Publications by authors named "Zezhang Zhu"

265 Publications

Contribution of postoperative vertebral remodeling to reversal of vertebral wedging and prevention of correction loss in patients with adolescent Scheuermann's kyphosis.

J Neurosurg Spine 2021 Jul 30:1-9. Epub 2021 Jul 30.

Objective: This study aimed to investigate reversal of vertebral wedging and to evaluate the contribution of vertebral remodeling to correction maintenance in patients with adolescent Scheuermann's kyphosis (SK) after posterior-only instrumented correction.

Methods: A retrospective cohort study of patients with SK was performed. In total, 45 SK patients aged 10-20 years at surgery were included. All patients received at least 24 months of follow-up and had Risser sign greater than grade 4 at latest follow-up. Patients with Risser grade 3 or less at surgery were assigned to the low-Risser group, whereas those with Risser grade 4 or 5 were assigned to the high-Risser group. Radiographic data and patient-reported outcomes were collected preoperatively, immediately postoperatively, and at latest follow-up and compared between the two groups.

Results: Remarkable postoperative correction of global kyphosis was observed, with similar correction rates between the two groups (p = 0.380). However, correction loss was slightly but significantly less in the low-Risser group during follow-up (p < 0.001). The ratio between anterior vertebral body height (AVBH) and posterior vertebral body height (PVBH) of deformed vertebrae notably increased in SK patients from postoperation to latest follow-up (p < 0.05). Loss of correction of global kyphosis was significantly and negatively correlated with increased AVBH/PVBH ratio. Compared with the high-Risser group, the low-Risser group had significantly greater increase in AVBH/PVBH ratio during follow-up (p < 0.05). The two groups had similar preoperative and postoperative Scoliosis Research Society-22 questionnaire scores for all domains.

Conclusions: Obvious reversal in wedge deformation of vertebrae was observed in adolescent SK patients. Patients with substantial growth potential had greater vertebral remodeling and less correction loss. Structural remodeling of vertebral bodies has a positive effect and protects against correction loss. These results could be help guide treatment decision-making.
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http://dx.doi.org/10.3171/2021.1.SPINE202086DOI Listing
July 2021

Comparison of 3D and 2D characterization of spinal geometry from biplanar X-rays: a large cohort study.

Quant Imaging Med Surg 2021 Jul;11(7):3306-3313

Arts et Métiers Institute of Technology, Université Sorbonne Paris Nord, Institut de Biomécanique Humaine Georges Charpak (IBHGC), HESAM Université, Paris, France.

Background: Biplanar X-ray system providing anteroposterior and sagittal plane with an ultra-low radiation dose and in weight-bearing position is increasingly used for spine imaging. The original three-dimensional (3D) reconstruction method from biplanar X-rays has been widely used for clinical parameters, however, the main issue is that manual adjustments of the 3D model was quite time-consuming and limited to thoracolumbar spine. A quasi-automated 3D reconstruction method of the spine from cervical vertebra to pelvis was proposed, which proved fast and accurate in 57 patients with adolescent idiopathic scoliosis. The aim of this study was to compare the newly developed technique of quasi-automatic 3D measurement with classical 2D measurements in a large cohort.

Methods: A total of 494 adults with biplanar EOS X-ray scanning were included in this study and divided into health and deformity group according to the presence of spinal deformity. The proposed method of quasi-automatic 3D measurement was applied to all these subjects. The radiographic parameters included: thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sagittal vertical axis (SVA), T1 pelvic angle (TPA) in sagittal plane, and cobb angle in coronal plane. Comparison was made between quasi-automatic and manual measurement.

Results: The mean age was 53.7±19.9 years old. In the whole population, the mean differences between the two methods were 3.9° for TK (30.5°±9.9° 26.5°±9.3°, P<0.001), -5.2° for LL (-47.5°±11.2° -42.4°±11.0°, P<0.001), 3.6° for PI (46.9°±10.3° 43.9°±10.3°, P<0.001), -0.2° for PT (11.9°±7.7° 12.0°±8.2°, P=0.328), -2.1 mm for SVA (15.7±26.2 17.8±26.3 mm, P=0.221) and -1.1° for TPA (9.0°±7.6° 10.1°±7.8°, P=0.051). The deformity group had similar mean differences with the asymptomatic group with the values ranged from -4.1° to 3.8° for sagittal parameters. The mean differences of Cobb angle were 1.9° for patients with Cobb angle <30° and 2.3° for patients with Cobb angle >30°, respectively. Correlation analysis showed r2 for all clinical parameters ranged from 0.667 to 0.923. On average, the new method takes 5 minutes to compute all the parameters for one case.

Conclusions: In conclusion, this ergonomic and efficient quasi-automatic method for full spine proved fast and accurate measurement in a large population, which showed great potential in extensive clinical application.
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http://dx.doi.org/10.21037/qims-20-861DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250026PMC
July 2021

Coronal imbalance after growing rod treatment in early-onset scoliosis: a minimum of 5 years' follow-up.

J Neurosurg Spine 2021 Jun 4:1-8. Epub 2021 Jun 4.

Objective: The objective of this study was to investigate the incidence and risk factors of coronal imbalance (CI) in patients with early-onset scoliosis (EOS) who underwent growing rod (GR) treatment.

Methods: A consecutive series of 61 patients with EOS (25 boys and 36 girls, mean age 5.8 ± 1.7 years) who underwent GR treatment was retrospectively reviewed. Postoperative CI was defined as postoperative C7 translation on either side ≥ 20 mm. Patients were divided into an imbalanced and a balanced group. Coronal patterns were classified into three types: type A (C7 translation < 20 mm), type B (C7 translation ≥ 20 mm with C7 plumb line [C7PL] shifted to the concave side of the curve), and type C (C7 translation ≥ 20 mm and a C7PL shifted to the convex side of the curve).

Results: Each patient had an average of 5.3 ± 1.0 lengthening procedures and was followed for an average of 6.2 ± 1.3 years. Eleven patients (18%) were diagnosed with CI at the latest distraction, 5 of whom graduated from GRs and underwent definitive fusion. However, these patients continued to present with CI at the last follow-up evaluation. The proportion of preoperative type C pattern (54.5% vs 16.0%, p = 0.018), immediate postoperative apical vertebral translation (30.4 ± 13.5 mm vs 21.2 ± 11.7 mm, p = 0.025), lowest instrumented vertebra tilt (11.4° ± 8.2° vs 7.3° ± 3.3°, p = 0.008), and spanned obliquity angle (SOA) (9.7° ± 10.5° vs 4.1° ± 4.5°, p = 0.006) values in the imbalanced group were significantly higher than in the balanced group. Multiple logistic regression demonstrated that a preoperative type C pattern and immediate postoperative SOA > 11° were independent risk factors for postoperative CI.

Conclusions: The incidence of CI in patients with EOS who underwent GR treatment was 18%. This complication could only be slightly improved after definitive spinal fusion because of the autofusion phenomenon. A preoperative type C pattern and immediate postoperative SOA > 11° were found to be the risk factors for CI occurrence at the latest follow-up.
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http://dx.doi.org/10.3171/2020.10.SPINE201581DOI Listing
June 2021

Genetic variant of MIR4300HG is associated with progression of adolescent idiopathic scoliosis in a Chinese population.

J Orthop Surg Res 2021 May 13;16(1):311. Epub 2021 May 13.

Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Zhongshan Road 321, Nanjing, 210008, China.

Background: A recent genome-wide association study identified a susceptible locus in MIR4300HG gene that was associated with curve progression of adolescent idiopathic scoliosis (AIS) in the Japanese population. However, the association between the gene and curve progression in other populations remains unclear.

