Pub Date : 2024-10-01DOI: 10.1016/j.xnsj.2024.100562
Vincent Challier , Joseph E. Nassar , Jean-Etienne Castelain , Matthieu Campana , Clément Jacquemin , Soufiane Ghailane
Background
With an aging population, degenerative spinal diseases are contributing significantly to the healthcare's burden. Spinal alignment in the context of adult spinal deformities has become an important domain of research.
Methods
We conducted a narrative review of the latest considerations in spinal alignment within the context of degenerative spinal conditions, discussed current strategies for morphological assessment and finally identified potential areas for future research.
Results
This review reported that degenerative spinal conditions lead to a complex disruption of spinal alignment. It also highlighted the importance of spino-pelvic alignment with specific attention to compensatory mechanisms that occur in response to spinal deformities. Emerging technologies including Artificial Intelligence and epigenetics are showing promises in terms of patient care.
Conclusions
Understanding spinal alignment in degenerative conditions underscores the importance of dynamic and individualized assessments. Future research should integrate emerging technologies along with traditional clinical practices in order to optimize patient outcomes and minimize complications for patients suffering from degenerative spinal diseases.
{"title":"Alignment considerations in degenerative spinal conditions: A narrative review","authors":"Vincent Challier , Joseph E. Nassar , Jean-Etienne Castelain , Matthieu Campana , Clément Jacquemin , Soufiane Ghailane","doi":"10.1016/j.xnsj.2024.100562","DOIUrl":"10.1016/j.xnsj.2024.100562","url":null,"abstract":"<div><h3>Background</h3><div>With an aging population, degenerative spinal diseases are contributing significantly to the healthcare's burden. Spinal alignment in the context of adult spinal deformities has become an important domain of research.</div></div><div><h3>Methods</h3><div>We conducted a narrative review of the latest considerations in spinal alignment within the context of degenerative spinal conditions, discussed current strategies for morphological assessment and finally identified potential areas for future research.</div></div><div><h3>Results</h3><div>This review reported that degenerative spinal conditions lead to a complex disruption of spinal alignment. It also highlighted the importance of spino-pelvic alignment with specific attention to compensatory mechanisms that occur in response to spinal deformities. Emerging technologies including Artificial Intelligence and epigenetics are showing promises in terms of patient care.</div></div><div><h3>Conclusions</h3><div>Understanding spinal alignment in degenerative conditions underscores the importance of dynamic and individualized assessments. Future research should integrate emerging technologies along with traditional clinical practices in order to optimize patient outcomes and minimize complications for patients suffering from degenerative spinal diseases.</div></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"20 ","pages":"Article 100562"},"PeriodicalIF":0.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142552286","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-27DOI: 10.1016/j.xnsj.2024.100561
Michal Ziga MD , Martin N. Stienen MD/FEBNS , Anna Maria Zeitlberger MD , Stefanos Voglis MD , Luca Regli MD , Oliver Bozinov MD , Nicolai Maldaner MD
Background
The 6-minute walking test (6WT) has previously shown to be reliable and valid outcome measure in patients undergoing surgery for degenerative lumbar disorders (DLD). A role of 6WT in conservatively treated patients undergoing epidural steroid injection (ESI) remains unclear.
Methods
About 50 patients with DLD, scheduled for ESI were assessed by the smartphone-based 6WT and common paper-based patient-reported outcome measures (PROMs), including the Core Outcome Measures Index [COMI] back, Oswestry Disability Index (ODI) and Short Form Survey (SF-12). Pearson correlation coefficient (PCC) was used to define the relationship between 6WT and PROMs. Reliability of the 6WT was determined by intraclass correlation coefficient (ICC). Age- and sex-adjusted objective functional impairment (OFI) z-scores were calculated for each patient.
Results
A total of 50 patients (mean age 52 years, SD 13; 25% female), including 35 patients (70%) with lumbar disc herniation and 15 patients (30%) with lumbar spinal stenosis were included. The mean 6-minute walking distance (6WD) was 454.1 m (SD 89.1); the age- and sex-adjusted mean OFI z-score was −2.1 (SD 4.0). A total of 17 (34%) patients had mild, 8 (16%) moderate, and 4 (8%) severe OFI, while 21 (42%) had 6WT results within the normal population range (no OFI). The PCCs between the 6WD and VAS back pain were r=−0.30, ODI r=−0.43, COMI back r=−0.36, and PCS-12 r=0.51 (all p<.05). The ICC of the 6WT was β=0.92.
Conclusions
This external validation in a patient cohort with DLD, which was managed conservatively, confirms the reliability and content validity of the 6WT with similar PCCs with PROMs compared to the original surgical cohort. The results confirm the 6WT as a valid and useful tool for assessing OFI in patients with DLD and a broad range of functional restrictions in an outpatient setting.
