Comparison of minimally invasive transforaminal lumbar interbody fusion and midline lumbar interbody fusion in patients with spondylolisthesis.

BACKGROUND: This study aimed to compare surgical outcomes, clinical outcomes, and complications between minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and midline lumbar interbody fusion (MIDLIF) in patients with spondylolisthesis. METHODS: This study retrospectively compared the patients who underwent MIS TLIF (n = 37) or MIDLIF (n = 50) for spinal spondylolisthesis. Data of surgical outcomes (postoperative one-year fusion rate and time to bony fusion), clinical outcomes (visual analog scale [VAS] for pain and Oswestry Disability Index [ODI] for spine function), and complications were collected and analyzed. RESULTS: There was more 2-level fusion in MIDLIF (46% vs. 24.3%, p = 0.038). The MIS TLIF and MIDLIF groups had similar one-year fusion rate and time to fusion. The MIDLIF group had significantly lower VAS at postoperative 3-months (2.2 vs. 3.1, p = 0.002) and postoperative 1-year (1.1 vs. 2.1, p = < 0.001). ODI was not significantly different. The operation time was shorter in MIDLIF (166.1 min vs. 196.2 min, p = 0.014). The facet joint violation is higher in MIS TLIF (21.6% vs. 2%, p = 0.009). The other complications were not significantly different including rate of implant removal, revision, and adjacent segment disease. CONCLUSION: In this study, postoperative VAS, operation time, and the rate of facet joint violation were significantly higher in the MIS TLIF group. Comparable outcomes were observed between MIDLIF and MIS TLIF in terms of fusion rate, time to fusion, and postoperative ODI score.

Preclinical Animal Study and Pilot Clinical Trial of Using Enriched Peripheral Blood-Derived Mononuclear Cells for Intervertebral Disc Degeneration.

Low back pain (LBP) is a leading cause of long-term disability globally. Intervertebral disk degeneration (IVDD) is mainly responsible for discogenic pain in LBP-affected young patients. There is no effective therapy to reverse disease severity and IVDD progression. This study investigates the effect of human peripheral blood-derived mononuclear cells (PBMCs) on pain relief and life quality improvement in IVDD patients. The enriched monocytes of the PBMCs could differentiate into CD14 and CD206 double-positive M2 macrophages in vitro. Preclinical evidence in rats showed that the transplanted PBMCs exhibited anti-inflammatory and moderate tissue-repair effects on controlling IVDD progress in the rat model. The PBMCs significantly steered the aggrecan and type II collagen expressions and attenuated the pro-inflammatory cytokines in the affected disk. Based on the animal results, 36 patients with chronic low back pain (CLBP) were included in clinical trials. The control group was conservative care only, and the experimental group was platelet-rich plasma (PRP) and PBMCs intradiscal injections. We first confirmed the single lumbar disk causing the discogenic pain by provocative discography or magnetic resonance imaging (MRI). Discogenic LBP participants received one intradiscal injection of autologous PBMCs and followed for 6 months. Our clinical trial showed that patients' LBP and disability were significantly ameliorated after the PBMCs transplantation rather than PRP. These preclinical and pilot clinical studies indicate that intradiscal injection of the enriched PBMCs might be a feasible and potential cell therapy to control pain and disability in IVDD patients.

Antibacterial Gelatin Composite Hydrogels Comprised of In Situ Formed Zinc Oxide Nanoparticles.

We report the feasibility of using gelatin hydrogel networks as the host for the in situ, environmentally friendly formation of well-dispersed zinc oxide nanoparticles (ZnONPs) and the evaluation of the antibacterial activity of the as-prepared composite hydrogels. The resulting composite hydrogels displayed remarkable biocompatibility and antibacterial activity as compared to those in previous studies, primarily attributed to the uniform distribution of the ZnONPs with sizes smaller than 15 nm within the hydrogel network. In addition, the composite hydrogels exhibited better thermal stability and mechanical properties as well as lower swelling ratios compared to the unloaded counterpart, which could be attributed to the non-covalent interactions between the in situ formed ZnONPs and polypeptide chains. The presence of ZnONPs contributed to the disruption of bacterial cell membranes, the alteration of DNA molecules, and the subsequent release of reactive oxygen species within the bacterial cells. This chain of events culminated in bacterial cell lysis and DNA fragmentation. This research underscores the potential benefits of incorporating antibacterial agents into hydrogels and highlights the significance of preparing antimicrobial agents within gel networks.

