1
|
Jin Y, Yin X. Aspergillus terreus spondylodiscitis following acupuncture and acupotomy in an immunocompetent host: case report and literature review. Front Cell Infect Microbiol 2024; 13:1269352. [PMID: 38239504 PMCID: PMC10794653 DOI: 10.3389/fcimb.2023.1269352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024] Open
Abstract
Aspergillus terreus is a fungus responsible for various infections in human beings; however, spine involvement is uncommon. Herein, we report a case of A. terreus spondylodiscitis following acupuncture and acupotomy in an immunocompetent Chinese patient. Admission lumbar magnetic resonance imaging (MRI) revealed infection at the L4/5 level without significant vertebral destruction. After unsuccessful symptomatic and anti-tuberculosis treatments, A. terreus was identified through culture, microscopy of isolate, histological examination and VITEK system. Intravenous voriconazole was then given; however, the patient's spinal condition deteriorated rapidly, resulting in evident destruction of the L4/5 vertebral bodies. Surgeries including L4/5 intervertebral disc debridement, spinal canal decompression, posterior lumbar interbody fusion (PLIF) with allogeneic fibula ring fusion cages, and posterior pedicle screw fixation were then performed. Imaging findings at one-month and six-month follow-up suggested that the patient was successfully treated. This case highlighted two important points: firstly, although acupuncture and acupotomy are generally regarded as safe conservative treatments for pain management, they can still lead to complications such as fungal spinal infection. Therefore, vigilance is necessary when considering these treatments; secondly, PLIF with allogeneic fibula ring fusion cages may be beneficial for A. terreus spondylodiscitis patients with spinal instability.
Collapse
Affiliation(s)
| | - Xiang Yin
- Department of Spine Surgery, Daping Hospital, Army Medical University, Chongqing, China
| |
Collapse
|
2
|
Vithiya G, Raja S, Mariappan M, Rajendran T. Case series of aspergillus spondylodiscitis from a tertiary care centre in India. Indian J Med Microbiol 2023; 44:100363. [PMID: 37356839 DOI: 10.1016/j.ijmmb.2023.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 02/04/2023] [Accepted: 02/16/2023] [Indexed: 06/27/2023]
Abstract
Aspergillus spondylodiscitis is a rare entity reported in the literature. In tuberculosis endemic regions like India, more often it could be misdiagnosed as tuberculous spondylodiscitis. Herein we report a case series of three patients with Aspergillus spondylodiscitis presenting with chronic low backpain and clinically diagnosed as tuberculosis spine. Culture and histopathological examination of the debrided tissue provided a definite diagnosis. Interestingly, one of the cases had coexisting tuberculosis spine. All three patients underwent surgical intervention-debridement, decompression and fusion of spine and combined medical management with voriconazole with successful outcome.
Collapse
Affiliation(s)
- G Vithiya
- Department of Microbiology, Velammal Medical College Hospital and Research Institute, Madurai, India.
| | - S Raja
- Department of Microbiology, AIIMS, Bibinagar, India
| | - M Mariappan
- Department of Radiodiagnosis, Velammal Medical College Hospital and Research Institute, Madurai, India
| | - T Rajendran
- Department of Microbiology, Velammal Medical College Hospital and Research Institute, Madurai, India
| |
Collapse
|
3
|
Karmilkar K, Patel A, Vaughn TM. Navigating the Diagnostic Challenge of Aspergillus Spinal Epidural Abscess in an Immunocompetent Patient: A Case Report and Literature Review. Cureus 2023; 15:e42770. [PMID: 37663990 PMCID: PMC10469057 DOI: 10.7759/cureus.42770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Aspergillus spinal epidural abscess (ASEA) is a rare, life-threatening condition that can cause spinal cord compression with neurologic deficits. The diagnosis of ASEA can be challenging due to the atypical clinical presentation and low prevalence. We describe the successful management of a rare, immunocompetent, 85-year-old male with ASEA at the T12-L1 and L1-L2 levels and present a review of the literature. Based on most case reports and our knowledge, this is a rare presentation of ASEA in a patient without systemic symptoms, leukocytosis, or a history of immunosuppressive status due to chronic steroid use. The patient presented with multiple falls and lower extremity paraparesis with near-complete paralysis of the right lower extremity for a duration of three months. Systemic symptoms of infection were absent and standard lab evaluations were unremarkable. CT imaging identified cord signal changes at the level of T10-T11 and a contrast block at L1 suspicious for spinal stenosis and impingement. During lumbar spine exploration, purulent fluid consistent with an abscess was found in the epidural space. Cultures were forwarded to microbiology and returned with Aspergillus. Postoperatively, Infectious Disease (ID) recommended treatment with voriconazole, cefepime, and vancomycin, which yielded gradual symptom improvement. The successful management of ASEA requires a multidisciplinary approach involving neurosurgeons, infectious disease specialists, radiologists, and physical therapists. Clinicians should be aware of the possibility of ASEA regardless of systemic symptoms, and early diagnosis and prompt treatment with surgical decompression and appropriate antifungal therapy are imperative for successful management.
