Soluble ST2 is a biomarker associated with left ventricular hypertrophy and concentric hypertrophy in patients with essential hypertension.

BACKGROUND: Elevated soluble stimulating factor 2 (sST2) level is observed in cardiovascular diseases, such as heart failure and acute coronary syndrome, which reflects myocardial fibrosis and hypertrophy, indicating adverse clinical outcomes. However, the association between sST2 and hypertensive heart disease are less understood. This study aimed to determine the relationship of sST2 with left ventricular hypertrophy (LVH) and geometric remodeling in essential hypertension (EH). METHODS: We enrolled 483 patients (aged 18-80 years; 51.35% female). sST2 measurements and echocardiographic analyses were performed. RESULTS: Stepwise multiple linear regression analysis showed significant associations between sST2, left ventricular (LV) mass, and LV mass index. The prevalence of LVH and concentric hypertrophy (CH) increased with higher sST2 grade levels (p for trend<0.05). Logistic regression analysis suggested that the highest tertile of sST2 was significantly associated with increased LVH risk, compared with the lowest tertile (multivariate-adjusted odds ratio [OR] of highest group: 6.61; p<0.001). Similar results were observed in the left ventricular geometric remodeling; the highest tertile of sST2 was significantly associated with increased CH risk (multivariate-adjusted OR of highest group: 5.80; p<0.001). The receiver operating characteristic analysis results revealed that sST2 had potential predictive value for LVH (area under the curve [AUC]: 0.752, 95% confidence interval [CI]: 0.704-0.800) and CH (AUC: 0.750, 95% CI: 0.699-0.802) in patients with EH. CONCLUSIONS: High sST2 level is strongly related to LVH and CH in patients with EH and can be used as a biomarker for the diagnosis and risk assessment of hypertensive heart disease.

Application of 3D­printed porous titanium interbody fusion cage vs. polyether ether ketone interbody fusion cage in anterior cervical discectomy and fusion: A systematic review and meta­analysis update.

The present study aimed to compare the differences between 3D-printed porous titanium and polyether ether ketone (PEEK) interbody fusion cages for anterior cervical discectomy and fusion (ACDF). Literature on the application of 3D-printed porous titanium and PEEK interbody fusion cages for ACDF was searched in the PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang and VIP databases. A total of 1,181 articles were retrieved and 12 were finally included. The Cochrane bias risk assessment criteria and Newcastle-Ottawa scale were used for quality evaluation and Review Manager 5.4 was used for data analysis. The 3D cage group was superior to the PEEK cage group in terms of operative time [mean difference (MD): -7.68; 95% confidence interval (CI): -11.08, -4.29; P<0.00001], intraoperative blood loss (MD: -6.17; 95%CI: -10.56, -1.78; P=0.006), hospitalization time (MD: -0.57; 95%CI: -0.86, -0.28: P=0.0001), postoperative complications [odds ratio (OR): 0.35; 95%CI: 0.15, 0.80; P=0.01], C2-7 Cobb angle (MD: 2.85; 95%CI: 1.45, 4.24; P<0.0001), intervertebral space height (MD: 1.20; 95%CI: 0.54, 1.87; P=0.0004), Japanese Orthopaedic Association Assessment of Treatment (MD: 0.69; 95%CI: 0.24, 1.15; P=0.003) and visual analogue scale score (MD: -0.43; 95%CI: -0.78, -0.07; P=0.02). The difference was statistically significant, while there was no significant difference between the two groups in terms of fusion rate (OR: 1.74; 95%CI: 0.71, 4.27; P=0.23). The use of 3D-printed porous titanium interbody fusion cage in ACDF has the advantages of short operation time, less bleeding loss, shorter hospitalization time and fewer postoperative complications. It can better maintain the cervical curvature and intervertebral height, relieve pain and accelerate postoperative functional recovery.

Low muscle density in children with osteogenesis imperfecta using opportunistic low-dose chest CT: a case-control study.

