Detection of Cervical Foraminal Stenosis from Oblique Radiograph Using Convolutional Neural Network Algorithm

Purpose@#This study was conducted to develop a convolutional neural network (CNN) algorithm that can diagnose cervical foraminal stenosis using oblique radiographs and evaluate its accuracy. @*Materials and Methods@#A total of 997 patients who underwent cervical MRI and cervical oblique radiographs within a 3-month interval were included. Oblique radiographs were labeled as “foraminal stenosis” or “no foraminal stenosis” according to whether foraminal stenosis was present in the C2–T1 levels based on MRI evaluation as ground truth. The CNN model involved data augmentation, image preprocessing, and transfer learning using DenseNet161. Visualization of the location of the CNN model was performed using gradient-weight class activation mapping (Grad-CAM). @*Results@#The area under the curve (AUC) of the receiver operating characteristic curve based on DenseNet161 was 0.889 (95% confidence interval, 0.851–0.927). The F1 score, accuracy, precision, and recall were 88.5%, 84.6%, 88.1%, and 88.5%, respectively.The accuracy of the proposed CNN model was significantly higher than that of two orthopedic surgeons (64.0%, p<0.001; 58.0%, p<0.001). Grad-CAM analysis demonstrated that the CNN model most frequently focused on the foramen location for the determination of foraminal stenosis, although disc space was also frequently taken into consideration. @*Conclusion@#A CNN algorithm that can detect neural foraminal stenosis in cervical oblique radiographs was developed. The AUC, F1 score, and accuracy were 0.889, 88.5%, and 84.6%, respectively. With the current CNN model, cervical oblique radiography could be a more effective screening tool for neural foraminal stenosis.

Preoperative Radiographic Simulation for Partial Uncinate Process Resection during Anterior Cervical Discectomy and Fusion to Achieve Adequate Foraminal Decompression and Prevention of Vertebral Artery Injury

Methods@#We retrospectively reviewed patients who underwent cervical magnetic resonance imaging and computed tomography angiography for preoperative ACDF evaluation. The segments were classified according to the presence of foraminal stenosis. The height, thickness, anteroposterior length, horizontal distance from the uncinate process to the VA, and vertical distance from the uncinate process baseline to the VA of the uncinate process were measured. The distance between the uncinate anterior margin and the resection trajectory (UAM-to-RT) was measured. @*Results@#There were no VA injuries or root injuries among the 101 patients who underwent ACDF (163 segments, mean age of 56.3±12.2). Uncinate anteroposterior length was considerably longer in foramens with foraminal stenosis, whereas uncinate process height, thickness, and distance between the uncinate process and VA were not significantly associated with foraminal stenosis. There were no significant differences in radiographic parameters based on uncinate degeneration. The UAM-to-RT distances for adequate decompression were 1.6±1.4 mm (range, 0–4.8 mm), 3.4±1.7 mm (range, 0–7.1 mm), 4.0±1.7 mm (range, 0–9.0 mm), and 4.5±1.2 mm (range, 2.5–7.5 mm) for C3–C4, C4–C5, C5–C6, and C6–C7, respectively. @*Conclusions@#More than half of the uncinate process in the anteroposterior plane should be removed for adequate neural foramen decompression. Foraminal stenosis or uncinate degeneration did not alter the relative anatomy of the uncinate process and the VA and did not impact VA injury risk.

Anterior Decompression and Fusion for the Treatment of Cervical Myelopathy Caused by Ossification of the Posterior Longitudinal Ligament: A Narrative Review

Occasionally, ossification of the posterior longitudinal ligament (OPLL) causes cord compression, resulting in cervical myelopathy. OPLL differs from other causes of cervical spondylotic myelopathy in several ways, and the surgical strategy should be chosen with OPLL’s characteristics in mind. Although both the anterior and posterior approaches are effective surgical methods for the treatment of OPLL cervical myelopathy, they each have their own set of benefits and drawbacks. Anterior decompression and fusion (ADF) may improve neurological recovery, restore lordosis, and prevent OPLL mass progression. The benefits can be seen in patients with a high canal occupying ratio or kyphotic alignment. We discussed the benefits, limitations, indications, and surgical techniques of ADF for the treatment of OPLL-induced cervical myelopathy in this narrative.

