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To evaluate changes in the sagittal parameters of the occipito-atlantoaxial complex after three-level anterior cervical decompression and fusion (ACDF) and identify the influential factors by comparing ACDF with a zero-profile anchored spacer (ACDF-Z) versus a cage-plate construct (ACDF-P). The cohort comprised 106 patients who underwent three-level contiguous ACDF-Z or ACDF-P for cervical radiculopathy and/or myelopathy. Standing, flexion, and extension radiographs of cervical spine were obtained preoperatively, and 3 and 12 months postoperatively. The assessed cervical sagittal parameters were the platform angle of the axis, Cobb angle, and range of motion (ROM) of C2⁃7, C0⁃1, and C1⁃2. In both the ACDF-Z and ACDF-P groups, the Cobb angle of the upper cervical spine decreased and the C0-1 ROM increased from preoperatively to 3 and 12 months postoperatively (P

Cervical focal kyphosis could often be observed in patients with cervical spondylotic myelopathy (CSM). However, the association between it and myelopathy severity remains unclear. This study aims to elucidate the association between cervical focal kyphosis and myelopathy severity before surgery. A retrospective review of 191 consecutive patients treated for CSM from 2017 to 2019 was surveyed. Seven MRI and five radiographic parameters were measured, clinical parameters were included. Patients were divided into two sagittal focal angle groups (lordosis/kyphosis) and two disc herniation severity groups (severe/non-severe). The potential risk factors of myelopathy symptoms were analysed. Significant correlations between cervical sagittal focal angles, several other imaging findings and myelopathy severity were found in both total patients (R2 = 0.51, P

BackgroundGlioblastoma multiforme (GBM) is the most common malignant tumor of the central nervous system. GBM with primitive neuronal component (GBM-PNC) is an aggressive variant identified in 0.5% of GBMs. Extracranial metastasis from GBM-PNC is a rare and challenging situation.MethodsA special case of early-onset GBM with systemic bone metastasis was enrolled. Clinical data, including patient characteristics, disease course, and serial radiological images were retrieved and analyzed. Tumor tissues were obtained by surgical resections and were made into formalin-fixed paraffin-embedded sections. Histopathological examinations and genetic testing were performed for both the primary and metastatic tumor specimens.ResultsA 20-year-old man suffered from GBM with acute intratumoral hemorrhage of the left temporal lobe. He was treated by gross total resection and chemoradiotherapy following the Stupp protocol. Seven months later, he returned with a five-week history of progressive neck pain and unsteady gait. The radiographic examinations identified vertebral collapse at C4 and C6. Similar osteolytic lesions were also observed at the thoracolumbar spine, pelvic, and left femur. Anterior spondylectomy of C4 and C6 was performed. The resected vertebral bodies were infiltrated with greyish, soft, and ill-defined tumor tissue. One month later, he developed mechanical low-back pain and paraplegia caused by thoracolumbar metastases. Another spine surgery was performed, including T10 total en-bloc spondylectomy, T7-9, L2-3, and L5-S1 laminectomy. After the operation, the patient’s neurological function and spinal stability remained stable. However, he finally succumbed to the rapidly increased tumor burden and died 15 months from onset because of cachexia and multiple organ failure. In addition to typical GBM morphology, the histological examinations identified monomorphic small-round cells with positive immunohistochemical staining of synaptophysin and CD99, indicating the coexistence of PNC. The next-generation sequencing detected pathogenic mutations in TP53 and DNMT3A. Based on above findings, a confirmed diagnosis of systemic metastases from GBM-PNC (IDH-wild type, WHO grade IV) was made.ConclusionsThe present case highlights the occurrence and severity of extensive axial skeletal metastases from GBM-PNC. This rare variant of GBM requires aggressive multimodal treatment including surgery and chemoradiotherapy targeting PNC. The pathological screening of PNC is recommended in patients with early-onset GBM and intratumoral hemorrhage. Surgery for spinal metastasis is appropriate in patients with chemoradioresistance and relatively good general status, with the objectives of restoring spinal stability and relieving spinal cord compression.

Background Metal allergy is frequently seen. Orthopedic metal implants, such as external fixators or other stainless implants, contain chromium, nickel, and molybdenum, which can cause type IV hypersensitivity. Case summary A patient diagnosed with open comminuted tibiofibular fracture was treated with external fixation surgery, and she showed contact dermatitis and eczema-like symptoms 2 weeks postoperatively. She was then diagnosed as allergic to several metals by patch test and subsequently treated with traditional Chinese medicine (TCM), both orally and externally for 1 month. TCM treatment significantly alleviated the hypersensitive symptoms and made the patient bear the external fixator for 2 months until bone union. Conclusion TCM therapy may be an effective treatment for external fixation-induced metal allergy and contact dermatitis.