BACKGROUND: The aim of the study was to investigate the muscle differences in children with osteogenesis imperfecta (OI) using opportunistic low-dose chest CT and to compare different methods for the segmentation of muscle in children. METHODS: This single center retrospective study enrolled children with OI and controls undergoing opportunistic low-dose chest CT obtained during the COVID pandemic. From the CT images, muscle size (cross-sectional area) and density (mean Hounsfield Units [HU]) of the trunk muscles were measured at the mid-T4 and the mid-T10 level using two methods, the fixed thresholds and the Gaussian mixture model. The Bland-Altman method was also used to compute the strength of agreement between two methods. Comparison of muscle results between OI and controls were analyzed with Student t tests. RESULTS: 20 children with OI (mean age, 9.1 ± 3.3 years, 15 males) and 40 age- and sex-matched controls were enrolled. Mean differences between two methods were good. Children with OI had lower T4 and T10 muscle density than controls measured by the fixed thresholds (41.2 HU vs. 48.0 HU, p < 0.01; 37.3 HU vs. 45.9 HU, p < 0.01). However, children with OI had lower T4 muscle size, T4 muscle density, T10 muscle size and T10 muscle density than controls measured by the Gaussian mixture model (110.9 vs. 127.2 cm2, p = 0.03; 44.6 HU vs. 51.3 HU, p < 0.01; 72.6 vs. 88.0 cm2, p = 0.01; 41.6 HU vs. 50.3 HU, p < 0.01, respectively). CONCLUSIONS: Children with OI had lower trunk muscle density indicating that OI might also impair muscle quality. Moreover, the fixed thresholds may not be suitable for segmentation of muscle in children.

Association of IL­6 and MMP­3 gene polymorphisms with adolescent idiopathic scoliosis: A systematic review and meta­analysis.

The pathogenesis of adolescent idiopathic scoliosis (AIS) remains unclear. It has been found that interleukin-6 (IL-6) rs1800795 locus and matrix metalloproteinase-3 (MMP-3) rs3025058 locus gene polymorphisms may be associated with AIS susceptibility, which has been controversial and needs to be further confirmed by updated meta-analysis. The aim of the present study was to investigate the association of MMP-3 rs3025058 and IL-6 rs1800795 single nucleotide polymorphisms (SNPs) with susceptibility to AIS. All relevant articles that met the criteria were retrieved and included, and the publication dates were limited from January 2005 to December 2023. The allele frequencies and different genotype frequencies of IL-6 rs1800795 and MMP-3 rs3025058 loci in each study were extracted and statistically analyzed by ReviewManager 5.4 software, and the odds ratio (OR) and 95% confidence interval (95% CI) of different genetic models were calculated. The results of the meta-analysis showed that there was no significant association between the gene polymorphism of IL-6 rs1800795 locus and the pathogenesis of AIS. The allele 5A and genotype 5A5A of MMP-3 rs3025058 SNP were associated with AIS susceptibility (5A vs. 6A, OR=1.18; 95% CI, 1.04-1.33; 5A5A vs. 6A6A, OR=1.65; 95% CI, 1.23-2.21; and 5A5A vs. 5A6A + 6A6A, OR=1.54; 95% CI, 1.19-1.99). Results of subgroup analysis revealed that the allele 5A and genotype 5A5A of MMP-3 rs3025058 SNP were associated with AIS susceptibility in the Caucasian population, and the susceptibility of AIS was associated with the genotype 5A5A of MMP-3 rs3025058 SNP in an Asian population. There was no significant association between the gene polymorphism of IL-6 rs1800795 locus and the pathogenesis of AIS, while the allele 5A of MMP-3 rs3025058 locus was associated with the susceptibility to AIS, especially in the Caucasian population.

Comparison between minimally invasive and open transforaminal lumbar interbody fusion for the treatment of multi­segmental lumbar degenerative disease: A systematic evaluation and meta­analysis.

The present study aimed to compare the differences between minimally invasive transforaminal lumbar fusion (MIS-TLIF) and open transforaminal lumbar fusion (TLIF) for multi-segmental lumbar degenerative disease regarding intraoperative indices and postoperative outcomes. PubMed, Web of Science, Embase, CNKI, Wanfang and VIP databases were searched for literature on MIS-TLIF and open TLIF in treating multi-segmental lumbar degenerative diseases. Of the 1,608 articles retrieved, 10 were included for final analysis. The Newcastle-Ottawa Scale and Review Manager 5.4 were used for quality evaluation and data analysis, respectively. The MIS-TLIF group was superior to the open TLIF group regarding intraoperative blood loss [95% confidence interval (CI): -254.33,-157.86; P<0.00001], postoperative in-bed time (95%CI: -3.49,-2.76; P<0.00001), hospitalization time (95%CI: -5.14,-1.78; P<0.0001) and postoperative leg pain Visual Analog Scale score (95%CI: -0.27,-0.13; P<0.00001). The fluoroscopy frequency for MIS-TLIF (95%CI: 2.07,6.12; P<0.0001) was significantly higher than that for open TLIF. The two groups had no significant differences in operation time, postoperative drainage volume, postoperative complications, fusion rate, or Oswestry Disability Index score. In treating multi-segmental lumbar degenerative diseases, MIS-TLIF has the advantages of less blood loss, shorter bedtime and hospitalization time and improved early postoperative efficacy; however, open TLIF has a lower fluoroscopy frequency.

