Deep-learning reconstructed lumbar spine 3D MRI for surgical planning: pedicle screw placement and geometric measurements compared to CT.

PURPOSE: To test equivalency of deep-learning 3D lumbar spine MRI with "CT-like" contrast to CT for virtual pedicle screw planning and geometric measurements in robotic-navigated spinal surgery. METHODS: Between December 2021 and June 2022, 16 patients referred for spinal fusion and decompression surgery with pre-operative CT and 3D MRI were retrospectively assessed. Pedicle screws were virtually placed on lumbar (L1-L5) and sacral (S1) vertebrae by three spine surgeons, and metrics (lateral deviation, axial/sagittal angles) were collected. Vertebral body length/width (VL/VW) and pedicle height/width (PH/PW) were measured at L1-L5 by three radiologists. Analysis included equivalency testing using the 95% confidence interval (CI), a margin of ± 1 mm (± 2.08° for angles), and intra-class correlation coefficients (ICCs). RESULTS: Across all vertebral levels, both combined and separately, equivalency between CT and MRI was proven for all pedicle screw metrics and geometric measurements, except for VL at L1 (mean difference: - 0.64 mm; [95%CI - 1.05, - 0.24]), L2 (- 0.65 mm; [95%CI - 1.11, - 0.20]), and L4 (- 0.78 mm; [95%CI - 1.11, - 0.46]). Inter- and intra-rater ICC for screw metrics across all vertebral levels combined ranged from 0.68 to 0.91 and 0.89-0.98 for CT, and from 0.62 to 0.92 and 0.81-0.97 for MRI, respectively. Inter- and intra-rater ICC for geometric measurements ranged from 0.60 to 0.95 and 0.84-0.97 for CT, and 0.61-0.95 and 0.93-0.98 for MRI, respectively. CONCLUSION: Deep-learning 3D MRI facilitates equivalent virtual pedicle screw placements and geometric assessments for most lumbar vertebrae, with the exception of vertebral body length at L1, L2, and L4, compared to CT for pre-operative planning in patients considered for robotic-navigated spine surgery.

What is the Incidence of Suicide in Patients with Bone and Soft Tissue Cancer? : Suicide and Sarcoma.

BACKGROUND: Patients with cancer in the United States are estimated to have a suicide incidence that is approximately twice that of the general population. Patients with bone and soft tissue cancer often have physical impairments and activity limitations develop that reduce their quality of life, which may put them at high risk for depression, anxiety, and suicidal ideation. To our knowledge, there have been no large studies determining incidence of suicide among patients with bone and soft tissue cancer; this information might allow screening of certain high-risk groups. QUESTIONS/PURPOSES: To determine (1) the incidence of suicide in patients with bone and soft tissue cancer, (2) whether the incidence of suicide is greater in patients with bone and soft tissue cancer than it is in the general US population, and (3) any demographic and tumor characteristics associated with increased suicide incidence. METHODS: A retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) program was performed. A total of 23,620 patients with primary bone and soft tissue cancer were identified in this database from 1973 and 2013. Patients with a cause of death listed as "suicide and self-inflicted injury" were considered to have committed suicide and suicide incidences were determined for different demographic and tumor characteristics in this subset of patients. Patient data for age, gender, race, marital status, year of diagnosis, primary cancer site, cancer stage, course of treatment, and survival time were collected and analyzed. The incidence of suicide in patients with bone and soft tissue sarcoma was compared with the age-, gender-, and race-adjusted incidence of suicide in the general US population from 1970 to 2013 available from the National Center for Health Statistics through the SEER Program. RESULTS: The overall suicide incidence in this population was 32 per 100,000 person-years, which was higher than the age-, race-, and gender-adjusted US general population suicide incidence of 13 per 100,000 person-years. When compared with the incidence of suicide in matched subgroups of the general US population, a higher suicide incidence was observed in men (standardized mortality ratio [SMR], 2.49; 95% CI, 1.92-3.22; p < 0.001), patients of white race (SMR, 2.68; 95% CI, 1.94-3.56; p < 0.001), patients 21 to 30 years old (SMR, 4.40; 95% CI, 3.44-5.54; p < 0.001) and 61 to 70 years old (SMR, 3.27; 95% CI, 2.54-4.18; p < 0.001), patients with cancer of the vertebral column (SMR, 2.88; 95% CI, 2.13-3.83; p < 0.001) and pelvic bones (SMR, 2.75; 95% CI, 2.00-3.65; p < 0.001), and patients within the first 5 years of cancer diagnosis (SMR, 10.8; 95% CI, 9.19-12.61; p < 0.001). CONCLUSIONS: With identification of these characteristics that are associated with higher incidence of suicide, physicians should consider screening patients possessing these traits. By identifying at-risk patients, we can hope to reduce the incidence of suicide in this population by providing the treatment that these patients need. Further research must be done to determine how best to screen these patients and to identify the best interventions to reduce suicide incidence. LEVEL OF EVIDENCE: Level III, prognostic study.