Feasibility of Non-window Three-Dimensional– Printed Porous Titanium Cage in Posterior Lumbar Interbody Fusion: A Pilot Trial

Background@#The commercially available design of a three-dimensional (3D)–printed titanium (3D-Ti) cage can be divided into two types according to the presence of a window: a cage with a window that allows filling of bone graft materials and a non-window cage for stand-alone use. This prospective observational case series study aimed to explore the clinical feasibility of using a nonwindow type 3D-Ti cage in cases of combined window and non-window cage implantation. Furthermore, we evaluated the bone in growth patterns of non-window cages and their correlation with published fusion grading systems. @*Methods@#A total of 31 consecutive patients who underwent single-level posterior lumbar interbody fusion surgery were included. Two 3D-Ti cages with different designs were inserted: a non-window cage on the left side and a window cage on the right side.Radiographic fusion was defined by the segmental angle between flexion and extension radiographs (F-E angle) and cage bridging bone (CBB) scores on computed tomography. The association between the F-E angle and osteointegration scoring system including the surface osteointegration ratio (SOR) score was analyzed. @*Results@#Radiographic fusion was achieved in 27 of 31 patients (87%) at 12 months postoperatively. Among the non-window cages, 23 of 31 (74.2%) had fair SOR scores, while 19 of 31 (61.3%) window cages had fair intra-cage CBB scores. The higher the SOR score was, the smaller the flexion-extension angle (SOR 0 vs. SOR 1: 6.30° ± 2.43° vs. 1.95° ± 0.99°, p < 0.001; SOR 0 vs. SOR 2: 6.03° ± 2.43° vs. 0.99°± 0.74°, p < 0.001). @*Conclusions@#The clinical feasibility of using a non-window 3D-Ti cage during lumbar interbody fusion might be acceptable. Furthermore, a newly suggested fusion criterion for the use of the non-window cage, the SOR score, showed a significant association with the published fusion grading systems, demonstrating its feasibility in determining interbody fusion in lumbar spinal surgery.

Prognostic Factors for Postsurgical Recovery of Deltoid Palsy due to Cervical Disc Herniations

STUDY DESIGN: Retrospective multicenter study. PURPOSE: We aimed to investigate prognostic factors affecting postsurgical recovery of deltoid palsy due to cervical disc herniation (CDH). OVERVIEW OF LITERATURE: Little information is available about prognostic factors affecting postsurgical recovery of deltoid palsy due to CDH. METHODS: Sixty-one patients with CDH causing deltoid palsy (less than grade 3) were included in this study: 35 soft discs and 26 hard discs. Average duration of preoperative deltoid palsy was 11.9 weeks. Thirty-two patients underwent single-level surgery, 22 two-level, four three-level, and three four-level. Patients with accompanying myelopathy, shoulder diseases, or peripheral neuropathy were excluded from the study. RESULTS: Deltoid palsy (2.4 grades vs. 4.5 grades, p<0.001) and radiculopathy (6.4 points vs. 2.1 points, p<0.001) significantly improved after surgery. Thirty-six of 61 patients (59%) achieved full recovery (grade 5) of deltoid palsy, with an average time of 8.4 weeks. Longer duration of preoperative deltoid palsy and more severe radiculopathy negatively affected the degree of improvement in deltoid palsy. Age, gender, number of surgery level, and disc type did not affect the degree of improvement of deltoid palsy. Contrary to our expectations, severity of preoperative deltoid palsy did not affect the degree of improvement. Due to the shorter duration of preoperative deltoid palsy, in the context of rapid referral, early surgical decompression resulted in significant recovery of more severe grades (grade 0 or 1) of deltoid palsy compared to grade 2 or 3 deltoid palsy. CONCLUSIONS: Early surgical decompression significantly improved deltoid palsy caused by CDH, irrespective of age, gender, number of surgery level, and disc type. However, longer duration of deltoid palsy and more severe intensity of preoperative radiating pain were associated with less improvement of deltoid palsy postoperatively.