Methods: A cohort of 1952 AIS patients and 2495 healthy controls were included in the case-control analysis. In the case-only analysis, 747 patients were assigned to the progression group and 520 patients were assigned to the non-progression group, respectively. Rs35333564 was genotyped for all the subjects. Paraspinal muscles of 76 patients were collected for the analysis of gene expression. Chi-square test and ANOVA test were used for the intergroup comparison. Pearson correlation analysis was performed to investigate the relationship between the gene expression and curve magnitude.

Results: Variant rs35333564 was significantly associated with the curve severity of AIS (p = 0.025), but not the development of AIS (p = 0.418). Genotype GG was indicated by remarkably lower expression of MIR4300 (p = 0.020) which was significantly correlated with curve magnitude (p = 0.010). As a predicted target gene of MIR4300, the expression of CRTC1 was negatively correlated with MIR4300 expression (p = 0.012, r = -0.287) and positively correlated with curve severity (p = 0.025, r = 0.257).

Conclusions: The association between rs35333564 and curve progression was successfully replicated in a Chinese AIS population. CRTC1 may be the target gene of MIR4300 that plays a role in the curve progression of AIS.
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http://dx.doi.org/10.1186/s13018-021-02455-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117547PMC
May 2021

Female-specific Susceptibility Locus in BOC and SEC16B are Associated with Adolescent Idiopathic Scoliosis.

Spine (Phila Pa 1976) 2021 May 6. Epub 2021 May 6.

Department of Spine Surgery, the Drum Tower Hospital of Nanjing University Medical School, Nanjing, China Joint Scoliosis Research Center of The Chinese University of Hong Kong and Nanjing University, Nanjing & Hong Kong, China Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.

Study Design: A genetic case-control study.

Objectives: To investigate whether the variants in BOC, SEC16B and SH2D1B are sex-specifically and functionally associated with the susceptibility of adolescent idiopathic scoliosis (AIS) in Chinese Han population.

Summary Of Background Data: A recent GWAS study identified three female-specific susceptibility loci of AIS in Japanese population. However, the association of these genes with AIS in other populations remains unclear. Further investigation of the functional role of the three genes was warranted.

Methods: SNPs rs73235136, rs545608 and rs142502288 were genotyped in 1599 AIS patients and 2985 controls. Paraspinal muscle collected from 40 AIS and 30 LDH patients during surgical interventions were used for gene expression analysis. The difference regarding genotype and allele frequency between patients and controls was analyzed by Chi-square analysis. Expression of BOC and SEC16B was compared between AIS and LDH patients by the Student t test. Pearson correlation analysis was performed to evaluate the relationship between gene expression level and clinical phenotypes.

Results: SNPs rs73235136 of BOC and rs545608 of SEC16B were found to be remarkably associated with AIS only in females. Allele C of rs73235136 and allele G of rs545608 could significantly add to the risk of female AIS patients, with an odds ratio of 1.087 and 1.033, respectively. However, there was no significant difference between the male patients and controls regarding genotype or allele frequency of rs73235136 and rs545608. No polymorphism at rs142502288 was detected in either patients or controls, and all the subjects had genotype of AA. Moreover, tissue expression of BOC and SEC16B was significantly lower in AIS patients compared with controls. BOC expression was positively associated with bone mineral contents, and expression of SEC16B was negatively correlated with curve severity in AIS patients.

Conclusions: Female-specific variants in BOC and SEC16B were associated with AIS. Expression of BOC and SEC16B was significantly lower in AIS patients. The role of BOC and SEC16B in the development of AIS is worthy of further investigation.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004098DOI Listing
May 2021

Sequential correction using satellite rod for severe thoracic idiopathic scoliosis: an effective method to optimize deformity correction.

J Neurosurg Spine 2021 Apr 2:1-7. Epub 2021 Apr 2.

Objective: The aim of this paper was to compare the radiographic and clinical outcomes between the sequential correction (SC) technique and the traditional 2-rod correction (TC) technique in patients with severe thoracic idiopathic scoliosis (STIS) undergoing posterior-only correction surgery.

Methods: Records of a consecutive series of STIS patients undergoing posterior-only correction surgery between October 2013 and October 2017 with more than 2 years of follow-up were reviewed. The radiographic parameters were assessed preoperatively, postoperatively, and at the last follow-up. Radiographic parameters, operative time, blood loss, and complications were compared between the two groups.

Results: A total of 33 patients were included in the SC group, and 21 patients were included in the TC group. There was no significant difference in age, sex, or deformity magnitude (93.6° ± 7.8° vs 89.8° ± 6.6°, p = 0.070) preoperatively between groups. The operation time was shorter in the SC group than in the TC group (251.5 ± 42.8 minutes vs 275.4 ± 39.8 minutes, p = 0.020), while both blood loss (1284.6 ± 483.3 vs 1398.0 ± 558.4 ml, p = 0.432) and number of fused levels (13.1 ± 2.8 vs 13.6 ± 2.4, p = 0.503) were similar between the groups. Compared with the TC group, patients in the SC group had a higher correction rate (55.8% ± 9.2% vs 45.7% ± 8.8%, p < 0.001), less coronal (1.1° ± 0.81° vs 2.9° ± 0.93°, p < 0.001) and sagittal (1.5° ± 0.96° vs 2.1° ± 0.64°, p = 0.015) correction loss at the 2-year follow-up, and a lower incidence of intraoperative pedicle screw pullout (14.3% vs 23.8%, p = 0.026).

Conclusions: The SC technique could significantly and practically reduce the difficulty of rod installation with better deformity correction outcomes than the traditional TC technique. The SC technique was an effective alternative for patients with STIS.
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http://dx.doi.org/10.3171/2020.9.SPINE201168DOI Listing
April 2021

Which thoracic curves are at the greater risk for distal adding-on: comparison between typical and atypical Lenke 1A curves.

Eur Spine J 2021 Jul 29;30(7):1865-1871. Epub 2021 Mar 29.

Department of Spine Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.

Purpose: To identify the characteristics and the incidence of adding-on (AO) in atypical Lenke 1A adolescent idiopathic scoliosis patients, and to investigate whether atypical and typical Lenke 1A curve should follow the same lowest instrumented vertebra (LIV) selection strategy.

Methods: A total of 251 Lenke 1A patients who underwent posterior spinal fusion were analyzed. The minimum follow-up was 2 years. Curves were classified into two groups according to the apex. At last, 42 atypical Lenke 1A patients (apex at T10/11-T11/12) were identified and divided into atypical group (G1). Meanwhile, 42 age, gender, and Cobb angle-matched typical Lenke 1A patients (apex at T7/8-T10) were enrolled into the typical group (G2). The radiographic characteristics were evaluated, and the incidence of AO was compared between the 2 groups.

Results: The incidence of atypical Lenke 1A curves was 16.7%. Patients in G1 were found to have more left thoracic curves (P = 0.029), better flexibility of thoracic (P = 0.011) and lumbar curve (P = 0.014), and more preoperative coronal imbalance (P = 0.001). At the final follow-up, G1 developed more AO (38.1% vs. 19.0%). Specificity, for patients with LIV proximal to last substantially touching vertebra (LSTV), the incidence of AO was significantly higher in G1 (82.4% vs. 42.9%, P = 0.022).

Conclusion: Atypical Lenke 1A curve had its own radiographic characteristics. It was more likely to develop AO when LIV was proximal to LSTV, which indicated different fusion levels should be considered in these two subtypes of Lenke 1A. We recommended LSTV as LIV in atypical Lenke 1A cases, while one level proximal to LSTV might be available in typical Lenke 1A curve.

