[Influence of paraspinal muscle degeneration and postoperative Roussouly classification restoration on mechanical complications in female patients with degenerative scoliosis after surgery]

Objective: To investigate the impact of lumbar paraspinal muscle degeneration and postoperative failure to restore ideal Roussouly classification on the occurrence of mechanical complications (MC) following long-segment spinal correction surgery in female patients with degenerative scoliosis (DS). Methods: The clinical data of 72 female DS patients who underwent long-segment spinal correction surgery in Gulou Hospital from June 2017 to November 2021 were retrospectively analyzed. According to whether restoring the ideal Roussouly classification after surgery, the patients were divided into R group(recovery group) (n=51) and N group(non-recovery group) (n=21). According to whether mechanical complications occurred after operation within two years, the patients were divided into MC (mechanical complications)group (n=24) and NMC(non-mechanical complications) group (n=48). The RM group (n=14) experienced mechanical complications in the R group, while the RN group (n=37) did not. The NM group (n=10) experienced mechanical complications in the N group, while the NN group (n=11) did not.Radiographic assessment included Sagittal parameters of spine and pelvis, standardized cross-sectional area (SCSA) and fat infiltration rate (FI%) of paraspinal muscle at each lumbar disc level. Results: The age of DS patients in this study was (61.4±6.2) years.The incidence of MC was 33.33%(n=24)in all patients. The incidence of MC was 27.45%(n=14)in group R and 47.62%(n=10) in group N. The correction amount of pelvic tilt angle (PT) (-11.62°±10.06° vs -7.04°±8.45°, P=0.046) and T1 pelvic angle(TPA)(-12.88°±11.23° vs -7.31°±9.55°, P=0.031)during surgery were significantly higher in MC group compared to the NMC group. In group R, the FI% of paraspinal muscles in each lumbar segment of patients with postoperative MC was higher than that in patients without MC (P<0.05). In the R and N groups, there was no significant difference inthe SCSA of the lumbar paravertebral muscles between patients with postoperative MC and those without MC at each level (all P>0.05). Multivariate logistic regression analysis showed that the average FI% of lumbar PSM was correlated with the occurrence of MC after spinal fusion in DS patients.The average FI% of lumbar PSM≥22.63% was a risk factors for MC after spinal fusion (P=0.010,OR=1.088, 95%CI:1.020-1.160). Conclusions: Female DS patients with higher degree of preoperative paraspinal muscle degeneration have a higher incidence of postoperative mechanical complications. For these patients,.there is still a higher risk of mechanical complications after surgery even if the ideal Roussouly classification is restored after surgery.

[Effect of different observations on evaluation of cosmetic shoulder balance in adolescent idiopathic scoliosis patients with thoracic curve]

Objective: To investigate the correlations between cosmetic and radiographic parameters of shoulder balance, as well as the variations in cosmetic shoulder balance observed from different perspectives, among patients with adolescent idiopathic scoliosis (AIS) characterized by thoracic curves. Methods: A total of 43 patients with thoracic curves treated from July to October in 2022 in Nanjing Drum Tower Hospital were recruited in this study. There were 9 males and 34 females with a mean age of (14.3±1.5) years. All participants underwent comprehensive radiographic assessments and were photographed both from posterior and anterior views, focusing on the shoulder region as well as a higher level (maintaining a consistent vertical distance of 180 cm from the ground). Six cosmetic parameters were measured on the photographs: shoulder angle(α1), axilla angle(α2), shoulder area index 1(SAI1), shoulder area index 2 (SAI2), inner shoulder height (SHi) and outer shoulder height (SHo). Eight radiographic parameters were measured on the radiographs: radiographic shoulder height difference (RSHD), first rib angle (FRA), clavicle-rib cage intersection (CRCI), coracoid process height (CPH), T1 tilt, clavicle angle(CA), clavicle chest cage angle difference (CCAD) and Cobb angle. Differences among bilateral cosmetic indicators from different perspectives were analyzed and compared, and their correlation with bilateral radiographic indicators was studied. Results: There was no significant differences between anterior cosmetic parameters and posterior cosmetic parameters at the same level of observation(all P>0.05). However, when observing SHi, SHo, α1, and α2 at the shoulder level, it became evident that they exhibited significantly higher values compared to the corresponding higher level on the same side of the patients' bodies. This contrast was observed in both the dorsal [SHo: (0.11±1.20) cm vs (-0.44±1.39) cm, P=0.005; SHi: (0.64±0.86) cm vs (0.32±0.56) cm, P=0.003; α1:-0.47°±2.27° vs -0.77°±2.49°, P=0.014; α2:-3.06°±3.23° vs -2.21°±3.03°, P=0.034] and ventral [SHo: (0.12±1.29) cm vs (-0.48±1.35) cm, P=0.007; SHi: (0.61±0.88) cm vs (0.30±0.59) cm, P=0.006; α1:-0.46°±2.18° vs -0.69°±2.35°, P=0.018; α2:-3.26°±3.12° vs -2.05°±2.97°, P=0.029] aspects of the patients. SHi and SHo were more sensitive to this difference of height. The correlation coefficients between radiographic parameters and cosmetic aspects at the shoulder level varied from 0.374 to 0.767. Similarly, the correlation coefficients between radiographic parameters and cosmetic factors at the higher level ranged from 0.273 to 0.579 (all P<0.05). Conclusions: The cosmetic parameters had significant difference between different perspective of observation, the cosmetic parameters are needed to be observed at the shoulder level in the evaluation of patients' shoulder balance.

[Clinical study of the Cobb+1 to Cobb fusion strategy for Lenke 5C adolescent idiopathic scoliosis patients with the lower lumbar apex]

Objective: To investigate the indications and surgical outcome of Cobb+1 to Cobb fusion strategy in Lenke 5C adolescent idiopathic scoliosis (AIS) patients with the lower lumbar apex. Methods: The clinical data of Lenke 5C AIS patients treated in Nanjing Drum Tower Hospital from August 2015 to December 2018 were retrospectively analyzed. The patients were followed-up for at least 2 years after surgery and treated with selective Cobb+1 to Cobb fusion strategy. The patients were divided into the normal lumbar apex group (apex location of the main curve was between T12 and L1) and the lower lumbar apex group (apex location of the main curve was below the disc of L1/L2). The occurrence of proximal decompensation in the two groups was compared. In addition, according to whether the patients had proximal decompensation at the last follow-up, the patients in the lower lumbar apex group were further divided into proximal decompensation group and non-decompensation group. The radiographic parameters and Scoliosis Research Society-22 (SRS-22) scores of the two groups were compared. Results: A total of 52 patients (19 cases in the normal lumbar apex group and 33 cases in the lower lumbar apex group), aged (15.3±1.6) years, were followed up for 2-5 (3.2±1.2) years. Six patients (6/19) in the normal lumbar apex group and 5 cases (15.2%) in the lower lumbar apex group showed proximal decompensation during follow-up, and the incidence was significantly higher in the normal lumbar apex group (P=0.034). Within the lower lumbar apex group, the patients with proximal decompensation (n=5) showed similar Risser grade, baseline thoracic Cobb angle, and main Cobb angle as those without proximal decompensation(n=28), and the differences were all not statistically significant (all P>0.05). However, the baseline thoracic/lumbar apical vertebra translation (AVT) ratio was significantly larger in patients with proximal decompensation (0.6±0.2 vs 0.4±0.2, P=0.042), but the postoperative upper instrumented vertebra (UIV) tilt angle was similar (4.5°±2.3° vs 6.2°±3.4°, P=0.312). Conclusion: Cobb+1 to Cobb fusion strategy, selecting UIV at 1 level above upper end vertebra (UEV), could be performed in Lenke 5C patients with the lower lumbar apex location. In addition, UIV could be selected at UEV+1 in patients with small baseline thoracic curve.

[Comparison of intraoperative neurophysiological monitoring between patients with arthrogryposis multiplex congenita and adolescent idiopathic scoliosis]

Objective: To compare the intraoperative neurophysiological monitoring (IONM) results between patients with arthrogryposis multiplex congenita (AMC) and adolescent idiopathic scoliosis (AIS) and to analyze the influence of congenital spinal deformity on IONM in AMC patients, thus to evaluate the efficiency of IONM in AMC patients. Methods: A cross-sectional study. The clinical data of 19 AMC patients underwent correction surgery from July 2013 to January 2022 in Nanjing Drum Tower Hospital were retrospectively reviewed. There were 13 males and 6 females with a mean age of (15.2±5.6) years, and the average Cobb angle of main curve was 60.8°±27.7°. And 57 female AIS patients of similar age and curve type with the AMC patients during the same period were selected as the control group, with an average age of (14.6±4.4) years and a mean Cobb angle of 55.2°±14.2°. The latency and amplitude of samatosensory evoked potentials (SSEPs) and transcranial electric motor evoked potentials (TCeMEPs) were compared between the two groups. The difference in IONM data between AMC patients with and without congenital spinal deformity was also evaluated. Results: The success rates of SSEPs and TCeMEPs were 100% and 14/19 for AMC patients, 100% and 100% for AIS patients. The SSEPs-P40 latency, SSEPs-N50 latency, SSEPs-amplitude, TCeMEPs-latency, TCeMEPs-amplitude showed no significant difference between AMC patients and AIS patients (P>0.05 for all). The side-difference of TCeMEPs-amplitude showed an increasing trend in AMC patients when compared with that in AIS patients, but there was no statistical difference between the two groups [(147.0±185.6) μV vs (68.1±311.4) μV, P=0.198]. The SSEPs-amplitude value was (1.4±1.1) μV on concave side in AMC patients with congenital spinal deformity, and it was (2.6±1.2) μV on concave side in AMC patients without congenital spinal deformity (P=0.041). The SSEPs-amplitude value was (1.4±0.8) μV on convex side in AMC patients with congenital spinal deformity, and it was (2.6±1.3) μV on convex side in AMC patients without congenital spinal deformity (P=0.028). Conclusions: The values of SSEPs-P40 latency, SSEPs-N50 latency, SSEPs-amplitude, TCeMEPs-latency and TCeMEPs-amplitude are similar in AMC and AIS patients. The SSEPs-amplitude of AMC patients with congenital spinal deformity is lower than that of AMC patients without congenital spinal deformity.

