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Wang D, Zhang BH, Wen X, Chen KH, Xiao HT, Xu XW, Li QF. Clinical features and surgical treatments of scoliosis in neurofibromatosis type 1: a systemic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2646-2665. [PMID: 38526628 DOI: 10.1007/s00586-024-08194-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 12/29/2023] [Accepted: 02/13/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Neurofibromatosis type 1 (NF 1) is an autosomal-dominant tumor predisposition genetic disease affecting approximately 1 in 3000 live births. The condition could present various manifestations ranging from skin abnormalities to neurological tumors. The musculoskeletal system could also be frequently affected, and scoliosis is the most common orthopedic manifestation. Characterized by the early-onset and rapid progression tendency, NF 1-related dystrophic scoliosis presented discrepancies from idiopathic scoliosis in terms of natural history, clinical features, and management outcomes and thus required special attention. In the current study, the authors conducted a systemic review to outline the body of evidence of the natural history, clinical characteristics, surgical outcomes, and surgical complications of NF 1-induced scoliosis, aiming to provide an elucidative insight into this condition. METHOD Systemic review and meta-analysis were conducted according to the latest Preferred Reporting Items for Systematic Reviews Meta-Analyses (PRISMA) guidelines. The search was performed in Medline, Embase, and Web of Science Core Collection up to December 27, 2022, using related keywords. Clinical features such as frequencies, segmental involvement, and hereditary information were summarized and described qualitatively. Meta-analysis was conducted using R software and the 'meta' package to yield an overall outcome of efficacy and safety of surgical management, precisely, spinal fusion procedure and growing rods procedure. Corrective rate of Cobb angle, sagittal kyphosis angle, and T1-S1 length post-operative and at the last follow-up was used to evaluate the efficacy, and the occurrence of surgery-related complications was used to evaluate the safety. RESULT A total of 37 articles involving 1023 patients were included. Approximately 26.6% of the NF 1 patients would present with scoliosis. Patients tend to develop scoliosis at an earlier age. The thoracic part turned out to be the most affected segment. No obvious correlation between scoliosis and genotype or hereditary type was observed. Both spinal fusion and growing rod surgery have shown acceptable treatment outcomes, with spinal fusion demonstrating better performance in terms of effectiveness and safety. The growing rods technique seemed to allow a better lengthening of the spine. The mainstay post-operative complications were implant-related complications but could be managed with limited revision surgery. Severe neurological deficits were rarely reported. CONCLUSION Scoliosis, especially the subtype characterized by dystrophic bony changes, is a significant orthopedic manifestation of NF1. It has an early onset, a tendency to persistently and rapidly progress, and is challenging to deal with. The current review outlines the available evidence from the perspective of natural history, clinical features, and the treatment efficacy and safety of the mainstay surgical options. Patients with NF1 scoliosis will benefit from a better understanding of the disease and evidence based treatment strategies.
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Affiliation(s)
- Dun Wang
- Department of Burn and Plastic Surgery, West China Hospital of Sichuan University, Sichuan University School of Medicine, No. 37 Wainan Guoxue Road, Chengdu, 610041, China
| | - Bo-Han Zhang
- Department of Burn and Plastic Surgery, West China Hospital of Sichuan University, Sichuan University School of Medicine, No. 37 Wainan Guoxue Road, Chengdu, 610041, China
| | - Xue Wen
- Department of Burn and Plastic Surgery, West China Hospital of Sichuan University, Sichuan University School of Medicine, No. 37 Wainan Guoxue Road, Chengdu, 610041, China
| | - Kun-Hao Chen
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, 610041, China
| | - Hai-Tao Xiao
- Department of Burn and Plastic Surgery, West China Hospital of Sichuan University, Sichuan University School of Medicine, No. 37 Wainan Guoxue Road, Chengdu, 610041, China
| | - Xue-Wen Xu
- Department of Burn and Plastic Surgery, West China Hospital of Sichuan University, Sichuan University School of Medicine, No. 37 Wainan Guoxue Road, Chengdu, 610041, China.
