Peptide/glycyrrhizic acid supramolecular polymer: An emerging medical adhesive for dural sealing and repairing

Medical adhesives have emerged as potential materials for sealing, hemostasis and wound repairing in modern clinical surgery. However, most of existing medical adhesives are still far away from the clinical requirements for simultaneously meeting desirable tissue adhesion, safety, biodegradability, anti-swelling property, and convenient operability. Here, we present an entirely new kind of peptide-based underwater adhesives, which are constructed via cross-linked supramolecular copolymerization between cationic short peptides and glycyrrhizic acid (GA) in an aqueous solution. We revealed the unique molecular mechanism of the peptide/GA supramolecular polymers and underlined the importance of arginine residues in the enhancement of the bulk cohesion of the peptide/GA adhesive. We thus concluded a design guideline that the peptide sequence has to be encoded with multiple arginine termini and hydrophobic residues. The resulting adhesives exhibited effective tissue adhesion, robust cohesion, low cell cytotoxicity, acceptable hemocompatibility, inappreciable inflammation response, appropriate biodegradability, and excellent anti-swelling property. More attractively, the dried peptide/GA powder was able to rapidly self-gel into adhesives by absorbing water, suggesting conveniently clinical operability. Animal experiments showed that the peptide/GA supramolecular polymers could be utilized as reliable medical adhesives for dural sealing and repairing.

Clinical management of dural defects: A review

Dural defects are common in spinal and cranial neurosurgery. A series of complications, such as cerebrospinal fluid leakage, occur after rupture of the dura. Therefore, treatment strategies are necessary to reduce or avoid complications. This review comprehensively summarizes the common causes, risk factors, clinical complications, and repair methods of dural defects. The latest research progress on dural repair methods and materials is summarized, including direct sutures, grafts, biomaterials, non-biomaterial materials, and composites formed by different materials. The characteristics and efficacy of these dural substitutes are reviewed, and these materials and methods are systematically evaluated. Finally, the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.

Late presentation of dural tears: Two case reports and review of literature

BACKGROUND

The late presentation of dural tears (LPDT) has a low incidence rate and hidden symptoms and is easily ignored in clinical practice. If the disease is not treated in time, a series of complications may occur, including low intracranial pressure headache, infection, pseudodural cyst formation, and sinus formation. Here, we describe two cases of LPDT.

CASE SUMMARY

Two patients had sudden fever 1 wk after lumbar surgery. Physical examination showed obvious tenderness in the operation area. The patients were confirmed as having LPDT by lumbar magnetic resonance imaging and surgical exploration. One case was caused by continuous negative pressure suction and malnutrition, and the other was caused by decreased dural ductility and low postoperative nutritional status. The first symptom of both patients was fever, with occasional headache. Both patients underwent secondary surgery to treat the LPDT. Dural defects were observed and dural sealants were used to seal the dural defects, then drainage tubes were retained for drainage. After the operation, the patients were treated with antibiotics and the patients’ surgical incisions healed well, without fever or incision tenderness. Both recovered and were discharged 1 wk after the operation.

CONCLUSION

LPDT is a rare complication of spinal surgery or neurosurgery that has hidden symptoms and can easily be overlooked. Since it may cause a series of complications, LPDT needs to be actively addressed in clinical practice.

Interpretable machine learning models for predicting in-hospital death in patients in the intensive care unit with cerebral infarction

BACKGROUND

Research on patients with cerebral infarction in the Intensive Care Unit (ICU) is still lacking. Our study aims to develop and validate multiple machine-learning (ML) models using two large ICU databases-Medical Information Mart for Intensive Care version III (MIMIC-III) and eICU Research Institute Database (eRI)-to guide clinical practice.

METHODS

We collected clinical data from patients with cerebral infarction in the MIMIC-III and eRI databases within 24 h of admission. The opinion of neurologists and the Least Absolute Shrinkage and Selection Operator regression was used to screen for relevant clinical features. Using eRI as the training set and MIMIC-III as the test set, we developed and validated six ML models. Based on the results of the model validation, we select the best model and perform the interpretability analysis on it.