Modified Tension Band Wiring Combined with Anti-Gliding Loop Augmentation Technique for the Treatment of Comminuted Patellar Fracture: Technical Note and Report of Early Results: Technical Note

In order to investigate the feasibility of a modified tension band combined with anti-gliding loop augmentation technique for the treatment of comminuted patellar fracture, 21 patients with comminuted patellar fracture were enrolled in this study. After the modified tension band wiring of patellar fracture, a cerclage wire was passed around the patella. Anti-gliding loops were made on the bending sites of Kirshner-wires. A knot was tied using both ends of the anti-gliding loops, and the cerclage wire was tightened using proximal knots. Bone union was achieved at 4.5+/-1.5 months postoperatively without nonunion. The Lysholm score was 87.1+/-2.8, and the range of motion of the knee was 2.1degrees+/-3.4degrees to 132.2degrees+/-6.5degrees at the last follow-up. The modified tension band combined with anti-gliding loop augmentation technique might be considered an alternative modification of modified tension band wiring for the treatment of comminuted patellar fracture.

Adjacent Segment Degeneration after Single-Level PLIF: Comparison between Spondylolytic Spondylolisthesis, Degenerative Spondylolisthesis and Spinal Stenosis

STUDY DESIGN: A retrospective study. PURPOSE: To comparatively investigated the rate of the adjacent segment degeneration and the clinical outcomes in patients with spondylolytic spondylolisthesis, spinal stenosis or degenerative spondylolisthesis. OVERVIEW OF LITERATURE: There have been few studies reported on the adjacent segment degeneration following posterior lumbar interbody fusion(PLIF). Many risk factors for the adjacent segment degeneration following PLIF have been proposed. The range of decompression has been presented as one of the risk factors, yet controversial. METHODS: This study enrolled sixty-three patients who had been treated with single-level PLIF and who were followed up for more than two years. The patients were divided into 3 groups based on the preoperative diagnosis. We analyzed the difference between the preoperative and postoperative intervertebral disc heights of the superior adjacent segments. The incidence rates of instability and the clinical outcomes were comparatively analyzed between each group. RESULTS: The average age of the patients was 55.8 years in the spondylolytic spondylolisthesis group, 65.9 years in the degenerative spondylolisthesis group and 60.4 years in the spinal stenosis group. The average follow-up period was 44 months, 43 months and 42 months, respectively. At the last follow-up, compared to the preoperative period, the intervertebral disc height decreased in all three groups. A statistically significant decrease (p < 0.01) was observed only in the spondylolytic spondylolisthesis group and no significant difference was observed between each group (p = 0.41). The incidence rate of instability and the clinical outcome were not significantly different between each group. CONCLUSIONS: Spondylolytic spondylolisthesis with total laminectomy and single-level PLIF showed no significant difference in the superior adjacent segment degeneration and instability, and the clinical outcome as compared to that of partial laminectomy with single-level PLIF for treating degenerative spondylolisthesis or spinal stenosis.

Subsidence and Nonunion after Anterior Cervical Interbody Fusion Using a Stand-Alone Polyetheretherketone (PEEK) Cage

BACKGROUND: The purposes of the present study are to evaluate the subsidence and nonunion that occurred after anterior cervical discectomy and fusion using a stand-alone intervertebral cage and to analyze the risk factors for the complications. METHODS: Thirty-eight patients (47 segments) who underwent anterior cervical fusion using a stand-alone polyetheretherketone (PEEK) cage and an autologous cancellous iliac bone graft from June 2003 to August 2008 were enrolled in this study. The anterior and posterior segmental heights and the distance from the anterior edge of the upper vertebra to the anterior margin of the cage were measured on the plain radiographs. Subsidence was defined as > or = a 2 mm (minor) or 3 mm (major) decrease of the segmental height at the final follow-up compared to that measured at the immediate postoperative period. Nonunion was evaluated according to the instability being > or = 2 mm in the interspinous distance on the flexion-extension lateral radiographs. RESULTS: The anterior and posterior segmental heights decreased from the immediate postoperative period to the final follow-up at 1.33 +/- 1.46 mm and 0.81 +/- 1.27 mm, respectively. Subsidence > or = 2 mm and 3 mm were observed in 12 segments (25.5%) and 7 segments (14.9%), respectively. Among the expected risk factors for subsidence, a smaller anteroposterior (AP) diameter (14 mm vs. 12 mm) of cages (p = 0.034; odds ratio [OR], 0.017) and larger intraoperative distraction (p = 0.041; OR, 3.988) had a significantly higher risk of subsidence. Intervertebral nonunion was observed in 7 segments (7/47, 14.9%). Compared with the union group, the nonunion group had a significantly higher ratio of two-level fusion to one-level fusions (p = 0.001). CONCLUSIONS: Anterior cervical fusion using a stand-alone cage with a large AP diameter while preventing anterior intraoperative over-distraction will be helpful to prevent the subsidence of cages. Two-level cervical fusion might require more careful attention for avoiding nonunion.

