To the Editor: The hemivertebra is an unusual but not rare spinal deformity, which could result in progressive congenital scoliosis (CS). Owing to its poor response to brace treatment, early surgical intervention is usually required for correcting deformity and preventing curve progression.[1] Hemivertebra resection has been proved to be an effective surgical treatment for CS secondary to hemivertebra. The best indication is isolated hemivertebra in young children.[2] Unfortunately, some CS patients, especially in the rural areas, remain under-diagnosed and untreated until reaching their adolescence. Aggravated spinal deformity and associated back pain urge them to seek for surgical treatment. Clinically, the adolescent case usually presents a large hemivertebra, which means conventional hemivertebra resection would leave a large residual gap between the vertebrae. Thus, it is a high-demanding technique to perform subsequent mechanical compression and shortening procedure, which may lead to failed bone fusion or other neurological complications.[3] As is known, progression of the curve is most rapid during the adolescent growth spurt and it stops at skeletal maturity. For a nearly matured spine, its remaining growth potential to cause further deformity is limited. Does a late adolescent patient really need a complete hemivertebra excision for CS? The other suitable surgical option is still worth investigating. Compared with conventional hemivertebra resection, wedge osteotomy (WO) may be another feasible option for some adolescent patients. This study is designed to compare the long-term clinical outcomes of different surgical strategies for adolescent patients with congenital hemivertebra. This retrospective study was approved by the Ethics Committee of Renji Hospital, Shanghai Jiaotong University School of Medicine (No. KY2022-002-B) and with a waiver of consent. This study included all adolescent patients with CS who underwent correction surgeries in Renji Hospital between January 2009 and June 2015. The inclusion criteria were as follows: (1) Diagnosed with CS due to hemivertebra; (2) Age between 14 years and 20 years; (3) Risser sign ≥grade 4; (4) Coronal scoliosis curve <60° and sagittal kyphosis <30°; and (5) With a minimum of 8-year follow-up. Patients with previous spinal surgery or incomplete medical data were excluded. Medical records were reviewed to identify demographic data, operating time, average blood loss, and any complications in the intraoperative and follow-up periods. This initial search yielded 67 CS patients due to hemivertebra. Of them, 10 patients lacked incomplete medical data and 14 patients (20.1%) were lost to follow-up. Finally, a total of 43 patients who satisfied the aforementioned criteria were enrolled in this study. Correction surgeries were indicated for their late-diagnosed spinal prominence and trunk imbalance. All patients' spinal growth was beyond the phase of adolescent growth spurt. Because there is no agreed-on standard for the surgical intervention for hemivertebra, the patients were treated by different surgical strategies according to the spine surgeons' own experience. They were divided into two categories: WO group and complete resection (CR) group. All surgeries were performed by a senior surgeon in our department. In the CR group, the patients were treated with CR of hemivertebra through posterior approach. The upper and lower disks of hemivertebra, including the cartilage endplates, were removed completely. In the WO group, the patients were treated by partial resection of hemivertebra. A wedge-shaped bone resection of the hemivertebra was performed on the guidance of preoperative designed angle of osteotomy [Figure 1]. During the procedure of osteotomy, the base was the posterior border of the vertebral body, and the apex of the osteotomy was the midpoint of the anterior margin of the hemivertebra body. The intervertebral disk and little cancellous bone of the hemivertebra were preserved.[4]Figure 1: The degree of the WO (W) is approximately equal to the coronal Cobb angle of the segmental curve (S). After wedge osteotomy of hemivertebra, the correction of the scoliosis and trunk imbalance was satisfied and maintained well after 10-year follow-up. The CT reconstruction show solid fusion. Line a/b: A vertical line is drawn along the inferior endplate of the upper end vertebral body and the superior endplate of the lower end vertebral body, respectively, named lines a and b, and the angle between the two lines is defined as coronal Cobb angle (S). CT: Computed tomography; WO: wedge osteotomy.Radiographic measurements were taken from standing posteroanterior and lateral radiographs before surgery, 1 week after surgery, and during the last follow-up. Proximal junctional kyphosis (PJK) was defined as the proximal junction angle at least 10° greater than the preoperative value. Radiographs taken at the latest follow-up were reviewed to determine the implant position, any implant failure, or pseudarthrosis. All radiographic parameters were independently measured by two spine surgeons. All patients were required to fulfill the Scoliosis Research Society-22 (SRS-22) Questionnaire both at preoperation and at the last follow-up in order to assess the improvement in health-related quality of life (HRQoL). The SRS-22 covers five domains including function, pain, self-image, satisfaction with treatment, and mental health. The WO group consisted of 23 patients with an average age of 16.4 years (range: 14.0–20.0 years) at surgery. The CR group comprised 20 patients with an average age of 15.9 years (range: 14.0–19.0 years). The hemivertebra was located in the thoracic spine in 9 cases, in the thoracolumbar region in 22 cases, and in the lumbar spine in 12 cases. All hemivertebra were non-incarcerated [Supplementary Table 1, https://links.lww.com/CM9/C313]. The average follow-up was 106.8 months (98.0–130.0 months) and all cases reached skeletal maturity at the final follow-up. The mean fusion level was 3.8 segments in the WO group and 3.5 segments in the CR group. The mean operation time was 193.8 ± 72.4 min (range: 145.0–275.0 min) in the WO group and 315.2 ± 100.6 min (range: 180.0–390.0 min) in the CR group. The average estimated blood loss was 435.2 ± 360.7 mL (range: 330.0–850.0 mL) in the WO group and 789.3 ± 581.4 mL (range: 380.0–1200.0 mL) in the CR group. The durations of surgery and blood loss were significantly lower in the WO group than that in the CR group (all P <0.05). The correction results in the two groups are presented in Supplementary Table 2, https://links.lww.com/CM9/C313. In the WO group, the mean segmental coronal curve was corrected from 42.5 ± 7.5 preoperatively to 14.3 ± 4.6 postoperatively (66.4% correction rate), and 16.8 ± 5.1° (60.5% correction rate) at the final follow-up. For patients in the CR group, the correction rate of coronal curve was 73.2%, and 62.2% at the final follow-up. In the sagittal plane, the segmental kyphosis was improved from 14.3 ± 12.3° to 7.2° ± 6.7° at the last follow-up with a correction rate of 49.7% in the WO group, and from 15.0° ± 10.8° to 6.3° ± 7.2° with a correction rate of 58.0% in the CR group. In both groups, compensatory cranial and caudal curve were spontaneously corrected well after surgery. Trunk shift was also significantly diminished after operation. Three patients (one in the WO group and two in the CR group) were found to have PJK. The average proximal junctional angle increased from 8.7° to 16.5° at 12 months postoperation. At the last follow-up, the average proximal junctional angle was 21.9°, showing a tendency of stability during the long-term follow-up. Fortunately, no revision surgery was needed. During the follow-up, X-ray and computed tomography (CT) scan showed that the scoliosis correction maintained well without any sign of implant failure or pseudarthrosis. Solid fusion of the posterior elements and osteotomy space were achieved in all patients. Postoperatively, all five domains of the SRS-22 scale showed a general improvement overall. In the WO group, the total SRS-22 score, including the pain domain (P = 0.009), self-image domain (P <0.001), and the satisfaction domain (P = 0.024) demonstrated significant difference compared with preoperative data [Supplementary Table 3, https://links.lww.com/CM9/C313]. In the CR group, two patients experienced transient neurological complications of lower extremity numbness. Postoperative CT and magnetic resonance imaging(MRI) examinations did not reveal dislocation of the pedicle screw, and thus the neurological deficits were attributed to the procedure of hemivertebra resection. While in the WO group, none of the patients suffered neurological compromise. CS secondary to hemivertebra is a complicated spinal deformity in young children and adolescents. Hemivertebra with normal end plates cause the asymmetric growth of the spine, which progressively lead to a wedge-shaped deformity. In our series, each patient was beyond the phase of the adolescent growth spurt. All the 43 patients included were in late adolescence aged between 14 years and 20 years and their Risser signs were 4 or 5 on presentation. Their spines were almost matured and the hemivertebra had limited growth potentials to cause progressive deformity. In previous practice, we noticed that the residual gap after CR of a large hemivertebra cannot be closed completely with a bone-on-bone contact. This defect may result in overload of the convex pedicles and postoperative spinal instability, increasing the risk of implant failures. Considering the above condition, WO of hemivertebra was performed, in which the hemivertebra was partial excised. The retained disk and a little cancellous bone of hemivertebra could fill the residual gap in osteotomy space, and functions as a hinge preventing critical translation of the vertebra when the convexity is compressed down and the gap is closed. This bone-on-bone closure not only decreases the stress of the instrumentation but also enhances the postoperative spinal stability, which could consequently reduce the risk of pseudarthrosis and implant-related complications. Besides, to further decrease the remaining growth potential of hemivertebra, both the cephalic and caudal endplates of hemivertebra were destructed by curette during the procedure. After long-term follow-up observation, all patients achieved solid spinal fusion, without implant failure or pseudarthrosis needed for revision surgery. For patients undergoing WO of hemivertebra, the average correction rates were 66.4%, with only 3° loss at the last follow-up. The compensatory curves, coronal imbalance, and segmental kyphosis also obtained satisfactory correction and maintained well during the follow-up. Moreover, HRQoL assessment demonstrated significant improvement of the SRS-22 score compared with preoperative status, especially in the self-image domain score. Taken together, these results reveal that WO can achieve satisfactory correction in adolescent CS patients. Notably, the average operation time was 193.8 min in the WO group and 315.2 min in the CR group. The average estimated blood loss was 435.2 mL in the WO group and 789.3 mL in the CR group. Compared with hemivertebra resection, WO strategy has a shorter operation time and lower blood loss. This advantage attributes to a simpler surgical procedure, without excessive excision of hemivertebra endplates and intervertebral disk. Hemivertebra resection, involving the complete removal of a vertebral level and both adjacent disks, should be defined as grade V osteotomy.[5] It is still a technically high demanding procedure and is usually associated with more risks of neurological deficits.[3,5] In the present study, two patients in the CR group suffered transient neurological compromises of sensory deficits. Whereas in the WO group, no neurologic complications occurred. Theoretically, the WO of hemivertebra can be classified as a grade III osteotomy, involving only partial resection of the posterior vertebral body and the posterior elements with pedicles. Therefore, this less invasive surgical strategy may be another safer surgical option for adolescent CS patients. In summary, WO of hemivertebra can be indicated for adolescent CS patients. Compared with hemivertebra resection, WO of hemivertebra is an advisable surgical strategy with advantages of reduced trauma, less blood loss, and a shorter operation time. Based on the long-term clinical outcomes, WO of hemivertebra is a relatively simpler and safer procedure with reliable correction effect. Funding This work was supported by grants from National Natural Science Foundation (Nos. 81802216 and 82272573). Conflicts of interest None.

