tomography angiography (SS-OCTA). METHOD: Medical records and multimodal imaging data of 33 eyes after PPV for ERM were retrospectively reviewed. Peripapillary SS-OCTA images of 6×6 mm2 were recorded at at pre- and post-operatively every 6 months for 1 year. A semi-automated method was used to analyzed SS-OCTA images, excluding the optic disc area, using the MATLAB software. The peripapillary vessel density (pVD) of superficial capillary plexus (SCP) and deep capillary plexus (DCP) was quantified in four quadrants (superior, inferior, nasal and temporal). RESULT: The mean pVD in SCP and DCP decreased at 6- and 12-months follow-up. In sectoral analysis, superior, inferior, and temporal quadrants pVD in SCP and DCP were significantly reduced at 1 year after vitrectomy (all p < 0.05). Meanwhile, inferior quadrants pVD in SCP and DCP showed the earliest significant reduction at 6-months (p = 0.022 and 0.048, respectively). A reduction of post-operative mean pVD in DCP was significantly greater in patients with diabetic retinopathy (p = 0.043). CONCLUSION: Peripapillary capillary density significantly decreased after surgical removal of ERM. Vitrectomy with ILM peeling can cause peripapillary microvascular damage starting in inferior sector.

Targeted Protein Upregulation of STING for Boosting the Efficacy of Immunotherapy.

Modulating target proteins via the ubiquitin-proteasome system has recently expanded the scope of pharmacological inventions. Stimulator of interferon genes (STING) is an auspicious target for immunotherapy. Seminal studies envisioned the importance of STING as well as the utility of its agonists in immunotherapy outcomes. Herein, we suggest UPPRIS (upregulation of target proteins by protein-protein interaction strategy) to pharmacologically increase cellular STING levels for improved immunotherapy. We discovered the small molecule SB24011 that inhibits STING-TRIM29 E3 ligase interaction, thus blocking TRIM29-induced degradation of STING. SB24011 enhanced STING immunity by upregulating STING protein levels, which robustly potentiated the immunotherapy efficacy of STING agonist and anti-PD-1 antibody via systemic anticancer immunity. Overall, we demonstrated that targeted protein upregulation of STING can be a promising approach for immuno-oncology.

AO Spine Adult Spinal Deformity Patient Profile: A Paradigm Shift in Comprehensive Patient Evaluation in Order to Optimize Treatment and Improve Patient Care.

STUDY DESIGN: Modified Delphi study. OBJECTIVE: Adult spinal deformity (ASD) is an increasingly recognized condition, comprising a spectrum of pathologies considerably impacting patients' health and functional status. Patients present with a combination of pain, disability, comorbidities and radiological deformity. The study aims to propose a systematic approach of gathering information on the factors that drive decision-making by developing a patient profile. METHODS: The present study comprises of 3 parts. Part 1: Development of prototype of patient profile: The data from the Core Outcome Study on SCOlisis (COSSCO) by Scoliosis Research Society (SRS) was categorized into a conceptual framework. Part 2: Modified Delphi study: Items reaching >70% agreement were included in a 4 round iterative process with 51 panellists across the globe. Part 3: Pilot testing-feasibility: Content validity and usability were evaluated quantitatively. RESULTS: The profile consisted of 4 domains. 1. General health with demographics and comorbidities, 2.Spine-specific health with spine related health and neurological status, 3. Imaging with radiographic and MRI parameters and 4. Deformity type. Each domain consisted of 1 or 2 components with various factors and their measuring instruments. Profile was found to have an excellent content validity (I-CVIr 0.78-1.00; Ave-CVI 0.92) appropriateness, relevance and usefulness. CONCLUSIONS: The present study, is first to provide a universally applicable multimodal ASD patient profile to methodically describe patients. Physicians are encouraged to assess ASD patients holistically using this profile and not just based on radiographic findings.

Inhibitory Effect of Insulin Treatment on Apoptosis of Intervertebral Disc Cells in a Streptozotocin-Induced Diabetic Rat Model.

