Objective:To investigate the risk factors for refracture after percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compression fracture (OVCF).Methods:A retrospective cohort study was conducted on the clinical data of 149 OVCF patients who were admitted to the First Affiliated Hospital of Soochow University from June 2019 to June 2022, including 21 males and 128 females, aged 56-97 years [(73.2±8.7)years]. Initial surgical segments included T 7 in 1 patient, T 8 in 10, T 9 in 6, T 10 in 6, T 11 in 19, T 12 in 28, L 1 in 38, L 2 in 18, L 3 in 11, L 4 in 7 and L 5 in 5. Patients were divided into refracture group ( n=32) and non-refracture group ( n=117) according to whether they had postoperative refracture after PKP. Refractured surgical segments included T 8 in 2 patients, T 9 in 2, T 11 in 4, T 12 in 5, L 1 in 7, L 2 in 4, L 3 in 6, and L 5 in 2. The age, gender, underlying diseases (hypertension, diabetes), body mass index (BMI), preoperative bone mineral density (BMD), smoking history, drinking history, follow-up time, preoperative visual analogue scale (VAS), and preoperative Oswestry dysfunction index (ODI) of the two groups were recorded. Preoperative paravertebral muscle-related parameters of the two groups were calculated including cross-sectional area of bilateral psoas, bilateral erector spinae, bilateral multifidus, and vertebral bodies, paravertebral muscle mass, and vertebral bone quality (VBQ) score. Univariate analysis was performed to evaluate the correlation between the fore-mentioned indicators and postoperative refracture after PKP in OVCF patients. Multivariate logistic regression analysis was employed to identify the independent risk factors for postoperative refracture after PKP in OVCF patients. Results:Univariate analysis revealed that there was certain correlation of BMI, preoperative BMD, cross-sectional area of bilateral psoas, bilateral erector spinae, bilateral multifidus, paravertebral muscle mass and VBQ score with postoperative refracture after PKP in OVCF patients ( P<0.01), while no correlation was found between age, gender, hypertension, diabetes, smoking history, drinking history, follow-up time, preoperative VAS, preoperative ODI, or cross-sectional area of vertebral bodies and postoperative refracture after PKP in OVCF patients ( P>0.05). Multivariate logistic regression analysis showed that preoperative BMD ≤-3.4 SD ( OR=0.27, 95% CI 0.09, 0.80, P<0.05), paravertebral muscle mass ≤281.2% ( OR=0.98, 95% CI 0.97, 0.99, P<0.01) and VBQ score ≥4.8 points ( OR=4.41, 95% CI 1.18, 16.44, P<0.05) were significantly correlated with postoperative refracture after PKP in OVCF patients. Conclusion:Preoperative BMD ≤-3.4 SD, paravertebral muscle mass ≤281.2%, and VBQ score ≥4.8 points are the independent risk factors for refracture after PKP in OVCF patients.

Objective To observe the effect of ultrasound-guided iliopsoas plane block(IPB)on the quality of postoperative recovery in patients undergoing hip arthroplasty.Methods Sixty patients who underwent hip arthroplasty were selected,37 males and 23 females,aged 40-79 years,BMI 18-30 kg/m2,ASA physical status Ⅰ-Ⅲ.The patients were divided into two groups by random number table method:the iliopsoas plane block group(group IPB)and the femoral nerve block(FNB)group(group FNB),30 pa-tients in each group.Before anesthesia induction,IPB was performed with 0.5%ropivacaine 10 ml and lat-eral femoral cutaneous nerve block was performed with 0.5%ropivacaine 5 ml in group IPB.And FNB was performed with 0.5%ropivacaine 10 ml and lateral femoral cutaneous nerve block was performed with 0.5%ropivacaine 5 ml in group FNB.The dosages of propofol,remifentanil,and cis-atracurium during operation were recorded.The quality of recovery-15(QoR-15)scale was evaluated preoperatively and postoperatively 1 day,2 and 3 days.The max VAS(VASmax)pain score and manual muscle test(MMT)score of quadri-ceps muscle were recorded 12,24,and 48 hours after surgery.The time of getting out of bed for the first time,opioid dosage,and patient satisfaction were recorded.The incidence of nerve injury,vascular injury,puncture site infection,and local anesthetic poisoning were recorded.The postoperative complications of diz-ziness,nausea and vomiting,deep vein thromboses,and elirium were also recorded.Results There was no significant difference in the dosage of propofol,remifentanil,and cis-atracurium between the two groups.Compared with group FNB,the QoR-15 scale score in group IPB was significantly higher 1 day,2 and 3 days after operation(P＜0.05).Compared with group FNB,the MMT scores of quadriceps muscle was sig-nificantly higher in group IPB 12 and 24 hours after surgery(P＜0.05),and the first time of getting out of bed was shortened in group IPB(P＜0.05).However,there were no significant differences in the VASmax pain score,MMT score of quadriceps muscle 48 hours after surgery,opioid dosage,and patient satisfaction between the two groups.No nerve block related complications were found in both groups.There were no sig-nificant differences in postoperative complications between the two groups.Conclusion The iliopsoas plane block can improve the quality of postoperative recovery and accelerate the recovery of patients with hip re-placement,and the effect is better than that of femoral nerve block.

