Early Lumbar Research Articles

Two-Stage Deep Learning Model for Diagnosis of Lumbar Spondylolisthesis Based on Lateral X-Ray Images

Diagnosing early lumbar spondylolisthesis is challenging for many doctors because of the lack of obvious symptoms. Using deep learning (DL) models to improve the accuracy of X-ray diagnoses can effectively reduce missed and misdiagnoses in clinical practice. This study aimed to use a two-stage deep learning model, the Res-SE-Net model with the YOLOv8 algorithm, to facilitate efficient and reliable diagnosis of early lumbar spondylolisthesis based on lateral X-ray image identification. A total of 2424 lumbar lateral radiographs of patients treated in the Beijing Tongren Hospital between January 2021 and September 2023 were obtained. The data were labeled and mutually identified by 3 orthopedic surgeons after reshuffling in a random order and divided into a training set, validation set, and test set in a ratio of 7:2:1. We trained 2 models for automatic detection of spondylolisthesis. YOLOv8 model was used to detect the position of lumbar spondylolisthesis, and the Res-SE-Net classification method was designed to classify the clipped area and determine whether it was lumbar spondylolisthesis. The model performance was evaluated using a test set and an external datasetfrom Beijing Haidian Hospital. Finally, we compared model validation results with professional clinicians' evaluation. The model achieved promising results, with a high diagnostic accuracy of 92.3%, precision of 93.5%, and recall of 93.1% for spondylolisthesis detection on the test set, the area under the curve (AUC) value was 0.934. Our two-stage deep learning model provides doctors with a reference basis for the better diagnosis and treatment of early lumbar spondylolisthesis.

Optimizing prediction accuracy for early recurrent lumbar disc herniation with a directional mutation-guided SVM model

Percutaneous endoscopic lumbar discectomy (PELD) is one of the main means of minimally invasive spinal surgery, and is an effective means of treating lumbar disc herniation, but its early recurrence is still difficult to predict. With the development of machine learning technology, the auxiliary model based on the prediction of early recurrent lumbar disc herniation (rLDH) and the identification of causative risk factors have become urgent problems in current research. However, the screening ability of current models for key factors affecting the prediction of rLDH, as well as their predictive ability, needs to be improved. Therefore, this paper presents a classification model that utilizes wrapper feature selection, developed through the integration of an enhanced bat algorithm (BDGBA) and support vector machine (SVM). Among them, BDGBA increases the population diversity and improves the population quality by introducing directional mutation strategy and guidance-based strategy, which in turn allows the model to secure better subsets of features. Furthermore, SVM serves as the classifier for the wrapper feature selection method, with its classification prediction results acting as a fitness function for the feature subset. In the proposed prediction method, BDGBA is used as an optimizer for feature subset filtering and as an objective function for feature subset evaluation based on the classification results of the support vector machine, which improves the interpretability and prediction accuracy of the model. In order to verify the performance of the proposed method, this paper proves the performance of the model through global optimization experiments and prediction experiments on real data sets. The accuracy of the proposed rLDH prediction model is 93.49% and sensitivity is 88.33%. The experimental results show that Level of herniated disk, Modic change, Disk height, Disk length, and Disk width are the key factors for predicting rLDH, and the proposed method is an effective auxiliary diagnosis method.

Is Surgical Treatment Optimal for Early Postoperative Recurrent Lumbar Disc Herniation?

Is Surgical Treatment Optimal for Early Postoperative Recurrent Lumbar Disc Herniation?

