Erector Spinae Plane Block Level Does Not Impact Analgesic Efficacy in Enhanced Recovery for Lumbar Spine Surgery

BACKGROUND CONTEXT

Postoperative pain control following spine surgery can be difficult. The Enhanced Recovery After Surgery (ERAS) programs use multimodal approaches to manage postoperative pain. While an erector spinae plane block (ESPB) is commonly utilized, the ideal distance for injection from the incision, referred to as the ES (ESPB to mid-surgical level) distance, remains undetermined.

PURPOSE

We evaluated the impact of varying ES distances for ESPB on Numerical Rating Scale (NRS) measures of postoperative pain within the ERAS protocol.

STUDY DESIGN/SETTING

Retrospective observational study.

PATIENT SAMPLE

Adult patients who underwent elective lumbar spine fusion surgery.

OUTCOME MEASURES

Primary outcome measures include the comparative postoperative NRS scores across groups at immediate (T1), 24 (T2), 48 (T3), and 72 (T4) hours post-surgery. For secondary outcomes, a propensity matching analysis compared these outcomes between the ERAS and non-ERAS groups, with opioid-related recovery metrics also assessed.

METHODS

All included patients were assigned to one of three ERAS groups according to the ES distance: Group 1 (G1, ES > 3 segments), Group 2 (G2, ES = 2-3 segments), and Group 3 (G3, ES<2 segments). Each patient underwent a bilateral ultrasound-guided ESPB with 60 mL of diluted ropivacaine or bupivacaine.

RESULTS

Patients within the ERAS cohort reported mild pain (NRS < 3), with no significant NRS variation across G1 to G3 at any time. Sixty-five patients were matched across ERAS and non-ERAS groups. The ERAS group exhibited significantly lower NRS scores from T1 to T3 than the non-ERAS group. Total morphine consumption during hospitalization was 26.7 mg for ERAS and 41.5 mg for non-ERAS patients. The ERAS group resumed water and food intake sooner and had less postoperative nausea and vomiting.

CONCLUSIONS

ESPBs can be effectively administered at or near the mid-surgical level to the low thoracic region for lumbar spine surgeries. Given challenges with sonovisualization, a lumbar ESPB may be preferred to minimize the risk of inadvertent pleural injury.

MRI-based lesion quality score assessing ossification of the posterior longitudinal ligament of the cervical spine

BACKGROUND CONTEXT

No method currently exists for MRI-based determination of ossification of the posterior longitudinal ligament (OPLL) of the cervical spine using objective criteria.

PURPOSE

The purpose of this study was to develop an MRI-based score to determine whether a lesion represents a cervical OPLL lesion and to establish the objective diagnostic value.

STUDY DESIGN

Retrospective cohort in a single medical institution.

PATIENT SAMPLE

Thirty-five patients undergoing surgery for OPLL (Group A) and 99 patients undergoing cervical disc arthroplasty for soft disc herniation (Group B) between 2011 and 2020 were retrospectively included. All OPLL lesions on unenhanced MRI scan were correlated with a corresponding CT scan. Demographics were comparable between the two groups.

OUTCOME MEASURES (PHYSIOLOGIC MEASURES)

Using unenhanced magnetic resonance imaging (MRI), the T1- and T2- lesion quality (LQ) scores were calculated. Receiver operating characteristic (ROC) analysis was performed to calculate the area-under-the-curve (AUC) of both LQ scores as a predictor of the presence of OPLL. Computed tomography- (CT-) based Hounsfield unit (HU) values of OPLL lesions were obtained and compared with both LQ scores. The LQ scores for MRI scanners from different manufacturers were compared using Student's t test to confirm the validity of the LQ score by scanner type.

METHODS

The regions of interest for signal intensity (SI) were defined as the darkest site of the lesion and the cerebrospinal fluid (CSF) at the cerebellomedullary cistern. The T1 and T2 LQ scores were measured as the ratio of the SI at the darkest site of the lesion divided by the SI of the CSF.

RESULTS

The T1 and T2 LQ scores in Group A were significantly lower than those in Group B (p < 0.001). ROC analysis determined that T1 and T2 LQ scores of 0.46 and 0.07, respectively, could distinguish the presence of OPLL with an accuracy of 0.93 and 0.89, respectively (p<.001). When the T1 LQ score of the lesion is <0.46, a diagnosis of OPLL may be suspected with 100% sensitivity and 92.3% specificity. The HU of the lesion had a moderate negative correlation with the T1 LQ score (r=-0.665, p<.0001). Both LQ scores were unaffected by manufacturer type.

CONCLUSIONS

This study found a correlation between the MRI-based T1 LQ scores and CT-based HU value for identifying OPLL lesions. Additional studies will be needed to validate that the T1 LQ score from the unenhanced MRI scan can identify cervical OPLL.

Proliferation and Differentiation Potential of Bone Marrow-Derived Mesenchymal Stem Cells From Children With Polydactyly and Adults With Basal Joint Arthritis

This study compared the proliferation and differentiation potential of bone marrow-derived mesenchymal stem cells (BMSCs) derived from infants with polydactyly and adults with basal joint arthritis. The proliferation rate of adult and infant BMSCs was determined by the cell number changes and doubling times. The γH2AX immunofluorescence staining, age-related gene expression, senescence-associated β-galactosidase (SA-β-gal) staining were analyzed to determine the senescence state of adult and infant BMSCs. The expression levels of superoxide dismutases (SODs) and genes associated with various types of differentiation were measured using Real-Time Quantitative Polymerase Chain Reaction (RT-qPCR). Differentiation levels were evaluated through histochemical and immunohistochemical staining. The results showed that infant BMSCs had a significantly higher increase in cell numbers and faster doubling times compared with adult BMSCs. Infant BMSCs at late stages exhibited reduced γH2AX expression and SA-β-gal staining, indicating lower levels of senescence. The expression levels of senescence-related genes (p16, p21, and p53) in infant BMSCs were also lower than in adult BMSCs. In addition, infant BMSCs demonstrated higher antioxidative ability with elevated expression of SOD1, SOD2, and SOD3 compared with adult BMSCs. In terms of differentiation potential, infant BMSCs outperformed adult BMSCs in chondrogenesis, as indicated by higher expression levels of chondrogenic genes (SOX9, COL2, and COL10) and positive immunohistochemical staining. Moreover, differentiated cells derived from infant BMSCs exhibited significantly higher expression levels of osteogenic, tenogenic, hepatogenic, and neurogenic genes compared with those derived from adult BMSCs. Histochemical and immunofluorescence staining confirmed these findings. However, adult BMSCs showed lower adipogenic differentiation potential compared with infant BMSCs. Overall, infant BMSCs demonstrated superior characteristics, including higher proliferation rates, enhanced antioxidative activity, and greater differentiation potential into various lineages. They also exhibited reduced cellular senescence. These findings, within the context of cellular differentiation, suggest potential implications for the use of allogeneic BMSC transplantation, emphasizing the need for further in vivo investigation.

Multilineage differentiation potential in the infant adipose- and umbilical cord-derived mesenchymal stem cells

BACKGROUND

This study aims to compare the biological properties of infant adipose-derived mesenchymal stem cells (infant ADSCs) from excised polydactyly fat tissue and umbilical cord-derived mesenchymal stem cells (UCSCs) in terms of proliferation and differentiation capabilities. The proliferation of infant ADSCs and UCSCs was analyzed by determining the fold changes of cell numbers and doubling time periods.

METHODS

The state of senescence and replicative stress was compared by analyzing the expression of age-related genes, senescence-associated β-galactosidase (SA-β-gal) staining, and phosphorylated histone variant H2AX (γH2AX) immunofluorescence staining. The expression levels of superoxide dismutase ( SODs ) and genes related to multilineage differentiation were analyzed using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Differentiation levels were determined using histochemical staining, immunohistochemical staining, and immunofluorescence staining.

RESULTS

Infant ADSCs exhibited higher proliferation rates and expression levels of SOD1 , SOD2 , and SOD3 at passages 3-5 compared with UCSCs. Senescence related genes ( p16 , p21 , and p53 ), SA-β-gal staining, and replicative stress analysis were reduced in infant ADSCs. The expression levels of chondrogenic genes ( COL2 and COL10 ), osteogenic genes ( RUNX2 and ALP ), adipogenic genes ( LPL ), and hepatogenic genes ( ALB and TAT ) in infant ADSC-differentiated cells were significantly higher than those in UCSCs. Histochemical and immunofluorescence staining confirmed these results. Only the expression levels of tenogenic genes ( MMP3 , DCN , and COL3 ) in infant ADSC-differentiated cells were lower than those in UCSCs.

CONCLUSION

Infant ADSCs exhibit higher proliferation rates, reduced cellular senescence and replicative stress, better antioxidative activity, and higher differentiation potential toward chondrogenic, osteogenic, adipogenic and hepatogenic lineages than UCSCs.

Reducing surgical site infections after spine surgery: the optimal amount of normal saline for intra-wound irrigation

BACKGROUND CONTEXT

Surgical site infection (SSI) following lumbar surgery can increase healthcare costs and lead to poor clinical outcome. Irrigation of wounds with saline solution is widely accepted globally and safe for nearly all kinds of surgery. However, the efficacy of different volumes of wound irrigation has not been addressed in elective spine surgery. The role and the optimal amount of intraoperative wound saline irrigation in preventing SSI in clean spinal surgery remain unclear.

PURPOSE

We aimed to investigate if insufficient intraoperative irrigation may be a risk factor for postoperative SSI. Additionally, we investigated the optimal amount of normal saline (NS) for irrigation to prevent postoperative SSI.

STUDY DESIGN

This is a retrospective study of patients with degenerative spinal stenosis who were treated surgically. Patients were grouped according to the amount of intra-wound irrigation during surgery.

PATIENT SAMPLE

We included 444 patients with degenerative lumbar spinal conditions who had undergone one to five level open spinal fusion surgeries from January 2015 through April 2020.

OUTCOME MEASURES

The definition of superficial or deep SSI in this study was based on the Centers for Disease Control and Prevention criteria for SSI. The fusion status accessed was based on the Bridwell grading system at the final follow-up. Self-reported and clinical outcome measures include visual analog scale and Oswestry Disability Index.

METHODS

A total of 193 patients underwent irrigation with a bulb syringe with manual method (B group) with 2,000 mL NS; 251 patients underwent interpulse battery-powered device irrigation (P group) with >6,000 mL NS. Based on our protocolized departmental guidelines, all patients received the same preoperative preparation and standard surgical steps and postoperative care plan. Patients' demographic and surgical parameters were recorded. The main outcome measures included superficial wound infection, deep infection and overall infection.

RESULTS

The incidence of overall SSI was 4.66% in the B group and 1.59% in the P group. The univariate analysis revealed a significant correlation with DM and irrigation amount per hour during surgery but not age, BMI, smoking, operative duration, fusion level, or blood loss. We determined the optimal irrigation amount during surgery as 1,400 mL per hour based on the receiver operating characteristic (ROC) curve (sensitivity, 92.3%; specificity, 44.1%). This was statistically significant (p=.033) with an odds ratio of 9.284 (95% confidence interval 1.2-72.0). In the analysis of surgical factors, the infection group had a significantly lower irrigation amount during surgery. To summarize, patients with diabetes and those receiving less than 1,400 mL of NS/hour had a higher likelihood of developing SSI.

CONCLUSIONS

We observed that diabetes and lower volume of intraoperative irrigation were both risk factors for postoperative SSI following degenerative lumbar spine surgery. To reduce SSI in lumbar spine surgery, intra-wound irrigation with more than 1,400 mL/h of NS was recommended.

