OBJECTIVE To evaluate the cost-effectiveness of brivaracetam （BRV） versus perampanel （PER） as add-on therapy for drug-resistant focal epilepsy in adults from the perspective of the Chinese healthcare system.METHODS A Markov model was established to simulate the progression of drug-resistant focal epilepsy in adults， with a simulation cycle of 5 months， a time horizon of 44 years， and a discount rate of 4.5%. Clinical data required for the model were derived from the phase Ⅲ clinical trial of BRV and a post hoc analysis of PER； cost data and utility data were obtained from Yaozh and related literature. The willingness-to-pay （WTP） threshold was set at twice China’s 2025 per capita gross domestic product （GDP） [199 330 yuan per quality-adjusted life year （QALY）]， and a cost-effectiveness analysis was adopted to compare the cost-effectiveness of the regimens. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to confirm the stability of the base-case analysis conclusions.RESULTS The incremental cost-effectiveness ratio （ICER） of BRV 50 mg/d as an add-on therapy versus PER 8 mg/d was 44 823.08 yuan/QALY， which was below the WTP threshold； the ICER of BRV 200 mg/d versus PER 12 mg/d was 238 783.00 yuan/QALY， which was above the WTP threshold. In the one-way sensitivity analysis， the direct medical cost of seizures ≥53 times/year and the health utility value of a seizure-free state per year had a relatively large impact on the two ICER results mentioned above， respectively. Probabilistic sensitivity analysis indicated that the above results were robust.CONCLUSIONS For the selection of add-on therapy for drug-resistant focal epilepsy in adults in China， when twice China’s per capita GDP is used as the WTP threshold， BRV 50 mg/d has a cost-effectiveness advantage over PER 8 mg/d， whereas BRV 200 mg/d not have a cost-effectiveness advantage over PER 12 mg/d.

Objective To explore the effects of different grinding amounts of articular processes on the biomechanical stability and inflammatory response of lumbar spine during percutaneous foraminoscopic surgery(PTED).Methods A total of 195 patients with lumbar disc herniation(LDH)in our hospital were selected for prospective study from January 2018 to October 2020,and they were divided into three groups by randomized numerical table method,each with 65 cases,and all of them were implemented PTED.Patients with intraoperative upper joint process grinding＜33％were treated as a small group,patients with intraoperative grinding＜33％～50％were treated as a medium group,and patients with＞50％were treated as a large group.The surgery-related indexes of the three groups of patients were observed,as well as the inflammatory indexes[interleukin-6(IL-6),tumor necrosis factor-alpha(TNF-α)],biomechanical stability,and joint functional recovery scores at different time points before and after surgery.Results The operation time and intraoperative bleeding were(61.32±7.86)min and(11.85±1.10)ml in the small group,(70.06±8.53)min and(14.32±2.21)ml in the medium group,and(74.47±10.00)min and(19.86±3.00)ml in the large group,and the differences among the three groups were statistically significant(P＜0.05).Serum IL-6 and TNF-α were(6.10±1.12)pg/ml and(8.21±1.87)ng/L in the small group 3d postoperatively,and(3.27±0.58)pg/ml and(4.32±1.00)ng/L in the discharge group,and in the medium group 3d postoperatively,they were(6.68±1.35)pg/ml and(9.00±1.20)ng/L at discharge and(4.10±0.63)pg/ml and(6.85±1.28)ng/L at discharge,respectively,and(7.32±1.00)pg/ml and(10.57±1.28)ng/L in the massive group at 3d postoperatively and(4.57±0.49)pg/ml and(8.14±1.35)ng/L at discharge,and the difference between the three groups was statistically significant(P＜0.05);the serum lumbar lordosis angle,lumbar flexion,and lumbar stability scores were(42.28±2.12)°,(1.86±0.36)cm,and(10.52±2.01)° at 1 month postoperatively,and(42.11±1.97)°,(1.87±0.52)cm,and(10.63±1.96)° at 1 year postoperatively,respectively,for the small group,and(40.86±1.89)°,(1.72±0.28)cm,(10.63±2.15)scores,(39.15±2.11)°,(1.60±0.42)cm,(12.11±1.63)scores for the medium group,respectively,1 month postoperatively in the large volume group,(39.01±2.35)°,(1.61±0.29)cm,(11.20±2.75)scores,and(38.11±2.32)°,(1.43±0.33)cm,(13.24±1.52)scores at 1 year postoperatively,respectively,and the difference between the three groups were statistically significant(P＜0.05).Conclusion PTED treatment of LDH can reduce the amount of grinding of the superior articular process during surgery,reduce operative time and intraoperative bleeding,alleviate inflammatory response,and achieve good short-and medium-term lumbar function and joint stability.

