Posterior fixation, anterior debridement and bone grafting in the treatment of thoracic and lumbar tuberculosis in children younger than 3 years of age.

PURPOSE: This study aimed to investigate the clinical outcomes of posterior fixation, combined with one- or two-stage anterior debridement and bone grafting in treating children younger than 3 years of age with thoracic and lumbar tuberculosis. METHODS: This was a retrospective study involving 16 young children with thoracic or lumbar tuberculosis. Surgical data were recorded. Frankel Grade was used to assess neurological function. The regional kyphosis angle was measured to evaluate the deformity correction. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were detected to assess the activity of tuberculosis. Bony fusion and complications were also recorded. RESULTS: The mean operation time was 204.4 ± 41.8 min. The mean estimated blood loss was 126.3 ± 94.4 ml. Preoperative Frankel Grade results indicated five patients with Grade C, six with Grade D, and five with Grade E. At the final follow-up, all patients were in Grade E. Twelve patients were brought back to normal spinal alignment and the rest four patients remained kyphotic. There was an improvement of 29.3° ± 18.3° in regional kyphotic angle postoperatively. And the deformity correction was 27.4° ± 19.1° at the final follow-up. ESR and CRP decreased to a normal range at three months follow-up. Bony fusion was achieved in all patients. None of the cases developed fixation failure, pseudoarthrosis, or tuberculosis recurrence. CONCLUSION: Posterior fixation, combined with one- or two-stage anterior debridement and bone grafting, is a safe and effective surgical strategy for treating young children with thoracic and lumbar tuberculosis.

Development and validation of a novel nomogram to predict the risk of the prolonged postoperative length of stay for lumbar spinal stenosis patients.

BACKGROUND: Lumber spinal stenosis (LSS) is the increasingly reason for spine surgery for elder patients since China is facing the fastest-growing aging population. The aim of this research was to create a model to predict the probabilities of requiring a prolonged postoperative length of stay (PLOS) for lumbar spinal stenosis patients, minimizing the healthcare burden. METHODS: A total of 540 LSS patients were enrolled in this project. The outcome was a prolonged PLOS after spine surgery, defined as hospitalizations ≥ 75th percentile for PLOS, including the day of discharge. The least absolute shrinkage and selection operator (LASSO) was used to identify independent risk variables related to prolonged PLOS. Multivariable logistic regression analysis was utilized to generate a prediction model utilizing the variables employed in the LASSO approach. The receiver operating characteristic (ROC) curve's area under the curve (AUC) and the calibration curve's respective curves were used to further validate the model's calibration with predictability and discriminative capabilities. By using decision curve analysis, the resulting model's clinical effectiveness was assessed. RESULTS: Among 540 individuals, 344 had PLOS that was within the usual range of P75 (8 days), according to the interquartile range of PLOS, and 196 had PLOS that was above the normal range of P75 (prolonged PLOS). Four variables were incorporated into the predictive model, named: transfusion, operation duration, blood loss and involved spine segments. A great difference in clinical scores can be found between the two groups (P < 0.001). In the development set, the model's AUC for predicting prolonged PLOS was 0.812 (95% CI: 0.768-0.859), while in the validation set, it was 0.830 (95% CI: 0.753-0.881). The calibration plots for the probability showed coherence between the expected probability and the actual probability both in the development set and validation set respectively. When intervention was chosen at the potential threshold of 2%, analysis of the decision curve revealed that the model was more clinically effective. CONCLUSIONS: The individualized prediction nomogram incorporating five common clinical features for LSS patients undergoing surgery can be suitably used to smooth early identification and improve screening of patients at higher risk of prolonged PLOS and minimize health care.

Development and validation of a diagnostic model for differentiating tuberculous spondylitis from brucellar spondylitis using machine learning: A retrospective cohort study.

Background: Tuberculous spondylitis (TS) and brucellar spondylitis (BS) are commonly observed in spinal infectious diseases, which are initially caused by bacteremia. BS is easily misdiagnosed as TS, especially in underdeveloped regions of northwestern China with less sensitive medical equipment. Nevertheless, a rapid and reliable diagnostic tool remains to be developed and a clinical diagnostic model to differentiate TS and BS using machine learning algorithms is of great significance. Methods: A total of 410 patients were included in this study. Independent factors to predict TS were selected by using the least absolute shrinkage and selection operator (LASSO) regression model, permutation feature importance, and multivariate logistic regression analysis. A TS risk prediction model was developed with six different machine learning algorithms. We used several metrics to evaluate the accuracy, calibration capability, and predictability of these models. The performance of the model with the best predictability was further verified with the area under the curve (AUC) of the receiver operating characteristic (ROC) curve and the calibration curve. The clinical performance of the final model was evaluated by decision curve analysis. Results: Six variables were incorporated in the final model, namely, pain severity, CRP, x-ray intervertebral disc height loss, x-ray endplate sclerosis, CT vertebral destruction, and MRI paravertebral abscess. The analysis of appraising six models revealed that the logistic regression model developed in the current study outperformed other methods in terms of sensitivity (0.88 ± 0.07) and accuracy (0.79 ± 0.07). The AUC of the logistic regression model predicting TS was 0.86 (95% CI, 0.81-0.90) in the training set and 0.86 (95% CI, 0.78-0.92) in the validation set. The decision curve analysis indicated that the logistic regression model displayed a higher clinical efficiency in the differential diagnosis. Conclusions: The logistic regression model developed in this study outperformed other methods. The logistic regression model demonstrated by a calculator exerts good discrimination and calibration capability and could be applicable in differentiating TS from BS in primary health care diagnosis.

