Objective:To investigate the effect of spinopelvic sagittal alignment and lordosis distribution index on adjacent segment degeneration (ASD) after short-segment lumbar interbody fusion.Methods:A total of 234 patients who underwent posterior lumbar interbody fusion due to lumbar degenerative diseases in the Affiliated Changzhou Second People's Hospital of Nanjing Medical University and Affiliated Drum Tower Hospital, Medical School of Nanjing University from January 2009 to January 2019 were retrospectively analyzed. There were 102 males and 132 females, aged 60.1±10.0 years (range, 41-78 years). The patients were divided into ASD group and non-ASD group according to whether ASD occurred after operation. The general data, pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), distal lordosis (DL), segmental lordosis (SL), lordosis distribution index (LDI) and sagittal vertical axis (SVA) before and after operation were compared between the two groups. Independent risk factors for the occurrence of ASD after lumbar fusion were analyzed using binary logistic regression. The receiver operating characteristic curve (ROC) was plotted, and the area under the curve was calculated for each independent risk factor.Results:All patients successfully completed the operation and were followed up for 70.6±11.9 months (range, 60-121 months). Among the 234 patients, 116 patients developed ASD after operation. Age ( t=2.697, P=0.008), fusion segment (χ 2=16.439, P<0.001), preoperative PT ( t=2.268, P=0.024), preoperative LL ( t=2.042, P=0.042), preoperative DL ( t=2.724, P=0.007), postoperative DL ( t=3.104, P=0.002), postoperative LDI ( t=2.063, P=0.040) and the difference of SVA before and after operation ( Z=2.001, P=0.045) were statistically significant. Binary logistic regression analysis showed that LDI decreased ( OR=0.971, P=0.002), two-level fusion ( OR=3.477, P<0.001), and increased SVA difference before and after operation ( OR=0.992, P=0.039) were independent risk factors for ASD after lumbar fusion. The ROC curve showed that the area under the curve and 95% CI of the number of fusion segments, postoperative LDI, and the difference of SVA before and after operation were 0.633 (0.561, 0.704), 0.583 (0.510, 0.656) and 0.576 (0.502, 0.649), respectively. The area under the curve of the combined prediction model was 0.702, and the prediction value was medium. Conclusion:Two-level fusion, decreased LDI after operation, and increased SVA difference before and after operation are independent risk factors for ASD after lumbar fusion, and the combined prediction of the three has good predictive efficiency.

Objective:To analyze the factors influencing prognosis of intrahepatic cholangiocarcinoma (ICC) after surgical resection.Methods:The clinical data of patients diagnosed with ICC and who underwent surgical resection from December 2015 to December 2019 at the Fifth Medical Center of PLA General Hospital were retrospectively analyzed. Of 39 patients who were included in this study, there were 23 males and 16 females, with age of (54.1±7.2) years old. The body mass index, hepatitis B virus infection status, tumor diameter, degree of differentiation, microvascular tumor thrombus, lymph node metastasis, and serum levels of carbohydrate antigen 19-9 (CA19-9) were analyzed as risk factors affecting postoperative recurrence and survival.Results:The median times to recurrence were significantly better in patients with a tumour length <5 cm (11 vs. 5 months), patients without microvascular tumor thrombus (54 vs. 6 months) and patients without lymph node metastasis (8 vs. 5 months) (all P<0.05). The median survival of patients with CA19-9≥100 U/ml was significantly shorter than that of patients with CA19-9<100 U/ml, (9 vs. 27 months, P<0.05). Tumor diameter>5 cm, microvascular tumor thrombus, lymph node metastasis, and CA19-9 ≥100 U/ml are risk factors affecting the recurrence time after ICC resection, CA19-9 ≥100 U/ml is a risk factor affecting survival time after ICC resection. Conclusion:Tumor diameter, microvascular tumor thrombus, lymph node metastasis and CA19-9 can be used to estimate the risk of ICC recurrence, and CA19-9 level can be used to estimate postoperative survival of ICC patients after resection.

