Objective To evaluate the risk factors of early gastric cancer with lymph node metastasis.Methods Clinicopathological data of 461 early gastric cancer cases admitted at Drum Tower Hospital from June 2010 to December 2015 were retrospectively analyzed.Results Of these 461 cases of early gastric cancer there were 338 male cases and 123 female cases,with male to female ratio of 2.74∶ 1.There were 48(10.4％) patients with lymph node metastasis.Female patients had a higher rate of metastasis (P =0.000).Lymph node metastasis rate in males,menopause females,premenopause females is 7.3％,16.3％,29.0％ respectively.Females had metastasis 5 years earlier than males (x2 =31.877,P =0.000).Metastasis rate in M invasion was 6.0％ and in SM invasion was 17.4％ (x2 =12.055,P =0.001).Conclusions There were much more males than females in early gastric cancer patients though females having a higher rate of lymph node metastasis.Gender,age and depth of invasion is independent risk factors for lymph node metastasis in early gastric cancer.

Objective:To evaluate the radiographic and clinical outcomes of pre-operative Halo-gravity traction (HGT) and posterior correction surgery in treating patients with neurological deficits secondary to severe focal angular kyphosis of the upper thoracic spine.Methods:A total of 16 patients (11 males, 5 females) with neurologic deficits secondary to severe focal angular kyphosis of the upper thoracic spine undergoing preoperative HGT and posterior correction operation from January 2010 to December 2019 were retrospectively analyzed. The average age was 12.9±5.6 years (range 6-27 years). The standing X-ray of whole spine was taken at pre-, post-traction and post-operation. The Cobb angles of main curve at both sagittal and coronal planes were measured accordingly. The neurologic function at pre-traction, post-traction and post-operation was assessed according to the American Spinal Injury Association (ASIA) grading. The complications during HGT, operation and post-operative follow-up were recorded for each patient.Results:The average values of focal kyphosis and scoliosis were 96.1°±16.0° (71°-128°) and 75.5°±20.5° (40°-107°) at pre-traction respectively. The spinal cord function graded by ASIA criteria at pre-traction was B in 1 patient, C in 6 and D in 9, respectively. The correction rates of focal kyphosis and scoliosis were 32.8%±15.0% (18.0%-65.9%) and 22.9%±8.0% (14.1%-38.6%) after traction, which were further improved to 45.4%±14.9% (29.0%-69.0%) and 33.6%±8.6% (23.3%-49.3%) at post-operation without significant correction loss during 35.6±14.2 (24-72) months follow-up. After traction, the spinal cord function improved to grade D in 4 patients and grade E in 12 patients. At the last follow-up, the spinal cord functions were grade E in 15 patients and grade C in 1 patient. No neurologic monitor events occurred during operation. One patient suffered from transient left brachial plexus after operation. Further, proximal hook loosening was observed in 2 patients during follow-up. The spinal cord function was ASIA grade C pre-operatively in one patient, who recovered to ASIA grade E after operation and significantly deteriorated to ASIA C at 4 years follow-up.Conclusion:The correction of spinal kyphoscoliosis was satisfactory in this cohort. Preoperative HGT followed by posterior spinal correction surgery is an effective and safe procedure in treating neurological deficits secondary to focal angular kyphosis in the upper thoracic spine.

