Value of Spinal Infection Treatment Evaluation Score, Pola Classification, and Brighton Spondylodiscitis Score from Decision to Surgery in Patients with Spondylodiscitis: A Receiver-Operating Characteristic Curve Analysis.

STUDY DESIGN: This was a retrospective study. PURPOSE: This study aimed to assess the value of the Spinal Infection Treatment Evaluation (SITE) score, Brighton Spondylodiscitis Score (BSDS), and Pola classification to predict the need for surgical intervention in patients with spondylodiscitis. OVERVIEW OF LITERATURE: Spondylodiscitis is a rare disease, and the prediction of its outcome is crucial in the decision-making process. METHODS: All case records were assessed to extract information on the American Spinal Injury Association (ASIA), Visual Analog Scale (VAS), and Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores before and after surgery. The SITE score, Pola classification, and BSDS were recorded. The receiver-operating characteristic (ROC) curve analysis and the area under the curve (AUC) were applied to estimate the predictive ability of the scoring systems. Patients' satisfaction with surgery outcomes was evaluated using the VAS, ASIA, JOABPEQ, and Likert scale for quality-of-life evaluation. RESULTS: In all 148 patients, case records were reviewed. The mean±standard deviation age of the patients was 54.6±14.7 years. Of these, 112 patients underwent surgery. The AUC scores were 0.86, 0.81, and 0.73 for the SITE score, BSDS, and Pola classification, respectively. In the comparison of the AUC of ROC curves, SITE score vs. BSDS showed a significantly greater AUC, 0.13 (Z =2.1, p =0.037); SITE score vs. Pola classification, 0.05 (Z =0.82, p =0.412); and Pola classification vs. BSDS, 0.08 (Z =1.22, p =0.219). The optimal cutoff score was 8.5 (sensitivity, 80.6%; specificity, 81.2%) for the SITE score and 9.5 (sensitivity, 52.8%; specificity, 83.0%) for the BSDS in the decision to surgery. VAS back pain and JOABPEQ subscales showed a significant difference when compared with preoperative scores. According to ASIA grading, none of the patients experienced neurological deterioration. Overall, patients' satisfaction was observed. CONCLUSIONS: The findings suggest that the SITE score is a useful measure and helps clinicians make clinically sound decisions in patients with spondylodiscitis.

Comprehensive somatic mutational analysis in glioblastoma: Implications for precision medicine approaches.

Glioblastoma multiforme (GBM), a malignant neoplasm originating from glial cells, remains challenging to treat despite the current standard treatment approach that involves maximal safe surgical resection, radiotherapy, and adjuvant temozolomide chemotherapy. This underscores the critical need to identify new molecular targets for improved therapeutic interventions. The current study aimed to explore the somatic mutations and potential therapeutic targets in GBM using somatic mutational information from four distinct GBM datasets including CGGA, TCGA, CPTAC and MAYO-PDX. The analysis included the evaluation of whole exome sequencing (WES) of GBM datasets, tumor mutation burden assessment, survival analysis, drug sensitivity prediction, and examination of domain-specific amino acid changes. The results identified the top ten commonly altered genes in the aforementioned GBM datasets and patients with mutations in OBSCN and AHNAK2 alone or in combination had a more favorable overall survival (OS). Also, the study identified potential drug sensitivity patterns in GBM patients with mutations in OBSCN and AHNAK2, and evaluated the impact of amino acid changes in specific protein domains on the survival of GBM patients. These findings provide important insights into the genetic alterations and somatic interactions in GBM, which could have implications for the development of new therapeutic strategies for this aggressive malignancy.

Monte Carlo Dosimetric Study of Percutaneous Vertebroplasty and Brachytherapy for the Treatment of Spinal Metastases.

