Intra-Operative Analysis of Scoliosis Surgery in 3-D

Scoliosis is a three-dimensional deformity characterized by coronal, sagittal and axial rotation of the spine. Surgical fusion of the spine is required in severe cases. Assessment of the surgical procedure requires enough accuracy and flexibility to allow planning of individual interventions or implant designs. Conventional 2-D radiography and even 3-D CT scanning have limitations for in-depth analysis of scoliosis that limit the ability to see the three-dimensional deformity and expose the patient to considerable doses of radiation, respectively. Our stereophotogrammetric analysis is able to provide accurate, intraoperative measurement of vertebral movement during surgical manuevres. Stereophoto pairs taken at each stage of the operation and robust statistical techniques can be used to determine rotation, translation, goodness of fit, and overall spinal contour before, during, and after the surgical instrumentation. A demonstration of data available from this system is included.     

脊柱侧弯患者下颌骨的三维形态分析

目的:通过锥形束CT对脊柱侧弯患者下颌骨三维重建模型进行测量,分析下颌骨对称性,为进一步揭示脊柱侧弯与错牙合畸形的相互关系提供参考依据。方法:对73例脊柱侧弯患者(其中特发性38例,先天性35例)及40例身体姿势无异常志愿者拍摄锥形束CT并经三维重建后,对下颌骨左右侧结构进行测量分析,对比不对称指数。结果:(1)先天性脊柱侧弯患者脊柱畸形及身体姿势失平衡程度较特发性脊柱侧弯患者严重。(2)脊柱侧弯患者下颌骨体长度、下颌升支长度、下颌骨总长度不对称指数均较对照组无明显差异(P0.05)。(3)脊柱侧弯组中下颌角点成角不对称指数均较对照组高(P0.05),先天性脊柱侧弯组髁突顶点成角也明显高于对照组(P0.05)。结论:脊柱侧弯患者下颌骨结构偏斜,提示脊柱形态及身体姿势对下颌骨发育可能存在一定影响。     

重度脊柱侧凸后路一期小切口矫形对肺功能的影响

目的:探讨采用脊柱后路分期矫形策略治疗重度脊柱侧后凸,一期小切口矫形术对患者肺功能的影响。方法:自2007年05月-2010年12月采用脊柱后路分期矫形策略中一期小切口矫形术治疗重度脊柱侧凸患者32例,其中男12例,女20例,年龄5～25(13.5±6.12)岁。一期小切口矫形术前侧凸主弯冠状面Cobb’s角为108°～150°(128.75°±13.51°),胸腰段矢状位后凸角60°～140°(97.78°±27.88°)。测量一期矫形术前及术后2周、3月、6月肺功能,包括肺活量(VC)、用力肺活量(FVC)、第一秒时间肺活量(FEV1)、最大呼气中段流速(MMEF)、最大通气量(MVV),计算其占预计值的百分比[VC%、FVC%、FEV1%、MMEF%、MVV%]。观察患者术前与术后不同时期肺功能的变化。结果:术后3月时肺功能较术前有明显提高(P<0.05),术后6月较术后3个月无显著提高(P>0.05)。结论:对于严重的脊柱侧凸患者,后路一期小切口矫形术后3月肺功能即可获得明显改善,可行二期手术治疗。     

Intra-Operative Tissue Oxygen Tension Is Increased by Local Insufflation of Humidified-Warm CO2 during Open Abdominal Surgery in a Rat Model

Introduction

Maintenance of high tissue oxygenation (PtO₂) is recommended during surgery because PtO₂ is highly predictive of surgical site infection and colonic anastomotic leakage. However, surgical site perfusion is often sub-optimal, creating an obstructive hurdle for traditional, systemically applied therapies to maintain or increase surgical site PtO_2. This research tested the hypothesis that insufflation of humidified-warm CO₂ into the abdominal cavity would increase sub-peritoneal PtO₂ during open abdominal surgery.

Materials and Methods

15 Wistar rats underwent laparotomy under general anesthesia. Three sets of randomized cross-over experiments were conducted in which the abdominal cavity was subjected to alternating exposure to 1) humidified-warm CO₂ & ambient air; 2) humidified-warm CO₂ & dry-cold CO₂; and 3) dry-cold CO₂ & ambient air. Sub-peritoneal PtO₂ and tissue temperature were measured with a polarographic oxygen probe.

