Multi-angle laser device improves novice learning of C-arm fluoroscopy for lumbar spine surgery.

PURPOSE: This study aims to evaluate the efficacy and satisfaction of using a multi-angle laser device (MLD) for C-arm fluoroscopy to assist novice learners during lumbar spine surgery. METHODS: Forty novice learners were randomly assigned to Group A using an MLD-equipped C-arm or Group B using a traditional C-arm. Both groups performed X-ray fluoroscopy on a lumbar spine model in supine and rotated positions. Time, number of shots, and deviation from the target were compared. A questionnaire was used to assess the learning experience. RESULTS: Group A required less time (13.66 vs. 25.63 min), and fewer shots (15.05 vs. 32.50), and had a smaller deviation (22.9% vs. 61.5%) than Group B (all p<0.05). The questionnaire revealed higher scores in Group A for comfort, efficiency, and knowledge mastery (all p<0.05). CONCLUSION: The MLD significantly improves novice learning of C-arm fluoroscopy during lumbar spine surgery.

Computerised modified paramedian approach technique versus conventional midline approach technique of lumbar puncture: a randomised control trial protocol.

INTRODUCTION: The lumbar puncture (LP) technique is widely used for diagnostic and therapeutic purposes. In recent years, the paramedian approach technique (PAT) has gained increasing interest due to its advantages over the conventional midline approach technique (MAT) that has been traditionally employed in clinical practice for LP. However, there have been inconsistent discussions regarding the efficacy of different LP techniques. Based on digital virtual human and computer simulation techniques, a new approach called computerised modified PAT (CMPAT) was proposed. Therefore, the aim of this study is to discuss a randomised controlled trial (RCT) protocol to investigate and compare the effects of CMPAT and MAT in patients undergoing LP. METHODS AND ANALYSIS: We will conduct a prospective, multicentre RCT. The study will recruit 84 patients aged 18-99 years who require LP. Participants will be randomly assigned to either the CMPAT treatment group (group A) or the MAT treatment group (group B). The primary outcome measure will be the number of needle insertion attempts required for a successful LP. Secondary outcomes will include the puncture success rate, pain assessment in the back, head, and legs, and the occurrence of complications. The measurement of these secondary outcomes will be taken during the procedure, as well as at specific time points: 30 min, 6 hours, 1 day, 3 days, 7 days, 2 weeks and 4 weeks after the procedure. Pain levels will be assessed using a Numerical Rating Scale. ETHICS AND DISSEMINATION: Ethical approval (2022YF052-01) has been obtained from the Ethics Committee of Fujian Medical University Union Hospital, Fuzhou, China. The research findings will be published in an international peer-reviewed scientific journal and presented at scientific conferences. TRIAL REGISTRATION NUMBER: ChiCTR2300067937.

Quantitative anatomical analysis of lumbar interspaces based on 3D CT imaging: optimized segment selection for lumbar puncture in different age groups.

BACKGROUND: Optimal lumbar puncture segment selection remains controversial. This study aims to analyze anatomical differences among L3-4, L4-5, and L5-S1 segments across age groups and provide quantitative evidence for optimized selection. METHODS: 80 cases of CT images were collected with patients aged 10-80 years old. Threedimensional models containing L3-S1 vertebrae, dural sac, and nerve roots were reconstructed. Computer simulation determined the optimal puncture angles for the L3-4, L4-5, and L5-S1 segments. The effective dural sac area (ALDS), traversing nerve root area (ATNR), and area of the lumbar inter-laminar space (ALILS) were measured. Puncture efficacy ratio (ALDS/ALILS) and nerve injury risk ratio (ATNR/ALILS) were calculated. Cases were divided into four groups: A (10-20 years), B (21-40 years), C (41-60 years), and D (61-80 years). Statistical analysis was performed using SPSS. RESULTS: 1) ALDS was similar among segments; 2) ATNR was greatest at L5-S1; 3) ALILS was greatest at L5-S1; 4) Puncture efficacy ratio was highest at L3-4 and lowest at L5-S1; 5) Nerve injury risk was highest at L5-S1. In group D, L5-S1 ALDS was larger than L3-4 and L4-5. ALDS decreased after age 40. Age variations were minimal across parameters. CONCLUSION: The comprehensive analysis demonstrated L3-4 as the optimal first-choice segment for ages 10-60 years, conferring maximal efficacy and safety. L5-S1 can serve as an alternative option for ages 61-80 years when upper interspaces narrow. This study provides quantitative imaging evidence supporting age-specific, optimized lumbar puncture segment selection.