Level Of Evidence: 3.
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http://dx.doi.org/10.1007/s00586-021-06721-7DOI Listing
July 2021

Different distal fixation anchors in lumbosacral spinal deformities associated with sacral agenesis: which one is better?

J Neurosurg Spine 2021 Mar 26:1-6. Epub 2021 Mar 26.

Objective: Sacral agenesis (SA) is a rare congenital malformation of the spine. There has been a paucity of clinical research to investigate the surgical outcome of spinopelvic fixation in these patients. In this study, the authors aimed to evaluate the outcome of different distal fixation anchors in lumbosacral spinal deformities associated with SA and to determine the optimal distal fixation anchor.

Methods: Patients with diagnoses of SA and lumbosacral scoliosis undergoing spinopelvic fixation with S1 screws, iliac screws, or S2-alar-iliac (S2AI) screws were analyzed. The main curve, coronal balance distance, and pelvic obliquity were compared at baseline, postoperatively, and during follow-up in three groups. The complications were also recorded.

Results: A total of 24 patients were included: 8 patients were stratified into group 1 (S1 screws), 9 into group 2 (iliac screws), and 7 into group 3 (S2AI screws). The main curves were well corrected postoperatively (p < 0.05) in all groups. Coronal balance showed a tendency of deterioration during follow-up in patients with S1 screws (from 18.8 mm to 27.0 mm). Regarding pelvic obliquity, patients with both iliac and S2AI screws showed significant correction (from 3.7° to 2.3° and from 3.3° to 1.6°). Implant-related complications were rod breakage in 3 patients and infection in 1 patient in group 2, and no implant-related complications were observed in group 3. There were 3 cases of unilateral S1 pedicle screw misplacement in group 1.

Conclusions: Spinopelvic fixation is a safe and effective procedure that can achieve coronal correction in lumbosacral scoliosis associated with SA. Compared with S1 and iliac screws, S2AI screws as distal fixation anchors can achieve a more satisfactory correction with fewer implant-related complications.
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http://dx.doi.org/10.3171/2020.9.SPINE201390DOI Listing
March 2021

Similar surgical outcomes of the growing rod technique for treatment of early-onset scoliosis with versus without untreated intraspinal anomalies.

J Neurosurg Spine 2021 Mar 5:1-7. Epub 2021 Mar 5.

Objective: The aim of this study was to compare the radiological and clinical outcomes of early-onset scoliosis (EOS) patients with or without intraspinal anomalies (IAs) managed with growing rods (GRs), and to evaluate the safety of the GR technique in EOS patients with untreated IAs.

Methods: EOS patients undergoing GR placement between August 2008 and July 2017 were retrospectively reviewed. Patients with untreated IAs were classified into the EOS+IA group, and those without IAs into the EOS-IA group. The radiographic parameters including Cobb angle of the major curve, T1-S1 height, and apical vertebral translation were measured, and a detailed assessment of the neurological status was performed at each visit.

Results: Seventy-six patients with EOS (32 boys, 44 girls) with an average age of 6.5 ± 2.3 years at initial surgery satisfied the inclusion and exclusion criteria, including 28 patients in the EOS+IA group and 48 patients in the EOS-IA group. The radiographic measurements were comparable between groups preoperatively, postoperatively, and at the latest follow-up. One patient in the EOS+IA group experienced sensory deficit in a unilateral lower extremity after initial surgery, and an intraoperative neurophysiological monitoring event was observed in a patient in the EOS-IA group. No permanent neurological deficit was observed in either group.

Conclusions: EOS patients with and those without IAs had comparable clinical and radiological outcomes of the GR technique. Repeated lengthening procedures may be safe for EOS patients with untreated IAs.
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http://dx.doi.org/10.3171/2020.8.SPINE20785DOI Listing
March 2021

Optimizing the fusion level for lenke 5C adolescent idiopathic scoliosis: is the S-line a validated and reproducible tool to predict coronal decompensation?

Eur Spine J 2021 Jul 4;30(7):1935-1942. Epub 2021 Mar 4.

Spine Surgery, Nanjing Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.

Purpose: To validate the predictability of S-line in Lenke 5C patients.

Methods: Lenke 5C patients with a minimum 2-year follow-up and with the lowest instrumented vertebra (LIV) at lower end vertebra were included. The S-line was defined as a line connecting the centers of concave-side pedicles of upper instrumented vertebra (UIV) and LIV on baseline films. The S-line tilt to right was defined as positive S-line status (S-line +) and tilt to left as S-line - status. Statistical analysis was performed between different subgroups.

Results: Among the 92 patients, 69 patients had a left lumbar curve and 23 patients had a right lumbar curve. For left curves, the S-line + status had a significantly higher incidence of both proximal and distal decompensation. However, for right curves, the S-line - status was the risk factor. Thus, we modified the definition of S-line: The value of S-line tilt for right curves was opposite to that for left curves. Patients with modified S-line + showed a significantly higher incidence of both proximal and distal decompensation in Lenke 5C patients with both left and right curves (p < 0.001 and p = 0.010). In UEV group, patients with modified S-line + showed significantly higher incidence of proximal decompensation (P = 0.001). However, in UEV-1 group, the incidence of proximal decompensation was not statistically affected by modified S-line + (P = 0.281).

Conclusion: Modified S-line + is a validated risk factor that predisposed to post-operative coronal decompensation in Lenke 5C AIS patients. Selecting UIV at one level caudal to UEV could be a possible solution if the modified S-line was positive.
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http://dx.doi.org/10.1007/s00586-021-06781-9DOI Listing
July 2021

MiR-122-5p Mitigates Inflammation, Reactive Oxygen Species and SH-SY5Y Apoptosis by Targeting CPEB1 After Spinal Cord Injury Via the PI3K/AKT Signaling Pathway.

Neurochem Res 2021 Apr 2;46(4):992-1005. Epub 2021 Feb 2.

Department of Spine Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, 210008, Jiangsu, People's Republic of China.

Spinal cord injury (SCI) is a threatening disease that lead to severe motor and sensory deficits. Previous research has revealed that miRNAs are involved in the pathogenesis of a variety of diseases. However, whether miR-122-5p was involved in SCI was rarely investigated. In our study, we intended to probe role of miR-122-5p in the regulation of inflammatory response, reactive oxygen species (ROS) and SH-SY5Y apoptosis. We found miR-122-5p was downregulated in SCI mouse model and LPS-induced SH-SY5Y cells. Moreover, miR-122-5p overexpression alleviated inflammatory response, ROS and SH-SY5Y apoptosis in SCI mice. In addition, miR-122-5p elevation also mitigated SCI in LPS-induced SH-SY5Y cells. Additionally, cytoplasmic polyadenylation element binding protein 1 (CPEB1) was verified to be a target of miR-122-5p. CPEB1 expression was upregulated in SCI mouse model and LPS-induced SH-SY5Y cells. CPEB1 expression was negatively related to miR-122-5p expression. Moreover, CPEB1 activated the PI3K/AKT signaling pathway in SH-SY5Y cells. Finally, CPEB1 elevation recovered the suppressive effect on inflammatory response, ROS and SH-SY5Y apoptosis in LPS-treated SH-SY5Y cells mediated by miR-122-5p upregulation and through the PI3K/AKT signaling pathway.
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http://dx.doi.org/10.1007/s11064-021-03232-1DOI Listing
April 2021

Long noncoding RNA ZFAS1 aggravates spinal cord injury by binding with miR-1953 and regulating the PTEN/PI3K/AKT pathway.

Neurochem Int 2021 Jul 30;147:104977. Epub 2021 Jan 30.

