bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Effect of Paraspinal Muscle Degeneration on Distal Pedicle Screw Loosening Following Corrective Surgery for Degenerative Lumbar Scoliosis
Authors: Leng Junsheng , Han Gengyu , Zeng Yan , Chen Zhongqiang , Li Weishi 
Published: November 2019

Mini
A total of 137 degenerative lumbar scoliosis patients were divided into two groups. In group A (six or more fused levels), mean rFCSA of erector spinae <0.71 was an independent risk factor of LIV screw loosening. In Group B (four or five fused levels), paraspinal muscle degeneration had no influence on LIV screw loosening.

Study Design.
A retrospective study.

Objective.
The aim of this study was to evaluate the effect of degeneration of paraspinal muscles, including psoas muscles, erector spinae muscles, and multifidus muscles on pedicle screw loosening at lower instrumented vertebra (LIV) following corrective surgery for degenerative lumbar scoliosis (DLS).

Summary of Background Data.
The relation between paraspinal muscles and pedicle screw loosening in DLS patients has not been reported.

Methods.
A total of 137 DLS patients underwent corrective surgery with at least 1-year follow-up were included. The patients were divided into two groups: Group A (68 patients) had six or more fused levels and Group B (69 patients) had four or five fused levels. Muscular parameters, including relative cross-sectional area (rCSA) and muscle-fat index (MFI), were measured on preoperative magnetic resonance imaging. rCSA and MFI were measured for both gross muscle (G) and functional muscle (F) as rGCSA, rFCSA, GMFI, and FMFI. Muscle ratio was calculated as rFCSA/rGCSA. Pedicle screw loosening was assessed on spine radiographs or CT at final follow-up. Clinical and radiological screw loosening were classified according to clinical significance.

Results.
LIV screw loosening occurred in 77 patients at final follow-up. In Group A, patients with LIV screw loosening had significantly higher FMFI of psoas muscles and lower rFCSA and rGCSA of erector spinae. Logistic regression revealed that mean rFCSA of erector spinae <0.71 (odds ratio = 5.0, 95% confidence interval = 1.5–16.4) was an independent risk factor of LIV screw loosening. Mean muscle ratio of erector spinae was significantly lower in patients with clinical screw loosening compared with radiological screw loosening in univariate analysis. In Group B, all muscular parameters showed no significant difference.

Conclusion.
Degeneration of paraspinal muscles, especially psoas muscles and erector spinae, affected LIV screw loosening in six or more level fusion in corrective surgery for DLS, whereas the four- or five-level fusion had no this influence.

Level of Evidence: 3
Improvement in Patient Mental Well-being After Surgery for Cervical Spondylotic Myelopathy
Authors: Tamai Koji , Suzuki Akinobu , Terai Hidetomi , Hoshino Masatoshi , Toyoda Hiromitsu , Takahashi Shinji , Ohyama Shoichiro , Hori Yusuke , Yabu Akito , Nakamura Hiroaki 
Published: November 2019

Study Design.
Retrospective cohort study.

Objective.
The aim of this study was to investigate changes in mental well-being after surgery for cervical spondylotic myelopathy (CSM) and identify factors associated with improvement.

Summary of Background Data.
Posterior cervical surgery with laminoplasty significantly improves myelopathy and physical function in patients with CSM. However, its impact on mental well-being is unclear.

Methods.
Patients who underwent laminoplasty for CSM and had >2 years of follow-up were reviewed (n = 111). The mental component summary (MCS) score was used as a measure of mental well-being. The trend in MCS score change was evaluated using the Jonckheere-Terpstra trend test. Preoperative clinical scores were compared between patients with improvements greater and less than the minimal clinically important difference (MCID). Significant variables were included in a multinomial logistic regression analysis and further validated in a receiver-operating characteristic (ROC) curve analysis. Additionally, the results were confirmed in a long-term observation cohort of patients followed up for >5 years (n = 46).

