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Photopoulos G, Hurry J, Bansal A, Miyanji F, Parent S, Murphy J, El-Hawary R. Differential vertebral body growth is maintained after vertebral body tethering surgery for idiopathic scoliosis: 4-year follow-up on 888 peri-apical vertebrae and 592 intervertebral discs. Spine Deform 2024; 12:1369-1379. [PMID: 38634997 DOI: 10.1007/s43390-024-00874-3] [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: 04/16/2023] [Accepted: 03/30/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE To radiographically evaluate if vertebral body tethering (VBT) can maintain differential peri-apical vertebral growth at medium-term follow-up of 4 years. METHODS A prospective, international, multicenter database was queried to identify idiopathic scoliosis patients treated with thoracic VBT. Concave vs. convex vertebral body height, vertebral wedging, and disc wedging of the 3 peri-apical vertebrae were measured by two independent observers at 5 timepoints (pre-operative to 4-year follow-up). RESULTS 65 skeletally immature patients (60 female, mean 12.8 years old, 21 with open triradiate cartilages) met inclusion criteria. Mean pre-operative maximum scoliosis of 50 ± 8° decreased significantly post-operatively to 27 ± 9° (p < 0.001), which remained stable at 4-year follow-up 30 ± 17° (p = 0.38 vs. post-operative). Mean instrumented scoliosis was 21 ± 14° at 4-year follow-up, which was significantly different than 4-year maximum scoliosis (p < 0.001). Mean pre-operative kyphosis of 30 ± 12° did not significantly change post-operatively (p = 1.0) and remained stable at 4-year follow-up (35 ± 18°; p = 0.05). Mean individual convex vertebral height increased from 17.7 ± 1.9 mm to 19.8 ± 1.5 mm (p < 0.001), while mean individual concave height increased from 14.8 ± 1.9 mm to 17.6 ± 1.6 mm (p < 0.001). Summing the peri-apical heights, the difference in height from pre-operative to 4-year follow-up was greater on the concave (8.3 ± 4.7 mm) than on the convex side (6.2 ± 4.7 mm) (p < 0.001). Mean individual vertebral wedging decreased from 6 ± 2° at pre-operative to 4 ± 2° at 4-year follow-up (p < 0.001). Mean total vertebral and disc wedging started at 29 ± 7° pre-operatively, decreased to 16 ± 6° at post-operative (p < 0.001), then further decreased to 14 ± 8° at 4-year follow-up (p < 0.001). Patients with open triradiate cartilages at the time of surgery had a larger height change over the 4 years compared to those with closed triradiate cartilages (p < 0.001). CONCLUSION Patients with idiopathic scoliosis treated with VBT demonstrated differential vertebral growth which was maintained at minimum 4-year follow-up. This effect was more pronounced in patients whose triradiate cartilages were open at the time of surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Gregory Photopoulos
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
- Division of Orthopedic Surgery, IWK Health Centre, Orthopaedic Clinic, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada
| | - Jennifer Hurry
- Division of Orthopedic Surgery, IWK Health Centre, Orthopaedic Clinic, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada
| | - Ankita Bansal
- Division of Orthopedic Surgery, IWK Health Centre, Orthopaedic Clinic, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada
| | - Firoz Miyanji
- Orthopaedics Research Department, BC Children's Hospital, Vancouver, BC, Canada
| | - Stefan Parent
- Department of Orthopaedics, CHU Sainte-Justine, Montreal, QC, Canada
- Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Joshua Murphy
- Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ron El-Hawary
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
- Division of Orthopedic Surgery, IWK Health Centre, Orthopaedic Clinic, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada.
