Multilevel Disease Research Articles

Hybrid vascular interventin for multilevel peripheral arterial disease

Abstract Objective To increase the effectiveness of intervention for the lower limb arteries multilevel lesion (MPAD) in patients with type C and D lesions by TASC II classification. Materials and methods 87 hybrid vascular reconstructions (74 male and 13 female, 59% (n=52) smokers) for MPAD were performed from 2017 to 2020. The average age was 64,6±8,1y. CLI was diagnosed in 47% (n=41) by Fontaine- Pokrovsky classification. Following concomitant disease were diagnosed: stage 2–3 of CHF by HYHA classification 33% (n=29), COPD 23% (n=20), arterial hypertension stage 2–3 54% (n=47), CAD 66% (n=58), postinfarction cardiosclerosis 29% (n=26). Registered lesion of iliac-femoral segment type A/B=44 (51%) and C/D=43 (49%); registered lesion of femoro-tibial segment A/B=14 (16%), C/D=73 (84%) by TASC-II classification. Common femoral artery (CFA) bifurcation was most important to perform hybrid intervention. Through CFA with patented method (RU 2621395C) we performed remote endartherectomy from external iliac or superficial femoral arteries, that allowed us to remove a total prolonged occlusion (>15–20 cm), reducing the time and complexity of the endovascular stage. The key note is that we perform CFA plasty with using an autovenous patch with a “trunk” through which we provide endovascular stage of hybrid intervention on natural blood flow, restored after open endartherectomy. This technique allows you to change the direction of introducer in both distal and proximal direction without the need for extra punctures or temporary clamping of the arteries. Results Technical success rate was 98%. Local aneurysm of EIA was found in one case that restricted to provide the loop endarterectomy. The average duration of hybrid operation was 223,7±88,2 min (134,2±72,3 min for open and 89,9±52,9 for endovascular stages). Average blood loss was 225,3±130,7 ml. ICU staying duration was 20,6±2,8 hours. 30-days patency was 98,8%, 12 and 36 months primary patency was 98% and 88,5% respectively. There were no deaths within 30 days after hybrid operation. The following complications occurred: bleeding n=2 (2,3%), acute thrombosis n=1 (1,2%), surgical site infection n=1 (1,2%) but cured safely. Limb salvage in critical ischemia was in 100% of patients for 20 months. Conclusion Hybrid surgery of MPAD is highly effective, reduces operation trauma, improves its results and limb salvage. By reducing trauma of surgical intervention reduces admition in ICU, postoperative risks, especially in patients with severe concomitant pathology. Funding Acknowledgement Type of funding sources: None.

712 Outcomes of Infrainguinal Stents in Peripheral Arterial Disease

Abstract Background Endovascular therapy is an established treatment for peripheral arterial disease. In aortoiliac disease, above the inguinal ligament, percutaneous transluminal angioplasty (PTA) + stent results in good long-term patency rates[1]. In comparison, long-term patency rates of PTA + stent in femoropopliteal disease, below the inguinal ligament are inferior, despite advancements in stent technology[2]. Multi-level disease is more common, lesions are often longer in length and rates of re-stenosis remain high. There is a paucity of data of long-term outcomes in infrainguinal stents and therefore debate to what the optimal treatment strategy should be[3]. Method 5-year retrospective analysis of 59 patients between 2014 and 2019 in a UK regional vascular centre. Patients with Rutherford Score 3 - 6 were treated by Vascular Surgeons and Interventional Radiologists with PTA + stent. Outcomes included patency at 6, 12, 24, 36 months, need for revascularisation/reintervention, major amputation, and death. Results 12% of stents occluded at 30 days and 39% of stents occluded at 12 months. 34% patients required further intervention (PTA, femoropopliteal bypass, amputation) and 7 out of 59 (12%) target limbs were amputated. Conclusions Whilst PTA + stent demonstrates an effective intervention for a selection of patients, it is evident that further work is required in order to identify the best treatment strategy and most clinically useful outcome measure.

Propensity-matched analysis does not support angiosome-guided revascularization of multilevel peripheral artery disease (PAD).