Cirrhotic-extracellular matrix attenuates aPD-1 treatment response by initiating immunosuppressive neutrophil extracellular traps formation in hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is closely associatedwith chronic liver diseases, particularly liver cirrhosis, which has an altered extracellular matrix (ECM) composition. The influence and its mechanism of the cirrhotic-ECM on the response of HCC to immune checkpoint inhibitor (ICI) remains less clarified. METHODS: In silico, proteomic and pathological assessment of alteration of cirrhotic-ECM were applied in clinical cohort. Multiple pre-clinical models with ECM manipulation were used to evaluate cirrhotic-ECM's effect on ICI treatment. In silico, flow cytometry and IHC were applied to explore how cirrhotic-ECM affect HCC microenvironment. In vitro and in vivo experiments were carried out to identify the mechanism of how cirrhotic-ECM undermined ICI treatment. RESULTS: We defined "a pro-tumor cirrhotic-ECM" which was featured as the up-regulation of collagen type 1 (Col1). Cirrhotic-ECM/Col1 was closely related to impaired T cell function and limited anti PD-1 (aPD-1) response of HCC patients from the TCGA pan cancer cohort and the authors' institution, as well as in multiple pre-clinical models. Mechanically, cirrhotic-ECM/Col1 orchestrated an immunosuppressive microenvironment (TME) by triggering Col1-DDR1-NFκB-CXCL8 axis, which initiated neutrophil extracellular traps (NETs) formation to shield HCC cells from attacking T cells and impede approaching T cells. Nilotinib, an inhibitor of DDR1, reversed the neutrophils/NETs dominant TME and efficiently enhanced the response of HCC to aPD-1. CONCLUSIONS: Cirrhotic-ECM modulated a NETs enriched TME in HCC, produced an immune suppressive TME and weakened ICI efficiency. Col1 receptor DDR1 could be a potential target synergically used with ICI to overcome ECM mediated ICI resistance. These provide a mechanical insight and novel strategy to overcome the ICI resistance of HCC.

Unraveling the genetic basis of grain number-related traits in a wheat-Agropyron cristatum introgressed line through high-resolution linkage mapping.

BACKGROUND: Grain number per spike (GNS) is a pivotal determinant of grain yield in wheat. Pubing 3228 (PB3228), a wheat-Agropyron cristatum germplasm, exhibits a notably higher GNS. RESULTS: In this study, we developed a recombinant inbred line (RIL) population derived from PB3228/Gao8901 (PG-RIL) and constructed a high-density genetic map comprising 101,136 loci, spanning 4357.3 cM using the Wheat 660 K SNP array. The genetic map demonstrated high collinearity with the wheat assembly IWGSC RefSeq v1.0. Traits related to grain number and spikelet number per spike were evaluated in seven environments for quantitative trait locus (QTL) analysis. Five environmentally stable QTLs were detected in at least three environments. Among these, two major QTLs, QGns-4A.2 and QGns-1A.1, associated with GNS, exhibited positive alleles contributed by PB3228. Further, the conditional QTL analysis revealed a predominant contribution of PB3228 to the GNS QTLs, with both grain number per spikelet (GNSL) and spikelet number per spike (SNS) contributing to the overall GNS trait. Four kompetitive allele-specific PCR (KASP) markers that linked to QGns-4A.2 and QGns-1A.1 were developed and found to be effective in verifying the QTL effect within a diversity panel. Compared to previous studies, QGns-4A.2 exhibited stability across different trials, while QGns-1A.1 represents a novel QTL. The results from unconditional and conditional QTL analyses are valuable for dissecting the genetic contribution of the component traits to GNS at the individual QTL level and for understanding the genetic basis of the superior grain number character in PB3228. The KASP markers can be utilized in marker-assisted selection for enhancing GNS. CONCLUSIONS: Five environmentally stable QTLs related to grain number and spikelet number per spike were identified. PB3228 contributed to the majority of the QTLs associated with GNS.