Department of Neurosurgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine (Jinhua Municipal Central Hospital), Jinhua, 321000, Zhejiang, China. Electronic address:

Multiple evidence has shown that long non-coding RNAs (lncRNAs) are novel modulators in the development of many neurological diseases, including spinal cord injury (SCI). Recently, a novel lncRNA zinc finger antisense 1 (ZFAS1) has been found to facilitate the development of many human diseases. However, the effect of ZFAS1 in SCI has not been explored. In the present study, we used the SCI mouse models and LPS-treated BV-2 cellular models to explore the role of ZFAS1 in SCI. Basso Mouse Scale score was applied to reveal locomotor function. Cresyl violet staining was used to reveal volume of spared myelin around the lesion in the injured cord. RIP and luciferase reporter assay were applied to detect binding capacity among RNAs. Next, ZFAS1 was identified to be upregulated in spinal cord tissues of SCI mice. ZFAS1 knockdown promoted functional recovery and inhibited cell apoptosis and the inflammatory response in SCI mice. ZFAS1 bound with microRNA 1953 (miR-1953), and miR-1953 was downregulated in spinal cord tissues of SCI mice. Furthermore, we confirmed that ZFAS1 promoted SCI progression via binding with miR-1953. In addition, phosphatase and tensin homolog (PTEN) was verified to be a downstream target for miR-1953 in vitro, and PTEN was upregulated in spinal cord tissues of SCI mice. Finally, we illustrated that ZFAS1 inactivated the PI3K/AKT pathway through upregulation of PTEN. In conclusion, our study revealed that ZFAS1 facilitated SCI by binding with miR-1953 and regulating the PTEN/PI3K/AKT pathway, which may provide a potential novel insight for treatment of SCI.
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http://dx.doi.org/10.1016/j.neuint.2021.104977DOI Listing
July 2021

Determining the association between the radiographic parameters and the SRS-22 scores in Chinese female patients with adolescent idiopathic scoliosis: does curve pattern matter?

Br J Neurosurg 2021 Jan 25:1-7. Epub 2021 Jan 25.

Department of Spine Surgery, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China.

The Scoliosis Research Society (SRS)-22 outcomes have been shown to be correlated with radiographic parameter of adolescent idiopathic scoliosis (AIS). A recent study suggested that curve patterns might play a role in assessing the influence of deformity on patient's reported outcomes. The aim of this study was to examine the relationship between radiographic parameters and SRS-22 questionnaire outcomes in female patients with adolescent AIS among the Chinese population based on five curve patterns. The radiographic data and SRS-22 questionnaires of 259 female AIS patients were reviewed. Radiographic measurements included: Cobb angle of the major curve, T1 tilt angle, apical vertebral rotation, apical vertebral translation (AVT), thoracic kyphosis, and lumbar lordosis. Curve patterns included single thoracic (T), single thoracolumbar/lumbar (TL), double thoracic (DT), double major (DM), and triple major (TM). The correlation between radiographic measurements and each domain in SRS-22 was determined by Pearson's correlation coefficient. The curve magnitude and AVT of the major curve were found to be significantly correlated with the self-image domain in all cases (Cobb angle: = -0.426,  = 0.002; AVT: = -0.281, =0.006) and in all curve patterns except for TM. Compared to other groups, the TM group had a significantly larger major curve than the DT group and TL group ( ≤ 0.004). In TM group, the self-image scores were lower than TL group ( =0.018), and the function scores were lower than that in T, TL ( < 0.001) and DM groups ( =0.013). In the DT group, the T1 tilt was significantly correlated with the self-image domain ( = -0.376,  =0.004). In the T group, coronal curve magnitude was significantly correlated with function domain ( = -0.397,  < 0.001). Our findings suggested curve patterns should be considered in evaluating the correlations between radiographic parameters and SRS-22 outcomes in patients with AIS.
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http://dx.doi.org/10.1080/02688697.2021.1875396DOI Listing
January 2021

Optimal Reconstruction of Sagittal Alignment According to Global Alignment And Proportion Score Can Reduce Adjacent Segment Degeneration After Lumbar Fusion.

Spine (Phila Pa 1976) 2021 Feb;46(4):E257-E266

Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China.

Study Design: A retrospective study.

Objective: The aim of this study was to investigate the ability of Global Alignment and Proportion (GAP) score to predict the occurrence of adjacent segment degeneration (ASD) after fusion surgery for lumbar degenerative diseases.

Summary Of Background Data: The recently developed GAP score was applied to predict postoperative complications for adult spinal deformity, as well as to facilitate future outcome-based research on optimal treatment for various spinal conditions. However, it remains unclear whether reconstruction of alignment according to GAP score can reduce the ASD rates.

Methods: This study retrospectively reviewed 126 consecutive patients who had undergone lumbar fusion and had been followed over 2 years. Pre- and postoperative radiographs and MRI were analyzed for ASD. GAP scores were calculated based on the early postoperative spinopelvic parameters. Cochran-Armitage test of trend was performed to investigate the association between GAP score and the occurrence of ASD. Receiver-operating characteristic curves were used to analyze the predictive accuracy of the GAP score for ASD.

Results: Radiographical ASD (R-ASD) and symptomatic ASD (S-ASD) were diagnosed in 44 (34.9%) patients and in 13 (10.3%) patients, respectively. The patients with a proportioned spinopelvic state according to the GAP score had significantly lower rates of ASD (R-ASD and S-ASD) or S-ASD than those with a moderately or severely disproportioned spinopelvic state. The area under curve for the GAP score predicting ASD and S-ASD was 0.691 (95% confidence interval [CI]: 0.596∼0.785, P < 0.01) and 0.865 (95% CI: 0.771∼0.958, P < 0.01), respectively.

Conclusion: Our study revealed a significant association between postoperative GAP score and occurrence of ASD after lumbar fusion surgery. Setting surgical goals according to the GAP score may help reduce the occurrence of ASD, especially for S-ASD.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003761DOI Listing
February 2021

Classification of neurofibromatosis-related dystrophic or nondystrophic scoliosis based on image features using Bilateral CNN.

Med Phys 2021 Apr 17;48(4):1571-1583. Epub 2021 Feb 17.

Department of Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.

Purpose: We developed a system that can automatically classify cases of scoliosis secondary to neurofibromatosis type 1 (NF1-S) using deep learning algorithms (DLAs) and improve the accuracy and effectiveness of classification, thereby assisting surgeons with the auxiliary diagnosis.

Methods: Comprehensive experiments in NF1 classification were performed based on a dataset consisting 211 NF1-S (131 dystrophic and 80 nondystrophic NF1-S) patients. Additionally, 100 congenital scoliosis (CS), 100 adolescent idiopathic scoliosis (AIS) patients, and 114 normal controls were used for experiments in primary classification. For identification of NF1-S with nondystrophic or dystrophic curves, we devised a novel network (i.e., Bilateral convolutional neural network [CNN]) utilizing a bilinear-like operation to discover the similar interest features between whole spine AP and lateral x-ray images. The performance of Bilateral CNN was compared with spine surgeons, conventional DLAs (i.e., VGG-16, ResNet-50, and Bilinear CNN [BCNN]), recently proposed DLAs (i.e., ShuffleNet, MobileNet, and EfficientNet), and Two-path BCNN which was the extension of BCNN using AP and lateral x-ray images as inputs.

Results: In NF1 classification, our proposed Bilateral CNN with 80.36% accuracy outperformed the other seven DLAs ranging from 61.90% to 76.19% with fivefold cross-validation. It also outperformed the spine surgeons (with an average accuracy of 77.5% for the senior surgeons and 65.0% for the junior surgeons). Our method is highly generalizable due to the proposed methodology and data augmentation. Furthermore, the heatmaps extracted by Bilateral CNN showed curve pattern and morphology of ribs and vertebrae contributing most to the classification results. In primary classification, our proposed method with an accuracy of 87.92% also outperformed all the other methods with varied accuracies between 52.58% and 83.35% with fivefold cross-validation.