{"title":"External validation of the smartphone-based 6-minute walking test in patients with degenerative lumbar disorders undergoing epidural steroid injection","authors":"Michal Ziga MD , Martin N. Stienen MD/FEBNS , Anna Maria Zeitlberger MD , Stefanos Voglis MD , Luca Regli MD , Oliver Bozinov MD , Nicolai Maldaner MD","doi":"10.1016/j.xnsj.2024.100561","DOIUrl":"10.1016/j.xnsj.2024.100561","url":null,"abstract":"<div><h3>Background</h3><div>The 6-minute walking test (6WT) has previously shown to be reliable and valid outcome measure in patients undergoing surgery for degenerative lumbar disorders (DLD). A role of 6WT in conservatively treated patients undergoing epidural steroid injection (ESI) remains unclear.</div></div><div><h3>Methods</h3><div>About 50 patients with DLD, scheduled for ESI were assessed by the smartphone-based 6WT and common paper-based patient-reported outcome measures (PROMs), including the Core Outcome Measures Index [COMI] back, Oswestry Disability Index (ODI) and Short Form Survey (SF-12). Pearson correlation coefficient (PCC) was used to define the relationship between 6WT and PROMs. Reliability of the 6WT was determined by intraclass correlation coefficient (ICC). Age- and sex-adjusted objective functional impairment (OFI) z-scores were calculated for each patient.</div></div><div><h3>Results</h3><div>A total of 50 patients (mean age 52 years, SD 13; 25% female), including 35 patients (70%) with lumbar disc herniation and 15 patients (30%) with lumbar spinal stenosis were included. The mean 6-minute walking distance (6WD) was 454.1 m (SD 89.1); the age- and sex-adjusted mean OFI z-score was −2.1 (SD 4.0). A total of 17 (34%) patients had mild, 8 (16%) moderate, and 4 (8%) severe OFI, while 21 (42%) had 6WT results within the normal population range (no OFI). The PCCs between the 6WD and VAS back pain were r=−0.30, ODI r=−0.43, COMI back r=−0.36, and PCS-12 r=0.51 (all p<.05). The ICC of the 6WT was β=0.92.</div></div><div><h3>Conclusions</h3><div>This external validation in a patient cohort with DLD, which was managed conservatively, confirms the reliability and content validity of the 6WT with similar PCCs with PROMs compared to the original surgical cohort. The results confirm the 6WT as a valid and useful tool for assessing OFI in patients with DLD and a broad range of functional restrictions in an outpatient setting.</div></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"20 ","pages":"Article 100561"},"PeriodicalIF":0.0,"publicationDate":"2024-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142530328","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1016/j.xnsj.2024.100559
Renzo A. Laynes MD , Christopher J. Kleck MD
Background
Patient specific (PS) technology has become popular in the field of spine surgery, as it gives surgeons control over the manufacturing of implants based on a patient's anatomy. Patient specific surgical guides, preoperative planning software, and patient specific implants – such as rods and cages, have demonstrated promising results in the literature for helping surgeons achieve spinal alignment goals.
Methods
A review of the literature regarding PS technology in spine surgery for the correction of spinal deformity was performed and is compiled here.
Results
A description of the PS tools currently used for deformity correction and treatment of degenerative spine pathology with example cases are included in this manuscript.
Conclusions
The use of PS technology in spine surgery is an important development in the field that should continue to be studied.
{"title":"Patient-specific implants and spinal alignment outcomes","authors":"Renzo A. Laynes MD , Christopher J. Kleck MD","doi":"10.1016/j.xnsj.2024.100559","DOIUrl":"10.1016/j.xnsj.2024.100559","url":null,"abstract":"<div><h3>Background</h3><div>Patient specific (PS) technology has become popular in the field of spine surgery, as it gives surgeons control over the manufacturing of implants based on a patient's anatomy. Patient specific surgical guides, preoperative planning software, and patient specific implants – such as rods and cages, have demonstrated promising results in the literature for helping surgeons achieve spinal alignment goals.</div></div><div><h3>Methods</h3><div>A review of the literature regarding PS technology in spine surgery for the correction of spinal deformity was performed and is compiled here.</div></div><div><h3>Results</h3><div>A description of the PS tools currently used for deformity correction and treatment of degenerative spine pathology with example cases are included in this manuscript.</div></div><div><h3>Conclusions</h3><div>The use of PS technology in spine surgery is an important development in the field that should continue to be studied.</div></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"20 ","pages":"Article 100559"},"PeriodicalIF":0.0,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142552285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-12DOI: 10.1016/j.xnsj.2024.100558
Xenia Zubenko BMedSc(Hons) , Susan Liew MBBS, FRACS , Sandra Reeder PhD , Yi Yang MBBS, FRACS , Ali Humadi MSurg, FRACS , Belinda Gabbe PhD
Background
Little is known about the incidence, management or long-term outcomes of traumatic cauda equina syndrome (CES), with few cohort studies. The purpose of this study is to establish the incidence and long-term outcomes of traumatic CES in Victoria, Australia. This study is a registry-based cohort study, and people with a diagnosis of traumatic CES from 2010 to 2022 were recruited from the Victorian State Trauma Registry.
Methods
An incidence rate was calculated by dividing the amount of new cases each year by the estimated population in Victoria. Demographic, injury and hospital admission details were extracted from the Victorian State Trauma Registry. Routine follow-up occurred at 6, 12- and 24- months postinjury, with a focus on health-related quality of life outcomes using the EuroQol EQ-5D scale, level of disability using the World Health Organization Disability Assessment Schedule (WHODAS) score and return to work outcomes. An additional telephone interview undertaken at a median 6.8 years postinjury collected the EQ-5D, bowel and bladder outcomes. Descriptive statistics were used to analyse data. Mixed effects regression modelling was used to model change in EQ-5D outcomes over time.
Results
Of the 94 participants, most were men (67%), the median age at injury was 41 years, and the most common cause was road trauma (35%). The incidence rate ranged from 0.56 to 2.51 per million per year. Most people reported problems on the EQ-5D at all 4 follow-up time points, with no clear improvement over time. 47% of people had not returned to work 24 months after injury. Of the survivors who completed the additional follow-up, 41% of people experienced constipation and 51% reported almost losing bladder continence at least once per week.
Conclusions
While the incidence rate of traumatic CES was low, most people experienced long-term sequelae, highlighting the impact of this injury on peoples’ lives. Multijurisdictional studies may be needed to comprehensively measure the impacts of this injury.