The association of growth differentiation factor 5 rs143383 gene polymorphism with osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: Osteoarthritis (OA) is caused by a complex set of pathophysiological factors. The genetic factors involved in the occurrence and progress of the disease have been widely discussed by scholars. It was found that growth differentiation factor 5 (GDF5) gene polymorphisms may be linked to OA susceptibility, which has been controversial and needs to be further confirmed by an updated meta-analysis. OBJECTIVES: We examined the association between GDF5 rs143383 single nucleotide polymorphism (SNP) and OA susceptibility. METHODS: All relevant articles that met the criteria are retrieved and included, and the search deadline is June 2022. The allele frequencies and different genotype frequencies of GDF5 rs143383 loci in each study were extracted and statistically analyzed by R4.1.3 software, and the different genetic models were analyzed based on their odds ratio (OR) and 95% confidence interval (CI). RESULTS: The meta-analysis explained that GDF5 rs143383 SNP was crucial correlated with OA in all patients with OA of knee, hip and hand. The codominant gene model in the whole crowd (OR = 1.17, 95% CI 1.07-1.27, P < 0.01) enlightened that OA was vitally associated with GDF5 gene polymorphism. At the same time, we did a subgroup analysis based on ethnicity. The codominant gene model (OR = 1.31, 95% CI 1.12-1.53, P < 0.01) in Asian population, the codominant homozygote model (OR = 1.28, 95% CI 1.14-1.43), codominant heterozygote gene model (OR = 1.12, 95% CI 1.01-1.23, P = 0.02), and dominant gene model (OR = 1.19, 95% CI 1.09-1.31, P < 0.01) in Caucasian are analyzed by subgroup analysis. It means that there is a momentous relationship between the GDF5rs143383 gene polymorphism and OA, especially among Caucasians. In addition, we also discussed different types of OA separately and discover that the GDF5rs143383 gene polymorphism was relevant for knee osteoarthritis (KOA) and hand osteoarthritis, and it was more significant in the Caucasian population. But due to the high heterogeneity in hip osteoarthritis, it could not be accurately concluded. Furthermore, we also analyzed the osteoarthritis of different genders and found that the GDF5 rs143383 SNP was associated with both men and women and was still significant in the Caucasian population. CONCLUSION: We found a close association between osteoarthritis and GDF5rs143383SNP in this study. From the analysis of each group, we got the same conclusion in KOA and hand OA, but which need further verification in hip OA. Considering gender, we found a close relationship between GDF5 rs143383 SNP and OA of the knee, hip and hand, both for men and women. This conclusion is more obvious in Caucasian people.

A rare presentation of Maffucci syndrome: A case report and literature review.

Maffucci syndrome is an extremely rare disease which can manifest symptoms as early as childhood. It is estimated that there have been <300 cases reported globally; however, this number is likely to be an underestimate. Maffucci syndrome is characterized by multiple enchondromas and soft tissue hemangiomas, which can cause growth and developmental malformations. In addition to bone deformities, pathological fractures and a loss of mobility, patients with Maffucci syndrome may develop secondary central chondrosarcoma and have a higher risk of developing non-skeletal malignant tumors, such as gliomas and mesenchymal ovarian tumors. The present study provides information for clinicians about this disease through the use of imaging, physical examinations, clinical manifestations and the treatment strategy used. There is need to summarize the existing cases of this disease around the world and produce an effective framework for the diagnosis, treatment and prevention of Maffucci syndrome, in order to better understand this disease. The present study reports on a 15-year-old male diagnosed with Maffucci syndrome. . Due to the risk of malignant tumor development in the absence of effective treatment, regular and careful observation through monitoring of tumor markers and imaging studies is important for patients with Maffucci syndrome. As cases of this disease are rare and case data is limited, it is difficult to create a clear treatment plan. There is an urgent need to establish a case database of Maffucci syndrome patients and explore its pathogenesis for early diagnosis, treatment and prevention of disease.

The development and application of pediatric complicated appendicitis prediction model.

BACKGROUND: Acute appendicitis in children refers to the acute inflammation of the appendix, which accounts for 20% ∼ 30% of cases of acute abdomen in pediatric surgery. OBJECTIVE: This study aimed to establish a decision tree model of complicated appendicitis in children using appendiceal ultrasound combined with an inflammatory index and evaluated its clinical efficacy in pediatric patients. METHODS: A total of 395 children admitted to the Emergency Department of the Shanghai Children's Hospital from January 2018 to December 2021 and diagnosed with appendicitis by postoperative pathology were retrospectively analyzed. According to the postoperative pathology, the children were divided into a complicated and non-complicated appendicitis group, respectively. Routine laboratory inflammatory indicators, including white blood cell count, N(%), neutrophil (Neu) count, Neu/lymphocyte ratio (NLR), C-reactive protein (CRP), and procalcitonin were collected from the two groups. Collecting data on ultrasound examination of the appendix includes whether the appendix diameter is thickened, whether the echogenicity of the mesenteric rim surrounding the appendix is enhanced, whether there is rich blood supply in the appendix, and whether there are fecaliths in the appendix lumen. The risk factors for complicated appendicitis were screened out by univariate and multivariate logistic regression analyses, the binary logistic regression prediction and decision tree models were established, respectively, and the receiver operating characteristic (ROC) curve was used to verify the accuracy of the two prediction models. RESULTS: Binary logistic regression analysis showed that CRP, NLR, the presence of an appendicolith, and peripheral retina echo enhancement were independent risk factors for complicated appendicitis in children (P< 0.05). The decision tree model had an overall accuracy of 79%, an area under the ROC curve (AUC) of 0.809 (95% confidence interval [CI] 0.780-0.865), and sensitivity and specificity of 71.3% and 77.7%, respectively. The logistic regression model had an overall accuracy of 74.9%, an AUC value of 0.823 (95% CI, 0.765-0.853), a sensitivity value of 80.3%, and a specificity of 71.8%. CONCLUSION: This predictive model, based on ultrasound of the appendix combined with inflammatory markers, provides a useful method to assist pediatric emergency physicians in diagnosing childhood appendicitis. The decision tree model reflected the interaction of various indexes, and the model was simple, intuitive, and effective.