Collapse
Affiliation(s)
- Kunal Karmilkar
- Medicine, Edward Via College of Osteopathic Medicine (VCOM) - Louisiana, Monroe, USA
| | - Aditi Patel
- Medicine, Edward Via College of Osteopathic Medicine (VCOM) - Louisiana, Monroe, USA
| | - Troy M Vaughn
- Neurological Surgery, Alexandria Neurosurgical Clinic, Alexandria, USA
| |
Collapse
|
4
|
Tsantes AG, Papadopoulos DV, Markou E, Zarokostas K, Sokou R, Trikoupis I, Mavrogenis AF, Houhoula D, Piovani D, Bonovas S, Tsantes AE, Tsakris A, Vrioni G. Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases. Med Mycol 2022; 60:myac052. [PMID: 35867975 PMCID: PMC9849853 DOI: 10.1093/mmy/myac052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 01/22/2023] Open
Abstract
Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment. LAY SUMMARY Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.
Collapse
Affiliation(s)
- Andreas G Tsantes
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
- Department of Microbiology, ‘Saint Savvas’ Oncology Hospital, 11522 Athens, Greece
| | | | - Eleftheria Markou
- Department of Microbiology, University Hospital of Ioannina, Ioannina 45500, Greece
| | | | - Rozeta Sokou
- Neonatal Intensive Care Unit, “Agios Panteleimon” General Hospital of Nikea, Piraeus 18454, Greece
| | - Ioannis Trikoupis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens 15772, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens 15772, Greece
| | - Dimitra Houhoula
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 15772, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve MI, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano 20089 MI, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve MI, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano 20089 MI, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 15772, Greece
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Georgia Vrioni
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
| |
Collapse
|
5
|
Mertens B, Van Daele R, Depypere M, Lagrou K, Debaveye Y, Wauters J, Nijs S, Metsemakers WJ, Spriet I. Isavuconazole in the Treatment of Aspergillus fumigatus Fracture-Related Infection: Case Report and Literature Review. Antibiotics (Basel) 2022; 11:antibiotics11030344. [PMID: 35326807 PMCID: PMC8944859 DOI: 10.3390/antibiotics11030344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 02/06/2023] Open
Abstract
Aspergillus fracture-related infection (FRI) is a rare, but severe complication in trauma surgery. The optimal antifungal treatment for Aspergillus osteomyelitis, including FRI, has not been established yet, as only cases have been documented and data on bone penetration of antifungal drugs are scarce. We describe a patient with Aspergillus fumigatus FRI of the tibia who was treated with isavuconazole after developing liver function disturbances during voriconazole therapy. Isavuconazole, the active moiety formed after hydrolysis of the prodrug isavuconazonium sulfate by plasma esterases, was administered in a maintenance dose of 200 mg q24 h, followed by 150 mg q24 h. The patient completed a six-month antifungal treatment course. Although fracture union was not achieved during six months of follow-up after therapy cessation, no confirmatory signs of FRI were observed. Additionally, two literature searches were conducted to review available data on antifungal treatment of Aspergillus osteomyelitis and bone penetration of antifungals. One hundred and eight cases of Aspergillus osteomyelitis, including six (5.6%) FRI cases, were identified. Voriconazole and (lipid formulations of) amphotericin B were the most commonly used antifungals. In three (2.8%) cases isavuconazole was prescribed as salvage therapy. Data on antifungal bone penetration were reported for itraconazole, voriconazole, amphotericin B, anidulafungin and 5-fluorocytosin. Isavuconazole might be a promising alternative for the treatment of Aspergillus osteomyelitis. However, standardized case documentation is needed to evaluate the efficacy of isavuconazole and other antifungals in the treatment of Aspergillus osteomyelitis, including FRI.
