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Bębenek A, Dominiak M, Karpiński G, Pawełczyk T, Godlewski B. Impact of Implant Size and Position on Subsidence Degree after Anterior Cervical Discectomy and Fusion: Radiological and Clinical Analysis. J Clin Med 2024; 13:1151. [PMID: 38398464 PMCID: PMC10889498 DOI: 10.3390/jcm13041151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Implant subsidence is recognized as a complication of interbody stabilization, although its relevance remains ambiguous, particularly in terms of relating the effect of the position and depth of subsidence on the clinical outcome of the procedure. This study aimed to evaluate how implant positioning and size influence the incidence and degree of subsidence and to examine their implications for clinical outcomes. METHODS An observational study of 94 patients (157 levels) who underwent ACDF was conducted. Radiological parameters (implant position, implant height, vertebral body height, segmental height and intervertebral height) were assessed. Clinical outcomes were evaluated using the Visual Analogue Scale (VAS) and Neck Disability Index (NDI). Subsidence was evaluated in groups according to its degree, and statistical analyses were performed. RESULTS The findings revealed that implant-to-endplate ratio and implant height were significant risk factors associated with the incidence and degree of subsidence. The incidence of subsidence varied as follows: 34 cases (41.5%) exhibited displacement of the implant into the adjacent endplate by 2-3 mm, 32 cases (39%) by 3-4 mm, 16 cases (19.5%) by ≥4 mm and 75 (47.8%) cases exhibited no subsidence. CONCLUSIONS The findings underscore that oversized or undersized implants relative to the disc space or endplate length elevate the risk and severity of subsidence.
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Affiliation(s)
- Adam Bębenek
- Department of Orthopaedics and Traumatology, with Spinal Surgery Ward, Scanmed—St. Raphael Hospital, 30693 Cracow, Poland
| | - Maciej Dominiak
- Department of Orthopaedics and Traumatology, with Spinal Surgery Ward, Scanmed—St. Raphael Hospital, 30693 Cracow, Poland
| | - Grzegorz Karpiński
- Department of Orthopaedics and Traumatology, with Spinal Surgery Ward, Scanmed—St. Raphael Hospital, 30693 Cracow, Poland
| | - Tomasz Pawełczyk
- Department of Affective and Psychotic Disorders, Medical University of Lodz, 92216 Lodz, Poland;
| | - Bartosz Godlewski
- Department of Orthopaedics and Traumatology, with Spinal Surgery Ward, Scanmed—St. Raphael Hospital, 30693 Cracow, Poland
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Azizpour K, Schutte PJ, Arts MP, Pondaag W, Bouma GJ, Coppes M, Steyerberg EW, Peul WC, Vleggeert-Lankamp CLA. Clinical outcome in decompression alone versus decompression and instrumented fusion in patients with isthmic spondylolisthesis: a prospective cohort study. J Neurosurg Spine 2023; 38:573-584. [PMID: 36738462 DOI: 10.3171/2022.12.spine22808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 12/27/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In the surgical treatment of isthmic spondylolisthesis, it is debatable whether instrumented fusion is mandatory in addition to decompression. The objective of this prospective cohort study was to assess the long-term effect of decompression alone compared with decompression and instrumented fusion in patients who underwent the intervention of their own preference. The results were compared with those in patients who underwent randomly assigned treatment. METHODS The authors performed a prospective observational multicenter cohort study, including 91 patients with isthmic spondylolisthesis assigned to undergo either decompression alone (n = 44) or decompression and fusion (n = 47). The main outcomes were the Roland-Morris Disability Questionnaire (RDQ) scores and the patient's perceived recovery at the 2-year follow-up. Secondary outcomes were visual analog scale (VAS) leg pain and back pain scores and the reoperation rate. A meta-analysis was performed for data from this cohort study (n = 91) and from a randomized controlled trial (RCT) previously reported by the authors (n = 84). Subgroup analyses were performed on these combined data for age, sex, weight, smoking, and Meyerding grade. RESULTS At the 12-week follow-up, improvements of RDQ scores were comparable for the two procedures (decompression alone [D group] 4.4, 95% CI 2.3-6.5; decompression and fusion [DF group] 5.8, 95% CI -4.3 to 1.4; p = 0.31). Likewise, VAS leg pain scores (D group 35.0, 95% CI 24.5-45.6; DF group 47.5, 95% CI 37.4-57.5; p = 0.09) and VAS back pain scores (D group 23.5, 95% CI 13.3-33.7; DF group 34.0, 95% CI 24.1-43.8; p = 0.15) were comparable. At the 2-year follow-up, there were no significant differences between the two groups in terms of scores for RDQ (difference -3.1, 95% CI -6.4 to 0.3, p = 0.07), VAS leg pain (difference -7.4, 95% CI -22.1 to 7.2, p = 0.31), and VAS back pain (difference -11.4, 95% CI -25.7 to 2.9, p = 0.12). In contrast, patient-perceived recovery from leg pain was significantly higher in the DF group (79% vs 51%, p = 0.02). Subgroup analyses did not demonstrate a superior outcome for decompression alone compared with decompression and fusion. Nine patients (20.5%) underwent reoperation in total, all in the D group. The meta-analysis including both the cohort and RCT populations yielded an estimated pooled mean difference in RDQ of -3.7 (95% CI -5.94 to -1.55, p = 0.0008) in favor of decompression and fusion at the 2-year follow-up. CONCLUSIONS In patients with isthmic spondylolisthesis, at the 2-year follow-up, patients who underwent decompression and fusion showed superior functional outcome and perceived recovery compared with those who underwent decompression alone. No subgroups benefited from decompression alone. Therefore, decompression and fusion is recommended over decompression alone as a primary surgical treatment option in isthmic spondylolisthesis.