Background: Percutaneous vertebroplasty employs bone cement for injecting into the fractured vertebral body (VB) caused by spinal metastases. Radioactive bone cement and also brachytherapy seeds have been utilized to suppress the tumor growth in the VB. Objective: This study aims to investigate the dose distributions of low-energy brachytherapy seeds, and to compare them to those of radioactive bone cement, by Monte Carlo simulation. Material and Methods: In this simulation study, nine CT scan images were imported in Geant4. For the simulation of brachytherapy, I-125, Cs-131, or Pd-103 seeds were positioned in the VB, and for the simulation of vertebroplasty, the VB was filled by a radioactive cement loaded by P-32, Ho-166, Y-90, or Sm-153 radioisotopes. The dose-volume histograms of the VB, and the spinal cord (SC) were obtained after segmentation, considering that the reference dose is the minimum dose covered 95% of the VB. Results: The SC sparing was improved by using beta-emitting cement because of their steep gradient dose distribution. I-125 seeds and Y-90 radioisotope showed better VB coverage for brachytherapy and vertebroplasty techniques, respectively. Pd-103 seeds and P-32 radioisotope showed better SC sparing for brachytherapy and vertebroplasty, respectively. The minimum mean doses that covered 100% of the VB were 62.0%, 56.5%, and 45.0% for I-125, Cs-131, and Pd-103 seeds, and 28.3%, 28.6%, 32.9%, and 17.7%, for P-32, Ho-166, Y-90, and Sm-153 sources, respectively. Conclusion: I-125 and Cs-131 seeds may be useful for large tumors filling the entire VB, and also for the extended tumors invading multiple vertebrae. Beta-emitting bone cement is recommended for tumors located near the SC.

Clinical outcomes of surgical treatment for Copenhagen syndrome: a case series.

BACKGROUND: Copenhagen syndrome (CS) is a rare disorder mostly observed in adolescent. The onset of the disease, with a progressive anterior vertebral ankylosis in the thoracic and/or lumbar areas often clinically revealed by thoracolumbar kyphosis. We report a series of three patients of CS with good outcome. CASE PRESENTATION: The mean age of patients were 14.0 (SD = 3.6) years at admission time. Patients underwent clinical and radiological examination (MRI, CT scan, and bone scan) before surgery and revealed Copenhagen syndrome. Case 2 received conservative treatment braces and regular follow-up. Finally, all patients were treated according to their clinical conditions through a combined surgical approach such as pedicle subtraction osteotomy (PSO), ponte osteotomy, hook, pedicular screw insertion, and fusion. In postoperative follow-up, the deformity correction was achieved with proper alignment in all the cases. CONCLUSION: The treatment of CS with PSO plus ponte osteotomy seems to result in an excellent surgical procedure and outcome for our patients based on deformity severity. Bone scan imaging could be considered as an aid to differential diagnosis, which is an effective method.

Metastasis of spine from adenoid cystic carcinoma of the parotid gland: two case reports.

BACKGROUND: Spinal metastasis from adenoid cystic carcinoma of the salivary gland is extremely rare. We present two interesting cases of spinal metastasis from adenoid cystic carcinoma of the parotid gland. A 29-year-old Persian male and a 48-year-old Persian female presented with parotid gland mass. The two patients received parotidectomy and radiotherapy. The pathological examination result was adenoid cystic carcinoma. Because of intractable back pain, patients were referred to the hospital after 7 years and 9 months, respectively. Both cases underwent spinal surgery. Histopathology confirmed spinal metastasis from adenoid cystic carcinoma of the parotid gland (case 1: T6, T12, and L1; case 2: T12). Anterior corpectomy of T12 and lateral screw fixation at T11 and L1 were done in case 2. Posterior spinal fusions from T2 to L3 and from T10 to L2 were performed in case 1 and case 2, respectively. Both patients showed good clinical improvement. The last follow-up (case 1: 24 months; case 2: 6 months after surgery), plain radiographs and computed tomography scan showed good fusion without instrumental failure and magnetic resonance imaging revealed good decompression of the spinal cord of both cases. CONCLUSION: Although spinal metastasis from adenoid cystic carcinoma of the parotid gland is extremely rare, it is necessary to be careful in the differential diagnosis.