Monolayer MSi2P4 (M = V, Nb, and Ta) as Highly Efficient Sulfur Host Materials for Lithium-Sulfur Batteries

Despite the high capacity and low cost of lithium-sulfur (Li-S) batteries, their commercialization is greatly blocked by multiple bottlenecks including the shuttle effect of lithium polysulfides (LiPSs), poor conductivity of sulfur, and sluggish reaction kinetics. Herein, we propose novel two-dimensional MSi₂P₄ (M = V, Nb, and Ta) monolayers as promising sulfur hosts to improve the Li-S battery performance. Our calculations show that MSi₂P₄ monolayers offer moderate binding strengths to the polysulfides, which are expected to effectively inhibit the LiPS shuttling and dissolution. Moreover, the conductive properties of the MSi₂P₄ systems are well maintained after LiPS adsorption, eliminating the insulating nature of sulfur species. Remarkably, MSi₂P₄ monolayers exhibit superior electrocatalytic activity for the sulfur reduction reaction and the Li₂S decomposition reaction, which considerably lowers the energy barriers of LiPS conversions during discharge and charge, thus ensuring the fast redox kinetics and high sulfur utilization of Li-S batteries. This study pioneers the application of MSi₂P₄ monolayers as highly efficient sulfur host materials for Li-S batteries and affords insights for further development of advanced Li-S batteries.

[Impact of C2-femoral heads center and sacroiliac fixation on the occurrence of post-operative proximal junctional kyphosis in adults with spinal deformity]

Objective: To analyze the relationship between post-operative proximal junctional kyphosis (PJK) and C₂-femoral heads center (C₂-FH), pelvic fixation in adult spinal deformity (ASD) patients, so as to provide a reference for the preoperative decision-making and the postoperative intervention timely. Methods: It was a retrospective study that analyzed 34 cases of ASD patients who underwent posterior pedicle screw fixation in Nanjing Drum Tower Hospital between January 2017 and May 2017. ASD patients were divided into two groups according to fixation options: the sacroiliac fixation group and the non-sacroiliac fixation group. The spine-pelvis parameters were evaluated on full-length X ray films of spine at preoperatively, 2 weeks postoperatively and the last follow-up, and the incidence of PJK was recorded. Results: A total of 34 ASD patients (3 males and 31 females) were included in this study, with an average age of (58±6) years. The mean follow-up period was (2.9±1.0) years (2.0-4.0 years). The age, follow-up time and various spine-pelvis parameters showed no significant differences between the two groups (all P>0.05). The immediate postoperative C₂-FH in the sacroiliac fixation group was significantly lower than that in the non-sacroiliac fixation group [(-69.46±30.85) mm vs (-31.62±15.31) mm, P<0.001]. The incidence of PJK was as high as 50.0% (8/16) in patients with sacroiliac fixation, but it was only 22% (4/18) in patients without sacroiliac fixation (P=0.016). At the last follow-up, the C₂-FH of both groups were both higher than -20 mm (both were approximately -15 mm, P=0.976), indicating that the C₂-FH was compensated in both groups. Due to the loss of the distal compensation ability, the incidence of PJK in the sacroiliac fixation group was higher than that in the non-sacroiliac fixation group. Due to the fixation of pelvis and most of lumbar spine, no significant differences were found in lumbar lordosis (LL), pelvic tilt (PT) and sacral slope (SS) at the last follow-up in both groups when compared with those after the operation (all P>0.05); while the thoracic kyphosis (TK) and cervical lordosis (CL) increased significantly (both P<0.05) to compensate C₂-FH at the last follow-up. Conclusion: It's demonstrated that C₂-FH< -2 cm and pelvic fixation are high risk factors of PJK in ASD patients. It is suggested that both global sagittal balance and pelvic fixation should be considered in decision-making and corrective surgery, rather than only focusing on spine-pelvic parameters.

[Neurological complications after three-column osteotomy in spinal deformity patients with different magnetic resonance imaging -based classification of spinal cord shape]

Objective: To compare the incidences of neurological complications after three-column osteotomy based on the magnetic resonance imaging(MRI)-based classification of spinal cord shape and cerebrospinal fluid in patients with severe thoracic kyphoscoliosis. Methods: A total of 112 patients (52 males, 60 females, age (M(Q₁,Q₃)) 13.5 years (9.0-38.5 years)) with thoracic kyphoscoliosis who underwent three-column osteotomy in Nanjing Drum Tower Hospital from August 2015 to August 2018 were retrospectively analyzed. The radiographic parameters including spinal cord morphology at apex, Cobb angle of main curve, distance between C₇ plumb line and center sacral vertical line (C₇PL-CSVL), global kyphosis (GK) and sagittal vertical axis (SVA) were measured, retrospectively. The Frankel scoring system was used for the evaluation of neurological status at pre-operation, post-operation and the last follow-up. Results: The spinal cord morphologies at apex were classified into type Ⅰ in 8 (7.1%) patients, type Ⅱ in 58 (51.8%), and type Ⅲ in 46 (41.1%), respectively. The patients were followed-up for (28.5±3.4) months. Compared with pre-operation, the Cobb angle of main curve, C₇PL-CSVL, GK and SVA showed significantly improvement at post-operation (all P<0.05) and with no significant correction loss at the last follow-up (all P>0.05). New neurological complications were detected in 3 patients with type Ⅱ spinal cord shape, of whom the neurological scores were Frankel D at post-operation. For patients with type Ⅲ spinal cord shape, new neurological complications were detected in 6 patients including 1 Frankel C and 5 Frankel D. In addition, deterioration of neurological status from Frankel D to Frankel C was found in 3 patients with type Ⅲ spinal cord shape. The incidence of new or deteriorating neurological complications in patients with type Ⅲ spinal cord shape was higher than that in type Ⅱ patients (19.6% vs 5.2%, P=0.037). Conclusions: The MRI-based classification is associated with post-operative neurological complications in patients with severe kyphoscoliosis undergoing three-column osteotomy. Patients with type Ⅲ spinal cord shape are at higher risk of post-operative neurological complications.

[Different concentrations of specialized pro-resolving mediators in eosinophilic and non-eosinophilic chronic rhinosinusitis with nasal polyps]

Objective: To investigate the difference of concentrations of specialized pro-resolving mediators (SPMs) derived from fatty acids in eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP) and non-eosinophilic chronic rhinosinusitis with nasal polyps (nECRSwNP). Methods: A total of 36 patients with bilateral chronic rhinosinusitis with nasal polyps (CRSwNP) who underwent endoscopic nasal surgeries in Peking Union Medical College Hospital from May 2019 to September 2020 were enrolled, including 27 males and 9 females, with the age from 13 to 67 years. There were 23 cases of ECRSwNP and 13 cases of nECRSwNP. At the same time, 12 control subjects were enrolled. The concentrations of multiple SPMs, including lipoxins (LXA₄ and LXB₄), resolvins (RvD₁, RvD₂, RvD₃, RvD₅ and RvE₁), protectins (PDX) and maresins (Mar-1) in nasal polyps with different histological subtypes and normal nasal mucosa were analyzed using liquid chromatography-tandem mass spectrometry. The concentrations of SPMs between groups were compared using Mann-Whitney U test. Spearman's rank correlation coefficient was used to measure the correlation between the concentrations of SPMs in nasal polyps and tissue eosinophil counts. Results: The concentrations of RvD₂, RvD₃, RvD₅, LXA₄, LXB₄, Mar-1 and PDX in ECRSwNP group were significantly higher than that in controls (Z value was -2.276, -2.313, -3.371, -2.094, -2.051, -3.104 and -2.294, respectively, all P<0.05). The concentrations of RvD₂, RvD₅, Mar-1 and PDX in ECRSwNP group were significantly higher than those in nECRSwNP group (Z value was -2.175, -2.289, -2.243 and -2.124, respectively, all P<0.05). There was no significant difference in all these SPMs between nECRSwNP and controls (all P>0.05). The concentrations of RvD₂, RvD₃, RvD₅, LXB₄, Mar-1 and PDX in nasal polyps correlated positively with tissue eosinophil counts (r value was 0.443, 0.436, 0.371, 0.502, 0.340 and 0.386, respectively, all P<0.05). Conclusions: A varienty of SPMs are elevated in ECRSwNP. Dysregulation of fatty acid metabolism might play an important role in the chronic inflammation of ECRSwNP.

