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Background: Spinal implants' longevity is crucial, but titanium alloys, while advantageous, lack strong bone integration. This study aimed to achieve better osseointegration rates by utilizing the ability of boron compounds to transform stem cells in the vertebra into osteoblasts., Method: Twenty male albino rabbits were divided into control (n = 10) and experimental (n = 10) groups. Control group received titanium alloy pedicle screws, while experimental group received boron-coated titanium alloy screws. Under general anesthesia, screws were inserted into the L6 and L7 lumbar spines. After 16 weeks, all animals were euthanized for histological examination. Vertebra samples underwent decalcification and H&E staining. Microscopic examination assessed osseointegration, necrosis, fibrosis, and vascularization using a triple scoring system by two blinded observers., Result: In the boron-coated titanium alloy group, all subjects exhibited osseointegration, with 50% showing focal, 40% moderate, and 10% complete osseointegration. In the titanium alloy group, 90% showed osseointegration (70% focal, 10% moderate, and 10% complete).The differences between the groups were not statistically significant (p = 0.302). Focal necrosis rates were similar between groups, with 50.0% in the titanium alloy and 60.0% in the boron-coated group (p = 0.653).Fibrosis was absent in the titanium alloy group but present in the boron-coated group, albeit with lower rates of focal fibrosis (20.0%). However, the difference was not statistically significant (p = 0.086).Vascularization patterns showed no significant difference between groups., Conclusion: Boron-coated titanium alloy pedicle screws provided osseointegration rates comparable to standard titanium screws and exhibited acceptable levels of necrosis and fibrosis. With stronger biomechanical properties, they could be a better alternative to currently used titanium screws., (© 2024. The Author(s).)

Background: We compared the raw Ti-Al-V super alloy transpedicular implant screws with boronized and surface-hardened transpedicular implant screws., Objective: To improve patients' postoperative prognosis with the production of harder and less fragile screws., Methods: Surface hardening was achieved by applying green-body encapsulation of the specimen with elemental boron paste which is sintered at elevated temperatures to ensure the boron-metal diffusion. Boron transported into the Ti-Al-V super alloy matrix gradually while suppressing aluminum and a homogeneously boronized surface with a thickness of ∼15 microns was obtained. The uniform external shell was enriched with TiB2, which is one of the hardest ceramics. The Ti-Al-V core material, where boron penetration diminishes, shows cohesive transition and ensures intact core-surface structure., Results: Scanning electron microscope images confirmed a complete homogeneous, uniform and non-laminating surface formation. Energy-dispersive X-ray monitored the elemental structural mapping and proved the replacement of the aluminum sites on the surface with boron ending up the TiB2. The procedure was 8.6 fold improved the hardness and the mechanical resistance of the tools., Conclusions: Surface-hardened, boronized pedicular screws can positively affect the prognosis. In vivo studies are needed to prove the safety of use.

Wastewater treatment is one of the crucial functions of industrial parks as wastewater from industrial facilities usually contains toxic compounds that can cause damage to the environment. To control their environmental loads, industrial parks make investment decisions for wastewater treatment plants. For this, they need to consider technical and economic factors as well as future growth projections as substantial construction and operational costs of wastewater treatment plants have to be shared by all companies in an industrial park. In this paper, we consider the long-term capacity planning problem for wastewater treatment facilities of a stochastically growing industrial park. By explicitly modeling randomness in the arrival of new tenants and their random wastewater discharges, our model calculates the future mean and variance of wastewater flow in the industrial park. Mean and variance are used in a Mixed Integer Programming Model to optimize wastewater treatment plant selection over a long planning horizon (30 years). By fitting our first model to empirical data from an industrial park in Turkey, we find that considering the variance of wastewater load is critical for long-term planning. Also, we quantify the economic significance of lowering wastewater discharges which can be achieved by water recycling or interplant water exchange., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Fusion surgery is applied to prevent segmental instability after surgery for cervical disk herniation. Motion-sparing surgeries have been