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Affiliation(s)
- Kayoumars Azizpour
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland
| | - Pieter J Schutte
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland
- 6Alrijne Hospital, Leiden & Leiderdorp, Zuid-Holland; and
| | - Mark P Arts
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague, Zuid-Holland
| | - Willem Pondaag
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland
- 6Alrijne Hospital, Leiden & Leiderdorp, Zuid-Holland; and
| | - Gerrit J Bouma
- 4Department of Neurosurgery, OLVG, Amsterdam, Noord-Holland
| | | | - Ewout W Steyerberg
- 2Department of Biostatistics, Leiden University Medical Center, Leiden, Zuid-Holland
| | - Wilco C Peul
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague, Zuid-Holland
- 6Alrijne Hospital, Leiden & Leiderdorp, Zuid-Holland; and
| | - Carmen L A Vleggeert-Lankamp
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague, Zuid-Holland
- 7Spaarne Gasthuis, Haarlem/Hoofddorp, Noord-Holland, The Netherlands
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3
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Azizpour K, Schutte P, Arts MP, Pondaag W, Bouma GJ, Coppes M, van Zwet E, Peul WC, Vleggeert-Lankamp CLA. Decompression alone versus decompression and instrumented fusion for the treatment of isthmic spondylolisthesis: a randomized controlled trial. J Neurosurg Spine 2021; 35:687-697. [PMID: 34416736 DOI: 10.3171/2021.1.spine201958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The most advocated surgical technique to treat symptoms of isthmic spondylolisthesis is decompression with instrumented fusion. A less-invasive classical approach has also been reported, which consists of decompression only. In this study the authors compared the clinical outcomes of decompression only with those of decompression with instrumented fusion in patients with isthmic spondylolisthesis. METHODS Eighty-four patients with lumbar radiculopathy or neurogenic claudication secondary to low-grade isthmic spondylolisthesis were randomly assigned to decompression only (n = 43) or decompression with instrumented fusion (n = 41). Primary outcome parameters were scores on the Roland Disability Questionnaire (RDQ), separate visual analog scales (VASs) for back pain and leg pain, and patient report of perceived recovery at 12-week and 2-year follow-ups. The proportion of reoperations was scored as a secondary outcome measure. Repeated measures ANOVA according to the intention-to-treat principle was performed. RESULTS Decompression alone did not show superiority in terms of disability scores at 12-week follow-up (p = 0.32, 95% CI -4.02 to 1.34), nor in any other outcome measure. At 2-year follow-up, RDQ disability scores improved more in the fusion group (10.3, 95% CI 3.9-8.2, vs 6.0, 95% CI 8.2-12.4; p = 0.006, 95% CI -7.3 to -1.3). Likewise, back pain decreased more in the fusion group (difference: -18.3 mm, CI -32.1 to -4.4, p = 0.01) on a 100-mm VAS scale, and a higher proportion of patients perceived recovery as showing "good results" (44% vs 74%, p = 0.01). Cumulative probabilities for reoperation were 47% in the decompression and 13% in the fusion group (p < 0.001) at the 2-year follow-up. CONCLUSIONS In patients with isthmic spondylolisthesis, decompression with instrumented fusion resulted in comparable short-term results, significantly better long-term outcomes, and fewer reoperations than decompression alone. Decompression with instrumented fusion is a superior surgical technique that should in general be offered as a first treatment option for isthmic spondylolisthesis, but not for degenerative spondylolisthesis, which has a different etiology.