Comparative study of Lutetium-177 and Phosphorus-32 in radioactive bone cement for the treatment of vertebral body metastasis.

BACKGROUND: Vertebroplasty is a minimally invasive outpatient procedure to stabilize compression fractures in the spine. This procedure involves injecting bone cement into the vertebrae that have been cracked or broken, typically due to osteoporosis. The cement hardens inside the bones, providing stability to the fractures and supporting the spine. Additionally, radioactive bone cement and brachytherapy sources have been utilized to suppress tumor growth in the vertebral body. OBJECTIVE: We present a novel brachytherapy technique for treating vertebral body metastases using a liquid form of radioactive sources, Phosphorus-32 and Lutetium-177, separately mixed with bone cement and injected into vertebral body bone prostheses. We also investigated the dose distribution of the radioactive bone cement by theoretically calculating it using GEANT4 Monte Carlo and measuring it using TLD dosimeters for Phosphorus-32 and Lutetium-177 loaded in vertebral bodies. MATERIAL AND METHODS: CT-scanned images of each vertebral body (L2 and L3) were imported into GEANT4 for simulation purposes. Two simulations were performed to evaluate the possibility of using PLA prostheses in ex vivo measurements, using bone and PLA material as a bone substitute for brachytherapy of Lutetium-177 and Phosphorus-32. The simulations calculated the dose distribution, dose rates, and deposited dose to the spinal cord and aorta. Next, 3D-printed bone prostheses were drilled and separately filled with bone cement, including PMMA-P32 and PMMA-Lu177, in liquid form using the Vertebroplasty technique. The dose to regions of interest was measured using Thermoluminescence dosimeters. CONCLUSIONS: When comparing the simulated and measured results of dose rates, it was observed that P32 delivers higher doses to normal organs such as the spinal cord and aorta. At the same time, Lu177 has better sparing in these regions of interest. Therefore, while P32 and Lu177 are suitable for radioactive bone cement treatment, Lu177 delivers relatively lower doses to vital organs such as the spinal cord and aorta. Additionally, Lu177 has characteristics such as a shorter range and lower energies of beta particles in tissue and the presence of gamma rays that make it a better choice for the same treatments. It also provides the possibility of SPECT imaging.

Autograft and allograft bone chips interbody fusion for spondylodiscitis: Surgery outcomes.

Background: Spondylodiscitis is a rare illness and serious complication of the vertebral column. The suitable type of surgery is debatable for these patients. This study describes a series of cases that are treated with modified interbody fusion for the treatment of spondylodiscitis by combining allograft and autograft bone chips with posterior segmental fusion. Methods: This was a retrospective study. The clinical deficit was evaluated with ASIA, VAS, and JOABPEQ scores before and after surgery. Radiological parameters were assessed with local kyphosis angle (degree), segmental height correction, and loss of correction. Post-operative bone union was evaluated as suggested by Tan et al. Results: The mean age of patients (n=34) was 52.3(SD=13.6) years and 67.6% were males. The mean follow-up duration was 25.8 (2.3) months. In the last follow-up, VAS back pain 4.9(0.77), VAS leg pain 4.6(0.78), JOABPEQ low back pain 68.1 (9.3), JOABPEQ lumbar function 81.3 (8.9), and JOABPEQ walking ability 72.8 (8.3) shows a significant difference when compared with preoperative scores. According to ASIA grading, none of the patients deteriorated neurologically (all p<0.0001). The average segmental height correction and loss of correction were observed 7.5(3.7) % and -1.8(3.6) %, respectively, indicating improvements in the patients. A high union fusion rate (82.4%) was observed in the last follow-up. Conclusion: This modified method can be a safe and effective technique for surgical intervention in patients with spondylodiscitis.

Primary lymphoma of the lumbar vertebrae: a case report and review of the literature.