Collapse
Affiliation(s)
- Beatrijs Mertens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
- Correspondence: ; Tel.: +32-16-34-69-57
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Melissa Depypere
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
| | - Katrien Lagrou
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
- Belgian National Reference Center for Mycosis, University Hospitals Leuven, B-3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, B-3000 Leuven, Belgium
| | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium;
- Intensive Care Unit, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Joost Wauters
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
- Medical Intensive Care Unit, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Stefaan Nijs
- Department of Development and Regeneration, KU Leuven, B-3000 Leuven, Belgium; (S.N.); (W.-J.M.)
- Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Development and Regeneration, KU Leuven, B-3000 Leuven, Belgium; (S.N.); (W.-J.M.)
- Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
| |
Collapse
|
6
|
Umana G, Rashid M, Hossain M, Ahmed N, Kazi R, Ferini G, Palmisciano P, Scalia G, Hoz S, Chaurasia B. Aspergillus spinal epidural abscess: A case report and review of the literature. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:204-211. [PMID: 35837429 PMCID: PMC9274668 DOI: 10.4103/jcvjs.jcvjs_35_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/02/2022] [Indexed: 11/30/2022] Open
Abstract
Aspergillus spinal epidural abscess (ASEA) is a rare entity that may mimic Pott's paraplegia as it commonly affects immunocompromised patients. We present one institutional case of ASEA with concomitant review of the literature. A 58-year-old female presented with intermittent low back pain for 10 years recently aggravated and with concurrent spastic paraparesis, fever, and weight loss. Emergent magnetic resonance imaging (MRI) showed T11–T12 epidural abscess with discitis and osteomyelitis. After empirical treatment with antibiotics, computed tomography-guided, percutaneous biopsy with drainage was performed, showing granulomatous tubercular-like collection. Antitubercular therapy was initiated, but after 1 month, the patient's condition deteriorated. Repeat MRI showed growth of the spinal epidural abscess with significant cord compression and vertebral osteomyelitis. T11–T12 laminectomy and tissue removal were performed with a posterior midline approach. Tissue histopathology showed necrotic debris colonies of Aspergillus spp. Antifungal therapy was started, and the patient rapidly improved. ASEA may mimic Pott's disease at imaging, leading to immediate start of antitubercular treatment without prior biopsy, leading to severe worsening of patients’ clinical status. Cases of ASEA should be considered at pretreatment planning, opting for biopsy confirmation before treatment initiation so to prevent the occurrence of fatal infection-related complications.