This retrospective comparative cohort study evaluated the clinical outcome of angiosome-guided endovascular arterial reconstructions in chronic limb-threatening ischemia (CLTI) due to multilevel peripheral artery disease (PAD). Patients treated in an endovascular fashion for CLTI with tissue loss due to multilevel PAD were analyzed. Limbs were classified as having undergone either angiosome-guided (direct) revascularization (DR) or nonangiosomic (indirect) revascularization (IR). DR was defined as uninterrupted in-line flow to the affected angiosome, revascularization through the pedal arch was also considered direct. Groups were adjusted with propensity score (PS) matching and compared for amputation-free survival (AFS), freedom from major adverse limb events (MALE), and healing rate at 12 months. A total of 174 patients (81 men, mean age 70.0 ± 10.4 y) were included. PS matching produced two groups of 55 patients each: DR (24 men, mean age 71.7 ± 10.7 y) and IR (26 men, mean age 72.0 ± 9.4 y). The matched groups had no significant differences in baseline variables. At 12 months there were no significant differences in AFS (73.2% vs 71.6%; p = 0.841), freedom from MALE (71.7% vs 66.1%; p = 0.617), and healing rate (72.7% vs 72.0%; p = 1.000) between DR and IR, respectively. This study failed to support the use of angiosome concept in CLTI due to multilevel disease.

A Case of Multilevel Aortic Disease Treated Using Cardiatis Multilayer Flow Modulator.

A recent systematic review and meta-analysis shows that synchronous and metachronous thoracic and abdominal aortic aneurysms are present in 19.2% of cases. The management remains controversial: elective simultaneous TEVAR and EVAR could increase morbidity due to increased aortic coverage during a single procedure, longer operative times, increased blood loss, and greater contrast exposure. Conversely, simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysms repair (EVAR) prevent the need for two interventions, reduces future access site complications, and obviates interval aortic complications.We present a case of a multilevel aortic disease treated in three stages: EVAR, TEVAR, and exclusion of an increasing aortic visceral penetrating aortic ulcer through a multilayer flow modulator endograft with an optimal result.

ОПТИМІЗАЦІЯ МЕТОДІВ ДОСЛІДЖЕННЯ ТРАНСМІСИВНИХ ІНФЕКЦІЙ, ЩО ПЕРЕДАЮТЬСЯ КЛІЩАМИ ТА КОМАРАМИ

In many European countries, research is being conducted on the presence of various pathogens of infections transmitted by ticks and mosquitoes by various methods, primarily by polymerase chain reaction. These include the study of certain species of spirochetes that cause multisystem disorders in the human body, including the little-known circulation of some species of Borrelia species and Ticks Borne Encephalitis Virus in northeastern Germany and the study of various stages of mite development in western Pomerania, Slovenia; study of eco-epidemiology of B. miyamotoi spirochetes and Lyme borreliosis in the popular hunting and recreational forest belt of Hungary, comprehensive studies by T. Chmielewski, J. Fiett, M. Gniadkowski, S. Tylewska-Wierzbanowska in the study of such a multisystem and multilevel disease as Lyme disease.
 We performed PCR studies based on ticks and mosquitoes, EDTA blood, cerebrospinal fluid and synovial fluid of patients affected by the bites of these arthropods. Ticks and mosquitoes were suspended and DNA/RNA was extracted depending on the pathogen and amplified. They were aimed mainly at detecting DNA-containing pathogens: B. burgdorferi s. l., (complex B. sensu stricto, B. afzelii, B. garini), B. miyamotoi, A. phagocytophilum, E. muris, E. chaffeensis, B. species and RNA-containing tick-borne encephalitis virus.
 To optimize research methods, a simultaneous combination of detection of all DNA-containing pathogens and a separate study of RNA-containing tick-borne encephalitis virus is used, which facilitates their faster detection. This reduces the time to get results.
 In our search, we have chosen to use a unified methodology we developed, which helps to give the results of determinations to clinicians as soon as possible to confirm or refute the diagnosis and monitor the epidemiological situation regarding the infection of ticks and mosquitoes.
 The use of our methodology allows us to conduct research to identify pathogens and obtain results in the time allotted for the full cycle of research. It saves time and electricity, the equipment itself is stored during its use.
 For the first time, mosquito studies were performed for the presence of DNA fragments of Babesia species and RNA of tick-borne encephalitis virus, which gave an intermediate positive result.

223. The psychological burden of disease among patients undergoing cervical spine surgery: are we underestimating our patients’ inherent disability?