Mixed reality technology enhances teaching of spinal blockade procedures.

To investigate the efficacy of utilizing mixed reality technology-assisted teaching of a spinal medial branch nerve block. Twenty undergraduate students from a 5-year clinical medicine program in Fujian Medical University were selected. They were divided into group A and group B using a random number generator, with 10 students in each group. Group A used the traditional teaching method and Group B used the mixed reality technology-assisted teaching method. At the end of the teaching period, both groups were assessed on the blocking operation, number of punctures required, puncture time, and final error value (distance between the final position and the reference position). A questionnaire was administered to both groups to assess teaching satisfaction. The number of punctures required was 7.40 ± 1.26 and 2.10 ± 0.74 for groups A and B, respectively. The puncture time in group A was 297.80 ± 50.95 s and 65.60 ± 22.02 s in group B. All differences were significant p < 0.01. The final error of the puncture in group A was 2.24 ± 0.35 mm and 1.96 ± 0.26 mm in group B-not significant. Group B had (p < 0.01) higher evaluation scores than group A for teaching effectiveness, learning interest, initiative, and teaching satisfaction. The application of mixed reality technology in the teaching of posterior medial branch blocks of the spinal nerve is superior to previous methods. This method should be adopted wherever possible to enhance learning of this difficult technique.

Computer-modified paramedian approach technique reduces failures and alleviates pain in lumbar puncture: a prospective comparative study.

Background: The conventional midline approach for lumbar puncture (MAT-LP) has a relatively low success rate of 70%. The paramedian approach can increase the effective puncture area and success rate but lacks standardized guidelines. This study evaluated a computer-modified paramedian approach technique (CMPAT) to optimize lumbar puncture using computational techniques. Methods: In this prospective study, 120 patients underwent CMPAT-LP (n = 60) or MAT-LP (n = 60). Puncture failure was defined after 6 attempts. Failure rate, number of attempts, pain score, and complications were compared. Subgroup analysis was conducted for age (≥ 50 years). Results: No significant demographic differences existed between groups. Failure rates were 3.3% for CMPAT vs. 13.3% for MAT. Puncture attempts averaged 2.0 vs. 3.5 and pain scores were 2.7 vs. 4.1 for CMPAT and MAT, respectively. All outcomes were significantly improved with CMPAT, especially in elderly patients. No significant difference in complications was observed. Conclusion: Compared to MAT, CMPAT-LP demonstrated lower failure rates, fewer puncture attempts, and less pain, without compromising safety. CMPAT may be superior and should be more widely implemented in clinical practice.

Clinical Evaluation of Surgery for Single-Segment Lumbar Spinal Stenosis: A Systematic Review and Bayesian Network Meta-Analysis.

To compare the efficacy and safety of different surgical procedures for patients with single-segment lumbar spinal stenosis (LSS), Bayesian network meta-analysis (NMA) was conducted in this study. Randomized controlled trials (RCTs) which reported 2 years' results after surgery were searched from PubMed, Embase, and Cochrane Register of Controlled Trials up to February 2021. Eligible RCTs that contained at least two of the following surgical procedures, bilateral decompression via the unilateral approach (BDUL), decompression with conventional laminectomy (CL), decompression with fusion (DF), endoscopic decompression (ED), interspinous process devices only (IPDs), decompression with interlaminar stabilization (DILS), decompression with lumbar spinal process-splitting laminectomy (LSPSL), and minimally invasive tubular decompression (MTD), would be included after screening based on the inclusion and exclusion criteria. The primary outcome was Oswestry Disability Index (ODI). Twenty eligible RCTs were included, with a total of 2201 patients enrolled. The NMA showed that the following surgical procedures ranked first (surface under the cumulative ranking) when compared with CL and DF: DILS for ODI (SUCRA 87.8%); LSPSL for back pain (95%); and MTD for leg pain (95.6%). MTD ranked among the top three surgical procedures for most outcomes. The quality of the synthesized evidence was low according to the Grading of Recommendations Assessment, Development, and Evaluation criteria. DILS, LSPSL, MTD, IPDs, and ED are the most effective procedures for patients with single-segment LSS. Because of combining efficacy and safety, MTD may be the most promising routine surgical option for treating single-segment LSS.

