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Ahmed-Yahia S, Decousser JW, Flouzat-Lachaniette CH, Dervin G, Roubineau F, Audureau E, Hourdille A, Royer G, Eymard F, Chevalier X. Is the discopathy associated with Modic changes an infectious process? Results from a prospective monocenter study. PLoS One 2019; 14:e0221030. [PMID: 31415619 PMCID: PMC6695213 DOI: 10.1371/journal.pone.0221030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The local infectious origin and the putative role of Cutibacterium acnes (CA) of a particular subtype of discopathy (Modic 1) are still debated. PURPOSE To establish the association of CA in intervertebral disc (IVD) and Modic 1 discopathy in patients with low back pain. METHODS The prevalence of bacteria in IVD samples obtained by anterior approach in patient with chronic low back pain harboring Modic type 1, 2 or no Modic changes was compared to that measured in IVD samples obtained by posterior approach for sciatica. From 45 patients included in the study, 77 discs samples were obtained: 58 by anterior approach (32 Modic 1/2 changes, 26 without Modic change) and 19 by posterior approach. Conventional microbial cultures, universal 16S rRNA molecular detection and a CA specific PCR were performed. RESULTS 12 /77 (15.6%) disc samples were culture positive. Among the 10 CA positive cultures, 5 out of 58 (8.6%) were identified from specimens obtained by anterior approach and 5/19 (26.3%) from posterior approach (p = 0.046). Moreover, the percentage of CA culture positive sample was statistically no different between the patient with or without Modic changes. The CA prevalence was lower through molecular, culture-free approaches: the universal 16S rRNA PCR was positive for 6 specimens, including one CA positive sample and the CA specific PCR was positive for one specimen obtained by posterior approach. CONCLUSIONS In spine surgery the prevalence of CA in culture was significantly higher in IVD samples collected through a posterior approach compared to an anterior approach, suggesting a contamination process. This study did not support the CA related local infectious origin of Modic 1 discopathy.
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Affiliation(s)
- Salim Ahmed-Yahia
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Jean-Winoc Decousser
- Department of Bacteriology and Infection Control, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
- EA 7380 Dynamyc Université Paris-Est Créteil (UPEC), Ecole nationale vétérinaire d’Alfort (EnvA), Faculté de Médecine de Créteil, Créteil, France
- * E-mail:
| | | | - Guillaume Dervin
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - François Roubineau
- Orthopaedic Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Etienne Audureau
- Public Health Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Alexia Hourdille
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Guilhem Royer
- Department of Bacteriology and Infection Control, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Florent Eymard
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Xavier Chevalier
- Rheumatology Departement, University Hospital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
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Abstract
Cutibacterium acnes, long thought to be skin flora of pathological insignificance, has seen a surge in interest for its role in spine pathology. C acnes has been identified as a pathogen in native spine infection and osteomyelitis, which has implications in the management compared with more commonly recognized pathogens. In addition, It has also been recognized as a pathogen in postoperative and implant-associated infections. Some evidence exists pointing to C acnes as an unrecognized source of otherwise aseptic pseudarthrosis. Recently, it is hypothesized that low virulent organisms, in particular C acnes, may play a role in degenerative disk disease and the development of Modic end plate changes found in MRI. To this end, controversial implications exist in terms of the use of antibiotics to treat certain patients in the setting of degenerative disk disease. C acnes continues to remain an expanding area of interest in spine pathology, with important implications for the treating spine surgeon.
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Alpantaki K, Zafiropoulos A, Tseliou M, Vasarmidi E, Sourvinos G. Herpes simplex virus type-1 infection affects the expression of extracellular matrix components in human nucleus pulposus cells. Virus Res 2018; 259:10-17. [PMID: 30339788 DOI: 10.1016/j.virusres.2018.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 12/22/2022]
Abstract
Intervertebral disc (IVD) degeneration has a complex multifactorial origin and it is tightly associated with changes in the secretion of proteoglycans and collagen of the Nucleus Pulposus (NP) extracellular matrix. Chronic infection by Herpes virus has been previously associated with disc degeneration after detection of Herpes Simplex Virus type-1 (HSV-1) and CMV DNA in human excised disc samples. The aim of the present study was to assess the effect of HSV-1 infection on proteoglycan synthesis employing human Nucleus Pulposus (HNPCs) cells as a model of intervertebral disc degeneration. During lytic HSV-1 infection, a significant reduction of Decorin expression was observed 8 h post infection (h.p.i) which furthered deteriorated at 24 h.p.i. Biglycan was also reduced but only 24 h.p.i. Collagen type II, although demonstrated a downward trend, it was not statistically significant, whereas both Versican and Aggrecan showed a substantial decrease at 24 h.p.i. Hyaluronan production was not significantly affected. In a non-productive HSV-1 infection, a substantial reduction of Decorin, Biglycan, Versican and Aggrecan expression was found, similarly to our findings from the lytic infection. Furthermore, collagen type II expression was completely abolished. HAS1 expression was not affected, whereas HAS 2 and 3 were found to be significantly reduced. These results indicate that HSV-1 infection of human NP cells yields a complex effect on host extracellular cell function. The viral-induced changes in proteoglycan and collagen type II concentration may affect cell-matrix interactions and lead to a dysfunctional intervertebral disc which may trigger or promote the degeneration process.