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Affiliation(s)
| | - Pieter Schutte
- Departments of1Neurosurgery and.,6Alrijne Hospital, Leiden and Leiderdorp, and
| | - Mark P Arts
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague
| | - Willem Pondaag
- Departments of1Neurosurgery and.,6Alrijne Hospital, Leiden and Leiderdorp, and
| | | | | | - Erik van Zwet
- 2Biostatistics, Leiden University Medical Center, Leiden
| | - Wilco C Peul
- Departments of1Neurosurgery and.,3Department of Neurosurgery, Haaglanden Medical Center, The Hague.,6Alrijne Hospital, Leiden and Leiderdorp, and
| | - Carmen L A Vleggeert-Lankamp
- Departments of1Neurosurgery and.,3Department of Neurosurgery, Haaglanden Medical Center, The Hague.,7Spaarne Gasthuis, Haarlem/Hoofddorp, The Netherlands
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van Gerven C, Eid K, Krüger T, Fell M, Kendoff D, Friedrich M, Kraft CN. Serum C-reactive protein and WBC count in conservatively and operatively managed bacterial spondylodiscitis. J Orthop Surg (Hong Kong) 2021; 29:2309499020968296. [PMID: 33377405 DOI: 10.1177/2309499020968296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE C-reactive protein (CRP) and white blood cell (WBC) count are routine blood chemistry parameters in monitoring infection. Little is known about the natural history of their serum levels in conservative and operative spondylodiscitis treatment. METHODS Pre- and postoperative serum levels of CRP and WBC count in 145 patients with spondylodiscitis were retrospectively assessed. One hundred and four patients were treated by debridement, spondylodesis, and an antibiotic regime, 41 only with a brace and antibiotics. The results of the surgical group were compared to 156 patients fused for degenerative disc disease (DDD). RESULTS Surgery had a significant effect on peak postoperative CRP levels. In surgically managed patients, CRP peaked at 2-3 days after surgery (spondylodiscitis: pre-OP: 90 mg/dl vs. post-OP days 2-3: 146 mg/dl; DDD: 9 mg/dl vs. 141 mg/dl; p < 0.001), followed by a sharp decline. Although values were higher for spondylodiscitis patients, dynamics of CRP values were similar in both groups. Nonoperative treatment showed a slower decline. Surgically managed spondylodiscitis showed a higher success rate in identifying bacteria. Specific antibiotic treatment led to a more predictable decline of CRP values. WBC did not show an interpretable profile. CONCLUSION CRP is a predictable serum parameter in patients with spondylodiscitis. WBC count is unspecific. Initial CRP increase after surgery is of little value in monitoring infection. A preoperative CRP value, and control once during the first 3 days after surgery is sufficient. Closer monitoring should then be continued. Should a decline not be observed, therapy needs to be scrutinized, antibiotic treatment reassessed, and concomitant infection contemplated.
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Affiliation(s)
- Christina van Gerven
- Department of Orthopaedics, Trauma Surgery and Hand Unit, 27664Helios Klinikum Krefeld, Krefeld, Germany
| | - Kevin Eid
- Department of Orthopaedics, Trauma Surgery and Hand Unit, 27664Helios Klinikum Krefeld, Krefeld, Germany
| | - Tobias Krüger
- Department of Radiology, 31098Zuger Kantonsspital AG, Baar, Switzerland
| | - Michael Fell
- Department of Orthopaedics, Trauma Surgery and Hand Unit, 27664Helios Klinikum Krefeld, Krefeld, Germany
| | - Daniel Kendoff
- Department of Orthopaedics and Trauma Surgery, 325716Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Michael Friedrich
- Department of Gynaecology and Obstetrics, 27664Helios Klinikum Krefeld, Krefeld, Germany
| | - Clayton N Kraft
- Department of Orthopaedics, Trauma Surgery and Hand Unit, 27664Helios Klinikum Krefeld, Krefeld, Germany
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Syundyukov АR, Nikolayev NS, Kuzmina VА, Aleksandrov SА, Kornyakov PN, Emelyanov VY. Minimally Invasive Reconstruction of Vertebral Arch in Spondylolisthesis in Children and Adolescents. Sovrem Tekhnologii Med 2021; 13:62-68. [PMID: 35265351 PMCID: PMC8858413 DOI: 10.17691/stm2021.13.5.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Indexed: 11/22/2022] Open
Abstract
The aim of the study was to assess the effectiveness of the minimally invasive technique used to reconstruct the vertebral arch with a pedicle screw hook system in grade I isthmic spondylolisthesis in comparison with the traditional technique of segment stabilization with interbody fusion.