STUDY DESIGN: Experimental study using a streptozotocin (STZ)-induced diabetic rat model. PURPOSE: This study aims to investigate whether insulin treatment could attenuate disc cell apoptosis and matrix degradation in a STZ-induced diabetic rat model. OVERVIEW OF LITERATURE: Diabetes is a significant risk factor for disc degeneration due to excessive apoptosis of disc cells and matrix degradation. However, no studies were noted to demonstrate the inhibitory effect of insulin treatment on the apoptosis of disc cells and matrix degradation in diabetic patients. METHODS: Rats were allocated randomly into one of three groups: control, STZ, and STZ-insulin. Diabetes was induced by a single intraperitoneal injection of STZ (65 mg/kg) in the STZ and STZ-insulin groups. The blood glucose level was consistently above 400 mg/ dL in the STZ and STZ-insulin groups 2 weeks after STZ injection. After 2 weeks of STZ injection, the STZ-insulin group was administered insulin treatment (1.5 unit/100 g) daily for up to 4 weeks. Blood glucose of the STZ-insulin rats significantly decreased to normal levels 4 weeks after insulin treatment. The rats were sacrificed 6 weeks after STZ injection, and disc cells and tissues were harvested to investigate the expression of apoptosis markers and matrix metalloproteinases (MMPs). RESULTS: Fas and caspase-8, -9, and -3 expressions were significantly increased in the STZ group, along with increased expressions of MMP-2 and -3. On the contrary, insulin treatment significantly decreased the expressions of Fas, caspase-8, -9, and -3 as well as MMP-2 and -3 in the STZ-insulin group. CONCLUSIONS: The results of the current study demonstrated that insulin treatment attenuates excessive apoptosis of disc cells and matrix degradation in the diabetic rat model. Accordingly, strict blood glucose control should be recommended to prevent disc degeneration in diabetic patients.

Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion.

Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.

Factors Affecting the Decision to Initiate Anticoagulation After Spine Surgery: Findings From the AOSpine Anticoagulation Global Initiative.

STUDY DESIGN: Cross-sectional, international survey. OBJECTIVES: To identify factors influencing pharmacologic anticoagulation initiation after spine surgery based on the AOSpine Anticoagulation Global Survey. METHODS: This survey was distributed to the international membership of AOSpine (n = 3805). A Likert-type scale described grade practice-specific factors on a scale from low (1) to high (5) importance, and patient-specific factors a scale from low (0) to high (3) importance. Analysis was performed to determine which factors were significant in the decision making surrounding the initiation of pharmacologic anticoagulation. RESULTS: A total of 316 spine surgeons from 64 countries completed the survey. In terms of practice-specific factors considered to initiate treatment, expert opinion was graded the highest (mean grade ± SD = 3.2 ± 1.3), followed by fellowship training (3.2 ± 1.3). Conversely, previous studies (2.7 ± 1.2) and unspecified guidelines were considered least important (2.6 ± 1.6). Patient body mass index (2.0 ± 1.0) and postoperative mobilization (2.3 ± 1.0) were deemed most important and graded highly overall. Those who rated estimated blood loss with greater importance in anticoagulation initiation decision making were more likely to administer thromboprophylaxis at later times (hazard ratio [HR] = 0.68-0.71), while those who rated drain output with greater importance were likely to administer thromboprophylaxis at earlier times (HR = 1.32-1.43). CONCLUSION: Among our global cohort of spine surgeons, certain patient factors (ie, patient mobilization and body mass index) and practice-specific factors (ie, expert opinion and fellowship training) were considered to be most important when considering anticoagulation start times.

Proximal Junctional Kyphosis in Adult Spinal Deformity: Definition, Classification, Risk Factors, and Prevention Strategies.

Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.

Subretinal fluid in a patient with systemic lupus erythematosus.

A 28-year-old male patient presented to the outpatient department with visual disturbance in both eyes. The patient had a history of stage IV lupus nephritis that was diagnosed at the age of 14 years and had undergone hemodialysis at the age of 23 years. After he started hemodialysis, the systemic condition was well controlled, and systemic steroids were not used. His best-corrected visual acuity (BCVA) was 20/200 in the right eye and 20/100 in the left eye. Funduscopic examination revealed shallow subretinal fluid (SRF) and serous retinal detachment in both eyes. The first impression of this patient was central serous chorioretinopathy. However, the late phase of fluorescein angiography (FA) demonstrated multiple subretinal leakages, and the late phase of indocyanine green angiography showed choroidal vascular engorgement and multiple hyperfluorescent plaques in both eyes. Systemic lupus erythematosus showed moderate activity according to the results of the systemic evaluation. Based on the clinical examination, lupus choroidopathy was suspected in both eyes. Half-fluence photodynamic therapy (PDT) was administered to both eyes rather than systemic steroids because the patient was systemically stable. Three months after PDT, no SRF was observed in either eye. In addition, multiple subretinal leakages on FA were reduced compared to those before treatment. There was no recurrence of SRF for 4 years after PDT, and the final BCVA was 20/70 in the right eye and 20/40 in the left eye. During this time, numerous hypoautofluorescence spots appeared adjacent to the major retinal vessels in fundus autofluorescence.

Central serous chorioretinopathy: Treatment.