To investigate the adjacent segment kinematics, including the instantaneous axis of rotation (IAR) and range of motion (ROM), after anterior cervical discectomy and fusion (ACDF), and to compare between ACDF with zero-profile anchored spacer (ACDF-Z) and ACDF with plate (ACDF-P).Eighty-seven patients (ACDF-Z = 63; ACDF-P = 24) were included. Flexion, extension and neutral cervical radiographs were obtained before operation and at 1-year follow-up. C2-C7 ROM, adjacent segment ROMs, and IARs were measured. Clinical evaluation was based on the Visual Analogue Scale, Neck Disability Index, and Japanese Orthopaedic Association score.After ACDF-Z, location of the superior IAR-AP reduced 1.60 mm, which represents 8% of the vertebral body (P 0.001), and location of the inferior IAR-SI reduced 2.19 mm, 17% of the vertebral body (P = 0.02). After ACDF-P, location of the superior IAR-AP increased 0.8 mm, which means 6% of the vertebral body (P = 0.008), location of the inferior IAR-AP increased 3.34 mm, 22% of the vertebral body (P = 0.03), and location of the inferior IAR-SI reduced 3.14 mm, 25% of the vertebral body (P = 0.002). C2-C7 ROM significantly decreased after both ACDF-Z and ACDF-P (P 0.001). Neither ACDF-Z nor ACDF-P significantly affected the adjacent segment ROMs (P 0.05).Both ACDF-Z and ACDF-P significantly impacted cervical kinematics, although both procedures obtained satisfactory clinical results in the treatment of cervical spondylosis. After both ACDF-Z and ACDF-P, C2-C7 ROM decreased significantly, while adjacent segment ROMs were preserved. ACDF-Z and ACDF-P impact the location of adjacent segment IAR-SI in similar way, while impact the location of adjacent segment IAR-AP in diverse ways. These slides can be retrieved under Electronic Supplementary Material.

Objective This meta-analysis was conducted to evaluate the therapeutic effects in clinical and radiologic outcomes of a self-locking stand-alone cage (SSC) and cage-with-plate (CP) for multilevel anterior cervical discectomy and fusion (ACDF). Methods A systematic search was performed for all comparative studies reported up to August 2018. Operative time, hospital stay, intraoperative blood loss, Japanese Orthopedic Association score, Neck Disability Index (NDI), cervical and segmental Cobb angle, intervertebral height, fusion rate, incidence of subsidence, dysphagia, and adjacent segment degeneration were analyzed with the RevMan 5.3.3 software. Results A total of 15 studies were included. There was no difference regarding preoperative or postoperative Japanese Orthopedic Association score, Neck Disability Index, segmental Cobb angle and intervertebral height, preoperative cervical Cobb angle, fusion rate, incidence of subsidence, and adjacent segment degeneration between the SSC and CP group (P > 0.05). However, the SSC group had shorter operative time (mean difference [MD], −11.35; 95% confidence interval [CI], −16.24 to −3.66) and hospital stay (MD, −0.64; 95% CI, −1.21 to −0.06), less intraoperative blood loss (MD, −13.22; 95% CI, −19.03 to −7.41) and postoperative cervical Cobb angle (MD, −0.70; 95% CI, −1.35 to −0.06), and lower incidence of dysphagia significantly (odds ratio, −0.57; 95% CI, 0.40–0.82) (P Conclusions ACDF with SSC and CP in multilevel cervical spondylosis achieved similar clinical relief. Although CP maintained better cervical lordosis, SSC contributed to less surgical pain and fewer complications. ACDF with SSC is safe and efficient in treating multilevel cervical spondylosis.