BACKGROUND: Primary lymphoma of the spinal vertebrae (PLSV) is an exceedingly rare disease with an unclear optimal treatment plan. We analyzed the clinical features of PLSV in the patient to strengthen our understanding of the disease and to review the literature. CASE PRESENTATION: A 65-year-old Persian man was admitted to our hospital with severe low back pain. The patient underwent radiological examinations including computed tomography (CT) scan, magnetic resonance imaging (MRI), and single-photon emission computed tomography (SPECT). These examinations revealed a lesion in the L3 vertebra. Histological analysis showed a high-grade lymphoma. The patient underwent an L3 corpectomy with expandable cage placement, followed by an L2-L4 lateral screw placement with rod fixation. Also, facetectomy, laminectomy, and total spondylectomy were performed. Pedicle screws were inserted from L1 to L5. Titanium mesh was placed on the post-laminectomy defect. The treatment continued with local radiotherapy and chemotherapy. Post-treatment, the patient showed no new neurological deficit, and in the final follow-up, the patient had achieved a good recovery. CONCLUSION: To our knowledge, no prior published literature has revealed a primary lymphoma of the lumbar vertebrae. Here, we report this case of PLSV for the first time and provide a brief review of the literature.

Simple bone cyst of spinal vertebrae: two case reports and literature review.

Simple bone cyst (SBC) is not a common lesion in the spine and especially in the vertebral body. We intend to report two cases of SBC located in the vertebral body, and review the literature. Two cases include a 24 year-old male and 26 year-old male with vertebral body lesion of T12 and L5 vertebrae,retrospectively. Both lesions were found to be SBC and confirmed by pathology. Both cases were managed with surgery, the cavity was filled with bone graft and posterior spinal fusion and instrumentation with pedicle screws, and rods were carried out. There was no recurrence. There have been 21 cases of SBCs in English literature, and only 8 cases have been reported in the vertebral body. SBC is a rare benign lesion in the spine and it should be considered in the differential diagnosis when suggested by radiologic investigations.

Design, Fabrication, and Accuracy of a Novel Noncovering Lock-Mechanism Bilateral Patient-Specific Drill Guide Template for Nondeformed and Deformed Thoracic Spines.

Background: Pedicle screw (PS) placement has been widely used in fusion surgeries on the thoracic spine. Achieving cost-effective yet accurate placements through nonradiation techniques remains challenging. Questions/Purposes: Novel noncovering lock-mechanism bilateral vertebra-specific drill guides for PS placement were designed/fabricated, and their accuracy for both nondeformed and deformed thoracic spines was tested. Methods: One nondeformed and 1 severe scoliosis human thoracic spine underwent computed tomographic (CT) scanning, and 2 identical proportions of each were 3-dimensional (3D) printed. Pedicle-specific optimal (no perforation) drilling trajectories were determined on the CT images based on the entry point/orientation/diameter/length of each PS. Vertebra-specific templates were designed and 3D printed, assuring minimal yet firm contacts with the vertebrae through a noncovering lock mechanism. One model of each patient was drilled using the freehand and one using the template guides (96 pedicle drillings). Postoperative CT scans from the models with the inserted PSs were obtained and superimposed on the preoperative planned models to evaluate deviations of the PSs. Results: All templates fitted their corresponding vertebra during the simulated operations. As compared with the freehand approach, PS placement deviations from their preplanned positions were significantly reduced: for the nonscoliosis model, from 2.4 to 0.9 mm for the entry point, 5.0° to 3.3° for the transverse plane angle, 7.1° to 2.2° for the sagittal plane angle, and 8.5° to 4.1° for the 3D angle, improving the success rate from 71.7% to 93.5%. Conclusions: These guides are valuable, as the accurate PS trajectory could be customized preoperatively to match the patients' unique anatomy. In vivo studies will be required to validate this approach.

Bactericidal fully human single-chain fragment variable antibodies protect mice against methicillin-resistant Staphylococcus aureus bacteraemia.