Early Recurrence of Lumbar Disc Herniation: A Retrospective Analysis of the Role of Discectomy Volume and Other Influencing Factors

Objective:
 The aim of this study is to conduct a detailed examination of cases of "Early Recurrence" encountered following lumbar disc herniation, and to compare the data obtained with findings in the existing literature.
 Materials and Methods:
 This retrospective study was conducted by analyzing the data of 856 patients who were operated for recurrent lumbar hernia in our hospital between 2012 and 2022. By expanding the definition of "early relapse" in the literature, inclusion and exclusion criteria were determined, and as a result, 43 patients who met the criteria were included in the study
 Results:
 The severity of symptoms was assessed based on patients' Visual Analog Scale (VAS) scores at baseline and during subsequent periods. Patients requiring reoperation within the first 12 months were divided into two main groups: those undergoing reoperation within the first 6 months and those undergoing reoperation between 6-12 months. However, no statistically significant difference was found between the two groups in terms of age, gender, comorbidities, and other determinants. Notably, patients undergoing surgery within the first 3 months were observed to be of advanced age.
 Conclusion:
 When comparing the data obtained from analyzing patients with "early recurrent lumbar disc herniation" with findings shared in the literature, we found that similar variables were not significant in our series. An interesting observation is that both full endoscopic and microscopic methods have similar early recurrence rates. This is particularly noteworthy because full endoscopic discectomy usually involves sequestrectomy, and the volume of the disk removed is typically minimal. Hence, our study suggests that the volume of the disk removed during surgery may not be as influential in the development of early recurrence as previously thought. These findings provide an important foundation for future research.

A comprehensive clinical analysis of the use of percutaneous endoscopic debridement for the treatment of early lumbar epidural abscesses.

The purpose of this study is to evaluate the safety and efficacy of a percutaneous endoscopic debridement and drainage for lumbar infections with early epidural abscesses. Eight cases of early epidural abscess underwent lumbar intervertebral space debridement and drainage by percutaneous endoscopic. Laboratory indicators, pathogenic microorganisms and complications were documented, and the ASIA scores were used to assess preoperative and postoperative neurological function changes. Additionally, the VAS was used to evaluate the therapeutic effect. The average duration of the drainage tube was 11.25 ± 3.96 days (7-20 days), and the epidural abscess was eliminated after the tube was taken out. Postoperative CRP (14.40 ± 12.50 mg/L) and ESR (48.37 ± 16.05 mm/1 h) were significantly lower than the preoperative CRP (62.5 ± 61.1 mg/L) and ESR (75.30 ± 26.20 mm/1 h). The VAS score after the operation (2.50 ± 0.92 points) was significantly lower than the one before the surgery (8.25 ± 0.83 points). 5 patients experienced lower extremity pain and neurological dysfunction prior to surgery, however, after drainage, the lower extremity pain dissipated and the lower extremity muscle strength improved in one patient. All 8 patients were followed up for a period of (28.13 ± 10.15) months, including 3 patients with spinal segmental instability who had lumbar bone graft and internal fixation for the second stage. At the end of the follow-up, all 8 patients were clinically cured without any progressive nerve injury, paraplegia or recurrence of infection. Percutaneous Endoscopic Debridement and Drainage is an effective way to drain intraspinal abscesses, thus avoiding any potential progressive harm to the spinal cord.

Early Lumbar Drain Placement Results in Improved Outcomes for Patients With Aneurysmal Subarachnoid Hemorrhage

Early Lumbar Drain Placement Results in Improved Outcomes for Patients With Aneurysmal Subarachnoid Hemorrhage

Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy.

Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC. The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema. A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21). In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.

Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage

After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04). In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. ClinicalTrials.gov Identifier: NCT01258257.

Management of lumbar bone stress injury in cricket fast bowlers and other athletes.

