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Liu L, Shi L, Su Y, Wang K, Wang H. Epidemiological features of spinal intradural tumors, a single-center clinical study in Beijing, China. BMC Musculoskelet Disord 2024; 25:613. [PMID: 39090624 PMCID: PMC11292946 DOI: 10.1186/s12891-024-07741-2] [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: 12/29/2023] [Accepted: 07/26/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Spinal intradural tumors are rare and heterogeneous in histological type, aggressiveness, and symptomatology, and there is a lack of data about them. This study investigated the epidemiological features of spinal intradural tumors. METHODS This retrospective analysis included patients with spinal intradural tumors who underwent surgical treatment at the Myelopathy and Spondylosis Ward Beijing Jishuitan Hospital between January 2012 and December 2022. RESULTS This study included 1321 patients [aged 47.19 ± 14.90 years, 603 (45.65%) males] with spinal intradural tumors. The most common histological subtype was schwannoma [n = 511 (38.68%)], followed by spinal meningioma [n = 184 (13.93%)] and ependymoma [n = 101 (7.65%)]. Fifteen (1.14%) patients were diagnosed with metastatic spinal intradural tumors as a presentation of another primary cancer type. The spinal intradural tumors were mostly found in the lumbar region [n = 436 (33.01%)], followed by the thoracic vertebrae [n = 390 (29.52%)], cervical vertebrae [n = 154 (11.66%)], and thoracolumbar region [n = 111 (8.40%)]. Schwannomas mostly affected the lumbar region [n = 256 (52.64%)], spinal meningiomas in the thoracic region [n = 153 (83.15)], and ependymomas in the lumbar region [56 (55.45%)]. The de novo metastases were mostly found in the lumbar region [n = 8 (53.33%)]. CONCLUSION According to the results of our single-center study, the most common spinal intradural tumor in Northern China is schwannoma, followed by spinal meningioma and ependymoma.
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Affiliation(s)
- Longqi Liu
- Department of Neurosurgery, Beijing Jishuitan Hospital, Capital Medical University, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Liang Shi
- Department of Neurosurgery, Beijing Jishuitan Hospital, Capital Medical University, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
| | - Yibing Su
- Department of Neurosurgery, Beijing Jishuitan Hospital, Capital Medical University, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Keda Wang
- Department of Neurosurgery, Beijing Jishuitan Hospital, Capital Medical University, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Hanbin Wang
- Department of Neurosurgery, Beijing Jishuitan Hospital, Capital Medical University, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035, China
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2
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Walter SG, Gaisendrees C, Kernich N, Weber M, Scheyerer MJ, Eysel P, Siewe J, Zarghooni K. Epidemiology of Surgically Treated Spinal Tumors: A Multicenter Surveillance Study of 9686 Patients from the German Spine Registry (DWG Register). ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:403-409. [PMID: 37308096 DOI: 10.1055/a-2077-7155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Tumors of the spine are challenging in terms of diagnoses and interdisciplinary treatment. This study was conducted to evaluate and characterize a large multicenter cohort of surgically treated spine tumor patients.Data of the German Spine Society (DWG) were used to characterize a cohort of all surgically treated spine tumor cases that were registered between 2017 and 2021. Subgroup analysis was performed for tumor entity, tumor localization, height of most severely affected segments, surgical treatment, and demographic parameters.In total, there were 9686 cases, of which 6747 were "malignant", 1942 were "primary benign", 180 were "tumor-like lesions", and 488 were "other" spinal tumors. Subgroups showed differences in number of affected segments as well as localization. There were further significant differences in surgical complication rates (p = 0.003), age (p < 0.001), morbidity (p < 0.001), and duration of surgery (p = 0.004).This is a representative study on spinal tumors from a large spine registry and allows for the epidemiological characterization of surgically treated tumor subgroups and quality control of registry data.