Efficacy and safety of unilateral biportal endoscopy compared with microscopic decompression in the treatment of lumbar spinal stenosis: A systematic review and updated meta­analysis.

The incidence of lumbar spinal stenosis is increasing annually, and with an ever-aging population and longer life expectancies, this trend will further continue. It is hoped that a more effective treatment can be found so that the patients can be relieved of their pain. The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of unilateral biportal endoscopic surgery (UBE) and microscopic decompression surgery (MD) for the treatment of lumbar spinal stenosis. A literature search of related studies published until April 2022 was performed using PubMed, EMBASE, Cochrane Library, Web of Science, ClinicalTrials.gov, Google Scholar, China National Knowledge Infrastructure (CNKI), and other databases. After filtering of references, 12 eligible studies were identified that compared UBE with MD as a treatment for lumbar spinal stenosis. Data were extracted and analysed using R. A total of 12 articles (four randomized controlled and eight cohort studies) were included, with a total of 1,067 patients: 250 men and 249 women in the UBE group and 290 men and 278 women in the MD group. The meta-analysis showed that the mean intraoperative blood loss in the UBE group [standardized mean difference (SMD)=-2.10, 95% confidence interval (CI) (-3.97, -0.23), P=0.03] was lower than that in the MD group. The postoperative Visual analogue scale (VAS) score for back pain [SMD=-0.52, 95% CI (-0.76, -0.27), P<0.01], leg pain [SMD=-0.30, 95% CI (-0.51, -0.08), P<0.01], postoperative Oswestry disability index [(ODI); SMD=-0.25, 95% CI (-0.48, -0.03), P=0.03], and postoperative C-reactive protein [(CRP); odds ratio (OR)=-0.92, 95% CI (-1.80, 0.03), P=0.04] were lower than those in the MD group. Complications (OR=0.60, 95% CI (0.37, 0.98), P=0.04) and hospital stay (SMD=-1.84, 95% CI (-2.85, 0.83), P <0.01] were also lesser in the UBE group than in the MD group. UBE was preferable to that in the MD group according to the modified MacNab score [OR=2.28, 95% CI (1.28, 4.06), P<0.01]. No significant differences were observed in the operation times between the groups. UBE surgery was found to be a better option for the treatment of lumbar spinal stenosis than MD surgery.

[Ultrasonographic and clinical features of common testicular germ cell tumors in children].

OBJECTIVE: To study the ultrasonographic manifestations and clinical features of common pediatric testicular germ cell tumors (TGCT) in children. METHODS: We retrospectively analyzed the laboratory, ultrasonographic and clinical data on 92 children with TGCT diagnosed in Shanghai Children's Hospital from March 2013 to January 2019, and investigated the values of the serum alpha-fetoprotein (AFP) level and maximum diameter of tumors in the diagnosis of benign and malignant tumors using the ROC curve. RESULTS: Of the 92 cases of pediatric TGCT, 64 (69.6%) were pathologically confirmed as benign tumors, including 40 cases of teratoma (62.5%), 18 cases of epidermoid cyst (28.1%) and 6 cases of dermoid cyst (9.4%), and the other 28 (30.4%) as malignant neoplasms, including 26 cases of yolk sac tumor (YST, 92.9%) and 2 cases of mixed germ cell tumor (MGCT, 7.1%). Ultrasonography showed that 62.5% of the teratomas were cystic-solid mixed (25/40) and 32.5% solid masses (12/40), that 33.3% of the epidermoid cysts exhibited a typical sign of "onion ring" (6/18) and 22.2% that of capsular calcification (4/18), and that 42.3% of the YSTs displayed isoechoic (11/26), 30.9% hypoechoic (8/26) solid masses without calcium and 26.9% cystic anechoic lesions (7/26). Color Doppler blood flow imaging manifested abundant blood flow signals in most of the YSTs (25/26, 96.2%) but none in either the epidermoid or the dermoid cysts. The area under the ROC curve (AUC) of the serum AFP value was 0.985, with an optimal cutoff value of 124.2 ng/ml, and the sensitivity and specificity of AFP in the diagnosis of benign and malignant tumors were 92.9% and 93.7%, respectively. The AUC of the maximum diameter of the tumors was 0.796, with an optimal cutoff value of 2.7 cm, and the sensitivity and specificity of the maximum diameter of the tumors in the diagnosis of benign and malignant neoplasms were 57.1% and 93.7%, respectively. CONCLUSIONS: Ultrasonographic images have different characteristic manifestations for different pathological types of pediatric TGCT. Pediatric TGCT has a good prognosis and radical orchiectomy should be considered for the treatment of the tumors with serum AFP ≥ 124.2 ng/ml and a diameter ≥ 2.7 cm.