Central serous chorioretinopathy (CSC) is a pachychoroid spectrum disease characterized by serous detachment of the neurosensory retina with subretinal fluid in young and middle-aged adults. The pathogenesis of CSC is not yet fully understood. However, it is considered a multifactorial disease that is strongly associated with choroidal dysfunction or vascular engorgement. Although there is no consensus on the treatment of CSC, photodynamic therapy has been effectively used to manage serous retinal detachment (SRD) in CSC. Moreover, micropulse diode laser photocoagulation and focal laser treatment have also been used. Recently, oral medications, including mineralocorticoid receptor antagonists, have been proposed for the management of CSC. Multimodal imaging plays a significant role in the diagnosis and treatment of CSC. Optical coherence tomography angiography (OCTA) has the advantage of detecting vascular flow in the retina and choroid layer, allowing for a better understanding of the pathology, severity, prognosis, and chronicity of CSC. In addition, early detection of choroidal neovascularization in CSC is possible using OCTA. This review article aims to provide a comprehensive and updated understanding of CSC, focusing on treatment.

15-year survivorship analysis of an interspinous device in surgery for single-level lumbar disc herniation.

BACKGROUND: Interspinous devices have been introduced as alternatives to decompression or fusion in surgery for degenerative lumbar diseases. This study aimed to investigate 15-year survivorship and risk factors for reoperation of a Device for Intervertebral Assisted Motion (DIAM) in surgery for 1-level lumbar disc herniation (LDH). METHODS: A total of 94 patients (54 men and 40 women) underwent discectomy and DIAM implantation for 1-level LDH, with a mean follow-up of 12.9 years (range, 6.3-15.3 years). The mean age was 46.2 years (range, 21-65 years). Sixty-two patients underwent DIAM implantation for L4-5, 27 for L5-6, and 5 for L3-4. Reoperations due to any reason associated with DIAM implantation level or adjacent levels were defined as failure and used as the end point of determining survivorship. RESULTS: During the 15-year follow-up, 8 patients (4 men and 4 women) underwent reoperation due to recurrence of LDH at the DIAM implantation level, a reoperation rate of 8.5%. The mean time to reoperation was 6.5 years (range, 0.8-13.9 years). Kaplan-Meier analysis showed a cumulative survival rate of the DIAM implantation of 97% at 5 years, 93% at 10 years, and 92% at 15 years after surgery; the cumulative reoperation rate of the DIAM implantation was 3% at 5 years, 7% at 10 years, and 8% at 15 years after surgery. Mean survival time was predicted to be 14.5 years (95% CI, 13.97-15.07). The log-rank test and Cox proportional hazard model showed that age, sex, and location did not significantly affect the reoperation rate of DIAM implantation. CONCLUSIONS: Our results showed that DIAM implantation significantly decreased reoperation rate for LDH in the 15-year survivorship analysis. We suggest that DIAM implantation could be considered a useful intermediate step procedure for LDH surgery. To the best of our knowledge, this is the longest follow-up study in which surgical outcomes of interspinous device surgery were reported.

Anterior Dens Screw Fixation for Traumatic C1-2 Lateral Subluxation With 3-Part Fractures of the C2 Axis (Dens, Lateral Mass, and Hangman Fractures): A Case Report.

INTRODUCTION: To report the first case of traumatic C1-2 lateral subluxation with three-part fractures of the C2 axis (dens, lateral mass, and hangman fractures) that was successfully treated with only anterior dens screw fixation. METHODS: A 56-year-old man was admitted to the hospital complaining of neck and left arm pains caused by a pedestrian traffic accident. Radiologic examination revealed traumatic C1-2 lateral subluxation, type 3 dens fracture (Anderson and D'Alonzo classification), fracture of both C2 lateral masses, and type 1 hangman fracture (Levine and Edwards classification). RESULTS: Preoperative closed reduction of the C1-2 lateral subluxation was successfully achieved by skull traction using a Gardner-Wells tong. The patient underwent anterior dens screw fixation for type 3 dens fracture with posterior angulation. At the 2-year follow-up visit, good reduction of traumatic C1-2 lateral subluxation and solid fusion of all three-part fractures of the C2 axis were achieved with full range of motion and stability at the C1-2 joint. In addition, notable improvement of neck and left arm pains was achieved. DISCUSSION: Preoperative closed reduction and anterior dens screw fixation can be considered as a less invasive and motion-preserving surgery for traumatic C1-2 lateral subluxation with three-part fractures of the C2 axis.

The Psychosocial Effects of Taekwondo Training: A Meta-Analysis.