Preoperative planning of compact zone trajectory is necessary in treating osteoporotic vertebral compression fracture with endplate involvement: A prospective randomized controlled study

BACKGROUND

This prospective randomized controlled study compares the clinical and radiological outcomes between reduction methods with or without compact trabecular bone during percutaneous kyphoplasty in osteoporotic vertebral fractures.

METHODS

The cohort of 100 patients who underwent percutaneous kyphoplasty was randomly divided into group A (guide pin and balloon introduced directly into fracture site) and group B (guide pin and balloon inserted away fracture site). The surgery duration, clinical and radiological outcomes postoperatively and at follow-up, and complications of cement leakage and adjacent fracture were recorded. Patients were followed up for an average of 20.18 months. The clinical outcomes were assessed using the Oswestry Disability Index and visual analog scale.

RESULTS

The two groups had similar patient demographics, surgery times, and volume of cement injected. The method using elevation of the collapsed endplate indirectly had no significant influence on radiological outcomes but significantly decreased the occurrence of intradiscal cement leakage and improved 1- and 12-month postoperative functional outcomes.

CONCLUSION

Elevating and reinforcing the collapsed endplate rather than just filling the defect during percutaneous kyphoplasty is safe and effective. This technique decreased pain and improved function with lower rates of further collapse of the osteoporotic vertebrae compared to defect-filling alone.

Differences in productivity and collaboration patterns on spine-related research between neurosurgeons and orthopedic spine surgeons: Bibliometric analysis

BACKGROUND

Spinal surgeries are commonly performed by neurosurgeons and orthopedic spine surgeons, with many spine-related articles published by them. However, there has been limited research that directly compares their research achievements. This article conducted a comparative analysis of spine-related research achievements between neurosurgeons and orthopedic spine surgeons. This study examines differences in productivity and impact on spine-related research between them using these measures, particularly with a novel clustering algorithm.

METHODS

We gathered 2148 articles written by neurosurgeons and orthopedic spine surgeons from the Web of Science core collections, covering the period from 2013 to 2022. To analyze author collaborations, we employed the follower-leader clustering algorithm (FLCA) and conducted cluster analysis. A 3-part analysis was carried out: cluster analysis of author collaborations; mean citation analysis; and a category, journal, authorship, L-index (CJAL) score based on article category, journal impact factors, authorships, and L-indices. We then utilized R to create visual displays of our findings, including circle bar charts, heatmaps with dendrograms, 4-quadrant radar plots, and forest plots. The mean citations and CJAL scores were compared between neurosurgeons and orthopedic spine surgeons.

RESULTS

When considering first and corresponding authors, orthopedics authors wrote a greater proportion of the articles in the article collections, accounting for 75% (1600 out of 2148). The CJAL score based on the top 10 units each also favored orthopedic spine surgeons, with 71% (3626 out of 6139) of the total score attributed to them. Using the FLCA, we observed that orthopedic spine surgeons tended to have more collaborations across countries. Additionally, while citation per article favored orthopedic spine surgeons with standard mean difference (= -0.66) and 95%CI: -0.76, -0.56, the mean CJAL score in difference (= 0.34) favored neurosurgeons with 95%CI: 0.24 0.44.

CONCLUSION

Orthopedic spine surgeons have a higher number of publications, citations, and CJAL scores in spine research than those in neurosurgeons. Orthopedic spine surgeons tend to have more collaborations and coauthored papers in the field. The study highlights the differences in research productivity and collaboration patterns between the 2 authors in spine research and sheds light on potential contributing factors. The study recommends the use of FLCA for future bibliographical studies.

Biomechanical Effects of a Novel Pedicle Screw W-Type Rod Fixation for Lumbar Spondylolysis: A Finite Element Analysis

Lumbar spondylolysis involves anatomical defects of the pars interarticularis, which causes instability during motion. The instability can be addressed through instrumentation with posterolateral fusion (PLF). We developed a novel pedicle screw W-type rod fixation system and evaluated its biomechanical effects in comparison with PLF and Dynesys stabilization for lumbar spondylolysis via finite element (FE) analysis. A validated lumbar spine model was built using ANSYS 14.5 software. Five FE models were established simulating the intact L1-L5 lumbar spine (INT), bilateral pars defect (Bipars), bilateral pars defect with PLF (Bipars_PLF), Dynesys stabilization (Bipars_Dyn), and W-type rod fixation (Bipars_Wtyp). The range of motion (ROM) of the affected segment, the disc stress (DS), and the facet contact force (FCF) of the cranial segment were compared. In the Bipars model, ROM increased in extension and rotation. Compared with the INT model, Bipars_PLF and Bipars_Dyn exhibited remarkably lower ROMs for the affected segment and imposed greater DS and FCF in the cranial segment. Bipars_Wtyp preserved more ROM and generated lower stress at the cranial segment than Bipars_PLF or Bipars_Dyn. The injury model indicates that this novel pedicle screw W-type rod for spondylolysis fixation could return ROM, DS, and FCF to levels similar to preinjury.

Posterior instrumentation for osteoporotic fractures in the thoracic or lumbar spine: Cement-augmented pedicle screws vs hybrid constructs

BACKGROUND

Cement-augmented pedicle screws (CPS) and hybrid construct (HC), consisting of pedicle screws and additional hooks, are common fixation methods for osteoporotic spine fracture. No study has compared surgical results of CPS and HC for treating osteoporotic spine fracture. The aim of the study was to compare surgical results using CPS or HC for osteoporotic fractures of the thoracic or lumbar spine.

METHODS

This retrospective cohort study included 84 patients who received surgical treatment with CPS (n = 43) or HC (n = 41) for osteoporotic spine fractures from January 2011 to December 2015, with a mean follow-up of 67 months. Sixty-five patients with neurological deficits received long posterior instrumentation, short posterior decompression, and posterolateral fusion. The 19 patients without neurologic deficits received long posterior instrumentation without posterior decompression and fusion. Radiographic, clinical, and neurologic outcomes were evaluated.

RESULTS

The HC group had significantly shorter operative times (231 vs 258 minutes), greater blood loss (497 vs 427 mL), better immediate postoperative kyphosis reduction (10.6° vs 9.1°), and greater final reduction loss (9.8° vs 7.1°) than the CPS group. In both groups, significant loss of the kyphotic angle was apparent during follow-up. Improved ambulation after surgery occurred in 51.2% and 58.5% of patients in the CPS and HC groups, respectively. Neurologic function after surgery improved 0.5 and 0.7 grades in the CPS and HC groups, respectively. Implants failed in 2.3% and 2.4% of patients in the CPS and HC groups, respectively. The incidence of cement leakage from screw augmentation was 38.9%.

CONCLUSION

The CPS and HC techniques for treating osteoporotic fractures of the thoracic or lumbar spine did not differ statistically in terms of improved radiologic and clinical outcomes, final neurologic and ambulatory function, or implant failure rates, making them equally comparable alternatives.

The Impact of Cage and End plate-Related Factors on Cage Subsidence in Oblique Lateral Interbody Fusion

OBJECTIVES

To identify cage and end plate factors of cage subsidence (CS) in patients who underwent oblique lateral interbody fusion (OLIF) and their association with patient-reported outcomes.

METHODS

Sixty-one patients (43 women and 18 men), with a total of 69 segments (138 end plates) which underwent OLIF at a single academic institution between November 2018 and November 2020, were included. All the end plates were separated into CS and nonsubsidence groups. Cage-related parameters (cage height, cage width, cage insertion level, and cage position) and end plate-related parameters (position of end plate, Hounsfield unit value of the vertebra, end plate concave angle [ECA], end plate injury, and angular mismatch measured with cage/end plate angle [C/EA]) were compared and analyzed using logistic regression to predict CS. Receiver operating characteristic curve analysis was used to determine the cutoff points of the parameters.

RESULTS

Postoperative CS was identified in 50 of the 138 end plates (36.2%). The CS group had significantly lower mean Hounsfield unit values of the vertebra, higher rate of end plate injury, lower ECA, and higher C/EA than the nonsubsidence group. ECA and C/EA were identified as independent risk factors for developing CS. The optimal cutoff points for ECA and C/EA were 176.9° and 5.4°, respectively.

CONCLUSIONS

An ECA greater than 176.9° and a cage/end plate angular mismatch greater than 5.4° were found to be independent risk factors of postoperative CS after the OLIF procedure. These findings aid in preoperative decision-making and intraoperative technical guidance.

Outcome of Ti/PEEK Versus PEEK Cages in Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective case-control study.

OBJECTIVES

This study aims to present the clinical and radiographical outcomes of the titanium-polyetheretherketone (Ti/PEEK) composite cage compared to those of the standard PEEK cage in patients receiving minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

METHODS

Patients receiving 1 level MI-TLIF between October 2015 and October 2017 were included with a minimum of 2-year follow-up. The patients were segregated into 2 groups; Ti/PEEK group and PEEK group. Each patient was propensity-matched using preoperative age, sex, and body mass index. Early fusion rate was evaluated by computed tomography at postoperative 6 months. Clinical outcomes were assessed using the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores.

RESULTS

After matching, there were 27 patients included in each group. The demographics, diagnosis, and surgical details were not significantly different between the 2 groups. The 6-month rate was 88.9% in Ti/PEEK group. The fusion rate and cage subsidence rate had no difference between the 2 groups. The complication rate in the Ti/PEEK group was comparable to that in the PEEK group. There was no difference in VAS and ODI scores during a 2-year follow-up period.

CONCLUSIONS

The use of Ti/PEEK composite cage was as safe and effective as the use of PEEK cage in MI-TLIF. The 6-month fusion rate was 88.9%. Our finding revealed comparable clinical results for surgeons using Ti/PEEK composite cages in MI-TLIF compared to those using the PEEK cage.

Shorter screw lengths in dynamic Dynesys fixation have less screw loosening: From clinical investigation to finite-element analysis

BACKGROUND

The dynamic Dynesys Stabilization System preserves lumbar mobility at instrumented levels. This study investigated the effect of screw length on screw loosening (SL) after dynamic Dynesys fixation and screw displacement during lumbar motion, using clinical investigation and finite-element (FE) analysis.

METHODS

Clinical data of 50 patients with degenerative spondylolisthesis treated with decompression and Dynesys fixation in 2011 were analyzed retrospectively. Horizontal sliding displacement and vertical displacement of screw tips at L4 were analyzed postoperatively using displacement-controlled FE analysis at the L4-L5 level with screw lengths 45 (long screw), 36 (median screw), and 27 (short screw), and 6.4 mm in diameter, under flexion, extension, lateral bending, and rotation.

RESULTS

In 13 patients (13/50, 26%), 40 screws (40/266, 15%) were loose at mean follow-up of 101.3 ± 4.4 months. Radiographic SL at 35, 40, 45, and 50 mm were 7.7%, 10.7%, 12.1%, and 37.5%, respectively, regardless of the fixation level ( p = 0.009). FE analysis revealed that the long screw model with corresponding longer lever arm had maximal horizontal sliding displacement under all directions and maximal vertical displacement, except for lateral bending.

CONCLUSION

Shorter screws in Dynesys fixation may help avoid dynamic SL. Clinically, 50 mm screws showed the greatest SL and median screw screws demonstrated the least displacement biomechanically.

Investigation of preoperative asymptomatic bacteriuria as a risk factor for postvertebroplasty infection

BACKGROUND

Postvertebroplasty infection (PVI) is a catastrophic complication after vertebroplasty (VP). Although the urinary tract has been considered as a source of infectious pathogens, whether asymptomatic bacteriuria (ASB) is a risk factors for PVI remains unknown.