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Mulford KL, Regan CM, Todderud JE, Nolte CP, Pinter Z, Chang-Chien C, Yan S, Wyles C, Khosravi B, Rouzrokh P, Maradit Kremers H, Larson AN. Deep learning classification of pediatric spinal radiographs for use in large scale imaging registries. Spine Deform 2024:10.1007/s43390-024-00933-9. [PMID: 39039392 DOI: 10.1007/s43390-024-00933-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 07/15/2024] [Indexed: 07/24/2024]
Abstract
PURPOSE The purpose of this study is to develop and apply an algorithm that automatically classifies spine radiographs of pediatric scoliosis patients. METHODS Anterior-posterior (AP) and lateral spine radiographs were extracted from the institutional picture archive for patients with scoliosis. Overall, there were 7777 AP images and 5621 lateral images. Radiographs were manually classified into ten categories: two preoperative and three postoperative categories each for AP and lateral images. The images were split into training, validation, and testing sets (70:15:15 proportional split). A deep learning classifier using the EfficientNet B6 architecture was trained on the spine training set. Hyperparameters and model architecture were tuned against the performance of the models in the validation set. RESULTS The trained classifiers had an overall accuracy on the test set of 1.00 on 1166 AP images and 1.00 on 843 lateral images. Precision ranged from 0.98 to 1.00 in the AP images, and from 0.91 to 1.00 on the lateral images. Lower performance was observed on classes with fewer than 100 images in the dataset. Final performance metrics were calculated on the assigned test set, including accuracy, precision, recall, and F1 score (the harmonic mean of precision and recall). CONCLUSIONS A deep learning convolutional neural network classifier was trained to a high degree of accuracy to distinguish between 10 categories pre- and postoperative spine radiographs of patients with scoliosis. Observed performance was higher in more prevalent categories. These models represent an important step in developing an automatic system for data ingestion into large, labeled imaging registries.
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Affiliation(s)
- Kellen L Mulford
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christina M Regan
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Julia E Todderud
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Charles P Nolte
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Zachariah Pinter
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Connie Chang-Chien
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Shi Yan
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Cody Wyles
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Bardia Khosravi
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Pouria Rouzrokh
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Hilal Maradit Kremers
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Boulet M, Hurry J, Skaggs D, Welborn MC, Andras L, Louer C, Larson AN, Miyanji F, Parent S, El-Hawary R. Analysis of three-dimensional spine growth for vertebral body tethering patients at 2 and 5 years post operatively. Spine Deform 2024; 12:1009-1016. [PMID: 38568378 DOI: 10.1007/s43390-024-00857-4] [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: 07/19/2023] [Accepted: 02/28/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE Scoliosis can be treated with vertebral body tethering (VBT) as a motion-sparing procedure. However, the knowledge of how growth is affected by a tether spanning multiple levels is unclear in the literature. Three-dimensional true spine length (3D-TSL) is a validated assessment technique that accounts for the shape of the spine in both the coronal and sagittal planes. This study aimed to assess if 3D-TSL increases over a five-year period after VBT implantation in thoracic curves for idiopathic scoliosis. METHODS Prospectively collected radiographic data from an international pediatric spine registry was analyzed. Complete radiographic data over three visits (post-operative, 2 years, and 5 years) was available for 53 patients who underwent VBT. RESULTS The mean age at instrumentation of this cohort was 12.2 (9-15) years. The average number of vertebrae instrumented was 7.3 (SD 0.7). Maximum Cobb angles were 50° pre-op, which improved to 26° post-op (p < 0.001) and was maintained at 5 years (30°; p = 0.543). Instrumented Cobb angle was 22° at 5 years (p < 0.001 vs 5-year maximum Cobb angle). An accentuation was seen in global kyphosis from 29° pre-operative to 41° at 5 years (p < 0.05). The global spine length (T1-S1 3D-TSL) started at 40.6 cm; measured 42.8 cm at 2 years; and 44.0 cm at the final visit (all p < 0.05). At 5 years, patients reached an average T1-S1 length that is comparable to a normal population at maturity. Immediate mean post-operative instrumented 3D-TSL (top of UIV-top of LIV) was 13.8 cm two-year length was 14.3 cm; and five-year length was 14.6 cm (all p < 0.05). The mean growth of 0.09 cm per instrumented level at 2 years was approximately 50% of normal thoracic growth. Patients who grew more than 0.5 cm at 2 years had a significantly lower BMI (17.0 vs 19.0, p < 0.05) and smaller pre-operative scoliosis (48° vs 53°, p < 0.05). Other subgroup analyses were not significant for age, skeletal maturity, Cobb angles or number of spanned vertebras as contributing factors. CONCLUSIONS This series demonstrates that 3D-TSL increased significantly over the thoracic instrumented levels after VBT surgery for idiopathic scoliosis. This represented approximately 50% of expected normal thoracic growth over 2 years.