Exploring the mechanism of cordycepin combined with doxorubicin in treating glioblastoma based on network pharmacology and biological verification.

BACKGROUND: Glioblastoma is the most common and fatal primary malignant tumor in the central nervous system, and the prognosis is poor. Currently, there are no effective treatments for glioblastoma. Cordycepin is a natural active substance with significant anticancer activity and doxorubicin is a broad-spectrum anticancer drug. Cordycepin administered with doxorubicin is a potential drug combination for the treatment of glioblastoma. However, the mechanism of action for this drug combination has not yet been elucidated. AIM OF THE STUDY: To explore the complex mechanism of cordycepin combined with doxorubicin against glioblastoma using network pharmacology and biological verification. MATERIALS AND METHODS: We used an MTT assay, colony formation assay, and scratch healing to detect the growth, proliferation, and migration of LN-229, U251 and T98G cells. Putative targets and the potential mechanism of action for the drug combination in glioblastoma were obtained through online databases, network construction, and enrichment analyses. We verified the expression of EMT-related genes and identified important therapeutic targets by western blot. RESULTS: In this study, the combination of doxorubicin and cordycepin was found to significantly inhibit cell proliferation and migration and can induce apoptosis. These effects are better together than with either drug alone. The drug combination inhibited EMT by upregulating the expression of E-cadherin protein and downregulating the expression of N-cadherin, ZEB1, and Twist1 proteins. There were 71 potential targets for the drug combination in glioblastoma, and Kyoto Encyclopedia of Genes and Genome analysis suggested that the anticancer process may be mediated by proteoglycans in cancer, the tumor necrosis factor signaling pathway, microRNA in cancer, pathways in cancer, and other pathways. To study the molecular mechanism of anticancer activity, we detected the expression of target proteins with downregulated expression of NFKB1, MAPK8, MYC, and MMP-9 proteins and upregulated expression of cleaved caspase 3 that promoted the apoptosis of LN-229 cells. CONCLUSIONS: This study shows that the drug combination of doxorubicin and cordycepin effectively inhibits the growth and proliferation of LN-229 cells through multiple targets and multiple pathways, and the combination inhibits cell invasion and migration by regulating the EMT switch of tumor cells. Our findings provide new ideas about, and a theoretical basis for, the treatment of glioblastoma.

Identification and validation of potential novel prognostic biomarkers for patients with glioma based on a gene co-expression network.

BACKGROUND: Glioma is widely regarded as one of most lethal and challenging diseases of the nervous system. The aim of this study was to identify novel biomarkers that offer better prognosis prediction for Chinese patients with glioma. METHODS: By using systematic approaches, the co-expression modules were identified from the Chinese Glioma Genome Atlas (CGGA) database through weighted gene co-expression network analysis and functional enrichment of essential modules of Kyoto Encyclopedia of Genes and Genomes terms. The co-expression modules were validated using The Cancer Genome Atlas database and the protein-protein interaction (PPI) network. RESULTS: For network construction, 5,374 among 21,494 genes were selected, and an increasing genetic variance was associated with the prognosis of glioma. By using functional enrichment analysis, the involvement of multiple vital processes, including metabolism of fatty acids, was correlated with the patient prognosis. Notably, five hub genes (KCNB1, UST, SOX8, KLHL42, and HDAC4) were identified for these processes. Accordingly, using the Kaplan-Meier method, there was enhanced expression of these genes in patients with significantly lower overall survival rates, especially those from the CGGA database. CONCLUSIONS: This study not only revealed the essential co-expression gene modules in patients with glioma, but it also unraveled the potential signaling pathways underlying these functional processes.