| | - Qing-Feng Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
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Miyagishima KJ, Qiao F, Stasheff SF, Nadal-Nicolás FM. Visual Deficits and Diagnostic and Therapeutic Strategies for Neurofibromatosis Type 1: Bridging Science and Patient-Centered Care. Vision (Basel) 2024; 8:31. [PMID: 38804352 PMCID: PMC11130890 DOI: 10.3390/vision8020031] [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: 03/02/2024] [Revised: 05/03/2024] [Accepted: 05/04/2024] [Indexed: 05/29/2024] Open
Abstract
Neurofibromatosis type 1 (NF1) is an inherited autosomal dominant disorder primarily affecting children and adolescents characterized by multisystemic clinical manifestations. Mutations in neurofibromin, the protein encoded by the Nf1 tumor suppressor gene, result in dysregulation of the RAS/MAPK pathway leading to uncontrolled cell growth and migration. Neurofibromin is highly expressed in several cell lineages including melanocytes, glial cells, neurons, and Schwann cells. Individuals with NF1 possess a genetic predisposition to central nervous system neoplasms, particularly gliomas affecting the visual pathway, known as optic pathway gliomas (OPGs). While OPGs are typically asymptomatic and benign, they can induce visual impairment in some patients. This review provides insight into the spectrum and visual outcomes of NF1, current diagnostic techniques and therapeutic interventions, and explores the influence of NF1-OPGS on visual abnormalities. We focus on recent advancements in preclinical animal models to elucidate the underlying mechanisms of NF1 pathology and therapies targeting NF1-OPGs. Overall, our review highlights the involvement of retinal ganglion cell dysfunction and degeneration in NF1 disease, and the need for further research to transform scientific laboratory discoveries to improved patient outcomes.
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Affiliation(s)
- Kiyoharu J. Miyagishima
- Retinal Neurophysiology Section, National Eye Institute, National Institutes of Health, Bethesda, MD 20892, USA; (K.J.M.); (F.Q.); (S.F.S.)
| | - Fengyu Qiao
- Retinal Neurophysiology Section, National Eye Institute, National Institutes of Health, Bethesda, MD 20892, USA; (K.J.M.); (F.Q.); (S.F.S.)
| | - Steven F. Stasheff
- Retinal Neurophysiology Section, National Eye Institute, National Institutes of Health, Bethesda, MD 20892, USA; (K.J.M.); (F.Q.); (S.F.S.)
- Center for Neuroscience and Behavioral Medicine, Gilbert Neurofibromatosis Institute, Children’s National Health System, Washington, DC 20010, USA
- Neurology Department, George Washington University School of Medicine, Washington, DC 20037, USA
| | - Francisco M. Nadal-Nicolás
- Retinal Neurophysiology Section, National Eye Institute, National Institutes of Health, Bethesda, MD 20892, USA; (K.J.M.); (F.Q.); (S.F.S.)
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Kerashvili N, Gutmann DH. The management of neurofibromatosis type 1 (NF1) in children and adolescents. Expert Rev Neurother 2024; 24:409-420. [PMID: 38406862 DOI: 10.1080/14737175.2024.2324117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/23/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Neurofibromatosis type 1 (NF1) is a rare neurogenetic disorder characterized by multiple organ system involvement and a predisposition to benign and malignant tumor development. With revised NF1 clinical criteria and the availability of germline genetic testing, there is now an opportunity to render an early diagnosis, expedite medical surveillance, and initiate treatment in a prompt and targeted manner. AREAS COVERED The authors review the spectrum of medical problems associated with NF1, focusing specifically on children and young adults. The age-dependent appearance of NF1-associated features is highlighted, and the currently accepted medical treatments are discussed. Additionally, future directions for optimizing the care of this unique population of children are outlined. EXPERT OPINION The appearance of NF1-related medical problems is age dependent, requiring surveillance for those features most likely to occur at any given age during childhood. As such, we advocate a life stage-focused screening approach beginning in infancy and continuing through the transition to adult care. With early detection, it becomes possible to promptly institute therapies and reduce patient morbidity. Importantly, with continued advancement in our understanding of disease pathogenesis, future improvements in the care of children with NF1 might incorporate improved risk assessments and more personalized molecularly targeted treatments.