{"title":"The incidence and outcomes of traumatic cauda equina syndrome in Victoria, Australia","authors":"Xenia Zubenko BMedSc(Hons) , Susan Liew MBBS, FRACS , Sandra Reeder PhD , Yi Yang MBBS, FRACS , Ali Humadi MSurg, FRACS , Belinda Gabbe PhD","doi":"10.1016/j.xnsj.2024.100558","DOIUrl":"10.1016/j.xnsj.2024.100558","url":null,"abstract":"<div><h3>Background</h3><div>Little is known about the incidence, management or long-term outcomes of traumatic cauda equina syndrome (CES), with few cohort studies. The purpose of this study is to establish the incidence and long-term outcomes of traumatic CES in Victoria, Australia. This study is a registry-based cohort study, and people with a diagnosis of traumatic CES from 2010 to 2022 were recruited from the Victorian State Trauma Registry.</div></div><div><h3>Methods</h3><div>An incidence rate was calculated by dividing the amount of new cases each year by the estimated population in Victoria. Demographic, injury and hospital admission details were extracted from the Victorian State Trauma Registry. Routine follow-up occurred at 6, 12- and 24- months postinjury, with a focus on health-related quality of life outcomes using the EuroQol EQ-5D scale, level of disability using the World Health Organization Disability Assessment Schedule (WHODAS) score and return to work outcomes. An additional telephone interview undertaken at a median 6.8 years postinjury collected the EQ-5D, bowel and bladder outcomes. Descriptive statistics were used to analyse data. Mixed effects regression modelling was used to model change in EQ-5D outcomes over time.</div></div><div><h3>Results</h3><div>Of the 94 participants, most were men (67%), the median age at injury was 41 years, and the most common cause was road trauma (35%). The incidence rate ranged from 0.56 to 2.51 per million per year. Most people reported problems on the EQ-5D at all 4 follow-up time points, with no clear improvement over time. 47% of people had not returned to work 24 months after injury. Of the survivors who completed the additional follow-up, 41% of people experienced constipation and 51% reported almost losing bladder continence at least once per week.</div></div><div><h3>Conclusions</h3><div>While the incidence rate of traumatic CES was low, most people experienced long-term sequelae, highlighting the impact of this injury on peoples’ lives. Multijurisdictional studies may be needed to comprehensively measure the impacts of this injury.</div></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"20 ","pages":"Article 100558"},"PeriodicalIF":0.0,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142417301","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-08DOI: 10.1016/j.xnsj.2024.100557
Yang Yang PhD , Sydne McCluskey PhD , Mohamad Bydon MD , Jaspal Ricky Singh MD , Robert D. Sheeler MD , Karim Rizwan Nathani MBBS , Ana C. Krieger MD, MPH , Neel D. Mehta MD , Joshua Weaver MD , Libin Jia MD , Sharon DeCelle MS, PT, LPC , Robert C. Schlagal PhD , Jay Ayar DrPH (c), MPH, BDS , Sahar Abduljawad DrPH, MPH , Steven D. Stovitz MD, MS , Ravindra Ganesh MBBS, MD , Jay Verkuilen PhD , Kenneth A. Knapp PhD , Lin Yang PhD , Roger Härtl MD
Background
Mind-body treatments have the potential to manage pain, yet their effectiveness when delivered online for the treatment of low back pain (LBP) is unknown. We sought to evaluate whether a virtually delivered mind-body program integrating tai chi, qigong, and meditation (VDTQM) is effective for treating LBP.
Methods
This randomized controlled trial compared VDTQM (n=175) to waitlist control (n=175). Eligible participants were at least 18 years old, had LBP for at least 6 weeks, were not pregnant, had not previously taken tai chi classes, and had not undergone spine surgery within 6 months. The treatment group received a 12-week VDTQM program in live online 60-minute twice-weekly group classes from September 2022 to December 2022. All participants continued their usual activities and care. Primary outcome was pain-related disability assessed by the Oswestry Disability Index (ODI) score. Secondary outcomes included pain intensity, sleep quality, and quality of life (QOL). Intent-to-treat analyses were conducted.
Results
Of the 350 participants 278 (79%) were female, mean age was 58.8 years (range: 21–92), 244 (69.7%) completed the 8-week survey, 248 (70.9%) the 12-week, and 238 (68%) the 16 -week. No participants withdrew due to adverse treatment effects. Compared with control group, treatment group experienced statistically and clinically significant improvement in ODI score by −4.7 (95% CI: −6.24 to −3.16, p<.01), −6.42 (95% CI: −7.96 to −4.88, p<.01), and −8.14 (95% CI: −9.68 to −6.59, p<.01) points at weeks 8, 12, and 16, respectively. Treatment group also experienced statistically significant improvement at all time points in the other outcomes.
Conclusions
Among adults with LBP, VDTQM treatment resulted in small to moderate improvements in pain-related disability, pain intensity, sleep quality, and QOL. Improvements persisted 1 month after treatment concluded. These findings suggest VDTQM may be a viable treatment option for patients with LBP.