Results

Upon insufflation of humidified-warm CO₂, PtO₂ increased by 29.8 mmHg (SD 13.3; p<0.001), or 96.6% (SD 51.9), and tissue temperature by 3.0°C (SD 1.7 p<0.001), in comparison with exposure to ambient air. Smaller, but significant, increases in PtO₂ were seen in experiments 2 and 3. Tissue temperature decreased upon exposure to dry-cold CO₂ compared with ambient air (-1.4°C, SD 0.5, p = 0.001).

Conclusions

In a rat model, insufflation of humidified-warm CO₂ into the abdominal cavity during open abdominal surgery causes an immediate and potentially clinically significant increase in PtO₂. The effect is an additive result of the delivery of CO₂ and avoidance of evaporative cooling via the delivery of the CO₂ gas humidified at body temperature.     

Mechanical Analysis of Single Myocyte Contraction in a 3-D Elastic Matrix

Background

Cardiac myocytes experience mechanical stress during each heartbeat. Excessive mechanical stresses under pathological conditions cause functional and structural remodeling that lead to heart diseases, yet the precise mechanisms are still incompletely understood. To study the cellular and molecular level mechanotransduction mechanisms, we developed a new ‘cell-in-gel’ experimental system to exert multiaxial (3-D) stresses on a single myocyte during active contraction.

Methods

Isolated myocytes are embedded in an elastic hydrogel to simulate the mechanical environment in myocardium (afterload). When electrically stimulated, the in-gel myocyte contracts while the matrix resists shortening and broadening of the cell, exerting normal and shear stresses on the cell. Here we provide a mechanical analysis, based on the Eshelby inclusion problem, of the 3-D strain and stress inside and outside the single myocyte during contraction in an elastic matrix.

Results

(1) The fractional shortening of the myocyte depends on the cell’s geometric dimensions and the relative stiffness of the cell to the gel. A slender or softer cell has less fractional shortening. A myocyte of typical dimensions embedded in a gel of similar elastic stiffness can contract only 20% of its load-free value. (2) The longitudinal stress inside the cell is about 15 times the transverse stress level. (3) The traction on the cell surface is highly non-uniform, with a maximum near its ends, showing ‘hot spots’ at the location of intercalated disks. (4) The mechanical energy expenditure of the myocyte increases with the matrix stiffness in a monotonic and nonlinear manner.

Conclusion

Our mechanical analyses provide analytic solutions that readily lend themselves to parametric studies. The resulting 3-D mapping of the strain and stress states serve to analyze and interpret ongoing cell-in-gel experiments, and the mathematical model provides an essential tool to decipher and quantify mechanotransduction mechanisms in cardiac myocytes.     

Molecular phylogeny in 3-D

Molecular phylogenetic trees are constructed in three dimensions relative to the distribution of MW and pl classes and immunocrossreactivity against polyclonal antibodies to lens crystallins, as well as multiple sequence alignment between amino acid sequences, coding nucleotide sequences and the gene nucleotide sequences for beta-globin. Euclidian distances are estimated to position species in x, y, z space by multidimensional scaling and merged with bootstrap-tested branching pattern of Fitch & Margoliash plots to obtain 3-D phylogenetic tree. Compared to single attributes, phylogenetic trees based on multiple parameters allow significant repositioning of rodents, chiroptera and primates.     

Topological and Statistical Analysis of 3-D Reconstructions of Axon Collaterals

This is the first statistical metrical, topological, and model-oriented study of the spatial properties of collaterals of the primary afferent and reticulo-spinal axons, which monosynaptically innervate motoneurons of the lumbar segments of the frog spinal cord. It has been shown that ramification of both types of the collaterals is significantly asymmetrical. They differ from each other in the degree of asymmetry, which may be used for their topological classification. Spatial distribution of the synaptic boutons of these collaterals corresponds to a compound Poisson scheme, which means that the contacts are aggregated in clusters within 3-D space. We also showed that this distribution is fiducially related to the distribution of the expectation time for contacts measured as the distance along the collateral from a site of the collateral origin to a contact.     