Effectiveness of personalized 3D printed models for patient education in degenerative lumbar disease.

OBJECTIVE: Three-dimensional printing may play an important role in patients' education. The objective of this study was to assess the effectiveness of personalized 3D printed models for increasing patient understanding of their medical condition and surgical plan. METHODS: Forty-five patients with degenerative lumbar diseases were randomized by block design into three groups: educational program presented by CT & MRI imaging (care-as-usual), 3D reconstructions, or personalized 3D printed models. Patients' level of understanding and satisfaction were evaluated by two questionnaires one day after education. RESULTS: Patients educated with personalized 3D printed models demonstrated an expanded level of understanding than patients educated with CT & MRI imaging (care-as-usual) (P ＜ 0.05) and 3D reconstructions (P ＜ 0.05). Personalized 3D printed models also resulted in a higher degree of patient satisfaction (P ＜ 0.05). CONCLUSIONS: Personalized 3D printed models and 3D reconstructions can simplify and enhance understanding of lumbar anatomy, physiology, and patients' disease and surgical plan. Personalized 3D printed models also enhance patients' subjective satisfaction. PRACTICE IMPLICATIONS: Personalized 3D printed models for patient education are feasible and could be generalized for degenerative lumbar diseases.

A reproducible model of intramedullary spinal cord tumor in rats bearing RG2 cells.

Intramedullary spinal cord tumors (IMSCTs) are lethal diseases to many patients. The lack of adequate animal model has hampered the development of novel treatments. In the current study, a rodent intramedullary glioma model is established to study IMSCT progression. Fischer 344 rats received a intramedullary implantation of RG2 glioma cells. The neurological state of each rat was evaluated on daily basis using the Basso, Beattie and Bresnahan (BBB) scale. Rats implanted with RG2 cells developed significant hind limb paraplegia 20 days after implantation. Magnetic resonance imaging (MRI) scans after three weeks revealed significant intramedullary RG2 tumors in the rats. Forty days post implantation, rats were sacrificed for histopathological examination. Neuro-imaging and HE staining cross sections confirmed intramedullary RG2 glioma cells invading to the spinal cord. Thus, our model displayed many of the same invasive characteristics as human IMSCTs. This model should be a reliable and reproducible methodology to correlate well with the features of human IMSCT.

Minimally invasive surgery for resection of ossification of the ligamentum flavum in the thoracic spine.

INTRODUCTION: Thoracic ossification of the ligamentum flavum (TOLF) is a common cause of progressive thoracic myelopathy. Surgical decompression is commonly used to treat TOLF. AIM: To evaluate the clinical outcomes of microsurgical decompression of TOLF via a paraspinal approach, using a percutaneous tubular retractor system. MATERIAL AND METHODS: First, three-dimensional (3D) image reconstruction and printed models were made from thin computed tomography scans for each patient. Then, 3D computer-assisted virtual surgery was performed using the 3D reconstruction to calculate the precise location and sizes of the bone window and the angle of insertion of the percutaneous tubular retractor system. In total, 13 patients underwent the surgery through the percutaneous micro channel unilateral vertebral approach under electrophysiological monitoring. Five days after the surgery, increased creatine phosphokinase levels returned to preoperative levels. The Japanese Orthopedic Association (JOA) score was improved and computed tomography reconstruction and magnetic resonance imaging of the thoracic spine showed that decompression was achieved without injuries to the spinal cord or nerve root. The stability of the spine was not affected, nor were any deformities of the spine detected. Finally, nerve functional recovery was achieved with minimal injury to the paraspinal muscle, articulum, spinous process and ligament. RESULTS: The mean operative time was 98.23 ±19.10 min, and mean blood loss was 19.77 ±5.97 ml. At a mean follow-up of 13.3 months (median: 12 months), the mean JOA score was 7.54 ±1.13 at the final follow-up, yielding a mean RR of 49.10 ±15.71%. Using The recovery rate, 7 (53.85%) patients had good outcomes, 5 (38.46%) patients had a fair outcome, and 1 (7.69%) patient had poor outcomes, indicating significant improvement by the final follow-up examination (p < 0.05). CONCLUSIONS: The 3D printed patient model-based microsurgical resection of TOLF via the paraspinal approach can achieve decompression of the spinal canal with minimal complications, faster recovery and improved stability of the vertebral body.