The efficacy of oral vitamin D supplements on fusion outcome in patients receiving elective lumbar spinal fusion-a randomized control trial.

BACKGROUND: Previous studies have reported that vitamin D supplement could improve fracture healing, but evidence regarding the role of vitamin D supplements in spinal fusion was limited. Thus, this study aimed to evaluate the effectiveness of oral vitamin D supplements on fusion outcomes in patients undergoing lumbar spinal fusion. METHODS: This randomized, double-blind, parallel-designed, active-control trial included the patients who planned for elective lumbar spinal fusion. Eligible patients were randomly assigned to receive either daily vitamin D3 (cholecalciferol) 800 IU and daily calcium citrate 600 mg (experimental group) or only daily calcium citrate 600 mg (control group). All supplements were given from postoperative day 1 and lasted for 3 months. Primary outcome was postoperative 1-year fusion rate, and secondary outcomes included time to fusion, Oswestry Disability Index (ODI), and visual analogue scale (VAS) for pain. RESULTS: Among the included 34 patients (21 in the experimental group and 13 in the control group), baseline 25-hydroxyvitamin D (25[OHVitD) level was 26.7 (10.4) ng/ml. Preoperative prevalence of vitamin D deficiency and insufficiency were 23.5% and 47.1%, respectively. Postoperative 1-year fusion rate was not significantly different between the two groups (95.2% vs. 84.6%, P = 0.544). The experimental group had significantly shorter time to fusion (Kaplan-Meier estimated: 169 days vs. 185 days [interquartile range: 88-182 days vs. 176-324 days], log-rank test: P = 0.028), lower postoperative 6-month ODI (P < 0.001), and lower postoperative 6-month VAS (P < 0.001) than the control group. Time to fusion was significantly and negatively correlated with preoperative, postoperative 3-month, and 6-month 25(OH)VitD levels (all P < 0.01). CONCLUSION: The patient with vitamin D supplements had shorter time to fusion, better spinal function and less pain after elective spinal fusion. Further research is warranted to identify the patients who can benefit the most from vitamin D supplements and the appropriate dose of vitamin D supplements. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05023122. Registered 20 August 2021. Retrospectively registered, http://clinicaltrials.gov/ct2/show/NCT03793530 .

Injectability, Processability, Drug Loading, and Antibacterial Activity of Gentamicin-Impregnated Mesoporous Bioactive Glass Composite Calcium Phosphate Bone Cement In Vitro.

Calcium phosphate cement (CPC) is similar to bone in composition and has plasticity, while mesoporous bioactive glass (MBG) has the advantage of releasing Si, which can promote osteogenic properties and drug loading capacity. A sol-gel-prepared MBG micro-powder (mMBG) and further impregnated antibiotic gentamicin sulfate (Genta@mMBG: 2, 3, and 4 mg/mL) antibiotic were added to CPC at different weight ratios (5, 10, and 15 wt.%) to study CPC's potential clinical applications. Different ratios of mMBG/CPC composite bone cement showed good injectability and disintegration resistance, but with increasing mMBG addition, the working/setting time and compressive strength decreased. The maximum additive amount was 10 wt.% mMBG due to the working time of ~5 min, the setting time of ~10 min, and the compressive strength of ~51 MPa, indicating that it was more suitable for clinical surgical applications than the other groups. The 2Genta@mMBG group loaded with 2 mg/mL gentamicin had good antibacterial activity, and the 10 wt.% 2Genta@mMBG/CPC composite bone cement still had good antibacterial activity but reduced the initial release of Genta. 2Genta@mMBG was found to have slight cytotoxicity, so 2Genta@mMBG was composited into CPC to improve the biocompatibility and to endow CPC with more advantages for clinical application.

Incorporation of Glutamic Acid or Amino-Protected Glutamic Acid into Poly(Glycerol Sebacate): Synthesis and Characterization.