<h3>BACKGROUND CONTEXT</h3> Recent studies have suggested that for patients with chronic neck pain, both psychological and psychosomatic symptoms need to be addressed as psychological distress is associated with poor outcomes in these patients. The fear avoidance model has been used to explain how maladaptive thoughts and behaviors contribute to chronicity and disability. Certain mental health scores have been previously analyzed in patients with pathologies in different spinal regions. However, these rates have yet to be assessed against patients undergoing cervical spine surgery. <h3>PURPOSE</h3> Identify the psychological burden among patients undergoing surgical treatment for their symptomatic cervical degenerative disease. <h3>STUDY DESIGN/SETTING</h3> Single-center prospective double-blinded, randomized control trial that consists of patients undergoing surgical arthrodesis for 3 single- or multilevel cervical disease, resulting in cervical radiculopathy. <h3>PATIENT SAMPLE</h3> This study included 47 symptomatic cervical degenerative disorders patients. <h3>OUTCOME MEASURES</h3> Fear Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS). Neck Disability Index (NDI), EuroQol Five Dimensions (EQ5D). <h3>METHODS</h3> A total of 47 patients age >18 with symptomatic cervical degenerative disease were included and those with active depression or history of major depression were excluded from the study. Basic demographics and baseline HRQLs (NDI, EQ5D, PCS, FABQ) were assessed via descriptive analyses. Patient psychosomatic scores that measure preoperative pain catastrophe and fear avoidance of procedure (PCS, FABQ) were compared to previously published benchmarks in a lumbar spine population. These mental health components and disability were further stratified by their severity as previously published (PCS >30; FABQ >34). Correlations assessed the relationship between these mental health components and severity of disability described by NDI (Not Disabled=0-4, Mild=5-14, Moderate=15-24, Severe=25-34, Complete=34+). Furthermore, logistic regressions were analyzed to determine whether NDI was an independent predictor of psychological burden described by PCS and FABQ. <h3>RESULTS</h3> Forty-seven patients were enrolled (age 53.6 years, BMI 29.4 kg/m2). 32% of these patients were diagnosed with radiculopathy, 26% with myelopathy, and 42% with concomitant imaging diagnosis (hnp, ddd, spondylosis all with or without central stenosis). These patients were all scheduled to undergo spinal fusions with decompression and had failed at least 3 months of conservative treatment. The average number of levels fused was 2.27±1.4. At baseline, the average PCS was 27.4 and FABQ: 40. By overall health metrics, the patient population had an average EQ5D score of 9.3 and an NDI of 25.6. 57.1% of patients had a severe FABQ, 40.8% had a severe PCS, and 27.7% had a severe NDI score. As compared to historical controls of lumbar patients, the patients in this study had greater levels of psychosomatic pathology measured by FABQ (40 vs 17.55; p<0.001) and PCS (27.4 vs 19.25; p<0.001). PCS was positively correlated with FABQ scores (r=0.55; p<0.001). Increasing neck disability was correlated with greater PCS measured disability (Overall r=0.7, Complete r=0.58; p<0.05). Being completely disabled was also identified to have a significant relationship with having a severe PCS score independent of levels fused and diagnosis (OR=11.7[1.5-90.5]; p=0.019). This trend was similarly identified for FABQ (Overall r=0.5, Complete r=0.4; all p<0.05). Age was also not a significant predictor for baseline severe PCS and FABQ nor were diagnosis and presence of stenosis. <h3>CONCLUSIONS</h3> Cervical spine patients have an overall great amount of mental health pathology; however, a large portion of these patients also have high fear avoidance beliefs and pain catastrophizing at baseline. These rates were identified to be higher than previously identified benchmarks of lumbar spine patients. Because this study excluded patients with an official diagnosis of depression or other psychological condition, it is reasonable to say that the mental health pathology of patients undergoing cervical surgery is greatly underestimated and should warrant preoperative treatment to help mitigate these mental health scores at baseline. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Long Segment Anterior Cervical Discectomy and Fusion, Including C2: Surgical Pearls and Review of Our Experience.

A retrospective study of thirteen patients undergoing 5-level anterior spinal surgery for cervical myelopathy. While limited literature exists in reviewing the treatment of high cervical pathology extending caudally, we believe long segment surgery beginning at C2-3 can be accomplished with good success and is an option more patients may benefit from. We aim to describe the technique in accessing the C2-C3 disk space and efficacy of treating multilevel disease beginning at the C2 vertebral body. This includes an extensive technical report and surgical pearls. Compression at the level of C2 can be daunting to access because of steep approach required. Few studies have described the technique in reaching the C2 level, with less information describing the efficacy of a 5-level anterior fusion starting at C2. Patients who underwent surgery between 2000 and 2016 were identified utilizing the department billing database and ICD codes. Patients age, operative indications, levels treated, length of hospital stay, fusion outcome, and operative complications were explored. Independent analysis of fusion was performed. The average length of hospital stay was 3.9 days. Eight patients reported significant improvement of hand weakness, numbness, and/or gait at 6 months follow-up. The most frequent complication was dysphagia (23%). One patient experienced recurrent symptoms secondary to nonunion, and another patient suffered a postoperative neurological worsening because of anterior spinal artery syndrome. This retrospective review discusses the technique to visualize and fully decompress C2-C3 spinal segments. In addition, we explored the efficacy and perioperative risk in long segment anterior cervical discectomy and fusion.