Recent guidelines (including a special series in The Lancet) have emphasised a minimal role for imaging when assessing low back pain in adults, as the majority of patients will have non-specific findings on imaging that do not correlate well with pain. To assess whether the diagnosis of lumbar bone stress injuries in young athletes should be considered an exception to the recommendation to avoid imaging for low back pain in adults. Narrative review. Early lumbar bone stress injury diagnosis has been available via traditional MRI sequences (and its precursor Single Photon Emission Computed Tomography (SPECT)) for 25-30 years. MRI assessments using bone window sequences (such as Volumetric Interpolated Breath-hold Examination (VIBE)) have allowed a better understanding of the diagnosis and prognosis of lumbar bone stress injury in young athletes. MRI with bone sequences has allowed non-radiating scans to serially follow the healing of unilateral stress fractures. In the majority of cases, non-chronic unilateral fractures can heal; however, this takes three-six months rather than the six-ten weeks that would be the typical unloading period if using symptoms (only) as a guide. The use of MRI to provide evidence of bony healing (as opposed to fibrous union, which creates the pars defect that predisposes to further bone stress lesions) can lead to better long-term outcomes in athletes. There is evidence to flag this as a structural lesion which is both painful and, more importantly, can heal/resolve if managed correctly. Therefore it represents an important 'specific' diagnostic subset within adult low back pain. Structural (rather than functional) management of bone stress injuries in high-demand athletes, such as cricket pace bowlers, is in contrast to the recommendation of functional management for general back pain in adults. Structural management is justified when there are demonstrable superior outcomes of having better structure. Although this has not yet been shown in randomised trials of elite athletes, apparent lengthier Test cricket careers of pace bowlers who do not have pars defects suggest better athletic outcomes if bony healing is achieved. For lower demand young adults, or athletes with established bilateral pars defects, functional management may be more pragmatic.

Comparison of Single Lumbar Transforaminal Epidural Steroid Injections for Treatment of Early and Late Recurrent Lumbar Disc Herniation.

To compare the results of fluoroscopically guided transforaminal epidural steroid injection (TESI) for pain reduction in ipsilateral early recurrent lumbar disc herniation (RLDH) with ipsilateral late RLDH. A total of 738 patients complaining of radicular pain due to ipsilateral early and late RLDH were assessed. Of these, TESI was administered to 390 subjects for ipsilateral early RLDH and 346 for ipsilateral late RLDH. TESIs were performed based on radicular leg pain; all subjects were followed up and reexamined after 12 weeks of the therapy. Pre- and postprocedural visual analog scale (VAS) scores and all complications were recorded for the study. For radicular pain, the mean pre-, and postprocedural VAS scores for ipsilateral early RLDH were 85.44 ± 6.85 and 20.16 ± 3.77 respectively. For late RLDH, the mean pre-, and postprocedural VAS scores were 72.82 ± 5.12 and 30.87 ± 4.17, respectively. A significant statistical difference for pre- and postprocedural VAS scores were observed between ipsilateral early and late recurrent disc herniation TESI groups (p < 0.05). TESI was more effective for early RLDH than for late RLDH during the 12-week follow-up period.

The effect of postoperative early lumbar drainage on delayed fever after cerebellopontine angle tumour surgery: study protocol for a randomized controlled trial

BackgroundPostoperative fever is one of the common complications in neurosurgery, and intracranial aseptic inflammation and infection are important risk factors. Continuous drainage of cerebrospinal fluid (CSF) via lumbar drainage (LD) is often used in the treatment of postoperative intracranial infection or aseptic inflammation. Compared with the previously reported placement of LD after the onset of meningitis symptoms, we designed this randomized controlled trial (RCT) to evaluate the effectiveness and safety of early drainage (1st day postoperation) of CSF using the preset lumbar cistern to prevent delayed fever (fever occurred after the third day postoperation) or reduce its treatment time after cerebellopontine angle (CPA) tumour surgery.MethodsPatients suffering from CPA tumours and who underwent resection of the tumour with an intraoperative dura opening time > 4 h are recruited for this study. The study is a 2-arm RCT to compare the early LD group and the no early LD group. Postoperative duration and rate of delayed fever and postoperative length of stay (LOS), as the main outcomes, will be compared in the two groups.DiscussionHere, we present the study design of a prospective RCT to evaluate the safety and efficacy of using preoperative preset LD to treat or reduce postoperative delayed fever.Trial registrationChina Clinical Trial Registry ChiCTR2100049057. Registered on July 20, 2021.