Long-term outcomes of posterior release and reduction for irreducible atlantoaxial dislocation / 中华骨科杂志

Objective:To evaluate the long-term outcomes of posterior release, reduction, fixation, and fusion for irreducible atlantoaxial dislocation (AAD).Methods:Between January 2005 and June 2016, a total of 31 patients with irreducible AAD who had received posterior approach surgery were included. Among them, there were 13 males and 18 females, the average age was 39.1±13.5 years (range 9-72 years). The clinical data of the eligible individuals were collected and analyzed. Neck disability index (NDI) and Japanese Orthopaedic Association (JOA) scores were recorded to evaluate the recovery of neck and neurological functions. The atlantodental interval (ADI), clivus-canal angle (CCA), and cervico-medullary angle (CMA) were measured to evaluate the reduction of AAD. C 0-C 2 angle and C 2-C 7 angle were measured to evaluate the recovery of cervical alignment. For individuals with basilar invagination, the distances from the tip of odontoid process to Chamberlain line and Wackenheim line were measured to assess the reduction in the vertical direction. The duration of bony fusion and complications were also analyzed. Results:The mean follow-up period was 82.7±26.4 months (range 61-170 months). In terms of functional scores, the NDI dropped from 43.41%±11.60% before surgery to 12.19%±6.97% at the six months follow-up, and 9.45%±7.51% at the last follow-up ( F=89.56, P<0.001). The JOA increased from 9.48±2.41 points before surgery to 14.71±1.42 points at the six months follow-up, and 14.97±1.47 points at the last follow-up ( F=52.89, P<0.001). Regarding the horizontal and vertical dislocations, the ADI decreased from 9.16±2.32 mm before surgery to 1.39±1.04 mm at the six months follow-up, and 1.29±1.08 mm at the last follow-up ( F=189.61, P<0.001). The distance from the tip of odontoid process to Chamberlain line decreased from 11.15±4.35 mm before surgery to 2.03±2.83 mm at the six months follow-up, and 2.15±3.02 mm at the last follow-up ( F=37.58, P<0.001). The distance from the tip of odontoid process to Wackenheim line reduced from 6.81±2.57 mm before surgery to -2.23±1.58 mm at the six months follow-up, and -2.27±1.58 mm at the last follow-up ( F=122.16, P<0.001). For the amelioration of the compression on medulla and spinal cord, the CCA increased from 113.68°±12.67° before surgery to 143.39°±7.38° at the six months follow-up, and 142.39°±7.13° at the last follow-up ( F=67.13, P<0.001). The CMA increased from 115.71°±13.69° before operation to 145.58°±10.78° at the last follow-up ( F=41.44, P<0.001). Regarding the curvature of the cervical spine, the C 0-C 2 angle recovered from 1.94°±15.82° before surgery to 14.84°±6.45° at the last follow-up ( F=11.97, P<0.001), and the C 2-C 7 angle ameliorated from 27.26°±8.49° before operation to 19.26°±5.44° at the last follow-up ( F=11.13, P<0.001). Bony fusion was achieved in all cases, the fusion time was 9.71±2.55 months (range 5-15 months). A total of five complications occurred in the cases (two cerebrospinal fluid leakages, one deep infection, one transient neurologic deficit, and one dysphagia). They were all cured with corresponding treatments. In the last follow-up, none of the cases developed failure of internal fixation or re-dislocation. Conclusion:Posterior approach release, reduction, fixation and fusion technique is a safe and efficient surgical strategy with favorable long-term follow-up outcomes for irreducible AAD.

Diagnosis and Surgical Treatment of Human Brucellar Spondylodiscitis.

