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Duan Y, Feng D, Chen J, Wu Y, Li T, Jiang L, Huang Y. Anterior, Posterior and Anterior-Posterior Approaches for the Treatment of Thoracolumbar Burst Fractures: A Network Meta-Analysis of Randomized Controlled Trials. J INVEST SURG 2024; 37:2301794. [PMID: 38199978 DOI: 10.1080/08941939.2024.2301794] [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: 10/26/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE To compare the clinical and radiological results of the anterior approach versus the posterior approach versus the anterior-posterior approach for the treatment of thoracolumbar burst fractures. METHODS The network meta-analysis was performed in accordance with the PRISMA Statement. Electronic searches of PubMed and Embase were conducted up to June 22, 2023, for relevant randomized controlled trials. STATA13.0 was used to perform network meta-analysis. p < .05 was considered significant. RESULTS Nine RCTs with a total of 550 patients receiving surgical treatment in at least two of the three approaches, including anterior, posterior and anterior-posterior approaches, were included. The surgical duration and intraoperative bleeding volume in the posterior approach were significantly lower than those in the anterior (SMD, -1.72; 95% CI, -2.82, -0.62) and anterior-posterior approaches (SMD, 3.33; 95% CI, 1.65, 5.00). The surgical duration in the anterior approach was significantly lower than that in the anterior-posterior approach (SMD, 1.61; 95% CI, 0.12, 3.10). The Cobb angle in the anterior-posterior approach was significantly lower than that in the anterior approach (MD, -4.83; 95% CI, -9.60, -0.05). The VAS score in the posterior approach was significantly higher than that in the anterior approach (MD, 0.85; 95% CI, 0.55, 1.16) and anterior-posterior approach (MD, -0.84; 95% CI, -1.12, -0.55). No significant difference was identified among the three surgical approaches in implant failure rate and infection rate. CONCLUSION All three approaches were safe approaches with advantages and disadvantages. The selection of surgical approaches for the treatment of thoracolumbar burst fractures may be individualized.
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Affiliation(s)
- Yuchen Duan
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Dagang Feng
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Jun Chen
- Department of Critical Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Yamei Wu
- Sichuan Academy of Chinese Medicine Sciences, Chengdu, China
| | - Tong Li
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Leiming Jiang
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Yong Huang
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
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Khan NA, Asim M, El-Menyar A, Biswas KH, Rizoli S, Al-Thani H. The evolving role of extracellular vesicles (exosomes) as biomarkers in traumatic brain injury: Clinical perspectives and therapeutic implications. Front Aging Neurosci 2022; 14:933434. [PMID: 36275010 PMCID: PMC9584168 DOI: 10.3389/fnagi.2022.933434] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Developing effective disease-modifying therapies for neurodegenerative diseases (NDs) requires reliable diagnostic, disease activity, and progression indicators. While desirable, identifying biomarkers for NDs can be difficult because of the complex cytoarchitecture of the brain and the distinct cell subsets seen in different parts of the central nervous system (CNS). Extracellular vesicles (EVs) are heterogeneous, cell-derived, membrane-bound vesicles involved in the intercellular communication and transport of cell-specific cargos, such as proteins, Ribonucleic acid (RNA), and lipids. The types of EVs include exosomes, microvesicles, and apoptotic bodies based on their size and origin of biogenesis. A growing body of evidence suggests that intercellular communication mediated through EVs is responsible for disseminating important proteins implicated in the progression of traumatic brain injury (TBI) and other NDs. Some studies showed that TBI is a risk factor for different NDs. In terms of therapeutic potential, EVs outperform the alternative synthetic drug delivery methods because they can transverse the blood–brain barrier (BBB) without inducing immunogenicity, impacting neuroinflammation, immunological responses, and prolonged bio-distribution. Furthermore, EV production varies across different cell types and represents intracellular processes. Moreover, proteomic markers, which can represent a variety of pathological processes, such as cellular damage or neuroinflammation, have been frequently studied in neurotrauma research. However, proteomic blood-based biomarkers have short half-lives as they are easily susceptible to degradation. EV-based biomarkers for TBI may represent the complex genetic and neurometabolic abnormalities that occur post-TBI. These biomarkers are not caught by proteomics, less susceptible to degradation and hence more reflective of these modifications (cellular damage and neuroinflammation). In the current narrative and comprehensive review, we sought to discuss the contemporary knowledge and better understanding the EV-based research in TBI, and thus its applications in modern medicine. These applications include the utilization of circulating EVs as biomarkers for diagnosis, developments of EV-based therapies, and managing their associated challenges and opportunities.