{"title":"A Tai chi and qigong mind-body program for low back pain: A virtually delivered randomized control trial","authors":"Yang Yang PhD , Sydne McCluskey PhD , Mohamad Bydon MD , Jaspal Ricky Singh MD , Robert D. Sheeler MD , Karim Rizwan Nathani MBBS , Ana C. Krieger MD, MPH , Neel D. Mehta MD , Joshua Weaver MD , Libin Jia MD , Sharon DeCelle MS, PT, LPC , Robert C. Schlagal PhD , Jay Ayar DrPH (c), MPH, BDS , Sahar Abduljawad DrPH, MPH , Steven D. Stovitz MD, MS , Ravindra Ganesh MBBS, MD , Jay Verkuilen PhD , Kenneth A. Knapp PhD , Lin Yang PhD , Roger Härtl MD","doi":"10.1016/j.xnsj.2024.100557","DOIUrl":"10.1016/j.xnsj.2024.100557","url":null,"abstract":"<div><h3>Background</h3><div>Mind-body treatments have the potential to manage pain, yet their effectiveness when delivered online for the treatment of low back pain (LBP) is unknown. We sought to evaluate whether a virtually delivered mind-body program integrating tai chi, qigong, and meditation (VDTQM) is effective for treating LBP.</div></div><div><h3>Methods</h3><div>This randomized controlled trial compared VDTQM (n=175) to waitlist control (n=175). Eligible participants were at least 18 years old, had LBP for at least 6 weeks, were not pregnant, had not previously taken tai chi classes, and had not undergone spine surgery within 6 months. The treatment group received a 12-week VDTQM program in live online 60-minute twice-weekly group classes from September 2022 to December 2022. All participants continued their usual activities and care. Primary outcome was pain-related disability assessed by the Oswestry Disability Index (ODI) score. Secondary outcomes included pain intensity, sleep quality, and quality of life (QOL). Intent-to-treat analyses were conducted.</div></div><div><h3>Results</h3><div>Of the 350 participants 278 (79%) were female, mean age was 58.8 years (range: 21–92), 244 (69.7%) completed the 8-week survey, 248 (70.9%) the 12-week, and 238 (68%) the 16 -week. No participants withdrew due to adverse treatment effects. Compared with control group, treatment group experienced statistically and clinically significant improvement in ODI score by −4.7 (95% CI: −6.24 to −3.16, p<.01), −6.42 (95% CI: −7.96 to −4.88, p<.01), and −8.14 (95% CI: −9.68 to −6.59, p<.01) points at weeks 8, 12, and 16, respectively. Treatment group also experienced statistically significant improvement at all time points in the other outcomes.</div></div><div><h3>Conclusions</h3><div>Among adults with LBP, VDTQM treatment resulted in small to moderate improvements in pain-related disability, pain intensity, sleep quality, and QOL. Improvements persisted 1 month after treatment concluded. These findings suggest VDTQM may be a viable treatment option for patients with LBP.</div><div><strong>Trial registration:</strong> clincaltrials.gov Identifier: NCT05801588.</div></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"20 ","pages":"Article 100557"},"PeriodicalIF":0.0,"publicationDate":"2024-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142445018","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-06DOI: 10.1016/j.xnsj.2024.100556
Edgar Petrosyan MD, Jawad Fares MD, Christopher S. Ahuja MD, PhD, Maciej S. Lesniak MD, Tyler R. Koski MD, Nader S. Dahdaleh MD, Najib E. El Tecle MD
Background
Scoliosis is defined as a lateral spine curvature of at least 10° with vertebral rotation, as seen on a posterior-anterior radiograph, often accompanied by reduced thoracic kyphosis. Scoliosis affects all age groups: idiopathic scoliosis is the most common spinal disorder in children and adolescents, while adult degenerative scoliosis typically affects individuals over fifty. In the United States, approximately 3 million new cases of scoliosis are diagnosed annually, with a predicted increase in part due to global aging. Despite its prevalence, the etiopathogenesis of scoliosis remains unclear.
Methods
This comprehensive review analyzes the literature on the etiopathogenetic evidence for both idiopathic and adult degenerative scoliosis. PubMed and Google Scholar databases were searched for studies on the genetic factors and etiopathogenetic mechanisms of scoliosis development and progression, with the search limited to articles in English.
Results
For idiopathic scoliosis, genetic factors are categorized into three groups: genes associated with susceptibility, disease progression, and both. We identify gene groups related to different biological processes and explore multifaceted pathogenesis of idiopathic scoliosis, including evolutionary adaptations to bipedalism and developmental and homeostatic spinal aberrations. For adult degenerative scoliosis, we segregate genetic and pathogenic evidence into categories of angiogenesis and inflammation, extracellular matrix degradation, neural associations, and hormonal influences. Finally, we compare findings in idiopathic scoliosis and adult degenerative scoliosis, discuss current limitations in scoliosis research, propose a new model for scoliosis etiopathogenesis, and highlight promising areas for future studies.
Conclusions
Scoliosis is a complex, multifaceted disease with largely enigmatic origins and mechanisms of progression, keeping it under continuous scientific scrutiny.