[Clinical study of selection of the upper instrumented vertebra at one level caudal to upper end vertebra in patients with Lenke 5C adolescent idiopathic scoliosis]

Objective: To investigate whether the upper instrumented vertebra (UIV) can be selected at one level caudal to upper end vertebra (UEV) in Lenke type 5C adolescent idiopathic scoliosis (AIS) patients. Methods: Total of 28 Lenke 5C AIS patients who underwent selective posterior fusion in Drum Tower Hospital of Nanjing University Medical School from September 2013 to September 2015 were included. There were 4 males and 24 females, with an age of (15.0±2.0) years, the Risser sign was graded 2-5. The following imaging parameters were measured on standing full spine X-ray before, immediately after the surgery and at the last follow-up: thoracolumbar/lumbar (TL/L) Cobb angle, coronal balance, UIV translation, lower instrumented vertebra (LIV) translation, UIV tilt, LIV tilt, and thoracic apical vertebral translation (T-AVT), lumbar apical vertebral translation (L-AVT). The patients were divided into two groups: decompensation group (n=6) and non-decompensation group (n=22). Radiographic parameters and Scoliosis Research Society (SRS)-22 scores were compared between the two groups. Results: Six cases (21.4%) had proximal decompensation at the last follow-up. There were no significant differences in Risser grade(3.8±1.0 vs 3.6±1.6), baseline thoracic Cobb angle(25.8°±2.2° vs 26.3°±6.4°) and TL/L Cobb angle(43.7°±3.4° vs 45.2°±6.5°) between the two groups (all P>0.05). However, the baseline lumbar/thoracic apical vertebra translation (L-T AVT ratio) was significantly higher in patients with proximal decompensation (6.3±1.3 vs 4.0±2.0, P=0.048). Conclusion: Selecting UIV at one level caudal to UEV, would not increase the incidence of proximal decompensation in Lenke 5C AIS patients with Risser higher than grade 2, the smaller baseline L-T AVT ratio, and with thoracic compensatory curve over 15°, and can obtain satisfactory clinical results.

[Clinical application of minimally invasive lumbar interbody fusion]

With the popularization of minimally invasive concept in the treatment of lumbar degenerative disease,minimally invasive lumbar interbody fusion has gradually developed into the mainstream technique of lumbar fixation and fusion.At present,there are many types of minimally invasive lumbar interbody fusion. In this paper, four kinds of minimally invasive lumbar interbody fusion (anterior lumbar interbody fusion,minimally invasive transforaminal lumbar interbody fusion,extreme lateral interbody fusion,oblique lumbar interbody fusion),which are widely used in clinical practice,are systematically described from the aspects of indication selection,technical characteristics, clinical efficacy and prevention of complications.In order to obtain the best treatment effect with the least trauma,it is necessary for the surgeons to formulate detailed surgical strategies on the basis of strictly grasping the indications,and choose the operation according to their own clinical experience and skills,so as to maximize the advantages of different minimally invasive lumbar interbody fusion.

[Occurrence of rod fracture and salvage methods after primary surgery of the congenital lumbosacral deformity associated with sacral agenesis]

Objective: To analyze the occurrence of rod fracture after surgery for lumbosacral deformity associated sacral agenesis and discuss the relevant salvage methods. Methods: The clinical records of 19 patients who underwent surgical treatment for lumbosacral deformity associated sacral agenesis from January 2001 to January 2018 were retrospectively reviewed, including 11 boys and 8 girls. The average age was (9.6±5.2) years. The outcomes of surgical correction and internal fixation were evaluated by postoperative regular follow-up. We also recorded the time and position of rod fracture occurrence. The Cobb angle, coronal balance and sagittal balance were measured and compared to analyze the corresponding salvage methods and revision outcomes. Results: Three patients encountered rod fracture during follow-up, so the incidence of rod fracture after surgery for lumbosacral deformity associated sacral agenesis was 15.8%(3/19). Based on their own conditions, we formulated the individualized strategy and performed the revision surgery through the posterior-only approach. The most critical step was abundant bone-grafting and fusion in the defected sacroiliac joint. After revision, the scoliotic Cobb angle improved in two patients (91.5° vs 47.5°, 49.0° vs 28.0°) and coronal balance improved in one patient (40.3 mm vs 24.3 mm). No complication reoccurred during follow-up. Conclusion: The rod fracture after surgery for lumbosacral deformity associated sacral agenesis is quite common, which is probably correlated with its unique deformed structure and biomechanical characteristics. The individualized salvage methods and adequate bone-grafting and fusion for the defected sacroiliac joint will guarantee the reconstruction and maintenance of spine balance after revision.

[Changes of histopathological and hematological characteristics in recurrent chronic rhinosinusitis with nasal polyps]

Objective: To investigate the histopathological and hematological changes in reoperation of recurrent chronic rhinosinusitis with nasal polyps (CRSwNP). Methods: A total of 41 patients with CRSwNP who underwent two consecutive endoscopic sinus surgeries in Peking Union Medical College Hospital from February 1999 to April 2019 were included retrospectively, including 25 males and 16 females, aged (40.7±13.6) years at the former surgery and (47.0±13.2) years at the recurrent surgery. The peripheral blood cell count results were collected. Differential inflammatory cells in nasal polyp tissue sections were counted and characteristics of tissue remodeling were scored. Paired t test was used to compare the hematological and histological data of the two surgeries in the same cohort. Spearman's rank correlation coefficient was used to determine the correlation between tissue and peripheral blood eosinophil contents. Results: In histopathological tissue sections of nasal polyps, the mean tissue eosinophil, lymphocyte and total inflammatory cell counts per high power field significantly decreased (54.04±34.67 vs 76.97±65.59, 35.27±16.61 vs 50.01±26.94, 128.88±41.32 vs 176.38±80.59, t value was 2.413, 2.923, 3.445, respectively, all P<0.05), whereas the percentages of different inflammatory cell types remained unchanged when comparing the recurrent surgery with the former surgery. There was a significant reduction of basement membrane thickness and goblet cell hyperplasia score in the recurrent surgery (1.29±0.84 vs 2.00±0.84, 1.81±1.31 vs 2.44±1.10, t value was 5.367, 2.714, respectively, all P<0.05). Subgroup analysis suggested that changes in asthmatic cases, younger cases and cases without previous surgery were more remarkable than non-asthmatics, older cases and cases with previous surgery, respectively. There was no significant change in peripheral white blood cell counts and differential cell percentages, except a small increase of blood monocyte percentage. Correlation analysis showed that tissue eosinophil content correlated positively with blood eosinophil content at each surgery. Conclusions: In the recurrent surgery of CRSwNP, tissue eosinophil, lymphocyte and total inflammatory cell counts decrease significantly compare with that of the former surgery. The histological inflammatory load decreases with improvement of tissue remodeling, which could be attributed to the integrated treatment with surgery and medications.

Bain and Nishiyama–Wassermann transition path separation in the martensitic transitions of Fe

The importance of martensitic transformations has led to tremendous efforts to explore the microscopic martensitic transition paths. There are five possible transformation paths (for γ → α transition) known for Fe at present, and at an arbitrary activation energy, any of the five paths might be followed. It then becomes considerably difficult to monitor the microscopic phase transition mechanism in experiments. Therefore, it is helpful to realize only one of the paths in a physical process. Based on first-principles calculations, we show that at suitable activation energies the Nishiyama–Wassermann (N–W) transformation path can be realized without the involvement of the Bain path, since the condition E_NW(θ) < E < E_Bain can be satisfied by pure Fe. E is the activation energy of the system, and E_NW(θ) and E_Bain are the energy barriers for the N–W and Bain transformations, respectively. In particular, the potential energy surface (PES) for the N–W transformation has been calculated as being four-dimensional, i.e., E = E(a,b,c,θ), where (a, b, c) are the lattice constants and θ is the shear angle involved in the shear distortion of the N–W path.

The importance of martensitic transformations has led to tremendous efforts to explore the microscopic martensitic transition paths.

[Efficacy of sequential correction based on satellite rod techniquein degenerative scoliosis with B-type coronal imbalance]

Objective: To evaluate the radiographic and clinical outcomes of sequential correction based on satellite rod technique in degenerative scoliosis (DS) with B-type coronal imbalance, and to investigate the efficacy of sequential correction in this cohort. Methods: Twenty-one DS patients with B-type coronal imbalance applying sequential correction from December 2015 to July 2017 in Nanjing Drum Tower Hospital were retrospectively reviewed. There were 4 males and 17 females in this group, the average age was (63±8) years. The coronal parameters including Cobb angle of main curve and distance between C(7) plumb line and center sacral vertical line (C(7)PL-CSVL), as well as sagittal parameters including global kyphosis (GK) and sagittal vertical axis (SVA) were assessed pre-operatively, post-operatively and at the last follow-up. The Scoliosis Research Society-22 (SRS-22) questionnaire was fulfilled before the operation and at each follow-up to evaluate the quality of life. Paired t test was performed for statistical analysis. Results: The patients were followed-up for (20±8) months. The post-operative Cobb angle of main curve was significantly improved from 52°±12° to 19°±7° (t=13.886, P<0.01), and it was 19°±8° at the last follow-up and no significant correction loss was attained (t=1.101, P=0.284). The values of C(7)PL-CSVL before the operation, after the operation and at the final follow-up were (46±11) mm, (12±7) mm and (12±7) mm, respectively; significant post-operative improvement achieved (t=19.718, P<0.01) while there was no correction loss at last follow-up (t=-1.393, P=0.179). After sequential correction, 20 patients (95.2%) improved to A-type coronal imbalance while 1 patient (4.8%) remained with B-type coronal imbalance. Significant post-operative improvements were found in terms of GK and SVA and no significant correction loss was found during follow-up. The scores of pain and self-image showed significant improvement at the last follow-up (t=8.706, 3.104, both P<0.01). In addition, there was no implant failure during follow-up. Conclusion: The sequential correction based on satellite rod technique in DS patients with B-type coronal imbalance corrects the deformity, relieves the clinical symptoms, improves the quality of life, and decreases the rates of post-operative coronal imbalance as well as implant-related complications.