Effects of early lumbar cistern drainage of cerebrospinal fluid and combination of edaravone and nimodipine on vasospasm, intracranial pressure, inflammatory factors in traumatic subarachnoid hemorrhage

Purpose: To investigate the effect of early lumbar cistern drainage (LCD) of cerebrospinal fluid (CSF) and combination of edaravone and nimodipine on vasospasm, intracranial pressure (ICP), serum inflammation, S100 and vascular endothelial growth factor (VEGF) levels in traumatic subarachnoid hemorrhage (tSAH).&#x0D; Methods: Treatment was administered to 136 patients divided into control group (n = 68) and study group (n = 68). Serum inflammation was determined by assessing the levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) while nitric oxide (NO), endothelin-1 (ET-1), S100 and VEGF levels were determined by enzyme-linked immunosorbent assay (ELISA). Serum C-reactive protein (CRP) level was measured by immunoturbidimetry. Perfusion weighted imaging was performed and the mean transit time (MTT), cerebral blood flow (CBF), cerebral blood volume (CBV), mean flow velocity (Vm) and pulsatility index (PI) were recorded. Glasgow coma scale (GCS) score and Montreal cognitive assessment (MoCA) score were used to compare the differences in therapeutic effect.&#x0D; Results: Compared with values before treatment, Vm, PI, NO, CBF, CBV, GCS score and MoCA score were significantly increased (p &lt; 0.05), while ICP, serum levels of TNF-α, IL-6, CRP, ET-1, S100 and VEGF and MTT significantly decreased (p &lt; 0.05). Therapeutic response rate of the study group (89.71 %) was higher than that of control group (66.18%) (p &lt; 0.05).&#x0D; Conclusion: Early LCD of CSF and combination of edaravone and nimodipine reduces the degree of cerebral vasospasm and contribute to brain function recovery in the treatment of patients with tSAH. This therapeutic strategy requires further clinical trials before application in clinical practice.

May the midline lumbar interbody fusion (MIDLIF) prevent the early radiographic adjacent segment degeneration? A minimum 3-year follow-up comparative study of MIDLIF in L4/5 with cortical bone trajectory screw versus traditional pedicle screw fixation

Study designRetrospective cohort study.ObjectiveTo compare the early radiographic adjacent segment degeneration (R-ASD) and regional lumbar sagittal alignment after midline lumbar interbody fusion (MIDLIF) with cortical bone trajectory (CBT) screw fixation (CBT-MIDLIF) and posterior lumbar interbody fusion (PLIF) with the traditional pedicle screw fixation (PS-PLIF) during long-term follow-up.MethodsAll patients who underwent CBT-MIDLIF or PS-PLIF were identified by a retrospective consecutive case review. Radiographic parameters in cephalad adjacent segment (L3/4), including intervertebral space height (ISH), foraminal height (FH), foraminal width (FW), range of motion were assessed. Lumbar lordosis (LL), sacral slope (SS), L4–L5 Cobb angle, Cobb angle of the intervertebral space at L4–L5, and height of the anterior and posterior edges of the intervertebral space at L4–L5, were measured and compared on preoperative, postoperative, and 3-year follow-up radiographic evaluation.ResultsSeventy-four patients underwent CBT-MIDLIF (CBT-MIDLIF group) and 114 patients underwent conventional PS-PLIF (PS-PLIF group). ISH, FH and FW were significantly smaller at 6-month follow-up than before operation with PS-PLIF (p < 0.001) but showed no significant changes with CBT-MIDLIF (p > 0.05). At the last follow-up, the changes in cephalad R-ASD parameters were more remarkable after PS-PLIF than after CBT-MIDLIF (p < 0.01). LL and SS were significant larger at the last follow-up than before operation in both groups (p < 0.001). Regarding long-term outcomes, the symptoms caused by degenerative spinal disorders significantly improved in both groups (p < 0.01).ConclusionCBT-MIDLIF had less radiographic degeneration in the adjacent segment than PS-PLIF at 3-year follow-up. The lumbar sagittal alignment could be improved significantly and the surgical outcomes were satisfactory after either CBT-MIDLIF or PS-PLIF.

