1
|
Spahn G, Ramadani M, Günther S, Retzlaff C, Klemm HT, Meyer-Clement M, Hofmann GO. Measurement of Intervertebral Disc Heights in the Lumbar Spine. Comparison of X-Ray and Magnetic Resonance Imaging, Method of Measurement and Determination of Inter-observer Reliability. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:254-262. [PMID: 36758585 DOI: 10.1055/a-1994-0879] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE Retrospective radiological examination (X-ray and MRI) aims to investigate the diagnostic value of various methods of measurement with regard to the determination of the intervertebral disc heights of the lumbar spine. METHODS Of 130 patients without detectable damage to the intervertebral discs, the X-ray and MRI images of the lumbar spine were evaluated. The measurements were made either in the center line (Hurxthal) or in the 2-point method according to Dabbs or in the 3-point method according to Fyllos. RESULTS The average intervertebral disc height for all measured segments was 8.8 mm (SD 1.4 mm). In the Hurxthal measurement, the significantly (p < 0.001) highest values were measured with an average of 9.1 mm (SD 1.3 mm). The average readings for the Fyllos method were 7.5 mm (SD 1.2 mm) and according to Dabbs 6.7 mm (SD 1.2 mm). The measured values of Observer I were on average 1.2 mm (SD 0.3 mm) smaller than those of Observer II (p < 0.001). The highest interobserver correlation was found in the measurements in projection radiography in the AP method according to Dabbs and Fyllos. The measured values in men were 0.5 mm (SD 0.01 mm) larger than in women (p < 0.001), regardless of the method. The height of the intervertebral discs increases significantly until the age of 40, but beyond the age of 40, the height of the intervertebral discs either remains constant or falls off slightly, but not significantly. The lordosis angle of the lumbar spine and the concavity index of the vertebral bodies showed no correlation with the measured disc heights. CONCLUSIONS The radiological measurements to determine the intervertebral disc height have only moderate reliability. The results of X-rays are superior to those of MRI examination. The most accurate results are provided by measurements based on exact landmarks of the vertebral bodies. The method according to Dabbs seems to be the most accurate at the moment. There is no clear age-atypical chondrosis in patients without intervertebral disc damage.
Collapse
Affiliation(s)
- Gunter Spahn
- Unfallchirurgie und Orthopädie, Praxisklinik für Unfallchirurgie und Orthopädie, Eisenach, Deutschland
- Klinik für Unfall,- Hand- und Wiederherstellungschirurgie, Universitatsklinikum Jena, Jena, Deutschland
| | - Milot Ramadani
- Center of Radiology Eisenach-Eschwege BAG, Eisenach, Deutschland
| | - Stephan Günther
- Center of Trauma and Orthopaedic Surgery Eisenach. Jena University Hospital, Eisenach, Deutschland
| | | | | | | | - Gunther O Hofmann
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena, Jena, Deutschland
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Kliniken Bergmannstrost, Halle, Deutschland
| |
Collapse
|
2
|
Cheng Y, Ma Y, Li K, Gungor C, Sesek R, Tang R. Morphology and Composition of Lumbar Intervertebral Discs: Comparative Analyses of Manual Measurement and Computer-Assisted Algorithms. Bioengineering (Basel) 2024; 11:466. [PMID: 38790333 PMCID: PMC11117579 DOI: 10.3390/bioengineering11050466] [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: 02/23/2024] [Revised: 04/18/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The morphology and internal composition, particularly the nucleus-to-cross sectional area (NP-to-CSA) ratio of the lumbar intervertebral discs (IVDs), is important information for finite element models (FEMs) of spinal loadings and biomechanical behaviors, and, yet, this has not been well investigated and reported. METHODS Anonymized MRI scans were retrieved from a previously established database, including a total of 400 lumbar IVDs from 123 subjects (58 F and 65 M). Measurements were conducted manually by a spine surgeon and using two computer-assisted segmentation algorithms, i.e., fuzzy C-means (FCM) and region growing (RG). The respective results were compared. The influence of gender and spinal level was also investigated. RESULTS Ratios derived from manual measurements and the two computer-assisted algorithms (FCM and RG) were 46%, 39%, and 38%, respectively. Ratios derived manually were significantly larger. CONCLUSIONS Computer-assisted methods provide reliable outcomes that are traditionally difficult for the manual measurement of internal composition. FEMs should consider the variability of NP-to-CSA ratios when studying the biomechanical behavior of the spine.