RESULTS

A total of 4,338 patients were included in the study (eRI:3002, MIMIC-III:1336), resulting in a total of 18 clinical characteristics through screening. Model validation results showed that random forest (RF) was the best model, with AUC and F1 scores of 0.799 and 0.417 in internal validation and 0.733 and 0.498 in external validation, respectively; moreover, its sensitivity and recall were the highest of the six algorithms for both the internal and external validation. The explanatory analysis of the model showed that the three most important variables in the RF model were Acute Physiology Score-III, Glasgow Coma Scale score, and heart rate, and that the influence of each variable on the judgement of the model was consistent with medical knowledge.

CONCLUSION

Based on a large sample of patients and advanced algorithms, our study bridges the limitations of studies on this area. With our model, physicians can use the admission information of cerebral infarction patients in the ICU to identify high-risk groups among them who are prone to in-hospital death, so that they could be more alert to this group of patients and upgrade medical measures early to minimize the mortality of patients.

Feasibility study of hallux valgus measurement with a deep convolutional neural network based on landmark detection

OBJECTIVE

To develop a deep learning algorithm based on automatic detection of landmarks that can be used to automatically calculate forefoot imaging parameters from radiographs and test its performance.

MATERIALS AND METHODS

A total of 1023 weight-bearing dorsoplantar (DP) radiographs were included. A total of 776 radiographs were used for training and verification of the model, and 247 radiographs were used for testing the performance of the model. The radiologists manually marked 18 landmarks on each image. By training our model to automatically label these landmarks, 4 imaging parameters commonly used for the diagnosis of hallux valgus could be measured, including the first-second intermetatarsal angle (IMA), hallux valgus angle (HVA), hallux interphalangeal angle (HIA), and distal metatarsal articular angle (DMAA). The reference standard was determined by the radiologists' measurements. The percentage of correct key points (PCK), intragroup correlation coefficient (ICC), Pearson correlation coefficient (r), root mean square error (RMSE), and mean absolute error (MAE) between the predicted value of the model and the reference standard were calculated. The Bland-Altman plot shows the mean difference and 95% LoA.

RESULTS

The PCK was 84-99% at the 3-mm threshold. The correlation between the observed and predicted values of the four angles was high (ICC: 0.89-0.96, r: 0.81-0.97, RMSE: 3.76-6.77, MAE: 3.22-5.52). However, there was a systematic error between the model predicted value and the reference standard (the mean difference ranged from - 3.00 to - 5.08°, and the standard deviation ranged from 2.25 to 4.47°).

CONCLUSION

Our model can accurately identify landmarks, but there is a certain amount of error in the angle measurement, which needs further improvement.

Spinal dural arteriovenous fistula 8 years after lumbar discectomy surgery: A case report and review of literature

BACKGROUND

Spinal dural arteriovenous fistula (SDAVF) is an extremely rare vascular malformation of the central nervous system that is often confused with degenerative spinal disorders due to similar early symptoms and clinical features. Here, we report a case of SDAVF recurrence 8 years after lumbar spine surgery and summarize relevant literature.

CASE SUMMARY

A 54-year-old male was admitted to our hospital complaining of lower back pain, numbness in both lower extremities and intermittent claudication. Subsequent imaging identified lumbar spinal stenosis. Following surgical treatment, the patient’s symptoms significantly resolved, and he was able to perform daily activities. However, similar symptoms appeared 8 years later, followed by confirmation of SDAVF diagnosis. The patient underwent neurosurgery 7 mo after symptom onset. The follow-up period lasted 14 mo, and the patient remains with marginal neurological symptoms.

CONCLUSION

This case highlights the importance of prompt SDAVF diagnosis. Due to its nonspecific clinical presentation, the clinical experience of the surgeon and definitive imaging examination are indispensable. Additionally, timely neurosurgery is effective and may significantly improve patient outcomes.

A novel computer navigation model guided unilateral percutaneous vertebroplasty for vertebral compression fracture: A case report

RATIONAL

Vertebral compression fracture (VCF) is one of the most common diseases in spinal surgery. Traditional percutaneous vertebroplasty (PVP) under fluoroscopy is an effective method to treat vertebral compression fracture. However, there is still a risk of vascular nerve injury and infection caused by inaccurate or repeated puncture. Therefore, the purpose of this paper was to assess the accuracy of unilateral PVP guided by screw view model of navigation (SVMN) for VCF.