[Effect of Modic changes on fusion rate and cage subsidence after transforaminal lumbar interbody fusion]

Objective: To investigate the effects of Modic changes on the fusion rate and cage subsidence after transforaminal lumbar interbody fusion (TLIF). Methods: From January 2015 to January 2018, a total of 186 patients with degenerative lumbar disease who received lumbar instrumentation fusion and monosegmental TLIF with single polyetheretherketone (PEEK) cage in Nanjing Drum Tower Hospital were retrospectively reviewed. Patients with Modic changes at the level where the cage was placed were enrolled as Modic group, and the remaining were assigned into non-Modic group. Disk height, lumbar lordosis and segmental lordosis of the level with TLIF were measured based on the preoperative, postoperative and latest follow-up lateral radiograph. The fusion rate and cage subsidence (more than 2 mm on either endplate) were recorded based on CT scan at the latest follow-up. The Oswestry disability index (ODI) and visual analogue scale (VAS) of pain was used to evaluate the clinical outcome. The data were compared with paired t test between the two groups. Results: In this study, there were 70 males and 116 females with an average age of (55±13) years. There were 99 patients in the Modic group (25 with type 1, 66 with type 2, 8 with type 3), and 87 patients in the non-Modic group. There was no significant difference between Modic group and non-Modic group in demographics and postoperative radiographs. The patients were followed-up for (19±4) months (13 to 48 months). All patients achieved grade 1 or 2 fusion. Cage subsidence was detected in 34 patients (18.3%, 34/186). The incidence of subsidence in Modic group (24.2%, 24/99) was significantly higher than that in non-Modic group (11.5%, 10/87) (χ(2)=5.038, P<0.05), and the incidence of subsidence in type Ⅰ (28.0%, 7/25) and type Ⅱ (24.2%, 16/66) were higher than that in non-Modic group (11.5%, 10/87). There was no significant difference in ODI and VAS between Modic group and non-Modic group before and after the operation and at the latest follow-up (t=0.397-1.568, all P>0.05). Conclusion: Preoperative Modic changes have no impact on fusion rate after transforaminal lumbar interbody fusion, but both type Ⅰ and Ⅱ Modic changes do increase the risk of cage subsidence.

[One-stage posterior correction and second-stage anterior debridement and fusion in treating children with thoracic tuberculosis complicated with kyphoscoliosis]

Objective: To investigate the clinical outcomes of one-stage posterior correction surgery and second-stage anterior debridement and fusion in treating children with thoracic tuberculosis complicated with kyphoscoliosis. Methods: From January 2008 to December 2014, a total of 17 children with thoracic vertebral tuberculosis complicated with kyphoscoliosis who underwent a one-stage posterior correction and second-stage anterior debridement and complementary fusion were included. There were 8 males and 9 females with an average age of (8±4) years (5-14 years). All patients underwent posterior correction and anterior debridement and bone graft fusion surgery. The neurological function was determined by Frankel grade. The operation time, estimated blood loss (EBL), levels fused and numbers of screws were recorded. The following radiographic parameters were measured: Cobb angle of the coronal curve, regional kyphosis and sagittal vertical axis (SVA). The incidence of intraoperative and postoperative complications was recorded. The data before and after the operation were compared with paired sample t test. Results: The tuberculosis lesions located in the thoracic vertebrae, and the abscess involved 2 to 4 vertebral segments. The average operation time was (4.1±0.8) h, the EBL was (526±275) ml, the levels fused were 7.6±2.3, and 173 pedicle screws were placed. The preoperative coronal curve averaged 12.6°±6.2°, and it was corrected to 4.2°±1.9° postoperatively (t=4.628, P<0.01), the regional kyphosis was 67.2°±19.4°, and it was corrected to 15.7°±8.2° postoperatively (t=8.192, P<0.01). The SVA improved from (8.1±5.0) mm to (3.0±1.7) mm postoperatively. The mean duration of follow-up for all the patients were (38±11) months. At final follow-up, SVA was reduced to (2.4±2.0) mm and the other parameter kept stable. Thirteen patients had more than one grade improvement of Frankel grade. The VAS score for all patients improved from 4.7±2.8 to 2.2±0.5 postoperatively (t=3.973, P=0.01), and improved to 0.5±0.5 at final follow-up (t=-7.880, P<0.01). No recurrence of primary spinal tuberculosis was seen at final follow-up of all patients. Conclusions: One-stage posterior correction and second-stage anterior complementary debridement and fusion is an effective procedure for children with thoracic tuberculosis complicated with kyphoscoliosis. Significant postoperative deformity correction could be achieved with satisfactory improvement of neurological function. Solid fusion and satisfactory correction maintenance were observed at mid-to long-term follow-up.

Direct observation of magnetic contrast obtained by photoemission electron microscopy with deep ultra-violet laser excitation

Magnetic circular dichroism (MCD) and magnetic linear dichroism (MLD) have been investigated in a photoemission electron microscopy (PEEM) system excited by a deep ultra-violet (DUV) laser (with λ = 177.3 nm and hυ = 7.0 eV) for the first time. High resolution PEEM magnetic images (down to 43.2 nm) were directly obtained on a (001)-oriented magnetic FePt film surface with a circularly-polarized light under normal incidence. Furthermore, a stepped Cr seeding layer was applied to induce the formation of large-area epitaxial FePt films with (001) and (111) two orientations, where MLD with large asymmetry was observed in the transition area of two phases. It demonstrates that DUV laser can be a powerful source for high resolution magnetic imaging in the laboratory in absence of synchrotron facilities.

[Comparison of hybrid and traditional growing rod techniques in the treatment of early-onset congenital scoliosis]

Objective: To compare the surgical outcomes between hybrid and traditional growing rod (GR) techniques in the treatment of early-onset congenital scoliosis (C-EOS). Methods: A review was conducted of C-EOS patients who had undergone hybrid GR treatment at Department of Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School. Another group of patients who had undergone traditional GR were well matched to the hybrid GR group at a 1∶1 ratio in terms of main Cobb angle, age at initial surgery, and lengthening numbers. There were 5 boys and 8 girls with an age of (5.6±2.8) years in the hybrid GR group, and 6 boys and 8 girls with an age of (6.1±3.0) years in the traditional GR group, respectively. All patients had minimum 2-year follow-up and over 2 lengthening procedures. Radiographic data were compared with paired t tests in either group between each visit, and with independent t tests between the two groups. Results: On average, the hybrid group had a follow-up of (42.2±13.4) months (range:27-81 months), and had (4.0±1.8) lengthening procedures with a lengthening interval of (10.5±1.0) months; and the traditional GR group had a follow-up of (45.4±15.2) months (range: 24-76 months), and experienced (4.2±1.9) lengthenings with an interval of (10.8±1.1) months. After the index surgery, the major Cobb angle, C(7) translation, apical vertebral translation, and thoracic kyphosis (TK) had remarkable improvement in both groups. Notably, the hybrid GR group had significantly higher correction rates of major Cobb angle (t=2.348, P=0.027) and TK (t=3.768, P<0.001) than the traditional GR group. At the latest follow-up, the hybrid GR group had remarkably smaller Cobb angle of the major curve than the traditional GR group (t=2.790, P=0.010). At the same time, the hybrid GR group had higher T(1)-S(1) height gain than the traditional GR group (t=2.846, P=0.008) after the index surgery. Whereas, non-significant difference was noted between two groups with regards to the T(1)-S(1) growth rate during follow-up (t=0.516, P=0.610). Ten complications occurred during the follow-up period, including 2 in the hybrid GR group and 8 in the traditional GR group. The incidence of rod breakage and PJK in the traditional group was 3 and 4 times as high as that of the hybrid GR group, respectively. Conclusions: The hybrid growing rod can not only help to improve the correction of spinal deformity but also decrease postoperative complications during follow-up. Moreover, apical short fusion shows no significant influence on spinal growth.