Poly(glycerol sebacate) (PGS), a soft, tough elastomer with excellent biocompatibility, has been exploited successfully in many tissue engineering applications. Although tunable to some extent, the rapid in vivo degradation kinetics of PGS is not compatible with the healing rate of some tissues. The incorporation of L-glutamic acid into a PGS network with an aim to retard the degradation rate of PGS through the formation of peptide bonds was conducted in this study. A series of poly(glycerol sebacate glutamate) (PGSE) containing various molar ratios of sebacic acid/L-glutamic acid were synthesized. Two kinds of amino-protected glutamic acids, Boc-L-glutamic acid and Z-L-glutamic acid were used to prepare controls that consist of no peptide bonds, denoted as PGSE-B and PGSE-Z, respectively. The prepolymers were characterized using 1H-NMR spectroscopy. Cured elastomers were characterized using FT-IR, DSC, TGA, mechanical testing, and contact angle measurement. In vitro enzymatic degradation of PGSE over a period of 28 days was investigated. FT-IR spectroscopy confirmed the formation of peptide bonds. The glass transition temperature for the elastomer was found to increase as the ratio of sebacic acid/glutamic acid was increased to four. The decomposition temperature of the elastomer decreased as the amount of glutamic acid was increased. PGSE exhibited less stiffness and larger elongation at break as the ratio of sebacic acid/glutamic acid was decreased. Notably, PGSE-Z was stiffer and had smaller elongation at break than PGSE and PGSE-B at the same molar ratio of monomers. The results of in vitro enzymatic degradation demonstrated that PGSE has a lower degradation rate than does PGS, whereas PGSE-B and PGSE-Z degrade at a greater rate than does PGS. SEM images suggest that the degradation of these crosslinked elastomers is due to surface erosion. The cytocompatibility of PGSE was considered acceptable although slightly lower than that of PGS. The altered mechanical properties and retarded degradation kinetics for PGSE reflect the influence of peptide bonds formed by the introduction of L-glutamic acid. PGSE displaying a lower degradation rate compared to that for PGS can be used as a scaffold material for the repair or regeneration of tissues that are featured by a low healing rate.

Surgical stabilization of the ipsilateral scapula and rib fractures using the mirror Judet approach: a preliminary result.

BACKGROUND: We report our preliminary results using a single approach, the mirror Judet approach, for patients with both ipsilateral scapula and multiple rib fractures. METHODS: Five consecutive patients [median age: 56 years (range: 44 ~ 60)] with ipsilateral scapula and multiple rib fractures that met the surgical indications were retrospectively reviewed. A single approach, the mirror Judet approach, was used for surgical stabilization of the scapula and targeted rib fractures. Thoracoscopic surgery was performed first for management of associated lung lesions and marking the targeted rib. All patients received the same rehabilitation protocol and a minimum 12-month follow-up. RESULTS: All surgically-fixed fractures eventually united without malunion. No complaints of intercostal neuralgia, infection, or other complications were seen. The mean range of motion in the injured shoulder returned to at least 90% of the contralateral side range. The mean Disabilities of the Arm, Shoulder, and Hand score at the 12th month was 2.0 (range: 0-7). All patients were able to return to their previous work. CONCLUSION: The mirror Judet approach allows for the surgical stabilization of the ipsilateral scapula and multiple rib fractures using the same approach and provides acceptable functional outcomes in well-selected patients. LEVEL OF EVIDENCE: Level IV.

Hyaluronic acid-based interpenetrating network hydrogel as a cell carrier for nucleus pulposus repair.

Hyaluronic acid (HA) is a key component of the intervertebral disc (IVD) that is widely investigated as an IVD biomaterial. One persisting challenge is introducing materials capable of supporting cell encapsulation and function, yet with sufficient mechanical stability. In this study, a hybrid interpenetrating polymer network (IPN) was produced as a non-covalent hydrogel, based on a covalently cross-linked HA (HA-BDDE) and HA-poly(N-isopropylacrylamide) (HA-pNIPAM). The hybrid IPN was investigated for its physicochemical properties, with histology and gene expression analysis to determine matrix deposition in vitro and in an ex vivo model. The IPN hydrogel displayed cohesiveness for at least one week and rheological properties resembling native nucleus pulposus (NP) tissue. When implanted in an ex vivo IVD organ culture model, the IPN supported cell viability, phenotype expression of encapsulated NP cells and IVD matrix production over four weeks under physiological loading. Overall, our results indicate the therapeutic potential of this HA-based IPN hydrogel for IVD regeneration.