developed to prevent adjacent segment disease after fusion surgery. Total disk replacement, one of these methods, has been applied in the cervical region for more than 20 years. We aimed to investigate the medium-term radiological and clinical outcomes of patients who had received Alpha-D disk prosthesis after cervical disk surgery, in terms of incidence of heterotopic ossification (HO) and other complications., Methods: We included 33 patients (17 women and 16 men) diagnosed with single-level cervical disk herniation and who had received prosthesis after anterior discectomy. The average follow-up period was 36 (18-78) months. The patients were followed up postoperatively at month 4, year 1, and annually thereafter. Patients, who had Alpha-D cervical disk prosthesis (CDP) (Medikon, Turkey), were monitored via radiological (standard and dynamic X-ray) and clinical (visual analog scale [VAS] and neck disability index [NDI]) modalities. Dynamic X-ray images were evaluated by an independent radiologist for HO and prosthesis movement., Results: Mean patient age was 40 ± 6.88 years. HO was observed in 7 (21.21%) patients, 6 of which were men. Significant intersex differences were noted for HO and movement rates ( p  = 0.039). Clinically, the mean preoperative and post-operative NDI levels were 35.4 ± 3.9 and 4 ± 2, respectively, whereas the mean pre- and post-operative VAS levels were 7 ± 1 and 1 ± 1, respectively. There was a clinically significant postoperative improvement in all the patients. However, there was no significant difference between the patients with and without HO in terms of age, operation level, and mean pre- and postoperative VAS, and postoperative NDI levels ( p  > 0.05). Despite the fact that there was a significant difference ( p  = 0.038) in favor of patients without HO in terms of mean preoperative NDI levels, this was not considered clinically significant., Conclusion: In the present study, all the patients demonstrated clinically significant improvement following CDP surgery. HO rate after CDP surgery was 21.21% in the medium term, and movement was preserved in 5 of the 7 patients with partial HO. The fact that the CDP design was based on the one-to-one reproduction of the movement segment in the cervical spine, might account for the underlying cause of success. However, these good results in the medium term may change in cases with long-term clinical follow-up., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest, (© Indian Orthopaedics Association 2022, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Objective: There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion., Methods: Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form 36., Results: Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution., Conclusions: Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and objective Spinal infection (SI) is an infectious disease affecting the vertebral column, spinal cord, and adjacent structures. The infection can occur following interventions or spontaneously. The aim of this study was to highlight the importance of employing a methodological approach for the accurate and rapid diagnosis of SI and to share information on the most effective treatment method, which involves using a diagnostic-treatment algorithm that can help with SI management. Methodology This study included 50 patients diagnosed with SI between 2016 and 2020. The treatment follow-up period was limited to six months, and the study was conducted as a retrospective cohort analysis. The sample consisted of 22 female patients and 28 male patients, and the mean age of the patients was 50.2 years. All patients received diagnosis and treatment according to the algorithm described in this article. Results In the study group, 60% of patients had an infection in the lumbar spine, 4% in the thoracal spine, 12% in the cervical spine, and 8% in the sacral spine. Previously operated patients were diagnosed on the 30.16th day on average. A total of 19 patients (38%) had no history of undergoing surgery. Radiologically, the most common finding was spondylodiscitis/discitis (32%). Osteomyelitis was detected in one (2%) patient. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most commonly isolated organism in culture results and was detected in 13 patients (26%). The culture results of 12 patients (24%) were negative. The number of patients with active SI who were unstable and stabilized at the time of diagnosis was 11 (22%), and stabilization materials were removed in two patients (4%). In the 6th month of control, the patients did not have any complaints, signs of an infection, or unstable vertebral column. Conclusions We conclude that the combined algorithm we recommend for the diagnosis and treatment of patients with SI can prevent negative deviation and is an effective treatment for this condition., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Başak et al.)

