1
|
Lvov I, Grin A, Talypov A, Kordonskiy A, Tupikin A. Short-term and long-term results of odontoid screw fixation in patients with Type II and rostral Type III dens fractures. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:233-240. [PMID: 38821449 DOI: 10.1016/j.neucie.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES To evaluate both the short-term and long-term outcomes of odontoid screw fixation (OSF), identifying potential risk factors for implant-related complications in patients with odontoid fractures. METHODS This is a retrospective observational cohort study. Inclusion criteria were as follows: 1) Type II fractures and rostral Type III fractures, according to the Anderson and D'Alonzo classification; 2) patients older than 15 years. Exclusion criteria were: 1) other Type III injuries; 2) osteoporosis confirmed by densitometry or a CT bone density score below 100 Hounsfield units; 3) odontoid fractures related to tumors or aneurysmal bone cysts. RESULTS In total, 56 patients were considered for the analysis of short-term results, and 26 patients were evaluated for long-term outcomes. No significant differences were observed in the preoperative imaging data and intraoperative features of OSF between patients with Type II and rostral Type III fractures. The mean operative duration was 63.9 ± 20.9 min, and the mean intraoperative blood loss was 22.1 ± 22.9 ml. Screw cut-out was identified in four patients with rostral Type III fractures (p = 0.04). The rate of screw cut-out was found to correlate with the degree of dens fragment displacement. The bone fusion rate was 95.7%. CT scans identified stable pseudarthrosis in two cases. We observed C2-C3 ankylosis in all cases following partial disc resection. One third of patients with screws placed through the anterior lip of C2 showed no C2-C3 ankylosis. A strong trend towards lateral joint ankylosis formation in patients with a median lateral mass dislocation of 11.9 mm was observed. Most SF-36 scores either matched or exceeded the corresponding normal median values in the published reference database. CONCLUSIONS OSF is a reliable treatment method of Type II and rostral Type III odontoid fractures with fragment displacement of 4 mm or less. The minimally invasive OSF through the anterior-inferior lip of C2, using monocortical screw placement and cannulated instruments, without rigid intraoperative head immobilization, is sufficient to achieve favorable clinical and fusion results. This technique reduces the risk of ankylosis in the C2-C3 segment. OSF restore the quality of life for patients with odontoid fractures to levels comparable to those of the general population norm.
Collapse
Affiliation(s)
- Ivan Lvov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia.
| | - Andrey Grin
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Aleksandr Talypov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Anton Kordonskiy
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Aleksandr Tupikin
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| |
Collapse
|
2
|
Roch PJ, Salge E, Cabrera MAB, Klockner FS, Meier MP, Jäckle K, Lehmann W, Weiser L. Two-screw osteosynthesis is biomechanically superior to single-screw osteosynthesis for type II odontoid fractures. Sci Rep 2024; 14:18947. [PMID: 39147821 PMCID: PMC11327284 DOI: 10.1038/s41598-024-69905-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 08/09/2024] [Indexed: 08/17/2024] Open
Abstract
The data on the use of a one- or two-screw technique (1S, 2S) for ventral osteosynthesis of type II dens fractures are contradictory. The aim was to design an apparatus to mimic the physiological conditions and test stability with 1S, 2S, and a headless compression screw (HCS) for osteosynthesis of artificially created type II odontoid fractures. The apparatus was mounted on a Zwick materials testing machine. A total of 18 C1-2 specimens were stratified into three groups (1S, 2S, HCS). Odontoid fractures were artificially created, and osteosynthesis was performed. Each specimen was tested at loads increasing from 1 to 40 N. Screw loosening was observed visually, by fatigue data, and by a camera tracking system. Analysis of the Zwick data and the camera data revealed a significant higher stability after 2S compared to 1S and HCS treatment (Zwick data: p = 0.021, camera data: p < 0.001), while visible screw loosening showed a superiority of the 2S only over HCS (p = 0.038). The developed apparatus allowed the dynamic study of the atlantoaxial joint with a high approximation to physiological conditions. The results demonstrated superiority of the 2S over the 1S and HCS in biomechanical stability in the treatment of type II odontoid fractures.