OBJECTIVES: The increasing prevalence of antibiotic-resistant Staphylococcus aureus, besides the inadequate numbers of effective antibiotics, emphasises the need to find new therapeutic agents against this lethal pathogen. METHODS: In this study, to obtain antibody fragments against S. aureus, a human single-chain fragment variable (scFv) library was enriched against living methicillin-resistant S. aureus (MRSA) cells, grown in three different conditions, that is human peripheral blood mononuclear cells with plasma, whole blood and biofilm. The antibacterial activity of scFvs was evaluated by the growth inhibition assay in vitro. Furthermore, the therapeutic efficacy of anti-S. aureus scFvs was appraised in a mouse model of bacteraemia. RESULTS: Three scFv antibodies, that is MEH63, MEH158 and MEH183, with unique sequences, were found, which exhibited significant binding to S. aureus and reduced the viability of S. aureus in in vitro inhibition assays. Based on the results, MEH63, MEH158 and MEH183, in addition to their combination, could prolong the survival rate, reduce the bacterial burden in the blood and prevent inflammation and tissue destruction in the kidneys and spleen of mice with MRSA bacteraemia compared with the vehicle group (treated with normal saline). CONCLUSION: The combination therapy with anti-S. aureus scFvs and conventional antibiotics might shed light on the treatment of patients with S. aureus infections.

Global Sagittal Balance of Spine in Asymptomatic Controls: A Systematic Review and Meta-Analysis.

OBJECTIVE: To assess the global sagittal balance of spine (GSBS) in asymptomatic controls. METHODS: PubMed, Scopus, Cochrane library, and Web of Science searched up to July 2020. Studies were screened for the GSB parameters including T1 pelvic angle (TPA), spinosacral angle (SSA), sagittal vertical axis (SVA), C7/sacrofemoral distance ratio (Barrey index), odontoid hip axis (OD-HA), and Full Balance Index (FBI) as measured in asymptomatic participants. A meta-analysis was performed to synthesize pooled estimates. Heterogeneity and publication bias were assessed. RESULTS: Overall, 76 studies were identified including 12,169 participants (54.7% female) with mean age ranges from 12.0 to 72.9 years old. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Begg's test did not indicate obvious publication bias. The pooled analysis reveals that the mean (standard deviation) normative values were: 1) age ˃18 years, SSA (°), 127.6 (0.89); SVA absolute value (millimeters), 13.1 (1.13); TPA (°), 9.8 (1.13); T1SPI (°), -4.3 (0.57); and Barrey index absolute value, 0.51 (0.3). The mean value of the OD-HA (°) was reported 2.9 (1.6), and the FBI average value was less than 5°. 2) Age ≤18 years, SSA (°), 132.1 (8.3); SVA absolute value (millimeters), 11.9 (2.0); and Barrey index, -0.7 (8.3). A significant difference was observed between the 2 age groups based on SVA and SSA. CONCLUSIONS: This paper presents normative data on TPA, SSA, SVA, Barrey index, OD-HA, and FBI as a reference for evaluating/measuring a GSB of spine in asymptomatic controls.

Iatrogenic injury to long thoracic nerve following thoracotomy for right thoracic scoliosis in Marfan syndrome: a case report.

BACKGROUND: Patients with Marfan syndrome commonly require spinal deformity surgery. The purpose of this case report is to present a rare thoracotomy complication. We present the management of such a patient. In a known case of Marfan syndrome, an 18-year-old Persian man was admitted to our hospital with scoliosis. The patient underwent radiological examinations, and thoracic scoliosis of 70° was diagnosed. A right thoracotomy for anterior spinal fusion from the sixth rib and posterior spinal fusion were performed successfully. Two months later, he was readmitted because of winging of the right scapula due to serratus anterior palsy. Electromyography and nerve conduction velocity confirmed long thoracic nerve injury. Conservative treatment was provided. Ultimately, the patient recovered completely in the last follow-up visit 6 months after the surgery. DISCUSSION: This is the first report of ipsilateral winged scapula after thoracotomy. Attention needs to be paid to surgical techniques in patients with Marfan syndrome.