Novel combination of paraspinal keyhole surgery with a tubular retractor system leads to significant improvements in lumbar intraspinal extramedullary schwannomas.

The aim of the present study was to investigate the efficacy of combining paraspinal keyhole surgery with a tubular retractor system for the microsurgical removal of lumbar intraspinal extramedullary schwannomas. A retrospective analysis was conducted of 56 patients with lumbar intraspinal extramedullary schwannomas who were treated using the microsurgical paraspinal keyhole approach with a tubular retractor system. The mean ± standard deviation was calculated for the following parameters: Surgery time (96.21±14.64 min), hemorrhagic volume (28.54±9.72 ml), bed rest (2.55±0.5 days) and hospital stay (5.68±0.72 days). Two patients presented with cerebrospinal fluid leakage and one patient exhibited a nerve root injury. At a 6-month follow-up visit, postoperative Japanese Orthopedic Association (JOA) and visual analog scale (VAS) scores were evaluated. The mean ± standard deviation JOA scores were 12.00±2.07 for preoperative, 14.73±2.05 for 1 week postoperative, 20.07±2.32 for 3 months postoperative and 21.75±2.18 for 6 months postoperative. The improvement rate was 16.07, 47.48 and 59.77%, respectively. The mean ± standard deviation VAS scores were 6.64±1.31 for preoperative, 3.82±1.51 for 1 week postoperative, 2.11±1.17 for 3 months postoperative and 1.50±1.51 for 6 months postoperative. The JOA and VAS scores improved significantly (P<0.05). Magnetic resonance imaging and computed tomography were performed preoperatively, immediately following surgery and at the 6-month postoperative visit to confirm the efficacy of the resections and evaluate spinal stability. No residual tumors were identified at follow-up. No alterations in the stability of the spine were observed postoperatively. The combination of the microsurgical paraspinal keyhole approach with the tubular retractor system was successful in treating lumbar intraspinal extramedullary schwannomas. The surgical approach was associated with decreased hemorrhages, decreased duration of hospital stay, faster recovery and improved postoperative maintenance of spinal stability.

Spontaneous spinal epidural hematoma management with minimally invasive surgery through tubular retractors: A case report and review of the literature.

To report a minimally invasive paraspinal approach in the treatment of a case of spontaneous spinal epidural hematoma (SSEH). We additionally aim to review the relevant literature to enhance our knowledge of this disease. SSEH is an uncommon but potentially catastrophic disease. Currently, most appropriate management is emergence decompression laminectomy and hematoma evacuation. An 81-year-old woman was admitted to the neurology department with a chief complaint of bilateral numbness and weakness of the lower limbs and difficulty walking for 4 days with progressive weakness developed over the following 3 days accompanied with pain in the lower limbs and lower back. No history of trauma was reported. Magnetic resonance imaging of the thoracolumbar spine demonstrated an epidural hematoma extending from T-12 to L-5 with thecal sac and cauda equina displacement anterior. The patient was treated in our department with a minimally invasive approach. This operation method had been approved by Chinese Independent Ethics Committee. Three months following the operation, the patient had regained the ability to walk with the aid of a cane and myodynamia tests revealed normal results for the left lower limb and a 4/5 grade for the right limb. Importantly, no complications were exhibited from the surgical operation. The minimally invasive paraspinal approach through tubular retractors is demonstrated here as an effective alternative method for the treatment of SSEH.