Brucellar spondylodiscitis (BS) is the most prevalent and significant osteoarticular presentation of human Brucellosis, which is commonly manifested in pastoral communities. It is difficult to differentially diagnose and usually leads to irreversible neurologic deficits and spinal deformities. The initial diagnosis of BS is based on clinical findings and radiographic assessments, and the confirmed diagnosis should be established by the isolation of Brucella species from the blood and/or the standard tube agglutination test. Differential diagnosis of multifocal BS from either degenerative disc diseases or tuberculosis is especially highlighted. The surgical approach, either endoscopic or open, is demonstrated in detail, accompanied by radiographic evidence of structural compression or severe instability. Further, the crucial surgical steps, including single-stage transforaminal decompression, debridement, interbody fusion, and internal fixation, are explained. Moreover, perioperative care and postoperative rehabilitation are also addressed. Taken together, this clinical algorithm presents a practical guide that has yielded substantially satisfactory outcomes in the past decades, which can also be introduced for large-scale application to manage human BS, especially in endemic regions.

Quercetin Alleviates Intervertebral Disc Degeneration by Modulating p38 MAPK-Mediated Autophagy.

Intervertebral disc degeneration (IVDD) is a degenerative and chronic spinal disorder often associated with the older population. Oxidative stress is a major pathogenic factor of aging that results in the apoptosis of nucleus pulposus cells (NPCs) and extracellular matrix (ECM) degradation. Quercetin (QUE), a naturally occurring flavonoid with antioxidant and anti-inflammatory properties, has been studied in research on degenerative diseases. However, the potential effects and mechanisms of action of QUE on IVDD remain unclear. In this study, the effects of QUE on antiapoptosis and ECM metabolism were firstly investigated in TBHP-treated NPCs. Meanwhile, the autophagy inhibitor, 3-MA, and p38 MAPK inhibitor, SB203580, were used in subsequent TBHP-induced NPC experiments to determine whether QUE exerted its protective effects through autophagy and the p38 MAPK/mTOR signaling pathway. Finally, the therapeutic effects of QUE were confirmed in vivo using a rat tail needle puncture-induced model of IVDD. We found that QUE treatment significantly alleviated oxidative stress-decreased cell viability and intracellular ROS levels in NPCs treated with TBHP. Furthermore, treatment with QUE led to a decrease in apoptosis as measured by decreased Bax and increased Bcl-2 expression and PE/7-AAD flow cytometry analysis. QUE also promoted ECM stability as measured by increased collagen II and aggrecan and decreased MMP13 levels. Our results also showed that QUE promoted the expression of autophagy markers beclin-1, LC3-II/I, and decreased p62. Inhibition of autophagy by inhibitor 3-MA may partially reverse the protective effect of QUE on apoptosis and ECM degeneration, indicating that autophagy was involved in the protective effect of QUE in NPCs. Further study confirmed that QUE partially inhibited the p38 MAPK signaling pathway and inhibition of p38 MAPK by SB203580 activated autophagy, indicating that QUE protected NPCs against apoptosis and prevented ECM degeneration via the p38 MAPK-autophagy pathway. Finally, using a rat tail puncture-induced model of IVDD, we confirmed that QUE had a protective effect against IVDD. Our results suggest that QUE could prevent IVDD by modulating p38 MAPK-mediated autophagy and, therefore, is a potential therapeutic strategy in the treatment of IVDD.

Comparison of the Clinical Efficacy of 3 Surgical Methods for Treating Spinal Tuberculosis in Children.

BACKGROUND This study aimed to investigate the safety and clinical efficacy of 3 different surgical methods for treating spinal tuberculosis (ST) in children. MATERIAL AND METHODS We reviewed the cases of 62 children with ST who were treated in our hospital from January 2010 to December 2014. In this study, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, Frankel classification of neurological function, pain visual analog scale (VAS) score, and kyphosis Cobb (k-Cobb) angle were dynamically monitored to evaluate the efficacy of different surgical methods. Complications in the patients were evaluated at 3 time points: before surgery (T1), after surgery (T2), and during final follow-up (T3). The average follow-up was 27.4 months. Twenty-two patients underwent simple anterior debridement alone or combined with internal fixation (Method A), 13 patients underwent posterior debridement alone (Method B), and 27 patients received anteroposterior debridement and bone graft fusion together with internal fixation (Method C). RESULTS In all 3 groups after surgery, ESR, CRP levels, VAS scores, and k-Cobb angles significantly decreased. However, compared with patients who received Methods B and C, patients who received Method A had a significant rebound in k-Cobb angle and a higher incidence of complications at the T3 time point. The overall reoperation rate during follow-up was 37.10%. Fourteen patients (22.58%) had kyphosis, 2 patients (3.23%) had tuberculosis recurrence combined with kyphosis, and other complications were reported in 5 patients (8.06%). CONCLUSIONS Considering the incidence of complications and level of postoperative biochemical indicators, we concluded that caution should be exercised in using an anterior approach to treat pediatric ST.