Taekwondo is a Korean martial art and international sport, and its psychosocial benefits for its trainees have been studied extensively. This review aims to systematically assess and meta-analyze the effects of Taekwondo training on sociality, character, etiquette, and school life adjustment. We searched the RISS, NDSL, and KISS electronic databases between January 1985 and December 2019. We also included gray literature, such as theses, in addition to peer-reviewed articles. R software (version 3.6.2, R Core Team, Vienna, Austria) was used to synthesize the effect sizes and perform moderation analyses. Twenty-eight studies (24 cross-sectional and four intervention studies) were included in the final meta-analysis. Significant positive effects of Taekwondo training were found on sociality (MD = 0.266, 95% CI: 0.191 to 0.341), character (MD = 0.446, 95% CI: 0.331-0.560), etiquette (MD = 0.562, 95% CI: 0.500-0.624), and school life adjustment (MD = 0.308, 95% CI: 0.195-0.421). Overall, the findings of this meta-analysis support that Taekwondo can have a positive impact on the psychosocial factors of trainees. Due to several limitations discussed, well-designed RCTs and multiple levels of Taekwondo intervention studies should be conducted in future research to validate the current findings.

Effects of Taekwondo Training on Body Composition: A Systematic Review and Meta-Analysis.

BACKGROUND: The purpose of this study is to investigate the effect of Taekwondo training on body composition and to evaluate the magnitude of the effect. METHODS: Databases were used to select studies related to the effectiveness of Taekwondo training, and the inclusion criteria were as follows. RESULTS: Thirty-seven studies were selected. We found statistically significant differences from the control group in weight, body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR), body fat mass, body fat percentage, lean mass, and muscle mass. Also, the age group was statistically significant in control variables on weight, BMI, and body fat percentage. CONCLUSIONS: Taekwondo training had a positive effect on body composition, and these results suggest that Taekwondo training is an effective exercise method to lower obesity.

Cervical Myelopathy Caused by Posttraumatic Osteophytes Resulting From Long-Standing Neglected Posterior Atlanto-Occipital Dislocation More Than 30 years: A Case Report.

INTRODUCTION: Traumatic atlanto-occipital dislocation (AOD) is a rare but usually fatal injury. To our knowledge, no study has reported long-standing neglected posterior AOD more than 30 years in a patient who survived and later experienced cervical myelopathy. METHODS: A 75-year-old man presented with symptoms of cervical myelopathy. On history, the patient was diagnosed with posterior AOD that occurred after a fall 31 years ago, but he did not undergo surgery. Radiologic evaluation of cervical spine revealed severe spinal cord compression caused by posttraumatic osteophytes of the C0-C1-C2 joints resulting from long-standing neglected posterior AOD. However, no instability of the C0-C1-C2 joints was found. RESULTS: Laminectomy of the C1 posterior arch was performed without occipitocervical fusion considering the long-standing severe osteoarthritic changes and no instability of the C0-C1-C2 joints. Cervical myelopathy significantly improved, and the patient was doing well without recurrence at the 7-year follow-up. DISCUSSION: To our knowledge, this is the first report of a patient with cervical myelopathy caused by neglected posterior AOD with posttraumatic osteophytes of the C0-C1-C2 joints. Laminectomy of the C1 posterior arch without occipitocervical fusion achieved satisfactory outcomes for cervical myelopathy caused by posttraumatic osteophytes resulting from long-standing neglected posterior AOD more than 30 years.

Proposal of Treatment Strategy for Pedicle Fractures of the C2: An Analysis of 49 Cases.

Spine surgeons often confuse C2 pedicle fractures (PFs) with pars interarticularis fractures. In addition, little information is available about the characteristics and treatment strategies for C2 PFs. We sought to investigate the characteristics of C2 PFs and to propose an appropriate treatment strategy. A total of forty-nine patients with C2 PFs were included in this study. We divided these patients into unilateral and bilateral C2 PF groups. The incidence rates and characteristics of other associated C2 and C2-3 injuries, and other cervical injuries, were evaluated. In addition, treatment methods and outcomes were analyzed. Twenty-two patients had unilateral C2 PFs and twenty-seven patients had bilateral C2 PFs. Among the cases of unilateral C2 PFs, all patients had one or more other C2 fractures, and twenty patients (90.9%) had one or two C2 body fractures. Meanwhile, among the cases of bilateral C2 PF, all patients had two or more other C2 fractures and one or two C2 body fractures. In unilateral C2 PFs, three patients with C2-3 anterior slip or adjacent cervical spine (C1-3) injury underwent surgery and nineteen patients (86.4%) were treated with conservative methods. In bilateral C2 PFs, three patients with C2-3 anterior slip or SCI at C2-3 underwent surgery and twenty-four patients (88.9%) were treated with conservative methods. Our results showed that C2 PFs do not occur alone and are always accompanied by other associated C2 injuries. C2 PFs should, generally, be thought of as a more complex fracture type than hangman's fracture or dens fracture. Despite the complex fracture characteristics, most C2 PFs can be managed with conservative treatment. However, surgical treatments should be considered if the C2 PFs are accompanied by the C2-3 anterior slip and adjacent cervical spine injury.