OBJECTIVE:To explore the impact of anterior versus posterior reconstruction techniques on T1 slope (T1S) minus cervical lordosis (CL) matching in patients with multilevel cervical spondylotic myelopathy (CSM). METHODS:Five hundred ninety-four multilevel CSM patients were enrolled from medical records spanning from 2015 to 2024. The anterior group comprised 305 patients with matching type 157 individuals and mismatching type 148 cases, posterior group included 289 patients with matching type 146 individuals and mismatching type 143 cases. This study retrospectively analyzed perioperative parameters including clinical parameters of Japanese Orthopedic Association score, visual analog scale and Neck Disability Index, and radiologic parameters T1S, CL, C2-7 sagittal vertical axis and T1S-CL. RESULTS:Prior to surgery, there were no significant differences in factors between two groups (P > 0.05) except for blood loss (P < 0.001). Postoperatively, radiological parameters (T1S, CL, C2-7 sagittal vertical axis and T1S-CL) and functional indicators (Japanese Orthopedic Association, Neck Disability Index and visual analog scale) changed significantly (P < 0.001) in anterior and posterior group, whether with T1S-CL matching or mismatching type. In anterior group, T1S-CL changed significantly (P < 0.05) under 20° in both type. While, T1S-CL changed significantly (P < 0.001) under 20° in posterior group with matching type, T1S-CL changed significantly (P < 0.001) above 20° in posterior group with mismatching type. In each group and types, T1S-CL showed positive correlations with T1S and negative correlations (P < 0.001) postoperatively. CONCLUSIONS:Anterior reconstruction surgeries can improve and optimize T1S-CL matching, while a T1S-CL mismatching is more likely to occur or deteriorate after posterior surgeries in patients with multilevel CSM.

