Research progress of Chiari malformation type I and atlantoaxial instability / 中华骨科杂志

Chiari malformation (CM) is a group of congenital cerebellar tonsillar hernia malformations involving the craniocervical junction. Chiari malformation type I (CMI) is the most common in clinic, however its pathogenesis is still unclear, and there is no consensus on the surgical treatment standard of CMI. At present, the most widely accepted is the theory of posterior fossa incompatibility, so doctors at home and abroad use posterior fossa decompression (PFD) and posterior fossa compression with duraplasty (PFDD) as the gold standard for surgical treatment, and have their own experience and technical improvement. However, the volume of the posterior cranial fossa in some patients is no different from that in healthy people, and about 30% of the patients with CMI have poor results after posterior cranial fossa decompression. As a result, this operation cannot treat all patients with CMI. In recent years, with the development of imaging, the progress of diagnostic technology and the deepening of understanding of CM, some studies have shown that CMI may be related to atlantoaxial instability, and proposed that CMI is the secondary factor of atlantoaxial instability, and atlantoaxial fusion is the standard of surgical treatment, which has caused great controversy in academic circles. Different clinical research results of scholars support or oppose this theory: some studies have shown that the clinical symptom relief rate of patients with CMI treated with atlantoaxial fusion is 96.9%; another study showed that 70% of patients with CMI underwent atlantoaxial fusion had improved neurological function, but the overall postoperative effect was not satisfactory. In short, CMI is related to many diseases and its clinical manifestations are complex. Therefore, individualized management and treatment should be carried out in combination with the clinical manifestations and auxiliary examination results of patients.

A preliminary study of MRI-based radiomics combined with clinical features for Differential Diagnosis of Brucella Spondylitis and Pyogenic Spondylitis / 中华骨科杂志

Objective:To elucidate the diagnostic utility of clinical features and radiomics characteristics derived from magnetic resonance imaging T2-weighted fat-suppressed images (T2WI-FS) in differentiating brucellosis spondylitis from pyogenic spondylitis.Methods:Clinical records of 26 patients diagnosed with Brucellosis Spondylitis and 23 with Pyogenic Spondylitis were retrospectively reviewed from Xinjiang Medical University First Affiliated Hospital between January 2019 and December 2021. Confirmatory diagnosis was ascertained through histopathological examination and/or microbial culture. Demographic characteristics, symptoms, clinical manifestations, and hematological tests were collected, followed by a univariate analysis to discern clinically significant risk factors. For the radiomics evaluation, preoperative sagittal T2WI-FS images were utilized. Regions of interest (ROIs) were manually outlined by two adept radiologists. Employing the PyRadiomics toolkit, an extensive array of radiomics features encompassing shape, texture, and gray-level attributes were extracted, yielding a total of 1,500 radiomics parameters. Feature normalization and redundancy elimination were implemented to optimize the predictive efficacy of the model. Discriminatory radiomics features were identified through statistical methods like t-tests or rank-sum tests, followed by refinement via least absolute shrinkage and selection operator (LASSO) regression. An integrative logistic regression model incorporated selected clinical risk factors, radiomics attributes, and a composite radiomics score (Rad-Score). The diagnostic performance of three models clinical risk factors alone, Rad-Score alone, and a synergistic combination were appraised using a confusion matrix and receiver operating characteristic (ROC) analysis.Results:The cohort comprised 49 patients, including 36 males and 13 females, with a mean age of 53.79±13.79 years. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) emerged as significant clinical risk factors ( P<0.005). A total of seven discriminative radiomics features (logarithm glrlm SRLGLE, exponential glcm Imc1, exponential glcm MCC, exponential gldm SDLGLE, square glcm ClusterShade, squareroot glszm SALGLE and wavelet.HHH glrlm Run Variance) were isolated through LASSO regression. Among these selected features, the square glcmClusterShade feature exhibited the best performance, with an area under the curve (AUC) value of 0.780. It demonstrated a sensitivity of 68.8%, specificity of 94.4%, accuracy of 82.4%, precision of 91.7%, and negative predictive value of 0.773. Furthermore, the logarithm glrlm SRLGLE feature had an AUC of 0.736, sensitivity of 68.8%, specificity of 72.2%, accuracy of 76.5%, precision of 72.2%, and negative predictive value of 0.812. The exponential glcm Imc1 feature had an AUC of 0.736, sensitivity of 50.0%, specificity of 94.4%, accuracy of 73.5%, precision of 88.9%, and negative predictive value of 0.680. Three diagnostic models were constructed: the clinical risk factors model, the radiomics score model, and the integrated model (clinical risk factors+radiomics score), which showed AUC values of 0.801, 0.818, and 0.875, respectively. Notably, the integrated model exhibited superior diagnostic efficacy. Conclusion:The amalgamation of clinical and radiomics variables within a sophisticated, integrated model demonstrates promising efficacy in accurately discriminating between Brucellosis Spondylitis and Pyogenic Spondylitis. This cutting-edge methodology underscores its potential in facilitating nuanced clinical decision-making, precise diagnostic differentiation, and the tailoring of therapeutic regimens.