PATIENT CONCERNS

A 59-year-old female patient suffered high falling injury, and with back pain as its main clinical symptom.

DIAGNOSES

The patient was diagnosed with a L1 VCF.

INTERVENTIONS

We placed the puncture needle under the guidance of SVMN to reach the ideal position designed before operation, and then injected the bone cement to complete the percutaneous kyphoplasty (PKP).

OUTCOMES

The operative time was 29.5 minutes, the puncture time was 1 time, the fluoroscopy time was 2.9 minutes, and the bone cement distribution was satisfactory. VAS and ODI scores were significant improved postoperatively. No surgical complications, including neurovascular injury and infection, were observed during 28-month follow up.

LESSONS

The SVMN guided percutaneous puncture needle insertion in PKP operation for VCF is an effective and safety technique. Besides, the SVMN has also been a contributor to reduce radiation doses and replace conventional fluoroscopy.

Combined 3-dimensional printing model and 3-dimensional fluoroscopic navigation to assist C2 pedicle screw insertion: A case report

RATIONALE

The misplaced cervical screw can cause catastrophic surgical complications, such as nerve root damage, vertebral artery compromise, spinal cord injury, and even paraplegia. Thus, the present study aims to describe a novel technique of 3-dimensional printing model (3DPM) combined with 3-dimensional fluoroscopic navigation (3DFN) to facilitate C2 pedicle screw insertion.

PATIENT CONCERNS

A 56-year-old male patient presented hypoesthesia of the trunk and extremities, accompanied by a walking disorder.

DIAGNOSES

Congenital atlantoaxial malformation with atlantoaxial dislocation.

INTERVENTIONS

He underwent an occipital cervical fusion. We used 3DPM and 3DFN technology to guide C2 pedicle screws insertion.

OUTCOMES

We inserted 2 pedicle screws and 4 lateral mass screws using the combined 3DPM and 3DFN technology. All screws were classified as excellent position postoperatively. The surgical duration, total fluoroscopic time, and the bleeding volume were 258 minutes, 3.9 minutes, and 237 mL, respectively. No surgical complications, such as neurological compromise, nonunion, dysphagia, infection, polypnea, fixation failure, pseudarthrosis formation, or revision surgery, were observed. The follow-up duration lasted 30 months.

LESSONS

The combination of 3DPM and 3DFN to promote C2 pedicle screws implantation is a safe, accurate, reliable, and useful technology, which can achieve an excellent therapeutic effect and avoid surgical complications. However, using the 3DPM and 3DFN technology may increase the financial burden of patients.

Spontaneous spinal epidural hematoma masquerading as atypical abdominal pain in a child: A case report

INTRODUCTION

There have been few case reports of abdominal pain as a symptom of spontaneous intraspinal hemorrhage. We herein describe a case involving a girl with paraplegia caused by spontaneous epidural hemorrhage in the thoracic spinal canal, characterized by abdominal pain.

PATIENT CONCERNS

An 8-year-old girl with sudden abdominal pain and back pain was misdiagnosed as having an abdominal disease until she had the symptom of paralysis.

DIAGNOSES

The patient was diagnosed with spontaneous intraspinal hemorrhage masquerading as atypical abdominal pain.

INTERVENTIONS

When the patient developed symptoms of lower extremity paralysis, thoracic magnetic resonance imaging was performed and epidural hemorrhage was found in the thoracic spinal canal. Surgical treatment was performed after the diagnosis was confirmed.

OUTCOMES

The patient could almost walk normally after 3 months. One year after surgery, the Frankel grade of spinal cord function was grade D. We continued to follow-up this patient.

CONCLUSION

The symptoms caused by intraspinal hemorrhage are mainly back pain with or without neurological dysfunction. However, sometimes atypical symptoms, such as abdominal and chest pain, can be identified in clinical settings. Emergency surgery is recommended as the treatment of choice for intraspinal hemorrhage with neurological dysfunction.

