Category: Spine

Journal of Neurosurgery: Spine. 2026;45(4):660-667

Soft-tissue closure deserves consideration as part of the reconstructive strategy in posterior cervical surgery, particularly when instrumentation leaves a substantial wound cavity. Adida and colleagues examine whether advancing the paraspinal musculature is associated with fewer wound complications than conventional closure after posterior cervical decompression and fusion. Their comparison of 508 patients provides a clinically relevant signal of fewer infections and wound-related reoperations in adjusted analyses, while illustrating the difficulty of separating a closure technique from changes in perioperative care. The practical contribution is a rationale for vascularized coverage and dead-space reduction, rather than definitive evidence that one closure method should replace all others.

Objective

To compare wound complications and wound-related reoperations after conventional closure or bilateral paraspinal muscle flap advancement following posterior cervical decompression and fusion.

Methods

The investigators compared 380 patients treated with conventional closure between 2011 and 2022 with a prospectively maintained series of 128 consecutive patients receiving muscle flap advancement between 2023 and 2025 at a single academic quaternary center. Active local or systemic infection and follow-up shorter than three months were exclusion criteria. Indications included degenerative disease, deformity, trauma and malignancy; approximately one fifth of each cohort underwent revision surgery.

Wound events included infection, dehiscence, hematoma and seroma. Wound-related reoperation was recorded per patient. Analyses included time-to-event comparisons and Firth-penalized logistic regression. Importantly, the methods and Table 2 describe adjustment with individual covariates rather than a single model simultaneously controlling for every potential confounder.

Main results

Infection was recorded in 31 of 380 conventional-closure patients and 4 of 128 muscle-flap patients, approximately 8% and 3%. Wound-related reoperation occurred in 47 and 9 patients, approximately 12% and 7%, respectively. The reported regression estimates associated muscle flap closure with lower odds of infection (OR 0.275, 95% CI 0.085-0.702) and wound-related reoperation (OR 0.445, 95% CI 0.198-0.912).

Dehiscence remained similar, at approximately 12% versus 11%. Seroma was numerically more frequent with muscle advancement, approximately 9% versus 5%, without a statistically significant difference. Hardware removal occurred in five conventional-closure patients and no muscle-flap patients. These small event counts do not establish a reliable hardware-retention advantage.

The time-to-event analyses were less conclusive than the logistic models. Log-rank comparisons for infection-free and reoperation-free survival did not reach statistical significance, and the reported Cox estimates had confidence intervals crossing unity. Thus, the evidence does not support describing the benefit as uniformly demonstrated across analytical approaches.

Interpretation

The operative decision is whether to incorporate paraspinal muscle advancement at the index operation to improve coverage of the instrumented cervical wound. The authors describe mobilizing the muscle complex and bringing vascularized tissue into the midline cavity. Their initial Lembert closure imbricated muscle into the defect; the subsequently adopted vest-over-pants configuration overlapped the advanced muscle margins. Both used absorbable sutures, and superficial drainage was described above the reconstructed muscle layer.

These details support a reconstructive concept: address the deep wound cavity and soft-tissue coverage rather than relying solely on superficial approximation. However, the study did not compare the two flap configurations, quantify tension reduction or perfusion, or establish which patients derive the greatest benefit. Its results also cannot define an optimal drain regimen or justify a specific antimicrobial adjunct independently of the overall closure strategy.

Limitations

The cohorts were noncontemporaneous, with retrospective ascertainment in the earlier group and prospective maintenance of the later series. Changes in practice, case selection and complication detection may therefore contribute to the observed associations. The muscle-flap cohort was older, and baseline characteristics were not identical. Limited events and adjustment one covariate at a time leave substantial potential for residual confounding.

Co-interventions are particularly important. Topical vancomycin was used in every muscle-flap case but only most conventional cases, while incisional negative-pressure therapy was introduced during the study and used in 63 muscle-flap patients. The contributions of these measures cannot be isolated. Drain number, duration and removal criteria were not analyzed. The two flap techniques were pooled, and a three-month minimum follow-up does not ensure equivalent long-term observation across cohorts.

The contrast between logistic and time-to-event findings further limits certainty. The study supports an association and a plausible operative rationale, not a causal estimate of how many infections or reoperations muscle advancement itself prevents.

Clinical takeaway

Paraspinal muscle advancement is a promising option for reconstructing the posterior cervical wound after decompression and fusion. The strongest practical message is to plan deep soft-tissue coverage and dead-space management deliberately. This series does not establish universal superiority over conventional closure, favor Lembert over vest-over-pants repair, or determine the independent benefit of drains, topical antibiotics or negative-pressure therapy.