Results.
The improvement in the average MCS score (5.6) was greater than the MCID (4.0). The trend of improvement was sustained for 2 years (P = 0.002), but not for 5 years (P = 0.130). In terms of individual cases, 56 patients (50.5%) achieved MCS score improvement greater than the MCID. These patients showed significantly lower preoperative MCS scores than those without meaningful improvement (P < 0.001). The preoperative “social functioning (SF)” score was independently associated with MCS score improvement (P = 0.001). ROC curve analysis validated the ability of preoperative SF to predict MCS score improvement at 2 and 5 years postoperatively (area under the curve: 0.744, 0.893, respectively).

Conclusion.
Half of the patients achieved meaningful improvement in mental well-being. A lower preoperative SF score was independently associated with improvement. These results may help identify patients who could experience an improvement in mental well-being after surgery and develop novel approaches to achieve further improvement.

Level of Evidence: 3
The Screw–Aorta Dilemma
Authors: Sarwahi Vishal , Galina Jesse , Wendolowski Stephen , Thornhill Beverly , Atlas Aaron , Gecelter Rachel , Hasan Sayyida , Lo Yungtai , Amaral Terry D. 
Published: November 2019

Study Design.
Retrospective chart review.

Objective.
To determine if obtaining a prone computed tomography (CT)-scan can better delineate a questionable screw–aorta relationship.

Summary of Background Data.
Pedicle screw misplacement rate is reported between 6% and 15%. Studies looking at misplacements on a per patient basis show up to 14% of patients have screws at risk (impinging vital structures). A screw abutting the aorta is a management challenge and often requires vascular surgery intervention. However, CT scans routinely done in supine position may overestimate screw–aorta relationship. Change in patient position may allow the aorta to roll away and, in most cases, reveal an uncompromised aorta. This will allow safe removal of pedicle screws without any vascular intervention.

Methods.
One hundred eleven spinal deformity patients who underwent Posterior spinal fusion from 2004 to 2009 were evaluated. Patients with concerning screw–aorta relationship underwent additional prone CT scan. Mobility of the aorta was determined and distance was compared using prone and supine CT scans.

Results.
Two thousand two hundred ninety five screws were reviewed, 36 screws in 18 patients were in proximity to the aorta. Fourteen screws (nine patients) appeared to be impinging the aorta. On prone CT, 13 out of the 14 instances the aorta moved away from the screw. The average distance at the screw level was 13.6 ± 4.8 mm in supine position and 8.9 ± 5.4 mm in prone position (P = 0.001). In one instance the relationship was unchanged on prone CT. No screw was noted to violate the lumen or distort the aorta.

Conclusion.
Supine CT scan alone is not entirely accurate in determining screw–aorta relationship. Prone-CT scan provides additional information for better delineation. This additional diagnostic step can change the treatment option by limiting the need for vascular intervention. When in doubt, the additional use of an arteriogram can allow for improved visualization.

Level of Evidence: 3
Postoperative Kyphosis in Cervical Spondylotic Myelopathy
Authors: Machino Masaaki , Ando Kei , Kobayashi Kazuyoshi , Morozumi Masayoshi , Tanaka Satoshi , Kanbara Shunsuke , Ito Sadayuki , Inoue Taro , Ito Keigo , Kato Fumihiko , Ishiguro Naoki , Imagama Shiro 
Published: November 2019

Study Design.
A prospective cohort study.

Objective.
This study aimed to investigate the relationship between preoperative cervical sagittal alignment and postoperative kyphosis in patients with cervical spondylotic myelopathy (CSM) and to determine the cut-off angle for predicting the postlaminoplasty kyphosis.

Summary of Background Data.
There have been several reports describing a cervical kyphosis after laminoplasty. However, there has been no study on the cut-off angle for predicting the postoperative kyphosis in a large series of patients with CSM.

Methods.
A total of 1025 consecutive patients with CSM (642 men and 383 women; mean age, 64.4 yr; range, 23–93 yrs) who underwent laminoplasty were included. The average follow-up period was 30.0 months. Radiography was performed before the surgery and at final follow-up. The cervical alignment with neutral view was measured by using the Cobb method. An alignment of C2–7 lordotic angle more than 0° was defined as lordosis and C2–7 lordotic angle less than 0° was defined as kyphosis. The incidence of postoperative kyphosis was evaluated on lateral radiographs.