Conclusions: The proposed Bilateral CNN can automatically capture representative features for classifying NF1-S utilizing AP and lateral x-ray images, leading to a relatively good performance. Moreover, the proposed method can identify other spine deformities for auxiliary diagnosis.
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http://dx.doi.org/10.1002/mp.14719DOI Listing
April 2021

Incidence, Management and Outcome of Delayed Deep Surgical Site Infection Following Spinal Deformity Surgery: 20-Year Experience at a Single Institution.

Global Spine J 2020 Dec 30:2192568220978225. Epub 2020 Dec 30.

Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China.

Study Design: A retrospective study.

Objectives: To investigate the incidence, management and outcome of delayed deep surgical site infection (SSI) after the spinal deformity surgery.

Methods: This study reviewed 5044 consecutive patients who underwent spinal deformity corrective surgery and had been followed over 2 years. Delayed deep SSI were defined as infection involving fascia and muscle and occurring >3 months after the initial procedure. An attempt to retain the implant were initially made for all patients. If the infection failed to be eradicated, the implant removal should be put off until solid fusion was confirmed, usually more than 2 years after the initial surgery. Radiographic data at latest follow-up were compared versus that before implant removal.

Results: With an average follow-up of 5.3 years, 56 (1.1%) patients were diagnosed as delayed deep SSI. Seven (12.5%) patients successfully retained instrumentation and there were no signs of recurrence during follow-up (average 3.4 years). The remaining patients, because of persistent or recurrent infection, underwent implant removal 2 years or beyond after the primary surgery, and solid fusion was detected in any case. However, at a minimum 1-year follow-up (average 3.9 years), an average loss of 9° in the thoracic curve and 8° in the thoracolumbar/lumbar curves was still observed.

Conclusions: Delayed deep SSI was rare after spinal deformity surgery. To eradicate infection, complete removal of implant may be required in the majority of delayed SSI. Surgeons must be aware of high likelihood of deformity progression after implant removal, despite radiographic solid fusion.
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http://dx.doi.org/10.1177/2192568220978225DOI Listing
December 2020

Position-related Change of Pelvic Incidence Depends on the Nonfused Sacroiliac Joint in Patients with Degenerative Spinal Diseases.

Spine (Phila Pa 1976) 2021 Jun;46(12):796-802

Spine Surgery, Nanjing Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.

Study Design: A retrospective cross-sectional study.

Objective: This study aims to determine whether the sacroiliac (SI) joint motion correlated to pelvic incidence (PI) change from standing to supine position in patients with degenerative spinal diseases.

Summary Of Background Data: PI was found an unstable parameter after adolescence as the fixed nature of PI was challenged by several studies. The SI joint has been shown to have some motion, age-related degenerative changes of cartilage and SI ligaments contribute to SI joint instability.

Methods: The study contains both specimen study and radiographic study. One human specimen was acquired, on which PI was measured with different sacrum-ilium positions. In radiographic study, patients with old thoracolumbar fracture, lumbar disc herniation, stenosis, and spondylolisthesis were included. Ankylosing spondylitis (AS) patients were also included as control group. PI was measured on standing x-rays and scanogram of computed tomography images in supine position.

Results: Specimen study result revealed that SI motion would lead to the change of PI with fixed pelvic thickness. In radiographic study, 101 patients with different etiology and 30 AS patients were included. After stratifying into different age groups, standing PI was significantly larger than supine PI in each age groups (P = 0.002, <0.001, and <0.001, respectively). In patients with degenerative diseases, PI was significantly larger on standing position than that on supine position. ΔPI showed no significant difference across etiologies. However, in AS patients, standing PI and supine PI revealed no significant difference (P = 0.528).

Conclusion: Mobile SI joint may be the cause of increased PI in the aging spine. The dynamic change of PI is etiology-independent if the SI joint was not fused. Older patients have greater position-related change of PI.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003884DOI Listing
June 2021

Using Satellite Rod Technique in Patients with Severe Kyphoscoliosis Undergoing Three-Column Osteotomy: A Minimum of 2 Years' Follow-up.

Orthop Surg 2021 Feb 14;13(1):83-89. Epub 2020 Dec 14.

Department of Spine Surgery, Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.

Objective: To introduce the satellite rod technique utilized in severe spinal deformity after three-column osteotomy (3CO) and to evaluate the radiographic and clinical outcomes at 2-year follow-up, further discussing its utilization in this particular cohort.

Methods: A total of 32 (19 females and 13 males) with an average age of 32.9 ± 18.3 years from December 2012 to March 2016 were retrospectively reviewed. Radiographic measurements were performed on standing full-spine anteroposterior and lateral radiographs preoperatively, postoperatively, and at last follow-up. The coronal parameters including Cobb angle and distance between C plumb line and center sacral vertical line (C7PL-CSVL), as well as the sagittal parameters including global kyphosis (GK) and sagittal vertical axis (SVA) were measured at three time points. The Scoliosis Research Society-22 questionnaire (SRS-22) was fulfilled preoperatively and at each follow-up. Paired t test would be used to determine whether there was a significant difference between time points.

Results: A total of 32 patients were enrolled in this study with mean age of 32.9 ± 18.3 (range, 12 to 66) years old. Twenty patients underwent pedicle subluxation osteotomy (PSO) and 12 patients underwent vertebral column resection (VCR). The pathogenesis of this cohort included neuromuscular scoliosis (11 cases), congenital kyphoscoliosis (seven with hemivertebrae and five with segmentation failure), degenerative spinal deformity (five cases), and thoracolumbar tuberculosis with angular kyphosis (four cases). The post-operative Cobb angle decreased significantly from 49.1° ± 28.0° to 19.0° ± 16.7° with a correction rate of 65.2% ± 21.8%. At final follow-up, the average Cobb angle was 19.4° ± 16.9° and no obvious loss of correction was found. The preoperative, postoperative, and last follow-up C7PL-CSVL were 23.9 ± 14.5 mm, 15.7 ± 11.1 mm, and 12.1 ± 7.4 mm, respectively. Significant postoperative improvement was attained while there was no change observed at last follow-up. Postoperative GK significantly improved from 73.8° ± 28.1° to 23.2° ± 11.7° with the correction rate of 66.0% ± 17.9%. SVA decreased significantly from 42.9 ± 33.9 mm to 24.1 ± 21.1 mm. The average GK and SVA at final follow-up were 22.7° ± 10.1° and 23.5 ± 21.1 mm, respectively and no obvious loss of correction was observed of them during follow-up. In addition, no change or loss of motor or somatosensory evoked potential occurred during surgery. During the follow-up, two malposition screws and one rod breakage were found.

Conclusion: The satellite rod used in patients with severe kyphoscoliosis undergoing 3CO could yield favorable radiological and clinical outcomes. With the utilization of this technique, the coronal and sagittal balance could be well-maintained during follow-up.
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http://dx.doi.org/10.1111/os.12836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862162PMC
February 2021

Genetic Variants of CHD7 Are Associated with Adolescent Idiopathic Scoliosis.

Spine (Phila Pa 1976) 2021 Jun;46(11):E618-E624

Department of Spine Surgery, the Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.

Study Design: A case-control association study.

Objectives: The aim of this study was to investigate whether CHD7 was associated with adolescent idiopathic scoliosis in Chinese Han population and to further explore the functional role of CHD7 in the development of adolescent idiopathic scoliosis (AIS).

Summary Of Background Data: Several studies have explored the association of CHD7 with scoliosis in patients of European descent, while the results were inconsistent. There was a lack of study investigating the association of CHD7 with AIS in Chinese Han population.