Background: Screw loosening, which is a major problem in dynamic systems, can be easily overcome with 2-stage surgery. In this article, the clinical and radiological results of patients undergoing dynamic stabilization with a Dynesys device in 2 stages are discussed., Methods: A total of 10 male and 13 female adult patients were included in this single-center retrospective study conducted between 2018 and 2021. The mean age of the patients was 65.6 years. All of the patients had pain complaints that affected their daily lives. Bone density T scores were determined with the dual-energy x-ray absorptiometry method before patients were admitted for surgery. In the first surgery, Dynesys system pedicle screws were inserted. After 6 months of osteointegration, Dynesys system spacers and elastic bandages were placed. Preoperative, early postoperative, and late postoperative visual analog pain scale (VAS) scores and Oswestry Disability Index (ODI) scores were determined and statistically compared., Results: Patients were followed for an average of 30 months. Complications and recurrence were not observed. Neurological deficits were not observed after patients recovered from anesthesia. Significant improvement was observed in the ODI and VAS parameters in the preoperative (ODI: 66.2%, VAS: 7.8), early postoperative (ODI: 20.3%, VAS: 2.4), and late postoperative (ODI: 6.8% and VAS: 1.1) periods. Symptomatic improvement was seen in all patients. No screw breakage or loosening was detected by radiological evaluation in any of the patients during the 2-year follow-up period., Conclusions: In our experience, the insufficiency of the proximal and distal end screws is eliminated when 2 stages of dynamic system stabilizations are completed after osteointegration of the screws., Competing Interests: Declaration of Conflicting Interests: The authors report no conflicts of interest in this work., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2022 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Background: There are numerous radiological and anatomical studies on lumbar foramina in the literature, but there are no distinctive studies about the relationship between treatment and the type of foraminal stenosis. This study was conducted to better evaluate foraminal stenosis and to plan treatment accordingly., Methods: Foraminal stenosis was divided into 2 groups: stable and unstable stenosis. Both groups were also divided into 4 subgroups in relation to the cause and type of compression and based on the structure of the intervertebral disc. The visual analog scale for leg pain (VAS-LP) and Oswestry Disability Index (ODI) scores were investigated before and after surgery., Results: A total of 115 patients (59 women and 56 men) underwent surgery for lumbar foraminal stenosis. The mean patient age was 56.1 years (range 17-80 years). The mean follow-up was 29 months (range 24-39 months). There were 36 patients (32%) with stable foraminal stenosis and 79 patients (68%) with unstable foraminal stenosis. The majority of the patients were identified as having unstable type 1 foraminal stenosis (45 of 115). The VAS-LP and ODI scores for each group decreased gradually during the follow-up periods and showed significant decrease during the last follow-up ( P < 0.001). Interobserver and intraobserver agreement in the classification of foraminal stenosis was found to be nearly perfect. No patients experienced postoperative radiculopathy complication. Only 2 patients experienced superficial operation site infection and 1 showed deep wound infection. The patient who had a deep wound infection needed to repeat surgery for the infection., Conclusions: We introduced a novel classification system for lumbar foraminal stenosis. We aimed to guide appropriate treatment modality depending on the determined classification. This classification helps to determine the optimal treatment. In the light of our findings, the patients who were operated according to our classification experienced satisfactory clinical outcomes and low complication rates., Competing Interests: Declaration of Conflicting Interests: The authors report no conflicts of interest in this work., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2022 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Objective Adjacent segment disease is a controversial process after spine stabilization. The two important factors discussed are natural aging and hypermobility in incidental segmental fusion anomalies; patients have two or more fused vertebrae from birth, which are the results of spinal movement restriction due to the fusion of some spinal units. This article's main purpose is to determine the degree of relationship of hypermobility and the aging process in the deterioration of the disks adjacent to fusion. Methods In this study, the degenerative process developed by hypermobility in the adjacent segment due to incidental segmental fusion was evaluated. The MRI images of 52 adjacent and nonadjacent disks of 45 patients in total were analyzed according to the Pfirrmann grading systems. The average Pfirrmann rating of the disks just above and below the fused segment and the distant first, second, and third non-neighboring levels were evaluated and calculated, respectively. Results The highest rate of incidental fusion is determined on the cervical area with 51.9%, followed by the thoracal area with 32.7%, and the lumbar area with 15.4%. Damage to the adjacent segment disks in cases with incidental fusion can still be seen at any age, with fusion, indicating that the hypermobility effect plays a more prominent role. The evidence of hypermobility without aging is that the segments adjacent to fusion undergo more degeneration than the distant disks. Conclusion Adjacent segment disease is under the influence of many factors. Our findings suggest that its incidence is increasing with the pathological processes initiated by hypermobility. It seems that, at least, it carries equal importance as compared to age. Fusion surgeries damage the adjacent segments under the influence of the passage of time beyond the physiological aging of the patient., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Hekimoğlu et al.)