Objective:To investigate the value of relative lumbar lordosis (RLL) and lumbar distribution index (LDI) in predicting the occurrence of adjacent segment disease (ASDis) after lumbar fusion surgery.Methods:This study retrospectively reviewed 163 consecutive patients (58 males and 105 females) who had undergone lumbar fusion and had been followed over 2 years,with an average age of 58.7 years; among them, 74, 71, and 18 patients had undergone fusion of one-level, two-level, and three-level, respectively. They were divided into the non-ASDis group and ASDis group based on the presence of ASDis or not. Pre- and post-operative spinopelvic parameters were measured on the upright lateral radiographs. RLL was calculated as measured lumbar lordosis (LL) minus ideal LL, and LDI was calculated as the ratio of postoperative low lumbar lordosis (LLL) to LL. Each parameter was stratified into 1 "aligned" subgroup and 3 "disproportioned" subgroups in accordance with values. Cochran-Armitage test of trend andlogistic analysis were performed to investigate the association between these two parameters and the occurrence of ASDis.Results:The average follow-up duration after initial surgery was 46±14 months (range, 25 to 134 months). Twenty-four (14.7%) patients were diagnosed as ASDis. The age ( t=3.13, P=0.002) and the proportion of 2-level and 3-level fusion (χ 2=10.27, P=0.006) in the ASDis group were significantly higher than those in the non-ASDis group ( P<0.05). There were no statistically significant differences between groups with respect to other general data. The ratios of moderate and severe hypolordosis of RLL were significantly higher in the ASDis group than that in the non-ASDis group (χ 2=16.92, P<0.001). There was also a significant linear trend with higher degree of hypolordosis being associated with higher rates of ASDis. However, distribution of four statuses of LDI did not differ statistically between groups. After controlling the confounders, the logistic regression analysis revealed that age, odd ratio ( OR)=1.07, 95% CI: (1.01, 1.13), P=0.018), moderate[ OR=4.34, 95% CI: (1.03, 18.41), P=0.046] and severe hypolordosis [ OR=11.64, 95% CI: (1.30, 104.49), P=0.028] were significantly associated with the occurrence of ASDis. Conclusion:A significant association between postoperative RLL and occurrence of ASDis after lumbar fusion surgery were detected. Setting surgical goals according to RLL may help reduce the ASDis rate. However, LDI is not identified to be predictive factors of the occurrence of ASDis.

Objective:To investigate the association of the cross-sectional area of lumbar paraspinal muscle with the spino-pelvic profile based on Roussouly classification.Methods:From January 2019 to December 2019, 102 patients with lumbar disc herniation were collected, the index level included L 2, 3 in 3 cases(2.9%), L 3, 4 in 14 cases(13.7%), L 4,5 in 58 cases (56.9%), and L 5S 1 in 27 cases (23.5%). According to Roussouly classification, there were 29 cases of type I (28.4%), aged 57.0±11.7 years old (range 43 to 72 years old), 31 of type II (30.4%), aged 56.9±10.3 years old (range 40 to 70 years old), 28 of type III (27.5%), aged 53.5±12.9 years old (range 42 to 70 years old), and 14 of type IV (13.7%), aged 59.7±9.5 years old (range 51 to 70 years old). The clinical status of the patients were evaluated with the MOS 36-item short-form health survey (SF-36), Oswestry disability index (ODI) and visual analog scale (VAS). Select all patients with L 1, 2, L 2, 3, L 3, 4, L 4, 5 and L 5S 1 disc level axial MRI images, to measure the cross-sectional area (CSA) of paraspinal muscles (back extensor muscle and psoas muscle) and the CSA of intervertebral disc at each disc level, and calculate the relative cross-sectional area (RCSA: the ratio of the CSA of muscles to that of the disc at the same level). One-way ANOVA was used to test the RCSA of the paraspinal muscles of the four groups, and then LSD- t test was used for pair wise comparisons to compare the RCSA of the paraspinal muscles in each group. Results:There was no significant difference in age ( F=1.067, P=0.367), female/male sex ratio ( χ2=2.412, P=0.491) and body mass index ( F=0.326, P=0.481). Roussouly type I group showed lower SF-36 score in both SF-36 PCS (31.5±6.5, F=3.207, P=0.047) and SF-36 MCS (33.9±5.7, F=3.409, P=0.031) compared with the other three types. In contrast, there were no significant differences in VAS Back Pain ( F=0.140, P>0.05), VAS leg pain ( F=0.622, P>0.05). and ODI scores ( F=1.075, P>0.05) among the types. At each level from L 1, 2 to L 5S 1, the RCSA of psoas muscle in Roussouly type IV (19.18±6.98, 35.36±10.37, 41.25±14.35, 61.58±12.03, 59.29±11.73) was significantly lower than that in patients with any other Roussouly type ( P<0.05), while no significant difference in the psoas RCSA among type I, type II and type III curves ( P>0.05). With regards to back extensor muscle, the RCSAs of back extensor muscle in Roussouly types I (135.32±19.86, 138.53±22.92, 125.06±21.44, 122.40±19.69, 110.87±18.08) and II (131.30±18.68, 136.39±24.87, 122.61±22.52, 121.10±20.47, 107.46±18.29) were significantly lower than those in Roussouly type III and IV at each level ( P<0.05), yet no significant difference between type I and II or between type III and IV. The ratio between the RCSA of back extensor muscle and psoas muscle in four types increased gradually from L 1, 2 to L 5S 1, with that being higher in type II (0.20±0.07, 0.33±0.09, 0.40±0.13, 0.58±0.11, 0.65±0.08) and lower in type IV (0.13±0.05, 0.24±0.07, 0.31±0.10, 0.47±0.10, 0.52±0.11). Conclusion:RCSA of paraspinal muscles varied among Roussouly types, suggesting a significant association between paraspinal muscles and the sagittal spino-pelvic alignment. Sagittal spino-pelvic alignment may be involved in the degeneration of paraspinal muscles.