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Affiliation(s)
- А R Syundyukov
- Head of the Pediatric Traumatological and Orthopedic Unit Federal Center of Traumatology, Orthopedics and Arthroplasty, Ministry of Health of the Russian Federation, 33 Fedor Gladkov St., Cheboksary, Chuvash Republic, 428020, Russia
| | - N S Nikolayev
- Professor, Chief Doctor Federal Center of Traumatology, Orthopedics and Arthroplasty, Ministry of Health of the Russian Federation, 33 Fedor Gladkov St., Cheboksary, Chuvash Republic, 428020, Russia;; Head of the Department of Traumatology, Orthopedics and Extreme Medicine Chuvash State University named after I.N. Ulyanov, 15 Moskovsky Prospect, Cheboksary, Chuvash Republic, 428015, Russia
| | - V А Kuzmina
- Functional Diagnostician Federal Center of Traumatology, Orthopedics and Arthroplasty, Ministry of Health of the Russian Federation, 33 Fedor Gladkov St., Cheboksary, Chuvash Republic, 428020, Russia
| | - S А Aleksandrov
- Traumatologist-Orthopedist Federal Center of Traumatology, Orthopedics and Arthroplasty, Ministry of Health of the Russian Federation, 33 Fedor Gladkov St., Cheboksary, Chuvash Republic, 428020, Russia
| | - P N Kornyakov
- Traumatologist-Orthopedist Federal Center of Traumatology, Orthopedics and Arthroplasty, Ministry of Health of the Russian Federation, 33 Fedor Gladkov St., Cheboksary, Chuvash Republic, 428020, Russia
| | - V Yu Emelyanov
- Researcher Federal Center of Traumatology, Orthopedics and Arthroplasty, Ministry of Health of the Russian Federation, 33 Fedor Gladkov St., Cheboksary, Chuvash Republic, 428020, Russia;; Associate Professor Chuvash State University named after I.N. Ulyanov, 15 Moskovsky Prospect, Cheboksary, Chuvash Republic, 428015, Russia
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Zippelius T, Bürger J, Schömig F, Putzier M, Matziolis G, Strube P. Clinical presentation and diagnosis of acute postoperative spinal implant infection (PSII). J Spine Surg 2020; 6:765-771. [PMID: 33447681 DOI: 10.21037/jss-20-587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute postoperative infections after surgical interventions on the spinal column are associated with prolonged treatment duration, poor patient outcomes, and a high socioeconomic burden. In the field of joint replacement, guidelines have been established with recommendations for the diagnosis and treatment of such complications, but in spinal surgery there are no definitions permitting distinction between early and late infections and no specific instructions for their management. Various factors increase the risk of acute postoperative infection, including blood transfusions, leakage of cerebrospinal fluid, urinary tract infection, injury of the dura mater, an American Society of Anesthesiologists (ASA) score >2, obesity, diabetes mellitus, and surgical revision. We suggest defining all infections occurring within the first 4 weeks after spinal surgery as early infections. The symptoms are pain at rest, on motion, and/or pressure pain, abnormal warmth, local erythema, circumscribed swelling of the wound, and newly occurring secretion. Together with laboratory parameters such as C-reactive protein (CRP) and leukocytes, a central role is played by imaging in the form of magnetic resonance imaging (MRI), although diagnosis can be hampered by the presence of postoperative fluid collections such as edema or hematoma or by artifacts from an implant. Once an infection has been confirmed, immediate wound revision with debridement and rinsing (sodium hypochlorite) is essential. Intraoperatively it may prove advantageous to use jet lavage and administer vancomycin. We recommend leaving the implant in place in cases of acute postoperative infection. Patients who are not conditional for surgery can first receive antibiotic suppression treatment before surgery at a later date. In such cases initial computed tomography (CT)-guided aspiration or drain insertion can take place.
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Affiliation(s)
- Timo Zippelius
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - Justus Bürger
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Friederike Schömig
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Putzier
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Georg Matziolis
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - Patrick Strube
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
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Abstract
Postoperative spinal implant infection (PSII) is a serious complication after spinal surgery. It is associated with increased morbidity and mortality for affected patients as well as significant costs for the healthcare system. Due to the formation of biofilm on foreign material, both diagnosis and treatment of PSII can pose a considerable challenge. Modern treatment protocols allow efficient eradication and good clinical outcomes in the majority of patients. In this article, we review the current antibiotic treatment concepts for PSII including the correct choice of antibiotics and their combination. In cases of late-onset PSII where the implants can be removed, two weeks of intravenous (IV) antibiotics followed by 4 weeks of oral antibiotics seem appropriate. If the implant needs to be retained, a 2-week IV antibiotic treatment should be followed by 10 weeks of oral antibiotic therapy with biofilm activity or, in case of problematic pathogens, a long-term suppression therapy. Initial empiric antibiotic therapy should cover staphylococci, streptococci, enterococci and Gram-negative bacilli as the most common pathogens. Antibiotic adjustments according to the type of pathogen and its antimicrobial susceptibility are essential for successful eradication of infection.