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Affiliation(s)
- Sebastian G Walter
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Germany
| | | | - Nikolaus Kernich
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Germany
| | - Maximilian Weber
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Germany
| | - Max J Scheyerer
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Germany
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Peer Eysel
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Germany
| | - Jan Siewe
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Germany
- Klinik für Orthopädie und Unfallchirurgie, Klinikum Leverkusen gGmbH, Leverkusen, Germany
| | - Kourosh Zarghooni
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Germany
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3
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Karabacak M, Shahbandi A, Mavridis O, Jagtiani P, Carr MT, Boylan A, Margetis K. Chondrosarcoma of the Mobile Spine in the Elderly: A National Cancer Database Study. World Neurosurg 2024:S1878-8750(24)01136-7. [PMID: 38968994 DOI: 10.1016/j.wneu.2024.06.160] [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: 05/29/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND The current research on geriatric patients with spinal chondrosarcoma is limited. This study aimed to investigate the demographics, patterns of care, and survival of geriatric patients with chondrosarcoma of the mobile spine. METHODS The National Cancer Database was queried from 2008 to 2018 for geriatric patients (60-89 years) with chondrosarcoma of the mobile spine. The primary outcome of this study was overall survival. The secondary outcome was treatment utilization patterns. Survival analyses were conducted using log-rank tests and Cox proportional hazards regressions. Logistic regression models were utilized to assess correlations between baseline variables and treatment utilization. RESULTS The database retrieved 122 patients. While 43.7% of the patients presented with tumors exceeding 5 cm in size, the incidence of regional lymph node involvement or distant metastases was relatively low, affecting only 5% of the patients. Furthermore, 22.3% of the patients had tumors graded as 3-4. The 5-year overall survival rate was 52.9% (95% confidence interval: 42-66.6). The mortality risk was significantly associated with age, tumor grade and stage, and treatment plan. Most patients (79.5%) underwent surgery, while 35.9% and 4.2% were treated with radiotherapy and chemotherapy, respectively. Age, race, comorbidities, geographical region, tumor stage, and healthcare facility type significantly correlated with treatment utilization. CONCLUSIONS Surgical resection significantly lowered the mortality risk in geriatric patients with spinal chondrosarcomas. Demographic and geographical factors significantly dictated treatment plans. Further studies are required to assess the role of radiotherapy and chemotherapy in treating these patients in the modern era.
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Affiliation(s)
- Mert Karabacak
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | | | - Olga Mavridis
- Dietrich College of Humanities and Social Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Pemla Jagtiani
- School of Medicine, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Matthew T Carr
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Arianne Boylan
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
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4
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Piscopo AJ, Teferi N, Hanson A, Challa M, Smith M, Eschbacher K, Hitchon P. Clinical diagnostic and radiographic features of a primary intradural spinal chondrosarcoma in a young adult: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 6:CASE23317. [PMID: 37728306 PMCID: PMC10555558 DOI: 10.3171/case23317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/19/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Mesenchymal chondrosarcoma (MCS) is an aggressive subtype of chondrosarcoma that occurs extremely rarely in the central nervous system. Patients often present with pain or sensorimotor deficits, and resection is considered the gold standard. The role of adjuvant radiation and/or chemotherapy is largely unknown. OBSERVATIONS A 22-year-old male presented with a 4-month history of progressive back and bilateral leg pain. He underwent imaging workup with magnetic resonance imaging of the lumbar spine and was found to have an intradural, extramedullary, heterogeneously enhancing mass spanning the L4-5 vertebral levels. Intraoperatively, a lobular, partially calcified mass with a ventral dural attachment displacing the nerve roots laterally was observed. The mass was removed en bloc, and the patient later underwent adjuvant radiotherapy, with no evidence of recurrence 2 years following surgery. LESSONS Spinal MCS is extremely rare and often presents with a more aggressive course than conventional chondrosarcoma. Radiological diagnosis is challenging, as the tumor mimics different pathologies. The presence of calcifications, heterogeneous enhancement, and a more rapid clinical course as well as the presence of HEY1::NCOA2 gene fusion, which can be detected by surrogate immunohistochemistry, aids in diagnosis. Resection is the standard of care, and adjuvant radiation may be considered to reduce local recurrence, although further studies are warranted.