Collapse
Affiliation(s)
- Yiting Cheng
- School of Mechanical Engineering, Sichuan University, Chengdu 610000, China;
| | - Yuyan Ma
- Sichuan University-Pittsburgh Institute (SCUPI), Sichuan University, Chengdu 610000, China;
| | - Kang Li
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610000, China;
| | - Celal Gungor
- Department of Forest Industrial Engineering, Izmir Katip Celebi University, Cigli 35620, Turkey;
| | - Richard Sesek
- Department of Industrial and Systems Engineering, Auburn University, Auburn, AL 36849, USA;
| | - Ruoliang Tang
- Sichuan University-Pittsburgh Institute (SCUPI), Sichuan University, Chengdu 610000, China;
- Nursing Key Laboratory of Sichuan Province, Chengdu 610000, China
| |
Collapse
|
3
|
Chen XL, Li XY, Wang Y, Lu SB. Relation of lumbar intervertebral disc height and severity of disc degeneration based on Pfirrmann scores. Heliyon 2023; 9:e20764. [PMID: 37867832 PMCID: PMC10585210 DOI: 10.1016/j.heliyon.2023.e20764] [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: 09/04/2022] [Revised: 09/27/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023] Open
Abstract
Background Disc height (DH) change is considered one of the most critical factors in assessing intervertebral disc degeneration (IVD). Pfirrmann et al. developed a scoring system for disc degeneration evaluation based on changes in DH in magnetic resonance imaging (MRI). While the relationship between DH measurements and Pfirrmann scores for disc degeneration has been explored, the validity of different DH measuring techniques or their connection with disc degeneration is yet uncertain. The present study investigates intra-rater and inter-rater agreement and reliability of different DH measurement methods on MRI and evaluates the relationship between different DH measurement methods and Pfirrmann scores of IVD degeneration, as well as between different Pfirrmann scores and clinical outcomes. Methods Adult patients with MRI scans of the lumbar spine were recruited. Eight DH measuring techniques were tested for intra-rater and inter-rater agreement and reliability. Bland and Altman's Limits of Agreement (LOA) was used to evaluate intra-rater and inter-rater agreements. Intra-rater and inter-rater reliability were evaluated using intra-class correlations (ICC) with 95 % confidence intervals (95 % CI). The association between DH and Pfirrmann scores was examined using one-way ANOVA. Results Excellent intra-rater reliability was reported for 332 participants on DH (ranging from 0.912 (0.901, 0.923) to 0.973 (0.964, 0.981) and from 0.902 (0.892, 0.915) to 0.975 (0.962, 0.985) by two independent raters). All measuring methods had high intra-rater agreement, except for methods 4 and 5. All methods had good-to-excellent of inter-rater reliability on DH (ICCs ranging from 0.812 (0.795, 0.828) to 0.995 (0.994, 0.995)) except for the posterior disc material length of method 5 (ICC 0.740 (0.718, 0.761)). Methods 1 to 6 for evaluating DH in patients with spondylolisthesis had poor inter-rater reliability. The IVD levels with grades IV and V in Pfirrmann scores had significantly lower DH than the IVD levels with grades I to III in Pfirrmann scores. IVD levels with grades IV and V in Pfirrmann scores had significantly higher VAS and ODI than IVD levels with grades I in Pfirrmann scores. Conclusion A good-to-excellent intra-rater and inter-rater reliability was achieved on most DH measuring methods on MRI following a standardized and structured protocol. However, small anatomical structures and different tissue borders could influence measurements. Additionally, DH can differentiate between grade IV and V Pfirrmann scores, and severe IVD degeneration (IV and V Pfirrmann) is linked to clinical outcomes.