Sagittal balance of the cervical spine: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review and meta-analysis was to compare the cervical sagittal parameters between patients with cervical spine disorder and asymptomatic controls. METHODS: Two independent authors systematically searched online databases including Pubmed, Scopus, Cochrane library, and Web of Science up to June 2020. Cervical sagittal balance parameters, such as T1 slope, cervical SVA (cSVA), and spine cranial angle (SCA), were compared between the cervical spine in healthy, symptomatic, and pre-operative participants. Where possible, we pooled data using random-effects meta-analysis, by CMA software. Heterogeneity and publication bias were assessed using the I-squared statistic and funnel plots, respectively. RESULTS: A total of 102 studies, comprising 13,802 cases (52.7% female), were included in this meta-analysis. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Funnel plot and Begg's test did not indicate obvious publication bias. The pooled analysis reveals that the mean (SD) values were: T1 slope (degree), 24.5 (0.98), 25.7 (0.99), 25.4 (0.34); cSVA (mm), 18.7 (1.76), 22.7 (0.66), 22.4 (0.68) for healthy population, symptomatic, and pre-operative assessment, respectively. The mean value of the SCA (degree) was 79.5 (3.55) and 75.6 (10.3) for healthy and symptomatic groups, respectively. Statistical differences were observed between the groups (all P values < 0.001). CONCLUSION: The findings showed that the T1 slope and the cSVA were significantly lower among patients with cervical spine disorder compared to controls and higher for the SCA. Further well-conducted studies are needed to complement our findings.

3D-printed navigation template in cervical spine fusion: a systematic review and meta-analysis.

PURPOSE: To explore the effectiveness and advantage of three-dimensional (3D)-printed navigation templates (3DPN-template) assisted in cervical spine fusion (CSF) surgery as compared to conventional surgery. METHODS: An electronic literature search in PubMed, Scopus, Web of Science, and Cochrane was conducted for studies of 3DPN-templates in CSF up to May 2020. Outcome measures as the accuracy rate, operation time, intra-operative blood loss, and fluoroscopy used, associated with CSF were extracted. Mean difference based on changes was quantified using Hedges' g. RESULTS: From 4414 potentially relevant studies, 61 full-text publications were screened. Thirteen studies comprising 330 cases with 1323 screw placements were eligible for inclusion. For template group, pooled estimates were as follows: 97.3% accuracy rate for screw placement, 144.7 min for operating time, 273.6 ml for blood loss, and 3.2 min for fluoroscopic times. A significantly positive difference was observed between the template group compared to control group in terms of accuracy rate of screw placement (Z = 5.3), operation time (Z = 2.41), intra-operative blood loss (Z = 2.64), and fluoroscopic times (Z = 3.64) (all, P value < 0.0001). Risk of bias for studies under review was assessed using the Newcastle-Ottawa Scale (NOS), and 11 studies were found as having high quality. Overall, funnel plot and Begg's test did not indicate obvious publication bias. CONCLUSION: The 3D-printed navigation template in the cervical surgery can improve accuracy of pedicle screw placement and consequently improve outcomes. In future, multi-center efforts are needed to validate the relationships found in this review.