Musculoskeletal injuries and management of victims from collapsed buildings in the 2016 Taiwan earthquake: Experiences in a tertiary medical center.

BACKGROUND: Previous studies have seldom focused on injury patterns, especially musculoskeletal injuries, caused by building collapse during earthquakes. The aim of this study was to investigate the musculoskeletal injury profiles and management of patients rescued from collapsed buildings in the 2016 Taiwan earthquake. METHODS: We conducted a retrospective study using the electronic medical record (EMR) system. We enrolled 31 patients rescued from specific collapsed buildings (the WJ group) and 56 patients injured in the same earthquake as a control group. We investigated the admission history, injury profile, treatment, and outcomes for these patients. RESULTS: The WJ group (51%) had significantly higher admission rates compared to the control group (25%) (p = 0.012). Although the odds ratio (OR) of fracture incidence was lower in the WJ group (OR: 0.79), there was a higher OR of multiple fractures (OR: 2.617) and axial skeletal fractures (OR: 2.893 for vertebral fracture, and OR: 1.893 ribs for rib fractures) in the WJ group. Among the 28 fracture patients, 9 (32.1%) underwent surgical interventions. A higher incidence of rhabdomyolysis was noted in the WJ group (OR: 34.73). Also, all 5 rhabdomyolysis cases combined with acute kidney injury were in the WJ group, and 1 of them required emergent hemodialysis for severe hyperkalemia. CONCLUSION: Patients extricated from collapsed buildings have a higher incidence of multiple fractures and axial skeletal fractures. More severe soft tissue injuries, including rhabdomyolysis and compartment syndrome, were also identified. The medical system should develop rescue and treatment strategies for this rare situation.

Antibacterial polypeptide/heparin composite hydrogels carrying growth factor for wound healing.

We report an efficient growth factor delivering system based on polypeptide/heparin composite hydrogels for wound healing application. Linear and star-shaped poly(l-lysine) (l-PLL and s-PLL) were chosen due to not only their cationic characteristics, facilitating the efficient complexation of negatively charged heparin, but also the ease to tune the physical and mechanical properties of as-prepared hydrogels simply by varying polypeptide topology and chain length. The results showed that polymer topology can be an additional parameter to tune hydrogel properties. Our experimental data showed that these composite hydrogels exhibited low hemolytic activity and good cell compatibility as well as excellent antibacterial activity, making them ideal as wound dressing materials. Unlike other heparin-based hydrogels, these composite hydrogels with heparin densely deposited on the surface can increase the stabilization and concentration of growth factor, which can facilitate the healing process as confirmed by our in vivo animal model. We believe that these PLL/heparin composite hydrogels are promising wound dressing materials and may have potential applications in other biomedical fields.

Clinical feasibility of the augmented reality computer-assisted spine surgery system for percutaneous vertebroplasty.

PURPOSE: This study aimed to demonstrate that the augmented reality computer-assisted spine surgery (ARCASS) system is clinically feasible for percutaneous vertebroplasty (PVP). METHODS: This prospective case-control study included the patients undergoing PVP under the assistance of the ARCASS system between July 1, 2013, and October 31, 2014. The control group was the age- and gender-matched patients who underwent standard PVP and met the same eligible criteria as the case group. Primary outcome was the frequency of fluoroscopy. Secondary outcomes were the accuracy of bony entry point and operative time. RESULTS: Eighteen patients were included in this study: 9 patients with 11 levels of lesions in the ARCASS group and 9 patients with 10 levels of lesions in the control group. Compared with the control group, the ARCASS group had significantly less frequency of fluoroscopy (6 vs. 18, P < 0.001) and shorter operative time (78 vs. 205 s, P < 0.001) during the process of entry point identification and local anesthesia, which started from the registration of skin entry point at lesion site to the end of bony entry point identification. Regarding accuracy, the ARCASS group had significant greater proportion of 'good' entry point than the control group on lateral views (81.8% vs. 30.0%, P = 0.028) and anteroposterior views (72.7% vs. 20.0%, P = 0.020). CONCLUSION: This study revealed that the ARCASS system was clinically feasible for PVP. The guidance of ARCASS system provided more accurate bony entry point with reduced operative time and unnecessary radiation exposure.