Collapse
Affiliation(s)
- Xiao-long Chen
- Department of Orthopaedics, Xuanwu Hospital Capital Medical University, Xicheng District, Beijing, China
| | - Xiang-yu Li
- Department of Orthopaedics, Xuanwu Hospital Capital Medical University, Xicheng District, Beijing, China
| | - Yu Wang
- Department of Orthopaedics, Xuanwu Hospital Capital Medical University, Xicheng District, Beijing, China
| | - Shi-bao Lu
- Department of Orthopaedics, Xuanwu Hospital Capital Medical University, Xicheng District, Beijing, China
| |
Collapse
|
4
|
Naidoo N, Khan R, Abdulwahab T, Almqvist KF, Lakshmanan J, Prithishkumar IJ. A novel reconstructive approach of the lumbar vertebral column from 2D MRI to 3D models. TRANSLATIONAL RESEARCH IN ANATOMY 2022. [DOI: 10.1016/j.tria.2022.100229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
5
|
Porto LR, Tang R, Sawka A, Lessoway V, Anas EMA, Behnami D, Abolmaesumi P, Rohling R. Comparison of Patient Position and Midline Lumbar Neuraxial Access Via Statistical Model Registration to Ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:255-263. [PMID: 30292460 DOI: 10.1016/j.ultrasmedbio.2018.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 08/09/2018] [Accepted: 08/20/2018] [Indexed: 06/08/2023]
Abstract
Patient positioning and needle puncture site are important for lumbar neuraxial anesthesia. We sought to identify optimal patient positioning and puncture sites with a novel ultrasound registration. We registered a statistical model to volumetric ultrasound data acquired from volunteers (n = 10) in three positions: (i) prone; (ii) seated with thoracic and lumbar flexion; and (iii) seated as in position ii, with a 10° dorsal tilt. We determined injection target size and penetration success by simulating lumbar injections on validated registered models. Injection window and target area sizes in seated positions were significantly larger than those in prone positions by 65% in L2-3 and 130% in L3-4; a 10° tilt had no significant effect on target sizes between seated positions. In agreement with computed tomography studies, simulated L2-3 and L3-4 injections had the highest success at the 50% and 75% midline puncture sites, respectively, measured from superior to inferior spinous process. We conclude that our registration to ultrasound technique is a potential tool for tolerable determination of puncture site success in vivo.
Collapse
Affiliation(s)
- Lucas Resque Porto
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada.
| | - Raymond Tang
- Department of Anesthesiology, Vancouver General Hospital, Vancouver, Canada
| | - Andrew Sawka
- Department of Anesthesiology, Vancouver General Hospital, Vancouver, Canada
| | | | - Emran Mohammad Abu Anas
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada
| | - Delaram Behnami
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada
| | - Purang Abolmaesumi
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada
| | - Robert Rohling
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada
| |
Collapse
|
6
|
Cacciola G, Anastasi G, Bertino S, Rizzo G, Cutroneo G, Trimarchi F, Pisani A, Cavaliere P, Barbanera A, Bruschetta D. Anatomical differences in the bony structure of L5 and L4: A possible classification according to the lateral tilt of the pedicles. J Orthop 2018; 15:205-209. [PMID: 29657469 DOI: 10.1016/j.jor.2018.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 09/27/2017] [Accepted: 01/14/2018] [Indexed: 10/18/2022] Open
Abstract
The aim of this study is to underline the necessity of a better knowledge of pedicles anatomy in order to improve surgical treatment of spine disorders such us low back pain, spinal fractures and scholiosis. A classification of pedicles lateral tilt which could help surgeons before the application of screws during transpedicular fixation is reported. Anatomical differences in the orientiation of the pedicles of L5 and L4 have been found. For each patient that met the inclusion criteria underwent: Radiography of the lumbo-sacral region, CT examination, MRI acquisition. Patients were divided into three categories thanks to 3D direct volume rendering of CT scan. Subjects belonged to W-Type, V-Type and U-type depending on their morphometric features. The subdivision was further implemented with measurements of the distance between pedicles and adjacent nervous structures. Concerning L5, W-Type (WT) exhibited a lateral tilt of L5 larger than 36°, V-Type exhibited a lateral tilt of L5 from 30° to 36°, U-type exhibited a lateral tilt of L5 smaller than 30°. Concerning L4, WT exhibited a lateral tilt of 28.4°, VT exhibited a lateral tilt of of 25.1, UT exhibited a lateral tilt of 22.2°; we assume that the degree of lateralization of L4 depends on the one of L5. The way the screw is applied during surgical treatment is clinically relevant, thus our classification may be very useful in order to decrease surgical risk and improve conditions of patients after surgical treatment.