[Efficiency of preoperative Halo-gravity traction in severe kyphoscoliosis secondary to neurofibromatosis type Ⅰ]

Objective: To evaluate the efficiency of preoperative Halo-gravity traction (HGT) in the treatment of severe kyphoscoliosis secondary to neurofibromatosis type Ⅰ (NF1). Methods: A retrospective review was conducted on patients with severe kyphoscoliosis secondary to NF1 at Department of Spinal Surgery, Drum Tower Hospital, Medical School of Nanjing University between July 2007 and May 2016. A total of 29 patients including 17 males and 12 females were finally enrolled and the age was (13.7±2.9) years. The Cobb angle of major coronal curve and global kyphosis were measured before and after HGT. The forced vital capacity (FVC)and forced expiratory volume in 1 second (FEV(1)) before and after traction were also recorded. The paired t test was used for comparison analysis. Results: The average maximum traction weight of HGT was (12.2±2.8) kg and the traction duration was (10.2±6.6) weeks. The coronal Cobb angle before HGT was (87.5±36.5)°, which improved to (68.4±25.9)° after HGT with a correction rate of (21.9±12.1)% (t=9.14, P<0.001); the average global kyphosis before HGT was (79.1±27.1)°, which improved to (59.9±19.4)° after HGT and the correction rate was (20.2±14.1)% (t=8.55, P<0.001). One patient had transient brachial plexus palsy which resolved completely after reducing the traction weight. After HGT treatment, FVC increased from (0.83±0.16) L to (0.89±0.19) L (t=1.48, P=0.12) and FEV(1) increased from (0.72±0.16) L to (0.78±0.20) L (t=0.49,P=0.63). FVC predicted and FEV(1) predicted improved from (42.9±20.1)% and (40.6±19.6)% to (46.9±20.5)% (t=0.98,P=0.33) and (43.6±25.8)% (t=1.24,P=0.22), respectively. Conclusion: Preoperative HGT in the treatment of severe kyphoscoliosis secondary to NF1 can improve spinal deformity and pulmonary function to some extent, which can further benefit the patients by improving their surgical tolerance.

[Correlation between syrinx resolution after posterior fossa decompression and cervical sagittal profile change in adolescents with Chiari malformation and syringomyelia]

Objective: To evaluate the long term change of the cervical sagittal profile in adolescent Chiari malformation type Ⅰ (CMI)/syringomyelia undergoing posterior fossa decompression (PFD) and to further evaluate the correlation between the syrinx resolution and cervical sagittal profile. Methods: A retrospective radiographic study was performed in 32 adolescents undergoing PFD for CMI/syringomyelia from October 2011 to August 2015 with a minimum 2-year follow-up. There were 23 males and 9 females, with a mean age of (13.7±2.8) years (range, 10-16 years). The following parameters including upper cervical angle (C(0)-C(2)), lower cervical angle (C(2)-C(7)), sagittal balance (C(2)-C(7)SVA), cervical curvature index (CCI), syrinx size and length were compared preoperatively and at the last follow-up. The correlation of syrinx resolution and cervical sagittal parameters were further analyzed with Pearson correlation analysis. Results: All patients received a followed-up for 2.0-6.5 years [mean (3.9±1.1) years]. The lower cervical angle and CCI were-29.8°±11.4° and 29.1%±7.1% at the last follow-up, respectively, which were significantly higher than those before surgery (-15.2°±8.8°, 13.4%±4.2%)(t=2.917, 2.902, both P<0.05). The syrinx size and length were also obviously decreased at the last follow-up. No significant difference was found in the upper cervical angle and C(2)-C(7)SVA before operation and at the last follow-up (t=0.302, 0.871, both P>0.05). There were significantly positive correlations between the differences of syrinx width and the lower cervical angle, and the CCI before and after surgery (r=0.611, 0.652, both P<0.05). Significantly positive correlations were also observed between the differences of syrinx length and the lower cervical angle, and the CCI before and after surgery (r=0.504, 0.514, both P<0.05). Conclusions: The cervical lordosis can be restored after PFD in adolescents with CMI/syringomyelia. The resolution of syrinx may play an important role in restoring the cervical sagittal alignment.

Loss at 16q22.1 identified as a risk factor for intrahepatic recurrence in hepatocellular carcinoma and screening of differentially expressed genes

Copy number alteration (CNA) of chromosome 16, a frequent genetic event in tumors including hepatocellular carcinoma (HCC), has been associated with HCC etiology of hepatitis B virus (HBV) and with clinical outcomes in multiple types of cancer. This study identified CNAs in chromosome 16 in relation to intrahepatic recurrence of HCC in a population with high HBV prevalence, and further screened for differentially expressed genes in recurrence-related CNAs. Array comparative genomic hybridization and expression arrays were used to detect CNAs and gene expression differences, respectively. The associations between CNAs and intrahepatic recurrence were analyzed on 66 patients, follow-up period of 3-73 months. One hundred and nine cases were further evaluated regarding the differentially expressed genes. Losses at 16q and 16p were detected in 62.1% and 51.5% of the 66 cases, respectively. The most recurrent CNAs (with frequency >20%) were losses at 16p13.3-13.2, 16p13.11, 16q11.2-22.1, 16q22.1, 16q22.2-24.2 and 16q24.2. Of the CNAs, 16q22.1 loss was significantly associated with unfavorable intrahepatic recurrence-free survival (P = 0.025). Multivariate Cox analysis identified 16q22.1 loss as an independent risk factor for intrahepatic recurrence (HR = 2.32, 95% CI = 1.26-4.27). A panel of 21 genes, including TRADD, PSMB10, THAP11, CTCF and ESRP2, were significantly downregulated in HCCs with 16q22.1 loss compared to those without the loss. These results suggest that loss at 16q22.1 was associated with increased risk for intrahepatic recurrence of HCC, at least in the HBV-prevalence population. Multiple downregulated genes correlated with the loss were screened.

[Design of cross-sectional anatomical model focused on drainage pathways of paranasal sinuses]

Objective:To design and produce cross-sectional anatomical models of paranasal sinuses for the purpose of demonstrating drainage pathways of each nasal sinus for the young doctors. Method:We reconstructed the three-dimensional model of sinuses area based on CT scan data, and divided it into 5 thick cross-sectional anatomy models by 4 coronal plane，which cross middle points of agger nasi cell, ethmoid bulla, posterior ethmoid sinuses and sphenoid sinus respectively. Then a 3D printerwas used to make anatomical cross-sectional anatomical models.Result:Successfully produced a digital 3D printing cross-sectional models of paranasal sinuses. Sinus drainage pathways were observed on the models. Conclusion:The cross-sectional anatomical models made by us can exactly and intuitively demonstrate the ostia of each sinus cell and they can help the young doctors to understand and master the key anatomies and relationships which are important to the endoscopic sinus surgery.

[Comparison of spontaneous correction in thoracic curves after anterior versus posterior selective fusion in Lenke type 5C adolescent idiopathic scoliosis]

Objective: To analyze the long-term results and the influence factors of spontaneous correction of unfused thoracic curves in anterior and posterior selective fusions in Lenke type 5C adolescent idiopathic scoliosis (AIS). Methods: From January 2005 to December 2011, 89 Lenke type 5C AIS patients with a minimum of 5-year follow-up who underwent thoracolumbar/lumbar (TL/L) selective fusion in Spine Surgery of Nanjing Drum Tower Hospital were reviewed.Forty-six patients underwent anterior fusion (anterior group), while 46 underwent posterior fusion (posterior group). The following radiological parameters were measured and analyzed at pre-operation, post-operation, and latest follow-up: curve magnitude of primary thoracolumbar/lumbar and secondary thoracic curve, trunk shift, thoracic apical vertebral translation, upper instrumented vertebra tilt, thoracic kyphosis, proximal junctional angle, sagittal vertical axis. Independent sample t test was used to compare the above parameters between the two groups. Results: Compared with those in posterior group, anterior group were found with less fusion levels (5.4±0.6 vs 5.9±0.8, t=3.318, P=0.001) and longer operation time[(276±28)min vs (186±36)min, t=13.101, P<0.001]. Immediately after surgery, the spinal deformity was significantly corrected in the two groups. The mean spontaneous correction rates of the minor curve were 50%±21% and 56%±20% in anterior and posterior groups, respectively (t=1.489, P=0.140). After a mean follow-up of (6.8±1.7) years in anterior group and (6.3±1.3) years in posterior group, the spontaneous correction rate of minor curve was maintained at 46%±22% and 49%±19%, respectively (t=0.703, P=0.484), with no significant correction loss. Other radiographic parameters were also stably maintained. According to the correlation analysis, the spontaneous correction rate was significantly correlated with upper instrumented vertebra (UIV) tilt in both groups (anterior: r=-0.526, posterior: r=-0.399, both P<0.05). Conclusions: Both anterior and posterior selective fusion can achieve satisfactory spontaneous correction of unfused thoracic curves in Lenke type 5C AIS, with no significant difference between the two surgical approaches. UIV tilt is a key influence factor of spontaneous correction of thoracic curves.