Results.
In all patients, the mean C2–7 alignment in the neutral position was 11.5° lordotic before surgery and 14.2° lordotic at final follow-up. In the patient without preoperative kyphotic alignment, receiver operating characteristic curve of preoperative C2–7 lordotic angle showed 7° as a predictor for the postlaminoplasty kyphosis (area under the curve  = 0.75, P < 0.0001). Among the preoperatively 720 patients with lordosis more than 7°, postoperative kyphosis was observed in 20 patients (2.8%), whereas in the preoperatively 191 patients with lordosis less than 7°, postoperative kyphosis was seen in 28 patients (14.7%).

Conclusion.
The cut-off value of preoperative C2–7 lordotic angle for predicting the postlaminoplasty kyphosis was 7° in CSM patient without preoperative kyphotic alignment.

Level of Evidence: 3
The Oblique Corridor at L4-L5
Authors: Ng Julia Poh-Hwee , Kaliya-Perumal Arun-Kumar , Tandon Ankit Anil , Oh Jacob Yoong-Leong 
Published: November 2019

Study Design.
Cross-sectional radioanatomical study.

Objective.
The aim of this study was to analyze the prevalence, size, and location of the oblique corridor (OC), and the morphology of the psoas muscle at the L4-L5 disc level.

Summary of Background Data.
Lateral lumbar interbody fusion via the OC has the advantage of avoiding injury to the psoas muscle and lumbar plexus. However, the varying anatomy of major vascular structures and the iliopsoas may preclude a safe oblique access to the L4-L5 level.

Methods.
Five hundred axial magnetic resonance images of the L4-L5 disc level were shortlisted. OCs were categorized into four grades: Grade 0 = no corridor, Grade 1 = small corridor (≤1 cm), Grade 2 = moderate corridor (1–2 cm) and Grade 3 = large corridor (>2 cm). OC location was labeled as antero-oblique, oblique, or oblique-lateral. Psoas morphology was categorized based on a modified Moro's classification, where the anterior section was further subdivided into types AI-AIV. Oblique approach was considered nonviable either when there was no corridor due to vascular obstruction (Grade 0) or when the psoas was high-rising (Types AII-AIV).

Results.
10.5% of the selected 449 patients had no measurable OC (grade 0) at the L4-L5 level. There were 35% and 37.2% patients with a grade 1and 2 OC, respectively. The location of the OC was anterior oblique, oblique, and oblique lateral in 3.7%, 89.6%, and 6.7%, respectively. According to the modified Moro's classification, 19.4% had a high-rising psoas. Predominantly, psoas was either in line with the disc (Type I; 30.7%) or low-rising (Type AI; 47.4%).

Conclusion.
Twenty-five percent of the patients did not have an accessible OC either due to obstruction by vascular structures or due to a high-rising psoas. Hence, proper evaluation of the relevant anatomy preoperatively is recommended for early adopters of this technique, as varying anatomy precludes universal suitability of oblique lateral interbody fusion for the L4-L5 level.

Level of Evidence: 3
Extradural Contralateral C7 Nerve Root Transfer in a Cervical Posterior Approach for Treating Spastic Limb Paralysis
Authors: Yang Kaixiang , Jiang Fan , Zhang Shaohua , Zhao Haiqiang , Shi Zongpo , Liu Jun , Cao Xiaojian 
Published: November 2019

Study Design.
Anatomic study in nine fresh-frozen cadavers.

Objective.
To confirm the anatomical feasibility of transferring the extradural ventral roots (VRs) and dorsal roots (DRs) of contralateral C7 nerves to those of the ipsilateral C7 nerves respectively through a cervical posterior approach.

Summary of Background Data.
The contralateral C7 nerve root transfer technique makes breakthrough for treating spastic limb paralysis. However, its limitations include large surgical trauma and limited indications.

Methods.
Nine fresh-frozen cadavers (four females and five males) were placed prone, and the feasibility of exposing the bilateral extradural C7 nerve roots, separation of the extradural C7 VR and DR, and transfer of the VR and DR of the contralateral C7 to those of the ipsilateral C7 on the dural mater were assessed. The pertinent distances and the myelography results of each specimen were analyzed. The acetylcholinesterase (AChE) and antineurofilament 200 (NF200) double immunofluorescent staining were preformed to determine the nerve fiber properties.