Assessing intraoperative pedicle screw placement accuracy using biplanar radiographs compared to three-dimensional imaging.

To date, biplanar imaging (2D) has been the method of choice for pedicle screw (PS) positioning and verified for the anteroposterior view and (spinal midline) M-line method. In recent years, the use of intraoperative three-dimensional (3D) imaging has become available with the Gertzbein-Robbins system (GRS) to assess PS breach and positioning confirmation. The aim is to determine if 2D imaging is sufficient to assess PS position in comparison to advanced 3D imaging.Retrospective review of prospectively collected data from 204 consecutive adult patients who underwent posterior thoracic and lumbar instrumented fusion for degenerative spinal surgery by a single surgeon (2019-2022).Of the 204 patients, 187 (91.6%) had intraoperative images available for analysis. A total of 1044 PS implants were used; 922 (88.3%) were robotically placed. Postoperative CT scans were verified with M-line/GRS findings. Among 103 patients (50.5%) with a total of 362 screws, (34.7%) had postoperative CT, intraoperative 3D scan, and intraoperative 2D scan for analysis. Postoperative CT findings were consistent with all GRS findings, validating that 3D imaging was accurate. Screws (1%) were falsely verified by the M-line as 3D imaging confirmed false negative or positive findings.In our series, intraoperative 3D scan was as accurate as postoperative CT scan in assessing PS breach. A significant number of PS may be falsely read as accurate on 2D imaging, that is in fact inaccurate when assessed on 3D imaging. An intraoperative post-instrumentation 3D scan may be preferable to prevent postoperative recognition of a falsely verified screw on biplanar imaging.

Discrepancies in recommendations for return to regular activities after cervical spine surgery: A survey study.

Background: The recommended timing for returning to common activities after cervical spine surgery varies widely among physicians based on training background and personal opinion, without clear guidelines or consensus. The purpose of this study was to analyze spine surgeons' responses about the recommended timing for returning to common activities after different cervical spine procedures. Methods: This was a survey study including 91 spine surgeons. The participants were asked to complete an anonymous online survey. Questions regarding their recommended time for returning to regular activities (showering, driving, biking, running, swimming, sedentary work, and nonsedentary work) after anterior cervical decompression and fusion (ACDF), cervical disc replacement (CDR), posterior cervical decompression and fusion (PCDF), and laminoplasty were included. Comparisons of recommended times for return to activities after each surgical procedure were made based on surgeons' years in practice. Results: For ACDF and PCDF, there were no statistically significant differences in recommended times for return to any activity when stratified by years in practice. When considering CDR, return to non-sedentary work differed between surgeons in practice for 10 to 15 years, who recommended return at 3 months, and all other groups of surgeons, who recommended 6 weeks. Laminoplasty surgery yielded the most variability in activity recommendations, with earlier recommended return (6 weeks) to biking, non-sedentary work, and sedentary work in the most experienced surgeon group (>15 years in practice) than in all other surgeon experience groups (3 months). Conclusions: We observed significant variability in surgeon recommendations for return to regular activities after cervical spine surgery.

Readability assessment of patient educational materials for pediatric spinal conditions from top academic orthopedic institutions.