{"title":"Genetics and pathogenesis of scoliosis","authors":"Edgar Petrosyan MD, Jawad Fares MD, Christopher S. Ahuja MD, PhD, Maciej S. Lesniak MD, Tyler R. Koski MD, Nader S. Dahdaleh MD, Najib E. El Tecle MD","doi":"10.1016/j.xnsj.2024.100556","DOIUrl":"10.1016/j.xnsj.2024.100556","url":null,"abstract":"<div><h3>Background</h3><div>Scoliosis is defined as a lateral spine curvature of at least 10° with vertebral rotation, as seen on a posterior-anterior radiograph, often accompanied by reduced thoracic kyphosis. Scoliosis affects all age groups: idiopathic scoliosis is the most common spinal disorder in children and adolescents, while adult degenerative scoliosis typically affects individuals over fifty. In the United States, approximately 3 million new cases of scoliosis are diagnosed annually, with a predicted increase in part due to global aging. Despite its prevalence, the etiopathogenesis of scoliosis remains unclear.</div></div><div><h3>Methods</h3><div>This comprehensive review analyzes the literature on the etiopathogenetic evidence for both idiopathic and adult degenerative scoliosis. PubMed and Google Scholar databases were searched for studies on the genetic factors and etiopathogenetic mechanisms of scoliosis development and progression, with the search limited to articles in English.</div></div><div><h3>Results</h3><div>For idiopathic scoliosis, genetic factors are categorized into three groups: genes associated with susceptibility, disease progression, and both. We identify gene groups related to different biological processes and explore multifaceted pathogenesis of idiopathic scoliosis, including evolutionary adaptations to bipedalism and developmental and homeostatic spinal aberrations. For adult degenerative scoliosis, we segregate genetic and pathogenic evidence into categories of angiogenesis and inflammation, extracellular matrix degradation, neural associations, and hormonal influences. Finally, we compare findings in idiopathic scoliosis and adult degenerative scoliosis, discuss current limitations in scoliosis research, propose a new model for scoliosis etiopathogenesis, and highlight promising areas for future studies.</div></div><div><h3>Conclusions</h3><div>Scoliosis is a complex, multifaceted disease with largely enigmatic origins and mechanisms of progression, keeping it under continuous scientific scrutiny.</div></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"20 ","pages":"Article 100556"},"PeriodicalIF":0.0,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142326653","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-03DOI: 10.1016/j.xnsj.2024.100555
Julius Gerstmeyer MD , August Avantaggio , Clifford Pierre MD , Neel Patel MD , Donald D. Davis MD , Bryan Anderson DO , Periklis Godolias MD , Thomas Schildhauer MD , Amir Abdul-Jabbar MD , Rod J. Oskouian MD , Jens R. Chapman MD
Objective
Intracranial hemorrhage (ICH) after durotomy in elective spine surgery, though rare, can pose a significant risk to patient outcomes. Spine surgeries bear a risk of dural tears (DT) with potential of postoperative cerebrospinal fluid leakage (PCSFL). Excessive PCSFL can precipitate a decrease in intracranial pressure, potentially leading to ICH. Literature on ICH as a postoperative complication is scarce. The aim was to assess the incidence and risk factors of ICH in patients undergoing elective spine surgery.
Methods
Utilizing the 2020 National Impatient Sample (NIS) adults (>18 years) were selected by primary procedure category codes for spine fusion, discectomy, spinal cord decompression and cervicothoracic/lumbosacral nerve decompression. Exclusion criteria were trauma and malignancy. The primary outcome was occurrence of ICH. Comparative analysis and a multivariable logistic regression were used to identify independent risk.
Results
In total, 40,990 patients met our criteria with an incidence of ICH at 0.08%. The ICH-group showed an increased length of stay and higher mortality compared to the control group. Spinal cord decompression, DT and PCSFL were significantly more frequent in patients with ICH. Alcohol, drug abuse and hypertension were significantly more prevalent in patients with ICH. DT, alcohol abuse and hypertension were independent risk factors for ICH.
Conclusions
This study underscores the rarity and severity of ICHs following elective spine surgery, emphasizing awareness and looking for possible preventive measures. Our finding suggests that DT, as a complication of surgical techniques, as well as alcohol abuse and hypertension are significant predictors of ICH.
目的在脊柱择期手术中进行硬脑膜切开术后发生颅内出血（ICH）的情况虽然罕见，但会对患者的预后构成重大风险。脊柱手术有硬脑膜撕裂（DT）的风险，术后可能出现脑脊液漏（PCSFL）。过多的 PCSFL 会导致颅内压下降，从而引发 ICH。有关术后并发症 ICH 的文献很少。方法利用 2020 年全国住院患者样本（NIS），根据脊柱融合术、椎间盘切除术、脊髓减压术和颈胸腰骶部神经减压术的主要手术类别代码筛选出成人（18 岁）。排除标准为外伤和恶性肿瘤。主要结果是发生 ICH。结果共有 40,990 名患者符合我们的标准，ICH 发生率为 0.08%。与对照组相比，ICH组患者的住院时间延长，死亡率升高。在 ICH 患者中，脊髓减压、DT 和 PCSFL 的发生率明显更高。酗酒、滥用药物和高血压在 ICH 患者中的发病率明显更高。结论本研究强调了脊柱择期手术后发生 ICH 的罕见性和严重性，强调要提高认识并寻找可能的预防措施。我们的研究结果表明，作为手术技术并发症的 DT 以及酗酒和高血压是导致 ICH 的重要预测因素。
{"title":"The hidden risk: Intracranial hemorrhage following durotomies in spine surgery","authors":"Julius Gerstmeyer MD , August Avantaggio , Clifford Pierre MD , Neel Patel MD , Donald D. Davis MD , Bryan Anderson DO , Periklis Godolias MD , Thomas Schildhauer MD , Amir Abdul-Jabbar MD , Rod J. Oskouian MD , Jens R. Chapman MD","doi":"10.1016/j.xnsj.2024.100555","DOIUrl":"10.1016/j.xnsj.2024.100555","url":null,"abstract":"<div><h3>Objective</h3><div>Intracranial hemorrhage (ICH) after durotomy in elective spine surgery, though rare, can pose a significant risk to patient outcomes. Spine surgeries bear a risk of dural tears (DT) with potential of postoperative cerebrospinal fluid leakage (PCSFL). Excessive PCSFL can precipitate a decrease in intracranial pressure, potentially leading to ICH. Literature on ICH as a postoperative complication is scarce. The aim was to assess the incidence and risk factors of ICH in patients undergoing elective spine surgery.</div></div><div><h3>Methods</h3><div>Utilizing the 2020 National Impatient Sample (NIS) adults (>18 years) were selected by primary procedure category codes for spine fusion, discectomy, spinal cord decompression and cervicothoracic/lumbosacral nerve decompression. Exclusion criteria were trauma and malignancy. The primary outcome was occurrence of ICH. Comparative analysis and a multivariable logistic regression were used to identify independent risk.</div></div><div><h3>Results</h3><div>In total, 40,990 patients met our criteria with an incidence of ICH at 0.08%. The ICH-group showed an increased length of stay and higher mortality compared to the control group. Spinal cord decompression, DT and PCSFL were significantly more frequent in patients with ICH. Alcohol, drug abuse and hypertension were significantly more prevalent in patients with ICH. DT, alcohol abuse and hypertension were independent risk factors for ICH.</div></div><div><h3>Conclusions</h3><div>This study underscores the rarity and severity of ICHs following elective spine surgery, emphasizing awareness and looking for possible preventive measures. Our finding suggests that DT, as a complication of surgical techniques, as well as alcohol abuse and hypertension are significant predictors of ICH.</div></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"20 ","pages":"Article 100555"},"PeriodicalIF":0.0,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142326446","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-03DOI: 10.1016/j.xnsj.2024.100554