Methods: Variants within CHD7 were genotyped in 965 AIS patients and 976 healthy controls. Whole exome sequencing was performed in 96 AIS patients. Paraspinal muscles of 43AIS patients and 38 lumbar disc herniation patients were collected for the evaluation of the gene expression. Intergroup comparison was performed with the χ2 test for genotyping data or Student t test for tissue expression. The relationship of CHD7 expression with clinical phenotypes was determined by the Pearson correlation.

Result: Variant rs121434341 of CHD7 was significantly associated with AIS. AIS patients were found to have a remarkable higher frequency of allele G when compared with healthy controls (2.89% vs. 1.57%, P = 0.0018), with an odds ratio value of 1.89. A pathogenic mutation affecting normal splicing was identified in a patient. Moreover, the expression level of CHD7 in AIS patients was significantly lower than in the controls (0.0008437 ± 0.00004583 vs. 0.001129 ± 0.00003773, P < 0.001), and CHD7 expression was positively correlated with bone mineral contents (P = 0.036, r = 0.32).

Conclusion: Genetic variants of CHD7 were significantly associated with AIS. Moreover, the decreased expression of CHD7 may be involved in the abnormal bone mass of AIS patients. Further studies are warranted to investigate the functional role of CHD7 in the pathogenesis of AIS.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003857DOI Listing
June 2021

Assessing the unique characteristics associated with surgical treatment of dystrophic lumbar scoliosis secondary to neurofibromatosis type 1: a single-center experience of more than 10 years.

J Neurosurg Spine 2020 Nov 20:1-11. Epub 2020 Nov 20.

Objective: Dystrophic lumbar scoliosis secondary to neurofibromatosis type 1 (DLS-NF1) may present an atypical, unique curve pattern associated with a high incidence of coronal imbalance and regional kyphosis. Early surgical intervention is complicated and risky but necessary. The present study aimed to assess the unique characteristics associated with the surgical treatment of DLS-NF1.

Methods: Thirty-nine consecutive patients with DLS-NF1 treated surgically at a mean age of 14.4 ± 3.9 years were retrospectively reviewed. Patients were stratified into three types according to the coronal balance classification: type A (C7 translation < 30 mm), 22 patients; type B (concave C7 translation ≥ 30 mm), 0 patients; and type C (convex C7 translation ≥ 30 mm), 17 patients. Types B and C were considered to be coronal imbalance. The diversity of surgical strategies, the outcomes, and the related complications were analyzed.

Results: The posterior-only approach accounted for 79.5% in total; the remaining 20.5% of patients received either additional anterior supplemental bone grafting (12.8%) to strengthen the fixation or convex growth arrest (7.7%) to reduce growth asymmetry. The lower instrumented vertebra (LIV) being L5 accounted for the largest share (41%), followed by L4 and above (35.9%), the sacrum (15.4%), and the pelvis (7.7%). Type C coronal imbalance was found in 23 patients (59%) postoperatively, and the incidence was significantly higher in the preoperative type C group (14/17 type C vs 9/22 type A, p = 0.020). All the patients with postoperative coronal imbalance showed ameliorative transition to type A at the last visit. The rate of screw malposition was 30.5%, including 9.9% breached medially and 20.6% breached laterally, although no serious neurological impairment occurred. The incidence of rod breakage was 16.1% (5/31) and 0% in patients with the posterior-only and combined approaches, respectively. Four revisions with satellite rods and 1 revision with removal of iliac screw for penetration into the hip joint were performed.

Conclusions: Surgical strategies for DLS-NF1 were diverse across a range of arthrodesis and surgical approaches, being crucially determined by the location and the severity of dystrophic changes. The LIV being L5 or lower involving the lumbosacral region and pelvis was not rare. Additional posterior satellite rods or supplementary anterior fusion is necessary in cases with insufficient apical screw density. Despite a high incidence of postoperative coronal imbalance, improvement of coronal balance was frequently confirmed during follow-up. Neurological impairment was scarce despite the higher rate of screw malposition.
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http://dx.doi.org/10.3171/2020.6.SPINE20898DOI Listing
November 2020

Intra-operative neurophysiological monitoring in patients with dystrophic neurofibromatosis type 1 scoliosis.

Somatosens Mot Res 2021 Jun 23;38(2):95-100. Epub 2020 Nov 23.

Spine Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.

Objective: To analyse the intra-operative neurophysiological monitoring (IONM) data in patients with dystrophic neurofibromatosis type 1 (NF1) associated scoliosis, and to investigate the possible risk factors for failed IONM monitoring.

Methods: Patients undergoing posterior spinal fusion from September 2015 to December 2019 were retrospectively reviewed. The latency (P37, N50) and amplitude of somatosensory evoked potentials (SEP) in bilateral lower extremities, latency and amplitude of motor evoked potentials (MEP) in bilateral lower extremities and unilateral upper extremity were recorded. The neurological status, curve pattern, Cobb angle of main curve, vertebral rotatory subluxation and dystrophic features at pre-operation were assessed for each patient. The failed IONM monitoring was defined as no reliable SEP or MEP waveforms of all monitored muscles.

Results: A total of 92 patients (53 M, 39 F) with an average age of 14.1 ± 2.7 years were included. Failed IONM monitoring was identified in 17 patients with overall success rates being 87.0 and 94.6% for SEP and MEP. The average P37 latency, N50 latency, SEP amplitude and MEP latency showed no significant difference between concave and convex sides ( > 0.05 for all). The MEP amplitudes of lower extremities were lower on concave side than convex side (334.5 ± 291.9 µV VS 417.5 ± 380.5 µV,  = 0.030). Higher risk of failed IONM monitoring was found in patients with neurological deficit ( = 0.014) and more dystrophic features ( = 0.002) at pre-operation.

Conclusions: The overall success rates were 87.0% for SEP and 94.6% for MEP in patients with NF1-associated scoliosis. Neurological deficit and more dystrophic features at pre-operation indicated higher risk of failed IONM monitoring.
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http://dx.doi.org/10.1080/08990220.2020.1850438DOI Listing
June 2021

Sacral Agenesis: A Neglected Deformity That Increases the Incidence of Postoperative Coronal Imbalance in Congenital Lumbosacral Deformities.

Global Spine J 2020 Nov 18:2192568220970509. Epub 2020 Nov 18.

Department of Spine Surgery, Nanjing Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.

Study Design: A retrospective study.

Objectives: To identify if there is a link between sacral agenesis (SA) and post-operative coronal imbalance in patients with congenital lumbosacral deformities.

Methods: This study reviewed a consecutive series of patients with congenital lumbosacral deformities. They had a minimum follow-up of 2 years. According to different diagnosis, they were divided into SA and non-SA group. Comparison analysis was performed between patients with and without post-operative coronal imbalance and risk factors were identified.

Results: A total of 45 patients (18 in SA group and 27 in non-SA group) were recruited into this study, among whom 33 patients maintained coronal balance while 12 demonstrated postoperative coronal imbalance at last follow-up (14.32 ± 7.67 mm vs 35.53 ± 3.91 mm, P < 0.001). Univariate analysis showed that preoperative lumbar Cobb angle, immediate postoperative coronal balance distance and diagnosis of SA were significantly different between patients with and without post-operative coronal imbalance (P < 0.05). Binary logistic regression analysis showed that SA was an independent risk factor for postoperative coronal imbalance.

Conclusions: As an independent risk factor for postoperative coronal imbalance, high level of suspicion of SA should be aware in children with congenital lumbosacral deformities. Sufficient bone grafts at sacroiliac joint are recommended for SA patients to prevent postoperative coronal imbalance.
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http://dx.doi.org/10.1177/2192568220970509DOI Listing
November 2020

Distal Adding-on Phenomenon in Scoliosis Secondary to Chiari Malformation Type I: Incidence and Risk Factors.