Efficient Higher Order Full-Wave Numerical Analysis of 3-D Cloaking Structures

Highly efficient and versatile computational electromagnetic analysis of 3-D transformation-based metamaterial cloaking structures based on a hybridization of a higher order finite element method for discretization of the cloaking region and a higher order method of moments for numerical termination of the computational domain is proposed and demonstrated. The technique allows for an effective modeling of the continuously inhomogeneous anisotropic cloaking region, for cloaks based on both linear and nonlinear coordinate transformations, using a very small number of large curved finite elements with continuous spatial variations of permittivity and permeability tensors and high-order p-refined field approximations throughout their volumes, with a very small total number of unknowns. In analysis, there is no need for a discretization of the permittivity and permeability profiles of the cloak, namely for piecewise homogeneous (layered) approximate models, with material tensors replaced by appropriate piecewise constant approximations. Numerical results show a very significant reduction (three to five orders of magnitude for the simplest possible 6-element model and five to seven orders of magnitude for an h-refined 24-element model) in the scattering cross section of a perfectly conducting sphere with a metamaterial cloak, in a broad range of wavelengths. Given the introduced explicit approximations in modeling of the spherical geometry and continuous material tensor profiles (both by fourth-order Lagrange interpolating functions), and inherent numerical approximations involved in the finite element and moment method techniques and codes, the cloaking effects are shown to be predicted rather accurately by the full-wave numerical analysis method.     

Deconvolution in 3-D optical microscopy

Summary Fluorescent probes are becoming ever more widely used in the study of subcellular structure, and determination of their three-dimensional distributions has become very important. Confocal microscopy is now a common technique for overcoming the problem of out-of-focus flare in fluorescence imaging, but an alternative method uses digital image processing of conventional fluorescence images — a technique often termed deconvolution or restoration. This review attempts to explain image deconvolution in a non-technical manner. It is also applicable to 3-D confocal images, and can provide a further significant improvement in clarity and interpretability of such images. Some examples of the application of image deconvolution to both conventional and confocal fluorescence images are shown.     

Effects of Intra-Operative Total Intravenous Anaesthesia with Propofol versus Inhalational Anaesthesia with Sevoflurane on Post-Operative Pain in Liver Surgery: A Retrospective Case-Control Study

Background

Patients receiving total intravenous anesthesia (TIVA) with propofol have been shown to experience less postoperative pain. We evaluated the post-operative analgesic effects of propofol compared with sevoflurane maintenance of anesthesia in liver surgery. This study was registered at ClinicalTrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT02179437","term_id":"NCT02179437"}}NCT02179437).

Methods

In this retrospective study, records of patients who underwent liver surgery between 2010 and 2013 were reviewed. Ninety-five patients anesthetized with propofol TIVA were matched with 95 patients anesthetized with sevoflurane. Numeric pain rating scale (NRS) pain scores, postoperative morphine consumption, side effects and patients’ satisfaction with pain relief were evaluated.

Results

The TIVA group reported lower NRS pain scores during coughing on postoperative days 1 and 2 but not 3 (p = 0.0127, p = 0.0472, p = 0.4556 respectively). They also consumed significantly less daily (p = 0.001 on day 1, p = 0.0231 on day 2, p = 0.0004 on day 3), accumulative (p = 0.001 on day 1, p<0.0001 on day 2 and p = 0.0064 on day 3) and total morphine (p = 0.03) when compared with the sevoflurane group. There were no differences in total duration of intravenous patient controlled analgesia (PCA) morphine use and patient satisfaction. No difference was found in reported side effects.

Conclusion

Patients anesthetized with propofol TIVA reported less pain during coughing and consumed less daily, accumulative and total morphine after liver surgery.     

3D打印技术在脊柱侧凸矫形术中的应用研究

目的:通过3D打印技术建立患者脊柱的立体实物模型,并探讨其在脊柱侧凸矫形手术中的临床应用价值。方法:2013年9月～2017年8月的15例脊柱侧凸畸形患者,采集患者的薄层CT扫描数据,利用3D打印技术建立实物模型,术前模拟置钉、模拟截骨,完善术前规划,并按照术前计划进行手术。结果:所有患者均按照根据术前3D打印模型制定的手术方案完成手术,术中置钉顺利,置钉准确率为93.6%。所有患者术中、术后无神经、血管、内脏损伤等并发症。结论:3D打印技术为术者提供了更加直观、立体、即时的影像资料,能够完善术前规划,提高置钉准确率,降低手术风险,在脊柱矫形手术中应用前景广泛。     

