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Hiyama A, Sakai D, Katoh H, Sato M, Watanabe M. Impact of Osteoporosis on Short-Term Surgical Outcomes in Lumbar Degenerative Disease Patients Undergoing Lateral Lumbar Interbody Fusion: A Retrospective Analysis. World Neurosurg 2024; 188:e424-e433. [PMID: 38802060 DOI: 10.1016/j.wneu.2024.05.130] [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: 04/17/2024] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE This retrospective study assesses the influence of osteoporosis on the short-term clinical outcomes of lateral lumbar interbody fusion (LLIF) surgery in patients with lumbar degenerative diseases (LDDs), focusing on complications, pain intensity, and quality of life (QOL) improvements. The primary aim of this study is to investigate the impact of osteoporosis on the short-term clinical outcomes following LLIF surgery in LDD patients, with a particular focus on the incidence of cage subsidence (CS) and overall patient well-being postoperatively. METHODS A retrospective review was conducted on 73 patients who underwent LLIF for LDD. Patients were categorized into 2 groups based on osteoporosis status determined by dual-energy X-ray absorptiometry scans: those with osteoporosis (n = 20) and those without osteoporosis (n = 53). Data collection included demographics, surgical details, complications, magnetic resonance imaging analysis, pain intensity, and QOL (Japanese Orthopaedic Association Back Pain Evaluation Questionnaire). RESULTS The groups had no significant differences regarding operative time, estimated blood loss, and hospital stay duration. However, the incidence of CS was 40% in patients with osteoporosis, compared to 17% in nonosteoporotic patients. Despite this, significant improvements in spinal canal dimensions were observed in both groups. Both groups experienced significant reductions in pain intensity, with notable improvements in functional outcomes assessed by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, indicating the overall effectiveness of LLIF in enhancing patient well-being and functionality, irrespective of osteoporosis status. CONCLUSIONS Osteoporosis increases the risk of CS in LLIF surgery for LDD patients but does not affect short-term pain relief and QOL improvements.
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Affiliation(s)
- Akihiko Hiyama
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masato Sato
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Li CC, Yang XL, Wu WW, Zhou R, Jiang YF, Xiao J, Zhang YX, Song L, Dai F. Injectable bone cement cannulated pedicle screw for lumbar degenerative disease in osteoporosis - clinical follow-up of over 5 years. J Orthop Surg Res 2024; 19:440. [PMID: 39068450 PMCID: PMC11282736 DOI: 10.1186/s13018-024-04934-2] [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: 06/01/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024] Open
Abstract
OBJECTIVE The aim of this study is to evaluate the clinical efficacy of injectable cemented hollow pedicle screw (CICPS) in the treatment of osteoporotic lumbar degenerative diseases through a large sample long-term follow-up study. Additionally, we aim to explore the risk factors affecting interbody fusion. METHODS A total of 98 patients who underwent CICPS for transforaminal lumbar interbody fusion (TLIF) for osteoporotic lumbar degenerative disease from March 2011 to September 2017 were analyzed. X-ray and electronic computed tomography (CT) imaging data were collected during preoperative, postoperative, and follow-up periods. The data included changes in intervertebral space height (ΔH), screw failure, cement leakage (CL), and intervertebral fusion. The patients were divided into two groups based on their fusion status one year after surgery: satisfied group A and dissatisfied group B. Surgical data such as operation time, intraoperative bleeding volume and surgical complications were recorded, and visual analog scale (VAS) and Oswestry disability index (ODI) were used to evaluate the improvement of lumbar and leg pain. RESULTS The mean follow-up time was 101.29 months (ranging from 70 to 128 months). A total of 320 CICPS were used, with 26 screws (8.13%) leaking, 3 screws (0.94%) experiencing cement augmentation failure, and 1 screw (0.31%) becoming loose and breaking. The remaining screws were not loose or pulled out. Female gender, decreased bone density, and CL were identified as risk factors affecting interbody fusion (P < 0.05). Early realization of interbody fusion can effectively prevent the loss of intervertebral space height (P < 0.05) and maintain the surgical treatment effect. Both VAS and ODI scores showed significant improvement during the follow-up period (P < 0.05). Binary logistic regression analysis revealed that decreased bone density and cement leakage were risk factors for prolonged interbody fusion. CONCLUSIONS The results of long-term follow-up indicate that PMMA enhanced CICPS has unique advantages in achieving good clinical efficacy in the treatment of osteoporosis lumbar degenerative diseases. Attention should be paid to identify female gender, severe osteoporosis, and CL as risk factors affecting interbody fusion.