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Affiliation(s)
| | | | - Alec Hanson
- University of Iowa Carver, College of Medicine, Iowa City, Iowa
| | - Meron Challa
- University of Iowa Carver, College of Medicine, Iowa City, Iowa
| | | | - Kathryn Eschbacher
- Pathology, University of Iowa Hospital and Clinics, Iowa City, Iowa; and
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Xu N, Chang S, Liu X, Jiang L, Yu M, Wu F, Dang L, Zhou H, Li Y, Wang Y, Liu X, Wu Y, Wei F, Liu Z. Medium to long term follow-up of survival and quality of life in patients with primary tumors of the cervical spine: Experience From a large single center. Front Surg 2023; 9:1011100. [PMID: 36684347 PMCID: PMC9852619 DOI: 10.3389/fsurg.2022.1011100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/28/2022] [Indexed: 01/07/2023] Open
Abstract
Objectives To evaluate the survival and medium to long term health-related quality of life (HRQoL) of patients with primary cervical spinal tumors in a cross-sectional study and to identify any significant associations with demographic or clinical characteristics. Methods Patients diagnosed with primary cervical spinal tumors were retrospectively enrolled and their clinical, radiologic, and follow-up data (specifically the EQ-5D questionnaire) were collected. Univariate and multivariate Cox time-dependent regression analyses were performed to examine the significance of certain variables on overall survival. Univariate and multivariate logistic regression analyses were conducted to identify variables significant for overall HRQoL and each dimension of the EQ-5D. Results A total of 341 patients were enrolled in the study with a mean follow-up of 70 months. The diagnosis was benign in 246 cases, malignant in 84, and unconfirmed in 11. The 5-year overall survival rate was 86% and the 10-year overall survival rate was 65%. Multivariate analysis suggested that surgical treatment (P = 0.002, hazard ratio [HR] = 0.431, 95% CI. [0.254, 0.729]), benign and malignant tumors [P < 0.001, HR = 2.788, 95% CI. (1.721, 4.516)], tumor and surrounding normal tissue boundary [P = 0.010, HR = 1.950, 95% CI. (1.171, 3.249)], and spinal instability [P = 0.031, HR = 1.731, 95% CI. (1.051, 2.851)] still had significant effects on survival. Conclusions In this cross-sectional study, we evaluated the survival period and medium and long-term health-related quality of life of patients with primary tumors of the cervical spine, and analyzed the significant related factors of tumor clinical characteristics. Surgery, myelopathy, malignancy, spinal pain relieved by lying down or supine position, and tumor infiltration on MRI were significant predictors for overall survival. Enneking stage and age were significant predictors for HRQoL.
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Affiliation(s)
- Nanfang Xu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Shuai Chang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Liang Jiang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Miao Yu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Fengliang Wu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Lei Dang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Hua Zhou
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Yan Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Yongqiang Wang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Xiao Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Yunxia Wu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Feng Wei
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China,Correspondence: Feng Wei Zhongjun Liu
| | - Zhongjun Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China,Correspondence: Feng Wei Zhongjun Liu
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Greenberg JK, Otun A, Ghogawala Z, Yen PY, Molina CA, Limbrick DD, Foraker RE, Kelly MP, Ray WZ. Translating Data Analytics Into Improved Spine Surgery Outcomes: A Roadmap for Biomedical Informatics Research in 2021. Global Spine J 2022; 12:952-963. [PMID: 33973491 PMCID: PMC9344511 DOI: 10.1177/21925682211008424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES There is growing interest in the use of biomedical informatics and data analytics tools in spine surgery. Yet despite the rapid growth in research on these topics, few analytic tools have been implemented in routine spine practice. The purpose of this review is to provide a health information technology (HIT) roadmap to help translate data assets and analytics tools into measurable advances in spine surgical care. METHODS We conducted a narrative review of PubMed and Google Scholar to identify publications discussing data assets, analytical approaches, and implementation strategies relevant to spine surgery practice. RESULTS A variety of data assets are available for spine research, ranging from commonly used datasets, such as administrative billing data, to emerging resources, such as mobile health and biobanks. Both regression and machine learning techniques are valuable for analyzing these assets, and researchers should recognize the particular strengths and weaknesses of each approach. Few studies have focused on the implementation of HIT, and a variety of methods exist to help translate analytic tools into clinically useful interventions. Finally, a number of HIT-related challenges must be recognized and addressed, including stakeholder acceptance, regulatory oversight, and ethical considerations. CONCLUSIONS Biomedical informatics has the potential to support the development of new HIT that can improve spine surgery quality and outcomes. By understanding the development life-cycle that includes identifying an appropriate data asset, selecting an analytic approach, and leveraging an effective implementation strategy, spine researchers can translate this potential into measurable advances in patient care.