Objective:The objective of this study was to explore the normal matching changes between T1 slope (T1S) and cervical lordosis (CL) in patients with multilevel cervical spondylotic myelopathy (CSM) after anterior and posterior reconstruction surgeries. Materials and Methods:One hundred thirty-four patients diagnosed with multilevel CSM and a normal matching of T1S-CL were enrolled from the medical records spanning 2015-2020. The anterior group comprised 69 patients, and the posterior group included 65 patients. This study retrospectively analyzed perioperative parameters, including clinical parameters of the Japanese Orthopedic Association (JOA) score, Visual Analog Scale (VAS), neck disability index (NDI), and radiologic parameters T1S, CL, C2-7 sagittal vertical axis (SVA), and T1S-CL. Results:Prior to surgery, there were no significant differences in factors between two groups (P > 0.05). Postoperatively, while the JOA scores were similar between groups (P > 0.05), the anterior group showed significantly lower in NDI, VAS, perioperative parameters, and incidences of complications (P < 0.001). Significant changes were observed in each group for T1S, CL, C2-7 SVA and T1S-CL (P < 0.001). Preoperatively, in the anterior group, significant correlations were identified between T1S-CL and T1S, CL, and C2-7 SVA (P < 0.05). In the posterior group, significant correlations were observed between T1S-CL and T1S, CL, and C2-7 SVA (P < 0.05). Following surgery, in the anterior group, the correlations persisted between T1S-CL and T1S, CL, and C2-7 SVA (P < 0.05). In the posterior group, the correlations between T1S-CL and T1S, and CL were not significant (P > 0.05). The comparative analysis of parameter changes between anterior and posterior groups revealed no significant difference in the changes of T1S and C2-7 SVA (P > 0.05), whereas significant differences were observed in the changes of C2-7 lordosis and T1S-CL (P < 0.001). Conclusions:Anterior reconstruction surgeries can improve or optimize the normal matching of T1S-CL, while a mismatching of T1S and CL is more likely to occur after posterior surgery, potentially leading to cervical sagittal malalignment and imbalance in patients with multilevel CSM.