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Affiliation(s)
- Mathieu Boulet
- Department of Orthopaedic Surgery, Orthopaedic Clinic, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada
| | - Jennifer Hurry
- Department of Orthopaedic Surgery, Orthopaedic Clinic, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada
| | - David Skaggs
- Cedars Sinai Spine Center, Department of Orthopaedics, Los Angeles, CA, USA
| | | | - Lindsay Andras
- Children's Hospital Los Angeles, Children's Orthopaedic Center, Los Angeles, CA, USA
| | - Craig Louer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Firoz Miyanji
- Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, BC, Canada
| | - Stefan Parent
- Department of Orthopaedic Surgery, CHU Sainte-Justine, Montreal, QC, Canada
| | - Ron El-Hawary
- Department of Orthopaedic Surgery, Orthopaedic Clinic, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada.
- Cedars Sinai Spine Center, Department of Orthopaedics, Los Angeles, CA, USA.
- Department of Spine Surgery, Shriners Hospital for Children Portland, Portland, OR, USA.
- Children's Hospital Los Angeles, Children's Orthopaedic Center, Los Angeles, CA, USA.
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
- Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, BC, Canada.
- Department of Orthopaedic Surgery, CHU Sainte-Justine, Montreal, QC, Canada.
- Pediatric Spine Study Group, Pediatric Spine Foundation, Valley Forge, PA, USA.
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
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Louer CR, Upasani VV, Hurry JK, Nian H, Farnsworth CL, Newton PO, Parent S, El-Hawary R. Growth modulation response in vertebral body tethering depends primarily on magnitude of concave vertebral body growth. Spine Deform 2024:10.1007/s43390-024-00909-9. [PMID: 38834863 DOI: 10.1007/s43390-024-00909-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/25/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE There is variability in clinical outcomes with vertebral body tethering (VBT) partly due to a limited understanding of the growth modulation (GM) response. We used the largest sample of patients with 3D spine reconstructions to characterize the vertebra and disc morphologic changes that accompany growth modulation during the first two years following VBT. METHODS A multicenter registry was used to identify idiopathic scoliosis patients who underwent VBT with 2 years of follow-up. Calibrated biplanar X-rays obtained at longitudinal timepoints underwent 3D reconstruction to obtain precision morphological measurements. GM was defined as change in instrumented coronal angulation from post-op to 2-years. RESULTS Fifty patients (mean age: 12.5 ± 1.3yrs) were analyzed over a mean of 27.7 months. GM was positively correlated with concave vertebra height growth (r = 0.57, p < 0.001), 3D spine length growth (r = 0.36, p = 0.008), and decreased convex disc height (r = - 0.42, p = 0.002). High modulators (patients experiencing GM > 10°) experienced an additional 1.6 mm (229% increase) of mean concave vertebra growth during study period compared to the Poor Modulators (GM < - 10°) group, (2.3 vs. 0.7 mm, p = 0.039), while convex vertebra height growth was similar (1.3 vs. 1.4 mm, p = 0.91). CONCLUSION When successful, VBT enables asymmetric vertebra body growth, leading to continued postoperative coronal angulation correction (GM). A strong GM response is correlated with concave vertebral body height growth and overall instrumented spine growth. A poor GM response is associated with an increase in convex disc height (suspected tether rupture). Future studies will investigate the patient and technique-specific factors that influence increased growth remodeling.
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Affiliation(s)
- Craig R Louer
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Childrens Way, Suite 4202, Nashville, TN, 37212, USA.