With the aging population, the increasing incidence of adult spinal deformity (ASD) associated with osteoporosis (OP) presents new challenges for evaluation and management. Although reasonable and standardized non-surgical treatment remains the first choice in the early stages of this disease, surgical treatment is necessary for patients with severe deformities and significant symptoms to achieve further improvement. Proximal junctional kyphosis/failure (PJK/PJF) is one of the most serious postoperative complications of ASD. Careful and comprehensive preoperative evaluation of bone quality and body sagittal alignment is crucial for the successful implementation of the operation. The Hounsfield unit (HU) based on CT imaging and the vertebral bone quality (VBQ) score based on MRI have proven to be reliable, effective, simple, and widely used in evaluating local vertebral bone quality in recent years. For the evaluation and prediction of PJF after ASD, the bone quality of the upper instrumented vertebra (UIV) can be assessed using HU values to identify high-risk patients and implement preventive measures. The VBQ score is predictive of the incidence of PJK/PJF in patients undergoing ASD surgery, with a high VBQ score being one of the risk factors for PJK/PJF after ASD correction. Patients with high VBQ scores can delay surgery and use anti-osteoporosis drugs before surgery to reduce the occurrence of PJK/PJF. Meanwhile, reasonable and personalized recovery parameters of ASD patients' sagittal sequence can help balance the benefits of efficacy and complications, maximizing the overall benefits. The prevention of PJK/PJF is challenging due to the stress gap between the internal fixation area and the original unfixed tissue area in the postoperative proximal junctional area, which is increasingly significant in OP patients. It is necessary to improve the fixation strength and bone riveting strength of the proximal junction area properly and to gradually decrease the fixed strength in the proximal junctional area to achieve a smooth transition of stress and avoid stress concentration resulting in failure. Relevant strategies include: 1. Enhanced proximal junction fixation, such as vertebral cement-enhanced pedicle screw fixation. 2. Strategies to cushion the stress in the proximal junction, such as Topping-off technology, which includes laminar/transverse hooks, dynamic rods, multi-segment stabilization screws, and multiple ligament-binding straps. 3. Minimally invasive technology can better protect the soft tissues such as the posterior ligament complex and muscles, reduce iatrogenic injury, and thus reduce the incidence of PJK/PJF. Currently, there are many controversies about the optimal treatment for ASD with OP, but the goal is to achieve maximum efficacy while minimizing complications. Additionally, attention should be paid to reasonable and standard anti-osteoporosis treatment in the perioperative period. This paper summarizes the relevant studies used to evaluate PJK/PJF after ASD in patients with OP and reviews the research progress on PJK/PJF prevention strategies, providing reference and ideas for reducing postoperative proximal junctional complications in adult spinal deformity patients with osteoporosis.