Robot-assisted technology has been gradually applied to pedicle screw placement in spinal surgery. This study was designed to detailedly evaluate the learning curve of junior surgeons in robot-assisted spine surgery. From December 2020 to February 2022, 199 patients requiring surgical treatment with posterior pedicle screw fixation were prospectively recruited into the study. The patients were randomized to the robot-assisted group (the RA group) or the conventional freehand group (the CF group). Under the senior specialist’s supervision, pedicle screws were placed by two junior fellows without prior experience. Cumulative summation (CUSUM) analysis was performed on the learning curve of pedicle screw placement for performing quantitative assessment based on the time of screw insertion. In total, 769 and 788 pedicle screws were placed in the RA and CF groups. Compared with the CF group, the learning duration in the RA group was shorter in the upper thoracic region (57 vs. 70 screws), but longer in the lower thoracic (62 vs. 58 screws) and the lumbosacral region (56 vs. 48 screws). The slope of learning curve was lower in the RA group than in the CF group. The screw accuracy in the RA group was superior to that in the CF group, especially in upper thoracic region (89.4

It is widely assumed that as connective tissue, the intervertebral disc (IVD) plays a crucial role in providing flexibility for the spinal column. The disc is comprised of three distinct tissues: the nucleus pulposus (NP), ligamentous annulus fibrous (AF) that surrounds the NP, and the hyaline cartilaginous endplates (CEP). Nucleus pulposus, composed of chondrocyte-like NP cells and its secreted gelatinous matrix, is critical for disc health and function. The NP matrix underwent dehydration accompanied by increasing fibrosis with age. The degeneration of matrix is almost impossible to repair, with the consequence of matrix stiffness and senescence of NP cells and intervertebral disc, suggesting the value of glycoproteins in extracellular matrix (ECM). Here, via database excavation and biological function screening, we investigated a C-type lectin protein, CLEC3A, which could support differentiation of chondrocytes as well as maintenance of NP cells and was essential to intervertebral disc homeostasis. Furthermore, mechanistic analysis revealed that CLEC3A could stimulate PI3K-AKT pathway to accelerate cell proliferation to further play part in NP cell regeneration.

Bone marrow mesenchymal stem cells (BMSCs) are capable of multidirectional differentiation, and engrafted BMSCs can be used to replace damaged chondrocytes for treatment of intervertebral disc disease. However, chondroblast differentiation of implanted BMSCs is inhibited by the anoxic environment of the articular cavity. Here, we found that leptin enhanced the transformation of BMSCs into chondrocytes under hypoxic conditions. BMSCs isolated from mice were cultured in medium supplemented with leptin under hypoxia. The expression of MFN1/2 and OPA1 were increased only in BMSCs cultured in an anoxic environment. In addition, in hypoxic environments cell energy metabolism relies on glycolysis regulated by leptin, rather than by mitochondrial oxidation. The expression of the de‐SUMOylation protease SENP1 was elevated, leading to SIRT3‐mediated activation of PGC‐1α; these processes were regulated by CREB phosphorylation, and promoted mitochondrial fusion and cell differentiation. The chondrogenic activity of BMSCs isolated from SIRT3‐knockout mice was lower than that of BMSCs isolated from wildtype mice. Implantation of SIRT3‐knockout murine‐derived BMSCs did not significantly improve the articular cartilage layer of the disc. In conclusion, the hypoxic microenvironment promoted BMSC differentiation into chondrocytes, whereas osteoblast differentiation was inhibited. SENP1 activated SIRT3 through the deSUMOylation of mitochondria and eliminated the antagonistic effect of SIRT3 acetylation on phosphorylation. When phosphorylation activity of CREB was increased, phosphorylated CREB is then transferred to the nucleus, affecting PGC‐1α. This promotes mitochondrial fusion and differentiation of BMSCs. Leptin not only maintains chondrogenic differentiation homeostasis of BMSCs, but also provides energy for differentiation of BMSCs under hypoxic conditions through glycolysis.