BACKGROUND: In the craniocervical junction, the ligaments between the anterior foramen magnum and the anterior arch of the atlas are not well defined, and ossification of the ligaments in this region has rarely been reported. Characterizing the anatomy and ossification of these ligaments may help in the diagnosis and treatment of disorders in this region. QUESTIONS/PURPOSES: (1) What is the prevalence of an unrecognized ossification at the craniocervical junction in patients with cervical spine disorders, and what are the patient characteristics associated with this ossification? (2) Do patients with this ossification have a greater risk of ossification of other structures at the craniocervical junction or cervical spine? (3) Is there an unreported ligament at this ossified site? METHODS: We conducted a retrospective study of 578 hospitalized patients who underwent CT for cervical spine disorders between January 2016 and July 2020. Based on the inclusion criteria, 11% (66 of 578) were excluded because of a cervical or craniocervical tumor, deformity, infection, fracture or dislocation, or prior surgery, leaving 89% (512 of 578) for analysis. These 512 patients had diagnoses of cervical radiculopathy, cervical myelopathy, cervical spondylotic amyotrophy, cervical spinal cord injury without a radiographic abnormality, or axial neck pain. Their mean age was 57 years (range 22-90 years), and 60% of the patients were men. Patient characteristics including age, gender, and diagnosis were retrieved from a longitudinally maintained institutional database. CT images were used to assess the presence of a previously unrecognized ossification and ossification of other structures in the craniocervical junction and cervical spine, including the posterior longitudinal ligament, anterior longitudinal ligament, nuchal ligament, ligamentum flavum, transverse ligament, and apical ligament, as well as diffuse idiopathic skeletal hyperostosis (DISH). The association between these structures was also assessed. This unreported ossification was called the capped dens sign. It was defined and graded from 1 to 3. Grade 3 was defined as the typical capped dens sign. Cervical spine MRI was used to assess whether there was an unreported structure in the same region as where the capped dens sign was detected on CT images. In the database of a recent study, there were 33 patients younger than 41 years. Nine percent (three of 33) were excluded because they did not have cervical spine MRI. MRIs of the remaining 30 patients were assessed. Their mean age was 35 years (range 22-40 years), and 58% were men. All cervical spine CT images and MRIs were reviewed by one senior spine surgeon and one junior spine surgeon twice with a 2-week interval. Blinding was accomplished by removing identifying information from the radiographs and randomly assigning them to each examiner. Any discrepancy with respect to the grade of the capped dens sign was adjudicated by a third blinded senior spine surgeon. Intrarater and interrater reliabilities were assessed by calculating weighted kappa statistics. No ligament or membrane was reported at this site. MRI is not sensitive to identify thin tissue in this region, especially when severe degeneration has occurred. A cadaveric study was conducted to discover a potential ligament between the inferior margin of the foramen magnum and the anterior arch of the atlas, as prompted by the newly discovered ossification in the clinical analysis of this study. Six embalmed human cadaveric craniocervical regions (three male and three female cadavers; median age 56 years, range 45-78 years) were dissected by a senior anatomist and a senior anatomy technician. A mid-sagittal section of the craniocervical junction was created, allowing us to explore the interval between the anterior foramen magnum and anterior arch of the atlas. A histologic analysis was conducted in two of the six cadavers (a male cadaver, 45 years; and a female cadaver, 51 years). Slides were made with 4-µm sections and stained with hematoxylin and eosin. RESULTS: A novel capped dens sign was detected in 39% (198 of 512) of the patients and the most typical capped dens sign was detected in 19% (96 of 512) of patients. The prevalence of this sign was the highest in patients with cervical spondylotic amyotrophy (12 of 25 patients). The prevalence of ossification of the anterior longitudinal ligament, ligamentum nuchae, and apical ligament, as well as DISH, was higher in patients with a capped dens sign than in those without (p = 0.04, p < 0.001, p < 0.001, and p = 0.001, respectively). The capped dens sign was identified in 69% (18 of 26) of the patients with DISH. A thin and short band-like structure or osteophyte was detected on MRI in 87% (26 of 30), in the same region as the capped dens sign. In the cadaveric study, an unreported, distinct ligamentous structure was identified at this ossified site. It originated from the posterosuperior rim of the anterior arch of the atlas to the inferior margin of the foramen magnum, which we called the inter-atlanto-occipital ligament. It was found in all six dissected craniocervical junctions. The histologic analysis revealed dense connective tissue. CONCLUSION: More than one-third of the patients in this series demonstrated CT evidence of a previously unrecognized ossification in the craniocervical junction, which we called the capped dens sign. Anatomic evidence of this sign, which was a previously unidentified ligament, was also newly discovered in this region. This study was conducted among Asian patients and specimens. Further studies among diverse ethnic groups may be needed to generalize the results. An additional well-designed prospective study will be needed to provide further evidence regarding the potential pathophysiology and clinical relevance of the capped dens sign. Furthermore, the cadaveric analysis in this study was only a preliminary report of the ligament; further biomechanical research is needed to investigate its function. CLINICAL RELEVANCE: Knowledge of this novel ligament may improve the diagnosis and treatment of craniocervical stability and dislocation. Ossification of this ligament is correlated with age, cervical spondylotic amyotrophy, and DISH. We wonder whether patients with cervical degenerative disorders who also have a capped dens sign may be at risk for the formation of osteophytes of an uncovertebral joint, which may result in palsy of the upper limb muscles. The capped dens sign may be the craniocervical manifestation of DISH. This possible association between the capped dens sign and DISH should be considered when performing surgery on patients with the capped dens sign.