Objective To explore the feasibility and efficacy of posterior minimally invasive scoliosis surgery in Lenke 5C adolescent idiopathic scoliosis (AIS).Methods From November 2012 to March 2014,a total of 16 patients underwent posterior minimally invasive scoliosis surgery assisted by O-arm three-dimensional CT navigation were included.There were 14 female and 2 male,with an average age of (16.7± 1.6) years (ranged from 14 to 18 years).The mean Cobb angles of lumbar and thoracic curve were 48.7°±5.6°and 24.1°±5.4°,respectively.Results 16 patients were successfully completed the operation,the average operation time was (246±89) min,the average intraoperative blood loss was (192± 105) ml,and the fusion level was 4.9±0.5 on average.A total of 155 screws were inserted in the 16 patients,with a mean implant density of 98.9％±4.9％.All the patients were followed up for (26.4±3.9) months on average.The following radiographic parameters were evaluated before surgery,immediately after surgery and at the last follow-up:curve magnitude,apical vertebral translation (AVT),apical vertebral rotation (AVR),trunk shift,thoracic kyphosis (TK),thoracolumbar kyphosis (TLK),lumbar lordosis (LL) and sagittal vertical axis (SVA).The accuracy of pedicle screw placement was assessed according to postoperative CT scans.SRS-22 scores and complications were also recorded during the follow-up.Immediately after surgery,the correction rate of main lumbar curve was 80.1％±8.3％,and thoracic curve was 59.3％±8.7％,and a obvious improvement was noted in terms of AVT,AVR,trunk shift and TLK.At the last follow-up,except the increase of SVA from (-27.6± 19.5) mm to (-12.3±6.6) mm,no obvious changes of AVT,AVR,trunk shift,TK,TLK and LL were observed during the follow-up.According to CT evaluation,the satisfactory rate of pedicle screw placement was 94.2％,while the perforation rate was 5.8％ (9/155).Fusion across the facet joint were satisfactory.In SRS-22 assessment,the mean scores of functional,pain,self-image,mental state and satisfaction were (4.3 ± 0.5) points,(4.7 ± 0.6) points,(4.2 ± 0.7) points,(4.2 ± 0.5)points and (4.4 ± 0.6) points.No wound infection,implant failure and neurologic complications were found after surgery.Conclusion Wiltse approach assisted by O-arm three-dimensional CT navigation has the characteristics of small injury,less bleeding,high accuracy placement of pedicle screws and high self-satisfaction of patients.It is a feasible,safe and effective way to treat Lenke 5C AIS.

Objective: To illustrate the surgical strategy of sequential correction in degenerative lumbar scoliosis (DLS) with type C coronal imbalance, and to evaluate the clinical outcomes and advances of sequential correction technique. Methods: Twelve patients (2 males and 10 females) applying sequential correction technique from January 2015 to August 2017 were retrospectively reviewed. The ages of the cohort ranged 48-74 years and the average value was 52.3±8.4 years. The sequential correction technique was mainly applied in 3 steps: correction of local kyphoscoliosis with satellite rod on convex side of lumbar spine; correction of lumbosacral curve with L ₄-S₁ Intervertebral fusion and satellite rod on convex side of lumbosacral spine; correction of global deformity with bilateral long rods. The coronal parameters including Cobb angle and distance between C₇ plumb line and center sacral vertical line (C₇PL-CSVL), and the sagittal parameters including global kyphosis (GK) and sagittal vertical axis (SVA) were assessed at pre-operation, post-operationand last follow-up. The quality of life was evaluated using SF-36 questionnaire, and paired t test was used for the statistical analysis. Results: The average follow-up period was 16.7±4.8 months. The Cobb angles at pre-operation and post-operation were 59.6°±18.7° and 25.6°±12.4° (t=3.705, P<0.001), respectively. At last follow-up, the average Cobb angle was 27.5°±13.0°, and there was no significant loss of correction (t=0.366, P=0.718). Post-operative C₇PL-CSVL changed from 48.5±17.2 mm to 9.7±4.3 mm (t=5.842, P<0.001), of which the average value was 10.1±4.5 mm at last follow-up (t=0.223, P=0.826). At post-operation, 11 patients were with type A coronal imbalance, and 1 patient was still with type C coronal imbalance. The scores of bodily pain, general health, and social functioning were 8.4±1.9, 78.1±9.4 and 76.7±8.4 at pre-operation, 10.2±2.0 (t=2.260, P=0.034) , 89.5±7.6 (t=3.267, P=0.004) and 84.5±9.3 (t=2.156, P=0.042) at post-operation. In addition, there was no implant-related complications during follow-up. Conclusion The sequential correction technique could be well used in adult degenerative lumbar scoliosis patients with type C coronal imbalance, which can simplify the surgical procedure, decrease the rates of post-operative coronal imbalance, and obtain rigid internal fixation.