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Affiliation(s)
- Cong-Can Li
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng street, Chongqing, 400038, China
| | - Xiu-Lun Yang
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng street, Chongqing, 400038, China
| | - Wen-Wen Wu
- Chinese People's Liberation Army 132U, Tunchangxian, 571627, China
| | - Rui Zhou
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng street, Chongqing, 400038, China
| | - Yi-Fan Jiang
- Fourth Department of Convalescence, Sanya Rehabilitation and Convalescent Center, Joint Logistics Support Force, Sanya, 572000, China
| | - Jun Xiao
- Department of Special Service Physiological Training, Guangzhou Special Service Recuperation Center, PLA Rocket Force, Guangzhou, Shantou, 515515, China
| | - Yu-Xuan Zhang
- Department of Special Service Physiological Training, Guangzhou Special Service Recuperation Center, PLA Rocket Force, Guangzhou, Shantou, 515515, China
| | - Lei Song
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng street, Chongqing, 400038, China.
| | - Fei Dai
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng street, Chongqing, 400038, China.
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Aguirre AO, Soliman MAR, Kuo CC, Kassay A, Parmar G, Kruk MD, Quiceno E, Khan A, Lim J, Hess RM, Mullin JP, Pollina J. Defining cage subsidence in anterior, oblique, and lateral lumbar spine fusion approaches: a systematic review of the literature. Neurosurg Rev 2024; 47:332. [PMID: 39009745 DOI: 10.1007/s10143-024-02551-5] [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: 01/05/2024] [Revised: 06/27/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024]
Abstract
One of the most common complications of lumbar fusions is cage subsidence, which leads to collapse of disc height and reappearance of the presenting symptomology. However, definitions of cage subsidence are inconsistent, leading to a variety of subsidence calculation methodologies and thresholds. To review previously published literature on cage subsidence in order to present the most common methods for calculating and defining subsidence in the anterior lumbar interbody fusion (ALIF), oblique lateral interbody fusion (OLIF), and lateral lumbar interbody fusion (LLIF) approaches. A search was completed in PubMed and Embase with inclusion criteria focused on identifying any study that provided descriptions of the method, imaging modality, or subsidence threshold used to calculate the presence of cage subsidence. A total of 69 articles were included in the final analysis, of which 18 (26.1%) reported on the ALIF approach, 22 (31.9%) on the OLIF approach, and 31 (44.9%) on the LLIF approach, 2 of which reported on more than one approach. ALIF articles most commonly calculated the loss of disc height over time with a subsidence threshold of > 2 mm. Most OLIF articles calculated the total amount of cage migration into the vertebral bodies, with a threshold of > 2 mm. LLIF was the only approach in which most articles applied the same method for calculation, namely, a grading scale for classifying the loss of disc height over time. We recommend future articles adhere to the most common methodologies presented here to ensure accuracy and generalizability in reporting cage subsidence.
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Affiliation(s)
- Alexander O Aguirre
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andrea Kassay
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Gaganjot Parmar
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Marissa D Kruk
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Esteban Quiceno
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA.
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.