Intervertebral disc degeneration (IDD) is a spinal degenerative disease and one of the most important causes of musculoskeletal disability. Matrix metalloproteinase (MMP)-mediated extracellular matrix degradation is the core process of IDD. The regulators of MMPs in the intervertebral disc are still not fully known. In this study, using quantitative reverse transcription PCR, luciferase reporter assay, Western blotting, immunofluorescence, flow cytometry, and Cell Counting Kit-8 assay, we found that the miR-874-3p expression level was significantly decreased in IDD patients. MiR-874-3p could target and repress MMP2 and MMP3 expression in nucleus pulposus cells. These results could improve the understanding of IDD and provide a possible diagnostic marker and treatment candidate for IDD. The miR-874-3p/MMP2/MMP3 axis might also provide direction for future cancer and inflammation investigations.

Objective: This study was designed to investigate the relationship between the laminar slope angle (LSA) and the lumbar disc degenerative grade, the cross-section area (CSA) of multifidus muscle, the muscle-fat index, and the thickness of the ligamentum flavum. Methods: Retrospective analysis of 122 patients who were scheduled to undergo a lumbar operation for diagnoses associated with degenerative lumbar disease between January and December 2017. The L4–L5 disc grade was evaluated from preoperative sagittal T2-weighed magnetic resonance imaging of the lumber region; the CSA of the multifidus and muscle-fat index were measured at the L4 level, while the thickness of the ligamentum flavum was measured at the L4–L5 facet level from axis T2-weighed magnetic resonance imaging. The slope of the laminar was evaluated from preoperative three-dimensional computer tomography at the tip level of the facet joints and selected by the axis plane. Independent-sample T-tests were used to assess the association between age and measurement indices. Results: Our results showed that age was positively connected with the LSA of L4 and L5 in different patients, although there was no significant difference between age and the difference of the two segment LSA. Partial correlation analysis, excluding the interference of age, revealed a strong negative relationship between the LSA of L4 and the thickness of the ligamentum flavum, irrespective of whether we considered the left or right. However, there was no correlation with lumbar disc degenerative grade, the CSA of the multifidus, and the muscle-fat index. Conclusion: The thickness of the ligamentum flavum showed changes with anatomical differences in the LSA, but not the lumbar disc degenerative grade, the CSA of the multifidus, and the muscle-fat index. A small change in LSA may cause large mechanical stress; this may be one of the causative factors responsible for lumbar spinal stenosis.

Lumbar spinal stenosis (LSS) is a condition wherein patients exhibit age-related fibrosis, elastin-to-collagen ratio reductions, and ligamentum flavum hypertrophy. This study was designed to assess the relationship between SIRT6 and telomerase activity in hypertrophic ligamentum flavum (LFH) cells from LSS patients. We observed significant reductions in SIRT6, TPP1, and POT1 protein levels as well as increases in telomerase reverse transcriptase (TERT) levels and telomerase activity in LFH tissues relative to non- hypertrophic ligamentum flavum (LFN) tissues. When SIRT6 was overexpressed in these LFH cells, this was associated with significant increases in telomerase activity and a significant reduction in fibrosis-related protein expression. These effects were reversed, however, when telomerase activity was inactivated by hTERT knockdown in these same cells. SIRT6 overexpression was further found to reduce the frequency of senescence-associated β-galactosidase (SA-β-Gal)-positive LFH cells and to decrease p16, MMP3, and L1 mRNA levels and telomere dysfunction-induced foci (TIFs) in LFH cells. In contrast, hTERT knockdown-induced telomerase inactivation eliminated these SIRT6-dependent effects. Overall, our results indicate that SIRT6 functions as a key protective factor that prevents cellular senescence and telomere dysfunction in ligamentum flavum cells, with this effect being at least partially attributable to SIRT6-dependent telomerase activation.

Study Design. Sequencing and experimental analysis of the expression profile of circular RNAs (circRNAs) in hypertrophic ligamentum flavum (LFH). Objectives. The aim of this study was to identify differentially expressed circRNAs between LFH and nonhypertrophic ligamentum flavum tissues from lumbar spinal stenosis (LSS) patients. Summary of Background Data. Hypertrophy of the ligamentum flavum (LF) can cause LSS. circRNAs are important in various diseases. However, no circRNA expression patterns related to LF hypertrophy have been reported. Methods. A total of 33 patients with LSS participated in this study. LF tissue samples were obtained when patients underwent decompressive laminectomy during surgery. The expression profile of circRNAs was analyzed by transcriptome high-throughput sequencing and validated with quantitative real-time polymerase chain reaction (PCR). Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses were performed for the differentially expressed circRNA-associated genes and related pathways. The connections between circRNAs and microRNAs were explored using Cytoscape. The role of hsa_circ_0052318 on LF cell fibrosis was assessed by analyzing the expression of collagen I and collagen III. Results. The results showed that 2439 circRNAs of 4025 were differentially expressed between the LFH and nonhypertrophic ligamentum flavum tissues, including 1276 upregulated and 1163 downregulated circRNAs. The Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses revealed that these differentially expressed circRNAs functioned in biological processes, cellular components, and molecular functions. Autophagy and mammalian target of rapamycin were the top two signaling pathways affected by these circRNAs. Five circRNAs (hsa_circ_0021604, hsa_circ_0025489, hsa_circ_0002599, hsa_circ_0052318, and hsa_circ_0003609) were confirmed by quantitative real-time PCR. The network indicated a strong relationship between circRNAs and miRNAs. Furthermore, hsa_circ_0052318 overexpression decreased mRNA and protein expression of collagen I and III in LF cells from LFH tissues. Conclusion. This study identified circRNA expression profiles characteristic of hypertrophied LF in LSS patients, and demonstrated that hsa_circ_0052318 may play an important role in the pathogenesis of LF hypertrophy. Level of Evidence: N/A