Accuracy and safety of C2 pedicle or pars screw placement: a systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. AIM: The purpose of this study was to compare the safety and accuracy of the C2 pedicle versus C2 pars screws placement and free-hand technique versus navigation for upper cervical fusion patients. METHODS: Databases searched included PubMed, Scopus, Web of Science, and Cochrane Library to identify all papers published up to April 2020 that have evaluated C2 pedicle/pars screws placement accuracy. Two authors individually screened the literature according to the inclusion and exclusion criteria. The accuracy rates associated with C2 pedicle/pars were extracted. The pooled accuracy rate estimated was performed by the CMA software. A funnel plot based on accuracy rate estimate was used to evaluate publication bias. RESULTS: From 1123 potentially relevant studies, 142 full-text publications were screened. We analyzed data from 79 studies involving 4431 patients with 6026 C2 pedicle or pars screw placement. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Overall, funnel plot and Begg's test did not indicate obvious publication bias. The pooled analysis reveals that the accuracy rates were 93.8% for C2 pedicle screw free-hand, 93.7% for pars screw free-hand, 92.2% for navigated C2 pedicle screw, and 86.2% for navigated C2 pars screw (all, P value < 0.001). No statistically significant differences were observed between the accuracy of placement C2 pedicle versus C2 pars screws with the free-hand technique and the free-hand C2 pedicle group versus the navigated C2 pedicle group (all, P value > 0.05). CONCLUSION: Overall, there was no difference in the safety and accuracy between the free-hand and navigated techniques. Further well-conducted studies with detailed stratification are needed to complement our findings.

A Review on the Use of Artificial Intelligence in Spinal Diseases.

Artificial neural networks (ANNs) have been used in a wide variety of real-world applications and it emerges as a promising field across various branches of medicine. This review aims to identify the role of ANNs in spinal diseases. Literature were searched from electronic databases of Scopus and Medline from 1993 to 2020 with English publications reported on the application of ANNs in spinal diseases. The search strategy was set as the combinations of the following keywords: "artificial neural networks," "spine," "back pain," "prognosis," "grading," "classification," "prediction," "segmentation," "biomechanics," "deep learning," and "imaging." The main findings of the included studies were summarized, with an emphasis on the recent advances in spinal diseases and its application in the diagnostic and prognostic procedures. According to the search strategy, a set of 3,653 articles were retrieved from Medline and Scopus databases. After careful evaluation of the abstracts, the full texts of 89 eligible papers were further examined, of which 79 articles satisfied the inclusion criteria of this review. Our review indicates several applications of ANNs in the management of spinal diseases including (1) diagnosis and assessment of spinal disease progression in the patients with low back pain, perioperative complications, and readmission rate following spine surgery; (2) enhancement of the clinically relevant information extracted from radiographic images to predict Pfirrmann grades, Modic changes, and spinal stenosis grades on magnetic resonance images automatically; (3) prediction of outcomes in lumbar spinal stenosis, lumbar disc herniation and patient-reported outcomes in lumbar fusion surgery, and preoperative planning and intraoperative assistance; and (4) its application in the biomechanical assessment of spinal diseases. The evidence suggests that ANNs can be successfully used for optimizing the diagnosis, prognosis and outcome prediction in spinal diseases. Therefore, incorporation of ANNs into spine clinical practice may improve clinical decision making.

Use of artificial neural networks to predict the probability of developing new cerebral metastases after radiosurgery alone.

BACKGROUND: The present study aimed to predict the probability of developing new cerebral metastases after Gamma Knife radiosurgery (GKR) alone in patients with 1-3 brain metastases by artificial neural network (ANN) model. METHODS: AAN and other methods were used. The AAN has been investigated in comparison of other models of analysis, including the logistic regression (LR) and the recently introduced Huttenlocher method. Patients were divided into a distant brain failure (DBF) or a distant brain control (DBC) within 6 months of follow-up. Eleven factors were determined as the input parameters for the established ANN and were trained to predict of DBF. Sensitivity analysis was performed. The ROC curve, accuracy rate, and Hosmer-Lemeshow (H-L) tests were used to assess the three different prediction methods. RESULTS: A total of 192 patients were categorized into the training (N.=96), testing (N.=48), and validation (N.=48) data sets in ANN. DBC rate was 60.4; based on the Huttenlocher classification method, it was 40.7% in Group I, 49.2% in Group II, and 88.1% in Group III. The number of cerebral metastases, primary tumor type, extra-cerebral metastases and recursive partitioning analysis (RPA) were the most important variables indicated by the ANN analysis. Compared to the other two methods, ANN model was associated to superior results: accuracy rate, 95.3%; H-L statistic, 40.9%; and AUC, 0. 0.88%. CONCLUSIONS: The ANNs can be used to effectively help for predicting DBF in patients with 1-3 brain metastasis treated with GKR alone.