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Filley A, Baldwin A, Ben-Natan AR, Hansen K, Arora A, Xiao A, Hammond D, Chen C, Tweedt I, Rohde J, Link T, Berven S, Sawyer A. The influence of osteoporosis on mechanical complications in lumbar fusion surgery: a systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100327. [PMID: 38962714 PMCID: PMC11219986 DOI: 10.1016/j.xnsj.2024.100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 07/05/2024]
Abstract
Background Adults undergoing spine surgery often have underlying osteoporosis, which may be a risk factor for postoperative complications. Although these associations have been described, osteoporosis remains profoundly underdiagnosed and undertreated in the spine surgery population. A thorough, comprehensive systematic review summarizing the relationships between bone mineral density (BMD) and specific complications of lumbar fusion surgery could be a valuable resource for raising awareness and supporting clinical practice changes. Methods PubMed, Embase, and Web of Science databases were searched for original clinical research articles reporting on BMD, or surrogate measure, as a predictor of complications in adults undergoing elective lumbar fusion for degenerative disease or deformity. Endpoints included cage subsidence, screw loosening, pseudarthrosis, vertebral fracture, junctional complications, and reoperation. Results A total of 71 studies comprising 12,278 patients were included. Overall, considerable heterogeneity in study populations, methods of bone health assessment, and definition and evaluation of clinical endpoints precluded meta-analysis. Nevertheless, low BMD was associated with higher rates of implant failures like cage subsidence and screw loosening, which were often diagnosed with concomitant pseudarthrosis. Osteoporosis was also a significant risk factor for proximal junctional kyphosis, particularly due to fracture. Many studies found surgical site-specific BMD to best predict focal complications. Functional outcomes were inconsistently addressed. Conclusions Our findings suggest osteoporosis is a significant risk factor for mechanical complications of lumbar fusion. These results emphasize the importance of preoperative osteoporosis screening, which allows for medical and surgical optimization of high-risk patients. This review also highlights current practical challenges facing bone health evaluation in patients undergoing elective surgery. Future prospective studies using standardized methods are necessary to strengthen existing evidence, identify optimal predictive thresholds, and establish specialty-specific practice guidelines. In the meantime, an awareness of the surgical implications of osteoporosis and utility of preoperative screening can provide for more informed, effective patient care.
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Affiliation(s)
- Anna Filley
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Avionna Baldwin
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Alma Rechav Ben-Natan
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Keith Hansen
- Department of General Surgery, University of California, San Francisco, CA, USA
| | - Ayush Arora
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Angel Xiao
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Deana Hammond
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Caressa Chen
- Loyola University Medical Center; Maywood IL, USA
| | - Isobel Tweedt
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, USA
| | - James Rohde
- Department of Integrative Biology, University of California Berkeley, USA
| | - Thomas Link
- Department of Radiology and Biomedical Imagery, University of California, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Aenor Sawyer
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
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Lee HJ, Lee SJ, Jung JM, Lee TH, Jeong C, Lee TJ, Jang JE, Lee JW. Biomechanical Evaluation of Lateral Lumbar Interbody Fusion with Various Fixation Options for Adjacent Segment Degeneration: A Finite Element Analysis. World Neurosurg 2023; 173:e156-e167. [PMID: 36775239 DOI: 10.1016/j.wneu.2023.02.023] [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: 01/15/2023] [Accepted: 02/04/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVE Adjacent segment degeneration (ASD) is a common phenomenon after lumbar fusion. Lateral lumbar interbody fusion (LLIF) may provide an alternative treatment method for ASD. This study used finite element analysis to evaluate the biomechanical effects of LLIF with various fixation options and identify an optimal surgical strategy for ASD. METHODS A validated L1-S1 finite element model was modified for simulation. Six finite element models of the lumbar spine were created and were divided into group 1 (L4-5 posterior lumbar interbody fusion [PLIF] + L3-4 LLIF) and group 2 (L5-S1 PLIF + L4-5 LLIF). Each group consisted of 1) cage-alone, 2) cage + lateral screw fixation (LSF), and 3) cage + bilateral pedicle screw fixation (BPSF) models. The range of motion, intradiscal pressure, and facet loads of adjacent segments as well as interbody cage stress were analyzed. RESULTS The stress on the LLIF cage-superior endplate interface was highest in the cage-alone model followed by the cage + LSF model and cage + BPSF model. The increase in range of motion, intradiscal pressure, and facet loads at the adjacent segment was highest in the cage + BPSF model followed by the cage + LSF model and cage-alone model. However, the biomechanical effect on the adjacent segment seemed similar in the cage-alone and cage + LSF models. CONCLUSIONS LLIF with BPSF is recommended when performing LLIF surgery for ASD after L4-5 and L5-S1 PLIF. Considering cage subsidence and biomechanical effects on the adjacent segment, LLIF with LSF may be a suboptimal option for ASD surgery.