Use of Aligned Microscale Sacrificial Fibers in Creating Biomimetic, Anisotropic Poly(glycerol sebacate) Scaffolds.

Poly(glycerol sebacate) (PGS) is a biocompatible, biodegradable elastomer that has been shown promise as a scaffolding material for tissue engineering; it is still challenging, however, to produce anisotropic scaffolds by using a thermoset polymer, such as PGS. Previously, we have used aligned sacrificial poly(vinyl alcohol) (PVA) fibers to help produce an anisotropic PGS membrane; a composite membrane, formed by embedding aligned PVA fibers in PGS prepolymer, was subjected to curing and subsequent PVA removal, resulting in aligned grooves and cylindrical pores on the surface of and within the membrane, respectively. PVA, however, appeared to react with PGS during its curing, altering the mechanical characteristics of PGS. In this study, aligned sacrificial fibers made of polylactide (PLA) were used instead. Specifically, PLA was blend-electrospun with polyethylene oxide to increase the sacrificial fiber diameter, which in turn increased the size of the grooves and cylindrical pores. The resultant PGS membrane was shown to be in vitro cyto-compatible and mechanically anisotropic. The membrane's Young's modulus was 1-2 MPa, similar to many soft tissues. In particular, the microscale grooves on the membrane surface were found to be capable of directing cell alignment. Finally, based on the same approach, we fabricated a biomimetic, anisotropic, PGS tubular scaffold. The compliance of the tubular scaffold was comparable to native arteries and in the range of 2% to 8% per 100 mmHg, depending on the orientations of the sacrificial fibers. The anisotropic PGS tubular scaffolds can potentially be used in vascular tissue engineering.

Preparation of aligned poly(glycerol sebacate) fibrous membranes for anisotropic tissue engineering.

The use of fibrous scaffolds for tissue repair or regeneration is advantageous for its microstructure similar to that of the native ECM. Aligned fibrous scaffold, in particular, can be used to manipulate cell alignment and hence the microstructure of the resultant tissue. In our previous study, nanofibers consisting of solely poly(glycerol sebacate) (PGS) have been successfully fabricated using core-shell coaxial electrospinning followed by curing and subsequent shell removal. When we tried to fabricate aligned PGS fibrous membranes by collecting the electrospun fibers on a rapidly rotating drum, however, loss of fibrous structure was observed upon curing. This might be due to the broken fibers that were collected under tension; the core PGS prepolymer that melts at high temperature could leak from the broken ends during curing. In this study, attempts were made to reduce the possibility of the fiber breakage. At each stage of preparation, fiber morphology was examined by SEM and fiber compositions were verified by Fourier transform infrared spectroscopy and differential scanning calorimetry. Mechanical properties of the aligned PGS fibrous membrane were evaluated by uniaxial tensile testing both in parallel and perpendicular to the principal fiber direction. SEM images showed that fibrous morphology was better preserved upon the adjustment of the shell composition and the rotational speed of the collector drum. The final PGS fibers remained to be aligned although the alignment was less strong than that of as-spun core-shell fibers. The aligned PGS fibrous membrane exhibited anisotropic mechanical properties with Young's modulus in parallel and perpendicular to the principal fiber direction being 0.98 ±â€¯0.04 MPa and 0.52 ±â€¯0.02 MPa, respectively. The aligned PGS fibrous membrane was capable of guiding the orientation of cultured cells and therefore has the potential to be used to fabricate structurally anisotropic tissue-engineered constructs.

Incorporation of Collagen in Calcium Phosphate Cements for Controlling Osseointegration.