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Affiliation(s)
- Nino Kerashvili
- Department of Neurology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - David H Gutmann
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
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Almuqbil M, Alshaikh FY, Altwaijri W, Baarmah D, Hommady RH, Alshaikh MY, Alammari F, Alhussain M, Almotawa R, Alqarny F, Kashgari A, Alkhodair R, Alkhater JN, Alkhater LN, Alharthi SA, Alsadi MA, AlRumayyan A. Epidemiology and Outcomes of Neurofibromatosis Type 1 (NF-1): Multicenter Tertiary Experience. J Multidiscip Healthc 2024; 17:1303-1314. [PMID: 38533410 PMCID: PMC10964784 DOI: 10.2147/jmdh.s454921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/13/2024] [Indexed: 03/28/2024] Open
Abstract
Purpose The aim of this manuscript was to assess the epidemiology and clinical features of Neurofibromatosis type 1 (NF-1) based on the newly published revised NF-1 diagnostic criteria and to evaluate complications of NF-1 including neurodevelopmental disorders. Patients and methods A retrospective cross-sectional observational study was conducted in the Ministry of National Guard Health Affairs (MNGHA) healthcare organization branches including four tertiary hospitals and 51 primary health care centers in different regions in Saudi Arabia. This study included all patients diagnosed with NF1 using the revised NIH diagnostic criteria published in 2021 that were registered at the electronic medical records (EMR) from 2015 to 2021. Results A total of 184 patients fulfilled the diagnostic criteria and were included in this study. The median age at diagnosis was 11 years (IQR: 4.00-20.25). The most encountered diagnostic criteria in this study were Café-au-lait macules (85.3%), and (42.9%) were found to have two or more neurofibromas with plexiform neurofibroma being the most common subtype (23.36%), approximately (36.4%) of the patient with optic pathway glioma. Nearby (26.6%) of the patients displayed different type of tumors. Iris Lisch nodules were presented in 36.4% of patients at a median age of 12 years (IQR: 9.0-21.8). Cardiovascular abnormality was encountered in 9.8% of the patients. Around 27.7% of the patients reported headache and 11.4% of the patient suffered from different type of epilepsy. Besides, 10.5% of the patients had intellectual disability, 33.8% suffered from communication disorders, and 4.9% patients had ADHD. Conclusion The results of this study will enable practitioners to adopt a more holistic approach and prioritize numerous attributes, which they can subsequently incorporate into their therapeutic methodologies. Furthermore, the identification of these attributes will facilitate an expeditious and accurate diagnosis. Hence, the implementation of intervention during its nascent phase may result in a more advantageous consequence.
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Affiliation(s)
- Mohammed Almuqbil
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children’s Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | | | - Waleed Altwaijri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children’s Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Duaa Baarmah
- Department of Pediatrics, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Raid Harb Hommady
- King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children’s Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Maryam Yaseen Alshaikh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
| | - Fares Alammari
- College of Medicine, Almaarefa University, Riyadh, Saudi Arabia
| | | | | | - Faris Alqarny
- College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Amna Kashgari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Department of Radiology, King Abdullah Specialist Children’s Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Rayan Alkhodair
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh, Saudi Arabia
- Division of Dermatology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Jumanah N Alkhater
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
| | | | - Sawsan A Alharthi
- Division of Dermatology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mada Abdulkarim Alsadi
- Division of Otolaryngology, Head and Neck Surgery, King Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Ahmed AlRumayyan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children’s Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
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Kodali N, Kumar KD, Schwartz RA. The role of scoliosis on the comorbidity and demographics of neurofibromatosis type 1 patients: A retrospective analysis of the National Inpatient Sample database. Exp Dermatol 2024; 33:e14996. [PMID: 38284196 DOI: 10.1111/exd.14996] [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: 06/26/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 01/30/2024]
Abstract
Neurofibromatosis type 1 (NF1) is the most common neurocutaneous syndrome in the United States, affecting every 1 in 3000 individuals. NF1 occurs due to non-functional mutations in the NF1 gene, which expresses neurofibromin, a protein involved in tumour suppression. As a result, NF1 typically presents with non-cancerous neoplasm masses called neurofibromas across the body. Out of all NF1 abnormalities, the most common skeletal abnormality seen in around 10%-30% of NF1 patients is scoliosis, an improver curvature of the spine. However, there is a lack of research on the effects of scoliosis on demographics and morbidities of NF1 patients. We performed a national analysis to investigate the complex relationship between NF1 and scoliosis on patients' demographics and comorbidities. We conducted a retrospective cross-sectional analysis of the 2017 US National Inpatient Sample database using univariable Chi-square analysis and multivariable binary logistic regression analysis to determine the interplay of NF1 and scoliosis on patients' demographics and comorbidities. Our query resulted in 4635 total NF1 patients, of which 475 (10.25%) had scoliosis and 4160 (89.75%) did not. Demographic analysis showed that NF1 patients with scoliosis were typically younger, female and white compared to NF1 patients without scoliosis. Comorbidity analysis showed that NF1 patients with scoliosis were more likely to develop malignant brain neoplasms, epilepsy, hydrocephalus, pigmentation disorders, hypothyroidism, diabetes with chronic complications and coagulopathy disorders. NF1 patients with scoliosis were less likely to develop congestive heart failure, pulmonary circulation disease, peripheral vascular disease, paralysis, chronic pulmonary disease, lymphoma and psychosis. NF1 patients with scoliosis were predominantly younger, female, white patients. The presence of scoliosis in NF1 patients increases the risks for certain brain neoplasms and disorders but serves a protective effect against some pulmonary and cardiac complications.