Paraspinal soft tissue edema ratio: An accurate marker for early lumbar spine spondylodiscitis on an unenhanced MRI

PurposeMRI is currently the gold standard imaging modality in the diagnosis of lumbar spine discitis/osteomyelitis. However, even with supportive clinical and laboratory data, the accuracy of MRI remains limited by several degenerative and inflammatory mimics, such that it continues to represent a challenge for radiologists. This study reports a new quantitative imaging marker of lumbar paraspinal soft tissue edema which shows significant accuracy for spondylodiscitis. MethodsThirty-five patients with equivocal MRI findings of lumbar discitis/osteomyelitis vs endplate degenerative changes were reviewed over a 24-month period. Patients with a history of surgery, fractures/recent trauma, signs of advanced infection such as abscesses, phlegmon or severe osseous destruction were excluded. Two ABR board certified neuroradiologists who were blinded to the final diagnosis evaluated a new marker; the superior-inferior paraspinal edema ratio (SI-PER). The SI-PER was obtained by measuring the superior-inferior extent of increased signal/edema in the paraspinal soft tissues on the paraspinal inversion recovery images divided by the vertebral body height measured at midpoint. Cases positive for spondylodiscitis were those confirmed by biopsy, aspiration/drainage, surgery, or clinical improvement following antibiotic treatment. The diagnostic sensitivity and specificity of SI-PER were determined by Receiver operating characteristic (ROC) analysis. ResultsIn 23/35 (66%) patients, the diagnosis of discitis/osteomyelitis was confirmed. The SI-PER showed a significant association with a positive MRI diagnosis (p = 0.001). Inter-observer correlation for SI-PER was 0.92. ROC analysis showed an area under the curve of 0.84. A SI-PER of 2.5 was 96% sensitive and 75% specific for the diagnosis of discitis/osteomyelitis, with a PPV of 88% and a NPV of 90%. ConclusionIn this study, the superior inferior paraspinal edema ratio (SI-PER), a newly defined MRI marker, was found to have high sensitivity for differentiating spondylodiscitis from endplate degenerative changes on lumbar spine MRI.

Postoperative Early Lumbar Drainage Can Reduce the Duration of Fever or Infection in Patients with Complicated Intracranial Tumors after a Long Operation Time.

Intracranial fever or infection is one of the common complications after craniotomy, especially for complicated intracranial tumors such as deep skull base tumors. We used early cerebrospinal fluid (CSF) drainage with a preplaced lumbar drainage (LD) tube after surgery and observed whether this procedure could reduce the rate and duration of fever or infection. The authors conducted a retrospective study of 142 patients who underwent complicated intracranial tumor surgery with no less than four hours of dural opening at the Center of Neurosurgery of Tangdu Hospital. The LD group underwent preoperative LD placement, intraoperative CSF release and postoperative continuous drainage, but the control group received routine craniotomy without preoperative LD. The primary outcomes included the rate, duration, and hospital length of stay (LOS) for patients with fever or infection after surgery, as compared between the two groups. The second outcome included complications related to LD and the rate of postoperative CSF leakage. There were 22 patients in the LD group and 23 patients in the control group who presented with delayed fever, which was supposed to be caused by intracranial infection or aseptic inflammation. The median duration of delayed fever in the LD group was obviously lower than that in the control group (7.762 ± 3.129 days vs 11.73 ± 5.239 days), and there was a statistically significant difference (P = 0.0046). In addition, there was a significant reduction in the median postoperative LOS (12 [8,10,15,21] days in the LD group vs 15 [9,13,20,28] days in the controls). Moreover, there was no significant difference in complications related to LD between the two groups. Three patients with brain herniation were observed in the LD group compared with one patient in the control group. All four patients had contemporary mild-to-moderate neurologic disorders after surgery or conservative treatment. Additionally, the rate of CSF leakage in the LD group was 5.41% (4/74), which was lower than that in the control group (8/68, [11.76%]), although there was no significant difference (P = 0.174). For patients receiving complicated intracranial lesions following a long operation time, postoperative early LD was beneficial for the treatment of patients with fever or infection. It not only reduced the duration of infection or fever in postoperative patients but also decreased the postoperative LOS. We should minimize the complications related to LD by careful and standardized LD and management processes, and ensure the effectiveness and safety of this treatment.