Calcifying Aponeurotic Fibroma: An Atypical Case

Calcifying aponeurotic fibroma is a very rare benign soft tissue tumor with predilection for the fingers and palms of children and adolescents. We describe an unusual case of a calcifying aponeurotic fibroma in old age that circumferentially involved the dorsal and palmar side of the third metacarpal head.We performed a wide excision using two incisions, resulting in satisfactory clinical result. A calcifying aponeurotic fibroma must be considered in the differential diagnosis of a calcifying soft tissue lesion occuring in the hand of old age.

Spinopelvic Fixation / 대한척추외과학회지

Lumbosacral fixation or spinopelvic fixation is frequently required for the surgical treatment of neuromuscular scoliosis and degenerative lesions, trauma and tumor in the lumbosacral vertebrae. However, the establishment of stable fixation with these procedures is difficult due to the anatomic characteristics of the sacrum and this is even more problematic for the cases with long segmental fixation, severe instability and bone defects. Although the emergence of pedicle screws makes spinal fixation easier and more rigid, S1 pedicle screws alone do not provide enough stability for lumbosacral fixation. For the purposes of reinforcing lumbosacral fixation, procedures using rods or screws can be used: the procedures using rods include the Galveston method, the McCarthy S-rod and the Jackson intrasacral rod, and the procedures using screws include sacral alar screws, transdiscal screws and iliac screws. The purpose of this study was to ascertain the proper fixation methods, according to each indication, for spinopelvic fixation and we analyzed the advantages and drawbacks of each fixation method. In addition, the fixation method of iliac screws, which has recently become more popular, is presented in detail to enhance the availability and reduce the complication of this technique.

Comparative Study of ACL Double-bundle Reconstruction with and without Functional Knee Brace: Minimum 1-year Follow-up Results / 대한정형외과학회잡지

PURPOSE: To compare the clinical efficacy after an arthroscopic ACL double-bundle reconstruction with and without functional knee brace. MATERIALS AND METHODS: Between July 2004 and May 2006, fifty patients who underwent an ACL double-bundle reconstruction with and without a functional knee brace for more than a 1-year follow-up were evaluated. The patients were treated with brace (Group 1, 22 cases) or without (Group 2, 28 cases) a brace after surgrey. Stability was assessed by maximal manual testing with a KT-1000 arthrometer, anterior stress radiographs using the Telos device and a lateral pivot shift test. The clinical results were assessed by the OAK (Orthopadische Arbeitsgruppe Knie) score, IKDC (International Knee Documentation Committee) score, mid thigh circumference and the range of motion. RESULTS: More than one year after surgery, average of OAK score, IKDC score, lateral pivot shift test of the stability results and maximal manual testing with the KT-1000 arthrometer, stress radiographs with the Telos device, mid thigh circumference difference, range of motion of the clinical results were similar in both groups. CONCLUSION: An ACL double-bundle reconstruction produces similar stability and clinical results regardlness of whether or not a functional knee brace is used.

Causes or Failure and Complications of Ureteroscopic Removal of Stone / 대한비뇨기과학회지

Ureteroscopic management of ureteral calculi is an established successful technique with low complication. We performed 140 ureteroscopies for stone removal from January 1990 to April 1995. The stone were removed successfully in 131 cases (94%), and complication occurred in 37 cases (27%). In 9 cases, complete removal of stone was failed due to upward migration of stone (3 cases), not mobilization of stone (3 cases), inability to introduce ureteroscope into the intramural ureter (2 cases), inadequate illumination due to bleeding (1 case). Complications of ureteroscopic removal of stone were ureteral perforation (8 cases), tearing of ureteral mucosa (5 cases), gross hematuria (19 cases), infection (3 cases) and fever (2 cases). All complications were treated successfully with conservative treatment. We conclude that ureteroscopic removal of stone is still primary useful treatment of middle and lower ureteral stones and can be done safely if certain guide lines such as proper selection of patient, adequate use of lithotriptor, careful dilatation of ureteral orifice are kept strictly.