Objective: To monitor changes in cervical parameters before and after laminoplasty surgery. Cervical parameters and health-related quality-of-life (HRQOL) values that may be affected after laminoplasty were examined before and after surgery. The clinical and radiological course of these values was monitored, and their interaction with all spinal radiological parameters was revealed., Materials and Methods: Nineteen patients who underwent clinical and radiological evaluation for 2 years were followed in this study. Neck disability index, visual analog scale, and short form 36 scores were determined to evaluate HRQOL. For radiological parameters, the C0-C2 angle, C2-C7 angle, cervical sagittal vertical axis, T1 slope angle, neck tilt (NT) and thoracic inlet angle were used. The results of the 4-month, 1 year and 2-year follow-ups were statistically evaluated., Results: Both the HRQOL and cervical radiological parameters deteriorated in the first 4 months and returned to normal in the 2 nd year. Statistically, all parameters were meaningful ( P < 0.05), except for NT., Conclusion: Cervical parameters and HRQOL values, which deteriorated in the early period, recovered in the late period in the long-term follow-up of patients undergoing laminoplasty. The important point is that preoperative cervical parameters suitable for laminoplasty should be present, and spinopelvic parameters should be normal., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Craniovertebral Junction and Spine.)

Background In this article, clinical satisfaction and radiological results are discussed in a series of patients where the iliac wings participate in dynamic stabilization. Dynamic stabilization is an effective alternative surgical treatment method, especially in clinical pictures that go with pain due to minor instabilities. Practically the unique surgical instrument used in multilevel instabilities is the Dynesys system. The most important drawback of the Dynesys system is that the S1 screws become loose in time. In this article, our aim is to find solution to S1 insufficiency by extension of the system to the iliac wings. Methods Nineteen patients (eight females, 11 males) with a mean age of 54.16 were included in the study. Patients had multilevel (level 2 and above) instability, iliac wings were included in the stabilized segments, and Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were used for patient follow-up. Results First year results showed a significant improvement in VAS and ODI. Regarding the complications, infection developed in one patient, loosening in the proximal iliac wing in one patient, and both S1 and iliac proximals in one patient, but no clinical findings were encountered. Conclusion When more than two levels of dynamic systems are used in chronic instability, especially in the elderly patients, S1 screws are loosened. In these patients, if the iliac bones are also included in stabilization, this problem is solved successfully. However unfortunately, Dynesys system does not have a screw suitable for the iliac bones., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Özer et al.)

Objective: Extraforaminal disc herniations are extraordinary herniations because they are located outside the foraminal bony borders and compress the root exiting at the corresponding level, whereas in median or paramedian herniations, the root 1 level below is compressed. Percutaneous endoscopic discectomy (PED) and microscopic extraforaminal discectomy (MEFD) are 2 popular contemporary techniques that have been performed extensively for these herniations since the 1970s., Methods: In this study, we retrospectively analyzed 118 patients who underwent either PED (66 patients) or MEFD (52 patients). All the patients were clinically evaluated for neurologic examination findings, visual analog scale (VAS) scores for leg pain and Oswestry Disability Index (ODI) preoperatively and on the seventh postoperative day as well as 6 and 12 months after surgery. The complication rates and types of both techniques were discussed., Results: The preoperative VAS score and ODI were all comparable. Improvements in VAS scores 6 months postoperatively and improvements in ODI at all follow-up periods were statistically significant in favor of PED. However, there was great discrepancy regarding the postsurgical complications in favor of MEFD., Conclusions: PED is more prone to complications because this technique is strictly dependent on the tubular system and the ideal anatomy of the Kambin triangle. Variations in or degeneration of the Kambin triangle can lead to devastating complications in the PED technique, but normal anatomic conditions are feasible in only approximately 20% of patients. The most important feature of this study was that both techniques were performed by the same experienced team, who developed their own concept., (Copyright © 2020 Elsevier Inc. All rights reserved.)