Objective: To investigate the efficacy and safety of Ponte osteotomy and sequential correction technique with satellite rod construction in the treatment of severe rigid thoracic scoliosis. Methods: A total of 32 patients (12 male, 20 female) with severe rigid thoracic scoliosis (Cobb angle>100°) who underwent posterior Ponte osteotomy and sequential correction technique with satellite rod construction between October 2012 and October 2016 and with more than 2 years follow-up were retrospectively reviewed. Major curve Cobb angle, apex vertebral translation, trunk shift, thoracic kyphosis and lumbar lordosis were measured through standing posterior-anterior X-ray preoperatively, postoperatively and at the final follow-up. The duration of operation, blood loss and complications were recorded. SRS-22 questionnaire was used to evaluate the clinical outcomes. Results: The average age was 21.3±10.8 years (range from 17 to 46 years). The mean preoperative major curve Cobb angle was 117.8°±9.8°(range from 104° to 131°) with a mean flexibility of 13.9% and the mean thoracic kyphosis was 65.5°±18.7° (range from 48° to 87°). The mean duration of operation was 267.4±42.3 min and the mean blood loss was 895.4±103.1 ml. The mean fused levels ranged from T2 to L4 with a mean 13.3±2.4 fused segments. The mean implant density was 62.1%±8.8%. Ponte osteotomy was performed in 4-9 segments which was 6.1±1.9 segments in average. The coronal main curve was corrected to 54.4°±10.9° with a mean correction rate of 53.9%±9.3% and the mean thoracic kyphosis was corrected to 35.6°±12.0°, which were both significantly improved. The average follow-up time was 34.3±8.9 months. At the last follow-up, the mean coronal main curve was 53.1°±1.9° with a mean correction loss of 1.3° and the thoracic kyphosis was 36.7°±11.4°. There were no neurological deficit or implant failure postoperatively and follow-up. Conclusion Ponte osteotomy followed by sequential correction technique with satellite rods construction was safe and effective which could achieve satisfactory correction rate and less correction loss during the longitudinal follow-up in the treatment of severe rigid thoracic scoliosis.

Objective:To compare the incidence of intraoperative neurological complications during correction surgery of spinal deformities in patients with or without rotatory subluxation (RS), and to analyze the correlation between RS and intraoperative neurological complications.Methods:From January 2012 to August 2017, a total of 37 patients with RS undergoing correction surgery, whom was excluded with preoperative spinal traction or three-column osteotomy during operation were retrospectively reviewedin our hospital. Thirty-seven patients without RS undergoing correction surgery were included asthe control group. The radiographic parameters included Cobb angle of main curve, coronal trunk balance (CTB) which was the distance between C 7 plumb line and center sacral vertical line, global kyphosis (GK), sagittal vertical axis (SVA), RS at coronal plane (CRS), RS at sagittal plane (SRS) and axial rotation (AR). The abnormal intraoperative neurophysiological monitoring events and positive wake-up test were recorded. Results:The mean age was 42.4±17.9 years (12-74 years) in the RS group and 42.7±18.3 years (12-74 years) in the control group( t=0.0713, P=0.943). The mean preoperative Cobb angle of main curve, CTB, GK, and SVA was 75.4°±29.7°, 38.4±28.4 mm, 52.8°±25.2°, and 40.3±36.8 mm respectively in the RS group, which was 75.1°±27.6°( t=0.045, P=0.964), 34.8±24.4 mm( t=0.584, P=0.560), 49.8°±22.5°( t=0.540, P=0.591), and 38.7±25.3 mm ( t=0.219, P=0.828) respectively in the control group. There was no significant difference between the two groups among the above preoperative index. Significant improvements in Cobb angle of main curve, CTB, GK, SVA,CRS, SRS and ARA were found between preoperation and postoperation ( P<0.05 for all), while no significant correction loss was observed during follow-up ( P>0.05 for all). There were 6 patients (16.2%) in the RS group and 4 patients (10.8%) in the control group with preoperative neurological deficit of Frankel grade D ( F=0.463, P=0.496). The abnormal intraoperative neurophysiological monitoring events were observed in 5 patients (13.5%) of the RS group and 1 patient (2.7%) of the control group ( F=2.902, P=0.088). Positive wake-up test was found in 2 patients of RS group (5.4%) ( F=2.056, P=0.493). Conclusion:Patients with RS had higher risks of preoperative neurological deficit, abnormal intraoperative neurophysiological monitoring events and deteriorative neurological deficit at postoperation. The RS at preoperation may be a risk factor for intraoperative neurological deficit.