[Genetic analysis of posterior cranial fossa morphology in families of Chiari malformation type Ⅰ]

Objective: To explore genetic characteristic of posterior cranial fossa morphology in families of Chiari malformation type Ⅰ (CMI). Methods: From April 2010 to May 2016, a total of 47 cases of CMI families (CMI group) and their 94 parents (CMI-P group)collected were retrospectively reviewed in Department of Spinal Surgery, Drum Tower Hospital, School of Medicine, Nanjing University.Another cohort of 50 asymptomatic adults was enrolled to serve as the control group.Patients with skull fracture or other diseases which can lead to secondary CMI were excluded.On mid-sagittal T2-weighted magnetic resonance (MR) imaging, four measurements were evaluated and compared between these three groups, including the length of cerebellar tonsillar descent, the area of posterior cranial fossa(PCF area), the area of the brain tissue in posterior cranial fossa (PCF tissue area), and the PCF crowdedness indexes (PCF tissue area/ PCF area×100%). Results: Totally 47 CMI patients (21 males and 26 females; mean age, 16.4 years), 94 parents (47 males and 47 females; mean age, 39.2 years) and 50 controls (23 males and 27 females; mean age, 22.3 years) were recruited in this study.Significant differences in all four indexes were found between CMI group and the control group.The length of cerebellar tonsillar descent were much bigger in CMI-P group than in the control group (1.5±2.2 mm vs -0.9±1.1 mm), with 7 cases reach the diagnostic criteria of Chiari malformation(≥5 mm) and one with syingomyelia.Compared to the control group, CMI-P group had smaller PCF area, and its PCF crowdedness indexes averaged 90.0% as between the control group (85.3%) and the CMI group (93.6%). Conclusions: In CMI families, parents have similar posterior cranial fossa abnormalities with their CMI children, presenting obviously narrow and crowded.Their PCF crowdedness indexes are between normal subjects and CMI patients, and their cerebellar tonsils are lower, even some parents are also CMI patients, suggesting genetic mechanisms involved in the development of CMI.

[Similar coronal curvature may not represent the same 3-dimensional deformity in adolescent idiopathic scoliosis: a matched-pair study using EOS imaging system]

Objective: To analyze the preoperative axial plane and the surgical outcomes of the Lenke type 1A patients with adolescent idiopathic scoliosis (AIS) whose coronal curve type was matched but thoracic kyphosis (TK) was different. Methods: This study retrospectively reviewed a series of Lenke type 1A female AIS patients who underwent corrective surgery in the Department of Spine Surgery of Nanjing Drum Tower Hospital from May to August 2017. After matched with the Cobb angle of the main thoracic curve, the apical vertebral, the vertebra number included in the curve, the lumber modifier in the Lenke classification and Risser sign, 12 pairs of AIS patients, whose coronal curve was matched but thoracic kyphosis was different, were included in this study. The patients were divided into normal TK group and thoracic hypokyphosis group. EOS whole-body images were taken preoperatively and reconstructed by three-dimensional reconstruction. The whole spine anteroposterior X-ray was taken at 3 weeks after surgery. The radiographic parameters were measured on the preoperative and postoperative two-dimensional X-ray images: coronal Cobb angle, TK, lumbar lordosis (LL), pelvic incidence (PI) and pelvic tilt (PT). The vertebra rotation was obtained on the EOS three-dimensional reconstructed image, and the average vertebral rotation of the major thoracic curve (MTR), the average vertebral rotation of the proximal thoracic curve (PTR) and the average vertebral rotation of the lumbar curve (LR) were calculated. The paired sample t test was used to compare the difference of preoperative and postoperative radiographic parameters between the groups. Results: A total of 24 patients (12 pairs) were included in this study with an average age of (13.7±2.9) years. The preoperative Cobb angle was similar in the two groups (53.8°±10.2° vs 51.0°±11.1°, t=0.27, P=0.81). The average preoperative TK of the normal TK groups was 28.2°±6.1°, while that of the thoracic hypokyphosis group was 11.2°±5.6°(t=7.68, P<0.01). The MTR in the normal TK group was significantly smaller than that in the thoracic hypokyphosis group (10.2° vs 12.7°, t=-3.74, P<0.01), and there was a significant correlation between TK and MTR (r=0.30, P=0.03). As for the lumbar curve rotation, the LR of the normal TK group was significantly smaller than that in the thoracic hypokyphosis group (t=-2.65, P=0.002), but the absolute value of the two groups was similar (t=-0.33, P=0.31). The lumbar Cobb angle correction rate was significantly greater in patients with thoracic and lumbar curve rotating in the same direction than that in the opposite direction (81.1% vs 61.9%, t=4.24, P=0.005). Conclusions: It indicated that when the coronal deformity is matched, the MTR of the patients with thoracic hypokyphosis is significantly larger than that in the patients with normal thoracic kyphosis. The direction of the thoracic and lumbar curve rotation is required to be well concerned in the preoperative surgical planning.

[Effects of Scoliosis Research Society-Schwab grade Ⅳ osteotomy for post-traumatic thoracolumbar kyphosis]

Objective: To evaluate the effectiveness of Scoliosis Research Society (SRS)-Schwab grade Ⅳ osteotomy in the treatment of post-traumatic thoracolumbar kyphosis (PTK). Methods: From October 2012 to January 2015, a total of 31 patients [12 males, 19 females, mean age (43±10) years] with symptomatic PTK undergoing SRS-Schwab grade Ⅳ osteotomy in Nanjing Drum Tower Hospital were retrospectively reviewed.Radiographic changes were evaluated with preoperative, postoperative and follow-up X-ray.The measurements included thoracic kyphosis (TK), lumbar lordosis (LL), thoracolumbar kyphosis (TLK), focal kyphosis (FK), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and sagittal vertical axis (SVA). Clinical outcome was assessed using the visual analogue scale (VAS), the Oswestry disability index (ODI) and Frankel neurological grade before surgery and during follow-up.The preoperative, postoperative and follow-up data were compared with paired t test. Results: All patients were followed-up for 28±5 months (24-38 months). The TK and LL improved significantly postoperatively from 15.6°±7.8° and 67.3°±12.2° to 28.1°±6.2° and 48.1°±9.3°(t=-6.985, 6.968, both P<0.05), and maintained at 27.3°±6.9° and 49.4°±7.9° at last follow-up, respectively.The TLK and FK improved significantly postoperatively from 29.4°±12.2° and 36.4°±9.5° to 7.7°±5.3° and 5.6°±4.2°(t=9.083, 16.510, both P<0.05), with a correction loss of 2.4°±2.0° and 2.3°±2.2° at final follow-up, respectively.No significant difference was observed in the PI, PT, SS and SVA among preoperative, post-operative and the last follow-up data.In addition, the VAS and ODI improved significantly at the final follow-up.Four cases with Frankel D experienced complete neurological recovery at the final follow-up.Radiographic evaluation showed solid bony fusion.No instrument-related complication was observed during the follow up. Conclusions: The SRS-Schwab grade Ⅳ osteotomy brings satisfactory sagittal alignment and good clinical outcomes in patients with PTK.

[Outcome of traditional growing rods for correction of apical vertebra rotation in early-onset scoliosis]

Objective: To evaluate the correction result of traditional dual growing rods on apical vertebral rotation. Methods: This study recruited 19 early-onset scoliosis patients (6 boys and 13 girls) who had received traditional dual growing rods treatment at Department of Spine Surgery, Nanjing Drum Tower Hospital from January 2009 to July 2015. The age at initial surgery was (5.7±1.7)years(range, 3 to 9 years). Measurements of primary curve magnitude, height of T(1)-S(1), apical vertebral translation(AVR), apical vertebral body-rib ratio, apical vertebral rotation, thoracic rotation and rib hump were compared between pre-operatively, post-operatively, and at latest follow-up, through a paired-t test. Pearson correlation test was used for correlation analysis between parameters. Results: All patients had a follow-up of (49.5±12.8)months(range, 24 to 71 months). A total of 111 operative procedures were performed, among which there were 92 lengthening procedures, averagely 4.8 lengthening procedures per patient. The average interval for each lengthening procedure was 10 months. The Cobb angle of primary curve was notably decreased from (66.5±13.2)° to (35.2±10.9)°(t=24.013, P<0.01), and no significant correction loss was found at the latest follow-up ((36.7±10.7)°)(t=-1.324, P=0.202). In addition, significant correction of AVR, thoracic rotation, apical vertebral translation, apical vertebra body-rib ratio, and rib hump were noted after initial surgery. Whereas, these parameters significant increased during follow-up(all P <0.05) except for thoracic rotation. Pearson correlation analysis showed that the increase of AVR during follow-up significantly correlated with change of apical vertebra translation, apical vertebral body-rib ratio, and rib hump(r=0.652, 0.814, 0.695; all P<0.05). Conclusions: Significant correction of AVR can be achieved after initial surgery in early-onset scoliosis patients treated with traditional dual growing rods. However, such a technique can hardly prevent the deterioration of AVR during follow-up.

[Comparison of the pulmonary function between adolescent patients with Chiari malformation associated scoliosis and idiopathic scoliosis]

Objective: To compare the pulmonary function between adolescent patients with Chiari malformation associated scoliosis (CMS) and adolescent idiopathic scoliosis (AIS). Methods: A retrospective analysis was performed on 52 patients with CMS, and 52 patients with AIS were selected as the control group to match the CMS patients by age, sex, and Cobb angle. Preoperative pulmonary function tests were completed by all the patients, including vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in one second (FEV(1)), maximal mid-expiratory flow (MMEF), and ratio of FEV(1) to FVC. The difference of pulmonary function parameters was analyzed between the two groups; Correlation between pulmonary function and radiographic parameters was analyzed in patients with CMS. Results: There were no significant differences in terms of sex, age, and the main coronal Cobb angle between the two groups. There were 42(80.7%) and 44(84.6%) of patients with restrictive ventilatory dysfunction (the percentage of predicted FVC<80%) in CMS and AIS group respectively. 18(42.8%) and 10 (22.7%) out of these patients were also with obstructive ventilation dysfunction (FEV(1)/FVC<92%) in CMS and AIS group respectively. Types of ventilation dysfunction distributed between the two groups had no significant difference (P>0.05). No significant difference was noted between the two groups in the percentage of predicted VC, FVC, FEV(1) and FEV(1)/FVC (P>0.05). The percentage of predicted MMEF in patients with CMS was lower compared to those with AIS[(57.9±13.3)% vs (67.2±23.3)%, P=0.053]. In patients with CMS, the percentage of predicted VC, FVC, FEV(1) and MMEF had significantly negative correlation with the number of vertebrae involved (P<0.01). Main coronal Cobb angle had negative correlation with the percentage of predicted VC, FVC and FEV(1) (P<0.05). The percentage of predicted VC, FVC and FEV(1) had positive correlation with thoracic kyphosis (P<0.05). Conclusions: There are no significant differences in characteristics of the pulmonary dysfunction between patients with AIS and CMS without obviously neural deficit. Both groups mainly present with restrictive ventilation dysfunction.