Disease defences across levels of biological organization: individual and social immunity in acorn ants

Eusocial insect societies possess complex multilevel disease defences, including individual level protection conferred by physical (e.g. cuticle) and immunological obstacles and colony level protection mediated by collective behaviours (social immunity). It remains unclear whether and how these two levels of disease protection are related to one another in jointly driving colonies’ susceptibility to disease. Here, we examine whether a relationship exists between individual worker survival after exposure to a fungal pathogen (a proxy for immunity) and corpse removal (a colony level social immunity metric) in the acorn ant Temnothorax curvispinosus . Since behavioural avoidance is the first line of defence against infection, we also tested whether individual ants exhibited parasite avoidance behaviour during exploration and whether colonies exhibit avoidance behaviour during foraging. We found that individual level and colony level immunity were negatively correlated: colonies that removed corpses more rapidly contained workers with weaker individual defences. We did not detect parasite avoidance behaviour by individual workers or whole colonies, nor were these two factors related. These data suggest that individual immunity and social immunity may trade off, regulating overall parasite protection. Alternatively, optimized social immunity at the colony level may compensate for disease vulnerability to infection at the individual level, and thus provide a protective benefit in overall colony defence in the absence of pathogen avoidance. • We measured individual and collective disease protection in acorn ants. • Colonies with stronger individual protection had weaker collective protection. • Avoidance was not detected at the individual or collective level. • Multilevel disease protection trade-offs may vary across colonies and environments.

The presence of a pathologic perforator may be predictive of central venous pathology and multilevel disease in severe chronic venous insufficiency

ObjectivesThe treatment of a refluxing perforator is indicated in the setting of severe chronic venous insufficiency, but there are limited data on the presence of multilevel disease in these patients. This study sought to evaluate whether the presence of a pathologic perforator is predictive of the presence of central venous pathology. MethodsThis study was a retrospective review of the institutional Vascular Quality Initiative database. Consecutive patient limbs were identified that underwent intervention of refluxing perforators. The patients who underwent imaging, including magnetic resonance imaging or computed tomography (group A), were compared with those who did not undergo imaging (group B). The treated limbs in group A were also compared with the contralateral limbs as an internal control. Anatomical findings on imaging were analyzed by two independent investigators. The primary outcome was the presence and degree of central venous stenosis as measured by an orthogonal diameter reduction of >50% by axial imaging. Secondary outcomes included demographic and clinical differences between the two groups, frequency of central venous intervention, and duration of ulcer healing. Standard statistical analysis was performed. ResultsNinety-three patient limbs underwent treatment of a pathologic perforator, with 30 in group A and 63 in group B. The following demographic and clinical variables were higher in group A compared with group B: male sex, body mass index, deep venous thrombosis history, recent or active anticoagulation use, perforator diameter, Clinical Etiology Anatomy Pathophysiology class 4, 5, or 6, and Venous Clinical Severity Score. Radiographic analysis of group A revealed concordance of a treated pathologic perforator with an ipsilateral central venous stenosis in 53.3% of patients, and a higher frequency of common iliac vein stenosis (50% vs 21.4%, P = .024) and external iliac vein stenosis (20% vs 0%, P = .012) compared with the contralateral limbs. When separated by the left or right limb, the left limbs exhibited a greater degree of common iliac vein stenosis as compared with the contralateral limbs (50.7% ± 20.9% vs 16.3% ± 16.5%, P < .001) as well as a greater frequency of >50% common iliac vein stenosis (46.7% vs 13.3%, P = .046). The right limbs exhibited a greater frequency of >50% external iliac vein stenosis as compared with the contralateral limbs (33.3% vs 0%, P = .022). ConclusionsThis study suggests that patients with severe chronic venous insufficiency who undergo treatment for a pathologic perforator may have additional ipsilateral central venous pathology, supporting the presence of multilevel disease. Additional axial imaging might unmask central venous pathology and provide another option for treatment.

The impact of smoking on outcomes following anterior cervical fusion-nonfusion hybrid surgery: a retrospective single-center cohort study