Objective:To evaluate the safety and efficacy of one-stage posterior-only jumping hemivertebra (HV) resection combined with respective short fusions in the treatment of congenital scoliosis (CS) caused by multiple HVs.Methods:All of 13 consecutive patients with multiple HVs treated surgically from January 2010 to December 2017 were retrospectively reviewed, including 4 males and 9 females with a mean age of 3.7±1.2 years. One child had 4 HVs, and the rest had 2 HVs. The responsible HVs causing local scoliosis/kyphosis deformity or coronal plane deviation were selected as the target of resection. The distal HV was removed firstly and then the proximal one was resected; both of the fixation vertebraes were horizontalized during surgery. The clinical and imaging data of the children before the initial operation, immediately after the operation and at the latest follow-up were collected, and the short-term and long-term complications related to surgery were recorded. The data were evaluated on the whole-standing spine anteroposterior and lateral films, including the corrections of proximal and distal main curves, coronal balance, local kyphosis, and the improvement of spinal growth height (upper and lower internal fixation length, T 1-S 1 length). At the same time, the re-progression of coronal and sagittal deformities of the spine during growth was recorded (coronal decompensation: emerging postoperative curve progression more than 20°; kyphosis progression: kyphosis aggravation between upper and lower internal fixation more than 40°) and internal-fixation-related complications (screw cutting, screw malposition) were recorded. Results:Dual HVs were resected in each child, of which 8 (61.5%) were located on contralateral side of the spine, and 5 (38.5%) were located on ipsilateral side of the spine. The follow-up time was 6.2±3.3 years (range 2.0-10.5 years) after surgery. The Cobb angles of proximal and distal main curves were 36.7°±11.8° and 35.2°±7.8° respectively before surgery and were corrected to 9.7°±6.6° and 6.1°±4.1° respectively after surgery ( F=31.249, F=93.83, P< 0.001) ( t=6.888, t=10.954, P<0.001), and the correction rates was 73.6%±19.6% and 82.7%±11.7%, respectively. They were maintained at 14.3°±5.4° and 8.0°±4.6° at the latest follow-up, showing the correction rates loss of 15.8%±26.9% and 6.9%±7%, respectively. The coronal balance improved from 17.2±14.8 mm pre-operatively to -0.2±15.7 mm postoperatively ( t=2.703, P=0.008), and it remained at 0±18.4 mm at the final follow-up ( F=4.137, P=0.024). The T 1-S 1 length was corrected to 273.8±27.3 mm postoperatively, slightly increased compared with pre-operation 256.3±24.0 mm, ( t=0.680, P=0.527), and significantly increased to 333.2±33.4 mm at the latest follow-up ( t=2.986, P<0.001; F=6.704, P=0.003). Seven patients had local kyphosis before operation, which was significantly improved from 32.2°±13.6° to 6.1°±9.8° with a correction rate of 93.4%±27.0% after surgery ( t=3.355, P=0.004), which showed no significant loss of correction at the latest follow-up (5.4°±10.4°) ( F=11.187, P=0.002). Six patients (46.2%) developed coronal decompensation (Curve magnitude >20 °), with an average of 21.7°±1.9°. Two cases (15.4%) had progressive kyphosis between the thoracic regional internal fixations at 3 months after surgery, which were 68° and 58° respectively. After bracing, both coronal decompensation and sagittal kyphosis were improved. At the last follow-up, the coronal decompensation was improved to 14.7±8.9° and the kyphosis was alleviated to 55° and 46°, respectively. Conclusion:Posterior-only skipping hemivertebra resection and short fusion is a safe, effective procedure yielding significantly improvement of the growth imbalance and reginal spinal deformities of CS with multiple HVs. The mid-term follow-up results showed that the progress of the scoliosis was common during the growth period, which could be further controlled by supplementary brace treatment.