Outcomes of Posterior Lumbar Hemivertebra Resection and Short Fusion in Patients With Severe Sacral Tilt.

ObjectiveTo introduce surgical strategies to restore coronal balance during limited fusion for early lumbar hemivertebra resection in patients with severe sacral tilt. MethodsSacral tilt was defined as a sacral tilt angle ≥ 5, and severe sacral tilt was defined as a sacral tilt angle > 10. From July 2004 to December 2017, 73 consecutive patients treated with posterior hemivertebra resection and short fusion in our institution were evaluated. Severe sacral tilt was noted in 26 patients (14 boys and 12 girls), and all were enrolled in this study. Undercorrection of the primary lumbar curve as compensation for the sacral tilt and short fusion was performed in these patients. The medical charts and imaging data of the patients were retrospectively reviewed to evaluate the outcomes. ResultsAll patients were followed for at least 2 years. The mean age at the time of surgery was 3.7 (2–9) years old, with a total of 31 lumbar hemivertebra excised. On average, 2.8 (2–5) segments were fused for each patient. Sacral tilt minimally improved from 14.5° preoperatively to 13.6° postoperatively (p=0.15) and remained stable at the follow-up. The overall lumbar curve was 41.9° preoperatively, 11.7° immediately postoperatively, and 14.6° at the final follow-up. The segmental scoliosis curve was 39.1° preoperatively, 9.7° immediately postoperatively, and 11.2° at the final follow-up. Segmental kyphosis was corrected from 27.2° to 6.5° after the surgery and was 7.1° at the latest follow-up. ConclusionSacral tilt is seen in patients with congenital scoliosis in lumbar hemivertebra. Undercorrection of the lumbar curve and segmental scoliosis to compensate for sacral tilt and short fusion after hemivertebra resection may be helpful to restore coronal balance and preserve mobility in segments in patients with pronounced severe sacral tilt.

Preoperative Radiographic Prediction Tool for Early Postoperative Segmental and Lumbar Lordosis Alignment After Transforaminal Lumbar Interbody Fusion.

ObjectiveTransforaminal lumbar interbody fusion (TLIF) is a common approach and results in varying degrees of lordosis correction. The purpose of this study is to determine preoperative radiographic spinopelvic parameters that predict change in postoperative segmental and lumbar lordosis after TLIF.Materials & MethodsThis study is a single surgeon retrospective review of one-level and two-level TLIFs from L3-S1. All patients underwent bilateral facetectomies, 10 mm TLIF cage (non-lordotic) insertions, and bilateral pedicle screw-rod construct placements. Pre- and post-operative X-rays were assessed for preoperative segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence (PI). Univariate and multi-predictor linear regression analyses were performed to determine the relationships between preoperative radiographic findings and change in early postoperative segmental and lumbar lordosis.ResultsNinety-seven patients contributing 128 intervertebral segments were examined. The mean change in SL after TLIF was 7.3 (range: 0.10-28.9°, SD 6.39°). The mean change in LL after TLIF was 5.5˚ (range: -14.8-39.2°, standard deviation (SD) 7.16°). Greater preoperative LL predicted less postoperative LL correction, while greater preoperative PI predicted more postoperative SL and LL correction. Greater anterior disk height was noted to be associated with a decreased change in SL (∆SL). An annular tear on preoperative magnetic resonance imaging (MRI) predicted a 2.7° decrease in ∆SL. A Schmorl's node on preoperative MRI predicted a 4.0° decrease in change in LL (∆LL).ConclusionsA greater preoperative lordosis and a lower spinopelvic mismatch lessen the potential for an increase in the postoperative SL and LL after a TLIF, which is likely due to a ‘ceiling’ effect of an otherwise optimized spinal alignment. A greater anterior disk height and the presence of an annular tear are associated with decreased ∆SL.

Comparison of early and delayed lumbar disc herniation surgery and the treatment outcome.