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Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery, Washington University School of Medicine,
St. Louis, MO, USA,Jacob K. Greenberg, Department of
Neurosurgery, Washington University School of Medicine, 660S. Euclid Ave., Box
8057, St. Louis, MO 63 110, USA.
| | - Ayodamola Otun
- Department of Neurological Surgery, Washington University School of Medicine,
St. Louis, MO, USA
| | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Po-Yin Yen
- Institute for Informatics, Washington University School of Medicine,
St. Louis, MO, USA
| | - Camilo A. Molina
- Department of Neurological Surgery, Washington University School of Medicine,
St. Louis, MO, USA
| | - David D. Limbrick
- Department of Neurological Surgery, Washington University School of Medicine,
St. Louis, MO, USA
| | - Randi E Foraker
- Institute for Informatics, Washington University School of Medicine,
St. Louis, MO, USA
| | - Michael P. Kelly
- Department of Orthopaedic Surgery, Washington University School of Medicine,
St. Louis, MO, USA
| | - Wilson Z. Ray
- Department of Neurological Surgery, Washington University School of Medicine,
St. Louis, MO, USA
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Primary Benign Tumors of the Spinal Canal. World Neurosurg 2022; 164:178-198. [PMID: 35552036 DOI: 10.1016/j.wneu.2022.04.135] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 11/23/2022]
Abstract
Benign tumors that grow in the spinal canal are heterogeneous neoplasms with low incidence; from these, meningiomas and nerve sheath tumors (neurofibromas and schwannomas) account for 60%-70% of all primary spinal tumors. Benign spinal canal tumors provoke nonspecific clinical manifestations, mostly related to the affected level of the spinal cord. These tumors present a challenge for the patient and healthcare professionals, for they are often difficult to diagnose and the high frequency of posttreatment complications. In this review, we describe the epidemiology, risk factors, clinical features, diagnosis, histopathology, molecular biology, and treatment of extramedullary benign meningiomas, osteoid osteomas, osteoblastomas, aneurysmal bone cysts, osteochondromas, neurofibromas, giant cell tumors of the bone, eosinophilic granulomas, hemangiomas, lipomas, and schwannomas located in the spine, as well as possible future targets that could lead to an improvement in their management.
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Feler J, Sun F, Bajaj A, Hagan M, Kanekar S, Sullivan PLZ, Fridley JS, Gokaslan ZL. Complication Avoidance in Surgical Management of Vertebral Column Tumors. Curr Oncol 2022; 29:1442-1454. [PMID: 35323321 PMCID: PMC8947448 DOI: 10.3390/curroncol29030121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/23/2022] Open
Abstract
The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.
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Affiliation(s)
- Joshua Feler
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Felicia Sun
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Ankush Bajaj
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Matthew Hagan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Samika Kanekar
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Patricia Leigh Zadnik Sullivan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Jared S. Fridley
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Ziya L. Gokaslan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
- Correspondence:
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9
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Pennington Z, Ehresman J, Pittman PD, Ahmed AK, Lubelski D, McCarthy EF, Goodwin CR, Sciubba DM. Chondrosarcoma of the spine: a narrative review. Spine J 2021; 21:2078-2096. [PMID: 33971325 DOI: 10.1016/j.spinee.2021.04.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/19/2021] [Accepted: 04/28/2021] [Indexed: 02/03/2023]
Abstract
Chondrosarcoma is an uncommon primary bone tumor with an estimated incidence of 0.5 per 100,000 patient-years. Primary chondrosarcoma of the mobile spine and sacrum cumulatively account for less than 20% of all cases, most .commonly causing patients to present with focal pain with or without radiculopathy, or myelopathy secondary to neural element compression. Because of the rarity, patients benefit from multidisciplinary care at academic tertiary-care centers. Current standard-of-care consists of en bloc surgical resection with negative margins; for high grade lesions adjuvant focused radiation with ≥60 gray equivalents is taking an increased role in improving local control. Prognosis is dictated by lesion grade at the time of resection. Several groups have put forth survival calculators and epidemiological evidence suggests prognosis is quite good for lesions receiving R0 resection. Future efforts will be focused on identifying potential chemotherapeutic adjuvants and refining radiation treatments as a means of improving local control.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Mayo Clinic, Rochester, MN USA 55905; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287.