Study Design: Retrospective analysis. Objective: We investigated whether complete correction of cervical sagittal malalignment is necessary during 4-level anterior cervical discectomy and fusion (ACDF) in patients with kyphosis. Methods: This retrospective study included 84 patients who underwent 4-level ACDF surgery at a university hospital between January 2010 and December 2015. Based on the degree of cervical lordosis correction, patients were categorized into the following groups: mild (0-10°), moderate (10-20°), and complete correction (>20°). The clinical outcomes, radiological parameters, and functional outcomes were analyzed. Results: We observed no significant intergroup differences in the baseline characteristics. The cervical sagittal vertical axis (CSVA) correction loss at the final follow-up was lesser in the mild- and moderate- than in the complete-correction group. The spinocranial angle (SCA) and T1 slope (T1 S) were significantly higher in the moderate- and complete-correction groups than in the mild-correction group, 3 days postoperatively. The cervical proximal junctional kyphosis (CPJK), adjacent segment degeneration (ASD), and ASD following CPJK rates were higher in the complete-correction group. We observed no significant intergroup differences in postoperative complications; however, 5 patients showed internal fixation failure in the complete-correction group; 4 of these patients required reoperation. No significant intergroup difference was observed in the Japanese Orthopedic Association and neck disability index scores at any time point. Conclusions: A mild-to-moderate correction of cervical lordosis is superior to complete correction in patients with kyphosis who undergo 4-level ACDF because this approach is associated with lesser axial stress and CSVA correction loss.

目的 观察磁共振弥散张量成像(DTI)技术在脊柱内镜精准减压治疗腰椎管狭窄症中的应用效果.方法 选择35例存在至少一侧下肢症状的腰椎管狭窄症患者,行MRI检查,使用磁共振后处理工作站进行DTI分析,从DTI图像的双侧L5及S1神经根在神经根与硬膜囊交接处、椎间孔处、椎间孔外下位椎间水平3个不同平面选取感兴趣区域,测量各位点的各向异性分数(FA)值.根据FA值确定减压部位,脊柱内镜采用后方经椎板间通道手术系统,对受累神经实现精准减压.于术前1周、术后次日及术后3个月,采用视觉模拟评分(VAS)评价患侧下肢疼痛程度;术后3个月行MRI检查,测量FA值,与术前及健测进行比较;术后3个月行CT和MR检查,观察责任神经的影像学恢复情况.结果 患者术后次日、术后3个月VAS均较术前降低,术后3个月患侧L5及S1神经根FA值较术前升高(P均<0.05).CT检查显示术后椎管扩大,受累神经压迫解除,腰椎稳定性未遭到破坏;MRI检查显示患侧责任神经DTI神经纤维成像较术前明显增粗,提示神经恢复良好.结论 通过磁共振DTI成像技术指导脊柱内镜精准治疗腰椎管狭窄症患者,有良好的疗效和安全性.

The authors have requested that this preprint be withdrawn due to erroneous posting.