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Affiliation(s)
- Nilesh Kodali
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Keshav D Kumar
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Robert A Schwartz
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Robinson D, Biswas S, Torrie C, MacArthur J, Snowdon E, Sial M, Sarkar V, George KJ. Determining the risk of spinal pathology progression in neurofibromatosis type 1 patients - a national tertiary neurofibromatosis type 1 centre study. Clin Neurol Neurosurg 2023; 234:107985. [PMID: 37778105 DOI: 10.1016/j.clineuro.2023.107985] [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: 08/11/2023] [Revised: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Neurofibromatosis type 1 (NF1) gives rise to a variety of spinal pathologies that include dural ectasia (DE), vertebral malalignments (VMA), spinal deformities (SD), syrinx, meningoceles, spinal nerve root tumours (SNRT), and spinal plexiform tumours (SPT). The relationship between these and the progression of these pathologies has not been explored before in detail and this paper aims to address this. METHODS Data was retrospectively collected from adult NF1 multi-disciplinary team meetings from 2016 to 2022 involving a total of 593 patients with 20 distinct predictor variables. Data were analyzed utilizing; Chi-Square tests, binary logistic regression, and Kaplan-Meier analysis. RESULTS SNRT (19.9%), SD (18.6%), and (17.7%) of VMA had the highest rates of progression. SD was significantly associated (p < 0.02) with the presence and progression of all spinal pathologies except for SPT. Statistically significant predictors of SD progression included the presence of DVA, VMA, syrinx, meningocele, and SNRT. Kaplan-Meier analysis revealed no statistically significant difference between the times to progression for SD (85 days), SNRT (1196 days), and VMA (2243 days). CONCLUSION This paper explores for the first time in detail, the progression of various spinal pathologies in NF1. The presence and progression of SD is a key factor that correlated with the progression of different spinal pathologies. Early identification of SD may help support clinical decision-making and guide radiological follow-up protocols and treatment.
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Affiliation(s)
- Daniel Robinson
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England, UK
| | - Sayan Biswas
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England, UK.
| | - Christopher Torrie
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England, UK
| | - Joshua MacArthur
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England, UK
| | - Ella Snowdon
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England, UK
| | - Moska Sial
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England, UK
| | - Ved Sarkar
- College of Letters and Sciences, University of California, Berkeley, California 94720, United States
| | - K Joshi George
- Department of Neurosurgery, Salford Royal Hospital, Manchester, England, UK
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Reinhold V, Saarinen A, Suominen E, Syrjänen S, Kankuri-Tammilehto M. Severe Untreated Scoliosis and Early Onset Breast Cancer in a Patient with Neurofibromatosis Associated with a Nonsense Variant of NF1 Gene. Orthop Res Rev 2023; 15:183-189. [PMID: 37791039 PMCID: PMC10543094 DOI: 10.2147/orr.s415978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/30/2023] [Indexed: 10/05/2023] Open
Abstract
Background Neurofibromatosis 1 (NF1) is a relatively common genetic disorder linked to skeletal abnormalities and elevated risk of cancer. Early onset scoliosis is common in patients with NF1 although severe scoliosis is rare. Scoliosis complicates the normal development and growth and may lead to thoracic insufficiency syndrome. The increased risk for breast cancer in young NF1 female patients has been recently identified. Case Presentation We describe a NF1 patient with dystrophic scoliosis symptoms emerged at childhood. At 37 years of age major scoliosis curve in the thoracolumbar region was 80 degrees. The patient was diagnosed with breast cancer at the age of 37 years, histologically the breast cancer was ductal, hormone receptor positive and Her2-positive. Results A novel pathogenic variant in NF1 p.(Trp2348*) was identified by next-generation sequencing method. The patient did not have pathogenic variants in BRCA genes or in other currently known hereditary breast cancer genes. Conclusion Here, we describe a novel pathogenic variant in NF1 named p.(Trp2348*) which may cause severe dystrophic scoliosis and deteriorate the quality of life and physical function, as well as Her-2 positive breast cancer. Untreated dystrophic scoliosis in patients with NF1 may result in significant spinal deformity and deteriorate the quality of life and physical function. Genetic counseling is recommended in all patients with NF1. Patients need routine follow-up throughout life. Multidisciplinary consulting is warranted in patients with neurofibromatosis 1.