Results.
A cervical posterior midline approach was made and the laminectomy was performed to expose the bilateral extradural C7 nerve roots. After the extradural C7 VR and DR are separated, the VR and DR of the contralateral C7 have sufficient lengths to be transferred to those of the ipsilateral C7 on the dural mater. The myelography results showed that the spinal cord is not compressed after the nerve anastomosis. The AChE and NF200 double immunofluorescent staining showed the distal ends of the contralateral C7 VRs were mostly motor nerve fibers, and the distal ends of the contralateral C7 DRs were mostly sensory nerve fibers.

Conclusion.
Extradural contralateral C7 nerve root transfer in a cervical posterior approach for treating spastic limb paralysis is anatomically feasible.

Level of Evidence: 5.
Biomarkers of Delirium Duration and Delirium Severity in the ICU*
Authors: Khan Babar A. , Perkins Anthony J. , Prasad Nagendra K. , Shekhar Anantha , Campbell Noll L. , Gao Sujuan , Wang Sophia , Khan Sikandar H. , Marcantonio Edward R. , Twigg Homer L. , Boustani Malaz A. 
Published: November 2019

Objectives:
Both delirium duration and delirium severity are associated with adverse patient outcomes. Serum biomarkers associated with delirium duration and delirium severity in ICU patients have not been reliably identified. We conducted our study to identify peripheral biomarkers representing systemic inflammation, impaired neuroprotection, and astrocyte activation associated with delirium duration, delirium severity, and in-hospital mortality.

Design:
Observational study.

Setting:
Three Indianapolis hospitals.

Patients:
Three-hundred twenty-one critically ill delirious patients.

Interventions:
None.

Measurements and Main Results:
We analyzed the associations between biomarkers collected at delirium onset and delirium-/coma-free days assessed through Richmond Agitation-Sedation Scale/Confusion Assessment Method for the ICU, delirium severity assessed through Confusion Assessment Method for the ICU-7, and in-hospital mortality. After adjusting for age, gender, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity score, sepsis diagnosis and study intervention group, interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were negatively associated with delirium-/coma-free days by 1 week and 30 days post enrollment. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium-/coma-free days at both time points. Interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were also associated with delirium severity by 1 week. At hospital discharge, interleukin-6, -8, and -10 retained the association but tumor necrosis factor-α, C-reactive protein, and S-100β lost their associations with delirium severity. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium severity at both time points. Interleukin-8 and S-100β levels in quartile 4 were also associated with higher in-hospital mortality. Interleukin-6 and -10, tumor necrosis factor-α, and insulin-like growth factor-1 were not found to be associated with in-hospital mortality.

Conclusions:
Biomarkers of systemic inflammation and those for astrocyte and glial activation were associated with longer delirium duration, higher delirium severity, and in-hospital mortality. Utility of these biomarkers early in delirium onset to identify patients at a higher risk of severe and prolonged delirium, and delirium related complications during hospitalization needs to be explored in future studies.
Bacterial and Fungal Etiology of Sepsis in Children in the United States: Reconsidering Empiric Therapy*
Authors: Prout Andrew J. , Talisa Victor B. , Carcillo Joseph A. , Decker Brooke K. , Yende Sachin 
Published: November 2019

Objectives:
Timely empiric antimicrobial therapy is associated with improved outcomes in pediatric sepsis, but minimal data exist to guide empiric therapy. We sought to describe the prevalence of four pathogens that are not part of routine empiric coverage (e.g., Staphylococcus aureus, Pseudomonas aeruginosa, Clostridium difficile, and fungal infections) in pediatric sepsis patients in a contemporary nationally representative sample.

Design:
This was a retrospective cohort study using administrative data.

Setting:
We used the Nationwide Readmissions Database from 2014, which is a nationally representative dataset that contains data from nearly half of all discharges from nonfederal hospitals in the United States.

Patients:
Discharges of patients who were less than 19 years old at discharge and were not neonatal with a discharge diagnosis of sepsis.

Interventions:
None.