Computer navigation-assisted minimally invasive percutaneous screw placement for pelvic fractures

Pelvic fractures are often caused by high-energy injuries and accompanied by hemodynamic instability. Traditional open surgery has a large amount of bleeding, which is not suitable for patients with acute pelvic fracture. Navigation-guided, percutaneous puncture-screw implantation has gradually become a preferred procedure due to its advantages, which include less trauma, faster recovery times, and less bleeding. However, due to the complexity of pelvic anatomy, doctors often encounter some problems when using navigation to treat pelvic fractures. This article reviews the indications, contraindications, surgical procedures, and related complications of this procedure for the treatment of sacral fractures, sacroiliac joint injuries, pelvic ring injuries, and acetabular fractures. We also analyze the causes of inaccurate screw placement. Percutaneous screw placement under navigational guidance has the advantages of high accuracy, low incidence of complications and small soft-tissue damage, minimal blood loss, short hospital stays, and quick recovery. There is no difference in the incidence of complications between surgeries performed by new doctors and experienced ones. However, computer navigation technology requires extensive training, and attention should be given to avoid complications such as screw misplacement, intestinal injury, and serious blood vessel and nerve injuries caused by navigational drift.

Combined navigated drilling and arthroscopy facilitate minimally invasive surgical treatment of ulnar-radial joint dislocation caused by epiphyseal premature closure: A case report

RATIONALE

In this paper, the efficacy and safety of using navigated drilling and arthroscopy (NDA) to assist surgery for ulnar-radial joint dislocation caused by epiphyseal premature closure (EPC) are described. Deformity correction surgery was mentioned in the literature, but there were numerous complications, for example, poor correction, infection, neurovascular injury, osteofascial compartment syndrome, failure of internal fixation, and nonunion after osteotomy. In order to minimize surgical complications, we utilized navigated drilling to finish accuracy bone bridge resection and applied arthroscopy to assess wrist lesions.

PATIENT CONCERNS

An 11-year-old male patient showed swelling and pain of the left wrist.

DIAGNOSES

The patient was diagnosed with a postoperative of Kirschner wire internal fixation for epiphyseal injury, left lower ulnar-radial joint dislocation, left wrist deformity, and EPC.

INTERVENTIONS

A NDA was used to assist the bone bridge resection in this patient.

OUTCOMES

Pain was relieved clearly in the patient. Dorsiflexion increased from 60.8° to 85.3°, palmar flexion increased from 45.3° to 65.8°, supination increased from 41.3° to 69.5°, and pronation increased from 31.6° to 62.9°. The preoperative disabilities of the arm, shoulder, and hand (DASH) score was 86.1, which was increased to 16.4 postoperatively. Surgery designing lasted for 2 minutes, bone bridge resection lasted for 56 minutes, and fluoroscopic time was 2.4 minutes. Complications, for example, neurological injury, vascular injury, infection and deformity aggressive, were not found during the 5-month follow up.

LESSONS

The outcome of the present study suggests that the NDA maximizes the bone bridge resection accuracy in EPC treatment, which is made efficient by reducing surgical trauma and avoiding neurovascular injury. An experience was gained that in the process of bone bridge removal, the bit of navigated drill should be continuously washed with normal saline to cool down, so as to avoid damage of nerve caused by heat conduction.

Technology of percutaneous cannulated screw implantation using screw view model of navigation in Garden type I of femoral neck fracture: A case report

RATIONALE

The aim of the present study was to assess the efficacy and safety of percutaneous cannulated screw (PCS) implantation assisted by screw view model of navigation (SVMN) to treat femoral neck fracture (FNF).

PATIENT CONCERNS

A 42-year-old male patient suffered from a high falling injury, causing pain, swelling, deformity, and limited mobility on his right hip.

DIAGNOSES

He was diagnosed with Garden type I of FNF.

INTERVENTIONS

PCS implantation assisted by SVMN was used to treat fracture of femoral neck in this patient.