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Affiliation(s)
- Vivian Reinhold
- Institute of Biomedicine, University of Turku, Turku, Finland
| | - Antti Saarinen
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University, Turku, Finland
| | - Eetu Suominen
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University, Turku, Finland
| | - Stina Syrjänen
- Department of Oral Pathology and Radiology, Institute of Dentistry, Faculty of Medicine, University of Turku, Turku, Finland
- Department of Pathology, University of Turku, Turku University Hospital, Turku, Finland
| | - Minna Kankuri-Tammilehto
- Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Clinical Genetics, Turku University Hospital and University of Turku, Turku, Finland
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Kumar JI, Jallo GI, Shimony N. Knowledge Review of Spinal Deformity and the Need for Fusion and Fixation following Treatment for Spinal Tumors among the Pediatric Age Group. Pediatr Neurosurg 2023; 58:281-289. [PMID: 37531944 DOI: 10.1159/000531984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 07/05/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Spinal tumors are rare pathology in the pediatric population. The tumors can be classified as extradural, intradural extramedullary, or intramedullary. Any of the spinal tumors can eventually lead to spinal deformity. The progressive spinal deformity can be part of the initial presentation or evolve on long follow-up, even years after the initial intervention and treatment. SUMMARY Management of spinal deformity associated with spinal tumors in children is not well defined. Patients with progressive symptoms and even neurological deficits need correction for their deformity when diagnosed. Patients that do not have pain or related neurological deficits should be evaluated for the severity of their deformity and followed long-term. Special consideration is needed for young patients who need multilevel surgery or have deformity at presentation. KEY MESSAGES When considering the need for instrumentation and fusion, the surgeon should consider the age of the patient, expected future growth of the spine, neurologic status, extent of initial deformity, and the number of vertebral levels involved by tumor. Providers should also consider how surgery may fix or prevent deformity, especially when instrumentation can affect imaging at follow-up.
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Affiliation(s)
- Jay I Kumar
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - George I Jallo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Neurosurgery, Johns Hopkins Medicine, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
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Hersh AM, Lubelski D, Theodore N, Sciubba DM, Jallo G, Shimony N. Approaches to Incidental Intradural Tumors of the Spine in the Pediatric Population. Pediatr Neurosurg 2023; 58:367-378. [PMID: 36948181 DOI: 10.1159/000530286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 03/10/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Incidental intradural tumors of the spine in the pediatric population are rare lesions whose management remains unclear. Surgeons must balance the risks of iatrogenic deficits and complications after surgical resection against the risks from progressive growth of the tumor. Moreover, the natural history of an incidental finding can be difficult to predict. Here, we review the literature on incidental intradural tumors of the spine and present considerations for their management. SUMMARY Growth of the tumor or changes in radiographic features are usually indications for resection. Asymptomatic lesions can be found in patients with genetic syndromes that predispose to tumor formation, such as neurofibromatosis type 1 and 2, schwannomatosis, and Von-Hippel-Lindau syndrome, and careful workup of a genetic cause is warranted in any patient presenting with multiple tumors and/or cutaneous features. Close follow-up is generally favored given the heavy tumor burden; however, some recommend pre-emptive resection to prevent permanent neurological deficits. Incidental intradural tumors can also occur in association with hydrocephalus, significant syringomyelia, and cord compression, and surgical treatment is usually warranted. Tumors may also be discovered as part of the workup for scoliosis, where they are not truly incidental to the scoliosis but rather are contributing to curve deformation. KEY MESSAGES Thorough workup of patients for associated genetic syndromes or comorbidities should be undertaken in pediatric patients with incidental intradural tumors. Further research is needed into the natural history of these incidental lesions. Incidental tumors can often be managed conservatively with close follow-up, with surgical intervention warranted for expanding tumors or new-onset symptoms.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA,
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Manhasset, New York, USA
| | - George Jallo
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Neurosurgery, Johns Hopkins Medicine, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Semmes-Murphey clinic, Memphis, Tennessee, USA
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Shao X, Zhang T, Yang J, Deng Y, Huang Z, Yang J, Sui W. How to select the lowest instrumented vertebra in NF-1 non-dystrophic scoliosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1153-1160. [PMID: 36809342 DOI: 10.1007/s00586-023-07600-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE To investigate lowest instrumented vertebra (LIV) selection strategy for neurofibromatosis type 1 (NF-1) non-dystrophic scoliosis. METHODS Consecutive eligible subjects with NF-1 non-dystrophic scoliosis were included. All patients were followed up at least for 24 months. Enrolled patients with LIV in stable vertebra were divided into stable vertebra group (SV group), and the other patients with LIV above the stable vertebra were divided into above stable vertebra group (ASV group). Demographic data, operative data, preoperative and postoperative radiographic data, and clinical outcome were collected and analyzed. RESULTS There were 14 patients in SV group (ten males and four females, mean age 13.9 ± 4.1 years) and 14 patients in ASV group (nine males and five females, mean age 12.9 ± 3.5 years). The mean follow-up period was 31.7 ± 17.4 months for patients in SV group and 33.6 ± 17.4 months for patients in ASV group, respectively. No significant differences were found in demographic data between two groups. The coronal Cobb angle, C7-CSVL, AVT, LIVDA, LIV tilt and SRS-22 questionnaire outcome significantly improved at the final follow-up in both groups. However, significantly higher loss of correction rate and increasement of LIVDA were found in ASV group. Two patients (14.3%) in ASV group but none in SV group suffered adding-on phenomenon. CONCLUSIONS Although patients in both SV and ASV groups obtained improved therapeutic efficacy at final follow-up, the radiographic and clinical outcome seemed more likely to deteriorate in ASV group after surgery. The stable vertebra should be recommended as LIV for NF-1 non-dystrophic scoliosis.