Abstract Background.One previous work confirmed that laminar slope angle was associated with the ossification of thoracic ligamentum flavum. Several studies have investigated the relevance of disc degeneration grade, thickness of ligamentum flavum, along with cross section area of multifidus and its fatty infiltration. However, there has been no research between the angle and them. This retrospectivestudyof clinical materials from 122 patients was designed to investigate the influence of laminar slope angle on degeneration of lumbar when eliminating the interference of age.Methods.122 individuals were retrospected randomly on the basis of age difference from 687inpatients scheduled to undergo a lumbar operation between January and December 2017.We registered their age and sex, evaluated and measuredL4-L5 disc degeneration grade,correspondingcross section area of multifidus, muscle-fat index,thickness of ligamentum flavum and laminar slope angle from preoperative magnetic resonance imagingand three-dimensional computer tomography. Independent-sample T tests were used to assess the association between age and measurement indices. The Pearson correlation coefficient, and partial correlation excluding age, was also performed to analyze thecorrelation between clinical parameters.Results.Our results showed that age was positively connected withthe laminar slope angle(L4:r=0.298, p=＜0.01; L5:r=0.303, p=＜0.01). Excluding the interference of age, revealed a credibly negative relationship between the angle of L4 and the thickness of the ligamentum flavum(Left: r=-0.303, p=＜0.01;Right:r=-0.340, p=＜0.01). However, there was no correlationwithother parameters(disc: r=-0.141, p＞0.05; left multifidus: r=0.248, p＞0.05; right multifidus: r=0.225, p＞0.05; left muscle-fat index: r=0.033, p＞0.05; right muscle-fat index: r=0.016, p＞0.05).Conclusion.Excluding the interference of age, Inclination of small laminar slope angle leads to hypertrophy of lumbar ligamentum flavum.LEVEL OF EVIDENCE:Level 4.

Background A growing body of studies have indicated that bone marrow mesenchymal stem cells (BMSCs) have powerful analgesic effects in animal models of bone cancer pain. Here, we explored the molecular mechanisms underlying how BMSCs alleviate pain sensation in a mouse model of bone cancer pain. Methods C3H/HeN adult male mice were used to generate a bone cancer pain model. BMSCs were isolated from mouse bone marrow, modified by transfection with microRNA-9-5p (miR-9-5p), and infused into the spinal cord. Spontaneous flinches, paw withdrawal latency, limb-use score, and weight-bearing score were used to assess pain-related behaviors. ELISA, RT-PCR, western blot, and luciferase assay were used to assess gene expressions. Results Our results show that miR-9-5p regulated the expression of both repressor element silencing transcription factor (REST) and μ-opioid receptors (MOR) by targeting REST in primary mouse BMSCs. Overexpression of miR-9-5p reversed the activation of inflammatory pathway in TNF-α- and IL-6-treated BMSCs. In addition, miR-9-5p modified BMSCs alleviated cancer pain in the sarcoma-inoculated mouse model. MiR-9-5p modified BMSCs suppressed cytokine expression in the spinal cord of sarcoma-inoculated mice by suppressing REST gene expression. Conclusions Our results indicate that miR-9-5p modified BMSCs can relieve bone cancer pain via modulating neuroinflammation in the central nervous system, suggesting genetically modified BMSCs could be a promising cell therapy in pain management.

Background Selective thoracolumbar/lumbar fusion technique was introduced to treat adolescent idiopathic scoliosis (AIS) patients with major thoracolumbar/lumbar curves. Theoretically, this surgical strategy could also be applied to syringomyelia patients. No previous study has specifically addressed the effectiveness of selective thoracolumbar/lumbar fusion for patients with syringomyelia-associated scoliosis. The aim of the study was to investigate the effectiveness of selective thoracolumbar/lumbar fusion for the surgical treatment of patients with syringomyelia-associated scoliosis. Methods From February 2010 to September 2016, 14 syringomyelia-associated patients with major thoracolumbar/lumbar curves were retrospectively reviewed. Besides, 30 Lenke 5C AIS patients were enrolled as a control group. Posterior selective thoracolumbar/lumbar fusion was performed for both groups. Patients’ demographic, operative, radiological, and quality of life data were reviewed with follow-up. Intragroup comparisons were performed for each parameter. Results The two groups were matched by age, gender, curve characteristics, duration of follow-up, and all preoperative radiographic parameters except for thoracic kyphosis. After surgery, the average correction rate of the major thoracolumbar/lumbar curve was 82.2 ± 7.8% in the syringomyelia group, which was not significantly different from that of AIS group (82.5 ± 10.6%, P = 0.47). A similar improvement of unfused thoracic curve was observed between the two groups (50.1 ± 16.5% vs. 48.5 ± 26.9%, P = 0.29). During the follow-up, the correction effect of scoliosis was well maintained, without aggravation of the original neural symptoms or fresh permanent neurological deficits. Of note, the number of fusion levels was significantly larger in syringomyelia group than that in AIS group (7.6 ± 1.4 vs. 6.5 ± 1.2, P < 0.01). The average follow up was 47.6 months (36–81 months). Conclusion Similar to AIS cases, syringomyelia-associated scoliosis can be effectively and safely corrected by selective thoracolumbar/lumbar fusion with satisfactory surgical outcomes. However, the syringomyelia group, on average, required an additional fused segment for treatment as compared to the AIS group (7.6 versus 6.5 in the AIS group).