OUTCOMES

The follow up lasted for 48 months. A total of 3 screws were inserted into femoral neck, all exhibiting excellent position. The mean screw deviation was 0.43° and 5.73° of femoral neck-shaft and anteversion angle, respectively. The guide wire drilling attempt of each screw was one-time. The fluoroscopic time lasted 6.3 minutes, the Harris hip scores improved from 67 to 88, and the blood loss was 35 mL. It took 11.7 minutes for designing the screws, 13.9 minutes for implanting the guide wires, and 37.3 minutes for placing the screws. No clinical complications were found during 48-month follow-up visit, including head penetration, implant failure, fracture nonunion, and femoral head osteonecrosis.

LESSONS

The study revealed that SVMN is conducive to the PCS insertion for FNF. Our lesson is that the FNF must be well reduction before SVMN assisted PCS placement.

Multimodal intraoperative monitoring during surgical correction of scoliosis to avoid neurologic damage

The purpose of this study was to evaluate the application of multimodal intraoperative monitoring (MIOM) system in patients with congenital scoliosis (CS) and adolescent idiopathic scoliosis (AIS).Twelve patients who underwent posterior surgical correction of scoliosis for CS and AIS from June 2014 to July 2018 were enrolled in this study. During the operation, we monitored the functional status of the spinal cord by MIOM. An abnormal somatosensory evoked potential was defined as a prolonged latency of more than 10% or a peak-to-peak amplitude decline of more than 50% when compared to baseline. An abnormal transcranial motor evoked potential (TcMEP) was defined as a TcMEP amplitude decrease of more than 50%. A normal triggered electromyography response, which presented with the absence of an electrical response on stimulation at 8.2 mA, indicated that the pedicle screw was not in contact with the spinal cord or nerve root.A total of 12 patients underwent MIOM surgery, of which 9 patients with negative MIOM had no significant deterioration of neurological function postoperatively, and exhibited satisfactory surgical correction of scoliosis during follow-ups. However, the remaining 3 patients suffered from MIOM events, 2 patients had normal neurological function, and 1 patient had deteriorated neurological function postoperatively.Using MIOM in CS and AIS surgery could promptly detect iatrogenic neurological injury at the early stage. Therefore, rapid response by appropriate intraoperative interventions can be taken to minimize the injury. Besides, stable MIOM recordings encourage surgeons to correct scoliosis even when the Cobb angle of scoliosis was extremely large.

Screw view model of navigation in posterior corrective surgery for adolescent idiopathic scoliosis: A case report and technique note

RATIONALE

The purpose of this study is to introduce the application of screw view model of navigation (SVMN) for adolescent idiopathic scoliosis (AIS). It is a challenge to insert pedicle screw into the vertebral body of scoliosis, and the misplaced screw may lead to neurovascular injury. In order to minimize surgical complications, we used a novel method of SVMN technology to facilitate pedicle screw insertion.

PATIENT CONCERNS

Her mother brought her to our outpatient department upon noticing the girl's different heights of shoulders and unbalance of the trunk.

DIAGNOSES

She was diagnosed with AIS and syringomyelia.

INTERVENTIONS

We used an SVMN technology to assist pedicle screw insertion and correction surgery in this 20-year-old patient.

OUTCOMES

This study indicates that the SVMN could obtain a satisfactory surgical effect for AIS. The Cobb angle of segmental scoliosis (T7-L2) was 55° before surgery, and 3.5° after surgery, and the rate of correction was 93.6%. The segmental kyphosis (T7-L1) was 56.8° preoperatively and 32° postoperatively with the rate of correction of 43.6%. The distance between the center sacral vertical line (CSVL) and the C7 plumb line (CPL) was reduced from 56.2 mm to 0.2 mm, and the sagittal imbalance of 35.8 mm was improved to 3.5 mm. In addition, the misplacement of pedicle screws, the volume of blood loss, the operation time, and surgical complications were also recorded. The follow-up duration was 33 months.

LESSONS

The utilization of SVMN in AIS might reduce the incidence of screw misplacement and avoid neurovascular damage, as well as a satisfactory correction. The application of SVMN for AIS is an efficacious and safe method.