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Affiliation(s)
- Xiexiang Shao
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiao Tong University Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Tianyuan Zhang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiao Tong University Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Jingfan Yang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiao Tong University Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Yaolong Deng
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiao Tong University Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Zifang Huang
- Department of Spine Surgery, Sun Yat-Sen University Third Affiliated Hospital, Guangzhou, 510630, China
| | - Junlin Yang
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiao Tong University Shanghai Jiao Tong University, Shanghai, 200092, China.
| | - Wenyuan Sui
- Spine Center, Xinhua Hospital Affiliated to Shanghai Jiao Tong University Shanghai Jiao Tong University, Shanghai, 200092, China.
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Peduto C, Zanobio M, Nigro V, Perrotta S, Piluso G, Santoro C. Neurofibromatosis Type 1: Pediatric Aspects and Review of Genotype-Phenotype Correlations. Cancers (Basel) 2023; 15:1217. [PMID: 36831560 PMCID: PMC9954221 DOI: 10.3390/cancers15041217] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Neurofibromatosis type 1 (NF1) is an autosomal dominant condition, with a birth incidence of approximately 1:2000-3000, caused by germline pathogenic variants in NF1, a tumor suppressor gene encoding neurofibromin, a negative regulator of the RAS/MAPK pathway. This explains why NF1 is included in the group of RASopathies and shares several clinical features with Noonan syndrome. Here, we describe the main clinical characteristics and complications associated with NF1, particularly those occurring in pediatric age. NF1 has complete penetrance and shows wide inter- and intrafamilial phenotypic variability and age-dependent appearance of manifestations. Clinical presentation and history of NF1 are multisystemic and highly unpredictable, especially in the first years of life when penetrance is still incomplete. In this scenario of extreme phenotypic variability, some genotype-phenotype associations need to be taken into consideration, as they strongly impact on genetic counseling and prognostication of the disease. We provide a synthetic review, based on the most recent literature data, of all known genotype-phenotype correlations from a genetic and clinical perspective. Molecular diagnosis is fundamental for the confirmation of doubtful clinical diagnoses, especially in the light of recently revised diagnostic criteria, and for the early identification of genotypes, albeit few, that correlate with specific phenotypes.
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Affiliation(s)
- Cristina Peduto
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio 7, 80138 Naples, Italy
| | - Mariateresa Zanobio
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio 7, 80138 Naples, Italy
| | - Vincenzo Nigro
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio 7, 80138 Naples, Italy
- Telethon Institute of Genetics and Medicine (TIGEM), Via Campi Flegrei 34, 80078 Pozzuoli, Italy
| | - Silverio Perrotta
- Department of Women’s and Children’s Health and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio 2, 80138 Naples, Italy
| | - Giulio Piluso
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio 7, 80138 Naples, Italy
| | - Claudia Santoro
- Department of Women’s and Children’s Health and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio 2, 80138 Naples, Italy
- Clinic of Child and Adolescent Neuropsychiatry, Department of Physical and Mental Health, and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie 1, 80138 Naples, Italy
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12
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Anders R, Hirsch FW, Roth C. [Neurofibromatosis type 1 : From diagnosis to follow-up]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:1050-1057. [PMID: 36070094 DOI: 10.1007/s00117-022-01059-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Neurofibromatosis type 1 (NF1) is a tumor predisposition syndrome and is one of the most common genetic diseases. It is therefore a condition encountered by radiologists in clinical routine. Since the variability of the clinical expression is very high and several organ systems are affected, we present a standardized diagnostic approach in this article. METHODS Evaluation of the literature on neurofibromatosis type 1 in the context of radiological examination methods. RESULTS In addition to the frequently known changes in the central and peripheral nervous system such as optic gliomas and plexiform neurofibromas, lesions from the orthopedic spectrum and vascular changes must also be included in the radiological diagnosis. CONCLUSIONS Due to the diversity of the clinical picture of NF1, it is reasonable to define an examination strategy which takes into account the needs of radiological routine and also reliably detects the most frequent and prognostically significant pathologies accompanying this disease. In this article, the current recommendations for diagnosis of neurofibromatosis-associated tumors and skeletal changes are summarized, and examination protocols and time intervals are suggested.