| | - Vidyadhar V Upasani
- Department of Orthopedics, Rady Children's Hospital, San Diego, CA, USA
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Jennifer K Hurry
- Division of Orthopaedic Surgery, IWK Health Centre, Halifax, NS, Canada
| | - Hui Nian
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 2200 Childrens Way, Suite 4202, Nashville, TN, 37212, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Peter O Newton
- Department of Orthopedics, Rady Children's Hospital, San Diego, CA, USA
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Stefan Parent
- Department of Surgery, Faculty of Medicine, Universite´ de Montre´Al, Montre´Al, QC, Canada
| | - Ron El-Hawary
- Division of Orthopaedic Surgery, IWK Health Centre, Halifax, NS, Canada
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Regan CM, Morgan J, Hilaire TS, El-Hawary R, Pahys JM, Skaggs DL, Yaszay B, Parent S, Larson AN. Does radiographic calibration affect linear radiographic measurements in a large pediatric spine registry? Spine Deform 2024; 12:335-339. [PMID: 38147269 DOI: 10.1007/s43390-023-00793-9] [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: 08/26/2023] [Accepted: 11/04/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE Large registries are increasingly at the forefront of modern pediatric spine research, with manual, centralized, trained radiographic measurement serving as the gold standard for spine research. However, there is limited data regarding the reliability of registry measurements which may be subject to differences in radiographic calibration. We undertook this study to evaluate reliability of T1-T12 height, L1-S1 height, and coronal balance measurements for a large registry of early onset scoliosis patients. METHODS Three trained technicians from the Pediatric Spine Study Group measured 43 radiographs for T1-T12, L1-S1, and coronal balance using 3 different calibration techniques. All radiographs were AP views of patients with magnetically controlled growing rods with known diameters. The calibration techniques used a pre-export manually drawn line, a digital automatically generated computerized marker, and the diameter of a magnetically controlled growing rod. The intraclass correlation coefficient (ICC) was calculated to determine reliability. RESULTS 1161 measurements were performed. For each of the three raters, coronal balance, T1-T12 height and L1-S1 height had excellent agreement regardless of the calibration technique (alpha 0.93-1.0). Among the parameters, coronal balance had the worst inter-rater reliability, whereas there was excellent interrater reliability regarding T1-T12 height and L1-S1 height (alpha 0.91-0.99). CONCLUSION There was excellent agreement among reviewers and between the 3 different calibration techniques. While calibration using rod diameter served as the gold standard, this data shows that other standard calibration methods were adequate and achieved excellent reliability for registry radiographs.
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Affiliation(s)
- Christina M Regan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | | | | | | | - Joshua M Pahys
- Philadelphia Shriners Hospital for Children, Philadelphia, PA, USA
| | | | - Burt Yaszay
- Seattle Children's Hospital, Seattle, WA, USA
| | | | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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Farivar D, Parent S, Miyanji F, Heffernan MJ, El-Hawary R, Larson AN, Andras LM, Skaggs DL. Concave and convex growth do not differ over tethered vertebral segments, even with open tri-radiate cartilage. Spine Deform 2023; 11:881-886. [PMID: 37004694 PMCID: PMC10261211 DOI: 10.1007/s43390-023-00683-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE To assess the following hypotheses related to vertebral body tethering (VBT): 1. VBT is associated with asymmetric (concave > convex) increases in height over the instrumented vertebra. 2. The instrumented Cobb angle improves following VBT surgery with growth. METHODS This is a retrospective case series of pediatric patients from a multicenter scoliosis registry treated with VBT between 2013 to 2021. INCLUSION CRITERIA patients with standing radiographs at < 4 months and ≥ 2 years after surgery. Distances between the superior endplate of the UIV and the inferior endplate of the LIV were measured at the concave corner, mid-point, and convex corner of the endplates. The UIV-LIV angle was recorded. Subgroup analyses included comparing different Risser scores and tri-radiate cartilage (TRC) closed versus open using student t-tests. RESULTS 83 patients met inclusion criteria (92% female; age at time of surgery 12.5 ± 1.4 years) with mean follow-up time of 3.8 ± 1.4 years. Risser scores at surgery were: 0 (n = 33), 1 (n = 12), 2 (n = 10), 3 (n = 11), 4 (n = 12), and 5 (n = 5). Of the 33 Risser 0 patients, 17 had an open TRC, 16 had a closed TRC. The UIV-LIV distance at concave, middle, and convex points significantly increased from immediate post-op to final-follow-up for Risser 0 patients, but not for Risser 1-5 patients. Increases in UIV-LIV distance were not significantly different between concave, middle, and convex points for all groups. There was no significant improvement or worsening in UIV-LIV angle for any group. CONCLUSION At a mean of 3.8 years following VBT, 33 Risser 0 patients demonstrated significant growth in the instrumented segment, though there was no difference between concave or convex growth, even for patients with open TRC.
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Affiliation(s)
- Daniel Farivar
- Cedars-Sinai Spine, 444 S San Vicente Blvd, Ste 901, Los Angeles, CA, 90048, USA
| | - Stefan Parent
- Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Firoz Miyanji
- Department of Orthopedics, BC Children's Hospital, Vancouver, BC, Canada
| | - Michael J Heffernan
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Ron El-Hawary
- Orthopedics, Izaak Walton Killam (IWK) Health Centre, Halifax, Canada
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - David L Skaggs
- Cedars-Sinai Spine, 444 S San Vicente Blvd, Ste 901, Los Angeles, CA, 90048, USA.
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