Collapse
Affiliation(s)
- Paul Jonathan Roch
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - Elisa Salge
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Miguel Angel Bravo Cabrera
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Friederike Sophie Klockner
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Marc-Pascal Meier
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Katharina Jäckle
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Wolfgang Lehmann
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Lukas Weiser
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| |
Collapse
|
3
|
Müller JU, Nowak S, Matthes M, Pillich DT, Schroeder HWS, Müller J. Biomechanical comparison of two different compression screws for the treatment of odontoid fractures in human dens axis specimen. Clin Biomech (Bristol, Avon) 2024; 111:106162. [PMID: 38159327 DOI: 10.1016/j.clinbiomech.2023.106162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Lag screw osteosynthesis for odontoid fractures has a high rate of pseudoarthrosis, especially in elderly patients. Besides biomechanical properties of the different screw types, insufficient fragment compression or unnoticed screw stripping may be the main causing factors for this adverse event. The aim of the study was to compare two screws in clinical use with different design principles in terms of compression force and stability against screw stripping. METHODS Twelve human cadaveric C2 vertebral bodies were considered. Bone density was determined. The specimens were matched according to bone density and randomly assigned to two experimental groups. An odontoid fracture was induced, which were fixed either with a 3.5 mm standard compression screw or with a 5 mm sleeve nut screw. Both screws are certified for the treatment of odontoid fractures. The bone samples were fixed in a measuring device. The screwdriver was driven mechanically. The tests were analyzed for peak interfragmentary compression and screw-in torque with a frequency of 20 Hz. FINDINGS The maximum fragment compression was significantly higher with screw with sleeve nut at 346.13(SD ±72.35) N compared with classic compression screw at 162.68(SD ±114.13) N (p = 0.025). Screw stripping occurred significantly earlier in classic compression screw at 255.5(SD ±192.0)° rotation after reaching maximum compression than in screw with sleeve nut at 1005.2(SD ±341.1)° (p = 0.0039). INTERPRETATION Screw with sleeve nut achieves greater fragment compression and is more robust to screw stripping compared to classic compression screw. Whether the better biomechanical properties lead to a reduction of pseudoarthrosis has to be proven in clinical studies.
Collapse
Affiliation(s)
- Jan-Uwe Müller
- Department of Neurosurgery, University Medicine, Greifswald, Germany.
| | - Stephan Nowak
- Department of Neurosurgery, University Medicine, Greifswald, Germany
| | - Marc Matthes
- Department of Neurosurgery, University Medicine, Greifswald, Germany
| | | | | | - Jonas Müller
- Department of Neurosurgery, University Medicine, Greifswald, Germany
| |
Collapse
|
4
|
Jo WR, Lee CY, Kwon SM, Kim CH, Kwon MY, Kim JH, Ko YS. Does the Surgical Approach Matter in Treating Odontoid Fractures? A Comparison of Mechanical Complication Rates Between Anterior Versus Posterior Surgical Approaches: A Meta-Analysis and Systematic Review. Korean J Neurotrauma 2023; 19:409-421. [PMID: 38222835 PMCID: PMC10782099 DOI: 10.13004/kjnt.2023.19.e64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Odontoid fractures are treated surgically through the anterior or posterior approach. Each surgical approach has its advantages and disadvantages, so the preferred approach remains debatable. There are few meta-analyses or systemic reviews on the mechanical complications of surgical treatment for odontoid fractures. This meta-analysis aimed to compare the operation-related morbidity, including mechanical complications, and mortality of patients with odontoid fractures, treated via the anterior or posterior approach. Methods A systematic search was performed on PubMed/Medline, Embase, and the Cochrane Library for the studies up to October 2023 on the complication rate of the surgical treatment of odontoid fractures, related to the surgical approach. The risk ratios (RR) with the 95% confidence intervals (CIs) were pooled to assess the mechanical complication rates, other complications, revision surgery, and mortality, depending on the surgical approach. Results A total of 1,519 studies were retrieved using the search strategy, and 782 patients from 15 articles were included in this meta-analysis. Mechanical complications were significantly more frequent in the anterior surgical group with low heterogeneity. The incidences of fracture nonunion and revision surgery were also higher in the anterior surgery group. However, there was no significant difference in systemic complications and mortality rates between the two groups. Conclusion The posterior approach was more advantageous than the anterior approach in terms of mechanical complications, fusion rates, and incidence of revision surgery. However, further studies, should be performed to strengthen these results.