Objective:To investigate the clinical significance and inducing factors of abnormal intraoperative neurophysiological monitoring (IONM) signals during surgery for cervical degenerative diseases.Methods:A retrospective analysis was performed on 586 patients who underwent cervical degenerative disease surgery with IONM at the Department of Orthopedics, The First Affiliated Hospital of Soochow University, from April 2015 to April 2024. Surgical approaches included 380 anterior spinal canal decompression and fusion procedures, 154 posterior spinal canal decompression and fusion procedures (including single-door laminoplasty, total laminectomy, and hemilaminectomy), and 52 combined anterior-posterior surgeries. The multimodal IONM protocol employed transcranial electrical stimulation motor evoked potentials (TES-MEP) and cortical somatosensory evoked potentials (CSEP), combined with electromyography (EMG). Bilateral deltoid muscles, thenar/hypothenar muscles and abductor hallucis muscles were monitored in all patients. Intraoperative MEP, SEP, and EMG results were recorded to analyze the causes of abnormal signals, intraoperative response strategies, and postoperative neurological function and outcomes. Fourfold table chi-square tests were used to analyze factors possibly associated with IONM alerts.Results:Among the 586 cervical surgeries, 17 cases (2.9%) exhibited abnormal IONM signals. These included 4 cases of anterior cervical discectomy and fusion (ACDF), 4 cases of anterior cervical corpectomy and fusion (ACCF), and 2 cases of combined anterior-posterior surgeries for cervical spondylotic myelopathy; and 5 posterior surgeries and 2 anterior ACCF procedures for ossification of the posterior longitudinal ligament (OPLL). The rate of abnormal IONM signals was significantly higher in patients with maximum spinal cord compression (MSCC)>60% (5.8%, 12/208) than in those with MSCC≤60% (χ 2=9.417, P=0.002); in patients with intraoperative hypotension during posterior surgery (mean arterial pressure reduction>20% from baseline, cumulative duration>20 min), the abnormal IONM rate was 22.2% (6/27), which was significantly higher than that in patients without intraoperative hypotension (χ 2=33.542, P<0.001); in patients who underwent calcified tissue removal during anterior surgery, the abnormal IONM rate was 9.3% (5/54), which was significantly higher than that in patients without calcified tissue removal (χ 2=13.162, P=0.003). Thus, MSCC>60%, intraoperative hypotension during posterior surgery, and calcified tissue removal during anterior surgery may be inducing factors for abnormal IONM signals. Among the 17 patients with monitoring abnormalities, 8 cases showed no significant improvement after corresponding intraoperative treatments, and 7 of these 8 cases experienced varying degrees of muscle strength decline and sensory numbness immediately after surgery; 9 cases showed partial or complete recovery of signals, among which 8 cases had no new-onset neurological impairment after surgery, and 1 case developed unilateral upper limb grip strength decline. IONM demonstrated a sensitivity of 0.8750 and specificity of 0.8889. Conclusions:Multimodal IONM can detect electrophysiological abnormalities of spinal cord nerve function during cervical degenerative disease surgery, providing real-time warning of potential nerve damage during the operation. The proportion of abnormal IONM signals is relatively high in cases with MSCC>60%, intraoperative hypotension during posterior cervical surgery, or calcified tissue removal during anterior cervical surgery.

Objective To explore the effects of different grinding amounts of articular processes on the biomechanical stability and inflammatory response of lumbar spine during percutaneous foraminoscopic surgery(PTED).Methods A total of 195 patients with lumbar disc herniation(LDH)in our hospital were selected for prospective study from January 2018 to October 2020,and they were divided into three groups by randomized numerical table method,each with 65 cases,and all of them were implemented PTED.Patients with intraoperative upper joint process grinding＜33％were treated as a small group,patients with intraoperative grinding＜33％～50％were treated as a medium group,and patients with＞50％were treated as a large group.The surgery-related indexes of the three groups of patients were observed,as well as the inflammatory indexes[interleukin-6(IL-6),tumor necrosis factor-alpha(TNF-α)],biomechanical stability,and joint functional recovery scores at different time points before and after surgery.Results The operation time and intraoperative bleeding were(61.32±7.86)min and(11.85±1.10)ml in the small group,(70.06±8.53)min and(14.32±2.21)ml in the medium group,and(74.47±10.00)min and(19.86±3.00)ml in the large group,and the differences among the three groups were statistically significant(P＜0.05).Serum IL-6 and TNF-α were(6.10±1.12)pg/ml and(8.21±1.87)ng/L in the small group 3d