Background: The Internet has become a popular source of health information for patients and their families. Healthcare experts recommend that the readability of online education materials be at or below a sixth grade reading level. This translates to a standardized Flesch Reading Ease Score between 81 and 90, which is equivalent to conversational English. However, previous studies have demonstrated that the readability of online education materials of various orthopedic topics is too advanced for the average patient. To date, the readability of online education materials for pediatric spinal conditions has not been analyzed. The objective of this study was to assess the readability of online educational materials of top pediatric orthopedic hospital websites for pediatric spinal conditions. Methods: Online patient education materials from the top 25 pediatric orthopedic institutions, as ranked by the U.S. News and World Report hospitals for pediatric orthopedics, were assessed utilizing multiple readability assessment metrics including Flesch-Kincaid, Flesch Reading Ease, Gunning Fog Index, and others. Correlations between academic institutional ranking, geographic location, and the use of concomitant multimedia modalities with Flesch-Kincaid scores were evaluated using a Spearman regression. Results: Only 32% (8 of 25) of top pediatric orthopedic hospitals provided online health information at or below a sixth grade reading level. The mean Flesch-Kincaid score was 9.3 ± 2.5, Flesch Reading Ease 48.3 ± 16.2, Gunning Fog Score 10.7 ± 3.0, Coleman-Liau Index 12.1 ± 2.8, Simple Measure of the Gobbledygook Index 11.7 ± 2.1, Automated Readability Index 9.0 ± 2.7, FORCAST 11.3 ± 1.2, and Dale-Chall Readability Index 6.7 ± 1.4. There was no significant correlation between institutional ranking, geographic location, or use of video material with Flesch-Kincaid scores (p = 0.1042, p = 0.7776, p = 0.3275, respectively). Conclusion: Online educational material for pediatric spinal conditions from top pediatric orthopedic institutional websites is associated with excessively complex language which may limit comprehension for the majority of the US population. Type of study/Level of evidence: Economic and Decision Analysis/level III.

Readability assessment of patient educational materials for pediatric spinal deformity from top academic orthopedic institutions.

STUDY DESIGN: Cross-sectional analysis of patient educational materials from top pediatric orthopedic hospital websites. OBJECTIVE: To assess the readability of online educational materials of top pediatric orthopedic hospital websites for pediatric spinal deformity. The internet has become an increasingly popular source of health information for patients and their families. Healthcare experts recommend that the readability of online education materials be at or below a 6th-grade reading level. However, previous studies have demonstrated that the readability of online education materials on various orthopedic topics is too advanced for the average patient. To date, the readability of online education materials for pediatric spinal deformity has not been analyzed. METHODS: Online patient education materials from the top 25 pediatric orthopedic institutions, as ranked by the U.S. News and World Report hospitals for pediatric orthopedics, were accessed utilizing the following readability assessments: Flesch-Kincaid (FK), Flesch Reading Ease, Gunning Fog Index, Coleman-Liau Index, Simple Measure of the Gobbledygook Index (SMOG), Automated Readability Index, FORCAST, and the New Dale and Chall Readability. Correlations between academic institutional ranking, geographic location, and the use of concomitant multi-media modalities with FK scores were evaluated using a Spearman regression. RESULTS: Only 48% (12 of 25) of top pediatric orthopedic hospitals provided online information regarding pediatric spinal deformity at or below a 6th-grade reading level. The mean FK score was 9.0 ± 2.7, Flesch Reading Ease 50.8 ± 15.6, Gunning Fog Score 10.6 ± 3.1, Coleman-Liau Index 11.6 ± 2.6, SMOG index 11.7 ± 2.0, Automated Readability Index 8.6 ± 2.8, and Dale-Chall Readability Score 6.4 ± 1.4. There was no significant correlation between institutional ranking, geographic location, or use of multimedia with FK scores. CONCLUSION: Online educational material for pediatric spinal deformity from top pediatric orthopedic institutional websites are associated with poor readability.

Evaluation of Intra-articular Fracture Extension After Gunshot Wounds to the Lower Extremity: Plain Radiographs Versus Computer Tomography.