Objective: To evaluate the efficiency of preoperative Halo-gravity traction (HGT) in the treatment of severe kyphoscoliosis secondary to neurofibromatosis type Ⅰ (NF1). Methods: A retrospective review was conducted on patients with severe kyphoscoliosis secondary to NF1 at Department of Spinal Surgery, Drum Tower Hospital, Medical School of Nanjing University between July 2007 and May 2016. A total of 29 patients including 17 males and 12 females were finally enrolled and the age was (13.7±2.9) years. The Cobb angle of major coronal curve and global kyphosis were measured before and after HGT. The forced vital capacity (FVC)and forced expiratory volume in 1 second (FEV₁) before and after traction were also recorded. The paired t test was used for comparison analysis. Results: The average maximum traction weight of HGT was (12.2±2.8) kg and the traction duration was (10.2±6.6) weeks. The coronal Cobb angle before HGT was (87.5±36.5)°, which improved to (68.4±25.9)° after HGT with a correction rate of (21.9±12.1)% (t=9.14, P<0.001); the average global kyphosis before HGT was (79.1±27.1)°, which improved to (59.9±19.4)° after HGT and the correction rate was (20.2±14.1)% (t=8.55, P<0.001). One patient had transient brachial plexus palsy which resolved completely after reducing the traction weight. After HGT treatment, FVC increased from (0.83±0.16) L to (0.89±0.19) L (t=1.48, P=0.12) and FEV₁ increased from (0.72±0.16) L to (0.78±0.20) L (t=0.49,P=0.63). FVC predicted and FEV₁ predicted improved from (42.9±20.1)% and (40.6±19.6)% to (46.9±20.5)% (t=0.98,P=0.33) and (43.6±25.8)% (t=1.24,P=0.22), respectively. Conclusion Preoperative HGT in the treatment of severe kyphoscoliosis secondary to NF1 can improve spinal deformity and pulmonary function to some extent, which can further benefit the patients by improving their surgical tolerance.