BackgroundThere is mixed evidence for the impact of cigarette smoking on outcomes following anterior cervical surgery. It has been reported to have a negative impact on healing after multilevel anterior cervical discectomy and fusion, however, segmental mobility has been suggested to be superior in smokers who underwent one- or two-level cervical disc replacement. Hybrid surgery, including anterior cervical discectomy and fusion and cervical disc replacement, has emerged as an alternative procedure for multilevel cervical degenerative disc disease. This study aimed to examine the impact of smoking on intermediate-term outcomes following hybrid surgery.MethodsRadiographical and clinical outcomes of 153 patients who had undergone continuous two- or three-level hybrid surgery were followed-up to a minimum of 2-years post-operatively. The early fusion effect, 1-year fusion rate, the incidence of bone loss and heterotopic ossification, as well as the clinical outcomes were compared across three smoking status groups: (1) current smokers; (2) former smokers; (3) nonsmokers.ResultsClinical outcomes were comparable among the three groups. However, the current smoking group had a poorer early fusion effect and 1-year fusion rate (P < 0.001 and P < 0.035 respectively). Both gender and smoking status were considered as key factors for 1-year fusion rate. Upon multivariable analysis, male gender (OR = 6.664, 95% CI: 1.248–35.581, P = 0.026) and current smoking status (OR = 0.009, 95% CI: 0.020–0.411, P = 0.002) were significantly associated with 1-year fusion rate. A subgroup analysis demonstrated statistically significant differences in both early fusion process (P < 0.001) and the 1-year fusion rate (P = 0.006) across the three smoking status groups in female patients. Finally, non-smoking status appeared to be protective against bone loss (OR = 0.427, 95% CI: 0.192–0.947, P = 0.036), with these patients likely to have at least one grade lower bone loss than current smokers.ConclusionsSmoking is associated with poor outcomes following hybrid surgery for multilevel cervical disc disease. Current smokers had the poorest fusion rate and most bone loss, but no statistically significant differences were seen in clinical outcomes across the three groups.

Simultaneous Hybrid Treatment of Multilevel Peripheral Arterial Disease in Patients with Chronic Limb-Threatening Ischemia.

Background: Hybrid treatments (HT) aim to reduce conventional open surgery invasiveness and address multilevel peripheral arterial disease (PAD). Herein, the simultaneous HT treatment in patients with chronic limb-threatening ischemia (CLTI) is reported. Methods: Retrospective analysis, for the period from May 2012 to April 2018, of patients presenting multilevel PAD with CLTI addressed with simultaneous HT. The outcomes of these interventions were measured the following metrics: early technical successes (within 30 days following treatment) and late technical successes (30 days or more following treatment) and included mortality, morbidity symptoms recurrence, and amputation. Survival and patencies were estimated. The median follow-up was 43.77 months. Results: In the 45 included patients, the HT consisted of femoral bifurcation patch angioplasty followed by an endovascular treatment in 38 patients (84.4%) and endovascular treatment followed by a surgical bypass in 7 patients (15.6%). Technical success was 100% without perioperative mortality. Eight (17.8%) patients presented early complications without major amputations. During the follow-up, seven (15.6%) deaths occurred and six patients (13.3%) experienced symptoms recurrence, with five of those patients requiring major amputation. An estimated survival time of 5 years, primary patency, and secondary patency was 84.4%, 79.2%, and 83.3% respectively. Conclusions: Hybrid treatments are effective in addressing patients presenting with multilevel PAD and CLTI. The common femoral artery involvement influences strategy selection. Larger studies with longer-term outcomes are required to validate the hybrid approach, indications, and results.

Foramen Magnum Dural Arteriovenous Fistula Presenting With Thoracic Myelopathy: Technical Case Report With 2-Dimensional Operative Video

Dural arteriovenous fistulas (dAVFs) are vascular abnormalities of the central nervous system that can cause a wide array of neurological dysfunction depending on their location, flow, and propensity to rupture. Symptomatic dAVFs at the cranio-cervical junction usually result in hemorrhage or cervical myelopathy. Distantly located dAVFs of the foramen magnum are a rare cause of thoracic intrinsic myelopathy. An 83-yr-old man presented with progressive lower extremity weakness, numbness, and difficulty walking along with episodes of bowel incontinence. Magnetic resonance imaging of the cervical spine demonstrated multilevel cervical disc disease with stenosis and longitudinal cervical cord signal change extending into the upper thoracic spinal cord. Cerebral and spinal angiography revealed a dAVF in the lateral foramen magnum region. Given the location, feeding vasculature, and morphology of the fistula, endovascular embolization was not attempted. Microsurgical resection with confirmative indocyanine green fluorescent imaging was performed with adequate obliteration of the fistula. The patient's neurological baseline was preserved postoperatively with improvement of lower extremity numbness. We present a brief overview of this neuropathologic entity and demonstrate microsurgical resection of a foramen magnum dAVF through operative video. Craniocervical dAVFs should remain on the differential diagnosis of patients presenting with progressive thoracolumbar myelopathy.

Distribution of Peripheral Arterial Disease in Patients Undergoing Endovascular Revascularization for Chronic Limb Threatening Ischaemia: Insights from the Vascular Quality Initiative in Singapore.