Objective:To analyze the risk factors for residual pain after percutaneous kyphoplasty (PKP) for osteoporotic vertebral fractures (OVF).Methods:Retrospectively analyzed were the patients with OVC who had been treated at Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University by single level PKP from January 2020 to December 2021. They were 40 men and 181 women, with an age of (69.6±8.2) years. By the pain score of visual analogue scale (VAS) on the postoperative day 3, they were assigned into 2 groups: a residual pain group (VAS≥4) and a control group (VAS<4). The general demographics, radiographic and surgical related data of the 2 groups were analyzed by single factor analysis, including their gender, age, bone mineral density, body mass index, glucocorticoid usage, follow-up time, duration of symptoms, fracture location, severity of fracture compression, intravertebral cleft, middle column involvement, thoracolumbar fascia injury, anesthesia method, puncture method, volume of bone cement injected, cement-endplates contact, pattern of cement distribution, cement leakage, vertebral height restoration, preoperative cobb angle and correction of cobb angle. The P<0.1 factors screened were further analyzed by the multivariate logistic regression to determine the final variables. Results:In the present study, 19 patients were assigned into the residual pain group and 202 patients the control group. The univariate analysis showed that body mass index ( P=0.059), intravertebral cleft ( P=0.049) and thoracolumbar fascia injury ( P< 0.001) increased the risk for residual pain. The multivariate logistic regression analysis showed that thora-columbar fascia injury was an independent risk factor for residual pain ( OR=6.127, 95% CI: 2.240 to 16.755, P<0.001). Conclusion:Thoracolumbar fascia injury is an independent risk factor for residual pain after PKP for OVF.

Objective To investigate the role of JAK2/STAT3 signaling pathway in regulating the expression and nuclear-cytoplasm translocation of high mobility group box 1 (HMGB1) in early brain injury (EBI) after subarachnoid hemorrhage (SAH).Methods Ninety SD rats were divided into a sham group (15 rats),an SAH group (altogether 45 rats,with 15 ones for each time point of 6 h,1 d,and 3 d),an SAH+AG490 (JAK2/STAT3 inhibitor) group (15 rats) and an SAH+dimethyl sulfoxide (DMSO)group (15 rats).The SAH models in the later 3 groups were established by endovascular perforation;the blood vessels were not perforated in the sham group but the other operations were the same as in the SAH groups.(1) Western blotting was used to detect the expression of HMGB1 and phosphorylated JAK2/STAT3 (p-JAK2/p-STAT3) in the 4 groups (at different time points in the SAH group) and compared the expression changes between the 4 groups after AG490 intervention.(2)Immunofluorescence confocal microscopy was used to detect HMGB1 nuclear translocation in the 4 groups.(3) TUNEL staining was used to detect apoptosis in the 4 groups.(4) Brain water contents and neurobehavioral scores in the 4 groups were measured.Results (1) Western blotting showed that the expression levels ofp-JAK2 and p-STAT3 were significantly increased at 6 h,1 d,and 3 d after SAH,and there were significant differences between the sham group and the SAH group (P＜0.05).HMGB1 total protein,cytoplasmic HMGB1 and nucleus HMGB1 also increased significantly at different time points after SAH,and statistically significant differences existed between the sham group and the SAH group (P＜0.05).The expression levels ofp-JAK2/p-STAT3,HMGB1 and cytoplasm and nucleus HMGB1 in the SAH+AG490 group were significantly lower than in the SAH group and SAH+DMSO group(P＜0.05).(2) The immunofluorescence staining showed that HMGB1 staining was positive in the SAH group while the positive staining of HMGB1 was present mainly in the nucleus but not in the cytoplasm in the sham and SAH+AG490 groups,suggesting that AG490 might inhibit the nucleus-cytoplasm transposition of HMGB1.(3) Compared with the SAH and SAH+DMSO groups,the TUNEL staining positive cells in the SAH+AG490 group were significantly decreased (P＜0.05).(4) Compared with the SAH and SAH+DMSO groups,the brain water contents in the SAH+AG490 group decreased significantly and the neurobehavioral scores increased significantly (P＜0.05).Conclusions JAK2/STAT3 signaling pathway is involved in the pathological process of early brain injury after SAH,and its mechanism may be related to the regulation of HMGB1 expression and nuclear-cytoplasm transposition.The regulation of JAK2/STAT3 may contribute to the neuroprotection dependent of HMGB 1.