A novel computer navigation method for accurate percutaneous sacroiliac screw implantation: A technical note and literature review

The purpose of this study was to assess the accuracy of percutaneous sacroiliac screw (PSS) placement assisted by screw view model of navigation system for treatment of sacroiliac fractures.Data pertaining to 18 consecutive patients with posterior pelvic ring fracture who received sacroiliac screw fixation between January 2015 and July 2018 at the Second Hospital of Jilin University were retrospectively analyzed. Kirschner wires were placed under the guidance of navigation's screw view mode. The position of the screws was evaluated by computed tomography (CT) scan postoperatively. Fracture dislocation of sacroiliac joint was measured in axial, sagittal, and coronal views of 3 dimensional (3D) CT images preoperatively, postoperatively and at the last follow-up visit. The duration of trajectory planning, guide wire implantation time, screw placement time, intraoperative blood loss, and incidence of screw loosening and clinical complications were also assessed.A total of 27 screws were placed unilaterally or bilaterally into segments S1 or S2. Screw placement was rated as excellent for 88.9% of screws (n = 24), good for 7.4% (n = 2), and poor for 3.7% (n = 1). Preoperatively, the average fracture dislocation of sacroiliac joint on axial, sagittal, and coronal views was 14.3 mm, 9.6 mm, and 7.4 mm, respectively, and the corresponding postoperative figures were 5.6 mm, 3.2 mm, 4.1 mm, respectively. The corresponding correction rates were 60.8%, 66.7%, and 44.6%, respectively. The mean duration of trajectory planning was 6.5 min (2.7-8.9 min). Mean screw implantation time was 32 min (range, 20-53 min), and the mean guide wire implantation time was 3.7 min (range, 2.1-5.3 min). No clinical complications such as neurovascular injury, infection or screw loosening were observed on follow-up.The PSS placement under guidance of screw view model of navigation is a convenient, safe and reliable method.

Accuracy and safety of percutaneous periacetabular screw insertion using screw view model of navigation in acetabular fracture: A case report

RATIONALE

The purpose of this study was to estimate the efficacy and safety of percutaneous periacetabular screw (PPS) insertion assisted by screw view model of navigation (SVMN) to treat fracture of acetabulum.

PATIENT CONCERNS

A 61-year-old male patient was injured in a motorcycle accident, which caused pain, swelling, deformity and limited mobility on his right hip.

DIAGNOSES

He was diagnosed with fracture of acetabulum.

INTERVENTIONS

We used PPS insertion assisted by SVMN to treat fracture of acetabulum in this patient.

OUTCOMES

The follow up lasted 24 months. Totally 2 screws were inserted into anterior and posterior column of acetabulum respectively and both of them displayed grade 0. Compared with the preoperative gap and step of fracture displacement, the postoperative ones were significantly reduced. It took 11.7 minutes for designing the screws, 6.7 minutes for implanting the guide wire, and 45.5 minutes for placing the screws. Intraoperative blood loss was 29 mL and total fluoroscopic time was 4.1 minutes. No clinical complications such as nerve vascular injury, infection and screw loosening were found after the operation.

LESSONS

The study indicated that SVMN is favorable to the PPS insertion for acetabular fracture. Our lesson is that the relative position between the acetabular and the patient tracker must be static to ensure the accuracy of the entire system throughout the operation.

A screw-view model of navigation aid retrograde transpubic screw fixation for anterior pelvic ring fracture: A case report with 28 months follow-up and technical note

RATIONALE

The purpose of this study was to evaluate the accuracy of a retrograde transpubic screw fixation assisted by a screw-view model of navigation in treating a pelvic fracture.

PATIENT CONCERNS

A 30-year-old female patient injured in a motor vehicle accident, displayed symptoms characterized by swelling and pain of the pudendum.

DIAGNOSES

The patient was diagnosed with a fracture of the pubic ramus.

INTERVENTIONS

We used a screw-view model of navigation to assist our retrograde transpubic screw fixation in this patient.

OUTCOMES

In total, 2 screws were inserted into the bilateral pubic ramus and both were excellently positioned. It took 7.4 minutes to design the screws, 8.1 minutes to implant the guidewire, and 39.3 minutes to place the screws. Intraoperative blood loss amounted to 21 mL and the total fluoroscopic time was 3.8 minutes. No clinical complications, such as neurologic, vascular, or urologic injury, infection, screw loosening, or loss of reduction, were found after the operation. Follow-up lasted 28 months.