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Affiliation(s)
- Yannick Palmowski
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Justus Bürger
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Arne Kienzle
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany.,Laboratory of Adaptive and Regenerative Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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Omar Pacha T, Omar M, Graulich T, Suero E, Mathis SchrÖder B, Krettek C, Stubig T. Comparison of Preoperative Pedicle Screw Measurement Between Computed Tomography and Magnet Resonance Imaging. Int J Spine Surg 2020; 14:671-680. [PMID: 33097582 DOI: 10.14444/7098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Pedicle screw fixation is commonly used in the treatment of spinal pathologies. While the biomechanical factors that affect bone fixation have been frequently described, questions remain as to which imaging modality is the ideal medium for preoperative planning. Due to its perceived superiority in assessing bony changes, computed tomography (CT) scan is assumed to be the gold standard for preparative planning, and we hypothesize that magnetic resonance imaging (MRI) is sufficiently accurate to predict screw length and diameter compared to CT. METHODS We retrospectively measured the length and diameter of vertebral bodies in the lumbar region in both MRI and CT and tested for differences between the modalities as well as for confounding effects of age, sex, and the presence of spondyloarthrosis. RESULTS We found a significant difference in pedicle screw length between CT and MRI measurements for both sides. For the left pedicle, the mean difference was 1.89 mm (95% confidence interval [CI] -3.03 to -0.75; P < .002), while for the right pedicle, the mean difference was 2.05 mm (95% CI -3.27 to -0.84; P = .001). We also found a significant difference in diameter measurements between CT and MRI for the left pedicle (0.53 mm; 95% CI 0.13 to 0.93; P = .011) but not for the right pedicle (0.36 mm; 95% CI -0.06 to 0.78; P = .094). We identified no significant effect of sex, age or spondyloarthrosis on the results (P > .05). CONCLUSIONS Pedicle screw planning measurements were more accurate using CT images compared to MRI images. CT scan remains the gold standard for pedicle screw planning in trauma surgery. When using MRI images, the surgeon should be aware of the differences in screw length and diameter compared to CT in order to avoid intra- and postoperative risks.
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Affiliation(s)
- Tarek Omar Pacha
- Trauma Department, Hannover Medical School(MHH); Lower Saxony, Germany
| | - Mohamed Omar
- Trauma Department, Hannover Medical School(MHH); Lower Saxony, Germany
| | - Tilmann Graulich
- Trauma Department, Hannover Medical School(MHH); Lower Saxony, Germany
| | - Eduardo Suero
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | | | - Christian Krettek
- Trauma Department, Hannover Medical School(MHH); Lower Saxony, Germany
| | - Timo Stubig
- Trauma Department, Hannover Medical School(MHH); Lower Saxony, Germany
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9
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Haffer H, Adl Amini D, Perka C, Pumberger M. The Impact of Spinopelvic Mobility on Arthroplasty: Implications for Hip and Spine Surgeons. J Clin Med 2020; 9:E2569. [PMID: 32784374 DOI: 10.3390/jcm9082569] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/01/2020] [Accepted: 08/04/2020] [Indexed: 12/29/2022] Open
Abstract
Spinopelvic mobility represents the complex interaction of hip, pelvis, and spine. Understanding this interaction is relevant for both arthroplasty and spine surgeons, as a predicted increasing number of patients will suffer from hip and spinal pathologies simultaneously. We conducted a comprehensive literature review, defined the nomenclature, summarized the various classifications of spinopelvic mobility, and outlined the corresponding treatment algorithms. In addition, we developed a step-by-step workup for spinopelvic mobility and total hip arthroplasty (THA). Normal spinopelvic mobility changes from standing to sitting; the hip flexes, and the posterior pelvic tilt increases with a concomitant increase in acetabular anteversion and decreasing lumbar lordosis. Most classifications are based on a division of spinopelvic mobility based on ΔSS (sacral slope) into stiff, normal, and hypermobile, and a categorization of the sagittal spinal balance regarding pelvic incidence (PI) and lumbar lordosis (LL) mismatch (PI–LL = ± 10° balanced versus PI–LL > 10° unbalanced) and corresponding adjustment of the acetabular component implantation. When performing THA, patients with suspected pathologic spinopelvic mobility should be identified by medical history and examination, and a radiological evaluation (a.p. pelvis standing and lateral femur to L1 or C7 (if EOS (EOS imaging, Paris, France) is available), respectively, for standing and sitting radiographs) of spinopelvic parameters should be conducted in order to classify the patient and determine the appropriate treatment strategy. Spine surgeons, before planned spinal fusion in the presence of osteoarthritis of the hip, should consider a hip flexion contracture and inform the patient of an increased risk of complications with existing or planned THA.