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Affiliation(s)
- Kalliopi Alpantaki
- Laboratory of Clinical Virology, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Alexandros Zafiropoulos
- Laboratory of Clinical Virology, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Melpomeni Tseliou
- Laboratory of Clinical Virology, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Eirini Vasarmidi
- Laboratory of Clinical Virology, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece
| | - George Sourvinos
- Laboratory of Clinical Virology, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece.
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Ribosomal PCR assay of excised intervertebral discs from patients undergoing single-level primary lumbar microdiscectomy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2038-2044. [PMID: 28567591 DOI: 10.1007/s00586-017-5141-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 03/07/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the presence of infectious microorganisms in the herniated discs of immunocompetent patients, using methodology that we hoped would be of higher sensitivity and specificity than has been reported in the past. Recent studies have demonstrated a significant rate of positive cultures for low virulent organisms in excised HNP samples (range 19-53%). These studies have served as the theoretical basis for a pilot trial, and then, a well done prospective randomized trial that demonstrated that systemic treatment with antibiotics may yield lasting improvements in a subset of patients with axial back pain. Whether the reported positive cultures in discectomy specimens represent true positives is as yet not proven, and critically important if underlying the basis of therapeutic approaches for chronic low back pain. METHODS This consecutive case series from a single academic center included 44 patients with radiculopathy and MRI findings of lumbar HNP. Patients elected for lumbar microdiscectomy after failure of conservative management. All patients received primary surgery at a single spinal level in the absence of immune compromise. Excised disc material was analyzed with a real-time PCR assay targeting the 16S ribosomal RNA gene followed by amplicon sequencing. No concurrent cultures were performed. Inclusion criteria were as follows: sensory or motor symptoms in a single lumbar nerve distribution; positive physical examination findings including positive straight leg raise test, distributional weakness, and/or a diminished deep tendon reflexes; and magnetic resonance imaging of the lumbar spine positive for HNP in a distribution correlating with the radicular complaint. RESULTS The PCR assay for the 16S rRNA sequence was negative in all 44 patients (100%). 95% CI 0-8%. CONCLUSIONS Based on the data presented here, there does not appear to be a significant underlying rate of bacterial disc infection in immunocompetent patients presenting with radiculopathy from disc herniation.
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Chen Z, Cao P, Zhou Z, Yuan Y, Jiao Y, Zheng Y. Overview: the role of Propionibacterium acnes in nonpyogenic intervertebral discs. INTERNATIONAL ORTHOPAEDICS 2016; 40:1291-8. [PMID: 26820744 DOI: 10.1007/s00264-016-3115-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/06/2016] [Indexed: 10/22/2022]
Abstract
Propionibacterium acnes (P. acnes), an important opportunistic anaerobic Gram-positive bacterium, causes bone and joint infections, discitis and spondylodiscitis. Accumulated evidence suggested that this microbe can colonise inside intervertebral discs without causing symptoms of discitis. Epidemiological investigation shows that the prevalence ranges from 13 % to 44 %. Furthermore, colonisation by P. acnes inside nonpyogenic intervertebral discs is thought to be one pathogen causing sciatica, Modic changes and nonspecific low back pain. Specially, patients can attain significant relief of low back pain, amelioration of Modic changes and alleviation of sciatica after antibiotic therapy, indicating the role of P. acnes in these pathological changes. However, until now, there were hypotheses only to explain problems such as how P. acnes access intervertebral discs and what the exact pathological mechanism it employs during its latent infection period. In addition, research regarding diagnostic procedures and treatment strategies were also rare. Overall, the prevalence and possible pathological role that P. acnes plays inside nonpyogenic intervertebral discs is summarised in this paper.