Extensor muscle-preserving laminectomy in treating multilevel cervical spondylotic myelopathy compared with laminoplasty.

BACKGROUND: Laminectomy and laminoplasty are popularly used in posterior cervical spine surgery but still have involved complications. We aimed to compare the clinical outcomes of microscope-assisted extensor muscle-preserving laminectomy (MA-EMPL) and open-door laminoplasty (ODLP) in treating multilevel cervical spondylotic myelopathy (MCSM). METHODS: A prospective study was designed to enroll twenty patients with MCSM underwent MA-EMPL, and recruit twenty-four patients with MCSM received ODLP (control). Radiographic measurements, outcome indicators including Japanese Orthopedic Association (JOA) score and visual analogue score (VAS) were used to evaluate technical effectiveness. Surgical complications were documented to assess technical safety. RESULTS: Postoperative cervical curvature index and range of neck motion (ROM) were not significantly changed except ROM in ODLP group. Postoperative JOA score and VAS in both groups showed improvements at final follow-up. There was no statistical difference in postoperative neurological recovery rates between two groups (67.6%±17.8% vs. 70.15%±19.6%, P=0.632). However, VAS was significantly lower at postoperative 1 month in MA-EMPL group compared with ODLP group (P<0.001). The incidences of C5 palsy were 0 vs. 16.7% between MA-EMPL group and ODLP group. There was no axial symptom occurred in MA-EMPL group while six patients in ODLP group (0 vs. 25%, P=0.049). In addition, the mean blood loss and hospital stay were lesser in MA-EMPL group compared with ODLP group (P<0.001, P=0.002, respectively). CONCLUSIONS: MA-EMPL is an effective, safe and minimally invasive method in treatment of MCSM. Compared with ODLP, MA-EMPL has advantage to decrease intraoperative blood loss, hospital stay, postoperative VAS and axial symptom, as well as preserve postoperative ROM.

The risk factors associated with delirium after lumbar spine surgery in elderly patients.

BACKGROUND: To prospectively explore the incidence and risk factors for postoperative delirium in elderly patients following lumbar spine surgery. METHODS: This prospective study enrolled 148 consecutive patients over the age of 65 who were scheduled to undergo spine surgery. Patients were screened for delirium using the short Confusion Assessment Method (CAM) postoperatively. Patient demographics and relevant medical information were collected. Logistic regression analysis was used to identify the risk factors associated with postoperative delirium. RESULTS: Eighty-three patients (56.1%) who underwent lumbar spine surgery (not coexisting with cervical or thoracic spine surgery) were enrolled in our study. Post-operative delirium was noted in 14.5% of patients over 65 years old. The presence of preoperative Parkinsonism was significantly higher in the delirium group (41.7% vs. 8.5%, P=0.002), as was a higher preoperative C-reactive protein (CRP) (7.0±15.2 vs. 1.3±2.3 mg/L, P=0.017) when compared with the non-delirium group. Of the risk factors, male sex [odds ratio (OR) =0.10, 95% confidence interval (CI): 0.01-0.66, P=0.017], Parkinsonism (OR =5.83, 95% CI: 1.03-32.89, P=0.046), and lower baseline MMSE score (OR =0.71, 95% CI: 0.52-0.97, P=0.032) were independently associated with postoperative delirium in elderly patients undergoing lumbar spine surgery. CONCLUSIONS: Post-operative delirium occurred in 14.5% of elderly patients who underwent lumbar spine surgery. Male sex, Parkinsonism, and lower baseline MMSE score were identified as independent risk factors for postoperative delirium in elderly patients following lumbar surgery.