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ USA 85013.
| | - Patricia D Pittman
- Department of Neuropathology, Duke University School of Medicine, Durham, NC USA 27710
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287
| | - Edward F McCarthy
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC USA 27710
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY USA 11030.
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10
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Abstract
BACKGROUND Primary benign osseous tumors and tumor-like lesions at the sacrum are rare in the pediatric population and exact surgical strategy is still unclear. In this study, we evaluate the outcome for pediatric patients with benign tumors and tumor-like lesions at the sacrum who were receiving surgical treatment according to our proposed surgical strategy and classification. METHODS We analyzed 49 pediatric patients with sacral benign tumors or tumor-like lesions aged 18 years and below from 2005 to 2018. There were 23 men and 26 women with a mean age of 14.0±3.8 years. Nineteen patients had giant cell tumors (GCTs), 9 aneurysmal bone cysts, 5 osteoblastomas, 5 neurogenic tumors, 3 hemangiomas, 3 teratomas, 2 Langerhans cell histiocytosis, 1 chondroblastoma, 1 fibrous dysplasia, and 1 GCT of tendon sheath. We proposed our surgical plan and surgical classification for pediatric patients with sacral benign tumors or tumor-like lesions. RESULTS The mean follow-up duration was 6.2 years (range, 1.0 to 18.9 y). GCTs (39%, 19/49) and primary aneurysmal bone cysts (18%, 9/49) are the top 2 common histologic types. Preoperative selective arterial embolization (SAE) was performed in 12 cases and 24 patients received intraoperative aortic balloon occlusion (ABO) as the preoperative surgical plan. Furthermore, according to tumor location at the sacrum, we classified surgical excision of sacral benign tumors and tumor-like lesions into 3 types. Fourteen cases were classified as type I, 27 as type II, 3 as type III, and 5 patients with neurogenic tumors cannot be classified into this surgical classification. Ten patients had wound complications. Two had femoral artery thrombosis because of ABO application. One had mechanical failure. Rate of local recurrence was 16%. Seven patients with GCTs and 1 with neurogenic tumor had local recurrence. No patient died of disease at the last follow-up. For the assessment of neurological function, the rate of neurological dysfunction was 12% (6/49). Four cases had urinary incontinence, 3 fecal incontinence, and 3 had bowel obstruction. Next, univariate analysis for influence of preoperative SAE and intraoperative ABO on complications demonstrated that both of them exerted no significant influence on the occurrence of oncological and nononcological complications. CONCLUSIONS The proposed surgical strategy can provide an excellent therapeutic effect for pediatric benign tumors and tumor-like lesions at the sacrum. Preoperative SAE and intraoperative ABO can safeguard pediatric patients with high vascularity of benign tumor at the sacrum during the operation. LEVEL OF EVIDENCE Level IV.
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Delancy MM, Perdanasari A, Davis MJ, Abu-Ghname A, Kaplan J, Winocour SJ, Reece EM, Sim AS. The Advent of Spinoplastics: Easing the Growing Global Disease Burden of Spinal Injury. Semin Plast Surg 2021; 35:41-49. [PMID: 33994878 PMCID: PMC8110365 DOI: 10.1055/s-0041-1725987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Epidemiologic studies have demonstrated a growing global disease burden of pathologies affecting the vertebral column. Allograft or implant-based reconstruction and fusion surgeries have been the mainstay of treatment. The efficacy of various surgical methods and the reliability of instrumentation or implants to execute these surgeries continue to be debated in the literature. Advances such as the free-tissue transfer have improved postoperative measures; however, they add high operative risk. The advent of spinoplastics introduces a practical surgical model to augment these spinal surgeries using vascularized bone grafts. As this technique becomes more widespread, it can be utilized to ease the growing disease burden that spinal injury places on both patients and the health care system. Ultimately, it will ameliorate strains on health care resources, reduce health care costs, and improve patient outcomes and quality of life.