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Affiliation(s)
- Zhe Chen
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Peng Cao
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China. .,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Zezhu Zhou
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ye Yuan
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yucheng Jiao
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.,Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases with Integrated Chinese-Western Medicine, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yuehuan Zheng
- Department of Orthopedics, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Modic Changes and Disc Degeneration Caused by Inoculation of Propionibacterium acnes inside Intervertebral Discs of Rabbits: A Pilot Study. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9612437. [PMID: 26925420 PMCID: PMC4746301 DOI: 10.1155/2016/9612437] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 01/14/2016] [Indexed: 02/04/2023]
Abstract
Purpose. To investigate whether P. acnes could induce disc degeneration and Modic changes when inoculated into the discs of rabbits. Method. A wild-type strain of P. acnes isolated from a patient associated with Modic change and disc degeneration was inoculated into the intervertebral discs of rabbits. Meanwhile, S. aureus was injected into the discs to establish a model of discitis as the comparison and a standard strain of P. acnes was inoculated as the control. MRI and histological change were observed. Results. Both the P. acnes-inoculated and S. aureus-inoculated rabbits showed hyperintense signals at endplates and hypointense signals at nucleus pulposus on T2WI. However, P. acnes only resulted in moderate disc degeneration and endplates rupture in histological examination, which was different from the pathological change of discitis caused by S. aureus. In addition, higher death rates (2/3 versus 0/5) were observed in S. aureus-inoculated rabbits. Conclusion. Compared to S. aureus, the pathological change caused by P. acnes would be considered as Modic-I change and disc degeneration rather than a discitis.
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Cai F, Wu XT, Xie XH, Wang F, Hong X, Zhuang SY, Zhu L, Rui YF, Shi R. Evaluation of intervertebral disc regeneration with implantation of bone marrow mesenchymal stem cells (BMSCs) using quantitative T2 mapping: a study in rabbits. INTERNATIONAL ORTHOPAEDICS 2014; 39:149-59. [PMID: 25117574 DOI: 10.1007/s00264-014-2481-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/24/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of the study was to investigate the curative effects of transplantation of bone marrow mesenchymal stem cells (BMSCs) on intervertebral disc regeneration and to investigate the feasibility of the quantitative T2 mapping method for evaluating repair of the nucleus pulposus after implantation of BMSCs. METHODS Forty-eight New Zealand white rabbits were used to establish the lumber disc degenerative model by stabbing the annulus fibrosus and then randomly divided into four groups, i.e. two weeks afterwards, BMSCs or phosphate-buffered saline (PBS) were transplanted into degenerative discs (BMSCs group and PBS group), while the operated rabbits without implantation of BMSCs or PBS served as the sham group and the rabbits without operation were used as the control group. At weeks two, six and ten after operation, the T2 values and disc height indices (DHI) were calculated by magnetic resonance imaging (MRI 3.0 T), and the gene expressions of type II collagen (COL2) and aggrecan (ACAN) in degenerative discs were evaluated by real-time reverse transcription polymerase chain reaction (RT-PCR). T2 values for the nucleus pulposus were correlated with ACAN or COL2 expression by regression analysis. RESULTS Cell clusters, disorganised fibres, interlamellar glycosaminoglycan (GAG) matrix and vascularisation were observed in lumber degenerative discs. BMSCs could be found to survive in intervertebral discs and differentiate into nucleus pulposus-like cells expressing COL2 and ACAN. The gene expression of COL2 and ACAN increased during ten weeks after transplantation as well as the T2 signal intensity and T2 value. The DHI in the BMSCs group decreased more slowly than that in PBS and sham groups. The T2 value correlated significantly with the gene expression of ACAN and COL2 in the nucleus pulposus. CONCLUSIONS Transplantation of BMSCs was able to promote the regeneration of degenerative discs. Quantitative and non-invasive T2 mapping could be used to evaluate the regeneration of the nucleus pulposus with good sensitivity.