METHODS

This retrospective study included 716 patients (207 males; 509 females) treated with VP for osteoporotic vertebral fractures in a single medical center between May 2015 and December 2019. Clinical symptoms, urinalysis results, and culture data were collected preoperatively to identify patients with ASB. The primary outcome was PVI at the index level during follow-up. Demographic data and laboratory test results were compared between the PVI and non-PVI groups.

RESULTS

The mean age of the cohort was 78.6 ± 9.6 (range, 63-106). The prevalence of ASB was 14.1%, with female predominance (63.4%). The overall PVI rate was 1.26% (9/716). The PVI group had more patients with ASB (4/9, 44.4%) than did the non-PVI group (97/707, 13.7%) (p = 0.027). The rate of ASB treatment was similar between the PVI and non-PVI groups (25% vs. 23.7%, respectively). No case of PVI was caused by the urine culture pathogen. Multivariate analysis identified the following risk factors for PVI: ASB (odds ratio [OR], 5.61; 95% CI, 1.14-27.66; p = 0.034), smoking (OR, 16.26; 95% CI, 2.58-102.65; p = 0.003), and malignancy (OR 7.27; 95% CI, 1.31-40.31; p = 0.023).

CONCLUSION

ASB was not uncommon among patients admitted for VP and should be considered a marker of relatively poor host immunity. Preoperative ASB, a history of malignancy, and smoking were identified as significant risk factors for PVI.

CT Hounsfield unit is a reliable parameter for screws loosening or cages subsidence in minimally invasive transforaminal lumbar interbody fusion

Retrospective cohort study. To validate computed tomography (CT) radiodensity in Hounsfield units (HU) as a prognostic marker for pedicle screw loosening or cage subsidence in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). The retrospective study involved 198 patients treated with MI-TLIF. Screw loosening (SL), cage subsidence (CS), and fusion status were assessed by plain radiographs. The risk factors of SL and CS were identified using logistic regression. A total of 258 levels and 930 screws were analyzed. During a 2-year follow-up, 16.2% and 24.7% of patients had CS and SL respectively. The cut-off value of L1 HU for predicting SL or CS was 117. The L1 HU < 117 and BMI ≥ 25 were two independent risk factors. The risk of SL or CS was 4.1 fold in patients L1 HU < 117 and 2.6 fold in patients with BMI ≥ 25. For patients concurrently having BMI ≥ 25 and pre-op L1 HU < 117, the risk was 4.3 fold. Fusion rate and clinical outcome were comparable in patients with SL or CS. L1 HU < 117 and BMI > 25 were two independent risk factors that can be screened preoperatively for preventing SL or CS and lead to better management of patients undergoing MI-TLIF.

Superior facet joint violation between open and minimally invasive techniques in lumbar fusion surgery: An updated systematic review and meta-analysis

BACKGROUND

Superior facet joint violation (FJV) is a potential risk factor for adjacent segment disease following lumbar fusion surgery. We sought to conduct a systematic review and meta-analysis to compare screw-related superior FJV rates between the open and different minimally invasive (MI) techniques-fluoroscopy-based, 3D-image navigation, and navigation with robotic assistance-in adult lumbar fusion surgery.

METHODS

We searched original articles comparing the rates of screw-related FJV between the open and different MI techniques in adult lumbar fusion surgery for lumbar degenerative diseases in PubMed, EMBASE, and the Cochrane Library from inception to September 2021. We compared the numbers of top-level pedicle screws and associated superior FJVs in the main analyses and performed subgroup analysis based on different MI techniques to examine whether individual MI approaches differed in superior FJV rate. Risk ratio (RR) and 95% confidence interval (CI) were calculated in a random-effect meta-analysis.

RESULTS

Included in the meta-analysis were 16 articles with 2655 patients and 4638 top-level pedicle screws. The pooled analysis showed no significant difference in superior FJV rates between the MI and open groups (RR: 0.89, 95% CI: 0.62-1.28). The subgroup analysis demonstrated that the overall rates of superior FJV were 27.1% (411/1518) for fluoroscopy-based, 7.1% (43/603) for 3D-image navigation, and 3.2% (7/216) for navigation with robotic assistance. Compared with the open method, the overall RRs were 1.53 (95% CI: 1.19-1.96) for fluoroscopy-based, 0.41 (95% CI: 0.22-0.75) for 3D-image navigation, and 0.25 (95% CI: 0.08-0.72) for navigation with robotic assistance.

CONCLUSION

Among the three common MI techniques, fluoroscopy-based can be associated with a higher risk of superior FJV, while both 3D-image navigation and navigation with robotic assistance may be associated with lower risks as compared with the open method. Considering the limitations of the study, more trials are needed to prove these clinical findings.

Thematic analysis of articles on artificial intelligence with spine trauma, vertebral metastasis, and osteoporosis using chord diagrams: A systematic review and meta-analysis

BACKGROUND

Spine trauma, vertebral metastases, and osteoporosis (SVO) can result in serious health problems. If the diagnosis of SVO is delayed, the prognosis may be deteriorated. The use of artificial intelligence (AI) is an essential method for minimizing the diagnostic errors associated with SVO. research achievements (RAs) of SVO on AI are required as a result of the greatest number of studies on AI solutions reported. The study aimed to: classify article themes using visualizations, illustrate the characteristics of SVO on AI recently, compare RAs of SVO on AI between entities (e.g., countries, institutes, departments, and authors), and determine whether the mean citations of keywords can be used to predict article citations.

METHODS

A total of 31 articles from SVO on AI (denoted by T31SVOAI) have been found in Web of Science since 2018. The dominant entities were analyzed using the CJAL score and the Y-index. Five visualizations were applied to report: the themes of T31SVOAI and their RAs in comparison for article entities and verification of the hypothesis that the mean citations of keywords can predict article citations, including: network diagrams, chord diagrams, dot plots, a Kano diagram, and radar plots.

RESULTS

There were five themes classified (osteoporosis, personalized medicine, fracture, deformity, and cervical spine) by a chord diagram. The dominant entities with the highest CJAL scores were the United States (22.05), the University of Pennsylvania (5.72), Radiology (6.12), and Nithin Kolanu (Australia) (9.88). The majority of articles were published in Bone, J. Bone Miner. Res., and Arch. Osteoporos., with an equal count (=3). There was a significant correlation between the number of article citations and the number of weighted keywords (F = 392.05; P < .0001).

CONCLUSION

A breakthrough was achieved by displaying the characteristics of T31SVOAI using the CJAL score, the Y-index, and the chord diagram. Weighted keywords can be used to predict article citations. The five visualizations employed in this study may be used in future bibliographical studies.

Whole-Exome Sequencing Identifies Genetic Variants for Severe Adolescent Idiopathic Scoliosis in a Taiwanese Population

Adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal curvature deformity that appears in the adolescent period. In this study, we performed whole-exome sequencing on 11 unrelated Taiwanese patients with a Cobb's angle greater than 40 degrees. Our results identified more than 200 potential pathogenic rare variants, however, most of which were carried only by one individual. By in silico pathogenicity annotation studies, we found that TTN, CLCN1, and SOX8 were the most important genes, as multiple pathogenic variants were within these genes. Furthermore, biological functional annotation indicated critical roles of these AIS candidate genes in the skeletal muscle. Importantly, a pathogenic variant on SOX8 was shared by over 35% of the patients. These results highlighted TTN, CLCN1, and SOX8 as the most likely susceptibility genes for severe AIS.

Comparing the similarity and differences in MeSH terms associated with spine-specific journals using the forest plot: A bibliometric analysis

BACKGROUND

A common concern in the literature is the comparison of the similarities and differences between research journals, as well as the types of research they publish. At present, there are no clear methodologies that can be applied to a given article of interest. When authors use an effective and efficient method to locate journals in similar fields, they benefit greatly. By using the forest plot and major medical subject headings (MeSH terms) of Spine (Phila Pa 1976) compared to Spine J, this study: displays relatively similar journals to the target journal online and identifies the effect of the similarity odds ratio of Spine (Phila Pa 1976) compared to Spine J.

METHODS

From the PubMed library, we downloaded 1000 of the most recent top 20 most similar articles related to Spine (Phila Pa 1976) and then plotted the clusters of related journals using social network analysis (SNA). The forest plot was used to compare the differences in MeSH terms for 2 journals (Spine (Phila Pa 1976) and Spine J) based on odds ratios. The heterogeneity of the data was evaluated using the Q statistic and the I-square (I2) index.

RESULTS

This study shows that: the journals related to Spine (Phila Pa 1976) can easily be presented on a dashboard via Google Maps; 8 journal clusters were identified using SNA; the 3 most frequently searched MeSH terms are surgery, diagnostic imaging, and methods; and the odds ratios of MeSH terms only show significant differences with the keyword "surgery" between Spine (Phila Pa 1976) and Spine J with homogeneity at I2 = 17.7% (P = .27).

CONCLUSIONS

The SNA and forest plot provide a detailed overview of the inter-journal relationships and the target journal using MeSH terms. Based on the findings of this research, readers are provided with knowledge and concept diagrams that can be used in future submissions to related journals.

Citation analysis of the 100 top-cited articles on discectomy via endoscopy since 2011 using alluvial diagrams: bibliometric analysis

Background

Percutaneous endoscopic lumbar discectomy (PELD) is synonymous with percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID). PEID has gained increasing recognition for its small incision, quick recovery, short hospital stay, and equivalent clinical outcome to open surgery. Numerous articles related to PEID have been published in the literature. However, which countries, journals, subject categories, and articles have ultimate influence remains unknown. The study aimed to (1) display influential entities in 100 top-cited PEID-related articles (T100PEID) on the alluvial diagram and (2) investigate whether medical subject headings (i.e., MeSH terms) can be used to predict article citations.

Methods

T100PEID data can be found since 2011 in the PubMed and Web of Science (WOS) databases. Using alluvial diagrams, citation analysis was conducted to compare the dominant entities. We used social network analysis (SNA) to classify MeSH terms and research areas extracted from PubMed and WOS. The difference in article citations across subject categories and the predictive power of MeSH terms on article citations in T100 PEID were examined using one-way analysis of variance (ANOVA) and regression analysis.

Results

A total of 81% of T100PEID is occupied by the top three countries (the US, China, and South Korea). There was an overall T100PEID impact factor of 41.3 (IF = citations/100). Articles were published in Spine (Phila Pa 1976) (23%; IF = 41.3). Six subject categories were classified using the SNA. The most cited article authored by D Scott Kreiner from Ahwatukee Sports and Spine in the US state of Phoenix had 123 citations in PubMed. The network characteristics of T100PEID are displayed on the alluvial diagram. No difference was found in article citations among subject categories (F = 0.813, p = 0.543). The most frequently occurring MeSH term was surgery. MeSH terms were evident in the prediction power of the number of article citations (F = 15.21; p < 0 .001).

Conclusion

We achieved a breakthrough by displaying the T100PEID network characteristics on the alluvial plateau. The MeSH terms can be used to classify article subject categories and predict T100PEID citations. The alluvial diagram can be applied to bibliometrics on 100 top-cited articles in future studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00782-0.

An Alluvial diagram was drawn to display the network characteristics of T100PEID, which is novel and modern in the literature.

The method of drawing the Alluvial demonstrated in detail with documents in supplemental digital contents can be applied to make bibliometric studies brief, concise, and powerful.

The impact beam plot (IBP) is an additional visualization introduced in this study. The online IBP was demonstrated and worthy of future similar studies to highlight the most influential articles with a glance at a picture.

Efficacy of Povidone Iodine Solution in the Prevention of Surgical Site Infections in Minimally Invasive Instrumented Spinal Fusion Surgery

STUDY DESIGN

A retrospective case-controlled study.