[Factors correlated with height gain after posterior spinal correction surgery in lenke 1 adolescent idiopathic scoliosis]

Objective: To investigate the correlated factors of height gain (ΔSH) after posterior spinal correction surgery in Lenke 1 adolescent idiopathic scoliosis (AIS), and to propose the predictive model of ΔSH. Methods: From 2013 to 2015, a total of 150 Lenke 1 AIS patients undergoing posterior spinal correction surgery were included in the study, with the age of (14.3±2.9) years. The Cobb angle of major curve, thoracic kyphosis (TK) and lumbar lordosis (LL) were measured on both pre-op and post-op standing whole spine x-rays. The change in Cobb angle, TK and LL were calculated. The difference between pre-operation and post-operation was compared and the linear regression analysis was used for the predictive model of ΔSH. Results: The pre-op and post-op values were (41.6±3.0)cm and (43.9±2.7)cm for spinal height (SH)[ΔSH=(2.4±0.8)cm, P=0.000]; (50.5±10.4)° and (14.6±6.4)° for Cobb angle (P=0.000). The Pearson correlation analysis showed that ΔSH was significantly correlated with pre-op SH (P=0.000), pre-op Cobb angle (P=0.000), pre-op TK (P=0.000), post-op SH (P=0.020), post-op Cobb angle (P=0.000), change in Cobb angle (P=0.000) and change in TK (P=0.000). The linear regression model 1 revealed that ΔSH was linearly correlated with change in Cobb angle (P=0.000) as well as change in TK (P=0.000); the linear regression model 2 showed that the pre-op Cobb angle (P=0.000) and pre-op TK (P=0.020) could be used for the pre-op prediction of ΔSH. Conclusions: The positively correlated factors of ΔSH include pre-op and post-op Cobb angle, TK, change in Cobb angle and change in TK. High pre-op Cobb angle and TK indicates high height gain in Lenke 1 AIS patients.

[Clinical application of three-dimensional O-arm navigation system in treating patients with dystrophic scoliosis secondary to neurofibromatosis type Ⅰ]

Objective: To investigate the clinical outcomes and the accuracy of O-arm-navigation system assisted pedicle screw insertion in dystrophic scoliosis secondary to neurofibromatosis type Ⅰ(NF-1). Methods: A retrospective study was conducted in 41 patients with dystrophic NF-1-associated thoracic scoliosis who were surgically treated at Department of Orthopaedics, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School between June 2012 and October 2014 with more than 18 months follow-up. The patients were then divided into two groups: 18 patients were under the assistance of O-arm-navigation-based pedicle screw insertion (O-arm group) and the remaining 23 patients' pedicle screws insertion were conducted by free-hand (free-hand group). The X-ray and CT were analyzed to investigate the correction rate and safety of pedicle insertion. t-test was used to analyze measurement data and χ(2) test was used to analyze accuracy of screw insertion between the two groups. Results: The mean coronal Cobb angle was 63.2°±8.7° in the O-arm group and 66.9°±7.4° in the free-hand group (P>0.05), which was then corrected into 23.1°±6.8° and 30.2°±7.6°(t=2.231, P=0.031) after surgery respectively.Operation time was (265.0±70.3)minutes and estimated blood loss was (1 024±465)ml in the O-arm group. Operation time and estimated blood loss was (243.0±49.6)minutes and (1 228±521)ml respectively in the free-hand group, which had no significant difference between the two groups. However, the implant density was higher in the O-arm group than that in the free-hand group ((64.1±10.8)% vs.(44.3±15.3)%)(t=4.652, P=0.000). The O-arm group comprised 122 screws, of which 72.9% were excellent, 22.1% were good and 4.9% were bad. The free-hand group comprised 136 screws and 48.5% of them were excellent, 33.8% were good and 17.6% were bad.Accuracy of pedicle screw insertion was higher in the O-arm group than that in the free-hand group(χ(2)=10.140, P<0.05). By June 2016, the average follow-up period was (20.9±3.4)months(ranging from18 to 26 months), including (20.3±3.1)months in the O-arm group and (21.4±5.5)months in the free-hand group. At last follow-up point, coronal correction loss was significantly higher in the free-hand group than that in the O-arm group (6.3°±2.6° vs. 4.4°±1.6°)(t=2.719, P=0.009). Conclusions: Compared with free-hand technique, O-arm-navigation technique could enhance accuracy of pedicle insertion and implant density of dystrophic region in dystrophic NF-1-associated scoliosis patients, which result in a better correction rate and less correction loss. Besides, the advantage of O-arm-navigation do not increase operative time and estimate blood loss.

[Copy number aberrations of genes related to extrohepatic metastasis-free survival after operation for hepatocellular carcinoma]

Objective: To investigate the molecular markers of copy number aberrations (CNAs) of genes related to extrohepatic metastasis-free survival after the operation for hepatocellular carcinoma (HCC). Methods: The CNA status of 20 candidate genes in 66 HCC samples was detected by microarray comparative genomic hybridization. The associations between gene CNAs and extrohepatic metastasis-free survival were evaluated using the Cox regression model, Log-rank test, and Kaplan-Meier survival analysis. Results: Multivariate Cox analysis revealed that the independent risk factors for metastasis-free survival were MDM4 gain (hazard ratio [HR] = 2.74, 95% confidence interval [CI] = 1.18-6.37, P < 0.05), APC loss (HR = 8.43, 95% CI = 2.48-28.66, P < 0.01), and BCL2L1 gain (HR = 3.45, 95% CI = 1.13-10.52, P < 0.05) and the independent protective factor was FBXW7 loss (HR = 0.32, 95% CI = 0.12-0.89, P < 0.05). By stepwise Cox regression analysis, three CNAs related to metastasis-free survival were screened out: MDM4 gain (HR = 2.71, 95% CI = 1.11-6.64, P < 0.05), APC loss (HR = 7.19, 95% CI = 1.88-27.60, P < 0.005), and FBXW7 loss (HR = 0.16, 95% CI = 0.05-0.46, P < 0.01). There were significant differences in metastasis-free survival rate between the HCC patients with FBXW7 loss and without MDM4 gain or APC loss, those with MDM4 gain and/or APC loss and without FBXW7 loss, and those with other CNA combinations (log-rank test, P < 0.01). Conclusion: MDM4 gain, APC loss, and FBXW7 loss are the independent prognostic factors for extrohepatic metastasis-free survival after the operation for HCC and can be used to predict the risk of extrohepatic metastasis after the operation for HCC.

[A novel self-growing rod technique for early onset scoliosis: an experimental study based on a porcine scoliosis model]

OBJECTIVE

To evaluate the efficacy of a growth-guidance growing rod in an established porcine scoliosis model via the Cobb angle correction and the continued spinal growth.

METHODS

Immature pigs (age: 6 weeks old, weight: 6-8 kg) were instrumented and tethered using a three separate incisions fashion.After considerable scoliosis was induced, the pigs were randomly assigned to an experiment group (EG) and a sham group (SG). In EG, the growing rod was implanted and the pigs were euthanized 8 weeks postoperatively; while in SG, the whole instrumentations were only removed and the pigs were followed up over a 8-week period.Dorsoventral (DV) X-ray radiographs were taken prior to and immediately after the growing rod implanting surgery, and at 4-week intervals to assess the Cobb angle orrection and instrumentation positioning.The continued spinal growth and the rod sliding were also assessed from the radiographs.

RESULTS

Of the 16 pigs, one pig encountered infection during the inducement of the experimental scoliosis and thus was excluded from analysis.Of the remaining 15 pigs, all animals developed progressive, structural scoliosis.The 15 pigs were randomized into EG(n=10) and SG(n=5). Two pigs in EG encountered infection and were also excluded from analysis.Of the remaining 8 pigs in EG, no neurologic complications, implant failure or infection were observed.In EG, the Cobb angle of the scoliosis before the growing rod implanted was (52.1 ±14.1)° and it decreased to (25.4±15.2)° postoperatively.After 8 weeks, the Cobb angle was (20.2±11.4)°.In SG, the Cobb angle of the scoliosis after 8-week tethering period was (55.2±15.7)° and it decreased to (53.6±15.8)° after removal of the tethering.The curvature remained stable (51.2°) during the subsequent 8 weeks.During the 8-16th week, the spinal height increased 14.2 cm and radiographic analysis of the growing rod sliding revealed an average distraction of 39.8 mm in EG; while in SG, the increased spinal height was 14.9 cm.The difference of the increased spinal height between EG and SG was not significant (P=0.821).