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Affiliation(s)
| | - Aurelia Perdanasari
- Division of Plastic Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Matthew J. Davis
- Division of Plastic Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Jordan Kaplan
- Division of Plastic Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J. Winocour
- Division of Plastic Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward M. Reece
- Division of Plastic Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Liu J, He X, Niu B, Yang Y, Gao Y, Xiu J, Wang H, Wang Y. Biomechanical properties of a novel nonfusion artificial vertebral body for anterior lumbar vertebra resection and internal fixation. Sci Rep 2021; 11:2632. [PMID: 33514823 PMCID: PMC7846776 DOI: 10.1038/s41598-021-82086-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/12/2021] [Indexed: 11/30/2022] Open
Abstract
The aim of the study was to evaluate the biomechanical properties of a novel nonfused artificial vertebral body in treating lumbar diseases and to compare with those of the fusion artificial vertebral body. An intact finite element model of the L1–L5 lumbar spine was constructed and validated. Then, the finite element models of the fusion group and nonfusion group were constructed by replacing the L3 vertebral body and adjacent intervertebral discs with prostheses. For all finite element models, an axial preload of 500 N and another 10 N m imposed on the superior surface of L1. The range of motion and stress peaks in the adjacent discs, endplates, and facet joints were compared among the three groups. The ranges of motion of the L1–2 and L4–5 discs in flexion, extension, left lateral bending, right lateral bending, left rotation and right rotation were greater in the fusion group than those in the intact group and nonfusion group. The fusion group induced the greatest stress peaks in the adjacent discs and adjacent facet joints compared to the intact group and nonfusion group. The nonfused artificial vertebral body could better retain mobility of the surgical site after implantation (3.6°–8.7°), avoid increased mobility and stress of the adjacent discs and facet joints.
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Affiliation(s)
- Jiantao Liu
- Department of Orthopedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China.
| | - Xijing He
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Binbin Niu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Medical University, Xi'an, 710021, China
| | - Yin Yang
- Department of Orthopedics, Xi'an Central Hospital, Xi'an, 710003, China
| | - Yanzheng Gao
- Department of Spine and Spinal Cord Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou Umiversity, Zhengzhou, 450003, China
| | - Jintao Xiu
- Department of Orthopedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Hongbo Wang
- Department of Spine and Spinal Cord Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou Umiversity, Zhengzhou, 450003, China
| | - Yanbiao Wang
- Department of Spine and Spinal Cord Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou Umiversity, Zhengzhou, 450003, China
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Abstract
The spine is a frequent location for metastatic disease. As local control of primary tumor pathology continues to improve, survival rates improve and, by extension, the opportunity for metastasis increases. Breast, lung, and prostate cancer are the leading contributors to spinal metastases. Spinal metastases can manifest as bone pain, pathologic fractures, spinal instability, nerve root compression, and, in its most severe form, spinal cord compression. The global extent of disease, the spinal burden, neurologic status, and life expectancy help to categorize patients as to their candidacy for treatment options. Efficient identification and workup of those with spinal metastases will expedite the treatment cascade and improve quality of life.
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Affiliation(s)
- Joshua T Wewel
- Atlanta Brain and Spine Care, Piedmont Healthcare, Atlanta, Georgia
| | - John E O'Toole
- Department of Neurosurgery, University Medical Center, Chicago, Illinois, US
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Wang J, Li D, Yang R, Tang X, Yan T, Guo W. Epidemiological characteristics of 1385 primary sacral tumors in one institution in China. World J Surg Oncol 2020; 18:297. [PMID: 33183334 PMCID: PMC7664043 DOI: 10.1186/s12957-020-02045-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022] Open
Abstract
Background Sacral tumors and tumor-like lesions are a rare group of lesions that can affect children and adults of all ages. Little is known about clinical characteristics of age, gender, histologic type, and anatomic site in China. Methods A total of 1385 patients with sacral tumors and tumor-like lesions, which had the clinical record at our bone tumor center from January 2000 to November 2018 were analyzed. The metastatic cancers were not included in the present study. Results A total of 51.7% (716 cases) were malignant and 48.3% (669 cases) were benign tumors or tumor-like lesions. Of malignant tumors, chordoma was the most common malignant tumor (316 cases, 22.8% of all tumors), followed by chondrosarcoma, myeloma, and other histologic types. The most common histological type of benign tumors was a giant cell tumor accounting for 14.8% (205 cases) of all tumors, followed by neurofibroma, schwannoma, and other types. The most common age group affected by malignant bone tumors was the 51- to 60-year-old group, followed by the 41- to 50-year-old group. The most commonly affected age group for benign tumors and tumor-like lesions was the 31- to 50-year-old group, followed by the 21- to 30-year old group. Furthermore, the following histologic types had gender predilection. Chordoma, chondrosarcoma, myeloma, and osteosarcoma affected more frequently males than females. Malignant peripheral nerve sheath tumor, lymphoma, giant cell tumor, neurofibroma, tuberculosis, teratoma, and epidermoid cyst more frequently affected females than males. Conclusions The large cohort of sacral tumors and tumor-like lesions in our database may reveal their clinical characteristics of age, gender, histologic type, and anatomic site in China and features of sacral tumors and tumor-like lesions are fairly distinct from the mobile spine and extremities.