OBJECTIVES

To evaluate overall infection rate and adverse event after harvesting bone graft soaking and surgical wound irrigation by povidone iodine solution (PVI) in the minimally invasive instrumented spinal fusion surgery. In order to reduce the rate of surgical site infection in spinal surgery, surgical wound irrigation by povidone iodine solution has been well-established. However, the efficacy of autologous bone graft soaking by PVI has not been evaluated before.

METHODS

This is a retrospective cohort study. 120 patients were enrolled in the PVI group and compared with 124 patients in the historical cohort. In the PVI group, the harvesting autologous bone graft was soaking and the surgical wound was also irrigated by diluted PVI solution. The outcome measures were overall infection rate, superficial wound infection and deep infection. In addition, the delayed union of the fusion mass was also evaluated through the radiograph evaluation.

RESULTS

Both groups shared similar patient demographics instead of body mass index. The use of PVI solution had decreased the overall infection rate (0% versus 4.03%, p = 0.026) and deep infection rate (0% versus 3.23%, p = 0.047). In addition, there was no delayed bone healing in the PVI group after autologous bone graft soaking.

CONCLUSIONS

In this study, we conclude that harvested autologous bone graft after PVI soaking in spinal fusion surgery can decrease the incidence of deep infection.

Classification and citation analysis of the 100 top-cited articles on adult spinal deformity since 2011: A bibliometric analysis

BACKGROUND

Studies of the 100 most-cited articles are reported for many subjects. However, none has analyzed the article characteristics associated with high citation frequency. This study aims to (1) graphically depict characteristics of the 100 top-cited articles addressing adult spinal deformity (ASD), (2) diagram the association between articles according to subject and major topic medical subject headings (MeSHs), and (3) investigate whether major topic MeSH correlates with article citation frequency.

METHODS

The 100 top-cited ASD publications since 2011 were retrieved using a PubMed Central search on May 6, 2020. Using titles and abstracts, eight subject categories were identified: surgery, conservative treatment, normal values in spinopelvic alignment, review, cervical alignment, classification, compensatory mechanism, and spine-hip relationship. Sankey diagrams were used to organize the information. Network analysis was performed according to article subject and major topic MeSHs. Pearson's r was used to determine whether the weighted number of citations correlates with major topic MeSHs and the number of citations.

RESULTS

The average number of citations per article was 34.8 (range, 19-156). The most represented country was USA (n = 51). The most productive and highly cited journal was Spine (Phila Pa 1976) (n = 34; average, 38.2 citations per article). The most frequent subject categories and major topic MeSHs were "surgery" (n = 53) and "scoliosis" (weighted count, 9.8), while articles with the subject "compensatory" had the highest average number of citations (64.7). The most highly cited article, by Dr. F. Schwab in 2012, had 156 citations. Network analysis revealed the relationships between these articles according to major topic MeSHs. The weighted number of citations according to major topic MeSHs correlated significantly with article citation frequency (Pearson's r, 0.57; p < 0.001).

CONCLUSION

Multiple characteristics of the 100 top-cited ASD articles are presented in diagrams to guide evidence-based clinical decision-making in ASD.

Healing of Vertebral Compression Fractures in the Elderly after Percutaneous Vertebroplasty-An Analysis of New Bone Formation and Sagittal Alignment in a 3-Year Follow-Up

BACKGROUND

Vertebral compression fractures, resulting in significant pain and disability, commonly occur in elderly osteoporotic patients. However, the current literature lacks long-term follow-up information related to image parameters and bone formation following vertebroplasty.

PURPOSE

To evaluate new bone formation after vertebroplasty and the long-term effect of vertebroplasty.

METHODS

A total of 157 patients with new osteoporotic compression fractures who underwent vertebroplasty were retrospectively analyzed. The image parameters, including wedge angles, compression ratios, global alignment, and new bone formation, were recorded before and after vertebroplasty up to three years postoperatively.

RESULTS

The wedge angle improved and was maintained for 12 months. The compression ratios also improved but gradually deteriorated during the follow-up period. New bone formation was found in 40% of the patients at 36 months, and the multivariate analysis showed that this might have been related to the correction of the anterior compression ratio.

CONCLUSIONS

Vertebroplasty significantly restored the wedge angles and compression ratios up to one year postoperatively, and new bone formation was noted on plain radiographs, which increased over time. Last, the restoration of vertebral parameters may contribute to new bone formation.

Predictability of the preoperative lateral fulcrum radiograph of success in one-level vertebroplasty to treat painful osteoporotic vertebral fracture

BACKGROUND

Restoration of height or angle has been reported following vertebroplasty (VP). The purpose of the study was to investigate the predictive value of the preoperative lateral fulcrum radiograph (LFR) of success in one-level VP for painful osteoporotic vertebral fracture.

METHODS

From January 2017 to January 2018, 71 patients (mean age, 76 years) receiving VP were retrospectively analyzed. Painful vertebra was defined as pseudarthrosis or edematous change in magnetic resonance imaging (MRI) scan. Fulcrum flexibility (FF) and fulcrum restoration index (FRI) of the vertebral wedge angle (VWA), regional kyphotic angle (RKA), and anterior vertebral body height (AVBH) were investigated. Back pain was evaluated using a visual analogue scale.

RESULTS

The 30 males and 41 females were followed for an average of 21 months. The sensitivity of LFR and MRI to detect pseudarthrosis was 92% and 97%, respectively. Preoperative FF of VWA, RKA, and AVBH was 52.4%, 58.3%, and 60%, respectively, indicating similar potential restoration ability. Postoperative average FRI for VWA, RKA, and AVBH was 1.29 ± 2.98, 0.46 ± 1.16, and 1.04 ± 1.68, respectively. Final average FRI was 0.94 ± 2.96, -0.03 ± 2.25, and 0.6 ± 2.04, respectively. VWA and AVBH had better immediate restoration, and VWA had better final maintenance. All parameters progressive lost significant levels of restoration to similar degrees but without increase in back pain.

CONCLUSION

LFR can help with evaluation for pseudarthrosis and the restoration effect of VP. VP had better immediate restoration of VWA and AVBH and better final VWA maintenance.

Incidences and Risk factors of Screw-related Superior Facet Articular Surface Violation at L4 and L5 levels in Transforaminal Lumbar Interbody Fusion: Open Surgery Versus Minimally Invasive Techniques

STUDY DESIGN

A retrospective comparative study with radiographic measurements.

OBJECTIVE

The aim of this study was to investigate incidences and risk factors of screw-related superior facet articular surface violation (FASV) and optimal pedicle screw angles (PSAs) to avoid FASV at L4 and L5 levels in transforaminal lumbar interbody fusion (TLIF) with either open surgery (OS) or minimal invasive (MIS) techniques with 3D C-arm navigation.

SUMMARY OF BACKGROUND DATA

L4 to S1 are common levels in TLIF. Adjacent segment diseases (ASD) following TLIF is not uncommon. Screw-related FASV at the superior level is one of the potential risk factors for ASD.

METHODS

In the OS and MIS groups, 111 and 110 screws were included at L4 level, and 114 and 110 screws at L5 level, respectively. Postoperative computed tomography examined screw-related FASV at L3-4 and L4-5 facet levels. The entry point was the location where pedicle screws placed into the facet joints.

RESULTS

The OS technique and insertion at the L5 level increased the likelihood of FASV 2.56 and 1.81 times, respec-tively. Multivariate logistic regressions analysis determined PSA was a significant factor associated with FASV. Pearson r between PSA and the distance between midline and entry point was 0.905 (P < .0001). Adding one degree of convergence in PSA led to a mean 0.87 lower odds of an FASV event, regardless of surgical techniques. In 90% of patients in the OS and MIS groups, PSA with FASV was < 11.9° and <15.9° at L4 level, and <15.9° and <21.8° at L5 level, respectively.

CONCLUSION

PSAs played an important role in FASV. MIS allowed greater PSAs and resulted in fewer incidences of FASV. To avoid FASV in 90% of patients, the PSAs might be at least 11.9° and 15.9° at L4 level, and 15.9° and 21.8° at L5 level for OS and MIS techniques, respectively.Level of Evidence: 3.

Multilevel calcium pyrophosphate dihydrate deposition in cervical ligamentum flavum: clinical characteristics and imaging features

BACKGROUND

Involvement in cervical ligamentum flavum is a rare manifestation of the calcium pyrophosphate dihydrate deposition disease. Only few cases of this condition have been reported. We revealed eighteen cases of CPPD in cervical ligamentum flavum that diagnosed at a single medical center. In our case series, clinical characteristics and magnetic resonance imaging findings of patients are described.

METHODS

We retrospectively reviewed the medical charts and imaging studies of the eighteen patients with pseudogout attack of the cervical ligamentum flavum. In addition, we discussed the differences between this disease and ossification of ligamentum flavum in image manifestations.

RESULTS

There were fourteen men and four women aged between 59 and 87 years. Diabetes mellitus and hypertension were the most common comorbidities. Myelopathy and neck pain were presented in most patients. C4-5 and C5-6 were attacked most frequently, and multiple- rather than single-level involvement could be observed in our series. "Acute on chronic phenomenon" was a specific magnetic resonance image finding in patients whose symptom durations were between 2 to 5 months. Compared to ossification of ligamentum flavum, calcium pyrophosphate dihydrate crystal deposition had different image signs, including morphology, side of the involved ligament, no continuity with the lamina, acute on chronic phenomenon, and presence of retro-odontoid mass.

CONCLUSIONS

Nodular calcifications in cervical ligamentum flavum raise highly suspicion for calcium pyrophosphate dihydrate deposition and must be diagnosed by histological examination and polarized light microscopy. This disease is different from ossification of ligamentum flavum, and it could be recognized by specific image features.

Postoperative spinal orthosis may not be necessary for minimally invasive lumbar spine fusion surgery: a prospective randomized controlled trial

Background

With the progress and success in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF), the musculoskeletal injury was minimized. However, the role of postoperative orthosis in MIS TLIF has not been established and there is little evidence supporting the routine use of orthosis in MIS TLIF.

Methods

This is a prospective randomized clinical study. 90 patients who underwent MIS TLIF were randomly divided into groups A (with postoperative spinal orthosis) and B (without postoperative spinal orthosis). Patients were followed up for an average of 12.6 months. Clinical outcome was assessed using the Oswestry disability index (ODI) and visual analogue scale (VAS). Fusion rate was classified with the BSF scale system at postoperative 6-month, and 12-month.

Results

Both groups had similar patient demographics. The use of postoperative spinal orthosis had no significant influence on instrumentation-related complications or radiological parameters at each follow-up.

Conclusions

In this study, we conclude that postoperative spinal orthosis is not necessary for MIS TLIF. Patients without postoperative spinal orthosis had the same fusion rates and improvement of VAS and ODI scores.

Can a Deep-learning Model for the Automated Detection of Vertebral Fractures Approach the Performance Level of Human Subspecialists?

BACKGROUND

Vertebral fractures are the most common osteoporotic fractures in older individuals. Recent studies suggest that the performance of artificial intelligence is equal to humans in detecting osteoporotic fractures, such as fractures of the hip, distal radius, and proximal humerus. However, whether artificial intelligence performs as well in the detection of vertebral fractures on plain lateral spine radiographs has not yet been reported.