In this study, we investigated the effect of supplementing a non-dispersive dicalcium phosphate-rich calcium phosphate bone cement (DCP-rich CPC) with type I collagen on in vitro cellular activities and its performance as a bone graft material. Varying amounts of type I collagen were added during the preparation of the DCP-rich CPC. In vitro cell adhesion, morphology, viability, and alkaline phosphatase (ALP) activity were evaluated using progenitor bone cells. Bone graft performance was evaluated via a rat posterolateral lumbar fusion model and osteointegration of the implant. New bone formations in the restorative sites were assessed by micro-computed tomography (micro-CT) and histological analysis. We found that the incorporation of collagen into the DCP-rich CPC was associated with increased cell adhesion, cell viability, and ALP activity in vitro. The spinal fusion model revealed a significant increase in bone regeneration. Additionally, better osseointegration was observed between the host bone and graft with the DCP-rich CPC supplemented with collagen than with the collagen-free DCP-rich CPC control graft. Furthermore, compared to the control graft, the results of micro-CT showed that a smaller amount of residual material was observed with the collagen-containing DCP-rich CPC graft compared with the control graft, which suggests the collagen supplement enhanced new bone formation. Of the different mixtures evaluated in this study (0.8 g DCP-rich CPC supplemented with 0.1, 0.2, and 0.4 mL type I collagen, respectively), DCP-rich CPC supplemented with 0.4 mL collagen led to the highest level of osteogenesis. Our results suggest that the DCP-rich CPC supplemented with collagen has potential to be used as an effective bone graft material in spinal surgery.

Fabrication of poly(glycerol sebacate) fibrous membranes by coaxial electrospinning: Influence of shell and core solutions.

Although poly(glycerol sebacate) (PGS) has enjoyed great success in soft tissue engineering, it remains challenging to fabricate PGS fibers. In this study, coaxial electrospinning, in which polylactide (PLA) was used to confine and draw PGS prepolymer, was used to fabricate PGS fibrous membranes. Specifically, effects of adding poly(ethylene oxide) (PEO), which was removed prior to curing, in the shell were investigated. Transmission and scanning electron microscopy were used to confirm core-shell structure and morphology of fibers, respectively. Both the removal of PEO or PLA in the shell and the efficacy of PGS curing were verified by Fourier transform infrared spectroscopy and differential scanning calorimetry. Mechanical properties of the membranes with different shell and core contents were examined. We found that the addition of PEO to the shell reduced Young׳s modulus of the resulting cured membrane and increased its elongation at break significantly, the latter indicating better PGS curing. Moreover, with the addition of PEO, increasing PGS prepolymer concentration further increased the elongation at break and appeared to enhance the structural integrity of fibers; PGS fibrous membranes (with no PLA shell) were thus successfully fabricated after the removal of PLA. The Young׳s modulus of the PGS fibrous membrane was ~0.47MPa, which is similar to that of PGS solid sheets and some soft tissues. Finally, the cytocompatibility of the electrospun membranes was validated by Alamar blue and LDH assays.

Comparison of three calcium phosphate bone graft substitutes from biomechanical, histological, and crystallographic perspectives using a rat posterolateral lumbar fusion model.

This study evaluated the effectiveness of three calcium phosphate bone graft substitutes with different chemical compositions on spinal fusion using a rat posterolateral lumbar fusion model. Specifically, two recently developed non-dispersive tetracalcium phosphate/dicalcium phosphate anhydrous-based calcium phosphate cements (CPCs), namely a CPC consisting of equimolar amounts of the two compounds (nd-CPC) and a CPC consisting of a two-fold greater amount of dicalcium phosphate anhydrous (DCP-rich CPC), were compared with a commercial calcium phosphate bone graft (c-CPG) consisting of hydroxyapatite (60%) and ß-tricalcium phosphate (40%). Single-level posterolateral lumbar fusion was performed at the L4-L5 vertebrae in fifteen adult rats (n=5 for each group). Spinal fusion was evaluated with radiographs, manual palpation, mechanical testing, micro-CT, and histology 8 weeks post-surgery. In particular, the crystallographic phases in the three substitutes were identified before and 8 weeks after their implantation. Manual palpation revealed stable constructs in nearly all of the spine specimens. The stiffness and bending load of fused spines in the two CPC groups were comparable to those in the c-CPG group. The radiographs specifically revealed implant resorption and bone remodeling in the DCP-rich CPC group. Analysis of 3D micro-CT images revealed that the bone volume ratio in the DCP-rich CPC group was significantly greater than those in the nd-CPC and c-CPG groups. Histology showed that the DCP-rich CPC group exhibited the highest degree of bone regeneration and osseointegration. Notably, DCP-rich CPC led to a pronounced phase transformation, generating the greatest amount of poorly crystalline apatite among the three groups, which together with adequate resorption may explain the aforementioned positive findings. We therefore conclude that of the bone graft substitutes considered, DCP-rich CPC has the greatest potential to be used in spinal fusion.