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Affiliation(s)
- Jun Wang
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Beijing, 100044, China
| | - Dasen Li
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Beijing, 100044, China
| | - Rongli Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Beijing, 100044, China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Beijing, 100044, China
| | - Taiqiang Yan
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Beijing, 100044, China
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Beijing, 100044, China.
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15
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Wang J, Du Z, Yang R, Tang X, Yan T, Guo W. Analysis of clinical outcome for adolescent patients undergoing conservative nerve-sparing surgery based on the proposed resection classification for sacral giant cell tumor. J Clin Neurosci 2020; 80:23-29. [PMID: 33099351 DOI: 10.1016/j.jocn.2020.07.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/21/2020] [Indexed: 01/18/2023]
Abstract
The most common of age distribution ranges from second to fourth decade of life and patients with giant cell tumors (GCT) aged less than 18 years is more uncommon. We are aiming to reveal what the conservative nerve-sparing surgery values for adolescent patients with sacral GCT. We retrospectively reviewed 15 adolescent patients with sacral GCT aged <eighteen years, who received the conservative nerve-sparing surgery at our center from 2007 to 2018. Four patients presented with tumor of Campanacci grade II and 11 patients with grade III. According to the location of tumor at the sacrum, we classified the surgical resection of sacral giant cell tumor into three types. In our adolescent cohort, nine had the aortic balloon occlusion and five received the selective arterial embolization. All patients were free of disease and no one had the pulmonary metastasis or died of disease. All five wound complications required the debridement. 6 out of 15 patients had the local recurrence that required surgery treatment. The average time to recurrence after initial surgery in the present adolescent cohort was 22.4 months. Two patients had the surgical site infection and three had the wound dehiscence. One had the femoral artery thrombosis due to the aortic balloon occlusion and received the surgical removal of thrombosis. With the help of preoperative selective embolization and intraoperative aortic balloon occlusion, adolescent patients undergoing conservative nerve-sparing surgery for giant cell tumor of sacrum based on the proposed surgical resection classification have an acceptable clinical outcome and neurologic function.
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Affiliation(s)
- Jun Wang
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xi, Zhimen South Street, 100044 Beijing, China
| | - Zhiye Du
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xi, Zhimen South Street, 100044 Beijing, China
| | - Rongli Yang
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xi, Zhimen South Street, 100044 Beijing, China
| | - Xiaodong Tang
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xi, Zhimen South Street, 100044 Beijing, China
| | - Taiqiang Yan
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xi, Zhimen South Street, 100044 Beijing, China
| | - Wei Guo
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xi, Zhimen South Street, 100044 Beijing, China.
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Abstract
Tumours of the sacrum can be primary or secondary. Since the sacrum is rich in haematopoietic bone marrow, bone metastases are the most frequent aetiologies. However, tumours can arise from all components of the sacrum and primary bone tumours should be considered in case of a solitary lesion and absence of oncologic history. As the clinical signs are usually non-specific, magnetic resonance imaging has become an indispensable tool in narrowing the differential diagnosis and determining the therapeutic approach. This pictorial essay illustrates specific features of the most common sacral tumours on magnetic resonance (MR) imaging.