Objective:To investigate effects of implantation of pectoralis major fascia combined with serratus anterior fatty fascia flap prosthesis on breast reconstruction after early breast cancer surgery.Methods:A total of 62 patients with early breast cancer undergoing breast reconstruction in Dongguan People's Hospital of Guangdong Province from July 2017 to December 2019 were selected and randomly divided into two groups, 31 cases in each group. The control group was treated with pectoralis major fascia covering prosthesis for breast reconstruction, and the observation group was treated with pectoralis major fascia combined with serratus anterior fatty fascia flap covering prosthesis for breast reconstruction. The clinical data of the two groups were recorded, the postoperative aesthetic appearance of breast was evaluated. According to the function assessment of cancer therapy-breast cancer (FACT-B) was used to evaluate the score of quality of life before and after operation, and postoperative complications were also observed.Results:In the control group and the observation group, the intraoperative blood loss was (82.61±12.38) ml, (88.76±13.57) ml, respectively; and drainage tube extubation time was (3.51±0.62) d and (3.64±0.58) d, respectively; there was no statistically significant difference between the two groups ( t value was 1.864, 0.853, respectively, all P > 0.05). The operation time of the observation group was longer than that of the control group [(2.59±0.29) h vs. (1.72±0.32) h, t = 11.217, P < 0.001]. The amount of drainage of the control group was higher than that of the observation group [(215.45±47.69) ml vs. (151.36±31.67) ml, t = 6.233, P < 0.001]; the length of hospital stay of the control group was longer than that of the observation group [(14.51±2.32) d vs. (10.79±1.86) d, t = 6.965, P < 0.001]. The excellent and good rate of postoperative breast appearance of the observation group was higher than that of the control group [96.77% (30/31) vs. 74.19% (23/31), χ 2adjusted=4.679, P = 0.031]. There were no statistical differences in all items including health, emotion, function, society/family and other conditions scores of FACT-B and total scores in both groups before the operation (all P > 0.05); all items scores and total scores of both groups after the operation were higher than those before the operation (all P < 0.001), and the sores after the operation of the observation group were higher than those of the control group (all P < 0.001). The total incidence of postoperative complications was 6.45% (2/31) of the observation group, 22.58% (7/31) of the control group, and the difference was not statistically significant (χ 2adjusted=2.080, P = 0.149). Conclusion:Breast reconstruction with implantation of pectoralis major fascia combined with serratus anterior fatty fascia flap prosthesis after early breast cancer surgery can shorten the postoperative hospital stay, improve the aesthetic appearance of breast, improve the long-term quality of life, and has a high safety.