Measurements and Main Results:
Of the 19,113 pediatric admissions with sepsis (6,300 [33%] previously healthy and 12,813 [67%] with a chronic disease), 31% received mechanical ventilation, 19% had shock, and 588 (3.1%) died during their hospitalization. Among all admissions, 8,204 (42.9%) had a bacterial or fungal pathogen identified. S. aureus was the most common pathogen identified in previously healthy patients (n = 593, 9.4%) and those with any chronic disease (n = 1,430, 11.1%). Methicillin-resistant S. aureus, P. aeruginosa, C. difficile, and fungal infections all had high prevalence in specific chronic diseases associated with frequent contact with the healthcare system, early surgery, indwelling devices, or immunosuppression.

Conclusions:
In this nationally representative administrative database, the most common identified pathogen was S. aureus in previously healthy and chronically ill children. In addition, a high proportion of children with sepsis and select chronic diseases had infections with methicillin-resistant S. aureus, fungal infections, Pseudomonas infections, and C. difficile. Clinicians caring for pediatric patients should consider coverage of these organisms when administering empiric antimicrobials for sepsis.
The Physician's Guide to Platelet-Rich Plasma in Dermatologic Surgery Part II: Clinical Evidence
Authors: Hausauer Amelia K. , Humphrey Shannon 
Published: November 2019

BACKGROUND
Platelet-rich plasma (PRP) is an increasingly popular treatment modality for various dermatologic conditions, but there are limitations in both the published literature and clinician knowledge.

OBJECTIVE
To create a high-yield, in-depth analysis of PRP in procedural dermatology by reviewing available data on its role in hair restoration, soft-tissue remodeling, resurfacing, and rejuvenation; identifying practice gaps and controversies; and making suggestions for future research that will establish dermatologists as pioneers of regenerative medicine.

MATERIALS AND METHODS
A two-part systematic review and expert analysis of publications before October 2018.

RESULTS AND CONCLUSION
Most studies on PRP report favorable outcomes with the strongest level of evidence existing for androgenetic alopecia followed by postprocedure wound healing, scar revision, striae, rejuvenation, and dermal filling. There is a dearth of large randomized controlled trials, considerable heterogeneity in the variables studied, and lack of specificity in the preparatory protocols, which may influence clinical outcomes. Future investigations should use consistent nomenclature, find ideal solution parameters for each cutaneous indication, determine significant outcome metrics, and follow double-blinded, randomized, controlled methodologies. Addressing these deficiencies will take sound scientific inquiry but ultimately has the potential to benefit the authors' specialty greatly.
Ulnar Nerve Injuries (Sunderland Grade V): A Simplified Classification System and Treatment Algorithm
Authors: Ghoraba Samir M. , Mahmoud Wael H. , Elsergany Mervat A. , Ayad Hashem M. 
Published: November 2019

Background:
This study introduced a novel technical approach to the ulnar nerve injuries. The ulnar nerve was divided into 4 distinct surgical zones, each mandating a unique management strategy.

Methods:
A prospective observational study was conducted to verify the hypothesized algorithm. The study included 110 patients diagnosed with ulnar nerve injury (Sunderland grade 5). We divided the patients into 4 groups depending on the site of injury. Each group of patients was managed in accordance with a particular strategy, exploiting nerve transfer techniques along with the updated knowledge of the internal topography of the ulnar nerve. The motor recovery of the small muscles of the hand was assessed after 2 years of follow-up, using the disabilities of the arm, shoulder, and hand score, and other parameters including key pinch strength, hand grip strength, and the motor power of the first dorsal interosseous muscle on the Medical Research Council scale.

Results:
The mean values of the disabilities of the arm, shoulder, and hand score, key pinch strength, and hand grip strength showed a statistically significant improvement across all patient groups (P < 0.05). Of those with zone (I) injury, postoperatively, 79.9% patients attained a first dorsal interosseous muscle power grade >3 on the Medical Research Council scale, while 93.9% of patients with zone (II) damage achieved the same result. Surprisingly, 84% of patients included in both zones (III) and (IV) also recovered to the same extent.

Conclusions:
This prospective observational study examined and successfully confirmed the validity of our proposed novel algorithm for the management of ulnar nerve injuries (Sunderland grade 5).