Correction to: Intrathecal Epigallocatechin Gallate Treatment Improves Functional Recovery After Spinal Cord Injury by Upregulating the Expression of BDNF and GDNF.

Since the publication of our article [1] it has come to our attention that there was an error in Figure 4 in which the bottom left immunochemistry panel Control/Bax was a duplication of the bottom right immunohistochemistry panel EGCG/GDNF in Figure 3.

Robotic navigation during spine surgery.

Introduction: Potential complications associated with screw malposition may result in neurological deficits or vascular injuries. Spine surgery has significantly developed under the assistance of technological progress. The advantages of applying robotic technology in spine surgery include the possibility of improving screw accuracy, reducing complications, decreasing fluoroscopy use.Areas covered: We critically evaluated the current literature on the radiographic and clinical outcomes of robotic-assisted spine surgery, including accuracy, radiation exposure, operative time, and complication rates.Expert opinion: Robotic-assisted spine surgery shows promising results and has the potentials for further investigations. The robot-assisted spine surgery is appeared to be more accurate in pedicle screw placement than the free-hand technique. In general, the robot-assisted technique is associated with shorter radiation exposure time but longer operative time than free-hand technique. For higher accuracy of robotic-assisted spine surgery, technical advancement and high-quality researches are needed. Artificial intelligent technology, decompression function, and higher accuracy are the directions for the development of robotic-assisted spine surgery.

Rate and Risk Factors of Superior Facet Joint Violation during Cortical Bone Trajectory Screw Placement: A Comparison of Robot-Assisted Approach with a Conventional Technique.

OBJECTIVE: To compare the incidence and risk factors of superior facet joint violation (FJV) during cortical bone trajectory screw placement in robot-assisted approach versus conventional technique. METHODS: A retrospective study, including 69 patients having cortical bone trajectory (CBT) screw instrumentation for symptomatic degenerated diseases or trauma, was conducted between June 2015 to January 2019. All patients underwent CBT surgery performed by the same team of experienced surgeons. Patients were randomly divided into two groups: a conventional group (CG, 46 cases) and a robot group (RG, 23 cases). The surgical robotic system was used for screw instrumentation in the robot group and the traditional screw instrumentation with fluoroscopic guidance was used in the conventional group. Cortical screws followed a medio-to-lateral path in the transverse plane and a caudal-to-cephalad path in the sagittal plane. Preoperative and postoperative computed tomography (CT) scans were obtained to determine the degree and incidence of FJV. The violation status of facet joint was evaluated according to the modified classification: grade 0, no violation; grade 1, screw shaft, screw head or rod within 1 mm of or abutting the facet joint, but did not enter the articular facet joint; grade 2, screw shaft, screw head or rod clearly in the facet joint. The following factors that may contribute to the occurrence of FJV were analyzed: age, sex, body mass index (BMI), proximal fusion level, fusion length, the side of screw, preoperative vertebral slip, superior facet angle, and degenerative scoliosis. The chi-squared test and Student's t-test were used for analysis of the variables for significance (P < 0.05). RESULTS: FJV occurred in 41.3% of patients in CG and 17.3% of patients in RG. A chi-squared analysis revealed a significantly lower rate of FJV for RG compared with CG (P = 0.04). In the CG, 17 of the 109 cephalad screws were grade 1 (15.6%), and five were grade 2 (4.6%). In the RG, three of the 46 cephalad screws were grade 1 (6.5%), and three were grade 2 (6.5%). There was a statistically significant difference in the incidence of FJV between the left and right screw with fluoroscopy-assisted CBT screw instrumentation (P < 0.05). A significant correlation between scoliosis with the FJV was found in CG (P < 0.05) and in RG (P < 0.05). With regard to superior facet angle, a measurement ≥45° was a significant risk factor of FJV in CG (P < 0.05) and in RG (P < 0.05). CONCLUSIONS: A robot-assisted approach could reduce the incidence of FJV compared with the conventional approach in CBT technique.