QUESTIONS/PURPOSES

(1) What is the accuracy, sensitivity, specificity, and interobserver reliability (kappa value) of an artificial intelligence model in detecting vertebral fractures, based on Genant fracture grades, using plain lateral spine radiographs compared with values obtained by human observers? (2) Do patients' clinical data, including the anatomic location of the fracture (thoracic or lumbar spine), T-score on dual-energy x-ray absorptiometry, or fracture grade severity, affect the performance of an artificial intelligence model? (3) How does the artificial intelligence model perform on external validation?

METHODS

Between 2016 and 2018, 1019 patients older than 60 years were treated for vertebral fractures in our institution. Seventy-eight patients were excluded because of missing CT or MRI scans (24% [19]), poor image quality in plain lateral radiographs of spines (54% [42]), multiple myeloma (5% [4]), and prior spine instrumentation (17% [13]). The plain lateral radiographs of 941 patients (one radiograph per person), with a mean age of 76 ± 12 years, and 1101 vertebral fractures between T7 and L5 were retrospectively evaluated for training (n = 565), validating (n = 188), and testing (n = 188) of an artificial intelligence deep-learning model. The gold standard for diagnosis (ground truth) of a vertebral fracture is the interpretation of the CT or MRI reports by a spine surgeon and a radiologist independently. If there were any disagreements between human observers, the corresponding CT or MRI images would be rechecked by them together to reach a consensus. For the Genant classification, the injured vertebral body height was measured in the anterior, middle, and posterior third. Fractures were classified as Grade 1 (< 25%), Grade 2 (26% to 40%), or Grade 3 (> 40%). The framework of the artificial intelligence deep-learning model included object detection, data preprocessing of radiographs, and classification to detect vertebral fractures. Approximately 90 seconds was needed to complete the procedure and obtain the artificial intelligence model results when applied clinically. The accuracy, sensitivity, specificity, interobserver reliability (kappa value), receiver operating characteristic curve, and area under the curve (AUC) were analyzed. The bootstrapping method was applied to our testing dataset and external validation dataset. The accuracy, sensitivity, and specificity were used to investigate whether fracture anatomic location or T-score in dual-energy x-ray absorptiometry report affected the performance of the artificial intelligence model. The receiver operating characteristic curve and AUC were used to investigate the relationship between the performance of the artificial intelligence model and fracture grade. External validation with a similar age population and plain lateral radiographs from another medical institute was also performed to investigate the performance of the artificial intelligence model.

RESULTS

The artificial intelligence model with ensemble method demonstrated excellent accuracy (93% [773 of 830] of vertebrae), sensitivity (91% [129 of 141]), and specificity (93% [644 of 689]) for detecting vertebral fractures of the lumbar spine. The interobserver reliability (kappa value) of the artificial intelligence performance and human observers for thoracic and lumbar vertebrae were 0.72 (95% CI 0.65 to 0.80; p < 0.001) and 0.77 (95% CI 0.72 to 0.83; p < 0.001), respectively. The AUCs for Grades 1, 2, and 3 vertebral fractures were 0.919, 0.989, and 0.990, respectively. The artificial intelligence model with ensemble method demonstrated poorer performance for discriminating normal osteoporotic lumbar vertebrae, with a specificity of 91% (260 of 285) compared with nonosteoporotic lumbar vertebrae, with a specificity of 95% (222 of 234). There was a higher sensitivity 97% (60 of 62) for detecting osteoporotic (dual-energy x-ray absorptiometry T-score ≤ -2.5) lumbar vertebral fractures, implying easier detection, than for nonosteoporotic vertebral fractures (83% [39 of 47]). The artificial intelligence model also demonstrated better detection of lumbar vertebral fractures compared with detection of thoracic vertebral fractures based on the external dataset using various radiographic techniques. Based on the dataset for external validation, the overall accuracy, sensitivity, and specificity on bootstrapping method were 89%, 83%, and 95%, respectively.

CONCLUSION

The artificial intelligence model detected vertebral fractures on plain lateral radiographs with high accuracy, sensitivity, and specificity, especially for osteoporotic lumbar vertebral fractures (Genant Grades 2 and 3). The rapid reporting of results using this artificial intelligence model may improve the efficiency of diagnosing vertebral fractures. The testing model is available at http://140.113.114.104/vght_demo/corr/. One or multiple plain lateral radiographs of the spine in the Digital Imaging and Communications in Medicine format can be uploaded to see the performance of the artificial intelligence model.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Assessment of sagittal spinopelvic parameters in a Taiwanese population with spondylolysis by the EOS imaging system: a retrospective radiological analysis

Background

The impact of sagittal spinopelvic alignment on spondylolysis is well established in Caucasian populations. However, prior studies suggest that people from different ethnological backgrounds showed divergence, and a few studies that focused on Asian populations reported conflicting results. The aim of this study is to use the EOS imaging system to evaluate the spinopelvic parameters of spondylolysis patients, and their relationship with spondylolisthesis, disc degeneration, and age in a Taiwanese population.

Methods

Radiographic sagittal spinopelvic parameters for 45 spondylolysis patients and 32 healthy people were evaluated, including pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), thoracic kyphosis (TK), and lumbar lordosis (LL). The spinopelvic parameters were compared between spondylolytic and control groups. These parameters were further compared between spondylolytic subjects with and without spondylolisthesis, with and without high-grade disc degeneration, and young (< 30 years old) and middle-aged.

Results

The PI and LL of the spondylolytic group (52.6°±12.0° and 41.3°±15.2°) were significantly higher than those of the healthy control group (47.16°±7.95° and 28.22°±10.65°). Further analysis of the spondylolytic patients revealed that those with high-grade disc degeneration were more prone to spondylolisthesis (92.3 %) compared to those without (50 %; p = 0.001). The middle-aged group had significantly higher rates of spondylolisthesis (80 %) and high-grade disc degeneration (52.4 %) compared with those for the young group (45 and 16.7 %, respectively; p = 0.017 and 0.047, respectively). No statistically significant difference in the sagittal spinopelvic parameters was found when spondylolytic patients were divided according to the occurrence of spondylolisthesis or high-grade disc degeneration.

Conclusions

In a Taiwanese population, PI and LL were significantly larger in spondylolytic patients. Disc degeneration and age were associated with the occurrence of spondylolisthesis. Ethnological differences should thus be taken into account when making clinical decisions regarding spondylolysis in a Taiwanese population.

Preoperative facet joint arthropathy does not impact long-term clinical outcomes after lumbar-stability-preserving decompression and dynesys fixation

To evaluate the impact of the preoperative severity of facet joint arthropathy on long-term functional outcomes and spinopelvic parameters in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. In this retrospective study, 88 patients undergoing combined surgery at our hospital from 2008 to 2015 were included. The patients were divided into two groups, the less and more than mean degeneration groups, based on preoperative facet joint arthropathy of the index level(s). The clinical outcomes were the Visual Analogue Scale (VAS) score, the Oswestry Disability Index (ODI) score and spinopelvic parameters. The mean follow-up durations for the less and more than mean degeneration groups were 84.83 ± 27.58 and 92.83 ± 20.45 months, respectively. The combined surgery significantly improved VAS and ODI scores, and increased sacral slope (SS) regardless of preoperative arthropathy severity. In addition, facet joint arthropathy at adjacent levels continued to worsen after surgery in both arthropathy severity groups. Preoperative facet joint arthropathy did not influence most long-term clinical outcomes in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. This combined surgery may be suitable for patients with facet joint arthropathy regardless of disease severity.

Adipose Derived Mesenchymal Stem Cells from a Hypoxic Culture Reduce Cartilage Damage

The method to benifit tissue engineering of adipose-derived stem cells (ADSCs) to cartilage has been an objective of intense research in treating increasing cartilage-related disease. In this study, whether hypoxic expansion would enhance the proliferation and in vitro chondrogenic differentiation of ADSCs was studied, and then hypoxic expansion was applied to reduce cartilage damage in a rat model in vivo. Hypoxic expansion increased the proliferation and decreased the expression of aging-related genes, including p16, p21, and p53, of human ADSCs in comparison with normoxic expansion. In addition, the γH2AX expression was reduced in the hypoxic ADSCs. The chondrogenic markers were enhanced in the hypoxic ADSC differentiated chondrogenic pellets, including SOX9 on day 7 and gene expressions of COL 2 and COL 10 on day 21. To determine the in vitro chondrogenic differentiation potential of ADSCs, ADSC differentiated 21-day chondrogenic pellets were stained by Alcian blue staining and the immunostaining of COL 2 and COL 10, the results of which confirmed the enhancement of differentiation potential after the hypoxic expansion. Moreover, cartilage injury in a rat model was reduced by hypoxic ADSC treatment that was determined by histological and immunohistochemical staining detections. The effects of hypoxic expansion of ADSCs and bone marrow-derived stem cells (BMSCs) on chondrogenic differentiation potential were also compared. Smaller sizes were presented in the in vitro hypoxic BMSC differentiated chondrogenic pellets, whereas the chondrogenic marker expressions were significantly higher than those of the hypoxic ADSCs. However, there was no significant difference between the treatments of the hypoxic ADSCs and BMSCs in the cartilage injury in vivo. In conclusion, hypoxic expansion increases the chondrogenic differentiation potential of ADSCs and BMSCs in vitro and enhances them to reduce cartilage damage in vivo. Although the hypoxic BMSCs showed compact chondrogenic pellet formation and higher potential of chondrogenesis, the easy access and large resources of ADSCs still uplifted the application.

Predicting Active NBA Players Most Likely to Be Inducted into the Basketball Hall of Famers Using Artificial Neural Networks in Microsoft Excel: Development and Usability Study

The prediction of whether active NBA players can be inducted into the Hall of Fame (HOF) is interesting and important. However, no such research have been published in the literature, particularly using the artificial neural network (ANN) technique. The aim of this study is to build an ANN model with an app for automatic prediction and classification of HOF for NBA players. We downloaded 4728 NBA players’ data of career stats and accolades from the website at basketball-reference.com. The training sample was collected from 85 HOF members and 113 retired Non-HOF players based on completed data and a longer career length (≥15 years). Featured variables were taken from the higher correlation coefficients (<0.1) with HOF and significant deviations apart from the two HOF/Non-HOF groups using logistical regression. Two models (i.e., ANN and convolutional neural network, CNN) were compared in model accuracy (e.g., sensitivity, specificity, area under the receiver operating characteristic curve, AUC). An app predicting HOF was then developed involving the model’s parameters. We observed that (1) 20 feature variables in the ANN model yielded a higher AUC of 0.93 (95% CI 0.93–0.97) based on the 198-case training sample, (2) the ANN performed better than CNN on the accuracy of AUC (= 0.91, 95% CI 0.87–0.95), and (3) an ready and available app for predicting HOF was successfully developed. The 20-variable ANN model with the 53 parameters estimated by the ANN for improving the accuracy of HOF has been developed. The app can help NBA fans to predict their players likely to be inducted into the HOF and is not just limited to the active NBA players.

Using Kano diagrams to display the most cited article types, affiliated countries, authors and MeSH terms on spinal surgery in recent 12 years

Background

Citation analysis has been increasingly applied to assess the quantity and quality of scientific research in various fields worldwide. However, these analyses on spinal surgery do not provide visualization of results. This study aims (1) to evaluate the worldwide research citations and publications on spinal surgery and (2) to provide visual representations using Kano diagrams onto the research analysis for spinal surgeons and researchers.

Methods

Article abstracts published between 2007 and 2018 were downloaded from PubMed Central (PMC) in 5 journals, including Spine, European Spine Journal, The Spine Journal, Journal of Neurosurgery: Spine, and Journal of Spinal Disorders and Techniques. The article types, affiliated countries, authors, and Medical subject headings (MeSH terms) were analyzed by the number of article citations using x-index. Choropleth maps and Kano diagrams were applied to present these results. The trends of MeSH terms over the years were plotted and analyzed.