Analysis of risk factors for prolonged postoperative hospitalization in patients with brucellosis spondylitis / 中华骨科杂志

Objective:To analyze risk factors for prolonged postoperative hospitalization in patients with Brucella spondylitis (BS).Methods:A total of 130 patients with BS who underwent surgical treatment in the Department of Spine Surgery, the First Affiliated Hospital of Xinjiang Medical University from June 2011 to December 2021 were retrospectively analyzed. There were 95 males and 35 females, aged 51.53±12.26 years (range, 20-76 years). The 75th percentile of patients' hospitalization time was used as the critical value, and hospitalization time≥75% quartile was defined as prolonged hospitalization time. Baseline data, clinical outcomes, laboratory test indices, and imaging findings were compared between patients with prolonged and normal length of stay. Indicators with statistically significant differences between the two groups were included in a binary logistic regression analysis to determine independent risk factors for prolonged postoperative hospitalization for BS. The receiver operating characteristic (ROC) curve was plotted for subjects with prolonged postoperative hospitalization, and the area under the curve (AUC) for each independent risk factor was calculated. Additionally, 95% confidence intervals (CI), sensitivity, and specificity were determined.Results:All patients were operated successfully. The length of hospitalization was 6.98±2.73 days (range, 6-20 days). The 75% quartile of the length of hospitalization was 9 days, so hospitalization time≤9 days was considered as normal length of hospitalization (normal group) and more than 9 days was considered as prolonged hospitalization (prolonged group), of which there were 99 cases in the normal group and 31 cases in the prolonged group. All patients were followed up for 12.3±3.2 months (range, 7-31 months). The results of univariate analysis showed elevated body mass index ( Z=901.00, P<0.001), recent wasting (χ 2=15.84, P<0.001), elevated erythrocyte sedimentation rate ( t=-4.82, P<0.001), elevated C-reactive protein ( Z=895.50, P<0.001), decreased albumin ( Z=2199.50, P<0.001), presence of epidural abscess on MRI (χ 2=10.45, P=0.001), and increased intraoperative blood loss (χ 2=8.81, P=0.003) may be risk factors for prolonged hospitalization after BS. Binary logistic regression analysis showed that increased body mass index ( OR=1.25, P=0.033), recent wasting ( OR=0.04, P=3.395), increased erythrocyte sedimentation rate ( OR=7.50, P<0.001), elevated C-reactive protein ( OR=4.71, P=0.008), and epidural abscess on MRI ( OR=3.69, P=0.033) were independent risk factors for prolonged postoperative hospital stay of BS, and the AUC of ROC was 0.70, 0.71, 0.71, 0.75, 0.66, respectively. The AUC of the combined prediction model was 0.89, and the prediction value was good. Conclusion:Elevated body mass index, recent wasting, elevated C-reactive protein, elevated erythrocyte sedimentation rate, and the presence of an epidural abscess on MRI are independent risk factors for prolonged postoperative hospitalization in patients with BS, and the combined prediction model has better predictive efficacy.