BACKGROUND CONTEXT The coordination of the alignment between the lower extremities and cervical spine helps to achieve balance and horizontal gaze during standing and walking. Malalignment in any segment can disturb the global balance, causing compensation in another segment. Knee flexion contracture (KFC) can cause spine inclination with increased C7 tilt or C7 SVA (sagittal vertical axis). Cervical alignment and the posterior muscles are essential for maintaining the horizontal gaze which is closely related to neck tension (NT). PURPOSE This study aimed to determine whether KFC can affect cervical alignment and its potential effects on the posterior muscles and NT. DESIGN A prospective pilot study was carried out in preoperative (pre-op) and postoperative (post-op) phases. PATIENT SAMPLE This study included 22 consecutive patients with KFC and 12 control subjects in our department who agreed to participate from between August 1, 2018 and February 28, 2019 in our department. OUTCOME MEASURES Visual analog scale (VAS) and neck disability index (NDI) were used. The sagittal alignment parameters and cervical range of motion (ROM) were measured on radiographic images, and included the C0–C2 lordosis (C0–2L), C2–C7 lordosis (C2–7L), C2 SVA, C7 SVA, T1 slope, thoracic kyphosis, lumbar lordosis (LL), pelvic tilt, sacral slope, and knee flexion angle (KA). Surface electromyography-based flexion-relaxation ratio (FRR) and ultrasound-based shear wave elastography (SWE) were performed. METHODS The control group was matched for age, sex, and body mass index with the KFC group. Patients in the KFC group underwent arthroscopic surgery to correct knee alignment. Comparisons between pre-op and post-op phases were performed using paired sample t tests, comparisons between KFC and control groups were performed using independent samples t tests. The correlation analysis between the parameters was performed using Spearman analysis. Funding for this study was provided by the National Natural Science Foundation of China (60,000 USD), Beijing Municipal Administration of Hospitals Incubating Program (50,000 USD), and Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (20,000 USD). There were no conflicts of interest associated with this study. RESULTS The average follow-up time for this pilot study was 11.4±1.5 days. Pre-op, the KFC group had higher KA, T1S, C7 SVA, C2 SVA, C0–2L, SWE, VAS, and NDI compared with the control group, but all of these parameters were decreased significantly post-op. The LL, FRR of splenius capitis (FRRsc), and ROM of the KFC group pre-op were lower than the control group, and all of these were increased significantly post-op. There were no differences in pelvic tilt, sacral slope, C2–7 L, or TK between the KFC and control groups, or in FRR of splenius capitis (FRRutr) between pre-op and post-op phases. KA had strong correlations with LL (r=−0.83), which correlated well with C7 SVA (r=−0.75). C7 SVA correlated strongly with C2 SVA (r=0.79), which also correlated strongly with C0–2 L (r=0.76). C0–2 L correlated well with FRRsc (r=−0.65) and SWEsc (r=0.72), and both of them correlated well with VAS (r=−0.54, r=0.71) and NDI (r=−0.57, r=0.76). ROM correlated well with FRRsc (r=0.71), SWEsc (r=−0.74), VAS (r=−0.66), and NDI (r=−0.66). CONCLUSIONS KFC may cause spine inclination and craniocervical malalignment, leading to NT and ROM reduction. The results of this pilot study may be helpful in guiding further studies concerning KFC and NT.