This study aimed to examine the distribution of lower limb atherosclerotic lesions in a multi-ethnic Asian cohort with chronic limb threatening ischemia (CLTI) from Singapore. The Society for Vascular Surgery Vascular Quality Initiative registry database was used to identify 265 CLTI patients who underwent percutaneous angioplasty between June 2019 and December 2019, of whom 171 (64.5%) were male, and the mean age was 67.9±11.0 years. The majority were diabetic (84.5%) and 145 (54.7%) had chronic kidney disease (CKD). The majority of the lower limb atherosclerotic lesions were de novo lesions (598/797, 75.0%), predominantly TransAtlantic Inter-Society Consensus II C/D (451/797, 56.6%), and were moderately to severely calcified (76.3%). The anterior tibial artery and femoral-popliteal artery were the most commonly affected vessels. The mean length of the treated lesions was 14.5±13.7 cm. There was a tendency, albeit insignificant, of multi-level disease in those who were diabetic or had CKD.

A Novel Hierarchical Deep Learning Framework for Diagnosing Multiple Visual Impairment Diseases in the Clinical Environment.

Early detection and treatment of visual impairment diseases are critical and integral to combating avoidable blindness. To enable this, artificial intelligence–based disease identification approaches are vital for visual impairment diseases, especially for people living in areas with a few ophthalmologists. In this study, we demonstrated the identification of a large variety of visual impairment diseases using a coarse-to-fine approach. We designed a hierarchical deep learning network, which is composed of a family of multi-task & multi-label learning classifiers representing different levels of eye diseases derived from a predefined hierarchical eye disease taxonomy. A multi-level disease–guided loss function was proposed to learn the fine-grained variability of eye disease features. The proposed framework was trained for both ocular surface and retinal images, independently. The training dataset comprised 7,100 clinical images from 1,600 patients with 100 diseases. To show the feasibility of the proposed framework, we demonstrated eye disease identification on the first two levels of the eye disease taxonomy, namely 7 ocular diseases with 4 ocular surface diseases and 3 retinal fundus diseases in level 1 and 17 subclasses with 9 ocular surface diseases and 8 retinal fundus diseases in level 2. The proposed framework is flexible and extensible, which can be inherently trained on more levels with sufficient training data for each subtype diseases (e.g., the 17 classes of level 2 include 100 subtype diseases defined as level 3 diseases). The performance of the proposed framework was evaluated against 40 board-certified ophthalmologists on clinical cases with various visual impairment diseases and showed that the proposed framework had high sensitivity and specificity with the area under the receiver operating characteristic curve ranging from 0.743 to 0.989 in identifying all identified major causes of blindness. Further assessment of 4,670 cases in a tertiary eye center also demonstrated that the proposed framework achieved a high identification accuracy rate for different visual impairment diseases compared with that of human graders in a clinical setting. The proposed hierarchical deep learning framework would improve clinical practice in ophthalmology and broaden the scope of service available, especially for people living in areas with a few ophthalmologists.

Clinical and radiographic outcomes using third-generation bioactive glass as a bone graft substitute for multi-level anterior cervical discectomy and fusion-a retrospective case series study.

Bioactive glasses have unique bone forming properties that have been used as a bone graft substitute for anterior cervical discectomy and fusions (ACDFs). Bone graft substitutes are used for achieving fusion while simultaneously avoiding donor site morbidity of iliac crest autograft. In this study, our principal intention is to assess the clinical and radiographic outcomes in patients with multi-level cervical disc disease undergoing ACDF using a third-generation bioactive glass as a bone graft substitute. A retrospective case series study was performed of patients who underwent primary multi-level instrumented fusions for degenerative cervical disc disease with bioactive glass bone graft substitute between May 2016 and December 2017 by a single fellowship-trained spine surgeon. All patients were treated with a porous PEEK interbody spacer and with a third-generation bioactive glass synthetic bone graft substitute. Patients were assessed pre-operatively, immediately following surgery, and at 3, 6, 12, and 24 months. Accepted standard outcome measures were applied to evaluate preoperative and postoperative metrics, including Visual Analog Scale neck pain and arm pain, and Neck Disability Index. Dynamic lateral radiographs were used to assess sagittal alignment, disc space height, arthrodesis status, osseous integration, and implant migration. Sagittal plane angulation was measured by Cobb's criteria. Thirty-nine patients underwent multi-level instrumented fusions: seventeen (43%) were two-level; 12 (31%) were three-level; 9 (23%) were four-level; and 1 (3%) was five-levels. All patients were followed for a minimum of 6 months for mean of 16.0 months (range, 6 to 36 months); none were lost to follow-up. Significant improvements from preoperative scores in Neck Disability Index scores as well as neck and arm visual analog scale pain scores were realized. All patients either maintained or improved their neurological status. Radiographically, all patients were fused by 6 months postoperatively and showed improvement in fusion segment lordosis (Pre-Post and Pre-Final P<0.001), C2-C7 lordosis angle (Pre-Post and Pre-Final P<0.001), T1 slope (Pre-Post P=0.01, Pre-Final P=0.07) and maintenance of disc height (Post-Final P=0.02). There were no adverse events, infections, or reoperations. Third-generation bioactive glass synthetic graft is a viable alternative to allograft or autograft in the setting of multi-level instrumented fusions for achieving improved clinical and radiographic outcomes.