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10
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Sussman ES, Ho A, Pendharkar AV, Tharin S. Image-guided Percutaneous Polymethylmethacrylate-augmented Spondylodesis for Painful Metastasis in the Veteran Population. Cureus 2019; 11:e4509. [PMID: 31259118 PMCID: PMC6590854 DOI: 10.7759/cureus.4509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The treatment of painful spinal metastases in patients with limited life-expectancy, significant perioperative risks, and poor bone quality poses a surgical challenge. Recent advances in minimal-access spine surgery allow for the surgical treatment of patients previously considered not to be operative candidates. The addition of fenestrated screws for cement augmentation to existing image-guided percutaneous pedicle screw fixation can enhance efficiency, decrease risk of hardware complications, and improve back pain in this patient population. The patient is a 70-year-old man with severe axial back pain due to metastatic prostate cancer and L5 pathologic fractures not amenable to kyphoplasty. In the setting of a 6-12-month life-expectancy, the primary goal of surgery was relief of back pain associated with instability with minimal operative morbidity and post-operative recovery time. This was achieved with an internal fixation construct including percutaneously placed cement-augmented fenestrated pedicle screws at L4 and S1. The patient was discharged to home on post-operative day 1 with substantial improvement of his low back pain. Image-guided, percutaneous placement of fenestrated, cement-augmented pedicle screws is an emerging treatment for back pain associated with metastasis. Fenestrated screws allow for integrated cement augmentation. The minimal associated blood loss and recovery time make this approach an option even for patients with limited life-expectancy. This is the first report of utilization of this technique for the veteran population.
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Affiliation(s)
- Eric S Sussman
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Allen Ho
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | | | - Suzanne Tharin
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
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Stolte B, Totzeck A, Kizina K, Bolz S, Pietruck L, Mönninghoff C, Guberina N, Oldenburg D, Forsting M, Kleinschnitz C, Hagenacker T. Feasibility and safety of intrathecal treatment with nusinersen in adult patients with spinal muscular atrophy. Ther Adv Neurol Disord 2018; 11:1756286418803246. [PMID: 30305849 PMCID: PMC6174643 DOI: 10.1177/1756286418803246] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/05/2018] [Indexed: 11/26/2022] Open
Abstract
Background: Nusinersen is an intrathecally administered antisense oligonucleotide (ASO) and the first approved drug for the treatment of spinal muscular atrophy (SMA). However, progressive neuromyopathic scoliosis and the presence of spondylodesis can impede lumbar punctures in SMA patients. Our aim was to assess the feasibility and safety of the treatment in adults with SMA. Methods: For the intrathecal administration of nusinersen, we performed conventional, fluoroscopy-assisted and computer tomography (CT)-guided lumbar punctures in adult patients with type 2 and type 3 SMA. We documented any reported adverse events and performed blood tests. Results: We treated a total of 28 adult SMA patients (9 patients with SMA type 2 and 19 patients with SMA type 3) aged between 18–61 years with nusinersen. The mean Revised Upper Limb Module (RULM) score at baseline in SMA type 2 and SMA type 3 patients was 9.9 ± 4.6 and 29.5 ± 8.5, respectively. The mean Hammersmith Functional Motor Scale Expanded (HFMSE) score at baseline was 3.1 ± 2.5 and 31.2 ± 18.1, respectively. Half of the SMA type 3 patients were ambulatory at treatment onset. In total, we performed 122 lumbar punctures with 120 successful intrathecal administrations of nusinersen. Lumbar punctures were well tolerated, and no serious adverse events occurred. Conclusions: Our data demonstrate the feasibility and tolerability of intrathecal treatment with nusinersen in adults with SMA type 2 and type 3. However, treatment can be medically and logistically challenging, particularly in patients with SMA type 2 and in patients with spondylodesis.
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Affiliation(s)
- Benjamin Stolte
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Andreas Totzeck
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Kathrin Kizina
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Saskia Bolz
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Lena Pietruck
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Christoph Mönninghoff
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Nika Guberina
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Denise Oldenburg
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Hufelandstr.55, Essen, 45147, Germany
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Karius T, Deborre C, Wirtz DC, Burger C, Prescher A, Fölsch A, Kabir K, Pflugmacher R, Goost H. Radiofrequency-activated PMMA-augmentation through cannulated pedicle screws: A cadaver study to determine the biomechanical benefits in the osteoporotic spine. Technol Health Care 2017; 25:327-342. [PMID: 27886018 DOI: 10.3233/thc-161273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION PMMA-augmentation of pedicle screws strengthens the bone-screw-interface reducing cut-out risk. Injection of fluid cement bears a higher risk of extravasation, with difficulty of application because of inconsistent viscosity and limited injection time. OBJECTIVE To test a new method of cement augmentation of pedicle screws using radiofrequency-activated PMMA, which is suspected to be easier to apply and have less extravasations. METHODS Twenty-seven fresh-frozen human cadaver lumbar spines were divided into 18 osteoporotic (BMD ≤ 0.8 g/cm2) and 9 non-osteoporotic (BMD > 0.8 g/cm2) vertebral bodies. Bipedicular cannulated pedicle screws were implanted into the vertebral bodies; right screws were augmented with ultra-high viscosity PMMA, whereas un-cemented left pedicle screws served as negative controls. Cement distribution was controlled with fluoroscopy and CT scans. Axial pullout forces of the screws were measured with a material testing machine, and results were analyzed statistically. RESULTS Fluoroscopy and CT scans showed that in all cases an adequately big cement depot with homogenous form and no signs of extravasation was injected. Pullout forces showed significant differences (p < 0.001) between the augmented and non-augmented pedicle screws for bone densities below 0.8 g/cm2 (661.9 N ± 439) and over 0.8 g/cm2 (744.9 N ± 415). CONCLUSIONS Pullout-forces were significantly increased in osteoporotic as well as in non-osteoporotic vertebral bodies without a significant difference between these groups using this standardized, simple procedure with increased control and less complications like extravasation.