Objective:To analyze the risk factors for lymph node metastasis in breast cancer patients with axillary lymph node metastasis after neoadjuvant chemotherapy.Methods:The data of 94 female patients with invasive breast cancer in Dongguan People′s Hospital of Guangdong Province from January 2017 to December 2019 were retrospectively analyzed.All patients planned to receive 4-8 cycles of neoadjuvant chemotherapy.After chemotherapy, modified radical mastectomy was performed.Estrogen receptor(ER), progesterone receptor(PR) and human epidermal growth factor receptor 2(HER-2) appeared for the first time in Chinese and English abstracts and texts positive patients received endocrine or targeted therapy.The rest patients received 2-4 cycles of adjuvant chemotherapy or radiotherapy according to the situation.Lymph node metastasis after neoadjuvant chemotherapy was analyzed.The relationship between lymph node metastasis after neoadjuvant chemotherapy and clinicopathological features was analyzed.Risk factors for lymph node metastasis after neoadjuvant chemotherapy were analyzed by Logistic regression.Results:After neoadjuvant chemotherapy, the positive rate of axillary lymph node was 74.47%(70/94). The number of positive axillary lymph nodes, ER status, HER-2 status and cell proliferation-associated human nuclear antigen(Ki67), the completion of chemotherapy cycle, the pathological remission of axillary lymph nodes after chemotherapy and the T stage of tumor after neoadjuvant chemotherapy were associated with lymph node metastasis in patients with positive axillary lymph nodes after neoadjuvant chemotherapy(χ 2=30.053, 10.233, 6.303, 7.666, 18.162, 10.148, 12.418; all P<0.05). More than 3 positive axillary lymph nodes( OR=2.788, 95% CI 1.253-5.318), ER positive( OR=3.298, 95% CI 1.744-7.837), Ki67 positive( OR=2.469, 95% CI 1.184-4.301)and pathological pPR( OR=4.197, 95% CI 2.168-13.788) were independent risk factors for lymph node metastasis after neoadjuvant chemotherapy(all P<0.05). Conclusion:Axillary lymph node-positive breast cancer patients have a high positive rate of axillary lymph nodes after neoadjuvant chemotherapy.More than 3 positive axillary lymph nodes before operation, ER positive, Ki67 positive, and axillary lymph node pPR after neoadjuvant chemotherapy are independent risk factors for lymph node metastasis after neoadjuvant chemotherapy.

Objective:To evaluate long-term results of growth friendly non-fusion technique (GF) in the treatment of early-onset scoliosis (EOS).Methods:From August 2008 to October 2019, a total of 26 EOS patients (mean age 7.2±2.4 years old) who had completed surgery with GF treatment, including 12 males and 14 females, were reviewed retrospectively. Among them, 16 patients underwent growing rod treatment while 10 patients underwent vertical expandable prosthetic titanium rib (VEPTR) treatment. All patients had minimum 2 lengthening procedure during distraction period and over 2-year follow-up after graduation. Radiographic data were collected before and after index surgery as well as at graduation and the latest follow-up. Complications were also recorded during distraction period and after graduation.Results:A total of 145 lengthening procedures were performed in 26 patients, averagely 5.6 procedures per patient. The mean age at graduation was 12.6±1.6 years old. The average follow-up was 4.7±1.4 years duringdistraction period, and 2.9±0.9 years after graduation.The main Cobb angle was significantly decreased from 81.2°±17.3° to 41.1°±13.1°( t=8.124, P<0.001)after the index surgery, but slightly increased to 48.8°±15.4° at the end of distraction. After definitive spinal fusion, the main Cobb angle was notably decreased from 52.8°±16.1° to 45.4°±14.8° in 16 patients( t=2.415, P=0.035), with an average correction rate of 14.1%±9.4%. At the latest follow-up, the main Cobb angle was 45.2°±15.6° and the average correction rate was 44.3%±15.5% when comparing with the value before the index surgery. The thoracic and spinal height were significantly increased after initial surgery. During distraction period, the average gain of thoracic and spinal height was 3.3±0.9 cm and 5.6±1.9 cm, with the growth rate of 0.6±0.3 cm and 1.0±0.4 cm per distraction, respectively. A total of 36complications were recorded in 14 patients. There were 27 complications occurred during distraction period and 9 after graduation. Conclusion:Surgical management of EOS with growing rod and VEPTR could effectively correct the spinal deformity and maintain spinal growth. The complication rate after graduation was relative lower than distraction period. However, the correction of definitive spinal fusion during graduation was relative lower.

Objective:To investigate the incidence and management of deep surgical site infection(SSI) after the spinal deformity surgery.Methods:This study retrospectively reviewed a consecutive cohort of 8818 patients with spinal deformity who received spinal deformity surgery between January1998 and December 2017 at our center. The diagnosis of deep SSI was based on the clinical symptoms, imaging data and laboratory findings. Early infection and late infection were defined as deep infections occurring <3 months and >3 months after the initial procedure, respectively. All deep SSIs were first treated with irrigation and debridement, closed suction irrigation system and antibiotics. If the infection cannot be eradicated, dressing change is recommended within 2 years after the initial surgery. The instrumentation can be removed 2 years after the initial surgery with careful evaluation of the fusion mass. The posterior-anterior and lateral radiographs were used to measure the coronal parameters and sagittal alignment.Results:Sixty patients were diagnosed as deep SSI after spinal deformity surgery, including 11 patients with early infection and 49 patients with late infection. No significant difference was observed in terms of age, gender ratio, surgical approach and fusion levels between the two groups. Deep SSI seemed to be more likely to occur between 2 and 5 years after surgery. Incidence of SSI was lowest in the patients with idiopathic scoliosis and ankylosing spondylitis, and highest in the patients with neuromuscular and syndromic scoliosis. There was a high rate of negative culture in the primary culture. Staphylococcus aureus and Escherichia coli were the most common organisms in the early infection, while patients with late infection had a high rate of low-virulent skin flora. In the early infection group, nine patients retained instrumentation while the implants were removed 2 years after the primary surgery in 2 patients. In patients with late infection, instrumentation was retained in 5 cases and removed in 10 cases until 2 years after the primary surgery. 34 cases were infected 2 years after the primary surgery and the implants were removed directly. One patient underwent reoperation with instrumentation 1 month after implant removal, another patient underwent reoperation 3 years after implant removal due to progression of deformity. Significant loss of coronal correction was noted at the latest follow-up.Conclusion:The rate of deep SSI after spinal deformity surgery was 0.68%, of which the incidence of early infection and delayed infection was 0.12% and 0.56%, respectively. An increased risk of SSI in patients with neuromuscular and syndromic scoliosis was noted. If the infection cannot be eradicated after repeated debridement, we recommend instrumentation removal 2 years after the initial surgery, but there is still a high risk of loss of correction in these patients.