LESSONS

The outcome of our study suggests that the screw-view model of navigation maximizes the retrograde transpubic screw insertion accuracy in the treatment of a pubic ramus fracture, which is made efficient by pain relief and early out-of-bed mobilization. Our suggestion is, therefore, that the relative position between the pubic ramus and the patient tracker must be static to ensure the accuracy of the entire system throughout the operation.

Combined 3D rapid prototyping and computer navigation facilitate surgical treatment of congenital scoliosis: A case report and description of technique

RATIONALE

This study describes the technique of combined Orbic 3D navigation (O3DN) and 3D rapid prototyping (3DRP) to assist surgical correction of congenital scoliosis.

PATIENT CONCERNS

A 12-year-old boy with congenital scoliosis. His father brought him to our hospital upon noticing the boy's asymmetry of the trunk.

DIAGNOSES

Congenital scoliosis.

INTERVENTIONS

O3DN and 3DRP were used to assist correction surgery in this patient.

OUTCOMES

The Cobb angle of segmental scoliosis (T8-L2) was 46.9° preoperatively and 2.3° at the last postoperative follow-up; correction was 95.1%. The average segmental kyphosis (T5-T12) was 45.2° preoperatively and 18.6° at the postoperative follow-up; correction was 58.9%. The preoperative sagittal imbalance of 56.2 mm was improved to 9.7 mm. The mean distance between the center sacral vertical line and the C7 plumb line was reduced from 5.7 to 4.1 mm. Operative time and bleeding volume was impressively little, with no misplacement of pedicle screws or other surgical complications.

LESSONS

Combined 3DRP and O3DN helped achieve satisfactory correction for this case of congenital scoliosis. The application of 3DRP aided by O3DN in surgical treatment of congenital scoliosis can reduce operative time, lessen blood loss, reduce screw misplacement, and avoid neurovascular damage. However, patients' hospital costs were greater. Our lessons learnt are that the relative position between the tracker and the pedicle must be static to ensure the accuracy of the whole system during the entire operation.

Multimodal intraoperative monitoring during reduction of spine burst fracture and dislocation prevents neurologic injury

This study aims to evaluate the application of multimodal intraoperative monitoring (MIOM) in surgical treatment for spine burst fracture and dislocation (SBFD) patients.Eleven patients who underwent posterior reduction and instrumentation (PRI) for SBFD from June 2014 to July 2016 were included into the study. The function of the spinal cord was monitored by MIOM. The muscle strength of the lower extremities and American Spinal Injury Association (ASIA) scores were, respectively, evaluated (before surgery, and at 1, 3, 6, and 12 months after surgery). Furthermore, the extent of reduction was also assessed.Muscle strength recovery, ASIA score changes, and the extent of reduction were correlated with MIOM results. Among the 11 patients who received surgery under MIOM, 8 patients with negative MIOM results during the operation did not demonstrate neurological deterioration postoperatively and exhibited improvements in ASIA scores during follow-ups. However, among the 3 patients who encountered MIOM events (case 4, 7, and 8), 2 patients avoided nerve lesion and 1 patient suffered from neurologic deterioration postoperatively.The application of MIOM technology during PRI surgery may detect spinal cord impairment at the early stage, and operative schemes can be modified before permanent nerve compromise is triggered by surgical manipulation.

Knockdown of long non-coding RNA HOXD-AS1 inhibits the progression of osteosarcoma

Long non-coding RNA HOXD-AS1 (HOXD-AS1) has recently been shown to be involved in the development and progression of multiple cancers. However, the expression, significance, and biological function of HOXD-AS1 in osteosarcoma (OS) remain unknown. Here, we found that the expression level of HOXD-AS1 was significantly upregulated in OS tissues and cells. Furthermore, high expression of HOXD-AS1 was positively associated with the clinical and pathological characteristics of OS, including tumor stage and lymph node metastasis, and negatively correlated with overall survival rate. in vitro assays confirmed that knockdown of HOXD-AS1 suppressed cell proliferation, colony formation, migration, and invasion, and promoted cell cycle arrest at G1 stage and apoptosis in OS cells. in vivo assays confirmed that knockdown of HOXD-AS1 significantly decreased tumor growth in xenograft mice, and decreased tumor size and weight. Importantly, we also showed that knockdown of HOXD-AS1 significantly reduced signal transducer and activator of transcription 3 and its target protein (CyclinD1, Bcl-2, and MMP-2) expression in vitro and in vivo. Moreover, overexpression of STAT3 could reverse the suppression of proliferation ability induced by sh-HOXD-AS1 in U2OS cells. Collectively, our data indicated that HOXD-AS1 might be an oncogenic long non-coding RNA (lncRNA) and might be a potential attractive therapeutic target for OS.