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Affiliation(s)
- T Karius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany.,Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - C Deborre
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany.,Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - D C Wirtz
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - C Burger
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - A Prescher
- Institute of Anatomy, University Hospital RWTH Aachen, Aachen, Germany
| | - A Fölsch
- Department of Orthopaedics, University Hospital Marburg, Marburg, Germany
| | - K Kabir
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - R Pflugmacher
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - H Goost
- Department of Orthopaedics and Trauma Surgery, Hospital Wermelskirchen, Wermelskirchen, Germany
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Hermann PC, Webler M, Bornemann R, Jansen TR, Rommelspacher Y, Sander K, Roessler PP, Frey SP, Pflugmacher R. Influence of smoking on spinal fusion after spondylodesis surgery: A comparative clinical study. Technol Health Care 2017; 24:737-44. [PMID: 27129031 DOI: 10.3233/thc-161164] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Smoking is a risk factor in the process of bone healing after lumbar spondylodesis, often associated with complications that occur intraoperatively or during follow-up periods. OBJECTIVE To assess if smokers yield worse results concerning lumbar interbody fusion than non-smokers in a clinical comparative setting. METHODS Spondylodesis outcomes in 50 patients, 34 non-smokers (mean 58 years; (range 29-81) and 16 smokers (mean 47 years; range 29-75) were compared preoperatively and one year after spondylodesis surgery using Oswestry-Disability-Index (ODI), visual analogue scale (VAS) and radiological outcome analysis of fusion-success. RESULTS Smokers showed a comparable ODI-improvement (p = 0.9343) and pain reduction to non-smokers (p = 0.5451). The intake of opioids was only reduced in non-smokers one year after surgery. Fusion success was significantly better in non-smokers (p = 0.01). CONCLUSIONS The results indicate that smoking adversely effects spinal fusion. Particularly re-operations caused by pseudarthrosis occur at a higher rate in smokers than in non-smokers.
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Abstract
Introduction: Patients with spinal injuries have been treated in the past by laminectomy in an attempt to decompress the spinal cord. The results have shown insignificant improvement or even a worsening of neurologic function and decreased stability without effectively removing the anterior bone and disc fragments compressing the spinal cord. The primary indication for anterior decompression and grafting is narrowing of the spinal canal with neurologic deficits that cannot be resolved by any other approach. One must think of subsequent surgical intervention for increased stability and compressive posterior fusion with short-armed internal fixators. Aim: To analyze the results and efficacy of spinal shortening combined with interbody fusion technique for the management of dorsal and lumbar unstable injuries. Materials and Methods: Twenty-three patients with traumatic fractures and or fracture-dislocation of dorsolumbar spine with neurologic deficit are presented. All had radiologic evidence of spinal cord or cauda equina compression, with either paraplegia or paraparesis. Patients underwent recapping laminoplasty in the thoracic or lumbar spine for decompression of spinal cord. The T-saw was used for division of the posterior elements. After decompression of the cord and removal of the extruded bone fragments and disc material, the excised laminae were replaced exactly in situ to their original anatomic position. Then application of a compression force via monosegmental transpedicular fixation was done, allowing vertebral end-plate compression and interbody fusion. Results: Lateral Cobb angle (T10–L2) was reduced from 26 to 4 degrees after surgery. The shortened vertebral body united and no or minimal loss of correction was seen. The preoperative vertebral kyphosis averaged +17 degrees and was corrected to +7 degrees at follow-up with the sagittal index improving from 0.59 to 0.86. The segmental local kyphosis was reduced from +15 degrees to −3 degrees. Radiography demonstrated anatomically correct reconstruction in all patients, as well as solid fusion. Conclusion: This technique permits circumferential decompression of the spinal cord through a posterior approach and posterior interbody fusion.