Matthew H. Claydon MB, BS, BMedSci, FRACS , Dean T. Biddau BBiomedSc , Alexander N. Claydon , Jordan P. Laggoune BSc (Hons) , Gregory M. Malham BSc, MB, ChB, DMed, FRACS
Background
Thromboembolic complications in anterior lumbar spinal surgery can rarely result in limb loss. Iliac vessel retraction can temporarily occlude the iliac artery risking thromboembolic sequelae. Studies estimate the incidence of iliac artery thrombosis at 0.45%. Brief intraoperative heparinization can potentially mitigate this risk. We aim to quantify the incidence of temporary iliac artery occlusion (TIAO) and examine its association with potential risk factors (sex, BMI, target disc level, and type of prosthesis).
Methods
Retrospective analysis of consecutive patients undergoing anterior lumbar spinal surgery by a single vascular surgeon and 5 spinal neurosurgeons between 2009 and 2022. Patients underwent single or double-level total disc replacement (TDR); single, double, or triple-level anterior lumbar interbody fusion (ALIF); or hybrid procedure (combined cranial TDR and caudal ALIF). A pulse oximeter monitored bilateral second toes perfusion. Loss of the waveform, combined with a nonpalpable external iliac artery pulse distal to the retractors was defined as TIAO of the ipsilateral artery. Heparin was administered if TIAO developed.
Results
Of 605 patients (318 males, 287 females), TIAO occurred in 176 patients (29.1%). TIAO occurred in 13.5% of the 377 patients who underwent single or multilevel ALIF and in 42.7% of the 110 patients who underwent single or multilevel TDR (p=.004). In single-level surgery at L5/S1, TIAO occurred in 3.1% of patients. In single-level surgery at L4/5, TIAO occurred in 65.2% of patients overall; the rate was higher for TDR than for ALIF (74.6% vs. 48.5%; p=.01). The TIAO rate was 44.3% in multilevel procedures and 66.1% in hybrid procedures. No patient developed postoperative thrombotic iliac artery occlusion or embolic complications.
Conclusions
TIAO occurred frequently during anterior lumbar exposure (29%). Anterior spinal exposure at L4/5 had a high incidence of TIAO, particularly for TDR, in contrast to L5/S1.
{"title":"Incidence of temporary intraoperative iliac artery occlusion during anterior spinal surgery","authors":"Matthew H. Claydon MB, BS, BMedSci, FRACS , Dean T. Biddau BBiomedSc , Alexander N. Claydon , Jordan P. Laggoune BSc (Hons) , Gregory M. Malham BSc, MB, ChB, DMed, FRACS","doi":"10.1016/j.xnsj.2024.100554","DOIUrl":"10.1016/j.xnsj.2024.100554","url":null,"abstract":"<div><h3>Background</h3><div>Thromboembolic complications in anterior lumbar spinal surgery can rarely result in limb loss. Iliac vessel retraction can temporarily occlude the iliac artery risking thromboembolic sequelae. Studies estimate the incidence of iliac artery thrombosis at 0.45%. Brief intraoperative heparinization can potentially mitigate this risk. We aim to quantify the incidence of temporary iliac artery occlusion (TIAO) and examine its association with potential risk factors (sex, BMI, target disc level, and type of prosthesis).</div></div><div><h3>Methods</h3><div>Retrospective analysis of consecutive patients undergoing anterior lumbar spinal surgery by a single vascular surgeon and 5 spinal neurosurgeons between 2009 and 2022. Patients underwent single or double-level total disc replacement (TDR); single, double, or triple-level anterior lumbar interbody fusion (ALIF); or hybrid procedure (combined cranial TDR and caudal ALIF). A pulse oximeter monitored bilateral second toes perfusion. Loss of the waveform, combined with a nonpalpable external iliac artery pulse distal to the retractors was defined as TIAO of the ipsilateral artery. Heparin was administered if TIAO developed.</div></div><div><h3>Results</h3><div>Of 605 patients (318 males, 287 females), TIAO occurred in 176 patients (29.1%). TIAO occurred in 13.5% of the 377 patients who underwent single or multilevel ALIF and in 42.7% of the 110 patients who underwent single or multilevel TDR (p=.004). In single-level surgery at L5/S1, TIAO occurred in 3.1% of patients. In single-level surgery at L4/5, TIAO occurred in 65.2% of patients overall; the rate was higher for TDR than for ALIF (74.6% vs. 48.5%; p=.01). The TIAO rate was 44.3% in multilevel procedures and 66.1% in hybrid procedures. No patient developed postoperative thrombotic iliac artery occlusion or embolic complications.</div></div><div><h3>Conclusions</h3><div>TIAO occurred frequently during anterior lumbar exposure (29%). Anterior spinal exposure at L4/5 had a high incidence of TIAO, particularly for TDR, in contrast to L5/S1.</div></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"20 ","pages":"Article 100554"},"PeriodicalIF":0.0,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666548424002476/pdfft?md5=38feab99b778dfb9ccecef68247ec64c&pid=1-s2.0-S2666548424002476-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142314174","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01DOI: 10.1016/j.xnsj.2024.100544
Ashley MacConnell MD , Joseph Krob MD , Muturi G. Muriuki PhD , Robert M. Havey MS , Lauren Matteini MD , Bartosz Wojewnik MD , Nikolas Baksh MD , Avinash G. Patwardhan PhD
Background
Flatback deformity, or lumbar hypolordosis, can cause sagittal imbalance, causing back pain, fatigue, and functional limitation. Surgical correction through osteotomies and interbody fusion techniques can restore sagittal balance and relieve pain. This study investigated sagittal vertical alignment (SVA) and lumbar lordosis correction achieved through sequential procedures on human spine specimens.