Cellular allograft for multilevel stand-alone anterior cervical discectomy and fusion.

Anterior cervical discectomy and fusion (ACDF) is the most common treatment for degenerative disease of the cervical spine. Given the high rate of pseudarthrosis in multilevel stand-alone ACDF, there is a need to explore the utility of novel grafting materials. In this study, the authors present a single-institution retrospective study of patients with multilevel degenerative spine disease who underwent multilevel stand-alone ACDF surgery with or without cellular allograft supplementation. In a prospectively collected database, 28 patients who underwent multilevel ACDF supplemented with cellular allograft (ViviGen) and 25 patients who underwent multilevel ACDF with decellularized allograft between 2014 and 2020 were identified. The primary outcome was radiographic fusion determined by a 1-year follow-up CT scan. Secondary outcomes included change in Neck Disability Index (NDI) scores and change in visual analog scale scores for neck and arm pain. The study included 53 patients with a mean age of 53 ± 0.7 years who underwent multilevel stand-alone ACDF encompassing 2.6 ± 0.7 levels on average. Patient demographics were similar between the two cohorts. In the cellular allograft cohort, 2 patients experienced postoperative dysphagia that resolved by the 3-month follow-up. One patient developed cervical radiculopathy due to graft subsidence and required a posterior foraminotomy. At the 1-year CT, successful fusion was achieved in 92.9% (26/28) of patients who underwent ACDF supplemented with cellular allograft, compared with 84.0% (21/25) of patients who underwent ACDF without cellular allograft. The cellular allograft cohort experienced a significantly greater improvement in the mean postoperative NDI score (p < 0.05) compared with the other cohort. Cellular allograft is a low-morbidity bone allograft option for ACDF. In this study, the authors determined favorable arthrodesis rates and functional outcomes in a complex patient cohort following multilevel stand-alone ACDF supplemented with cellular allograft.

Is spinal tuberculosis changing with changing time?

IntroductionSpinal tuberculosis is a chronic destructive disease with long-term morbidity. Patients are usually young especially from a poor socioeconomic background. Destruction of the intervertebral disk space and the adjacent vertebral bodies is the characteristic lesion. The dorsal spine is the most affected region with multi-level noncontiguous involvement being detected more frequently. Patients usually present with chronic back pain associated with spinal tenderness, paraplegia, spinal deformities, as well as with constitutional symptoms. Magnetic resonance imaging has proved to be more sensitive and specific for its diagnosis, but availability and affordability of this investigation remain a problem in developing countries. Anti-tuberculous drug therapy has revolutionized the treatment of this debilitating disease. Surgery is still required in selected cases especially with evolving neurological deficit, progressive deformity, intractable pain and lack of response to drug therapy. With early diagnosis and effective treatment, prognosis is generally good.Materials/Methods: After getting permission from the clinical governance department, We collected the retrospective data of 305 patients with diagnosed spinal tuberculosis, who underwent surgical intervention. ResultsThere was no significant difference in incidence among males and females. Housewives were the most affected. Lower dorsal spinal was the commonest site involved but our study didn't confirm the incidence of multi-level disease process. Anterior decompression along with Cage fixation was most frequently performed procedure. ConclusionDespite the availability of highly effective antituberculous drugs, advanced surgical procedure, the spinal tuberculosis still maintains its demographic profile. There has been no change in characteristics of spinal presentation of this chronic debilitating disease. Patients continue to suffer the same way as they were suffering decades ago.

Multilevel, Percutaneous Posterior Cervical Interfacet Distraction and Fusion for Cervical Spondylotic Radiculopathy: Clinical and Radiographic Outcomes.