Value of CT grayscale histogram features in the differential diagnosis of brucella spondylitis and pyogenic spondylitis / 中国脊柱脊髓杂志

Objectives:To evaluate the values of sagittal CT image histogram features in the differential diagnosis of brucella spondylitis(BS)and pyogenic spondylitis(PS).Methods:The data of 40 BS patients[25 males,15 females;age:51.6±13.0 years old;body mass index(BMI):23(20,28)kg/m2,the BS group]and 33 PS patients[13 males,20 females;age:50.8±16.7 years old;BMI:23(20,26)kg/m2,the PS group]who underwent CT examination of the spine in our hospital and were confirmed through pathology and/or etiology were collected.The region of interest(ROI)was delineated on each level of the sagittal CT images of the two groups of patients by using the 3D Slicer platform and grayscale global histogram analysis was performed.The clinical data were compared using chi square test,independent sample t-test,and Mann Whitney U test between the two groups of patients;Univariate analysis,correlation analysis,and multivariate analysis were used in sequence to identify the histogram features with significant differences between the two groups(including 10％percentile,1％percentile,25％percentile,5％percentile,median,minimum,skewness,and variance);Logistic regression and the screened features were combined for modeling,and receiver operating characteristic(ROC)curves were drawn and areas under the curve(AUC)were calculated to compare the discriminative ability of each histogram feature.Results:There was no statistically significant difference in age,gender,and BMI between the two groups of patients(P＞0.05).Among the histogram parameters,10％percentile value,1％percentile value,25％percentile value,5％percentile value,median,minimum value,skewness,and variance were statistically different between the two groups(P＜0.05).The 10％percentile value displayed the best diagnostic performance,with an AUC value of 0.824 and a specificity of 0.893.The combined model had an AUC value of 0.860 and a specificity of 0.946.Conclusions:Based on 10％percentile value of CT grayscale histogram and joint model,PS and BS can be distinguished effectively,providing a basis for accurately distinguishing the two diseases in clinical practice.

Comparative study of native vertebral osteomyelitis and pyogenic postoperative and analysis of prognostic factors / 中华骨科杂志