Methods
Human T10-sacrum specimens were stratified into 2 groups: degenerative flatback specimens had smaller L1-S1 lordosis compared to the iatrogenic group (26.1°±15.0° vs. 47.8°±19.3°, p<.05). Specimens were mounted in the apparatus in simulated standing posture with a nominal sacral slope of 45 degrees and subjected to a 400N compressive follower preload. Sequential correction of degenerative lumbar flatback deformity involved: anterior lumbar interbody fusion (ALIF) at L5-S1, ALIF at L4-5, lateral lumbar interbody fusion (LLIF) at L2-3 and L3-4, and posterior column osteotomy (PCO) at L2-3 and L3-4. In iatrogenic specimens, flatback deformity was created by performing a posterior in-situ immobilization using pedicle screw instrumentation at L4-L5-S1 followed by distraction across the pedicle screws. We then performed LLIF at L2-3 and L3-4, followed by PCO at L2-3 and L3-4.
Results
Statistically significant incremental corrections were noted in SVAs and lordosis after L5-S1 ALIF, L4-5 ALIF, and PCO in degenerative flatback specimens. For the iatrogenic group, statistically significant worsening was noted in measures of standing alignment after L4-L5-S1 hypolordotic fusion. Subsequent LLIF at L2-3 and L3-4 did not significantly improve sagittal alignment. However, after PCO at L2-3 and L3-4, final alignment parameters were not significantly different than preoperative baseline values prior to hypolordotic fusion.
Conclusions
ALIF cages in the lower lumbar segments significantly improved sagittal alignment in degenerative flatback specimens. In the upper lumbar segments, LLIF cages alone were ineffective at enhancing lumbar lordosis. LLIF cages in conjunction with PCO improved alignment parameters in degenerative and iatrogenic flatback deformities.
{"title":"Sequential correction of sagittal vertical alignment and lumbar lordosis in adult flatback deformity","authors":"Ashley MacConnell MD , Joseph Krob MD , Muturi G. Muriuki PhD , Robert M. Havey MS , Lauren Matteini MD , Bartosz Wojewnik MD , Nikolas Baksh MD , Avinash G. Patwardhan PhD","doi":"10.1016/j.xnsj.2024.100544","DOIUrl":"10.1016/j.xnsj.2024.100544","url":null,"abstract":"<div><h3>Background</h3><p>Flatback deformity, or lumbar hypolordosis, can cause sagittal imbalance, causing back pain, fatigue, and functional limitation. Surgical correction through osteotomies and interbody fusion techniques can restore sagittal balance and relieve pain. This study investigated sagittal vertical alignment (SVA) and lumbar lordosis correction achieved through sequential procedures on human spine specimens.</p></div><div><h3>Methods</h3><p>Human T10-sacrum specimens were stratified into 2 groups: degenerative flatback specimens had smaller L1-S1 lordosis compared to the iatrogenic group (26.1°±15.0° vs. 47.8°±19.3°, p<.05). Specimens were mounted in the apparatus in simulated standing posture with a nominal sacral slope of 45 degrees and subjected to a 400N compressive follower preload. Sequential correction of degenerative lumbar flatback deformity involved: anterior lumbar interbody fusion (ALIF) at L5-S1, ALIF at L4-5, lateral lumbar interbody fusion (LLIF) at L2-3 and L3-4, and posterior column osteotomy (PCO) at L2-3 and L3-4. In iatrogenic specimens, flatback deformity was created by performing a posterior <em>in-situ</em> immobilization using pedicle screw instrumentation at L4-L5-S1 followed by distraction across the pedicle screws. We then performed LLIF at L2-3 and L3-4, followed by PCO at L2-3 and L3-4.</p></div><div><h3>Results</h3><p>Statistically significant incremental corrections were noted in SVAs and lordosis after L5-S1 ALIF, L4-5 ALIF, and PCO in degenerative flatback specimens. For the iatrogenic group, statistically significant worsening was noted in measures of standing alignment after L4-L5-S1 hypolordotic fusion. Subsequent LLIF at L2-3 and L3-4 did not significantly improve sagittal alignment. However, after PCO at L2-3 and L3-4, final alignment parameters were not significantly different than preoperative baseline values prior to hypolordotic fusion.</p></div><div><h3>Conclusions</h3><p>ALIF cages in the lower lumbar segments significantly improved sagittal alignment in degenerative flatback specimens. In the upper lumbar segments, LLIF cages alone were ineffective at enhancing lumbar lordosis. LLIF cages in conjunction with PCO improved alignment parameters in degenerative and iatrogenic flatback deformities.</p></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"19 ","pages":"Article 100544"},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666548424002373/pdfft?md5=01ce596880a7a254dde34451a39319d3&pid=1-s2.0-S2666548424002373-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142094830","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01DOI: 10.1016/j.xnsj.2024.100545
Donna J. Oeffinger PhD , Henry Iwinski MD , Vishwas Talwalkar MD , David M. Dueber PhD
Background
Despite widespread usage of the SRS-22r questionnaire (Scoliosis Research Society Questionnaire-22r), the English version has only sparingly been subjected to analysis using modern psychometric techniques for patients with adolescent idiopathic scoliosis (AIS). The study purpose was to improve interpretation and clinical utility of the SRS-22r for adolescents with AIS by generating additional robust evidence, using modern statistical techniques. Questions about (1) Structure and (2) Item and Scale Functioning are addressed and interpreted for clinicians and researchers.