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Affiliation(s)
- Hyun Ji Lee
- Department of Biomedical Engineering, Inje University, Gimhae, Republic of Korea
| | - Sung-Jae Lee
- Department of Biomedical Engineering, Inje University, Gimhae, Republic of Korea
| | - Jong-Myung Jung
- Department of Neurosurgery, 9988 Joint & Spine Hospital, Seoul, Republic of Korea.
| | - Tae Hoon Lee
- Department of Orthopedic Surgery, 9988 Joint & Spine Hospital, Seoul, Republic of Korea
| | - Chandong Jeong
- Department of Orthopedic Surgery, 9988 Joint & Spine Hospital, Seoul, Republic of Korea
| | - Tae Jin Lee
- Department of Orthopedic Surgery, 9988 Joint & Spine Hospital, Seoul, Republic of Korea
| | - Ji-Eun Jang
- R&D Center, GS Medical Co., Ltd., Cheongju, Republic of Korea
| | - Jae-Won Lee
- R&D Center, GS Medical Co., Ltd., Cheongju, Republic of Korea
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Lin W, He C, Xie F, Chen T, Zheng G, Yin H, Chen H, Wang Z. Assessment of bone density using the 1.5 T or 3.0 T MRI-based vertebral bone quality score in older patients undergoing spine surgery: Does field strength matter? Spine J 2023:S1529-9430(23)00152-3. [PMID: 37031891 DOI: 10.1016/j.spinee.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/25/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND CONTEXT Recently published studies have revealed a correlation between MRI-based vertebral bone quality (VBQ) score and bone mineral density (BMD) measured using dual X-ray absorptiometry (DXA) or quantitative computed tomography (QCT). However, no studies have determined if differences in field strength (1.5 vs. 3.0 T) could affect the comparability of the VBQ score among different individuals. PURPOSE To compare the VBQ score obtained from 1.5 T and 3.0 T MRI (VBQ1.5T versus VBQ3.0T) in patients undergoing spine surgery and assess the predictive performance of VBQ for osteoporosis and osteoporotic vertebral fracture (VCF). DESIGN A nested case‒control study based on an ongoing prospective cohort study of patients undergoing spine surgery. PATIENT SAMPLE All older patients (men aged > 60 years and postmenopausal women) with available DXA, QCT and MR images within one month were included. OUTCOME MEASURES VBQ score, DXA T-score, and QCT derived vBMD. METHODS The osteoporotic classifications recommended by the World Health Organization and American College of Radiology were used to categorize the DXA T-score and QCT-derived BMD, respectively. For each patient, the VBQ score was calculated using T1-weighted MR images. Correlation analysis between VBQ and DXA/QCT was performed. Receiver operating characteristic (ROC) curve analysis, including determination of the area under the curve (AUC), was performed to assess the predictive performance of VBQ for osteoporosis. RESULTS A total of 452 patients (98 men aged > 60 years and 354 postmenopausal women) were included in the analysis. Across different BMD categories, the correlation coefficients between the VBQ score and BMD ranged from -0.211 to -0.511, and the VBQ1.5T score and QCT BMD demonstrated the strongest correlation. The VBQ score was a significant classifier of osteoporosis detected by either DXA or QCT, with VBQ1.5T showing the highest discriminative power for QCT-osteoporosis (AUC = 0.744, 95% CI = 0.685-0.803). In ROC analysis, the VBQ1.5T threshold values ranged from 3.705 to 3.835 with a sensitivity between 48% and 55.6% and a specificity between 70.8% and 74.8%, while the VBQ3.0T threshold values ranged from 2.59 to 2.605 with a sensitivity between 57.6% and 67.1% and a specificity between 67.8% and 69.7%. CONCLUSIONS VBQ1.5T exhibited better discriminability between patients with and without osteoporosis than VBQ3.0T. Considering the nonnegligible difference in osteoporosis diagnosis threshold values between the VBQ1.5T and VBQ3.0T scores, it is essential to clearly distinguish the magnetic field strength when assessing the VBQ score.
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Affiliation(s)
- Wentao Lin
- Department of Spine Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan, Guangdong, China
| | - Chaoqin He
- Department of Spine Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan, Guangdong, China
| | - Faqin Xie
- Department of Spine Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan, Guangdong, China
| | - Tao Chen
- Department of Spine Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan, Guangdong, China
| | - Guanghao Zheng
- Department of Spine Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan, Guangdong, China
| | - Houjie Yin
- Department of Spine Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan, Guangdong, China
| | - Haixiong Chen
- Department of Radiology and Image, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan, Guangdong, China
| | - Zhiyun Wang
- Department of Spine Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Foshan, Guangdong, China.