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Affiliation(s)
- Tarek A Aly
- Assistant professor of orthopedic surgery, Tanta university school of medicine, Tanta, Egypt
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Schoenmakers MAGC, Gulmans VAM, Gooskens RHJM, Pruijs JEH, Helders PJM. Spinal fusion in children with spina bifida: influence on ambulation level and functional abilities. Eur Spine J 2005; 14:415-22. [PMID: 15258836 PMCID: PMC3489207 DOI: 10.1007/s00586-004-0768-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2003] [Revised: 04/02/2004] [Accepted: 05/28/2004] [Indexed: 10/26/2022]
Abstract
The aim of this study was to determine the influence of spinal fusion on ambulation and functional abilities in children with spina bifida for whom early mobilization was stimulated. Ten children (three males and seven females) with myelomeningocele were prospectively followed. Their mean age at operation was 9.3 years (standard deviation (SD): 2.4). Spinal curvature was measured according to Cobb. Pelvic obliquity and trunk decompensation were measured as well. The ambulation level was scored according to Hoffer, and functional abilities, as well as the amount of caregiver assistance, were documented using the Pediatric Evaluation of Disability Inventory. All patients were assessed before surgery and three times after surgery, with a total follow-up duration of 18 months after surgery. After spinal fusion, magnitude of primary curvature decreased significantly (p=0.002). Pelvic obliquity and trunk decompensation did not change. In spite of less immobilization as compared with other reported experiences, ambulation became difficult in three out of four patients who had been able to ambulate prior to surgery. Functional abilities and amount of caregiver assistance concerning self-care (especially regarding dressing upper and lower body, and self-catheterization) and mobility (especially regarding transfers) showed a nonsignificant trend to deterioration within the first 6 months after surgery, but recovered afterwards. From pre-surgery to 18 months after surgery, functional skills on self-care showed borderline improvement (p=0.07), whereas mobility did not (p=0.2). Mean scores on caregiver assistance improved significantly on self-care (p=0.03), and borderline on mobility (p=0.06), meaning that less caregiver assistance was needed compared with pre-surgery. The complication rate was high (80%). In conclusion, within the first 6 months after spinal fusion, more caregiver assistance is needed in self-care and mobility. It takes about 12 months to recover to pre-surgery level, while small improvement is seen afterwards. After spinal fusion, ambulation often becomes difficult, especially in exercise walkers. These findings are important for health-care professionals, in order to inform and prepare the patients and their parents properly for a planned spinal fusion.
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Affiliation(s)
- M A G C Schoenmakers
- Department of Pediatric Physical Therapy, Wilhelmina Children's Hospital, University Medical Center, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
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Tolboom N, Cats EA, Helders PJM, Pruijs JEH, Engelbert RHH. Osteogenesis imperfecta in childhood: effects of spondylodesis on functional ability, ambulation and perceived competence. Eur Spine J 2004; 13:108-13. [PMID: 14608498 PMCID: PMC3476567 DOI: 10.1007/s00586-003-0574-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2002] [Revised: 03/14/2003] [Accepted: 04/25/2003] [Indexed: 11/30/2022]
Abstract
We studied the effects of spondylodesis on spinal curvature, functional outcome, level of ambulation and perceived competence in 11 children with osteogenesis imperfecta (OI). Mean age at surgical intervention was 13.1 years (SD 2.5 years) and follow-up amounted to 3.4 years (SD 2.3 years). Spinal curvature was measured according to Cobb. The level of ambulation was scored according to the modified criteria of Bleck. Functional abilities and the amount of parental assistance were scored using the Dutch version of the Pediatric Evaluation of Disability Inventory (PEDI). Perceived competence was measured using the Harter Self-Perception Profile for Children. The amount of fatigue, spinal pain and presence of subjective dyspnea were scored with a visual analog scale. The median progression per year before spondylodesis was 6.1 degrees (interquartile range 2.9 degrees -12.9 degrees ) and after the spondylodesis it was 5.0 degrees (interquartile range 1.6 degrees -11.0 degrees ). No significant progression or regression in the level of ambulation was found. Perceived competence improved slightly. In the total score of the perceived competence, a borderline significant increase was found ( P-value 0.068). We concluded that spinal fusion in children with OI does not materially influence functional ability and level of ambulation. Self-perceived competence seemed to improve after surgery. The amount of pain, fatigue and subjective dyspnea seemed to diminish after spinal surgery. Progression of scoliosis proceeded, as did development of spinal curvature at the junction of the spondylodesis. Therefore, oral or intravenous bisphosphonates before and after spinal surgery should be considered.
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Affiliation(s)
- N. Tolboom
- Utrecht University Medical School, Utrecht, The Netherlands
| | - E. A. Cats
- Utrecht University Medical School, Utrecht, The Netherlands
| | - P. J. M. Helders
- Department of Pediatric Physical Therapy, Wilhelmina Children’s Hospital, Room KB 02.056.0, University Medical Center, P.O. Box 85090, 3508 AB Utrecht, The Netherlands
| | - J. E. H. Pruijs
- Department of Pediatric Orthopedics, Wilhelmina Children’s Hospital, University Medical Center Utrecht, The Netherlands
| | - R. H. H. Engelbert
- Department of Pediatric Physical Therapy, Wilhelmina Children’s Hospital, Room KB 02.056.0, University Medical Center, P.O. Box 85090, 3508 AB Utrecht, The Netherlands
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