Results

A total of 18,808 publications were extracted from the PMC database, and 17,245 were affiliated to countries/areas. The 12-year impact factor for the five spine journals is 5.758. We observed that (1) the largest number of articles on spinal surgery was from North America (6417, 37.21%). Spine earns the highest x-index (= 82.96). Comparative Study has the highest x-index (= 66.74) among all article types. (2) The United States performed exceptionally in x-indexes (= 56.86 and 44.5) on both analyses done on the total 18,808 and the top 100 most cited articles, respectively. The most influential author whose x-index reaches 15.11 was Simon Dagenais from the US. (3) The most cited MeSH term with an x-index of 23.05 was surgery based on the top 100 most cited articles. The most cited article (PMID = 18164449) was written by Dagenais and his colleagues in 2008. The most productive author was Michael G. Fehlings, whose x-index and the author's impact factor are 13.57(= √(13.16*14)) and 9.86(= 331.57/33.64), respectively.

Conclusions

There was a rapidly increasing scientific productivity in the field of spinal surgery in the past 12 years. The US has extraordinary contributions to the publications. Furthermore, China and Japan have increasing numbers of publications on spinal surgery. This study with Kano diagrams provides an insight into the research for spinal surgeons and researchers.

Small molecule antagonist of C-C chemokine receptor 1 (CCR1) reduces disc inflammation in the rabbit model

BACKGROUND CONTEXT

Targeting chemokines or chemokine receptors is a promising treatment strategy for diseases with chronic inflammation such as rheumatoid arthritis and discogenic pain. Identifying specific molecules and determining their effectiveness in animal models are the first steps in developing these treatments. Macrophage markers have been detected in the intervertebral disc tissues of patients with disc degenerative disease and discogenic pain and in different animal models. Macrophage recruitment into the disc may play a role in initiation of inflammation and if unresolved may lead to chronic inflammation and subsequent back pain.

PURPOSE

The objectives of these studies are to (1) identify chemokine receptor antagonists that can block macrophage migration induced by disc cells in vitro and (2) determine if intradiscal treatment with these antagonists can reduce disc inflammation and degeneration in vivo.

STUDY DESIGN

In vitro migration assays were used to test effectiveness of chemokine receptor antagonists to block macrophage migration induced by disc cells. The rabbit annular puncture model was used to test for anti-inflammatory and regenerative effects of chemokine receptor antagonist treatment in vivo.

METHODS

In vitro - THP-1 human monocytic cell line and freshly isolated rabbit primary splenocytes were assayed for migration using 3 µm Corning Transwell inserts with conditioned media of interleukin (IL)-1β treated human or rabbit disc cells. Inhibition of macrophage migration was evaluated using different concentrations of small molecule antagonists of C-C chemokine receptor (CCR)1 and CCR2. In vivo - New Zealand White rabbits (n=40) underwent disc puncture and intradiscal treatment with saline, CCR1 or CCR2 antagonists within the same procedure. X-ray and magnetic resonance (MR) images and serum samples were taken for disc height, MRI grade and IL-8 serum level analyses. Intervertebral discs were isolated for RNA analysis of inflammatory and disc phenotypic markers and for immunohistochemical analysis of macrophage marker, RAM11. The outcome measures were compared between the three treatment groups. These studies were funded by a research grant from AO Foundation, Switzerland (Project no S-14-86A; 120000 CHF). CCR1 and CCR2 antagonists were kindly provided by ChemoCentryx (Mountain View, CA).

RESULTS

In vitro migration assays showed that THP-1 migration induced by disc cells was blocked by CCR2 antagonist more effectively than CCR1 antagonist, while rabbit splenocyte migration was inhibited by CCR1 antagonist and not the other. In the rabbit annular puncture model, rabbit discs treated with CCR1 antagonist had significantly better MRI grades than those treated with CCR2 antagonist at 6 weeks post-treatment. Gene expression studies demonstrate that discs treated with CCR1 or CCR2 antagonists expressed less inflammatory markers than saline-treated discs at 3 weeks post-treatment. Although CCR2 antagonist treatment did not reduce inflammatory marker expression at 6 weeks, discs treated with CCR1 antagonist expressed less inflammatory markers and also a higher ratio of collagen type 2 to collagen type 1 genes indicating favorable disc matrix production. There were no significant differences between all three treatment groups in regards to disc height indexes, IL-8 serum levels or macrophage marker detection.

CONCLUSIONS

These studies have identified that small molecule antagonists against CCR2 and CCR1 were respectively effective in blocking THP-1 and rabbit splenocyte migration induced by disc cells in vitro. Further, both CCR2 and CCR1 antagonist intradiscal treatments were effective in reducing disc inflammation at an early time point of 3 weeks. Lastly, only CCR1 antagonist demonstrated anti-inflammatory effects and better MRI grades at 6 weeks.

CLINICAL SIGNIFICANCE

Our preclinical studies demonstrate that CCR1 and CCR2 antagonist delivery through intradiscal injection is sufficient to reduce disc inflammation at early time points, whereas CCR1 antagonists had longer term anti-inflammatory effects. Clinical studies have found that CCR1 antagonist was safe, tolerable and clinically active in reducing inflammation in rheumatoid arthritis patients. These studies suggest that CCR1 antagonist may be a promising biological treatment to reduce disc inflammation that translates to back pain relief.

Risk factors for residual neurologic deficits after surgical treatment for epidural abscess in the thoracic or lumbar spine

BACKGROUND CONTEXT

Spinal epidural abscess (SEA) can cause neurologic deficits and needs urgent surgical intervention. Many clinical factors had been proposed to predict surgical outcomes in patients with SEA, but the predictive radiographic risk factors for residual neurologic deficits were not addressed sufficiently.

PURPOSE

To analyze the clinical and radiographic risk factors for residual neurologic deficit in patients with SEA after surgical intervention of the thoracic or lumbar spine.

STUDY DESIGN/SETTING

A retrospective consecutive case series.

PATIENT SAMPLE

From January 2005 through December 2014, 53 patients with primary SEA, confirmed by culture or histopathology, in the thoracic or lumbar spine who underwent posterior-only approach surgery at our hospital.

OUTCOME MEASURES

Neurologic status was assessed using the Frankel grading system preoperatively, postoperatively, and at final follow-up.

METHODS

The patients were allocated into two groups based on the presence of postoperative residual neurologic deficits. Patients' demographic, clinical, and factors based on magnetic resonance imaging (MRI) were analyzed for their influence on residual neurologic deficits. Clinical factors included age, sex, diabetes, comorbidities, pathogens, affected spinal levels, the interval between onset of symptoms to surgery, preoperative neurologic status, presence of cauda equina syndrome, and surgical procedures. MRI factors included the distribution of abscesses within the spinal canal, presence of ring enhancement, presence of paravertebral abscess or psoas abscess, canal compromise anteroposterior (AP) ratio and cross-sectional area ratio, abscess length, and abscess thickness.

RESULTS

Thirty-five of the 53 patients (66%) had preoperative neurologic deficits, and 21 of 53 patients (40%) had postoperative residual neurologic deficits. Patients' neurologic status improved significantly after the surgery (p<.001). Risk factors including age, diabetes, cauda equina syndrome, presence of anterior with posterior (A+P) dural abscess, canal compromise AP ratio, cross-sectional area ratio, abscess length, and abscess thickness were significantly correlated with postoperative residual neurologic deficits. In multivariate logistic regression analysis, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the four most significant factors related to residual neurologic deficits.

CONCLUSIONS

In patients with SEA of the thoracic and lumbar spine, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the most significant preoperative risk factors for residual neurologic deficits after surgery.

Is bony attachment necessary for dynamic reference frame in navigation-assisted minimally invasive lumbar spine fusion surgery?

This study aimed to compare the accuracy of navigation-assisted percutaneous pedicle screw insertions between traditional posterior superior iliac spine (PSIS) fixed and cutaneously fixed dynamic reference frame (DRF) in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF). This is a prospective randomized clinical study. Between May 2016 and Nov 2017, 100 patients who underwent MIS TLIF were randomly divided into bone fixed group (with PSIS fixed DRF) and skin fixed group (with cutaneously fixed DRF). The pedicel screws were inserted under navigational guidance using computed tomography (CT) data acquired intraoperatively with a Ziehm 3-dimensional fluoroscopy-based navigation system. Screw positions were immediately checked by a final intraoperative scan. The accuracy of screw placement was evaluated by a sophisticated computed tomography protocol. Both groups had similar patient demographics. Totally Five-hundred Twelve pedicle screws were placed in the lumbar spine. There were 2 moderate (2-4 mm) pedicle perforations in each group. The accuracy showed no significant difference between bone fixed and skin fixed DRF. There were no significant procedure-related complications. The skin fixed DRF provides similar accuracy in pedicle screw insertions with bone fixed DRF using intraoperative 3D image guided navigation in MIS TLIF. Skin fixed DRF not only serves as an alternative method but also saves a separate incision wound for bony attachment.

Therapeutic Duplication in Taiwan Hospitals for Patients With High Blood Pressure, Sugar, and Lipids: Evaluation With a Mobile Health Mapping Tool

BACKGROUND

Cardiovascular disease causes approximately half of all deaths in patients with type 2 diabetes. Duplicative prescriptions of medication in patients with high blood pressure (hypertension), high blood sugar (hyperglycemia), and high blood lipids (hyperlipidemia) have attracted substantial attention regarding the abuse of health care resources and to implement preventive measures for such abuse. Duplicative prescriptions may occur by patients receiving redundant medications for the same condition from two or more sources such as doctors, hospitals, and multiple providers, or as a result of the patient's wandering among hospitals.

OBJECTIVE

We evaluated the degree of duplicative prescriptions in Taiwanese hospitals for outpatients with three types of medications (antihypertension, antihyperglycemia, and antihyperlipidemia), and then used an online dashboard based on mobile health (mHealth) on a map to determine whether the situation has improved in the recent 25 fiscal quarters.

METHODS

Data on duplicate prescription rates of drugs for the three conditions were downloaded from the website of Taiwan's National Health Insurance Administration (TNHIA) from the third quarter of 2010 to the third quarter of 2016. Complete data on antihypertension, antihyperglycemia, and antihyperlipidemia prescriptions were obtained from 408, 414, and 359 hospitals, respectively. We used scale quality indicators to assess the attributes of the study data, created a dashboard that can be traced using mHealth, and selected the hospital type with the best performance regarding improvement on duplicate prescriptions for the three types of drugs using the weighted scores on an online dashboard. Kendall coefficient of concordance (W) was used to evaluate whether the performance rankings were unanimous.

RESULTS

The data quality was found to be acceptable and showed good reliability and construct validity. The online dashboard using mHealth on Google Maps allowed for easy and clear interpretation of duplicative prescriptions regarding hospital performance using multidisciplinary functionalities, and showed significant improvement in the reduction of duplicative prescriptions among all types of hospitals. Medical centers and regional hospitals showed better performance with improvement in the three types of duplicative prescriptions compared with the district hospitals. Kendall W was 0.78, indicating that the performance rankings were not unanimous (Chi square₂=4.67, P=.10).

CONCLUSIONS

This demonstration of a dashboard using mHealth on a map can inspire using the 42 other quality indicators of the TNHIA by hospitals in the future.

Evaluating the research domain and achievement for a productive researcher who published 114 sole-author articles: A bibliometric analysis

BACKGROUND

Team science research includes authors from various fields collaborating to publish their work on certain topics. Despite the numerous papers that discussed the ordering of author names and the contributions of authors to an article, no paper evaluatedIn addition, few researchers publish academic articles without co-author collaboration. Whether the bibliometric indexes (eg, h-/x-index) of sole-author researchers are higher than those of other types of multiple authors is required for comparison. We aimed to evaluate a productive author who published 114 sole-author articles with exceptional RA and RD in academics.