Collapse
Affiliation(s)
- Giorgio Cacciola
- University of Messina, Department of Biomedical, Dental Sciences and Morphological and Functional Images, Messina, Italy
| | - Giuseppe Anastasi
- University of Messina, Department of Biomedical, Dental Sciences and Morphological and Functional Images, Messina, Italy
| | - Salvatore Bertino
- University of Messina, Department of Biomedical, Dental Sciences and Morphological and Functional Images, Messina, Italy
| | - Giuseppina Rizzo
- University of Messina, Department of Biomedical, Dental Sciences and Morphological and Functional Images, Messina, Italy
| | - Giuseppina Cutroneo
- University of Messina, Department of Biomedical, Dental Sciences and Morphological and Functional Images, Messina, Italy
| | - Fabio Trimarchi
- University of Messina, Department of Biomedical, Dental Sciences and Morphological and Functional Images, Messina, Italy
| | - Alessandro Pisani
- Istituto Ortopedico del Mezzogiorno d'Italia "Franco Scalabrino", Dipartimento di Chirurgia Vertebrale, Messina, Italy
| | - Pietro Cavaliere
- Istituto Ortopedico del Mezzogiorno d'Italia "Franco Scalabrino", Dipartimento di Chirurgia Vertebrale, Messina, Italy
| | - Andrea Barbanera
- A.O.N. SS Antonio Biagio e Cesare Arrigo, Dipartimento di Neurochirurgia, Alessandria, Italy
| | - Daniele Bruschetta
- University of Messina, Department of Biomedical, Dental Sciences and Morphological and Functional Images, Messina, Italy.,IRCCS Neurolesi "Bonino Pulejo", Messina, Italy
| |
Collapse
|
7
|
Software-assisted morphometry and volumetry of the lumbar spine. Neurol Neurochir Pol 2016; 50:143-50. [PMID: 27154439 DOI: 10.1016/j.pjnns.2016.01.010] [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: 08/17/2015] [Accepted: 01/18/2016] [Indexed: 11/23/2022]
Abstract
The aim of the study was to measure volumes of the lumbar vertebral bodies with use dedicated Computed Tomography (CT) workstation software to predict expected volume of PMMA for vertebroplasty and supplement calculations using computed tomography scanogram. Quantitative CT scans of 87 women's (mean age 69.4 years; SD 10.9) and 15 men's (mean age 64.3 years; SD 11.8) lumbar spines were analyzed; this made a total of 379 vertebrae. The population of patients was divided into three groups depending on measured BMD value, in accordance with American College of Radiology Practice Parameter for the Performance of Quantitative Computed Tomography (QCT) Bone Densitometry. With the use of the general linear model and least squares means groups were compared regarding vertebral volume, anterior, middle, and posterior vertebral heights. Morphometric parameters tended to be greater in males than in females, in a population of diversified bone mineral density. BMD result should be considered as the modifying factor for preoperative planning of the bone cement volume to be deposited inside the vertebra. Vertebral body volumetry might prove to be a useful tool in pre-operative planning as well as an alternative for treatment monitoring after minimally invasive spinal procedures.