Objective:To compare the microbiology, clinical characteristics and therapeutic efficacy of native suppurative spondylitis (NVO) and postoperative suppurative spondylitis (PVO), and analyze the factors affecting the prognosis.Methods:All patients with suppurative spondylitis were retrospectively analyzed from December 2010 to December 2019. A total of 46 patients were enrolled in this study. They were divided into two groups. There were 30 cases in NVO group, 18 males and 12 females; The age was 50.47±20.45 years, aged 15-73 years. There were 16 cases in PVO group, 10 males and 6 females; The age was 52.13±18.80 years, aged 14-73 years. In group NVO, 23 cases (76.7%) were in lumbar vertebrae, 5 cases (16.7%) in thoracic vertebrae and 2 cases (6.7%) in cervical vertebrae; in group PVO, 11 cases (68.8%) in lumbar vertebrae and 5 cases (31.2%) in thoracic vertebrae. Twenty-eight patients had neurological dysfunction before surgery. There were 25 cases of grade D (16 cases in group NVO and 9 cases in group PVO) and 3 cases of grade C (1 case in group NVO and 2 cases in group PVO), following the instructions of American Spinal Injury Association (ASIA) neurological function classification. All patients were given bed rest, nutritional support and antibiotic therapy; surgical treatment for patients with poor outcomes or aggravated symptoms. The patients were followed up after operation, the observation indexes included leukocyte count, erythrocyte sedimentation rate and C -reactive protein to evaluate the postoperative curative effect. The internal fixation device was evaluated for looseness and fracture by imaging examination. At the same time, the changes of visual analogue scale, ASIA neurological function grade were recorded to evaluate the clinical efficacy.Results:Two patients in NVO group were treated with antibiotics, and all the other patients successfully completed the operation. The diseased tissues were sent for pathological examination during the operation. The results showed that they were diagnosed as suppurative spondylitis. All patients were followed up for 12-24 months. Both groups were treated with intravenous and oral antibiotics, and the time of antibiotic treatment in group PVO was longer than that in group NVO without significant difference ( t=1.74, P=0.088). The leukocyte, C-reactive protein, erythrocyte sedimentation rate, visual analogue scale (VAS), were significantly improved in both groups at different time points after operation ( P<0.05) . There was no significant difference in leukocyte, C -reactive protein, erythrocyte sedimentation rate or VAS score between the two groups at the same time point after operation ( P>0.05). The neurological function of patients after operation was significantly improved compared with that before operation. In group NVO, 16 cases recovered from ASIA grade D to grade E, 1 case from grade C to grade D; 9 cases in group PVO recovered from grade D to grade E and 2 cases recovered from grade C to grade D. Till the last follow-up, 3 patients in group NVO recurred, the recurrence rate was 10% (3/30); 7 patients in group PVO recurred, the recurrence rate was 43.8%; the recurrence rate of group PVO was higher than that of group NVO, the difference was statistically significant (χ 2=5.14, P=0.023). Among 39 patients with spinal internal fixation, 12.8% (1 NVO, 4 PVO) had recurrent infection after internal fixation. Therefore, re-operation was performed to remove the internal fixator for infection control, patients recovered after conservative treatment such as immobilization and systemic anti-infection By univariate analysis, multiple vertebral involvement and abscess formation ( OR=11.00, P=0.006; OR=9.00, P=0.047) were significantly associated with pyogenic spondylitis recurrence; there was a tendency for pyogenic spondylitis recurrence among microbial infection ( OR=1.87, P=0.416), spinal prosthesis ( OR=7.20, P=0.074) and allogenic bone ( OR=1.78, P=0.478), yet not obvious. Multivariate analysis indicated that multiple vertebral involvement ( OR=10.49, P=0.038) was a risk factor for pyogenic spondylitis recurrence. Conclusion:The treatment of PVO is more challenging than NVO, especially in the cases of spinal implant infection. Although the antibiotic treatment time of PVO is longer than that of NVO, the recurrence rate of PVO is higher. Longer antibiotic therapy and, if necessary, surgical debridement or removal of implants are important approaches to successful treatment of PVO.

Imaging study of simple Chiari malformation type I and atlantoaxial instability / 中华骨科杂志

Objective:To investigate the relationship between simple Chiari malformation type I (CMI) and atlantoaxial instability from the imaging point of view.Methods:A retrospective analysis were performed on 46 patients diagnosed with simple CMI from January 2014 to December 2020. Forty-six normal people matched for age and sex were selected as the normal control group, while 30 patients with atlantoaxial dislocation were selected as the dislocation group. The degree of atlantoaxial joint degeneration in each group was assessed according to Weishaupt degeneration grading; the atlantoaxial joint angulation angle was measured in the control group of patients with simple CMI; and the sagittal imaging parameters of cervical spine X-ray were measured, including C 0-C 1 Cobb angle, C 0-C 2 Cobb angle, C 1-C 2 Cobb angle, C 1-C 7 Cobb angle, C 2-C 7 Cobb angle, C 7 Slope, C 2 Tilt, spino cranial angle (SCA), and C 2-C 7 sagittal vertebral axis (SVA). All radiographic parameters were measured twice independently by two spine surgeons, and intraclass correlation coefficient (ICC) were determined to demonstrate intra- and inter-observer reliability. Results:ICC ranged between 0.842 and 0.974 in the current study, demonstrating "excellent" reliability of radiographic measurements. No significant difference was noted regarding age and the distribution of genders among the three groups. There were significant differences in the distribution of Weishaupt degeneration grading of atlantoaxial joints between simple CMI, normal and dislocation group ( H=53.68, P<0.001 on the left side; H=43.39, P<0.001 on the right side). There were significant differences in the degree of atlantoaxial joint degeneration between the normal group and dislocation group (left, Z=6.60, P<0.001; right, Z=6.29, P<0.001); There were significant differences in the degree of atlantoaxial joint degeneration between the normal group and simple CMI patients (left, Z=5.31, P<0.001; right, Z=4.13, P<0.001); There were significant differences in the degree of atlantoaxial joint degeneration between simple CMI and dislocation group (left, Z=3.20, P=0.001; right, Z=3.15, P=0.002). There were significant difference in the angulation angle of the atlantoaxial articular surface between the normal group and simple CMI patients (left, Z=3.32, P<0.001; right, Z=5.74, P<0.001). There were significant differences in C 0-C 1 Cobb angle ( t=2.41, P=0.018), C 1-C 7 Cobb angle ( t=2.88, P=0.005), C 2-C 7 Cobb angle ( t=3.29, P=0.001), and C 2-C 7 SVA ( t=2.87, P=0.005) between the normal group and simple CMI patients, but there was no significant difference in other parameters. Conclusion:The degree of atlantoaxial joint degeneration in patients with simple CMI is higher than that in normal people, the angulation angle is larger, and the cervical lordosis is larger, suggesting that there may be atlantoaxial joint instability. This study provides further evidence that Chiari malformation type I is associated with atlantoaxial instability.