METHODS

By searching the PubMed database (Pubmed.com), we used the keyword of (Taiwan[affiliation]) from 2016 to 2017 and downloaded 29,356 articles. One physician (Dr. Tseng from the field of Internal Medicine) who published 12 articles as a single author was selected. His articles and citations were searched in PubMed. A comparison of various types of author ordering placements was conducted using sensitivity analysis to inspect whether this sole author earns the highest metrics in RA. Social network analysis (SNA), Gini coefficient (GC), pyramid plot, and the Kano diagram were applied to gather the following data for visualization: RESULTS:: We observed that CONCLUSIONS:: The metrics on RA are high for the sole author studied. The author's RD can be denoted by the MeSH terms and measured by the GC. The author-weighted scheme is required for quantifying author credits in an article to evaluate the author's RA. Social network analysis incorporating the Kano diagrams provided insights into the relationships between actors (eg, coauthors, MeSH terms, or journals). The methods used in this study can be replicated to evaluate other productive studies on RA and RD in the future.

An App for Detecting Bullying of Nurses Using Convolutional Neural Networks and Web-Based Computerized Adaptive Testing: Development and Usability Study

Background

Workplace bullying has been measured in many studies to investigate its effects on mental health issues. However, none have used web-based computerized adaptive testing (CAT) with bully classifications and convolutional neural networks (CNN) for reporting the extent of individual bullying in the workplace.

Objective

This study aims to build a model using CNN to develop an app for automatic detection and classification of nurse bullying-levels, incorporated with online Rasch computerized adaptive testing, to help assess nurse bullying at an earlier stage.

Methods

We recruited 960 nurses working in a Taiwan Ch-Mei hospital group to fill out the 22-item Negative Acts Questionnaire-Revised (NAQ-R) in August 2012. The k-mean and the CNN were used as unsupervised and supervised learnings, respectively, for: (1) dividing nurses into three classes (n=918, 29, and 13 with suspicious mild, moderate, and severe extent of being bullied, respectively); and (2) building a bully prediction model to estimate 69 different parameters. Finally, data were separated into training and testing sets in a proportion of 70:30, where the former was used to predict the latter. We calculated the sensitivity, specificity, and receiver operating characteristic curve (area under the curve [AUC]), along with the accuracy across studies for comparison. An app predicting the respondent bullying-level was developed, involving the model’s 69 estimated parameters and the online Rasch CAT module as a website assessment.

Results

We observed that: (1) the 22-item model yields higher accuracy rates for three categories, with an accuracy of 94% for the total 960 cases, and accuracies of 99% (AUC 0.99; 95% CI 0.99-1.00) and 83% (AUC 0.94; 95% CI 0.82-0.99) for the lower and upper groups (cutoff points at 49 and 66 points) based on the 947 cases and 42 cases, respectively; and (2) the 700-case training set, with 95% accuracy, predicts the 260-case testing set reaching an accuracy of 97. Thus, a NAQ-R app for nurses that predicts bullying-level was successfully developed and demonstrated in this study.

Conclusions

The 22-item CNN model, combined with the Rasch online CAT, is recommended for improving the accuracy of the nurse NAQ-R assessment. An app developed for helping nurses self-assess workplace bullying at an early stage is required for application in the future.

An App Developed for Detecting Nurse Burnouts Using the Convolutional Neural Networks in Microsoft Excel: Population-Based Questionnaire Study

Background

Burnout (BO), a critical syndrome particularly for nurses in health care settings, substantially affects their physical and psychological status, the institute’s well-being, and indirectly, patient outcomes. However, objectively classifying BO levels has not been defined and noticed in the literature.

Objective

The aim of this study is to build a model using the convolutional neural network (CNN) to develop an app for automatic detection and classification of nurse BO using the Maslach Burnout Inventory–Human Services Survey (MBI-HSS) to help assess nurse BO at an earlier stage.

Methods

We recruited 1002 nurses working in a medical center in Taiwan to complete the Chinese version of the 20-item MBI-HSS in August 2016. The k-mean and CNN were used as unsupervised and supervised learnings for dividing nurses into two classes (n=531 and n=471 of suspicious BO+ and BO−, respectively) and building a BO predictive model to estimate 38 parameters. Data were separated into training and testing sets in a proportion 70%:30%, and the former was used to predict the latter. We calculated the sensitivity, specificity, and receiver operating characteristic curve (area under the curve) across studies for comparison. An app predicting respondent BO was developed involving the model’s 38 estimated parameters for a website assessment.

Results

We observed that (1) the 20-item model yields a higher accuracy rate (0.95) with an area under the curve of 0.97 (95% CI 0.94-0.95) based on the 1002 cases, (2) the scheme named matching personal response to adapt for the correct classification in model drives the prior model’s predictive accuracy at 100%, (3) the 700-case training set with 0.96 accuracy predicts the 302-case testing set reaching an accuracy of 0.91, and (4) an available MBI-HSS app for nurses predicting BO was successfully developed and demonstrated in this study.

Conclusions

The 20-item model with the 38 parameters estimated by using CNN for improving the accuracy of nurse BO has been particularly demonstrated in Excel (Microsoft Corp). An app developed for helping nurses to self-assess job BO at an early stage is required for application in the future.

The Most-Cited Authors Who Published Papers in JMIR mHealth and uHealth Using the Authorship-Weighted Scheme: Bibliometric Analysis

Background

Many previous papers have investigated most-cited articles or most productive authors in academics, but few have studied most-cited authors. Two challenges are faced in doing so, one of which is that some different authors will have the same name in the bibliometric data, and the second is that coauthors’ contributions are different in the article byline. No study has dealt with the matter of duplicate names in bibliometric data. Although betweenness centrality (BC) is one of the most popular degrees of density in social network analysis (SNA), few have applied the BC algorithm to interpret a network’s characteristics. A quantitative scheme must be used for calculating weighted author credits and then applying the metrics in comparison.

Objective

This study aimed to apply the BC algorithm to examine possible identical names in a network and report the most-cited authors for a journal related to international mobile health (mHealth) research.

Methods

We obtained 676 abstracts from Medline based on the keywords “JMIR mHealth and uHealth” (Journal) on June 30, 2018. The author names, countries/areas, and author-defined keywords were recorded. The BCs were then calculated for the following: (1) the most-cited authors displayed on Google Maps; (2) the geographical distribution of countries/areas for the first author; and (3) the keywords dispersed by BC and related to article topics in comparison on citation indices. Pajek software was used to yield the BC for each entity (or node). Bibliometric indices, including h-, g-, and x-indexes, the mean of core articles on g(Ag)=sum (citations on g-core/publications on g-core), and author impact factor (AIF), were applied.

Results

We found that the most-cited author was Sherif M Badawy (from the United States), who had published six articles on JMIR mHealth and uHealth with high bibliometric indices (h=3; AIF=8.47; x=4.68; Ag=5.26). We also found that the two countries with the highest BC were the United States and the United Kingdom and that the two keyword clusters of mHealth and telemedicine earned the highest indices in comparison to other counterparts. All visual representations were successfully displayed on Google Maps.

Conclusions

The most cited authors were selected using the authorship-weighted scheme (AWS), and the keywords of mHealth and telemedicine were more highly cited than other counterparts. The results on Google Maps are novel and unique as knowledge concept maps for understanding the feature of a journal. The research approaches used in this study (ie, BC and AWS) can be applied to other bibliometric analyses in the future.

Using the Kano model to display the most cited authors and affiliated countries in schizophrenia research

In order to improve individual research achievements (IRA), this study investigates which affiliated countries and authors earn the most cited IRAs and whether those types of articles are associated with the number of cited papers on schizophrenia from a leading journal in the field. The Kano model was used for displaying the IRAs. Clusters of medical subject headings (MeSH) were applied to explore the core concepts of a given journal. This study aimed to apply social network analysis (SNA) and an authorship-weighted scheme (AWS) to inspect the association between MeSH terms and IRA. About 2,008 abstracts published between 2012 and 2016 in the journal Schizophrenia Research were downloaded from Pubmed Central using the keyword (Schizophr Res)[Journal] on September 20, 2018. The MeSH terms were clustered by using SNA to separate the core concepts and compare the differences in bibliometric indices (i.e., h, Ag, x and author impact factor or AIF). Visual dashboards were shown on Google Maps. Results indicate that (1) the US, the UK, and Canada earn the highest x-index; (2) the top one author from the US has the highest x-index (= 5.73 with x-core at cited = 16.44 and citable = 2); (3) the article type of schizophrenic psychology shows distinctly higher frequencies than others; and (4) article types are associated with the number of cited papers. Four approaches of the Kano model, SNA, MeSH terms, and AWS can be accommodated to display IRAs, classify article types, and quantify coauthor contributions in the article byline, respectively, and applied to other scientific disciplines in the future, not just in this specific journal.

What is the difference in morphologic features of the lumbar vertebrae between Caucasian and Taiwanese subjects? A CT-based study: implications of pedicle screw placement via Roy-Camille or Weinstein method

BACKGROUND

Safe placement of pedicle screws without jeopardizing neurovascular structures medially and anteriorly is important during spine surgery. Inferior breach of pedicle is also dangerous due to low margin of error. Lumbar morphology and identical pedicle orientation at L1 to L5 shown on CT scan of young Taiwanese patients (90 patients) were analyzed and compared with findings reported for Caucasian subjects.

METHODS

Previously reported techniques were employed to quantitatively elucidate the parameters regarding lumbar morphology and identical pedicle orientation at each vertebra. The parameters for pedicle angle (PA), pedicle diameter (PD), pedicle axis distance (PAD), midline axis distance (MAD), transverse pedicle axis distance (TPAD) and transverse intertangential angle (TITA) were measured.

RESULTS

Taiwanese subjects had different PA, PD, PAD, MAD at L1 to L5 and TITA at L3 to L5 compared with Caucasian subjects. L5 had the most convergent pedicle axis, the widest PD and the shortest antero-posterior axis morphology.

CONCLUSIONS

This study provides detailed information for identifying pedicle orientation during pedicle screw placement and elucidate racial differences in lumbar morphology and pedicle orientation between Taiwanese and Caucasian populations.

Therapeutic effects of cell therapy with neonatal human dermal fibroblasts and rabbit dermal fibroblasts on disc degeneration and inflammation

BACKGROUND CONTEXT

Increasing evidence suggests transplanting viable cells into the degenerating intervertebral disc (IVD) may be effective in treating disc degeneration and back pain. Clinical studies utilizing autologous or allogeneic mesenchymal stem cells to treat patients with back pain have reported some encouraging results. Animal studies have shown that cells injected into the disc can survive for months and have regenerative effects. Studies to determine the advantages and disadvantages of cell types and sources for therapy are needed.

PURPOSE

The objective of this study is to determine the impact of donor source on the therapeutic effects of dermal fibroblast treatment on disc degeneration and inflammation.

STUDY DESIGN

Using the rabbit disc degeneration model, we compared transplantation of neonatal human dermal fibroblasts (nHDFs) and rabbit dermal fibroblasts (RDFs) into rabbit degenerated discs on host immune response, disc height, and IVD composition.