Collapse
Affiliation(s)
- Woong Rae Jo
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Sae Min Kwon
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Min-Yong Kwon
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Jae Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Young San Ko
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| |
Collapse
|
5
|
Sucu HK. A True Percutaneous Anterior Odontoid Screw Fixation: The Results of 42 Cases by a Single Surgeon. World Neurosurg 2022; 166:e892-e904. [PMID: 35948230 DOI: 10.1016/j.wneu.2022.07.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This study aimed to analyze a clinical series of odontoid fractures treated with true percutaneous anterior odontoid screws. The technique we used is different from the traditional approach of using blunt dissection to arrive at the anterior surface of the vertebral body. METHODS Between 2004 and 2021, forty-two patients underwent anterior screw fixation of the odontoid process using the true percutaneous technique without dissection among the fascial planes. Instead, we pressed from the medial border of the sternocleidomastoideus muscle with our second and third fingers to feel the vertebrae under the skin. Thus, the carotid artery is pushed laterally, the trachea-esophageal complex is moved medially, and when no esophagus, great vessels, etc., can be felt under our fingers; we have reached the anterior surface of the spine. Advancing the Jamshidi needle between the fingers causes it to pass only through the fascial layers. The absence of a gap between the dilatation tubes prevents any tissue from escaping into the tubes. RESULTS We had no intraoperative complications, such as esophageal, tracheal, or carotid injury. One patient required screw revision. In total, 5 patients died during the follow-up period, and 3 were lost to follow-up. There was no residual neck pain in our cohort, and no instability was noted on flexion-extension radiographs, even in ten patients without solid bone fusion. CONCLUSIONS True percutaneous anterior odontoid screw fixation is a safe and reliable procedure for treating odontoid fractures. The fibrous union of odontoid fractures provides as much stability as a solid bone fusion.
Collapse
Affiliation(s)
- Hasan Kamil Sucu
- İzmir Atatürk Research and Training Hospital, Neurosurgery Department, İzmir, Turkey.
| |
Collapse
|
6
|
Kotheeranurak V, Pholprajug P, Jitpakdee K, Pruttikul P, Chitragran R, Singhatanadgige W, Limthongkul W, Yingsakmongkol W, Kim J. Full-Endoscopic Anterior Odontoid Screw Fixation: A Novel Surgical Technique. Orthop Surg 2022; 14:990-996. [PMID: 35445547 PMCID: PMC9087464 DOI: 10.1111/os.13271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 02/22/2022] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE First, to propose a novel minimally invasive technique of full-endoscopic anterior odontoid fixation (FEAOF) that aims to reduce the risk of retropharyngeal approach (both open and percutaneous techniques) to anterior odontoid screw fixation. Second, to describe steps of the procedure and, lastly, to report the initial outcomes in patients treated with this novel technique. METHODS Four non-consecutive patients who were diagnosed with a displaced odontoid fracture (Anderson-D'Alonzo classification type II and Grauer subclassification type A or B) from 2019 to 2020 underwent surgical fixation by our novel technique for anterior odontoid screw fixation. A detailed technical approach of FEAOF for the surgical treatment of type II odontoid fractures was described, and the patients' outcomes based on postoperative radiographic results including computed tomography (CT), clinical outcome parameters including visual analogue scale (VAS) for neck pain both preoperatively and at postoperative follow-up, and range of neck motion at the final follow-up were reported. RESULTS The mean age was 33.5 years (24-41), three patients were male. The mean operative time was 93.75 min, and the mean blood loss was 7.5 ml. An immediate post-operative thin-sliced CT showed that all patients achieved satisfactory reduction and proper screw position. No screw malposition or penetration was found. At a 6-month follow-up, a thin-sliced CT demonstrated solid bony union in every case. The mean VAS for neck pain was reduced from 6.5 to 0.6 at the 6-months follow-up. At the final follow-up, all patients showed improvement in ranges of motion without any complications; however, one patient was lost to follow-up. CONCLUSIONS FEAOF is a feasible and effective option for treating type II odontoid fractures. The procedure is less invasive than other techniques and provides clear direct visualization of the involved structures.