Comparison of Superior-Level Facet Joint Violations Between Robot-Assisted Percutaneous Pedicle Screw Placement and Conventional Open Fluoroscopic-Guided Pedicle Screw Placement.

OBJECTIVE: To compare the superior-level facet joint violations (FJV) between robot-assisted (RA) percutaneous pedicle screw placement and conventional open fluoroscopic-guided (FG) pedicle screw placement in a prospective cohort study. METHODS: This was a prospective cohort study without randomization. One-hundred patients scheduled to undergo RA (n = 50) or FG (n = 50) transforaminal lumbar interbody fusion were included from February 2016 to May 2018. The grade of FJV, the distance between pedicle screws and the corresponding proximal facet joint, and intra-pedicle accuracy of the top screw were evaluated based on postoperative CT scan. Patient demographics, perioperative outcomes, and radiation exposure were recorded and compared. Perioperative outcomes include surgical time, intraoperative blood loss, postoperative length of stay, conversion, and revision surgeries. RESULTS: Of the 100 screws in the RA group, 4 violated the proximal facet joint, while 26 of 100 in the FG group had FJV (P = 0.000). In the RA group, 3 and 1 screws were classified as grade 1 and 2, respectively. Of the 26 FJV screws in the FG group, 17 screws were scored as grade 1, 6 screws were grade 2, and 3 screws were grade 3. Significantly more severe FJV were noted in the FG group than in the RA group (P = 0.000). There was a statistically significant difference between RA and FG for overall violation grade (0.05 vs 0.38, P = 0.000). The average distance of pedicle screws from facet joints in the RA group (4.16 ± 2.60 mm) was larger than that in the FG group (1.92 ± 1.55 mm; P = 0.000). For intra-pedicle accuracy, the rate of perfect screw position was greater in the RA group than in the FG group (85% vs 71%; P = 0.017). No statistically significant difference was found between the clinically acceptable screws between groups (P = 0.279). The radiation dose was higher in the FG group (30.3 ± 11.3 vs 65.3 ± 28.3 µSv; P = 0.000). The operative time in the RA group was significantly longer (184.7 ± 54.3 vs 117.8 ± 36.9 min; P = 0.000). CONCLUSIONS: Compared to the open FG technique, minimally invasive RA spine surgery was associated with fewer proximal facet joint violations, larger facet to screw distance, and higher intra-pedicle accuracy.

Comparison of the One-Time Accuracy of Simulated Freehand and Navigation Simulated Pedicle Screw Insertion.

OBJECTIVE: To compare one-time accuracy rate between simulated freehand (SFH) and navigation simulated (NS) pedicle screw insertion, assuming no second chance to correct screws. METHODS: A simulated, comparative, cross-sectional study was conducted on 69 patients undergoing lumbar spine surgery. An intraoperative registration system captured the planned point of entry and trajectory of pedicle screws for both SFH under direct visualization and NS under navigation-aided visualization. Pedicle screw insertion was simulated for each captured image (370 screws) using Surgimap. Rajasekaran's method helped evaluate the point of entry accuracy and trajectory. RESULTS: Accuracy rate was better for the NS method (97.8%) than for the SFH method (63.8%). Of 370 screws in the SFH group, 134 penetrated the cortex, with 31 resulting in >4 mm penetration. Of 370 screws in the NS group, 8 penetrated the cortex, <4 mm penetration. Of 134 misplaced screws in the SFH group, 64 were due to error in the point of entry, 63 were due to error in the trajectory angle, and 7 were due to both errors. Of 8 errors in the NS group, 7 were due to the point of entry. CONCLUSIONS: Intraoperative navigation had significantly better one-time accuracy of pedicle screw insertion than freehand insertion and should be used to avoid injury to the pedicle and surrounding tissue from screw reinsertion.

Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease.