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Affiliation(s)
- Rebecca Anders
- Institut für Kinderradiologie, Universitätsklinikum Leipzig, Liebigstr. 20a, 04103, Leipzig, Deutschland
| | - Franz Wolfgang Hirsch
- Institut für Kinderradiologie, Universitätsklinikum Leipzig, Liebigstr. 20a, 04103, Leipzig, Deutschland
| | - Christian Roth
- Institut für Kinderradiologie, Universitätsklinikum Leipzig, Liebigstr. 20a, 04103, Leipzig, Deutschland.
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Vertebral Related Diseases in Healthcare: The Role of Pain Management and Rehabilitation. Healthcare (Basel) 2022; 10:healthcare10061109. [PMID: 35742160 PMCID: PMC9223211 DOI: 10.3390/healthcare10061109] [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: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022] Open
Abstract
The increase in the life expectancy of the general population implied for vertebral diseases an impacting role for the medical condition of the person, not only in the clinical context, but also from a social and economic point of view, due to the underestimation of primary prevention and complex secondary prevention rehabilitation frameworks [...]
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Neifert SN, Khan HA, Kurland DB, Kim NC, Yohay K, Segal D, Samdani A, Hwang S, Lau D. Management and surgical outcomes of dystrophic scoliosis in neurofibromatosis type 1: a systematic review. Neurosurg Focus 2022; 52:E7. [DOI: 10.3171/2022.2.focus21790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Neurofibromatosis type 1 (NF1) dystrophic scoliosis is an early-onset, rapidly progressive multiplanar deformity. There are few studies on the surgical management of this patient population. Specifically, perioperative morbidity, instrument-related complications, and quality-of-life outcomes associated with surgical management have not been systematically evaluated. In this study, the authors aimed to perform a systematic review on the natural history, management options, and surgical outcomes in patients who underwent NF1 dystrophic scoliosis surgery.
METHODS
A PubMed search for articles with “neurofibromatosis” and either “dystrophic” or “scoliosis” in the title or abstract was performed. Articles with 10 or more patients undergoing surgery for NF1 dystrophic scoliosis were included. Data regarding indications, treatment details, morbidity, and outcomes were summarized and analyzed with descriptive statistics.
RESULTS
A total of 310 articles were identified, 48 of which were selected for full-text review; 30 studies describing 761 patients met the inclusion criteria. The mean age ranged from 7 to 22 years, and 99.7% of patients were younger than 18 years. The mean preoperative coronal Cobb angle was 75.2°, and the average correction achieved was 40.3°. The mean clinical follow-up in each study was at least 2 years (range 2.2–19 years). All patients underwent surgery with the intent of deformity correction. The scoliosis regions addressed were thoracic curves (69.6%) and thoracolumbar (11.1%) and lumbar (14.3%) regions. The authors reported on a variety of approaches: posterior-only, combined anterior-posterior, and growth-friendly surgery. For fixation techniques, 42.5% of patients were treated with hybrid constructs, 51.5% with pedicle screw–only constructs, and 6.0% with hook-based constructs. Only 0.9% of patients underwent a vertebral column resection. The nonneurological complication rate was 14.0%, primarily dural tears and wound infections. The immediate postoperative neurological deficit rate was 2.1%, and the permanent neurological deficit rate was 1.2%. Ultimately, 21.5% required revision surgery, most commonly for implant-related complications. Loss of correction in both the sagittal and coronal planes commonly occurred at follow-up. Five papers supplied validated patient-reported outcome measures, showing improvement in the mental health, self-image, and activity domains.
CONCLUSIONS
Data on the surgical outcomes of dystrophic scoliosis correction are heterogeneous and sparse. The perioperative complication rate appears to be high, although reported rates of neurological deficits appear to be lower than clinically observed and may be underreported. The incidence of implant-related failures requiring revision surgery is high. There is a great need for multicenter prospective studies of this complex type of deformity.