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Hiyama A, Sakai D, Katoh H, Nomura S, Sato M, Watanabe M. Comparative Study of Cage Subsidence in Single-Level Lateral Lumbar Interbody Fusion. J Clin Med 2022; 11:jcm11051374. [PMID: 35268465 PMCID: PMC8911078 DOI: 10.3390/jcm11051374] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 11/17/2022] Open
Abstract
We investigated the incidence and clinical features of cage subsidence after single-level lateral lumbar interbody fusion (LLIF). We studied a retrospective cohort of 59 patients (34 males, 25 females; mean age, 68.9 years) who received single-level LLIF. Patients were classified into subsidence and no-subsidence groups. Cage subsidence was defined as any violation of either endplate, classified using radiographs and computed tomography (CT) images. After one year, we compared patient characteristics, surgical parameters, radiological findings, pain scores, and fusion status. We also compared the Hounsfield unit (HU) endplate value obtained on CT preoperatively. Twenty patients (33.9%) had radiographic evidence of interbody cage subsidence. There were significant differences between the subsidence and no-subsidence groups in sex, cage height, fusion rate, and average HU value of both endplates (p < 0.05). There were no significant differences in age, height, weight, or body mass index. Moreover, there were no significant differences in global alignment and Numerical Rating Scale change in low back pain, leg pain, and numbness. Despite suggestions that patients with lower HU values might develop cage subsidence, our results showed that cage subsidence after single-level LLIF was not associated with low back pain, leg pain, or numbness one year post-operation.
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Jung JM, Chung CK, Kim CH, Yang SH, Ko YS. The Modified 11-Item Frailty Index and Postoperative Outcomes in Patients Undergoing Lateral Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2022; 47:396-404. [PMID: 34669672 DOI: 10.1097/brs.0000000000004260] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to analyze postoperative complications and recovery patterns in different modified 11-item frailty index (mFI-11) groups after lateral lumbar interbody fusion (LLIF) surgery. SUMMARY OF BACKGROUND DATA The relationship between the mFI-11 score and LLIF surgery has not been previously reported. METHODS A single-center, consecutive series of patients who underwent LLIF with at least two years of follow-up were retrospectively reviewed. Complications after LLIF surgery were recorded. Clinical outcomes, including the visual analog scale (VAS) for back/leg pain and the Oswestry Disability Index (ODI), were evaluated preoperatively and at 1 and 2 years postoperatively. The proportions of patients who achieved substantial clinical benefit (SCB) for the VAS-B, VAS-L, and ODI were also analyzed. RESULTS One hundred fifty-two patients included in the present study were grouped according to their mFI-11 score: 0 (n = 39), 0.09 (n = 69), 0.18 (n = 31), and ≥0.27 (n = 13). An mFI-11 score ≥0.27 was a significant predictor of urinary complications (adjusted odds ratio: 3.829, P = 0.013). At 2 years postoperatively, patients in all frailty categories experienced improvements in the VAS for back pain, VAS for leg pain, and ODI, without significant differences between the four groups (p = 0.182, 0.121, and 0.804, respectively). There were also no significant differences in the proportions of patients achieving SCB for back/leg pain and the ODI between the four groups (P = 0.843, 0.957, and 0.915, respectively). CONCLUSION An mFI-11 score was found to be independently associated with urologic complications in patients who underwent LLIF. Patients in all frailty categories experienced significant improvements in back pain, leg pain, and the ODI at 1 year and 2 years postoperatively. LLIF surgery may be useful for patients with high frailty index.Level of Evidence: 4.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young San Ko