Collapse
|
8
|
Tang R, Gungor C, Sesek RF, Foreman KB, Gallagher S, Davis GA. Morphometry of the lower lumbar intervertebral discs and endplates: comparative analyses of new MRI data with previous findings. 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 2016; 25:4116-4131. [DOI: 10.1007/s00586-016-4405-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 11/24/2022]
|
9
|
Korez R, Likar B, Pernuš F, Vrtovec T. Parametric modeling of the intervertebral disc space in 3D: Application to CT images of the lumbar spine. Comput Med Imaging Graph 2014; 38:596-605. [DOI: 10.1016/j.compmedimag.2014.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 04/12/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
|
10
|
Yoo JS, Min SH, Yoon SH. Fusion rate according to mixture ratio and volumes of bone graft in minimally invasive transforaminal lumbar interbody fusion: minimum 2-year follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 25 Suppl 1:S183-9. [DOI: 10.1007/s00590-014-1529-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 08/03/2014] [Indexed: 10/24/2022]
|
11
|
Khiami F, Aziria SA, Ragot S, Pascal-Moussellard H, Richer JP, Scepi M, Brèque C, Hirsch C. Reliability and validity of a new measurement of lumbar foraminal volume using a computed tomography. Surg Radiol Anat 2014; 37:93-9. [PMID: 24951014 DOI: 10.1007/s00276-014-1324-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 06/06/2014] [Indexed: 12/01/2022]
Abstract
PURPOSE Measuring foraminal stenosis is generally determined by an area calculation. It is difficult to know exactly where it is most appropriate to measure. No precise data are available on a method for calculating the foraminal volume using a CT. To develop a new method for measuring lumbar foraminal volume, we analyzed repeatability and reliability for measuring methods for foraminal volume using CT. METHODS The measurements were performed using a CT scan from ten healthy patients, with a mean age of 26.3 years. L3-L4, L4-L5 and L5-S1 foramen were studied, to obtain 60 foraminal measurements. Inter- and intra-observer reproducibility was calculated. Each series was analyzed using the VitreaCore® reconstruction software for volume calculation. RESULTS Average volume measurements of 60 foramina and 20 L4-L5 foramina were, respectively, 1.17 and 1.25 mm(3) for observer 1 and 1.21 and 1.29 for observer 2. The intra-observer correlation coefficients for observer 1 when measuring all foramina and L4-L5 foramina were 0.98 and 0.99, respectively. For observer 2, coefficients were 0.90 and 0.92, respectively. The inter-observer correlation coefficients for observer 1 when measuring all foramina and L4-L5 foramina were 0.78 and 0.83, respectively. For observer 2, coefficients were 0.77 and 0.8, respectively. The average differences in intra- and inter-observer measurements regardless of the evaluator group were less than 0.2 mm(3). CONCLUSIONS This is the first study measuring lumbar foraminal volume using CT. The excellent reproducibility of this simple measure can supplement a range of foramen measurement tools.
Collapse
Affiliation(s)
- Frédéric Khiami
- Department of Orthopaedic and Sport Traumatology Surgery, AP-HP, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013, Paris, France,
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Treatment results in the differential surgery of intradural extramedullary schwannoma of 110 cases. PLoS One 2013; 8:e63867. [PMID: 23724010 PMCID: PMC3664559 DOI: 10.1371/journal.pone.0063867] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 04/07/2013] [Indexed: 11/19/2022] Open
Abstract
STUDY DESIGN A retrospective study of intradural extramedullary schwannoma. OBJECTIVE The purpose of this study was to compare treatment results in the differential surgery of intradural extramedullary schwannoma. BACKGROUND A reference guide to the surgical procedures available to treat intradural extramedullary schwannoma has not yet been established. METHODS The study retrospectively reviewed 110 patients: Group A: laminectomy+microscopic excision; Group B: hemilaminectomy+microscopic excision; Group C: laminectomy+microscopic excision+pedicle screw fixation. Researchers selected patients for this retrospective review by applying the following criteria: 1) back pain spread out from the tumor level, sensory and motor loss; 2) treatment by surgery; 3) clinical diagnosis made by physical examination, magnetic resonance imaging (MRI), and pathology; 4) a minimum clinical and radiologic follow-up of 12 months. The clinical outcomes were assessed by comparing the Visual Analogue Pain Scores (VAS) and the Japanese Orthopedic Association Scores (JOA score). The study also performed a cost-effectiveness analysis. RESULTS Cervical vertebrae: The estimated blood loss in Group B was significantly less than in Group C (P<0.05) (Table 1). Thoracic vertebrae: The duration of hospital stay and estimated blood loss in Group A was significantly less than in Group C (P<0.05) (Table 2, 3). Lumbar vertebrae: The resection rate in Group C was significantly higher than in Group A and Group B (P<0.05) (Table 4). Treatment in Group B was the least expensive, and therefore, the most cost-effective. CONCLUSION In the case of appropriate surgical indications, the study suggests that hemilaminectomy+microscopic excision is advantageous in the removal of cervical schwannoma, and that laminectomy+microscopic excision is advantageous in the removal of thoracic schwannoma; lumbar intradural extramedullary schwannoma can be managed by laminectomy+microscopic excision+pedicle screw fixation.
Collapse
|