OBJECTIVE: This study was to compare the use of computer tomography with plain radiographs for the evaluation of intra-articular extension of long bone fractures in the lower extremity after low-energy gunshot wounds. DESIGN: Retrospective chart and radiographic review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Data were collected from a single institution from 2000 to 2014. Inclusion criteria consisted of patients greater than 17 years of age, low-velocity gunshot injuries causing fracture of the femur or tibia, plain radiographs with adequate films, and computed tomography (CT) imaging of the fracture. This consisted of 133 patients with 140 fractures. INTERVENTION: Intra-articular fracture extension was evaluated on initial plain radiographs and CTs. MAIN OUTCOME MEASURES: Comparison of "gold standard" CT with all reviewers' evaluation of plain radiographs. RESULTS: There were 140 total fractures; 108 were femoral fractures and 32 were tibial fractures. By comparing plain radiographs with the gold standard CT, the reviewers demonstrated correct diagnosis in 85% of intra-articular fractures and 96% of non-intra-articular fractures. In addition, the reviewers accurately diagnosed 70.8% of intra-articular extensions in the diaphysis and 70.5% in the metaphysis. The sensitivity and specificity for plain radiographs were 85.3% and 96.0%, respectively, for all locations. Metaphyseal and diaphyseal fractures demonstrated the poorest sensitivity at 80.7% and 82.1%, respectively. CONCLUSIONS: Low-energy gunshot wounds with fractures in the diaphyseal of the distal femur and all metaphyseal fractures warrant CT evaluation to better examine for intra-articular fracture extension. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minipool caprylic acid fractionation of plasma using disposable equipment: a practical method to enhance immunoglobulin supply in developing countries.

BACKGROUND: Immunoglobulin G (IgG) is an essential plasma-derived medicine that is lacking in developing countries. IgG shortages leave immunodeficient patients without treatment, exposing them to devastating recurrent infections from local pathogens. A simple and practical method for producing IgG from normal or convalescent plasma collected in developing countries is needed to provide better, faster access to IgG for patients in need. METHODOLOGY/PRINCIPAL FINDINGS: IgG was purified from 10 consecutive minipools of 20 plasma donations collected in Egypt using single-use equipment. Plasma donations in their collection bags were subjected to 5%-pH5.5 caprylic acid treatment for 90 min at 31°C, and centrifuged to remove the precipitate. Supernatants were pooled, then dialyzed and concentrated using a commercial disposable hemodialyzer. The final preparation was filtered online by gravity, aseptically dispensed into storage transfusion bags, and frozen at <-20°C. The resulting preparation had a mean protein content of 60.5 g/L, 90.2% immunoglobulins, including 83.2% IgG, 12.4% IgA, and 4.4% IgM, and residual albumin. There was fourfold to sixfold enrichment of anti-hepatitis B and anti-rubella antibodies. Analyses of aggregates (<3%), prekallicrein (5-7 IU/mL), plasmin (26.3 mU/mL), thrombin (2.5 mU/mL), thrombin-like activity (0.011 U/g), thrombin generation capacity (< 223 nM), and Factor XI (<0.01 U/mL) activity, Factor XI/XIa antigen (2.4 ng/g) endotoxin (<0.5 EU/mL), and general safety test in rats showed the in vitro safety profile. Viral validation revealed >5 logs reduction of HIV, BVDV, and PRV infectivity in less than 15 min of caprylic acid treatment. CONCLUSIONS/SIGNIFICANCE: 90% pure, virally-inactivated immunoglobulins can be prepared from plasma minipools using simple disposable equipment and bag systems. This easy-to-implement process could be used to produce immunoglobulins from local plasma in developing countries to treat immunodeficient patients. It is also relevant for preparing hyperimmune IgG from convalescent plasma during infectious outbreaks such as the current Ebola virus episode.

Incidence of Suicide in Patients With Head and Neck Cancer.

IMPORTANCE: Suicide rates among patients with cancer in the US are significantly higher than those of the general population. To our knowledge, large cohort studies examining suicide rates among patients with head and neck cancer have not been performed. OBJECTIVE: To identify incidence rate, trends, and risk factors of suicide in patients with cancer of the head and neck. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of geographic areas served by the Surveillance, Epidemiology, and End Results (SEER) program. In total, 350,413 cases of patients with head and neck cancer were recorded within the SEER registry between 1973 and 2011. Data analyses were performed in 2014. Incidence data were calculated from the subset of that population that had the cause of death category coded as "suicide and self-inflicted injury." EXPOSURES: Patients diagnosed as having a primary cancer of the head and neck region. MAIN OUTCOMES AND MEASURES: Influence of demographic factors, anatomic site of tumor, disease stage, and time since diagnosis on risk for suicide. RESULTS: Among 350,413 SEER registry patients with head and neck cancer, observed for 2,263,376 person-years, 857 suicides were identified with an age-, sex-, and race-adjusted suicide rate of 37.9/100,000 person-years. In contrast, the US general population suicide rate was 11.8 per 100,000 person-years. Suicide rates were higher in those treated with radiation alone (standardized mortality ratio [SMR], 5.12; 95% CI, 3.83-6.41) compared with those treated with surgery alone (SMR, 2.57; 95% CI, 1.66-3.49). The highest suicide risk was seen in patients with cancers of the hypopharynx (SMR, 13.91; 95% CI, 11.78-16.03) and larynx (SMR, 5.48; 95% CI, 4.14-6.81). CONCLUSIONS AND RELEVANCE: Patients with head and neck cancer have more than 3 times the incidence of suicide compared with the general US population. Furthermore, suicide rates were highest among those with cancers of the larynx and hypopharynx.