OBJECTIVE: To compare the clinical accuracy and perioperative outcomes for pedicle screw placement in transforaminal lumbar interbody fusion (TLIF) between the robot-assisted (RA) technique and fluoroscopy-guided (FG) technique. METHODS: Seventy-seven patients scheduled to undergo RA (n = 43) and FG (n = 44) TLIF surgery were included. Patient demographics, radiographic accuracy, and perioperative outcomes were recorded and compared. The accuracy of pedicle screw placement was according to the Gertzbein and Robbins scale and facet joint violation. Perioperative outcomes mainly included operative time, radiation exposure, and revisions. RESULTS: Of the 176 screws in the RA group, 164 screws were grade A, and 9, 2, and 1 screws were grades B, C, and D, respectively. Of the 204 screws in the FG group, 175 screws were grade A, with 16 screws scored as grade B, 8 screws scored as grade C, 3 screws scored as grade D, and 2 screws scored as grade E. The rate of perfect screw position (grade A) was higher in the RA group than in the FG group (93.2% vs. 85.8%, respectively; P = 0.020). In the FG group, 191 screws (93.6%) were clinically acceptable (groups A and B), whereas more acceptable screw positions were achieved in the RA group (98.3%; P = 0.024). Fewer screws in the RA group violated the proximal facet joint (5 vs. 24 screws, respectively; P = 0.001). The radiation dose was lower in the RA group (25.9 ± 14.2 vs. 70.5 ± 27.3 µSv, respectively; P < 0.001). Two screws in the FG group required a revision, but no revision was required in the RA group. CONCLUSIONS: RA pedicle screw placement is an accurate and safe procedure in TLIF for lumbar degenerative disease.

Computer-assisted, minimally invasive transforaminal lumbar interbody fusion: One surgeon's learning curve A STROBE-compliant article.

Minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) is a challenging technique with a long learning curve. We combined computer-assisted navigation and MI TLIF (CAMISS TLIF) to treat lumbar degenerative disease. This study aimed to evaluate the learning curve associated with computer-assisted navigation MI spine surgery (CAMISS) and TLIF for the surgical treatment of lumbar degenerative disease. Seventy four consecutive patients with lumbar degenerative disease underwent CAMISS TLIF between March 2011 and May 2015; all surgeries were performed by a single surgeon. According to the plateau of the asymptote, the initial 25 patients constituted the early group and the remaining patients comprised the latter group. The clinical evaluation data included operative times, anesthesia times, intraoperative blood losses, days until ambulation, postoperative hospital stays, visual analog scale (VAS) leg and back pain scores, Oswestry disability index (ODI) values, Macnab outcome scale scores, complications, radiological outcomes, and rates of conversion to open surgery. The complexity of the cases increased over the series, but the complication rate decreased (12.00%-6.12%). There were significant differences between the early and late groups with respect to the average surgical times and durations of anesthesia, but no differences in intraoperative blood losses, days until ambulation, postoperative hospital stays, complication rate, VAS, ODI, Macnab outcome scale scores, or solid fusion rates. There was no need for conversion to open procedures in either group. Our study showed that a plateau asymptote for CAMISS TLIF was reached after 25 operations. The later patients experienced shorter operative times and anesthesia durations.

[Clinical and ultrasonographic features of testis tumor in children of different ages].

OBJECTIVE: To explore the ultrasonographic characteristics of testis tumor in children of different ages. METHODS: We retrospectively analyzed the clinical data, ultrasonographic results, surgical methods and pathological findings of 76 children with testis tumor treated in Shanghai Children's Hospital between April 2013 and March 2018. According to the age at the first diagnosis, we divided the patients into a 0－4 yr (n = 57) and a 5－12 yr group (n = 19), and compared the clinical manifestations, tumor markers, ultrasonographic features such as the tumor size, echogenicity, calcification and color flow images, pathological findings, and surgical methods between the two groups of patients. RESULTS: Benign tumors were found in 73.4% of the 76 children and in 100% of the patients in the 5－12 yr group, with epidermoid cyst as the most common type (52.6% ï¼»10/19ï¼½), 47.4% (9/19) found accidentally, 94.7% (9/19) without elevation of the alpha-fetoprotein (AFP) level, and 94.7% (9/19) treated by testis-sparing surgery (TSS). In the 0－4 yr group, teratoma and yolk sac tumors were the most common and 87.7% (50/57) of the cases were characterized by painless scrotal swelling with a normal or elevated AFP level, treated by TSS or radical orchiectomy. There were statistically significant differences between the two groups of patients in the clinical manifestations, AFP values, pathological findings and surgical methods (all P < 0.05), but not in the ultrasonographic results, mostly solid or mixed cystic-solid masses (χ2 = 0.908, P = 0.635). The maximum diameter of the tumors was smaller and the volume of the healthy contralateral testis was greater in the 5－12 yr than in the 0－4 yr group (t = 2.673 and 2.858, P = 0.009 and 0.010). The proportions of the tumors with calcification and those with grade 0 blood flow were significantly higher in the former than in the latter group (χ2 = 4.825 and 12.298, P = 0.028 and 0.006). CONCLUSIONS: Testis tumors have different clinical and ultrasonographic features in children of different age groups, malignancy mostly in 0- to 4-year-olds while benignancy commonly in 5- to 12-year-olds, frequently with normal AFP, calcification, and less abundant color blood flow. TSS is recommended for the treatment of testis tumor with serum AFP negative in 5－12 years old children.