METHODS

New Zealand white rabbits received an annular puncture using an 18-guage needle to induce disc degeneration. Four weeks after injury, rabbit IVDs were treated with 5 × 10⁶ nHDFs, RDFs, or saline. At eight weeks post-treatment, animals were sacrificed. X-ray images were obtained. IVDs were isolated for inflammatory and collagen gene expression analysis using real-time polymerase chain reaction and biochemical analysis of proteoglycan contents using dimethylmethylene blue assay. These studies were funded by a research grant from SpinalCyte, LLC ($414,431).

RESULTS

Eight weeks after treatment, disc height indexes of discs treated with nHDF increased significantly by 7.8% (p<.01), whereas those treated with saline or RDF increased by 1.5% and 2.0%, respectively. Gene expression analysis showed that discs transplanted with nHDFs and RDFs displayed similar inflammatory responses (p=.2 to .8). Compared to intact discs, expression of both collagen types I and II increased significantly in nHDF-treated discs (p<.05), trending to significant in RDF-treated discs, and not significantly in saline treated discs. The ratio of collagen type II/collagen type I was higher in the IVDs treated with nHDFs (1.26) than those treated with RDFs (0.81) or saline (0.59) and intact discs (1.00). Last, proteoglycan contents increased significantly in discs treated with nHDF (p<.05) and were trending toward significance in the RDF-treated discs compared to those treated with saline.

CONCLUSIONS

This study showed that cell transplantation with nHDF into degenerated IVDs can significantly increase markers of disc regeneration (disc height, collagen type I and II gene expression, and proteoglycan contents). Transplantation with RDFs showed similar regenerative trends, but these trends were not significant. This study also showed that the human cells transplanted into the rabbit discs did not induce a higher immune response than the rabbit cells. These results support that the IVD is immune privileged and would tolerate allogeneic or xenogeneic grafts.

Short-segment decompression and fixation for thoracolumbar osteoporotic fractures with neurological deficits

Objective

We assessed our results of short-segment decompression and fixation for osteoporotic thoracolumbar fractures with neurological deficits.

Methods

We evaluated 20 elderly patients (age, 60–89 years; mean, 73.2 years) with osteoporotic thoracolumbar fractures and neurological deficits. They underwent short-segment decompression and fixation and followed up for 40.6 (range, 24–68) months. A visual analog scale (VAS) and the Oswestry Disability Index (ODI) were used to measure back pain and disability. We also analyzed patients’ radiologic findings and neurological status. Perioperative and postoperative complications were recorded.

Results

At the latest follow-up, the average VAS score for back pain and ODI scores had significantly improved. The radiologic assessment showed significant improvements in local kyphosis, anterior vertebral height, and the vertebral wedge angle compared with the original measures. Neurological function also improved in 18 of 20 patients. No major complications occurred perioperatively. Our techniques included preservation of the posterior ligament complex, decortication of facet joints for fusion, no tapping to increase the screw insertional torque, pre-contouring of the rods according to the “adaptive” curve obtained from postural reduction, and postoperative spinal bracing.

Conclusions

Posterior short-segment decompression and fixation could be an effective surgical option for osteoporotic thoracolumbar burst fractures with neurological deficits.

Anterior release may not be necessary for idiopathic scoliosis with a large curve of more than 75° and a flexibility of less than 25

BACKGROUND CONTEXT

To improve correction and fusion rates, an anterior release is often needed for the treatment of idiopathic scoliosis with a curve of more than 75° before posterior correction, instrumentation, and fusion. However, there are disadvantages to anterior release, and we are concerned about whether it is necessary for anterior-posterior spinal fusion in these patients.

PURPOSE

The objective of this study was to compare the surgical results for idiopathic scoliosis with a curve of more than 75° and a flexibility of less than 25% between using posterior-only approach and combined anterior release followed by posterior correction with a hybrid construct (hooks and pedicle screws) and spinal fusion.

STUDY DESIGN/SETTING

This was a retrospective cohort study.

PATIENT SAMPLE

From 2000 to 2014, 388 consecutive patients with idiopathic scoliosis were treated surgically at our hospital. Of these patients, 53 whose primary curves were more than 75° with a flexibility of less than 25%, at an incidence of 13.6%, were included and divided into two groups. Thirty-one patients (mean age: 16.3 years old) who underwent anterior release followed by posterior correction, instrumentation, and fusion were included in the A+P group, and the remaining 22 patients (mean age: 17.3 years old) were designated as the P group for posterior procedure alone.

OUTCOME MEASURES

The clinical outcomes were analyzed in terms of correction and loss of correction and by the Scoliosis Patient Questionnaire: Version 30 functional questionnaire.

MATERIALS AND METHODS

In the A+P group, halo-femoral traction was applied for 1 week between the anterior release and the posterior procedure. Posterior instrumentation with a hybrid construct with hooks and pedicle screws was used for both groups. The radiological and functional outcomes were compared between the two groups.

RESULTS

The average preoperative Cobb angle was 85.3° for the A+P group, with an average 17.4% flexibility, and 80° for the P group, with 15.3% flexibility. The postoperative Cobb angle was 53.1° for the A+P group and 45.6° for the P group. The Cobb angle at the final follow-up for the A+P group was 55.2° and that for the P group was 48°. The average correction rates of the A+P and P groups were 37% and 43.4%, respectively. There were no statistically significant differences between the groups in gender, age, number of levels fused, and flexibility of coronal curve. With a minimum 2-year follow-up, similar results were found between these two groups in terms of correction rate, loss of correction, and functional outcome.

CONCLUSIONS

In this study, we found that a posterior-only approach with hybrid construct (hooks and pedicle screws) could provide a correction similar to that of an anterior-posterior approach. Also, the disadvantages of anterior release could be avoided by the posterior-only approach.

Staged protocol for the treatment of chronic femoral shaft osteomyelitis with Ilizarov's technique followed by the use of intramedullary locked nail

BACKGROUND

Infected nonunion of the femoral shaft is uncommon, and usually presents with challenging therapeutic and reconstructive problems. There are still controversies over treating infected nonunion of the femoral shaft. The purposes of this retrospective study were to review the treatment outcomes and describe a staged protocol for spontaneous wound healing.

METHODS

Six patients with chronic femoral shaft infected-nonunion from October 2002 to September 2010 were included in this retrospective study. Serial plain films and triple films of lower legs were performed to evaluate the alignment of the treated femoral shaft and bony union following our staged protocol of Ilizarov distraction osteogenesis and intramedullary nailing.

RESULTS

An average bone defect of 7 cm was noted after staged osteotomy. Mean follow-up was 87.5 (range, 38-133) months. Union was achieved in all six patients, with an average external fixation time of 6.8 (range, 5-11) months. There was no reinfection. One complication of a 4-cm leg discrepancy was noted, with an initial shortening of 15 cm. The mean knee ranges of motion (ROM) before staged protocols and at final follow-up were 64.2±8.6 (range, 60-75)° and 53.3±9.3 (range, 40-65)°, respectively. The ROM at the knee joint statistically decreased following staged protocols.

CONCLUSION

In the treatment of chronic femur osteomyelitis, the staged protocol of Ilizarov distraction osteogenesis followed by intramedullary nailing was safe and successful, and allowed for union, realignment, reorientation, and leg-length restoration. With regard to the soft tissue, this technique provides a unique type of reconstructive closure for infected wounds. It is suggested that the staged protocol is reliable in providing successful simultaneous reconstruction for bone and soft tissue defects without flap coverage.

Preoperative Planning of the Lateral Entry Point Is Necessary in Percutaneous L5 Vertebroplasty

OBJECTIVE

To compare treatment outcomes and complications between the computer-assisted preoperative planning of lateral entry approach and the traditional approach for L5 percutaneous vertebroplasty.

METHODS

In this prospective randomized clinical study performed from January 2008 to December 2014, 68 patients scheduled for L5 percutaneous vertebroplasty were divided at random into group A, in which the traditional transpedicle approach was used, and group B, in which the computer-assisted lateral entry point approach was used. A visual analog scale and Oswestry Disability Index were evaluated preoperatively, postoperatively, and at the latest follow-up.

RESULTS

Patient demographics were similar in the 2 groups. The mean duration of follow-up was 65 months. The mean distance between the entry point and the midline was 3.05 ± 0.5 cm in group A and 7.04 ± 0.7 cm in group B. The mean inclination angle measured on the preoperative axial image was 17.1 ± 3.4° in group A and 41 ± 3.8° in group B. Clinical outcomes were comparable in the 2 groups; however, cement leakage was significantly greater in group A (P < 0.001).

CONCLUSIONS

Owing to the hemispherical morphology and convergent pedicle axis of the L5 vertebrae, a more lateral skin entry point and convergent angle of the puncture needle should be emphasized to reach the optimal point according to the preoperative assessment. The approach involving computer-assisted preoperative planning of the lateral entry point was associated with a higher rate of bilateral cement infiltration with fewer complications.

Annulus fibrosus cells express and utilize C-C chemokine receptor 5 (CCR5) for migration

BACKGROUND CONTEXT

Disc degeneration is associated with the progressive loss of the proteoglycan content of the intervertebral disc, decreased matrix synthesis, higher concentrations of proteolytic enzymes, and increased levels of proinflammatory cytokines. In previous studies, we have shown that C-C chemokine ligand (CCL)2, CCL3, and CCL5 are highly expressed by cultured nucleus pulposus (NP) and annulus fibrosus (AF) cells that have been treated by interleukin-1. The major function of these chemokines is to recruit immune cells into the disc. It is unclear if disc cells can respond to these chemokines. Recent studies by Phillips et al. (2015) showed that NP cells express a number of cytokines and chemokine receptors.

PURPOSE

The purpose of this study is to determine the gene and protein expression of C-C chemokine receptor (CCR)1, CCR2, and CCR5 in NP and AF cells, and to test if these receptors can respond to their ligands in these cells by cell signaling and migration.

STUDY DESIGN/SETTING

This is an in vitro study.

METHODS

For RNA, surface expression, and cell signaling studies, human cells were isolated from the NP and AF tissues collected after spine surgery or from donated spine segments (Gift of Hope Human Donor & Tissue Network of Illinois) and cultured in monolayer. The gene expression of human CCR1, CCR2, and CCR5 was analyzed using real-time polymerase chain reaction. The surface expression of CCR1, CCR2, and CCR5 was analyzed using flow cytometry and fluorescently tagged antibodies specific for these proteins. Extracellular signal-regulated kinase (ERK) phosphorylation was analyzed from the cell lysates of NP and AF cells treated with CCL2 and CCL5 for 1 hour using enzyme-linked immunosorbent assay. Migration of primary rabbit AF cells was assayed using 8-µm Corning Transwell inserts in the presence or absence of CCL5. This study was partially funded by a North American Spine Society 2014 Basic Research Grant Award ($50,000).

RESULTS

RNA analysis showed that gene expression of CCR1, CCR2, and CCR5 was evident in human NP and AF cells (n=6). Only a small population of NP and AF cells expressed CCR1 (1.9% and 1.2%, respectively) and CCR2 (0.8% and 1.4%, respectively) on the cell surface, whereas a larger percentage expressed CCR5 (12.7% and 11.6%, respectively). Significantly higher levels of ERK phosphorylation were detected in AF cells after treatment with CCL5 and not CCL2. Treatment with either chemokine did not cause significantly higher ERK phosphorylation in NP cells. There was an increase in average AF cell migration in the presence of CCL5. The increase was significant when the migration was induced with CCL5 (500 ng/mL) at both 2- and 6-hour time points.

CONCLUSIONS

CCR5 is expressed at the RNA level and on the cell surface of NP and AF cells. In the presence of CCL5, we detected increased levels of ERK phosphorylation and AF cell migration, suggesting that the CCR5 receptors in AF cells are functional. These data suggest that AF cells may have the ability to migrate in response to disc damage or inflammation.