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Affiliation(s)
- Naushad Ahmad Khan
- Clinical Research, Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- *Correspondence: Ayman El-Menyar
| | - Kabir H. Biswas
- Division of Biological and Biomedical Sciences, College of Health and Life Sciences, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
| | - Sandro Rizoli
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
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Greenberg JK, Burks SS, Dibble CF, Javeed S, Gupta VP, Yahanda AT, Perez-Roman RJ, Govindarajan V, Dailey AT, Dhall S, Hoh DJ, Gelb DE, Kanter AS, Klineberg EO, Lee MJ, Mummaneni PV, Park P, Sansur CA, Than KD, Yoon JJW, Wang MY, Ray WZ. An updated management algorithm for incorporating minimally invasive techniques to treat thoracolumbar trauma. J Neurosurg Spine 2022; 36:558-567. [PMID: 34715673 DOI: 10.3171/2021.7.spine21790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) techniques can effectively stabilize and decompress many thoracolumbar injuries with decreased morbidity and tissue destruction compared with open approaches. Nonetheless, there is limited direction regarding the breadth and limitations of MIS techniques for thoracolumbar injuries. Consequently, the objectives of this study were to 1) identify the range of current practice patterns for thoracolumbar trauma and 2) integrate expert opinion and literature review to develop an updated treatment algorithm. METHODS A survey describing 10 clinical cases with a range of thoracolumbar injuries was sent to 12 surgeons with expertise in spine trauma. The survey results were summarized using descriptive statistics, along with the Fleiss kappa statistic of interrater agreement. To develop an updated treatment algorithm, the authors used a modified Delphi technique that incorporated a literature review, the survey results, and iterative feedback from a group of 14 spine trauma experts. The final algorithm represented the consensus opinion of that expert group. RESULTS Eleven of 12 surgeons contacted completed the case survey, including 8 (73%) neurosurgeons and 3 (27%) orthopedic surgeons. For the 4 cases involving patients with neurological deficits, nearly all respondents recommended decompression and fusion, and the proportion recommending open surgery ranged from 55% to 100% by case. Recommendations for the remaining cases were heterogeneous. Among the neurologically intact patients, MIS techniques were typically recommended more often than open techniques. The overall interrater agreement in recommendations was 0.23, indicating fair agreement. Considering both literature review and expert opinion, the updated algorithm indicated that MIS techniques could be used to treat most thoracolumbar injuries. Among neurologically intact patients, percutaneous instrumentation without arthrodesis was recommended for those with AO Spine Thoracolumbar Classification System subtype A3/A4 (Thoracolumbar Injury Classification and Severity Score [TLICS] 4) injuries, but MIS posterior arthrodesis was recommended for most patients with AO Spine subtype B2/B3 (TLICS > 4) injuries. Depending on vertebral body integrity, anterolateral corpectomy or mini-open decompression could be used for patients with neurological deficits. CONCLUSIONS Spine trauma experts endorsed a range of strategies for treating thoracolumbar injuries but felt that MIS techniques were an option for most patients. The updated treatment algorithm may provide a foundation for surgeons interested in safe approaches for using MIS techniques to treat thoracolumbar trauma.
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Affiliation(s)
- Jacob K Greenberg
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Stephen Shelby Burks
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Christopher F Dibble
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Saad Javeed
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Vivek P Gupta
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Alexander T Yahanda
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Roberto J Perez-Roman
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Vaidya Govindarajan
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Andrew T Dailey
- 3Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay Dhall
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel J Hoh
- 5Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Adam S Kanter
- 8Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric O Klineberg
- 9Department of Orthopedic Surgery, University of California, Davis, Sacramento, California
| | - Michael J Lee
- 10Department of Orthopedic Surgery, University of Chicago, Chicago, Illinois
| | - Praveen V Mummaneni
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Paul Park
- 11Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Charles A Sansur
- 7Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Khoi D Than
- 12Department of Neurosurgery, Duke University, Durham, North Carolina; and
| | - Jon J W Yoon
- 13Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael Y Wang
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Wilson Z Ray
- 1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
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Kim KD, Lee KS, Coric D, Chang JJ, Harrop JS, Theodore N, Toselli RM. A study of probable benefit of a bioresorbable polymer scaffold for safety and neurological recovery in patients with complete thoracic spinal cord injury: 6-month results from the INSPIRE study. J Neurosurg Spine 2021:1-10. [PMID: 33545674 DOI: 10.3171/2020.8.spine191507] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether the investigational Neuro-Spinal Scaffold (NSS), a highly porous bioresorbable polymer device, demonstrates probable benefit for safety and neurological recovery in patients with complete (AIS grade A) T2-12 spinal cord injury (SCI) when implanted ≤ 96 hours postinjury. METHODS This was a prospective, open-label, multicenter, single-arm study in patients with a visible contusion on MRI. The NSS was implanted into the epicenter of the postirrigation intramedullary spinal cord contusion cavity with the intention of providing structural support to the injured spinal cord parenchyma. The primary efficacy endpoint was the proportion of patients who had an improvement of ≥ 1 AIS grade (i.e., conversion from complete paraplegia to incomplete paraplegia) at the 6-month follow-up visit. A preset objective performance criterion established for the study was defined as an AIS grade conversion rate of ≥ 25%. Secondary endpoints included change in neurological level of injury (NLI). This analysis reports on data through 6-month follow-up assessments. RESULTS Nineteen patients underwent NSS implantation. There were 3 early withdrawals due to death, which were all determined by investigators to be unrelated to the NSS or the implantation procedure. Seven of 16 patients (43.8%) who completed the 6-month follow-up visit had conversion of neurological status (AIS grade A to grade B [n = 5] or C [n = 2]). Five patients showed improvement in NLI of 1 to 2 levels compared with preimplantation assessment, 3 patients showed no change, and 8 patients showed deterioration of 1 to 4 levels. There were no unanticipated or serious adverse device effects or serious adverse events related to the NSS or the implantation procedure as determined by investigators. CONCLUSIONS In this first-in-human study, implantation of the NSS within the spinal cord appeared to be safe in the setting of surgical decompression and stabilization for complete (AIS grade A) thoracic SCI. It was associated with a 6-month AIS grade conversion rate that exceeded historical controls. The INSPIRE study data demonstrate that the potential benefits of the NSS outweigh the risks in this patient population and support further clinical investigation in a randomized controlled trial.Clinical trial registration no.: NCT02138110 (clinicaltrials.gov).