Methods
This retrospective case review analyzed SRS-22r data collected from 1823 patients (mean age 14.9±2.2years) with a primary diagnosis of AIS who clinically completed an SRS-22r questionnaire.
Individual SRS-22r questions and domain scores were retrieved through data queries. Patient information collected through chart review included diagnosis, age at assessment, sex, race and radiographic parameters. From 6044 SRS-22r assessments, 1 assessment per patient was randomly selected. Exploratory structural equation modeling (ESEM) and item response theory (IRT) techniques were used for data modeling, item calibration, and reliability assessment.
Results
ESEM demonstrated acceptable fit to the data: χ2 (130)=343.73, p<.001; RMSEA=0.035; CFI=0.98; TLI=0.96; SRMR=0.02. Several items failed to adequately load onto their assigned factor. Item fit was adequate for all items except SRSq10 (Self-Image), SRSq16 (Mental Health), and SRSq20 (Mental Health). IRT models found item discriminations are within normal levels for items in psychological measures, except items SRSq1 (pain), SRSq2 (pain), and SRSq16 (mental health). Estimated reliability of the Function domain (ρ=0.69) was low, however, Pain, Self-Image and Mental Health domains exhibited high (ρ>0.80) reliability.
Conclusions
Modern psychometric assessment of the SRS-22r, in adolescent patients with AIS, are presented and interpreted to assist clinicians and researchers in understanding its strengths and limitations. Overall, the SRS-22r demonstrated good psychometric properties in all domains except function. Cautious interpretation of the total score is suggested, as it does not reflect a single HRQoL construct.
{"title":"Psychometric analysis and the implications for the use of the scoliosis research society questionnaire (SRS-22r English) for individuals with adolescent idiopathic scoliosis","authors":"Donna J. Oeffinger PhD , Henry Iwinski MD , Vishwas Talwalkar MD , David M. Dueber PhD","doi":"10.1016/j.xnsj.2024.100545","DOIUrl":"10.1016/j.xnsj.2024.100545","url":null,"abstract":"<div><h3>Background</h3><p>Despite widespread usage of the SRS-22r questionnaire (Scoliosis Research Society Questionnaire-22r), the English version has only sparingly been subjected to analysis using modern psychometric techniques for patients with adolescent idiopathic scoliosis (AIS). The study purpose was to improve interpretation and clinical utility of the SRS-22r for adolescents with AIS by generating additional robust evidence, using modern statistical techniques. Questions about (1) Structure and (2) Item and Scale Functioning are addressed and interpreted for clinicians and researchers.</p></div><div><h3>Methods</h3><p>This retrospective case review analyzed SRS-22r data collected from 1823 patients (mean age 14.9±2.2years) with a primary diagnosis of AIS who clinically completed an SRS-22r questionnaire.</p><p>Individual SRS-22r questions and domain scores were retrieved through data queries. Patient information collected through chart review included diagnosis, age at assessment, sex, race and radiographic parameters. From 6044 SRS-22r assessments, 1 assessment per patient was randomly selected. Exploratory structural equation modeling (ESEM) and item response theory (IRT) techniques were used for data modeling, item calibration, and reliability assessment.</p></div><div><h3>Results</h3><p>ESEM demonstrated acceptable fit to the data: χ<sup>2</sup> (130)=343.73, p<.001; RMSEA=0.035; CFI=0.98; TLI=0.96; SRMR=0.02. Several items failed to adequately load onto their assigned factor. Item fit was adequate for all items except SRSq10 (Self-Image), SRSq16 (Mental Health), and SRSq20 (Mental Health). IRT models found item discriminations are within normal levels for items in psychological measures, except items SRSq1 (pain), SRSq2 (pain), and SRSq16 (mental health). Estimated reliability of the Function domain (ρ=0.69) was low, however, Pain, Self-Image and Mental Health domains exhibited high (ρ>0.80) reliability.</p></div><div><h3>Conclusions</h3><p>Modern psychometric assessment of the SRS-22r, in adolescent patients with AIS, are presented and interpreted to assist clinicians and researchers in understanding its strengths and limitations. Overall, the SRS-22r demonstrated good psychometric properties in all domains except function. Cautious interpretation of the total score is suggested, as it does not reflect a single HRQoL construct.</p></div>","PeriodicalId":34622,"journal":{"name":"North American Spine Society Journal","volume":"19 ","pages":"Article 100545"},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666548424002385/pdfft?md5=deb143c4dbd29dd929e7e5ecc0e8a289&pid=1-s2.0-S2666548424002385-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142150522","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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