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Affiliation(s)
- Feng Cai
- Department of Orthopedics, Zhong Da Hospital, Southeast University, Nanjing, China
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Perilli E, Parkinson IH, Truong LH, Chong KC, Fazzalari NL, Osti OL. Modic (endplate) changes in the lumbar spine: bone micro-architecture and remodelling. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:1926-34. [PMID: 25063369 DOI: 10.1007/s00586-014-3455-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 07/01/2014] [Accepted: 07/02/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE In the literature, inter-vertebral MRI signal intensity changes (Modic changes) were associated with corresponding histological observations on endplate biopsies. However, tissue-level studies were limited. No quantitative histomorphometric study on bone biopsies has yet been conducted for Modic changes. The aim of this study was to characterise the bone micro-architectural parameters and bone remodelling indices associated with Modic changes. METHODS Forty patients suffering from disabling low back pain, undergoing elective spinal surgery, and exhibiting Modic changes on MRI (Modic 1, n = 9; Modic 2, n = 25; Modic 3, n = 6), had a transpedicular vertebral body biopsy taken of subchondral bone. Biopsies were first examined by micro-CT, for 3D morphometric analysis of bone volume fraction (BV/TV), trabecular thickness (Tb.Th), trabecular separation, trabecular number, and structure model index. Then, samples underwent histological analysis, for determination of bone remodelling indices: osteoid surface to bone surface ratio (OS/BS), eroded surface to bone surface (ES/BS) and osteoid surface to eroded surface ratio (OS/ES). RESULTS Micro-CT analysis revealed significantly higher BV/TV (up to 70% increase, p < 0.01) and Tb.Th (up to +57%, p < 0.01) in Modic 3 biopsies, compared to Modic 1 and 2. Histological analysis showed significantly lower OS/BS in Modic 2 biopsies (more than 28% decrease, p < 0.05) compared to 1 and 3. ES/BS progressively decreased from Modic 1 to 2 to 3, whereas OS/ES progressively increased with significantly higher values in Modic 3 (up to 159% increase, p < 0.05) than in Modic 1 and 2. CONCLUSIONS Significant differences were found in bone micro-architectural parameters and remodelling indices among Modic types. Modic 1 biopsies had evidence of highest bone turnover, possibly due to an inflammatory process; Modic 2 biopsies were consistent with a reduced bone formation/remodelling stage; Modic 3 biopsies suggested a more stable sclerotic phase, with significantly increased BV/TV and Tb.Th compared to Modic 1 and 2, linked to increased bone formation and reduced resorption.
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Affiliation(s)
- Egon Perilli
- Medical Device Research Institute, School of Computer Science, Engineering and Mathematics, Flinders University, Sturt Rd., Bedford Park, South Australia, 5042, Australia,
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The Michel Benoist and Robert Mulholland Yearly European Spine Journal Review: a survey of the "surgical and research" articles in the European Spine Journal, 2013. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:9-18. [PMID: 24384830 DOI: 10.1007/s00586-013-3126-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Indexed: 10/25/2022]
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Benoist M. The Michel Benoist and Robert Mulholland Yearly European Spine Journal Review: a survey of the "medical" articles in the European Spine Journal, 2013. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23:1-8. [PMID: 24337322 DOI: 10.1007/s00586-013-3124-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Michel Benoist
- Département de Rhumatologie, Service de Chirurgie Orthopédique, Hôpital Beaujon, 100 Boulevard Général Leclerc, Clichy, 92118, Paris, France,
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Birkenmaier C. Should we start treating chronic low back pain with antibiotics rather than with pain medications? Korean J Pain 2013; 26:327-35. [PMID: 24155998 PMCID: PMC3800704 DOI: 10.3344/kjp.2013.26.4.327] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 09/17/2013] [Indexed: 01/29/2023] Open
Abstract
For those of us who have read the 2 recently published articles by a Danish - British research group, it might appear that we are observing an impending paradigm shift on the origins of chronic low back pain. The results of this research indicate, that chronic low back pain associated with bone marrow edema in vertebral endplates that are adjacent to herniated intervertebral discs may be caused by infections with anaerobic bacteria of low virulence. According to these articles, treatment with certain antibiotics is significantly more effective than placebo against this low back pain. If these findings are to hold true in repeat studies by other researchers, they stand to fundamentally change our concepts of low back pain, degenerative disc disease and in consequence the suitable therapies for these entities. It may in fact require pain specialists to become familiarized with the details of antibiotic treatments and their specific risks in order to be able to properly counsel their patients. While this seems hard to believe at first glance, bacteria have been implicated in the pathogenesis of other conditions that do not primarily impose as infectious diseases such as gastric ulcers. While the authors refer to a few previous studies pointing into the same direction, the relevant research is really only from one group of collaborating scientists. Therefore, before we start prescribing antibiotics for chronic low back pain, it is imperative that other researchers in different institutions confirm these results.
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Affiliation(s)
- Christof Birkenmaier
- Department of Orthopaedics, Ludwig-Maximilian-University Munich, Grosshadern Campus, Munich, Germany
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Almefty KK, Turner JD, Theodore N. From narcotics to antibiotics: evolving concepts in the treatment of lower back pain. World Neurosurg 2013; 80:442-3. [PMID: 24035987 DOI: 10.1016/j.wneu.2013.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Kaith K Almefty
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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