Objective To investigate the mechanism of unbalanced expressions of endothelin receptors (ETA/ETB )in cerebral vasospasm (CVS)after subarachnoid hemorrhage (SAH).Methods The rat CVS models were established by injecting autologous blood into the cisterna magna the second time.Basilar artery morphology was observed under light microscope and immunofluorescence staining was conducted to dynamically detect ETA/ETB receptor expression.Results The cross-sectional area of the basilar artery in the SAH model group decreased at 2 d to 3 d,and then gradually returned to normal.ETA receptor expression in endothelial cells of the basilar artery increased at 2 d after SAH,peaked at 3 d and remained increased till 14 d.ETB receptor expression increased significantly in endothelial cells at 3 d,peaked at 7 d and remained the same level till 14 d.Conclusion The results suggest that ETA/ETB receptors play an important role in cerebral vasospasm after SAH.The specific expression differences of ETB receptor subtypes in the brain vascular layers need further study.

Objective To study the dynamic expression and distribution of high mobility group box 1 (HMGB-1)in diffuse axonal injury (DAI)in rats and to clarify its involvement in the inflammatory reaction after DAI in rats,in order to provide new targets for the clinical treatment of DAI.Methods A DAI model was established using a coronal rotation device and evaluated by HE,Glees-Marsland silver staining,and Mallory phosphotungstic acid hematoxylin staining.Immunohistochemistry,Western blot and RT-PCR were used to detect the expression and distribution of HMGB-1 in the cortex of DAI rats at 6 h,1 d,3 d and 7 d.And TUNEL was used to examine the apoptosis of neurons in DAI rats.Results Immunohistochemical results showed that at 6 h and 1 d after DAI,the number of HMGB-1-positive cells decreased,but at 3 and 7 d it began to increase.Western blot also showed that during the early stage after DAI (6 h and 1 d),the level of HMGB-1 protein in the cortex was significantly lower than that in the control group,but at the late stage (3 and 7 d)after DAI it significantly increased compared with that in the control group until 7 d.RT-PCR showed that at 6 h after DAI there was no significant increase in the level of HMGB-1mRNA,but at 1 d there was a slight increase compared with the control group;at 3 and 7 d,it showed an obvious significance.TUNEL staining indicated that the significant neuronal apoptosis appeared as early as 6 h after DAI,and reached the peak at 3 d;it started to decrease at 7 d but still remained at a relatively high level.Conclusion The dynamic expression and distribution of HMGB-1 showed significant changes with the time course after DAI in rats.They decreased at the early stage but increased at the late stage.At the early stage, HMGB-1 is mainly passively released by the necrotic neurons,and at the late stage it may be actively secreted by the active inflammatory cells.HMGB-1 may mediate the post-DAI neural cell apoptosis by inducing the inflammatory reaction.

Objective To investigate the role of AMP-activated protein kinase (AMPK) signal path in cell autophagy activation at early brain injury in rats after subarachnoid hemorrhage (SAH).Methods Adult male SD rats (weighting 300-350 g) were divided into five groups (n=12):sham-operated group,SAH group,and SAH+AICAR group,SAH+Compound C group and SAH+vehicle group.SAH models in the later four groups were established by endovascular perforation technique,and rats in the later three groups were performed left intracerebroventricular injection of AMPK agonist AICAR,AMPK inhibitor Compound C or normal saline 30 min before modeling;animals were subsequently sacrificed at 24 h after modeling.Immunohistochemical method was used to detect the phosphorylated mammalian target of rapamycin (p-mTOR) expression.Expressions of cortex autophagy related proteins LC3,AMPK and phosphorylated AMPK (p-AMPK) were observed by Western blotting.Loeffler's method was used to evaluate the neurologic behavior scores.Results As compared with those in the sham-operated group,the p-AMPK level,p-mTOR expression level and LC3Ⅱ/LC3Ⅰ ratio were significantly increased,while the behavioral deficit scores were significantly lower in the SAH group,with statistical differences (P＜0.05);the p-mTOR mainly expressed at cortex surrounding the hemorrhage areas,and integration areas of deep cortex and brain white matter.As compared with the sham-operated group and SAH+vehicle group,SAH+AICAR group had significantly increased p-AMPK level,decreased p-mTOR expression level,increased LC3Ⅱ/LC3Ⅰ ratio,and decreased behavioral deficit scores (P＜0.05);as compared with the sham-operated group and SAH+vehicle group,SAH+Compound C group had significantly decreased p-AMPK level,decreased LC3Ⅱ/LC3Ⅰ ratio,and decreased behavioral deficit scores (P＜0.05).Conclusion AMPK is involved in the process ofautophagy activation after SAH through regulating mTOR,and the regulation of AMPK may contribute to neuroprotection related to autophagy.