Unilateral or bilateral posterior fenestration debridement and bone graft fusion for the treatment of lumbosacral brucellosis spondylitis / 中华骨科杂志

Objective:To analyze the application and clinical efficacy of one-stage unilateral or bilateral fenestration, debridement, interbody fusion combined with posterior internal fixation for the treatment of lumbosacral brucellosis spondylitis.Methods:All patients with lumbosacral brucellosis spondylitis were retrospectively analyzed, who underwent fenestration, debridement, interbody fusion combined with posterior internal fixation from June 2013 to June 2019. A total of 48 patients were enrolled in this study. According to the surgical method, they were divided into two groups. Unilateral fenestration group: 27 cases of one-stage posterior unilateral fenestration, debridement, interbody fusion combined with posterior internal fixation were performed, 21 males and 6 females, aged 23-71 years; Bilateral fenestration group: 21 cases of one-stage posterior bilateral fenestration, debridement, interbody fusion combined with posterior internal fixation were performed, aged 26-58 years. There were 16 males and 5 females. The preoperative and postoperative clinical symptoms, neurological function, C-reactive protein, the surgery duration time, the blood loss, and erythrocyte sedimentation rate were observed. The internal fixation device was evaluated for looseness or fracture by imaging examination. The Bridwell classification criteria were used to evaluate the bone graft fusion. Postoperative complications were also assessed.Results:All patients completed the operation successfully, and the diseased tissues were sent for pathological examination during the operation, and all of them were diagnosed as brucellosis. All patients were followed up for 12-48 months (mean 23.7 ±6.3 months). C-reactive protein, erythrocyte sedimentation rate, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association Scores (JOA) were significantly improved in both groups at different time points after operation. There was no significant difference in the general condition before operation between the two groups ( P>0.05). The mean operation time and mean blood loss were 120.5±34.1 min and 214.4±150.2 ml, in the unilateral fenestration group; 187.1±30.3 min and 455.8±250.5 ml in the bilateral fenestration group; and the difference was significant ( t=8.123, t=2.962, P<0.05) . The postoperative lumbar and leg pain were significantly relieved. There was no significant difference in C-reactive protein, erythrocyte sedimentation rate, VAS, ODI and JOA scores between the two groups at the same time point. In the bilateral fenestration group, one patient developed incision infection half a month after the operation, who underwent debridement and drainage, and finally cured. There was no significant difference in the time of bone graft fusion between the two groups ( t=0.542, P>0.05). At the last follow-up, all the patients were completely fused. Conclusion:Unilateral or bilateral fenestration, debridement and bone graft fusion and internal fixation for the treatment of lumbosacral brucellosis spondylitis can achieve good clinical results, and the former has the advantages of short operation time and low cost.