Establishment and Initial Testing of a Medium-Sized, Surgically Feasible Animal Model for Brucellar Spondylodiscitis: A Preliminary Study.

Brucellar spondylodiscitis, the most prevalent and significant osteoarticular presentation of human Brucellosis, is difficult to diagnose and usually yields irreversible neurologic deficits and spinal deformities. However, no animal models of Brucellar spondylodiscitis exist, allowing for preclinical investigations. The present study investigated whether intraosseous injection of attenuated Brucella melitensis vaccine into rabbits' lumbar vertebrae imitates the radiographic and histopathological characteristics of human Brucellar spondylodiscitis. Radiographic and histopathological analyses at 8 weeks postoperatively revealed radiographic changes within vertebral bodies and intervertebral discs, abscesses formation within the paravertebral soft tissue, and typical prominent inflammation response without caseous necrosis, which were largely comparable to human Brucellar spondylodiscitis. Such a medium-sized, surgically feasible rabbit model provides a promising in vivo setting for further preclinical investigation of Brucellar spondylodiscitis.

Smith-Petersen osteotomy combined with anterior debridement and allografting for active thoracic and lumbar spinal tuberculosis with kyphotic deformity in young children: A prospective study and literature review.

The purpose of this study is to determine the efficacy and safety of Smith-Petersen osteotomy combined with anterior debridement and allogenic strut bone grafting for the treatment of active thoracic and lumbar spinal tuberculosis with kyphotic deformity in young children.Spinal tuberculosis is more destructive in young children and often causes severe kyphosis and paraplegia. Despite much progress has been made, surgical treatment is still controversial and technically challenging.From October 2010 to August 2014, 25 children (11 males, 14 females; aged under 6 years) with active thoracic and lumbar spinal tuberculosis treated by Smith-Petersen osteotomy combined with anterior debridement and allogenic strut bone grafting were enrolled in this study. The pre- and postoperative data, follow-up medical records, imaging studies, and laboratory data were collected prospectively. Clinical outcomes were evaluated on the basis of kyphotic angle and the Frankel motor score system. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms, and complications were investigated. Graft fusion was evaluated using the Bridwell grading criteria.The mean age was 3.5 ±â€Š1.76 years (range, 1-6 years). All patients were followed up for 25 to 45 months (average, 34.3 ±â€Š5.86 months). The average kyphotic angle was changed significantly from a preoperative value of 44.1 ±â€Š10.8° to a postoperative value of 11.4 ±â€Š3.9°, with an average correction rate of 74% (P < .05). According to the Frankle motor score system, neurological deficits were significantly improved by the time of the last follow-up, with an average improvement of 1.7 grades (P < .05). There were 2 cases of rod breakage and 1 case of graft bone displacement. No patients experienced a recurrence of tuberculosis. According to Bridwell criteria, the degree of fusion was grade I in 23 patients and grade II in 2 patients with a fusion rate of 92%.For young children with active thoracic and lumbar spinal tuberculosis, Smith-Petersen osteotomy combined with anterior debridement and allogenic strut bone grafting is a safe and simple procedure to achieve sufficient kyphosis correction, good neurological recovery, and reliable anterior column reconstruction.

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral brucellosis.

BACKGROUND: Spinal brucellosis is a less commonly reported infectious spinal pathology. There are few reports regarding the surgical treatment of spinal brucellosis in existing literature. This retrospective study was conducted to determine the effectiveness of single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral spinal brucellosis. METHODS: From February 2012 to April 2015, 32 consecutive patients (19 males and 13 females, mean age 53.7 ± 8.7) with lumbosacral brucellosis treated by transforaminal decompression, debridement, interbody fusion, and posterior instrumentation were enrolled. Medical records, imaging studies, laboratory data were collected and summarized. Surgical outcomes were evaluated based on visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scale. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms and complications were investigated. Graft fusion was evaluated using Bridwell grading criteria. RESULTS: The mean follow-up period was 24.9 ± 8.2 months. Back pain and radiating leg pain was relieved significantly in all patients after operation. No implant failures were observed in any patients. Wound infection was observed in two patients and sinus formation was observed in one patient. Solid bony fusion was achieved in 30 patients and the fusion rate was 93.8%. The levels of ESR and CRP were returned to normal by the end of three months' follow-up. VAS and ODI scores were significantly improved (P < 0.05). According to JOA score, surgical improvement was excellent in 22 cases (68.8%), good in 9 cases (28.1%), moderate in 1 case (3.1%) at the last follow-up. CONCLUSIONS: Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation is an effective and safe approach for lumbosacral brucellosis.