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Imaging features of primary spinal osseous tumors and their value in clinical diagnosis. Oncol Lett 2019; 17:1089-1093. [PMID: 30655869 PMCID: PMC6312963 DOI: 10.3892/ol.2018.9659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 09/28/2018] [Indexed: 12/22/2022] Open
Abstract
This study explored the method of imaging diagnosis of primary spinal osseous tumors and the application value of imaging in clinical diagnosis. Sixty-nine patients with primary spinal osseous tumors who received treatment in Nankai Hospital from July 2016 to June 2017 were selected. All of them received X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) examinations to analyze the imaging features of the three examination methods. Sensitivity (Sen), specificity (Spe), positive predictive value (PV+), negative predictive value (PV−) and accuracy (Acc) were compared. The consistency of the three examination methods in diagnosing primary spinal osseous tumors was analyzed. Sen, Acc and PV− of the three examination methods in diagnosing spinal osseous tumors had obvious differences. MRI showed the highest Sen (P<0.05). MRI had relatively high consistency with CT scan in diagnosing primary spinal osseous tumors, and κ-value was 0.72. CT scan and X-ray had obvious difference in diagnosing primary spinal osseous tumors (P<0.05). The consistency between CT scan and X-ray in diagnosing primary spinal osseous tumors was relatively low, and κ-value was 0.47. MRI and X-ray had obvious difference in diagnosing primary spinal osseous tumors (P<0.05). The consistency between MRI and X-ray in diagnosing primary spinal osseous tumors was relatively low, and κ-value was 0.41. X-ray examination is easy to operate with high resolution. CT scan has obvious advantages in displaying lesions with complex structure, many of which locate in overlapping sites. MRI has more advantages and higher accuracy in judging the scope of the tumor. CT and MRI examinations have obviously higher efficacy than X-ray in diagnosing primary spinal osseous tumors. They are conducive in improving the accuracy of diagnosing primary spinal osseous tumors.
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Liu J, Zhang F, Gao Z, Li Y, Niu B, He X. Lumbar subtotal corpectomy non-fusion model produced using a novel prosthesis. Arch Orthop Trauma Surg 2017; 137:1467-1476. [PMID: 28889244 DOI: 10.1007/s00402-017-2753-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE In this study, we aimed to design a movable artificial lumbar complex (MALC) prosthesis for non-fusion reconstruction after lumbar subtotal corpectomy and to establish an in vitro anterolateral lumbar corpectomy non-fusion model for evaluating the biomechanical stability, preservation of segment movements and influence on adjacent inter-vertebral movements of this prosthesis. METHODS Imaging was performed on a total of 26 fresh goat lumbar spine specimens to determine which of the specimens did not meet the requirements (free of deformity and fractures); the residual specimens were randomly divided into an intact group, a fusion group and a non-fusion group. Bone mineral density (BMD) was tested and compared among the three groups. Biomechanical testing was conducted to obtain the range of motion (ROM) in flexion-extension, lateral bending at L2-3, L3-4 and L4-5 and axial rotation at L2-5 in the three groups. RESULTS Two specimens were excluded due to vertebral fractures. BMD showed no statistical significance among three groups (P > 0.05). The stability of the prosthesis did not differ significantly during flexion, extension, and lateral bending at L2-3, L3-4, and L4-5 and axial torsion at L2-5 between the intact group and the non-fusion group (P > 0.05). Segment movements of the specimens in the non-fusion group revealed significantly decreased L2-3 ROM and significantly increased L3-4 and L4-5 ROM in flexion and lateral bending compared with the fusion group (P < 0.05). CONCLUSIONS Reconstruction with a MALC prosthesis after lumbar subtotal corpectomy not only produced instant stability but also effectively preserved segment movements, without any abnormal gain of mobility in adjacent inter-vertebral spaces. However, additional studies, including in vivo animal experiments as well as biocompatibility and biomechanical tests of human body specimens are needed.
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Affiliation(s)
- Jiantao Liu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, No. 157, The West Fifth Road, Xincheng District, Xi'an, Shaanxi, People's Republic of China
| | - Feng Zhang
- Department of Orthopedics, The Fourth Hospital of Xi'an, Xi'an, Shaanxi, People's Republic of China
| | - Zhengchao Gao
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, No. 157, The West Fifth Road, Xincheng District, Xi'an, Shaanxi, People's Republic of China
| | - Yuhuan Li
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, No. 157, The West Fifth Road, Xincheng District, Xi'an, Shaanxi, People's Republic of China
| | - Binbin Niu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, No. 157, The West Fifth Road, Xincheng District, Xi'an, Shaanxi, People's Republic of China
| | - Xijing He
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, No. 157, The West Fifth Road, Xincheng District, Xi'an, Shaanxi, People's Republic of China.
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