Aim To evaluate the influence of preoperative symptoms duration on surgical outcome of one-level lumbar disc herniation surgery. Methods In a prospective randomized study, 67 adult patients with one-level lumbar disc herniation were analysed. The patients whose duration of symptoms was <6 months were included in the case group, while those with the duration of symptoms ˃6 months formed the control group. The investigated preoperative variables were: pain intensity in the back and legs (Visual Analogue Scale - VAS), Sciatica Bothersomeness Index (SBI), index of disability (Oswestry Disability Index - ODI). Postoperative variables were: pain intensity in the back and legs (VAS), SBI, ODI, and outcome according to the Odom's criteria (excellent, good, satisfactory and poor). Significance level was set at p <0.05. Results A statistically significant difference was recorded between the groups, showing a better decrease of radicular pain intensity and sciatica bothersome, as well as patients disability in the case group (p<0.001). According to the Odom's criteria the outcome was better in the case group, since the difference between the groups was statistically significant too (p<0.05). Conclusion Early lumbar disc herniation surgery performed within the first 6 months from the start of symptoms is beneficial due to decreases of radicular pain intensity, sciatica bothersomeness, and patient's disability.

Radiologic prognostic factors of curve progression in early degenerative lumbar scoliosis.

Several radiological parameters related to the aging spine have been reported as progression factors of early degenerative lumbar scoliosis (DLS). However, it has not been determined which factors are the most important. In this study the authors aimed to determine the risk factors associated with curve progression in early DLS. Fifty-one patients with early DLS and Cobb angles of 5°-15° were investigated. In total, 7 men and 44 women (mean age 61.6 years) were observed for a mean period of 13.7 years. The subjects were divided into two groups according to Cobb angle progression (≥ 15° or < 15°) at the final follow-up, and radiological parameters were compared. The direction of scoliosis, apical vertebral level and rotational grade, lateral subluxation, disc space difference, osteophyte difference, upper and lower disc wedging angles, and relationship between the intercrest line and L5 vertebra were evaluated. During the follow-up period, the mean curve progression increased from 8.8° ± 3.2° to 19.4° ± 8.9°. The Cobb angle had progressed by ≥ 15° in 17 patients (33.3%) at the final follow-up. In these patients the mean Cobb angle increased from 9.4° ± 3.4° to 28.8° ± 7.5°, and in the 34 remaining patients it increased from 8.5° ± 3.1° to 14.7° ± 4.8°. The baseline lateral subluxation, disc space difference, and upper and lower disc wedging angles significantly differed between the groups. In multivariate logistic regression analysis, only the upper and lower disc wedging angles were significantly correlated with curve progression (OR 1.55, p = 0.035, and OR 1.89, p = 0.004, respectively). Asymmetrical degenerative change in the lower apical vertebral disc, which leads to upper and lower disc wedging angles, is the most substantial factor in predicting early DLS progression.

Acute bacterial meningitis.

Purpose of reviewCommunity-acquired bacterial meningitis is a continually changing disease. This review summarises both dynamic epidemiology and emerging data on pathogenesis. Updated clinical guidelines are discussed, new agents undergoing clinical trials intended to reduce secondary brain damage are presented.Recent findingsConjugate vaccines are effective against serotype/serogroup-specific meningitis but vaccine escape variants are rising in prevalence. Meningitis occurs when bacteria evade mucosal and circulating immune responses and invade the brain: directly, or across the blood–brain barrier. Tissue damage is caused when host genetic susceptibility is exploited by bacterial virulence. The classical clinical triad of fever, neck stiffness and headache has poor diagnostic sensitivity, all guidelines reflect the necessity for a low index of suspicion and early Lumbar puncture. Unnecessary cranial imaging causes diagnostic delays. cerebrospinal fluid (CSF) culture and PCR are diagnostic, direct next-generation sequencing of CSF may revolutionise diagnostics. Administration of early antibiotics is essential to improve survival. Dexamethasone partially mitigates central nervous system inflammation in high-income settings. New agents in clinical trials include C5 inhibitors and daptomycin, data are expected in 2025.SummaryClinicians must remain vigilant for bacterial meningitis. Constantly changing epidemiology and emerging pathogenesis data are increasing the understanding of meningitis. Prospects for better treatments are forthcoming.