Spine (Phila Pa 1976) 2021 Apr;46(8):E491-E497

Department of Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.

Study Design: A retrospective study.

Objective: The aim of this study was to investigate the incidence and risk factors for distal adding-on (AO) phenomenon after posterior spinal fusion (PSF) in scoliosis secondary to Chiari malformation type I (CMS) patients with right major thoracic curve.

Summary Of Background Data: Distal AO phenomenon is a common complication observed in adolescent idiopathic scoliosis (AIS), which is significantly associated with unsatisfactory outcomes. However, few studies specifically focused on the incidence and risk factors of distal AO in CMS.

Methods: Seventy-eight CMS adolescents were included with a minimum of 2-year follow-up after PSF. patients with distal AO at the final follow-up were divided into AO group and those without were No-AO group. The coronal and sagittal parameters were evaluated preoperatively, immediately after surgery, and at the last follow-up. Clinical outcome was analyzed using the Chicago Chiari Outcome Scale (CCOS).

Results: Distal AO was observed in 18 of 78 patients (23.1%). Compared with No-AO group, patients with distal AO had significantly lower Risser sign (P = 0.001), more flexibility of lumbar curve (P = 0.021), higher incidence of lowest instrumented vertebra-last substantially touched vertebra (LIV-LSTV) ≤0 (P = 0.001), smaller postoperative Cobb angle of lumbar curve (P < 0.001), and greater correction rate of lumbar curve (P = 0.001). Logistic regression analysis revealed that low Risser sign (Grade 1-2, odds ratio [OR] = 5.7, P = 0.029) and LIV-LSTV ≤0 (OR = 6.4, P = 0.019) were independent risk factors for distal AO. There was no significant difference of CCOS scores between two groups at the final follow-up (P > 0.05 for all).

Conclusion: The incidence of distal AO was 23.1% in CMS patients after PSF. Patients with low Risser sign and LIV-LSTV ≤0 were high risk factors for distal AO.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003820DOI Listing
April 2021

Utility of Natural Sitting Lateral Radiograph in the Diagnosis of Segmental Instability for Patients with Degenerative Lumbar Spondylolisthesis.

Clin Orthop Relat Res 2021 04;479(4):817-825

Q.-S. Zhou, X. Sun, X. Chen, B.-P. Qian, Z. Zhu, Y. Qiu, Department of Spine Surgery, Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.

Background: Segmental instability in patients with degenerative lumbar spondylolisthesis is an indication for surgical intervention. The most common method to evaluate segmental mobility is lumbar standing flexion-extension radiographs. Meanwhile, other simple radiographs, such as standing upright radiograph, a supine sagittal magnetic resonance imaging (MRI) or supine lateral radiograph, or a slump or natural sitting lateral radiograph, have been reported to diagnose segmental instability. However, those common posture radiographs have not been well characterized in one group of patients. Therefore, we measured slip percentage in a group of patients with degenerative lumbar spondylolisthesis using radiographs of patients in standing upright, natural sitting, standing flexion, and standing extension positions as well as supine MRI.

Questions/purposes: We asked: (1) Does the natural sitting radiograph have a larger slip percentage than the standing upright or standing flexion radiograph? (2) Does the supine sagittal MRI reveal a lower slip percentage than the standing extension radiograph? (3) Does the combination of the natural sitting radiograph and the supine sagittal MRI have a higher translational range of motion (ROM) and positive detection rate of translational instability than traditional flexion-extension mobility using translational instability criteria of greater than or equal to 8%?

Methods: We retrospectively performed a study of 62 patients (18 men and 44 women) with symptomatic degenerative lumbar spondylolisthesis at L4 who planned to undergo a surgical intervention at our institution between September 2018 and June 2019. Each patient underwent radiography in the standing upright, standing flexion, standing extension, and natural sitting positions, as well as MRI in the supine position. The slip percentage was measured three times by single observer on these five radiographs using Meyerding's technique (intraclass correlation coefficient 0.88 [95% CI 0.86 to 0.90]). Translational ROM was calculated by absolute values of difference between two radiograph positions. Based on the results of comparison of slip percentage and translational ROM, we developed the diagnostic algorithm to evaluate segmental instability. Also, the positive rate of translational instability using our diagnostic algorithms was compared with traditional flexion-extension radiographs.

Results: The natural sitting radiograph revealed a larger mean slip percentage than the standing upright radiograph (21% ± 7.4% versus 17.7% ± 8.2%; p < 0.001) and the standing flexion radiograph (21% ±7.4% versus 18% ± 8.4%; p = 0.002). The supine sagittal MRI revealed a lower slip percentage than the standing extension radiograph (95% CI 0.49% to 2.8%; p = 0.006). The combination of natural sitting radiograph and the supine sagittal MRI had higher translational ROM than the standing flexion and extension radiographs (10% ± 4.8% versus 5.4% ± 3.7%; p < 0.001). More patients were diagnosed with translational instability using the combination of natural sitting radiograph and supine sagittal MRI than the standing flexion and extension radiographs (61% [38 of 62] versus 19% [12 of 62]; odds ratio 3.9; p < 0.001).

Conclusion: Our results indicate that a sitting radiograph reveals high slip percentage, and supine sagittal MRI demonstrated a reduction in anterolisthesis. The combination of natural sitting and supine sagittal MRI was suitable to the traditional flexion-extension modality for assessing translational instability in patients with degenerative lumbar spondylolisthesis.

Level Of Evidence: Level III, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083840PMC
April 2021

Preoperative Halo-Gravity Traction for Patients with Severe Focal Kyphosis in the Upper Thoracic Spine: A Safe and Effective Alternative for Three-Column Osteotomy.

Spine (Phila Pa 1976) 2021 Mar;46(5):307-312

Department of Spine Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.

Study Design: Retrospective review.

Objective: To evaluate the effect of preoperative Halo-gravity traction (HGT) in the treatment of severe focal kyphosis in the upper thoracic spine (UTS), and to propose the indications that HGT could serve as an alternative for three-column osteotomy (3CO) among these patients.

Summary Of Background Data: The HGT has been proven to be effective for severe kyphoscoliosis secondary to multiple etiologies. However, the safety and efficacy of HGT in severe focal kyphosis in UTS was still unclear.

Methods: Patients with focal kyphosis in UTS undergoing HGT and without 3CO operation were reviewed. The sagittal focal kyphosis was measured at pre-, posttraction, and postoperation. The neurologic function at pretraction, posttraction, and postoperation were assessed according to the American Spinal Injury Association (ASIA) grading. The complications during HGT, operation, and follow-up were recorded. The comparison between pretraction and posttraction was performed using paired samples t test.

Results: A total of 19 patients were included in this study, with a mean age of 13.2 ± 5.8 years. The average duration of HGT was 62.6 ± 8.4 days, during which the average kyphosis decreased from 95.3 ± 16.4° to 64.1 ± 19.2° (P < 0.001). After HGT, the ASIA grade improved from C to D in three patients and from C to E in three patients, from D to E in seven patients, from B to D in one patient. No deterioration in neurologic function was observed during HGT. The neurological status in one patient improved from ASIA C at pretraction to ASIA E at postoperation, but deteriorated to C at 4 years follow-up.

Conclusion: Preoperative HGT could help to correct deformity and improve neurological deficit. 3CO procedure might be unnecessary in patients with severe focal kyphosis in UTS with the utilization of HGT.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003782DOI Listing
March 2021

Novel Mutations in UTS2R are Associated with Adolescent Idiopathic Scoliosis in the Chinese Population.