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Affiliation(s)
- Sean N. Neifert
- Department of Neurological Surgery, New York University, New York, New York
| | - Hammad A. Khan
- Department of Neurological Surgery, New York University, New York, New York
| | - David B. Kurland
- Department of Neurological Surgery, New York University, New York, New York
| | - Nora C. Kim
- Department of Neurological Surgery, New York University, New York, New York
| | - Kaleb Yohay
- Department of Neurology and Comprehensive Neurofibromatosis Center, New York University, New York, New York; and
| | - Devorah Segal
- Department of Neurology and Comprehensive Neurofibromatosis Center, New York University, New York, New York; and
| | - Amer Samdani
- Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Steven Hwang
- Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Darryl Lau
- Department of Neurological Surgery, New York University, New York, New York
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15
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Current Aspects on the Pathophysiology of Bone Metabolic Defects during Progression of Scoliosis in Neurofibromatosis Type 1. J Clin Med 2022; 11:jcm11020444. [PMID: 35054138 PMCID: PMC8781800 DOI: 10.3390/jcm11020444] [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] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 02/04/2023] Open
Abstract
Neurofibromatosis type 1 (NF1), which is the most common phacomatoses, is an autosomal dominant disorder characterized by clinical presentations in various tissues and organs, such as the skin, eyes and nervous and skeletal systems. The musculoskeletal implications of NF1 include a variety of deformities, including scoliosis, kyphoscoliosis, spondylolistheses, congenital bony bowing, pseudarthrosis and bone dysplasia. Scoliosis is the most common skeletal problem, affecting 10-30% of NF1 patients. Although the pathophysiology of spinal deformities has not been elucidated yet, defects in bone metabolism have been implicated in the progression of scoliotic curves. Measurements of Bone Mineral Density (BMD) in the lumbar spine by using dual energy absorptiometry (DXA) and quantitative computer tomography (QCT) have demonstrated a marked reduction in Z-score and osteoporosis. Additionally, serum bone metabolic markers, such as vitamin D, calcium, phosphorus, osteocalcin and alkaline phosphatase, have been found to be abnormal. Intraoperative and histological vertebral analysis confirmed that alterations of the trabecular microarchitecture are associated with inadequate bone turnover, indicating generalized bone metabolic defects. At the molecular level, loss of function of neurofibromin dysregulates Ras and Transforming Growth factor-β1 (TGF-β1) signaling and leads to altered osteoclastic proliferation, osteoblastic activity and collagen production. Correlation between clinical characteristics and molecular pathways may provide targets for novel therapeutic approaches in NF1.
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Shao X, Huang Z, Yang J, Deng Y, Yang J, Sui W. Efficacy and safety for combination of t-EMG with O-arm assisted pedicle screw placement in neurofibromatosis type I scoliosis surgery. J Orthop Surg Res 2021; 16:731. [PMID: 34930400 PMCID: PMC8686534 DOI: 10.1186/s13018-021-02882-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background Due to the characteristics of neurofibromatosis type I (NF-1) scoliosis, the precise placement of pedicle screws still remains to be a challenge. Triggered screw electromyography (t-EMG) has been proved to exhibit high sensitivity to identify mal-positioned pedicle screws, but no previous study assessed the combination of t-EMG with O-arm-assisted pedicle screw placement in NF-1 scoliosis surgery. Objective To evaluate efficacy and safety for combination of t-EMG with O-arm-assisted pedicle screw placement in NF-1 scoliosis surgery. Materials and methods From March 2018 to April 2020, sixty-five NF-1 scoliosis patients underwent t-EMG and O-arm-assisted pedicle screw fixation were retrospectively reviewed. The channel classification system was applied to classify the pedicle morphology based on pedicle width measurement by preoperative computed tomography scans. The minimal t-EMG threshold for screw path inspection was used as 8 mA, and operative screw redirection was also recorded. All pedicle screws were verified using a second intraoperative O-arm scan. The correlation between demographic and clinical data with amplitude of t-EMG were also analyzed. Results A total of 652 pedicle screws (T10-S1) in 65 patients were analyzed. The incidence of an absent pedicle (channel classification type C or D morphology) was 150 (23%). Overall, abnormal t-EMG threshold was identified in 26 patients with 48 screws (7.4%), while 16 out of the 48 screws were classified as G0, 14 out of the 48 screws were classified as G1, and 18 out of the 48 screws were classified as G2. The screw redirection rate was 2.8% (18/652). It showed that t-EMG stimulation detected 3 unacceptable mal-positioned screws in 2 patients (G2) which were missed by O-arm scan. No screw-related neurological or vascular complications were observed. Conclusions Combination of t-EMG with O-arm-assisted pedicle screw placement was demonstrated to be a safe and effective method in NF-1 scoliosis surgery. The t-EMG could contribute to detecting the rupture of the medial wall which might be missed by O-arm scan. Combination of t-EMG with O-arm could be recommended for routine use of screw insertion in NF-1 scoliosis surgery.
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Affiliation(s)
- Xiexiang Shao
- Spine Center, Xin Hua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Shanghai, People's Republic of China
| | - Zifang Huang
- Department of Spine Surgery, Sun Yat-Sen University First Affiliated Hospital, No. 58 Second Zhongshan Road, Guangzhou, Guangdong, People's Republic of China
| | - Jingfan Yang
- Spine Center, Xin Hua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Shanghai, People's Republic of China
| | - Yaolong Deng
- Spine Center, Xin Hua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Shanghai, People's Republic of China
| | - Junlin Yang
- Spine Center, Xin Hua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Shanghai, People's Republic of China.
| | - Wenyuan Sui
- Spine Center, Xin Hua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Shanghai, People's Republic of China.
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