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Poor Bone Quality, Multilevel Surgery, and Narrow and Tall Cages Are Associated with Intraoperative Endplate Injuries and Late-onset Cage Subsidence in Lateral Lumbar Interbody Fusion: A Systematic Review. Clin Orthop Relat Res 2022; 480:163-188. [PMID: 34324459 PMCID: PMC8673985 DOI: 10.1097/corr.0000000000001915] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/06/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND A major complication of lateral lumbar interbody fusion (LLIF) is cage subsidence, which may lead to clinical problems, including loss of disc height correction, altered spinal alignment, recurrent pain, and vertebral body fracture. A thorough review of the current knowledge about the risk factors for the two types of cage subsidence after LLIF-intraoperative endplate injury and late-onset cage subsidence-could bring attention to well-established risk factors for clinical consideration while identifying any incompletely characterized factors that require further research to clarify. QUESTIONS/PURPOSES We performed a systematic review to answer the following questions: (1) Are bone quality and surrogates for bone quality, such as patient age and sex, associated with an increased likelihood of cage subsidence? (2) Are implant-related factors associated with an increased likelihood of cage subsidence? METHODS Two independent reviewers comprehensively searched Medline, Embase, Cochrane Library, PubMed, and Web of Science from 1997 to 2020 to identify all potential risk factors for cage subsidence after LLIF. Discrepancies were settled through discussion during full-text screening. Search terms included "lateral" AND "interbody fusion" AND "subsidence" OR "settling" OR "endplate injury" OR "endplate violation" WITHOUT "cervical" OR "transforaminal" OR "biomechanical." Eligible studies were retrospective or prospective comparative studies, randomized controlled trials, and case series with sample sizes of 10 patients or more reporting risk factors for cage subsidence or endplate injury after LLIF. Studies that involved cervical interbody fusions and biomechanical and cadaveric experiments were excluded. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the studies' quality of evidence. The initial database review found 400 articles. Thirty-four articles with moderate- to very-low-quality evidence met the inclusion criteria for analysis. A total of 3233 patients (58% [1860] of whom were female) were included in this review. Two types of cage subsidence were reviewed: late-onset cage subsidence, which occurs gradually postoperatively, and intraoperative endplate injury, which is derived from iatrogenic endplate violation during endplate preparation or cage insertion. Among 20 studies with moderate quality of evidence according to the GRADE criteria, eight studies reported risk factors for cage subsidence related to bone mineral density and its surrogates and 12 studies focused on risk factors regarding implant factors, including cage dimension, cage material, construct length, and supplementary instrumentation. RESULTS Patients with a dual x-ray absorptiometry T-score of -1.0 or less, age older than 65 years, and female sex were considered to have a high risk of both types of cage subsidence. Regarding cage size, cage width ≥ 22 mm helped to avoid late-onset cage subsidence, and cage height ≤ 11 mm was recommended by some studies to avoid intraoperative endplate injuries. Studies recommended that multilevel LLIF should be conducted with extra caution because of a high risk of losing the effect of indirect decompression. Studies found that standalone LLIF might be sufficient for patients without osteoporosis or obesity, and supplementary instrumentation should be considered to maintain the postoperative disc height and prevent subsidence progression in patients with multiple risk factors. The effect of the bone graft, cage material, endplate condition, and supplementary instrumentation on cage subsidence remained vague or controversial. CONCLUSION Patients with poor bone density, patients who are older than 65 years, and female patients should be counseled about their high risk of developing cage subsidence. Surgeons should avoid narrow cages when performing LLIF to minimize the risk of late-onset cage subsidence, while being cautious of an aggressive attempt to restore disc height with a tall cage as it may lead to intraoperative endplate injury. For multilevel constructs, direct decompression approaches, such as posterior and transforaminal LIF, should be considered before LLIF, since the effect of indirect decompression may be difficult to maintain in multilevel LLIF because of high risks of cage subsidence. The effect of the cage material and supplementary instrumentation require stronger evidence from prospectively designed studies with larger sample size that randomly assign patients to polyetheretherketone (PEEK) or titanium cages and different fixation types. Future research on intraoperative endplate injuries should focus on the specific timing of when endplate violation occurs with the help of intraoperative imaging so that attempts can be made to minimize its occurrence. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Prognosis of Symptomatic Pseudarthrosis Observed at 1 Year After Lateral Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2021; 46:E1006-E1013. [PMID: 33534522 DOI: 10.1097/brs.0000000000003980] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the prognosis of symptomatic pseudarthrosis observed at 1 year after lateral lumbar interbody fusion (LLIF) surgery and to analyze the risk factors for persistent pseudarthrosis for 2 years postoperatively. SUMMARY OF BACKGROUND DATA Few articles have evaluated the prognosis of symptomatic pseudarthrosis following LLIF surgery. METHODS One hundred fifty-two patients with a minimum follow-up of 2 years were screened. Fusion status was assessed at 1 year postoperatively, and unfused segments were reevaluated at 2 years postoperatively. Dynamic x-rays and computed tomography images were acquired to evaluate the fusion status. Demographic data were evaluated to identify the risk factors associated with persistent pseudarthrosis. Clinical outcomes, including the visual analog scale (VAS) for back/leg pain and the Oswestry disability index (ODI), were evaluated preoperatively and at 1 and 2 years postoperatively. RESULTS Symptomatic pseudarthrosis was detected in 42 patients at 1 year postoperatively. Among them, 23 patients (54.8%) exhibited solid bony fusion 2 years postoperatively without further intervention. Fourteen patients (33.3%) showed asymptomatic pseudarthrosis, and the remaining five patients (11.9%) showed symptomatic pseudarthrosis. Multivariable analysis showed that diabetes (adjusted odds ratio [OR]: 2.817, P = 0.007), smoking (adjusted OR: 6.497, P = 0.008), and fusion at more than three levels (adjusted OR: 2.525, P = 0.031) were risk factors for persistent pseudarthrosis. Improvements in the VAS scores for back pain and ODI scores were significantly lower in the persistent pseudarthrosis group than in the final solid fusion group at 2 years postoperatively. CONCLUSION It is not necessary to intervene for all patients in whom symptomatic pseudarthrosis is detected at 1 year postoperatively because only 11.9% of them will show persistent symptomatic pseudarthrosis. However, early revision surgery should be considered when severe symptomatic pseudarthrosis associated with diabetes, smoking, and fusion at more than three levels is present.Level of Evidence: 4.
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Jung JM, Chung CK, Kim CH, Yang SH, Won YI, Choi Y. Effects of Total Psoas Area Index on Surgical Outcomes of Single-Level Lateral Lumbar Interbody Fusion. World Neurosurg 2021; 154:e838-e845. [PMID: 34411761 DOI: 10.1016/j.wneu.2021.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We evaluated the effect of the total psoas area index (TPAI = total psoas muscle area [cm2]/height squared [m2]) on neurological complications and clinical outcomes after lateral lumbar interbody fusion and identified the appropriate TPAI to achieve a substantial clinical benefit (SCB). METHODS A consecutive series of 123 patients who had undergone single-level lateral lumbar interbody fusion at a single center with ≥2 years of follow-up were retrospectively reviewed. The patient characteristics and operative data were evaluated. The neurological complications were classified as transient and persistent symptoms. The visual analog scale score for back pain was assessed preoperatively and at 1 and 2 years postoperatively. RESULTS The present study included 31 men and 92 women. The mean TPAI was 8.97 cm2/m2 for the men and 5.04 cm2/m2 for the women. The mean TPAI was not significantly different between the patients with and without perioperative neurological complications. Multiple logistic regression analysis showed that solid interbody fusion was the most significant factor for achieving an SCB regarding back pain in men (odds ratio [OR], 2.453; P = 0.019) and women (OR, 2.906; P = 0.042). The TPAI was one of the predictors for achieving an SCB in men (OR, 1.251; P = 0.038) and women (OR, 1.795; P = 0.023). The optimal cutoff point of the TPAI for an SCB was 8.18 cm2/m2 for the men and 4.43 cm2/m2 for the women. CONCLUSIONS The TPAI had little effect on the incidence of perioperative neurological complications. However, the TPAI was identified as one of the predictors for achieving an SCB regarding back pain.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea.