To investigate the effect of osteoporosis and intervertebral disc degeneration on the endplate cartilage injury in rats.A total of 48 female Sprague Dawley rats (3 months) were randomly divided into Groups A, B, C and D with 12 rats in each group. Osteoporosis and intervertebral disc degeneration composite model, simple degeneration model and simple osteoporosis model were prepared in Groups A, B and C respectively. After modeling, four rats of each group at 12th, 18th and 24th week were sacrificed. Intervertebral height of cervical vertebra C6/C7 was measured. Micro-CT was used to image the endplate of cephalic and caudal cartilage at C6/C7 intervertebral disc. Abraded area rate of C6 caudal and C7 cephalic cartilage endplate was calculated, and then C6/C7 intervertebral disc was routinely embedded and sectioned, stained with safranin O to observe histological changes microscopically.At 12, 18 and 24 weeks, intervertebral disc height of C6/C7 were (0.58±0.09) mm, (0.53±0.04) mm and (0.04±0.06) mm in Group A rats, (0.55±0.05) mm, (0.52±0.07) mm and (0.07±0.05) mm in Group B rats. At 24th week, intervertebral disc height of Group A rats was significantly lower than that of Group B rats (P0.05); intervertebral disc height of Groups A and B rats at each time point were significantly lower than that of Groups C and D (P0.05). There was no significantly statistical difference of intervertebral disc height between Groups C and D (P0.05). At 12 and 18 weeks, the abraded rate of C6 caudal and C7 cephalic cartilage endplate in Group A rats were significantly higher than that in Groups B, C and D rats (P0.05); the abraded rate in Group B was significantly higher than that in Groups C and D (P0.05). Microscopic observation of CT showed that ventral defects in C6 caudal or C7 cephalic cartilage endplate in Groups A and B appeared after 12 weeks of modeling; obvious cracks were found in front of the C6 and C7 vertebral body, and cartilage defect shown the trend of "repairing" at 18 and 24 weeks after modeling.Intervertebral disc degeneration and osteoporosis can cause damage to the cartilage endplate. Co-existence of these two factors can induce more serious damage to the endplate, which has possitive correlation with intervertebral disc degeneration. Osteoporosis plays a certain role in intervertebral disc degeneration process, and accelerates the degeneration of intervertebral disc in a specific time window.

Study design In a radiographic study, postoperative segmental alignment was compared between 2 cohorts of 20 consecutive patients operated with a Bryan Cervical Disc Prosthesis. In group 2, patients with severe preoperative kyphosis were excluded for disc replacement surgery and the surgical technique was slightly altered to avoid asymmetric overdrilling of the posterior part of the cranial endplate of the caudal vertebral body. Objective The aim was to investigate whether this change in patient inclusion criteria and modification of the surgical technique had an influence on postoperative segmental alignment and whether postoperative kyphosis is related to the mechanical properties and/or the design of the prosthesis. Summary of background data Several research groups reported segmental kyphosis after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis. Methods On the basis of lateral radiographs, the disc insertion angle (as a postoperative estimate for the intraoperative angle of approach) and the angle of the functional spinal unit (FSU) and disc angle (both as measures for segmental alignment) were calculated. Results In group 1, 80% of the patients had a kyphotic FSU angle and 40% had a kyphotic disc angle preoperatively. At follow-up, 65% of the patients had a kyphotic FSU angle, whereas 55% had a kyphotic disc angle. In group 2, 40% of the patients had a kyphotic FSU angle and 5% had a kyphotic disc angle preoperatively. At follow-up, 40% of the patients had a kyphotic FSU angle, whereas 5% had a kyphotic disc angle. Due to the change in patient inclusion criteria, there was a significant difference in preoperative FSU angle between groups 1 and 2; however, no significant difference in preoperative disc angle was found. Owing to the change in surgical technique, the disc insertion angle was significantly different between both the groups. A difference in postoperative FSU angle, however, nonsignificant, between both the groups was observed. There was a significant difference in postoperative disc angle between both the groups; group 1 showed significantly more kyphosis of the shells, than group 2. Conclusions This study shows that segmental malalignment with the Bryan Disc can be reduced and is therefore not device related. Proper patient selection and a modified surgical technique can prevent this adverse outcome.