Collapse
Affiliation(s)
- Vit Kotheeranurak
- Department of OrthopaedicsQueen Savang Vadhana Memorial HospitalSrirachaThailand
| | | | - Khanathip Jitpakdee
- Department of OrthopaedicsQueen Savang Vadhana Memorial HospitalSrirachaThailand
| | | | - Roongrath Chitragran
- Department of OrthopaedicsPhramongkutklao hospital and college of medicineBangkokThailand
| | - Weerasak Singhatanadgige
- Department of Orthopaedics, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Center of Excellence in Biomechanics and Innovative Spine SurgeryChulalongkorn UniversityBangkokThailand
| | - Worawat Limthongkul
- Department of Orthopaedics, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Center of Excellence in Biomechanics and Innovative Spine SurgeryChulalongkorn UniversityBangkokThailand
| | - Wicharn Yingsakmongkol
- Department of Orthopaedics, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Center of Excellence in Biomechanics and Innovative Spine SurgeryChulalongkorn UniversityBangkokThailand
| | - Jin‐Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, Spine CenterCollege of medicineSeoulSouth Korea
| |
Collapse
|
7
|
Tyagi G, Patel KR, Singh GJ, Uppar AM, Beniwal M, Rao KVLN, Pruthi N, Bhat D, Somanna S, Chandramouli B, Dwarakanath S. Anterior Odontoid Screw Fixation for C2 Fractures: Surgical Nuances, Complications, and Factors Affecting Fracture Union. World Neurosurg 2021; 152:e279-e288. [PMID: 34058365 DOI: 10.1016/j.wneu.2021.05.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Type II odontoid fractures are the commonest C2 fractures. The management of dens fractures remains controversial with various radiological and fracture morphological factors affecting the approach and outcomes. METHODS All cases of anterior odontoid screw fixation between 2010 and 2020 were retrospectively analyzed. Patients' clinical, radiological (type of fracture, orientation, displacement, and diastasis), operative (single vs. double screw) and follow-up records were documented. The postoperative imaging findings were classified into grades I (excellent), II (good), and III (poor) based on the anatomical alignment with the screw. Follow-up cervical computed tomography was reviewed for fracture union. RESULTS A total of 49 patients with a mean age of 37.3 ± 13.8 years were included in the study. The average time from injury to surgery was 23.1 ± 22.2 days. The bicortical screw purchase and superoposterior odontoid tip breach significantly affected the postoperative alignment (P = 0.035 each). Fracture union was noted in 41 (83.7%) patients. The horizontal fracture displacement ≥2.5 mm (P = 0.02) and poor postoperative fracture alignment (P < 0.001) resulted in worse fracture union rates. Transient dysphagia was the commonest complication (n = 12), whereas screw breakout (n = 2) and pullout (n = 2) were other hardware-related complications. One patient underwent re-exploration for screw readjustment and 2 underwent posterior instrumentation. CONCLUSIONS Anterior odontoid screw fixation is technically straightforward, less morbid, and preserves biomechanical cervical mobility, when compared with the posterior instrumentation. With careful patient selection, meticulous surgical planning, and intraoperative image-guided screw insertion, good fracture union outcomes can be obtained. In the current study, we were able to achieve stable fracture union in 83.7% patients.
Collapse
Affiliation(s)
- Gaurav Tyagi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Kautilya R Patel
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Gyani Jail Singh
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Alok Mohan Uppar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Manish Beniwal
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | | | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Sampath Somanna
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Bangalore Chandramouli
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Srinivas Dwarakanath
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.
| |
Collapse
|
8
|
Fiani B, Doan T, Covarrubias C, Shields J, Sekhon M, Rose A. Determination and optimization of ideal patient candidacy for anterior odontoid screw fixation. Surg Neurol Int 2021; 12:170. [PMID: 34084598 PMCID: PMC8168802 DOI: 10.25259/sni_165_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Odontoid process fractures are one of the most common spine fractures, especially in patients over age 70. There is still much controversy over the ideal candidate for anterior odontoid screw fixation (AOSF), with outcomes affected by characteristics such as fracture morphology, nonideal body habitus, and osteoporosis. Therefore, this systematic review seeks to discuss the optimal criteria, indications, and adverse postoperative considerations when deciding to pursue AOSF. Methods: This investigation was conducted from experiential recall and article selection performed using the PubMed electronic bibliographic databases. The search yielded 124 articles that were assessed and filtered for relevance. Following the screening of titles and abstracts, 48 articles were deemed significant for final selection. Results: AOSF is often utilized to treat Type IIB odontoid fractures, which has been shown to preserve atlantoaxial motion, limit soft-tissue injuries/blood loss/vertebral artery injury/reduce operative time, provide adequate osteosynthesis, incur immediate spinal stabilization, and allow motion preservation of C1 and C2. However, this technique is limited by patient characteristics such as fracture morphology, transverse ligament rupture, remote injuries, short neck or inability to extend neck, barrel chested, and severe spinal kyphosis, in addition to adverse postoperative outcomes such as dysphagia and vocal cord paralysis. Conclusion: Due to the fact that odontoid fractures have a significant morbidity in elderly population, treatment with AOSF is generally recommended for this population with higher risk for nonoperative fusion. Considerations should be made to achieve fracture stability and fusion, while lowering the risk for operative and postoperative complications.
Collapse
Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
| | - Thao Doan
- University of Texas Medical Branch at Galveston, Galveston, Texas, United States
| | - Claudia Covarrubias
- School of Medicine, Anahuac Querétaro University, Santiago de Querétaro, México
| | - Jennifer Shields
- College of Human Medicine, Michigan State University, East Lansing, Michigan, United States
| | - Manraj Sekhon
- William Beaumont School of Medicine, Oakland University, Rochester, Michigan, United States
| | - Alexander Rose
- School of Medicine, University of New Mexico, Albuquerque, New Mexico, United States
| |
Collapse
|