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Affiliation(s)
- Kee D Kim
- 1Department of Neurological Surgery, UC Davis, Sacramento, California
| | - K Stuart Lee
- 2Division of Neurosurgery, Vidant Health, Greenville, North Carolina
| | - Domagoj Coric
- 3Atrium Musculoskeletal Institute, Carolina NeuroSurgery & Spine Associates, Charlotte, North Carolina
| | - Jason J Chang
- 4Department of Neurological Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - James S Harrop
- 5Department of Neurological and Orthopedic Surgery, Division of Spine and Peripheral Nerve Surgery, and Delaware Valley SCI Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicholas Theodore
- 6Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
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Magogo J, Lazaro A, Mango M, Zuckerman SL, Leidinger A, Msuya S, Rutabasibwa N, Shabani HK, Härtl R. Operative Treatment of Traumatic Spinal Injuries in Tanzania: Surgical Management, Neurologic Outcomes, and Time to Surgery. Global Spine J 2021; 11:89-98. [PMID: 32875835 PMCID: PMC7734258 DOI: 10.1177/2192568219894956] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE Little is known about operative management of traumatic spinal injuries (TSI) in low- and middle-income countries (LMIC). In patients undergoing surgery for TSI in Tanzania, we sought to (1) determine factors involved in the operative decision-making process, specifically implant availability and surgical judgment; (2) report neurologic outcomes; and (3) evaluate time to surgery. METHODS All patients from October 2016 to June 2019 who presented with TSI and underwent surgical stabilization. Fracture type, operation, neurologic status, and time-to-care was collected. RESULTS Ninety-seven patients underwent operative stabilization, 23 (24%) cervical and 74 (77%) thoracic/lumbar. Cervical operations included 4 (17%) anterior cervical discectomy and fusion with plate, 7 (30%) anterior cervical corpectomy with tricortical iliac crest graft and plate, and 12 (52%) posterior cervical laminectomy and fusion with lateral mass screws. All 74 (100%) of thoracic/lumbar fractures were treated with posterolateral pedicle screws. Short-segment fixation was used in 86%, and constructs often ended at an injured (61%) or junctional (62%) level. Sixteen (17%) patients improved at least 1 ASIA grade. The sole predictor of neurologic improvement was faster time from admission to surgery (odds ratio = 1.04, P = .011, 95%CI = 1.01-1.07). Median (range) time in days included: injury to admission 2 (0-29), admission to operating room 23 (0-81), and operating room to discharge 8 (2-31). CONCLUSIONS In a cohort of LMIC patients with TSI undergoing stabilization, the principle driver of operative decision making was cost of implants. Faster time from admission to surgery was associated with neurologic improvement, yet significant delays to surgery were seen due to patients' inability to pay for implants. Several themes for improvement emerged: early surgery, implant availability, prehospital transfer, and long-term follow-up.
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Affiliation(s)
- Juma Magogo
- Muhimbili Orthopedic Institute, Dar es Salaam, Tanzania
| | - Albert Lazaro
- Muhimbili Orthopedic Institute, Dar es Salaam, Tanzania
| | - Mechris Mango
- Muhimbili Orthopedic Institute, Dar es Salaam, Tanzania
| | - Scott L. Zuckerman
- New York–Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA,Vanderbilt University Medical Center, Nashville, TN, USA,Roger Härtl, Weill Cornell Brain and Spine Center, Department of Neurological Surgery, New York–Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, Box 99, New York, NY 10065, USA. Scott L. Zuckerman
| | - Andreas Leidinger
- New York–Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Salim Msuya
- Muhimbili Orthopedic Institute, Dar es Salaam, Tanzania
| | | | | | - Roger Härtl
- New York–Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA,Roger Härtl, Weill Cornell Brain and Spine Center, Department of Neurological Surgery, New York–Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, Box 99, New York, NY 10065, USA. Scott L. Zuckerman
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