postoperatively,and(3.27±0.58)pg/ml and(4.32±1.00)ng/L in the discharge group,and in the medium group 3d postoperatively,they were(6.68±1.35)pg/ml and(9.00±1.20)ng/L at discharge and(4.10±0.63)pg/ml and(6.85±1.28)ng/L at discharge,respectively,and(7.32±1.00)pg/ml and(10.57±1.28)ng/L in the massive group at 3d postoperatively and(4.57±0.49)pg/ml and(8.14±1.35)ng/L at discharge,and the difference between the three groups was statistically significant(P＜0.05);the serum lumbar lordosis angle,lumbar flexion,and lumbar stability scores were(42.28±2.12)°,(1.86±0.36)cm,and(10.52±2.01)° at 1 month postoperatively,and(42.11±1.97)°,(1.87±0.52)cm,and(10.63±1.96)° at 1 year postoperatively,respectively,for the small group,and(40.86±1.89)°,(1.72±0.28)cm,(10.63±2.15)scores,(39.15±2.11)°,(1.60±0.42)cm,(12.11±1.63)scores for the medium group,respectively,1 month postoperatively in the large volume group,(39.01±2.35)°,(1.61±0.29)cm,(11.20±2.75)scores,and(38.11±2.32)°,(1.43±0.33)cm,(13.24±1.52)scores at 1 year postoperatively,respectively,and the difference between the three groups were statistically significant(P＜0.05).Conclusion PTED treatment of LDH can reduce the amount of grinding of the superior articular process during surgery,reduce operative time and intraoperative bleeding,alleviate inflammatory response,and achieve good short-and medium-term lumbar function and joint stability.

Objective:To investigate the clinical significance and inducing factors of abnormal intraoperative neurophysiological monitoring (IONM) signals during surgery for cervical degenerative diseases.Methods:A retrospective analysis was performed on 586 patients who underwent cervical degenerative disease surgery with IONM at the Department of Orthopedics, The First Affiliated Hospital of Soochow University, from April 2015 to April 2024. Surgical approaches included 380 anterior spinal canal decompression and fusion procedures, 154 posterior spinal canal decompression and fusion procedures (including single-door laminoplasty, total laminectomy, and hemilaminectomy), and 52 combined anterior-posterior surgeries. The multimodal IONM protocol employed transcranial electrical stimulation motor evoked potentials (TES-MEP) and cortical somatosensory evoked potentials (CSEP), combined with electromyography (EMG). Bilateral deltoid muscles, thenar/hypothenar muscles and abductor hallucis muscles were monitored in all patients. Intraoperative MEP, SEP, and EMG results were recorded to analyze the causes of abnormal signals, intraoperative response strategies, and postoperative neurological function and outcomes. Fourfold table chi-square tests were used to analyze factors possibly associated with IONM alerts.Results:Among the 586 cervical surgeries, 17 cases (2.9%) exhibited abnormal IONM signals. These included 4 cases of anterior cervical discectomy and fusion (ACDF), 4 cases of anterior cervical corpectomy and fusion (ACCF), and 2 cases of combined anterior-posterior surgeries for cervical spondylotic myelopathy; and 5 posterior surgeries and 2 anterior ACCF procedures for ossification of the posterior longitudinal ligament (OPLL). The rate of abnormal IONM signals was significantly higher in patients with maximum spinal cord compression (MSCC)>60% (5.8%, 12/208) than in those with MSCC≤60% (χ 2=9.417, P=0.002); in patients with intraoperative hypotension during posterior surgery (mean arterial pressure reduction>20% from baseline, cumulative duration>20 min), the abnormal IONM rate was 22.2% (6/27), which was significantly higher than that in patients without intraoperative hypotension (χ 2=33.542, P<0.001); in patients who underwent calcified tissue removal during anterior surgery, the abnormal IONM rate was 9.3% (5/54), which was significantly higher than that in patients without calcified tissue removal (χ 2=13.162, P=0.003). Thus, MSCC>60%, intraoperative hypotension during posterior surgery, and calcified tissue removal during anterior surgery may be inducing factors for abnormal IONM signals. Among the 17 patients with monitoring abnormalities, 8 cases showed no significant improvement after corresponding intraoperative treatments, and 7 of these 8 cases experienced varying degrees of muscle strength decline and sensory numbness immediately after surgery; 9 cases showed partial or complete recovery of signals, among which 8 cases had no new-onset neurological impairment after surgery, and 1 case developed unilateral upper limb grip strength decline. IONM demonstrated a sensitivity of 0.8750 and specificity of 0.8889. Conclusions:Multimodal IONM can detect electrophysiological abnormalities of spinal cord nerve function during cervical degenerative disease surgery, providing real-time warning of potential nerve damage during the operation. The proportion of abnormal IONM signals is relatively high in cases with MSCC>60%, intraoperative hypotension during posterior cervical surgery, or calcified tissue removal during anterior cervical surgery.