Collapse
|
7
|
Spondylodiscitis Caused by Aspergillus Species. Diagnostics (Basel) 2021; 11:diagnostics11101899. [PMID: 34679596 PMCID: PMC8534844 DOI: 10.3390/diagnostics11101899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/10/2021] [Accepted: 10/12/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Spondylodiscitis caused by Aspergillus spp. is a rare but life-threatening clinical entity. However, a consensus on diagnostic criteria and most effective medical management is still missing. The present study is a review of all published cases of spondylodiscitis caused by Aspergillus spp., in an effort to elucidate epidemiology, patients’ characteristics, andand the medical and surgical treatment options and their effectiveness. Methods: A thorough review of all existing spondylodiscitis cases caused by Aspergillus was performed. Data regarding demographics, responsible fungus, time between symptoms’ onset and firm diagnosis, antifungal treatment (AFT), surgical intervention, andand the infection’s outcome were investigated. Results: A total of 118 Aspergillus spondylodiscitis cases, yielding 119 Aspergillus spp. isolates, were identified in the literature. The patients’ mean age was 40.6 years. Magnetic resonance imaging (MRI) (after its introduction) indicated the diagnosis in most cases (66.7%), while definite diagnosis was established through cultures in the majority of cases (73.7%). Aspergillus fumigatus was isolated in most cases (73; 61.3%), followed by Aspergillus flavus (15; 12.6%) andand Aspergillus nidulans and terreus (7; 5.9%, each). The mean time between symptoms’ onset and diagnosis was 5.7 months. Amphotericin B was the preferred antifungal regiment (84 cases; 71.2%), followed by voriconazole (31; 26.3%), and the mean AFT duration was 6.1 months. The final outcome was successful in 93 cases (78.8%). Furthermore, 77 patients (65.3%) underwent surgery. Conclusions: Spondylodiscitis caused by Aspergillus spp. represents a clinical challenge, requiring a multidisciplinary approach. The present review has shown that prolonged AFT has been the standard of care of the studied cases, while surgical treatment seems to play an important role in selected patents.
Collapse
|
8
|
Liu JW, Liu PY, Lai KL. Aspergillus terreus septic arthritis and pyomyositis of shoulder. J Formos Med Assoc 2020; 120:1153-1154. [PMID: 33115625 DOI: 10.1016/j.jfma.2020.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 10/01/2020] [Accepted: 10/12/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Jai-Wen Liu
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
| |
Collapse
|
9
|
Dai G, Wang T, Yin C, Sun Y, Xu D, Wang Z, Luan L, Hou J, Li S. Aspergillus spondylitis: case series and literature review. BMC Musculoskelet Disord 2020; 21:572. [PMID: 32828133 PMCID: PMC7443290 DOI: 10.1186/s12891-020-03582-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/10/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Spinal fungal infections, especially spinal Aspergillus infections, are rare in the clinic. Here, we introduce the clinical features, diagnosis, treatment, and prognoses of 6 cases of Aspergillus spondylitis. METHODS We retrospectively analysed the complete clinical data of patients with Aspergillus spondylitis treated in our hospital from January 2013 to January 2020. RESULTS Aspergillus fumigatus was isolated in 4 cases, and Aspergillus spp. and Aspergillus niger were isolated in 1 case each. All six patients reported varying degrees of focal spinal pain; one patient reported radiating pain, one patient experienced bowel dysfunction and numbness in both lower limbs, and three patients had fever symptoms. One case involved the thoracic spine, one case involved the thoracolumbar junction, and 4 cases involved the lumbar spine. Three patients were already in an immunosuppressed state, and three patients entered an immunosuppressed state after spinal surgery. All six patients were successfully cured, and five required surgery. Of the 5 patients who underwent surgical treatment, 2 had spinal cord compression symptoms, and 3 had spinal instability. At the end of follow-up, 1 patient reported left back pain and 1 patient reported left limb numbness. CONCLUSION The clinical manifestations of Aspergillus spondylitis are non-specific, and the diagnosis depends on typical imaging findings and microbiological and histopathological examination results. When there is no spinal instability, spinal nerve compression symptoms, or progressive deterioration, antifungal therapy alone may be considered. If spinal instability, spinal nerve compression, or epidural abscess formation is present, surgery combined with antifungal therapy is recommended.
Collapse
Affiliation(s)
- Guohua Dai
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China
| | - Ting Wang
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China.
| | - Chuqiang Yin
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China
| | - Yuanliang Sun
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China
| | - Derong Xu
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China
| | - Zhongying Wang
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China
| | - Liangrui Luan
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China
| | - Jianwen Hou
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China
| | - Shuzhong Li
- Department of Spine Surgery, Affiliated Hospital of Qingdao University, 16 jiangsu road, Shinan District, Qingdao City, Post Code: 266000, Shandong Province, China.
| |
Collapse
|