Spine (Phila Pa 1976) 2021 Mar;46(5):E288-E293

Department of Spine Surgery, the Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.

Study Design: A case-control study.

Objectives: To investigate the association of urotensin II (UTS2) signals with the susceptibility of adolescent idiopathic scoliosis (AIS) in the Chinese Han population.

Summary Of Background Data: Dysregulated UTS2 signals induced by impaired cerebrospinal fluid flow have been implicated in the development of idiopathic scoliosis through studies on zebrafish. Furthermore, mutations in urotensin II receptor (UTS2R) were reported to cause severe scoliosis in zebrafish. In spite of the evidence presented in animal models, there is still a lack of knowledge concerning the role of UTS2 signaling related genes in AIS.

Methods: In the discovery stage, exons of UTS2, UTS2R, and UTS2D were sequenced for 200 AIS patients and 200 healthy controls. Newly identified mutations were further genotyped in another independent cohort of 1000 AIS patients and 1000 controls by allelic-specific multiple ligase detection reactions. Gene expression analysis was performed in 36 AIS patients and 36 age-matched congenital scoliosis patients. The Chi-square test was used to compare the genotyping data between the groups. Gene expression analysis was compared with the Student t test.

Results: Association between two novel mutations (rs11654140, c.51T > C; rs568196624, c.1146C > G) and the development of AIS was identified. Allele C of rs11654140 and allele G of rs568196624 were significantly associated with the risk of AIS (1.5% vs. 0.5%, odds ratio = 3.02, P = 0.01 for rs11654140; 1.41% vs. 0.58%, odds ratio = 2.29, P = 0.04 for rs568196624). The mRNA expression of UTS2R in the AIS group was significantly higher as compared with that in the control group (0.059 ± 0.015 vs. 0.035 ± 0.013, P < 0.01).

Conclusions: Rare mutations in UTS2R were significantly associated with AIS. Expression of UTS2R was significantly increased in AIS patients. The role of UTS2 signaling in the development of AIS is worthy of further investigation.Level of Evidence: N/A.
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http://dx.doi.org/10.1097/BRS.0000000000003786DOI Listing
March 2021

Quality of Life During Pregnancy, Caesarean Section Rate, and Anesthesia in Women with a History of Anterior Correction Surgery for Lumbar Scoliosis: A Case-Control Study.

Med Sci Monit 2020 Oct 17;26:e926960. Epub 2020 Oct 17.

Department of Spine Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China (mainland).

BACKGROUND This study investigated the prevalence and severity of low back pain (LBP), caesarean section (C-section) rate, and the anesthesia approaches among lumbar scoliosis patients undergoing anterior correction surgery, and compared them with a healthy control cohort. MATERIAL AND METHODS The inclusion criteria for adolescent idiopathic scoliosis (AIS) patients were: presence of lumbar scoliosis, history of 1 or more pregnancies after surgery, and underwent anterior-only surgery. Healthy women with a history of 1 pregnancy were included as the control group. We recorded the type of delivery, neonatal birth weight, and perinatal complications. The quality of life was also evaluated. RESULTS New-onset LBP was reported in 65.6% of AIS patients, significantly higher than in the control group (p<0.001). C-section was performed in 11 scoliosis patients (34.4%) and 25 healthy controls (31.25%), and the rates were not significantly different between groups (P=0.75). No serious perinatal complications were reported in either group. General anesthesia was used for all C-section AIS patients. The rate of successful neuraxial anesthesia in the control group was significantly higher (P<0.001). CONCLUSIONS Compared with the healthy control group, lumbar AIS patients did not experience a higher risk of perinatal complications or C-section rate after anterior surgical correction, but general anesthesia was more commonly used than neuraxial regional anesthesia. LBP was more frequently observed in the post-operative AIS patients.
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http://dx.doi.org/10.12659/MSM.926960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577072PMC
October 2020

Risk factors for postoperative coronal decompensation in adult lumbar scoliosis after posterior correction with osteotomy.

Arch Orthop Trauma Surg 2020 Oct 15. Epub 2020 Oct 15.

Spine Surgery, Drum Town Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.

Introduction: To determine potential risk factors for postoperative coronal imbalance following posterior osteotomy for adult scoliosis.

Materials And Methods: A total of 74 patients underwent osteotomy for rigid adult lumbar scoliosis. A group of 20 patients with postoperative coronal imbalance was identified. Clinical data and surgical strategies were compared to determine the risk factors, including age, gender, etiology, Cobb angle, preoperative coronal balance distance, direction of preoperative imbalance, T1 tilt, tilt of upper instrumented vertebra (UIV), UIV translation, location of UIV (T6 above or below), fusion to L5 or S1, lower instrumented vertebra (LIV) tilt, LIV rotation, screw density, osteotomy procedure (PSO or SPOs) and use of iliac screws.

Results: Comparison between patients with and without postoperative coronal imbalance showed that postoperative coronal imbalance occurred in older patients and those with degenerative scoliosis as the etiology, UIV above T6, preoperative LIV rotation, preoperative LIV tilt and preoperative coronal imbalance towards the convex side and who underwent Smith-Petersen osteotomy. All seven parameters were included in the logistic regression analysis. UIV above T6 (P = 0.010), LIV rotation (P = 0.012) and preoperative coronal imbalance towards the convex side (P = 0.005) were identified as risk factors for postoperative coronal imbalance after osteotomy.

Conclusions: Patients with preoperative coronal imbalance towards the convex side (UIV above T6) and LIV rotation were more likely to develop coronal imbalance than those without risk factors. Older patients and those with degenerative scoliosis were also at a relatively higher risk of postoperative coronal imbalance.
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http://dx.doi.org/10.1007/s00402-020-03633-xDOI Listing
October 2020

Potential Risk of Thoracic Aorta Injury from Excessively Long Right Pedicle Screws in Patients with Left Thoracic Scoliosis: A Computed Tomography Image Study.

World Neurosurg 2021 01 9;145:e177-e183. Epub 2020 Oct 9.

Spine Surgery, Nanjing Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China. Electronic address:

Objective: We sought to investigate the changed position of thoracic aorta relative to spine in patients with left thoracic scoliosis and to analyze the potential risks of thoracic aorta injury from pedicle screw insertion in these patients.

Methods: Twenty patients with left thoracic scoliosis (Group A) and 15 normal subjects with a straight spine (Group B) were included. Axial computed tomography images from T5 to T12 of all these subjects were obtained to measure the aorta-vertebral angle. The percentages of thoracic aorta located anteriorly to the screw trajectory were calculated on both the left and right sides.

Results: The average aorta-vertebral angle in Group A was significantly larger than that in Group B at each level (P < 0.05) except T5. In Group A, both left and right pedicle screws might pose threats to the thoracic aorta. The percentages of aortas at risk from the right pedicle screw were high in the apical region. However, in Group B, only the left pedicle screw might pose threats to the aorta. No aorta was found to be at risk of injury from right pedicle screw insertion in Group B.

Conclusions: The thoracic aorta often lies anteriorly to the left pedicle screw trajectory in normal subjects, especially in the lower thoracic region. However, the thoracic aorta moves to the right side in patients with left thoracic scoliosis, making a large proportion of patients at risk of injury from right pedicle screw insertion in the apical region.
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http://dx.doi.org/10.1016/j.wneu.2020.09.171DOI Listing
January 2021

Surgical Releasing for Severe and Rigid Scoliosis: Posterior Approach is Better than Anterior Approach.

Clin Spine Surg 2020 Oct 9. Epub 2020 Oct 9.

Department of Spine Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.

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http://dx.doi.org/10.1097/BSD.0000000000001086DOI Listing
October 2020
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