Retrospective review of patients who underwent multilevel posterior cervical interfacet distraction and fusion (PCIDF) using cages for cervical spondylotic radiculopathy (CSR). To determine clinical and radiographic outcomes following multilevel PCIDF. Anterior cervical discectomy and fusion has long been the standard of treatment for CSR. Advancements in surgery have employed minimally invasive techniques such as endoscopic discectomy, foraminotomy, and PCIDF. Studies on single-level PCIDF have reported good clinical outcomes, short hospital stays, and rare complications, but its application in multilevel disease is still evolving. Patients with CSR and confirmed radiologic evidence of multilevel foraminal stenosis without central canal stenosis were reviewed. Two-year outcomes of multilevel PCIDF included Neck Disability Index, neck and arm Visual Analogue Scale (VAS), radiographic cervical alignment parameters, evidence of fusion, and incidence of adjacent segment degeneration were compared at different time points. Thirty patients (mean age 54.6 ± 8.3) were included in the study with an average of 3.4 ± 0.8 levels treated. Mean surgical duration and intraoperative blood loss was 143.2 ± 69.7 minutes and 27.7 ± 28.7 mL, respectively, with an average length of stay at 1.8 ± 1.5 days. Neck Disability Index, VAS-neck, and VAS-arm all significantly improved at 2 weeks (P < 0.001) and was maintained until 2 years postoperatively. A significant decrease in segmental and C2-C7 lordosis, with a corresponding increase in sagittal vertical axis, was observed at 3 months postoperatively (P < 0.001) but did not deteriorate further on subsequent visits. Successful fusion was achieved in 90% of patients after 2 years. There was a 13.3% incidence of adjacent segment degeneration in the study cohort and one perioperative complication (3.3%). Our study suggests that multilevel PCIDF is safe and effective for CSR caused by foraminal stenosis. However, its potential to cause kyphosis and clinical impact on global sagittal alignment requires further scrutiny and long-term evaluation.Level of Evidence: 4.

Association between septal deviation and OSA diagnoses: a nationwide 9-year follow-up cohort study.

Obstructive sleep apnea (OSA) is a multilevel problematic disease. Major septal deviation (SD) can lead to severe nasal congestion, which, in turn, can lead to sleep apnea. Although SD seems to be related to OSA, very few studies have quantitatively examined this relationship. In this study, we investigate this using a 9-year large-scale cohort study. The SD group was selected out of 1 million individuals randomly extracted by the National Health Insurance Service. The non-SD group was obtained through propensity score matching considering several variables. The primary end point was OSA diagnosis. The study (SD) group included 11,238 individuals and the non-SD group (control group) included 22,476 persons. The overall hazard ratio for OSA in the SD group was 4.39 (95% confidence interval [CI]: 3.56-5.42). In subgroup analysis, the hazard ratio for OSA of male individuals was 3.77 (95% CI: 2.83-5.03), high economic status was 1.27 (95% CI: 1.05-1.56), metropolitan area was 1.31 (95% CI: 1.07-1.62), young age was 0.79 (95% CI: 0.64-0.98), hypertension was 1.00 (95% CI: 0.37-2.7), and diabetes mellitus was 2.44 (95% CI: 1.15-5.21). In the SD group, the hazard ratio for OSA after septoplasty was 0.71 (95% CI: 0.54-0.94). From long-term follow-up, the prevalence of OSA was 4.39 times higher in the SD group compared with the control group. This phenomenon was more pronounced with increasing body mass index and decreased significantly after septoplasty. Yeom SW, Chung SK, Lee EJ, etal. Association between septal deviation and OSA diagnoses: a nationwide 9-year follow-up cohort study. J Clin Sleep Med. 2021;17(10):2099-2106.

Anterior hybrid construction of multilevel cervical disc disease and spondylotic spinal stenosis: surgical results and factors affecting adjacent segment problems

ObjectiveWe aimed to evaluate reliability, radiological outcomes, and the impacts of anterior cervical hybrid construction on the adjacent segments for the multilevel cervical degenerative disc disease (mCDDD) and spondylotic spinal stenosis (SSS).MethodsA retrospective analysis was performed using data extracted from the medical files of 195 patients (105 males, 90 females; mean age: 47.7 years). From 2008 to 2018, these patients underwent anterior cervical hybrid construction for symptomatic contiguous at least 2-level cervical degenerative disc diseases and cervical spondylosis. Clinical and radiological data including Neck Disability Index (NDI), visual analogue scale (VAS), local cervical degenerative disk disease in adjacent segments on magnetic resonance imaging (MRI) views, and complications were reviewed.ResultsThe mean clinical and radiological follow-up was 45.2 months (range 24 to 102). Radiculopathy and/or myelopathy were the main clinical problems in all patients. The mean VAS scores of HC for arm pain were 7.4 ± 0.8 preoperatively; 2.8 ± 0.6, 1 month after surgery; 2.3 ± 0.6, 6 months after surgery; 1.8 ± 0.6, 12 month after surgery; and 1.6 ± 0.6, 24 months after surgery. The mean NDI scores (mean ± SD) of HC significantly improved after surgery (on admission, 57.2 ± 5.5%; 1 month after surgery, 27.35 ± 5.3%; 6 month after surgery, 21.43 ± 2.8%; 12 months after surgery, 21.9 ± 2.3%; 24 months after surgery, 20.6 ± 2.6%, p = 0.006). Hoarseness and dysphagia were the most common complications and osteophyte formation was the most frequent radiographic change.ConclusionAnterior cervical hybrid construction appears to be an acceptable option in the management of multilevel cervical degenerative disc diseases and spondylotic spinal stenosis.