Comparison of Penetration Capability of Levofloxacin and Ciprofloxacin into Prostatic Tissue / 대한비뇨기과학회지

PURPOSE: To evaluate the penetration capability of Levofloxacin and Ciprofloxacin into prostatic tissue, we analysed the concentration of each drug in serum and prostatic tissue simultaneously after oral administration. MATERIALS AND METHODS: Eleven patients with benign prostatic hyperplasia treated with transurethral resection of the prostate were entered in this study. A single dose of 200mg Levofloxacin(LVFX) and 250mg ciprofloxacin(CPFX) were administered orally. Two hours after administration, blood and prostatic tissue samples were taken during operation. Concentration of each drug in serum and prostatic tissue was measured simultaneously by high performance liquid chromatography. RESULTS: The mean concentration of LVFX in serum was 1.970 +/- 0.759 microgram/ml, which was significantly higher than that of CPFX(0.903 +/- 0.291 microgram /ml)(p < 0.05). The mean concentration of LVFX in prostatic tissue(2.256 +/- 1.121 microgram/g), however, was not significantly different from that of CPFX(2.395 +/- 0.846 microgram/g). And the concentration ratio(tissue/serum concentration) of LVFX and CPFX was 1.16 and 2.76, respectively. CONCLUSIONS: These results show that LVFX is not superior to CPFX with respect to the penetration capability into prostatic tissue. Considering that the concentration of LVFX in prostatic tissue was higher than that in serum and not different from that of CPH, LVFX may be another potential effective agent in treating patients with chronic bacterial prostatitis.

A Study of Correlations among International Prostate Symptom Score (IPSS), Volume of Total and Transition Zone of Prostate Measured by Transrectal Ultrasonography, Serum PSA Level in Benign Prostatic Hyperplasia / 대한비뇨기과학회지

This study was aimed to investigate the possible correlations between International Prostate Symptom Score (IPSS), volume of total and transition zone of prostate, and serum prostate specific antigen (PSA) level in 42 patients diagnosed and treated as benign prostatic hyperplasia. We got IPSS by interview and calculated the volume of the total and the transition zone (TZ vol) of prostate by transrectal ultrasonography. The size of the total prostate was 37.35+/-12.9 cc (mean+/-standard deviation) and that of the transition zone was 17.72 +/- 10.04 cc. Transition zone index(transition zone volume/total prostate volume, TZ index) was calculated and its value was 0.45 +/- 0.14. Symptom score was not correlated with total prostate volume, TZ volume or 72 index (r=0.27, p>0.05; r=0.23, p>0.05; r=0.16, p>0.05, respectively). Either it did not show correlation with serum PSA level (r=0.16, p>0.05). However, there were statistically significant correlations among serum PSA, total volume, TZ volume, TZ index (r=0.66, p<0.05; r=0.64, p<0.05; r=0.47, p<0.05). From these results, it is difficult to find significant correlations between symptom severity easured by IPSS and several clinical indices such as total prostate volume, transitional volume, TZ index or serum PSA level. Prospective study including developing a more objective symptom scoring system is needed to get a more useful clinical index reflecting the symptom severity of the BPH patients as well as clinical status of them.

A Case of Prostatic Rhabdomyosarcoma in Adult / 대한비뇨기과학회지

Rhabdomyosarcoma of the prostate is a very rare tumor in adulthood. Twenty five-year-old man with obstructive urinary symptoms was admitted. He was diagnosed as embryonal type rhabdomyosarcoma of the prostate, and treated with multimodal therapies, i.e. radical prostatectomy, radiation therapy and adjutant chemotherapy. He is now being followed up without any evidence of recurrence for 11 months. This case is presented with reviewing references.