Impact of Triton X-100 on alpha 2-antiplasmin (SERPINF2) activity in solvent/detergent-treated plasma.

Large-pool solvent/detergent (SD) plasma for transfusion exhibits reduced alpha 2-antiplasmin (alpha2-AP; SERPINF2) functional activity. The reason for the loss of alpha2-AP has not been described and could be due to the SD incubation itself and/or to the processing steps implemented to remove the solvent and the detergent. We have studied alpha2-AP activity during six down-scale preparations of plasma virally-inactivated by 1% (v/v) TnBP combined with two different non-ionic detergents, either 1% Triton X-100 or 1% Triton X-45, at 31 degrees C for 4h. The SD-treated plasmas were then extracted with 7.5% (v/v) soybean oil, centrifuged at 3800 x g for 30 min, and subjected to hydrophobic interaction chromatography (HIC) to remove the SD agents. Control runs without TnBP and Triton were performed to evidence possible impacts of each process step on alpha2-AP activity. TnBP, Triton X-100, and Triton X-45 were measured at all stages of the processes to evaluate potential interferences with the alpha2-AP assay. Alpha 2-AP activity was about 10% that of starting plasma after 1% TnBP-1% Triton X-100 incubation and about 50% after oil extractions, centrifugation, and HIC. By contrast about 73% of the antiplasmin activity was found after the incubation with 1% TnBP and 1% Triton X-45, 88% after removal of the SD agents by oil extractions, 90% after centrifugation and 92% after HIC. The control runs performed without SD agents showed that the process steps did not affect the alpha2-AP activity. In conclusion, the agent altering alpha2-AP activity in SD-plasma is Triton X-100. The choice of detergents for the SD viral inactivation of therapeutic plasma fractions used in patients at risk of fibrinolysis should consider the impact on alpha2-AP activity.

A process for solvent/detergent treatment of plasma for transfusion at blood centers that use a disposable-bag system.

BACKGROUND: Solvent/detergent (S/D) inactivates enveloped viruses in plasma. The current technology requires a plasma fractionation facility and is applied to large plasma pools, which increases the cost and risks of exposure to S/D-resistant pathogens and lowers the content of protein S and alpha2-antiplasmin. Two S/D treatment procedures for single donations or minipools of plasma have been developed with a single-use bag system. STUDY DESIGN AND METHODS: Frozen plasma samples were thawed and treated in disposable bags with either 2 percent tri(n-butyl)phosphate (TnBP) at 37 degrees C or 1 percent TnBP and 1 percent Triton X-45 at 31 degrees C for 4 hours. Plasma samples were extracted three times with 7.5 percent sterile castor oil to remove TnBP and Triton X-45. The TnBP-treated plasma samples were further subjected to a clarifying centrifugation (3800 x g, 30 min). Final plasma samples were dispensed into individual bags and frozen at -30 degrees C. Plasma quality was assessed at each step of the procedures. RESULTS: Both processes yielded greater than 90 percent mean recovery of coagulation factors (clottable fibrinogen, von Willebrand factor, and factors VIII, V, VII, IX, X, and XI), anticoagulants (protein C, protein S), protease inhibitors (antithrombin, alpha2-antiplasmin), total protein, albumin, and immunoglobulins. Global coagulation tests of the treated plasma samples were normal. Final TnBP and Triton X-45 content was less than 10 and 50 ppm, respectively. CONCLUSION: S/D treatment of plasma can be performed in a closed-bag system under conditions that maintain plasma protein quality. The technology is simple, presents advantages over the industrial large-scale S/D plasma process, and could be performed in blood centers.