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Ii Won
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Does obesity affect long-term outcomes of extreme lateral interbody fusion with posterior stabilization? Spine J 2021; 21:1318-1324. [PMID: 33744435 DOI: 10.1016/j.spinee.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/24/2021] [Accepted: 03/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Obese patients can pose significant challenges to spine surgeons in lumbar fusion procedures. The increased risk of complications has led surgeons to be wary in pursing operative interventions in these patients. Since the advent of minimally-invasive techniques in lumbar fusion, surgeons are turning to these procedures in an attempt to minimize operative time, blood loss and overall cost. With an increased proportion of obese patients in the population, it is imperative to understand the long-term outcomes in these minimally-invasive approaches. PURPOSE The purpose of this study was to evaluate the long-term safety and efficacy of extreme lateral interbody fusion (XLIF) in the obese. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 115 patients (53 nonobese and 62 obese) who underwent XLIF with a minimum of 5-year follow-up. OUTCOME MEASURES (1) Patient reported outcome scores: Visual Analog Scale (VAS) for back pain, Oswestry Disability Index (ODI), (2) Reoperation rate, (3) Pelvic incidence (PI)- Lumbar lordosis (LL) mismatch correction, (4) Graft subsidence and fusion rate METHODS: A retrospective review was performed to identify patients who underwent XLIF with percutaneous posterior stabilization since 2007 with a minimum follow-up of 5 years. Demographics including BMI were recorded and patients were subdivided into 2 cohorts: nonobese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2). Functional outcomes were assessed by comparing pre- and postoperative VAS and ODI scores. Reoperation rates were compared between cohorts. PI-LL mismatch was calculated from both pre- and postoperative radiographs. Rates of graft subsidence and fusion were measured at final follow-up. RESULTS A total of 115 consecutive patients were included (53 nonobese and 62 obese) with a mean follow up of 95.3 months. Mean BMI was 25.3 in the nonobese group and 35.3 in the obese group (p<.001). There were more females in nonobese cohort. VAS scores decreased by a mean of 5.7 in the nonobese cohort, and 5.4 in the obese cohort (p=.213). ODI improvement was also similar between the groups. 5.6% of nonobese patients required reoperation compared to 9.6% of obese patients (p=.503). Graft subsidence rates at final follow-up were 5.66% and 8.06% for the nonobese and obese groups, respectively (p=.613). Rates of successful fusion were 96.23% and 98.39% for the nonobese and obese groups, respectively (p=.469). Both cohorts achieved a similar proportion of PI-LL mismatch correction, 85% in obese versus 78% in nonobese patients (p=.526). CONCLUSION Obese patients have similar surgical outcomes to nonobese patients with respect to functional outcome scores, reoperation rates, graft subsidence and correction of PI-LL mismatch after long-term follow-up. With similar outcome and reoperation profiles, minimally-invasive approaches to the spine, such as XLIF, may be an acceptable alternative to traditional open procedures in obese patients.
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Jung JM, Chung CK, Kim CH, Yang SH, Ko YS, Choi Y. Intraoperative Radiographs in Single-level Lateral Lumbar Interbody Fusion Can Predict Radiographic and Clinical Outcomes of Follow-up 2 Years After Surgery. Spine (Phila Pa 1976) 2021; 46:772-780. [PMID: 33337681 DOI: 10.1097/brs.0000000000003889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
MINI Some of the improvements in DH, FH, and SLL achieved intraoperatively during lateral lumbar interbody fusion surgery were lost by the postoperative 1-week follow-up. An intraoperative radiograph can predict radiographic and clinical outcomes of the 2-year follow-up. The difference between preoperative DH and intraoperative DH should be >4.18 mm.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young San Ko
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Wang QD, Guo LX. Biomechanical role of osteoporosis in the vibration characteristics of human spine after lumbar interbody fusion. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2020; 36:e3402. [PMID: 33021071 DOI: 10.1002/cnm.3402] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/30/2020] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
Lumbar vertebrae osteoporosis is the most common challenge for lumbar interbody fusion, and this challenge has been widely concerned by scholars for many years. However, under whole-body vibration, osteoporosis how to affect the vibration characteristics of the fusion lumbar spine, complications, and fusion outcomes is urgent to know. The L1-L5 finite element model of lumbar spine was modified to simulate the transforaminal lumbar interbody fusion model with the bilateral pedicle screw fixator at L4-L5 level. A 5 Hz, 40 N sinusoidal vertical load supplemented with a 400 N preload was used to simulate the vertical vibration of human body. The results showed that under whole-body vibration, osteoporosis of fused vertebrae may cause the adjacent segments more unstable and increase the risk of adjacent segment diseases, subsidence, cage failure, rod failure, and lumbar instability. Osteoporosis of the fused vertebrae may cause the vertebral cells an unstable, inhibited growth and lead to poorer fusion outcomes. The findings may assist us in understanding the effect of osteoporosis on the vibration characteristics of lumbar spine fusion and provide references to clinical treatments for lumbar interbody fusion and lumbar vertebrae osteoporosis.
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Affiliation(s)
- Qing-Dong Wang
- School of Mechanical Engineering and Automation, Northeastern University, Shenyang, China
| | - Li-Xin Guo
- School of Mechanical Engineering and Automation, Northeastern University, Shenyang, China
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