Objective: To evaluate the radiographic and clinical outcomes of Scoliosis Research Society(SRS)-Schwab Grade IV osteotomy in type I congenital kyphosis. Methods: All of 28 patients with type I congenital kyphosis who underwent SRS-Schwab Grade 4 osteotomy from June 2015 to June 2017 were retrospectively reviewed,including 21 males and 7 females aged 10 to 28 years old, with an average of 13.6±8.5 years. On standing wholespinal X-rays at pre-operation, post-operation and each follow-up, global kyphosis(GK), thoracic kyphosis(TK), lumbar lordosis(LL) and sagittal vertical axis(SVA) were measured. The intra-operative and post-operative complications were recorded for each patient. The Scoliosis Research Society-22 questionnaires(SRS-22) and visual analog scale(VAS) for back pain were collected from patients elder than 12 years old at pre-operation and last follow-up. The comparison analysiswasperformed by paired samples t test. Results: At pre-operation, the GK, TK, LL and SVA were 47.0°±4.9°, 16.8°±3.7°, 36.6°±7.7°, (-31.9±13.6) mm, respectively. At 3 months post-operation, the average values improved to 3.7°±2.3°, 36.8°±4.0°, 46.5°±4.4°, 4.0±19.1 mm, respectively. Significant differences were found in all parametersbetween pre- and post-operation. The post-operative follow-up was 12 to 24 months, with an average of 13.2±5.2 months. At the last follow-up, the GK, TK, LL and SVA were 4.0°±2.4°, 38.0°±6.0°, 45.9°±5.4°, 7.6±15.3 mm, and no significant correction loss was found during follow-up. The scores of each domain of SRS-22 questionnaire improved at different level during follow-up, of which the improvement in self-imagewas statistically significant (P<0.001). The scores of VAS for back pain improved significantly after operation (P<0.001). One patient hadabnormal intra-operative monitoringwhile no neurological defectwas detected at post-opera tion. Proximal junctional kyphosis occurred in 2 patients at 3 months follow-up while no patients needed revision surgery. There wereno implant-related complicationsduring follow-up. Conclusion The SRS-Schwab Grade 4 osteotomycould provide satisfying correction with relatively low rates of complications in type I congenital kyphosis. Thus, the SRS-Schwab Grade IV osteotomy is a safe strategy for type I congenital kyphosis.

Objective:To analyze the radiographic improvements after Halo-gravity traction in severe kyphoscoliosis patientswith type III spinal cord on preoperative apex MRI, and to assess the clinical outcomes and surgical safety of Halo-gravity traction in this cohort.Methods:A total of 47 severe thoracic kyphoscoliosis patients with type III spinal cord on preoperative apex MRI who underwent preoperative Halo-gravity traction followed by one-stage posterior spinal fusion from February 2019 to June 2021 in the Nanjing Drum Tower Hospital were retrospectively analyzed. There were 18 males and 29 females with an average age of 22.5±12.8 years (range, 9-60 years). The average duration of traction was 7.4±3.9 weeks (range, 4-16 weeks). Radiographic parameters were measured including the coronal Cobb angle, distance between C 7 plumb line and center sacral vertical line (C 7PL-CSVL), sagittalglobal kyphosis (GK) and sagittal vertical axis (SVA) atpre-traction, post-traction and post-operation, respectively. The traction correction rate was measured as "traction degree before traction-traction degree after traction)/traction degree before traction" and the surgical correction rate was represented as "traction degree before traction-postoperative degree)/ traction degree before traction". The Frankel scoring system was used for the evaluation of neurological status at pre-traction, post-traction and post-operation. Results:All of 47 patients underwent the Halo-gravity traction and posterior spinal correction surgery. The C 7PL-CSVL was 35.7±16.9 mm at initial visit. At post-operation, C 7PL-CSVL was improved to 22.0±13.7 mm ( t=13.75, P<0.001), and the improvement rate was 39.9%±15.5%. The GK was 110.9°±22.1° at initial visit, which was improved to 84.1°±19.9° ( t=8.84, P<0.001) after Halo-gravity traction with an average correction of 23.7%±8.9%. At post-operation, GK was improved to 65.3°±19.3° ( t=10.63, P<0.001), and the improvement rate were 40.1%±20.7%. The SVA was 43.8±19.5 mm at initial visit. At post-operation, SVA was improved to 21.1±14.9 mm ( t=10.32, P<0.001), and the improvement rate were 53.1%±27.0%. A total of 14 patients showed neurological deficits of lower limbs at pre-traction, of which 8 patients had significant neurological improvement after Halo gravity traction; 3 patients had significant neurological improvement after surgery, and the remaining 3 patients had no significant neurological improvement during treatment. No new neurological deficits were observed after Halo-gravity traction or surgery. Conclusion:For severe kyphoscoliosis patients with type III spinal cord on preoperative apex MRI, the Halo-gravity traction could effectively correct the deformity, improve neurological function, enhance the tolerance of spinal cord to surgery and reduce the risk of intraoperative iatrogenic neurological deficit.