Degeneration of intervertebral discs and facet joints is one of the most frequently encountered spinal disorders. In order to describe and quantify degeneration and evaluate a possible relationship between degeneration and biomechanical parameters, e.g., the intervertebral range of motion and intradiscal pressure, a scoring system for degeneration is mandatory. However, few scoring systems for the assessment of degeneration of the cervical spine exist. Therefore, two separate objective scoring systems to qualitatively and quantitatively assess the degree of cervical intervertebral disc and facet joint degeneration were developed and validated. The scoring system for cervical disc degeneration consists of three variables which are individually scored on neutral lateral radiographs: "height loss" (0-4 points), "anterior osteophytes" (0-3 points) and "endplate sclerosis" (0-2 points). The scoring system for facet joint degeneration consists of four variables which are individually scored on neutral computed tomography scans: "hypertrophy" (0-2 points), "osteophytes" (0-1 point), "irregularity" on the articular surface (0-1 point) and "joint space narrowing" (0-1 point). Each variable contributes with varying importance to the overall degeneration score (max 9 points for the scoring system of cervical disc degeneration and max 5 points for facet joint degeneration). Degeneration of 20 discs and facet joints of 20 patients was blindly assessed by four raters: two neurosurgeons (one senior and one junior) and two radiologists (one senior and one junior), firstly based on first subjective impression and secondly using the scoring systems. Measurement errors and inter- and intra-rater agreement were determined. The measurement error of the scoring system for cervical disc degeneration was 11.1 versus 17.9% of the subjective impression results. This scoring system showed excellent intra-rater agreement (ICC = 0.86, 0.75-0.93) and excellent inter-rater agreement (ICC = 0.78, 0.64-0.88). Surgeons as well as radiologists and seniors as well as juniors obtained excellent inter- and intra-rater agreement. The measurement error of the scoring system for cervical facet joint degeneration was 20.1 versus 24.2% of the subjective impression results. This scoring system showed good intra-rater agreement (ICC = 0.71, 0.42-0.89) and fair inter-rater agreement (ICC = 0.49, 0.26-0.74). Both scoring systems fulfilled the criteria for recommendation proposed by Kettler and Wilke. Our scoring systems can be reliable and objective tools for assessing cervical disc and facet joint degeneration. Moreover, the scoring system of cervical disc degeneration was shown to be experience- and discipline-independent. ispartof: European Spine Journal vol:18 issue:3 pages:358-369 ispartof: location:Germany status: published

To investigate the upper-extremity abduction, and lifting limitations and associated factors after anterior cervical decompression and fusion.A total of 117 patients who underwent anterior cervical decompression and fusion for cervical spondylosis were assessed retrospectively. Their upper-extremity abduction and lifting capacity after operation and manual muscle test grade for deltoid muscle strength and its sensory status were recorded. In addition, spinal cord function (Japanese Orthopaedic Association and Neck Disability Index scores) and C4-5 intervertebral height (radiographs) were assessed. Finally, high signal and ossification of posterior longitudinal ligament were observed by T2 magnetic resonance imaging and computed tomography, respectively.Seven individuals had a decrease in muscle strength, with 2 patients also exhibiting sensory defect. Six individuals had bilateral weakness of deltoid and biceps brachii and 1 of unilateral. After 8-16 months of follow-up, the abduction function and lift capacity were restored. The manual muscle test grade recovered to 5 and 4 degrees, respectively, in 6 and 1 patients. Two patients remained with sensory defect. The mean recovery time 19.7 days on average, and Japanese Orthopaedic Association scores significantly improved. Among the 117 patients, less than 2-level decompression showed upper-extremity function limitations in 1 of 67 (1.5%), whereas more than a 3-level decompression resulted in greater rate in 6 of 50 (12%), a significant difference (P0.05). No significant difference was obtained in C4-5 intervertebral heights, as well as for rates of C3-5 high signal area in magnetic resonance imaging.The rate of upper-extremity abduction and lifting limitation after anterior cervical decompression and fusion is low, indicating a good prognosis after active treatment.

The International Society on Thrombosis and Haemostasis (ISTH) scoring system is a useful tool to diagnosis overt disseminated intravascular coagulation in clinical practice. The main purposes of this study were to investigate the prognostic value of the ISTH score in emergency department (ED) sepsis and compare the ISTH score with two established scoring systems, the Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and two biomarkers,procalcitonin (PCT) and C-reactive protein (CRP).Septic patients were consecutively enrolled from the ED of Beijing Chaoyang Hospital, China. The ISTH score, SOFA score and APACHE II score were calculated, and PCT and CRP levels were measured on enrollment. A 30-day follow-up was performed.A total of 680 septic patients were enrolled in this study. The Cox regression analysis showed that the ISTH score had a greater effect on 30-day mortality prediction, and the receiver operating characteristic curve analysis showed that the accuracy of the ISTH score in prediction of 30-day mortality was better than the SOFA score, the APACHE II score, PCT and CRP. Combination of the ISTH score and CRP can enhance the predictive accuracy of 30-day mortality.The ISTH score is a valuable scoring system in the prognosis evaluation in ED sepsis.