Polydatin, a natural product, is detected in many daily diets, such as grape juices and peanut. Autophagy regulation is recognized as a new potential strategy for cancer therapy, and previous studies demonstrated that polydatin showed remarkable anti-cancer ability. Nevertheless, the capability of polydatin to induce autophagy and its role in anti-osteosarcoma remains obscure. In this study, we investigated the anticancer effect of polydatin on human osteosarcoma cell line MG-63 and its underlying mechanism. Our results indicated that polydatin significantly inhibited proliferation of MG-63 cells in a dose- and time-dependent manner, and increased their apoptosis and autophagic flux. Further experiments showed that polydatin reduced the expression and phosphorylation (Y705) level of STAT3 (Signal transducer and activator of transcription 3), increased the expression of autophagy-related genes (Atg12, Atg14, BECN1, PIC3K3), and therewith triggered autophagic cell death in MG-63 cells. Of note, the cytotoxicity effect of polydatin was rescued by co-treatment with Colivelin (STAT3 activator), suggesting the dependency of MG-63 cells on STAT3 for survival in this process. Moreover, polydatin-triggered autophagy and apoptosis were remarkably reduced following exposure to autophagy inhibitor 3-methyladenine, while cell viability was increased. In conclusion, these data demonstrated that polydatin induced MG-63 cell death through inducing apoptosis, and autophagy which was mediated via the STAT3 signaling. Therefore, polydatin might be a potential clinical drug in the remedy of osteosarcoma.

高等医学院校培育的是未来的医务工作者,其价值观和职业道德关系着广大患者的健康、医疗卫生事业的发展及社会的和谐稳定,运用社会主义核心价值观对医学生进行教育具有非常重要的现实意义.将社会主义核心价值观教育融入医学临床教学中,并对其教学现状进行思考.

目的 比较新型颈椎前路滑动钢板(Atlantis Translational)与常规颈椎前路钢板(Skyline)在颈椎前路椎间盘切除减压融合内固定(ACDF)术中应用的效果.方法 回顾性分析自2017-06-2018-09行ACDF手术治疗的36例多节段颈椎病,16例术中采用新型颈椎前路滑动钢板内固定(滑动钢板组),20例术中采用常规颈椎前路钢板内固定(常规钢板组).比较2组手术时间、术中出血量、椎间融合时间、并发症情况,以及术后JOA评分、颈椎Cobb角、NDI指数及Odom评分.结果 36例均获得随访,随访时间平均12(8～16)个月.滑动钢板组手术时间较常规钢板组短,术中出血量较常规钢板组少,椎间融合时间较常规钢板组短,差异有统计学意义(P＜0.05).滑动钢板组与常规钢板组术后3d、6个月、末次随访时JOA评分、颈椎Cobb角、NDI指数,以及并发症发生率、末次随访时Odom评分差异无统计学意义(P＞0.05).结论 新型颈椎前路滑动钢板由于其独特设计结构可满足不同患者解剖和生物力学需求,在ACDF治疗多节段颈椎病术中应用操作更简单,能够明显缩短手术时间,减少手术创伤,促进椎间融合.

Objective To evaluate the application effect of mini-clinical evaluation exercise (Mini-CEX) in the clinical teaching of orthopedics. Methods A total of 60 students who finished their orthopedics internship in Renji Hospital of Shanghai Jiao Tong University from January 2017 to July 2017 were in-volved and randomly divided into the experimental group and the control group with 30 students in each group. The experimental group received Mini-CEX while the control group received traditional lessons. Sur-veys and tests were conducted after the internship and the results were recorded. All statistical analyses were performed with the independent sample t test and Chi-square test using SPSS software (version 21.0). Results Except for communication skills, the medical counseling skills, physical examination skills, humanistic qualities, clinical diagnosis, organization and overall clinical competence were higher in the experimental group than in the control group and the difference was statistically significant (P<0.05). The improvements in clinical diagnosis ( χ2=6.674, P=0.036), professional knowledge and skills ( χ2=6.455, P= 0.040), clinical practice skills ( χ2=6.673, P=0.036) and satisfaction ( χ2=6.881, P=0.032) were greater in the experimental group than in the control group and the difference was statistically significant (P<0.05). No significant difference was observed in the inspiration of learning interest(χ2=4.025, P=0.134) and the improve-ments in language proficiency ( χ2=4.993, P=0.085), medical history acquisition ability ( χ2=1.564, P=0.458), humanistic qualities ( χ2=2.982, P=0.255) and teamwork ( χ2=2.651, P=0.266) between the two groups. Conclusion Mini-CEX not only achieves higher satisfaction but also helps students to improve their pro-fessional knowledge and skills, clinical diagnosis and clinical practice skills. Besides, Mini-CEX in the clinical teaching of orthopedics can effectively improve the quality of teaching and the satisfaction of students, thus providing a new teaching mode worthy of popularization.