Chitin Oligosaccharide (COS) Reduces Antibiotics Dose and Prevents Antibiotics-Caused Side Effects in Adolescent Idiopathic Scoliosis (AIS) Patients with Spinal Fusion Surgery

Antibiotics are always considered for surgical site infection (SSI) in adolescent idiopathic scoliosis (AIS) surgery. However, the use of antibiotics often causes the antibiotic resistance of pathogens and side effects. Thus, it is necessary to explore natural products as drug candidates. Chitin Oligosaccharide (COS) has anti-inflammation and anti-bacteria functions. The effects of COS on surgical infection in AIS surgery were investigated. A total of 312 AIS patients were evenly and randomly assigned into control group (CG, each patient took one-gram alternative Azithromycin/Erythromycin/Cloxacillin/Aztreonam/Ceftazidime or combined daily), experiment group (EG, each patient took 20 mg COS and half-dose antibiotics daily), and placebo group (PG, each patient took 20 mg placebo and half-dose antibiotics daily). The average follow-up was one month, and infection severity and side effects were analyzed. The effects of COS on isolated pathogens were analyzed. SSI rates were 2%, 3% and 8% for spine wounds and 1%, 2% and 7% for iliac wound in CG, EG and PG (p < 0.05), respectively. COS reduces the side effects caused by antibiotics (p < 0.05). COS improved biochemical indexes and reduced the levels of interleukin (IL)-6 and tumor necrosis factor (TNF) alpha. COS reduced the antibiotics dose and antibiotics-caused side effects in AIS patients with spinal fusion surgery by improving antioxidant and anti-inflammatory activities. COS should be developed as potential adjuvant for antibiotics therapies.

Does heterotopic ossification affect the outcomes of cervical total disc replacement? A meta-analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVE

The purpose of this study was to answer the following questions: (1) Does heterotopic ossification (HO) negatively influence clinical outcomes after cervical total disc replacement (CTDR)? (2) Should patients be classified into HO and non-HO groups? (3) Is there a more rational classification?

SUMMARY OF BACKGROUND DATA

Heterotopic ossification has emerged as a common complication after CTDR and has been an important reason for reoperation, thus limiting the use of the surgery. However, the influence of HO on clinical outcomes after CTDR has not been well established.

METHODS

A meta-analysis was conducted with studies identified by searches of MEDLINE, EMBASE, and the Cochrane Library. We calculated the weighted mean differences of the visual analogue scale pain score, Neck Disability Index, and range of motion (ROM). Patients were classified into 2 groups under 3 classifications on the basis of the grade of HO. Results were pooled using a fixed effect model or a random effects model, according to the heterogeneity.

RESULTS

There were significant differences in ROM under all 3 classifications. The visual analogue scale pain score and the Neck Disability Index between the patients with and without HO showed no significant difference after CTDR. Significant differences in visual analogue scale pain score were observed when patients were classified into a "high-grade HO" group (McAfee grades 3 or 4 HO) and a "low-grade HO" group (McAfee grade 0, 1, or 2 HO).

CONCLUSIONS

The presence of HO is not associated with clinical outcomes after CTDR. However, the severity of HO actually impacts clinical outcomes in an inverse manner, which needs further investigation. It is inappropriate to classify patients on the basis of the presence of HO; further studies of the classifications (ROM-affecting HO vs. ROM-preserving HO; high-grade HO vs. low-grade HO) and cervical stability after CTDR are needed.

LEVEL OF EVIDENCE

2.