BACKGROUNDAs a common form of gastric cancer migration, lymph node metastasis largely affects the surgical treatment and prognosis of gastric cancer. Surgery is the fundamental curative option for gastric cancer that varies depending on different stages. The study aimed to compare the clinicopathological characteristics and lymph node metastatic patterns in patients of proximal gastric cancer with different T stages and investigate a reasonable radical gastrectomy approach in terms of the range of lymphadenectomy for proximal gastric cancer.

METHODSIn our retrospective study, the data of 328 patients of proximal gastric cancer with different T stages were analyzed. By comparing the differences of lymph node metastatic rate and ratio, we investigated the clinicopathological characteristics and metastatic patterns of lymph nodes. Also, we were especially interested in the differences in survival rates between patients with and without No. 5 and 6 group metastasis with the same TNM stage.

RESULTSThe overall lymph node metastatic rate and ratio of advanced proximal gastric cancer were 73.4% and 23.3%, respectively. The tumors of different T stages were statistically significant in size and differentiation degree (P < 0.05), multivariate analysis showed that the depth of tumor invasion was an independent risk factor for lymph node metastasis in proximal gastric cancer (RR, 12.025; 95% CI, 2.326 to 62.157; P = 0.003). The overall survival rate of patients with No. 5, 6 group lymph node metastasis and those without was significantly different, but the differences in survival rates between patients with and without No. 5 and 6 group metastasis with the same TNM stage were not statistically significant.

CONCLUSIONSDifferent T stages in proximal gastric cancer showed different patterns and characteristics of lymph node metastasis. D2 lymphadenectomy in patients with early gastric cancer had little survival benefit because metastasis to level 2 nodes was rare. Therefore the range of the lymph node dissection in radical gastrectomy for early gastric cancer was considered reasonable. Moreover, to meet the requirements of the lymph node dissection, total gastrectomy plus D2 lymphadenectomy or more are supposed to be applied for the advanced proximal gastric cancer patients. Precise T staging largely determines the range of gastrectomy and lymphadenectomy.

Aged ; Female ; Gastrectomy ; Humans ; Lymph Node Excision ; Lymphatic Metastasis ; pathology ; Male ; Middle Aged ; Retrospective Studies ; Stomach Neoplasms ; pathology ; surgery

Background As a common form of gastric cancer migration,lymph node metastasis largely affects the surgical treatment and prognosis of gastric cancer.Surgery is the fundamental curative option for gastric cancer that varies depending on different stages.The study aimed to compare the clinicopathological characteristics and lymph node metastatic patterns in patients of proximal gastric cancer with different T stages and investigate a reasonable radical gastrectomy approach in terms of the range of lymphadenectomy for proximal gastric cancer.Methods In our retrospective study,the data of 328 patients of proximal gastric cancer with different T stages were analyzed.By comparing the differences of lymph node metastatic rate and ratio,we investigated the clinicopathological characteristics and metastatic patterns of lymph nodes.Also,we were especially interested in the differences in survival rates between patients with and without No.5 and 6 group metastasis with the same TNM stage.Results The overall lymph node metastatic rate and ratio of advanced proximal gastric cancer were 73.4％ and 23.3％,respectively.The tumors of different T stages were statistically significant in size and differentiation degree (P ＜0.05),multivariate analysis showed that the depth of tumor invasion was an independent risk factor for lymph node metastasis in proximal gastric cancer (RR,12.025; 95％ CI,2.326 to 62.157; P=0.003).The overall survival rate of patients with No.5,6 group lymph node metastasis and those without was significantly different,but the differences in survival rates between patients with and without No.5 and 6 group metastasis with the same TNM stage were not statistically significant.Conclusions Different T stages in proximal gastric cancer showed different patterns and characteristics of lymph node metastasis.D2 lymphadenectomy in patients with early gastric cancer had little survival benefit because metastasis to level 2 nodes was rare.Therefore the range of the lymph node dissection in radical gastrectomy for earty gastric cancer was considered reasonable.Moreover,to meet the requirements of the lymph node dissection,total gastrectomy plus D2 lymphadenectomy or more are supposed to be applied for the advanced proximal gastric cancer patients.Precise T staging larqely determines the range of gastrectomy and lymphadenectomy.