CONCLUSION

The novel growing rod system can provide substantial correction of deformity, and additionally, allow for continually spinal growth without significant growing disturbance.

A model of blind zone for in situ monitoring the solid/liquid interface using ultrasonic wave

To in situ monitor a solid/liquid interface to control metal qualities, the paper analysis blind models of the ultrasonic propagation in the solidifying molten metal with a solid/liquid interface in the Bridgman type furnace, and a mathematical calculation model of blind zone with different source locations and surface concavities is built. The study points out that the blind zone I is caused by ray bending in the interface edge, and the blind zone II is caused by totally reflection which is related with initial ray angle, critical refraction angle of solid/liquid media. A serial of simulation experiments are operated on the base of the model, and numerical computation results coincide with model calculated results very well. Therefore, receiver should locate beyond these blind zones in the right boundary to obtain time of flight data which is used to reconstruct the solid/liquid interface.

Common characteristics shared by different differential phase contrast imaging methods

There are many variations of differential phase contrast imaging methods. Although these imaging methods are different in configuration, they are alike in imaging by extracting differential phase information through the evaluation of the refraction angles. In this paper, we investigate common characteristics shared by various different differential phase contrast imaging methods.

Posterior second sacral alar iliac screw insertion: anatomic study in a Chinese population

OBJECTIVE

To provide radiographic parameters for optimal placement of posterior second sacral alar iliac (S2AI) screw for instrumentation and fusion of scoliosis to the second sacral level in a Chinese population.

METHODS

S2AI screw trajectories were mapped on three-dimensional computed tomography (3DCT) reconstructions of 60 normal adult pelvises. 1 mm inferior and 1 mm lateral to the S1 dorsal foramen were chosen as the entry point, and ideal S2AI screw trajectories were explored by rotating and cutting the 3D pelvis, ensuring that the trajectories were of maximum length and width. The directions and depth of these determined trajectories were then measured.

RESULTS

The ideal S2AI screw trajectories could be found in each pelvis. The left and right screw trajectory parameters for males were shown as follows: angulation was L 29.15 ± 8.60° vs. R 29.96 ± 8.28° (p = 0.286) caudally in the sagittal plane and L 36.49 ± 3.14° vs. R 37.16 ± 3.14° (p = 0.165) laterally in the transverse plane. The maximal and intrasacral lengths of trajectory were L 121.25 ± 8.33 vs. R 120.63 ± 7.54 mm (p = 0.460) and L 26.20 ± 3.31 vs. R 26.92 ± 4.76 mm (p = 0.268). The entry point was L 28.87 ± 3.33 vs. R 29.79 ± 3.55 mm (p = 0.186) lateral to the second sacral midline, and L 44.14 ± 11.87 vs. R 43.89 ± 12.53 mm (p = 0.687) underneath the skin. The trajectories for females were more caudal (L: 34.50 ± 6.56° vs. 29.15 ± 8.60°, p = 0.009; R: 35.72 ± 7.53° vs. 29.96 ± 8.28°, p = 0.007) in the sagittal plane, but the lateral angulation in the transverse plane showed no difference between genders (p > 0.05). The female iliac medullar cavities were obviously narrower than those of males (L: 14.76 ± 2.46 vs. 16.98 ± 3.52, p = 0.006; R: 14.94 ± 2.60 vs. 17.00 ± 2.81, p = 0.005). Although the average maximal length of trajectories for females were about 5 mm shorter than those of males, intrasacral length were equal to those of males. Furthermore, both the distance from entry point to the S2 midline and skin in the transverse plane showed no difference between genders.

CONCLUSION

The feasibility to insert S2AI screws to the sacrum and ilium in an Asian population along with the ideal entry angle and length of trajectory were identified for clinical practice.

STAT3 gene polymorphisms and susceptibility to non-small cell lung cancer

Signal transducer and activator of transcription protein 3 (STAT3) has been implicated in cancer development and is recognized as a type of oncogene. However, association studies of single nucleotide polymorphisms (SNPs) in the STAT3 gene with cancer risk are rare and not available for lung cancer. We examined whether STAT3 polymorphisms are associated with the risk of non-small cell lung cancer (NSCLC). Eight SNPs in the STAT3 gene were genotyped by TaqMan assays in 326 NSCLC cases and 432 controls in a Chinese population. Significant decreased risk of NSCLC was observed for carriers of minor alleles rs4796793 (odds ratio (OR) = 0.68, 95% confidence interval (CI) = 0.51-0.92), rs7211777 (OR = 0.67, 95%CI = 0.50-0.90), rs12949918 (OR = 0.73, 95%CI = 0.54-0.97), rs744166 (OR = 0.69, 95%CI = 0.51-0.92), rs9912773 (OR = 0.75, 95%CI = 0.55-0.98), and rs3869550 (OR = 0.70, 95%CI = 0.53-0.94). The GGCGGC haplotype, comprised of minor alleles of the six NSCLC-associated SNPs, had a 0.78-fold (95%CI = 0.62-0.97) significantly decreased risk of NSCLC, as compared to the most common haplotype of CATACT. Stratification analyses by clinical stage showed that the trend for the association between STAT3 polymorphisms and NSCLC risk was present both for stage I/II and stage III/IV, and appeared moderately stronger for stage III/IV. We conclude that polymorphisms in the STAT3 gene may have a protective role in the development of NSCLC, particular of stage III/IV NSCLC.

[Effect of sanhuang jiangtang recipe on insulin peripheral resistance in type II diabetics]

OBJECTIVE

To observe the effect of Sanhuang Jiangtang recipe (SHJT) on insulin peripheral resistance in type II diabetics.

METHODS

Ninety-five patients with type II diabetics were randomly divided into two groups. Fifty-three cases of SHJT group were given orally decoction and tablets of SHJT for 4-6 months. The efficacy was compared with that of 42 cases treated with Glipizide as the control. Before and after treatment standard steamed bread meal test was performed to measure the insulin peripheral sensitivity, insulin release to glucose and insulin sensitivity index.

RESULTS

(1) The total effective rates of improving insulin peripheral resistance and reducing blood sugar in SHJT group were 79.2% and 80.1%, which was equivalent to levels in the control group, but SHJT recipe was more effective in relieving symptoms of Qi deficiency and signs of blood stasis. (2) In SHJT group, the insulin peripheral sensitivity and insulin sensitivity index were significantly increased (P < 0.05 and P < 0.01), meanwhile the fasting blood sugar and blood sugar area were reduced (P < 0.05), but the change of insulin release to glucose was blunted. (3) The lowering of blood sugar in SHJT group was significantly negative correlated with the changing of degree of insulin peripheral sensitivity and index of insulin sensitivity (P < 0.01 and P < 0.05), but not with that of insulin area.

CONCLUSIONS

It suggested that the treatment of SHJT recipe might decrease insulin peripheral resistance (partial reversal) by means of reducing hyperinsulinemia and improving insulin sensitivity.

[Effects of supplemented taohe chengqi decoction in treating insulin resistance in rats with non-insulin dependent diabetes mellitus]

OBJECTIVE

To investigate the effect of Supplemented Taohe Chengqi Decoction (STHCQD) in treating non-insulin dependent diabetes mellitus (NIDDM).

METHODS

The model of rats with NIDDM was formed with injection of streptozotocin and fed on high calorie diet to study the effects of STHCQD on the release of insulin mediator from liver cell membranes, the glucose oxidation in adipocytes as well as the insulin sensitivity.

RESULTS

(1) Fasting serum glucose, serum insulin, intake of food and water were significantly decreased (P < 0.05-0.01) in STHCQD-treated diabetic rats as compared with untreated diabetic rats, while the insulin sensitivity was significantly increased (P < 0.05). (2) The liver cell membranes from STHCQD-treated diabetic rats released the quantity of insulin receptor which inhibited adenylate cyclase activity, but this effect was blunted in untreated diabetic rats (P < 0.05). (3) A significantly increased glucose oxidation in adipocyte of STHCQD-treated diabetic rats was found as compared with those of untreated diabetic rats (P < 0.05).

CONCLUSIONS

STHCQD therapy increased sensitivity and responsiveness of target cells to insulin, i.e., it might decrease insulin resistance at receptor sites and postreceptor sites in rats with NIDDM, but could not reverse the insulin resistance.

[Relationship between various syndrome-types and defect of erythrocyte insulin receptors in non-insulin dependent diabetes mellitus]

Fifty-seven patients of non-insulin dependent diabetes mellitus (NIDDM) were divided into various groups by Syndrome Differentiation in TCM and 18 cases of non-diabetes mellitus were taken as control. The relationship of Syndrome-types and defect of the erythrocyte insulin receptors were studied with the percentage of specific insulin binding to erythrocyte, number and average affinity of erythrocyte insulin receptors. The results showed: (1) The patients of NIDDM had defect of erythrocyte insulin receptors specified with decreased number of insulin receptors; (2)Mild defect of erythrocyte insulin receptors was found in Syndrome of Yin Deficiency and hyperactivity of Heat, but serious defect in the Syndrome of both Qi and Yin Deficiency, in the Syndrome of both Yin and Yang Deficiency. Above data suggested that the defect of erythrocyte insulin receptors was correlated with Syndrome-types of patients with NIDDM, the more serious Deficiency Syndrome, the more serious defect of erythrocyte insulin receptors.