Hyperacute onset of adjacent segment disease with dorsally migrated herniated nucleus pulposus causing cauda equina syndrome: a case report.

PURPOSE: To report the first case of hyperacute onset of adjacent segmental disease (ASD) with dorsally migrated herniated nucleus pulposus (HNP) causing cauda equina syndrome. METHODS: A 55-year-old female complained of lower back pain with radiating pain in both lower extremities that had not responded to conservative treatment over the previous six months. Plain radiographs and magnetic resonance imaging (MRI) findings revealed degenerative spondylolisthesis with spinal stenosis at L3-4, L4-5, and a slight bulging disc at L2-3. The patient underwent decompressive total laminectomy and posterior fusion at L3-4 and L4-5. The stenotic symptoms improved significantly after surgery, and she was then discharged on postoperative day 7. RESULTS: However, the patient visited the emergency department four days after discharge (postoperative day 11) complaining of sudden onset of bilateral lower extremity weakness and voiding and defecation difficulties. The follow-up MRI showed dorsally migrated huge HNP and a detached posterior longitudinal ligament (PLL) at L2-3, which was diagnosed as hyperacute onset of ASD causing cauda equina syndrome. The patient underwent an emergency second operation consisting of partial laminectomy at L2-3 with removal of the dorsally migrated huge HNP. After the second operation, the symptoms of cauda equina syndrome improved. One year after the second operation, the patient is doing well without recurrence of symptoms. CONCLUSIONS: Our case showed that hyperacute onset of ASD with dorsally migrated huge HNP can cause cauda equina syndrome, even within 2 weeks after lumbar fusion surgery. Therefore, a high index of suspicion, timely diagnosis, and surgical treatment are needed to avoid the catastrophic neurologic complications in similar extremely rare cases.

Challenges to the orthopedic resident workforce during the first wave of COVID-19 pandemic: Lessons learnt from a global cross-sectional survey.

BACKGROUND: The COVID-19 pandemic has caused unprecedented concerns on the safety, well-being, quality of life(QOL), and training of the orthopedic resident physician workforce worldwide. Although orthopedic residency programs across the globe have attempted to redefine resident roles, educational priorities, and teaching methods, the global orthopedic residents' perspective with regards to their safety, well-being, QOL, and training, taking into account regional variances remains unknown. METHODS: A 56-item-questionnaire-based cross-sectional survey was conducted online during the COVID-19 pandemic involving 1193 orthopedic residents from 29 countries across six geographical regions to investigate the impact of the COVID-19 pandemic on the well-being, safety, and training of orthopedic residents at a global level, as well as to analyze the challenges confronted by orthopedic residency programs around the world to safeguard and train their resident workforce during this period. RESULTS: The total response rate was 90.3%(1077/1193). Time spent on residency-training activities decreased by 24.7 h/week (95% CI, -26.5 to -22.9,p < 0.001), with 50.2% (n = 541) residents performing duties outside their residency curriculum. 80.5% (n = 869) residents had no prior experience working in infectious outbreaks. A greater percentage of residents from Middle East, Asia and Europe were redeployed to the COVID-19 frontlines, p < 0.001. Only 46.5% (n = 491) and 58.4% (n = 600) of residents underwent training in critical care or PPE (Personal Protective equipment) usage, respectively; 28.5% (n = 302) residents (majority from Africa, Middle East, South America) reported lack of institutional guidelines to handle infectious outbreaks; 15.4% (n = 160) residents (majority from Africa, Asia, Europe) had concerns regarding availability of PPE and risk of infection. An increase in technology-based virtual teaching modalities was observed. The most significant stressor for residents was the concern for their family's health. Residents' QOL significantly decreased from 80/100 (IQR 70-90) to 65/100 (IQR 50-80) before and during the pandemic, p < 0.001. CONCLUSIONS: The COVID-19 pandemic has significantly impacted the safety, well-being, QOL, and training of the global orthopedic resident physician workforce to different extents across geographical regions. The findings of this study will aid educators, program leaderships, and policy makers globally in formulating flexible, generalizable, and sustainable strategies to ensure resident safety, well-being, and training, while maintaining patient care.