Real-time advanced spinal surgery via visible patient model and augmented reality system.

This paper presents an advanced augmented reality system for spinal surgery assistance, and develops entry-point guidance prior to vertebroplasty spinal surgery. Based on image-based marker detection and tracking, the proposed camera-projector system superimposes pre-operative 3-D images onto patients. The patients' preoperative 3-D image model is registered by projecting it onto the patient such that the synthetic 3-D model merges with the real patient image, enabling the surgeon to see through the patients' anatomy. The proposed method is much simpler than heavy and computationally challenging navigation systems, and also reduces radiation exposure. The system is experimentally tested on a preoperative 3D model, dummy patient model and animal cadaver model. The feasibility and accuracy of the proposed system is verified on three patients undergoing spinal surgery in the operating theater. The results of these clinical trials are extremely promising, with surgeons reporting favorably on the reduced time of finding a suitable entry point and reduced radiation dose to patients.

Polymethylmethacrylate augmentation of the pedicle screw: the cement distribution in the vertebral body.

Many studies have proven that the polymethylmethacrylate (PMMA) augmentation of the pedicle screw can significantly increase stiffness and strength of spinal fixation. Some major complications have also been reported. However, there are no reports discussing cement distribution and its morphology in the osteoporotic vertebral body, which is critical in the analysis of the biomechanical strength of the pedicle screw and the risk of cement leakage after pedicle screw augmentation. In this study, we used computed tomography (CT) to evaluate the cement distribution in the osteoporotic vertebral body after PMMA augmentation of a pedicle screw and to analyze the factors leading to cement leakage. Two groups of patients were studied. Group A consisted 25 osteoporotic patients (mean age of 73 years) with spinal instrumentation who had a total of 145 pedicle screws and cement augmentation with biopsy needles. Group B consisted of 23 osteoporotic patients (mean age of 74.6 years) with spinal instrumentation who had a total of 125 cannulated pedicle screws with cement augmentation. All patients had CT evaluation of the cement distribution in the vertebral body after the surgery. The cement distribution in the vertebrae was divided into four zones in the axial CT view: anterior one-third, middle third, and posterior third of vertebral body, and the pedicle. The morphology of the cement distribution around the pedicle screw was defined as scattered type or concentrate type. The leakage pattern was divided to anterior-lateral, posterior-lateral, and canal leakage. The correlations among bone mineral density (BMD), the cement leakage rate, and cement distribution morphology were also analyzed. The results showed that most augmented pedicle screws had cement extension into three of the four zones of the vertebral body (66.3%), followed by two zones (20%), all four zones (11.5%), and only one zone (2.2%). Overall, 123 screws (84.8%) in Group A and 108 screws (86.4%) in Group B had cement concentrate type distribution. The cement leakage rate in Group A is 18.3% and 13.6% in Group B. Patients with a BMD <0.6 g/cm(2) had significantly higher rates of cement leakage and tended toward a scattered cement distribution. There was only one patient who had a symptomatic leakage (sciatica) in Group B. We concluded that the cement distribution after pedicle screw augmentation with biopsy needle or cannulated screw technique was mostly localized in three zones of the vertebral body, and patients with lower BMD had a higher risk of cement leakage and scattered cement distribution.