Objective:To investigate the outcome of posterior correction surgery for severe kyphoscoliosis secondary to spinal Gorham disease, further to explore the countermeasure in such complicated condition.Methods:From January 2005 to December 2019, a total of 12 consecutive patients were diagnosed with spinal Gorham disease. Four patients who had undergone correction surgery were reviewed retrospectively. There were 3 males and 1 female. The median age of surgery was 14.5 years (11.5 years, 27.5 years), with the median of Cobb angle of scoliosis and kyphosis 29° (21.5°, 78.0°) and 94° (78.0°, 103.0°), respectively. After Halo-gravity traction, one-stage posterior correction surgeryand Schwab grade I or II osteotomy, with pedicle screw fixation bridging the diseased vertebrae was performed. Drug therapy of bisphosphonate was recommended after surgery. The Cobb angle of scoliosis and kyphosis, coronal and sagittal balance were measured on the standing upright radiographs of the spine. CT and MRI were used to give precise evaluation of spinal and peripheral soft tissue involvement.Results:After Halo-gravity traction of 3 months (2.5 months, 3.5 months), the median of Cobb angle of scoliosis decreased to 23.5° (15.5°, 77.0°) and kyphosis decreased to 65° (57°, 83.5°) respectively. Two patients underwent facetectomyand 2 received Ponte osteotomy. The median operative time and blood loss were 5.5 h (5.1 h, 5.9 h) and 3 095ml (2 950 ml, 3 320 ml), with the fusion segment of 13.5 (12.5, 14.5) and the fixation density of 47.8% (40.9%, 57.3%). After surgery, the median of Cobb angle of scoliosis and kyphosis decreased to 18° (10.5°, 38.5°) and 59° (42.0°, 78.0°). Compared to the values before traction, the median of correction rates of scoliosis and kyphosis after surgery were 46.7% (33.1%, 59.5%) and 35% (12.3%, 51.1%) respectively. Moreover, the median of coronal balance decreased from 15.5 mm (9.0 mm, 21.0 mm) to 6.5 mm (4.0 mm, 9.0 mm), while the median of sagittal balance decreased from 14 mm (-18.0 mm, 27.5 mm) to 5.5 mm (-5.5 mm, 12.5 mm). During a median of follow-up of 2.8 years (2.0 years, 3.5 years), no complication was detected except one patient whounderwent revision surgery for rod broken.Conclusion:One-stage posterior correction surgery combined with preoperative halo-gravity tractionand postoperative anti-osteoporosis therapydemonstratedto be safe and effective for severe kyphoscoliosis secondary to spinal Gorham disease. More attention should be paid to the failure of internal fixation after surgery.

Objective: To explore the nursing countermeasures of children with facial rhabdomyosarcoma treated by radioactive seed implantation. Methods: Retrospective analysis was performed on the diagnosis, treatment and nursing process of a child orbital embryonal rhabdomyosarcoma admitted to the department of tumor radiotherapy, Peking University Third Hospital in February 2018. Results: Mild wound swelling and pain occurred after treatment, and no acute complications such as increased intracranial pressure, particle displacement, wound bleeding and infection, or visual acuity change occurred. Conclusions Disease evaluation and preoperative preparation should be done strictly before the implantation of radioactive particles; changes of the disease should be monitored strictly during the operation to ensure the safety of treatment posture; postoperative complications observation and radiation protection guidance are the basis to ensure the smooth completion of the stage treatment of children.