Intrathecal Morphine Use in Adolescent Idiopathic Scoliosis Surgery is Associated with Decreased Opioid Use and Decreased Length of Stay

BackgroundLength of stay (LOS) in the hospital following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) has decreased over the past decade due to well-defined postoperative clinical pathways, earlier mobilization, and improved pain control methods. Historically, liberal use of parenteral and oral opioids for pain control caused side effects, resulting in delayed discharge. Intraoperative intrathecal morphine (ITM) has been posited to reduce the need for postoperative opioids and to expedite the discharge process. This study examines the relationship between the use of ITM with average required postoperative opioid usage and with average LOS.MethodsThis IRB-approved retrospective cohort study examined 105 patients with AIS who received PSF with instrumentation split into two cohorts. One cohort underwent PSF via standard surgical protocol (n=40) while the other cohort received intraoperative ITM with the standard surgical protocol (n=65). Power analysis demonstrated a study power of 0.8. LOS and total postoperative opioid analgesic medication (morphine milligram equivalent, MME) data were collected. Age at surgery, gender, number of spinal levels fused, estimated intraoperative blood loss (EBL), preoperative Cobb angle, and any complications related to the use of ITM were also recorded. Continuous variables were analyzed with Student’s t-test and categorical variables were analyzed with chi-square independent-sample tests using SAS 9.4 (α = 0.05).ResultsPatients who were treated with ITM displayed shorter LOS (p<0.0001) and reduced postoperative analgesic requirement (p<0.0001). Patients who received ITM spent an average of 1.8 fewer midnights in the hospital and received an average of 221.2 MME less than patients who received standard protocol (57% decrease). There were no significant differences between the two groups for any other variable.ConclusionIntraoperative ITM is a simple and effective treatment for scoliosis surgeons to better control postoperative pain in patients, reduce the risk of dependency, and achieve earlier discharge from the hospital. Shortened LOS reduces the overall cost of care, benefitting patients, hospitals, and insurance companies. Based on the results of this study and several earlier studies, the authors recommended that scoliosis surgeons consider incorporating use of ITM into their standard operative protocols. Level of Evidence: IV     

Scoliosis in the community.

Screening for scoliosis at schools has become more and more popular despite the lack of knowledge concerning the clinical course of idiopathic scoliosis. An epidemiological study of 5303 schoolchildren showed three types of scoliosis in the community: (1) pelvic tilt scoliosis (an inconsequential deformity caused by an inequality in the length of the legs but accounting for almost 40% of curves detected); (2) spinal scoliosis (a minor asymmetry of the spine in the coronal plane that tends to remain static or to resolve and which may be normal in growing children, accounting for the remaining 60%); and (3) progressive scoliosis (10% of the spinal scolioses measuring 10 degrees or more that progress by 5 degrees or more a year). Progressive scoliosis resembles idiopathic scoliosis because in girls with right thoracic curves the potential for progression is appreciable. Until the natural history is better established growing awareness in the community of spinal deformity should help earlier detection, and screening should be directed towards providing subjects for further epidemiological work.     

Analysis of Polymorphism of the Number of Tandem Repeats in the Aggrecan Gene Exon G3 in the Families with Idiopathic Scoliosis

In our previous study we showed that the inheritance of pronounced forms of idiopathic scoliosis was described by an autosomal-dominant major gene model assuming incomplete sex- and age-dependent penetrance. In the present study a search for the major gene was carried out by means of testing candidate genes. The aggrecan gene with known polymorphism of the number of tandem repeats in exon G3 was considered to be one of these candidate genes. Various alleles of this gene provide attachment of different number of chondroitin sulfate chains to a proteoglycan core protein, thereby changing functional properties of cartilage. Using the TDT analysis of 33 unrelated families consisting of a proband and his/her parents, we examined the existence of associations between the aggrecan alleles and the disease. Among nine alleles identified, three alleles with tandem repeats numbers of 25, 26, and 27 prevailed. We did not reveal preferable transmission of any of these alleles to the proband (TDT-statistics for different alleles varied from 0 to 0.71). There was also no correlation between the number of tandem repeats and the disease severity. Thus, either the polymorphism of the number of tandem repeats is not the direct reason for development of idiopathic scoliosis in the families tested, or its effect is too low to be detected using the samples examined.