Spine (Phila Pa 1976). 2026;51(19):1354-1362

Body mass index is readily available during preoperative assessment, but its implications for cervical myelopathy surgery are not straightforward. A technically more demanding operation does not necessarily imply less neurological recovery, and similar average outcomes do not establish equal risk for every patient. Okubo and colleagues address this distinction in a prospective Japanese multicenter cohort, relating BMI to operative variables, cervical alignment and two-year clinical outcomes. Their findings associate obesity with longer procedures and greater blood loss, while showing no statistically significant differences in neurological improvement across BMI categories. The principal relevance is to individualized planning and counseling rather than selection of a specific surgical technique.

Objective

To assess the association between BMI and operative demands, perioperative complications, cervical alignment, neurological recovery and patient-reported outcomes after surgery for degenerative cervical myelopathy.

Methods

The study drew on a prospective cohort from ten high-volume spine centers in Japan between 2018 and 2022. Of 1,105 patients identified with degenerative cervical myelopathy, 935 entered the final analysis after exclusions for previous cervical surgery, missing essential information, loss to follow-up or death during observation.

Patients were classified as underweight (BMI below 18.5; n=35), normal weight (18.5-24.9; n=522), overweight (25.0-29.9; n=292), or having obesity (30 or above; n=86). Posterior decompression predominated in every group; anterior and posterior fusion procedures were less frequent. Complications were defined as adverse events within 30 days of surgery.

Assessment included Japanese Orthopaedic Association (JOA) scores, pain ratings, SF-36 physical and mental component scores, neuropathic pain symptoms, and cervical radiographs. Clinical outcomes at two years were compared using general linear models with adjustment for demographic, comorbidity and imaging variables. Models for outcome changes also incorporated operative time, blood loss and postoperative alignment and motion measurements.

Main results

Patients with obesity had mean operative time of 128.3 minutes and blood loss of 91.2 mL, versus 102.1 minutes and 38.1 mL in normal-weight patients; global comparisons across the four groups were significant. OPLL prevalence was 47.7% versus 16.9%. Adjusted JOA improvement was 3.5, 3.2, 2.6 and 3.1 points across ascending BMI categories (P=.129). Reported complication categories did not differ significantly. Obesity remained associated with less cervical lordosis and motion at two years. Between-group differences in pain, SF-36 and neuropathic pain changes were not statistically significant; this does not demonstrate equivalent outcomes.

Interpretation

The decision informed by this study is how BMI contributes to preparation and expectations when clinical and imaging findings already support surgery. Greater operative demands justify attention to associated comorbidities and cervical anatomy, particularly the higher frequency of OPLL, rather than assuming that neurological recovery will be poor. However, the study does not compare approach-selection algorithms or validate a BMI-specific exposure, fixation or closure technique. Persistent differences in alignment and motion also should not be described as surgical failure: they coexisted with neurological improvement. Conversely, favorable average recovery should not be interpreted as eliminating individual perioperative risk.

Limitations

This observational cohort cannot establish the independent causal effect of BMI. Patients with obesity were younger and more frequently had OPLL, diabetes and hypertension. Statistical adjustment reduces some measured confounding but does not resolve unmeasured differences. Moreover, adjusting for operative demands and postoperative radiographic findings may account for intermediate pathways through which BMI could affect outcomes, rather than estimating its total association with recovery.

The analysis included patients selected for surgery and excluded those who died or were lost during follow-up. Consequently, its complication comparisons cannot be generalized to all patients initially considered for surgery or used to establish mortality safety. Care at high-volume Japanese centers and the predominance of posterior decompression further limit extrapolation to other settings or procedure mixes.

Only 35 patients were underweight and 86 had obesity, without a separate analysis of severe obesity classes. Rare complications and modest clinical differences could therefore have been missed. The authors’ post hoc analysis indicated limited power for JOA and mental-component changes; nonsignificant findings are not evidence of equivalence. BMI also does not characterize muscle mass, nutritional status or visceral adiposity. Two years is insufficient to settle long-term adjacent-segment disease, reoperation or progressive alignment changes. Finally, inconsistencies in some tabulated variability labels and secondary outcome intervals warrant caution when interpreting precise estimates.

Clinical takeaway

In this selected surgical cohort, a higher BMI was associated with greater operative demands but not a statistically significant reduction in two-year neurological improvement. The findings argue against treating BMI alone as a reliable predictor of poor recovery. They do not establish a universal BMI threshold for proceeding with surgery, prove equal complication risk, or test whether preoperative weight reduction changes outcomes. Clinical severity, anatomy, comorbidities and the planned operation remain central to individualized assessment.

Operative Neurosurgery 31:431–444, 2026

Planning anterior lumbar interbody fusion requires distinguishing the lordosis built into an implant from the additional correction achieved at the treated segment. Hamouda and colleagues examine how baseline alignment, cage characteristics, operative level and posterior fixation contribute to this relationship. By comparing intraoperative and postoperative imaging, their study also addresses whether the correction obtained during surgery is maintained on standing. The findings support individualized alignment planning, while cautioning against interpreting implant geometry or the choice of construct as an isolated determinant of surgical success.

Objective

To identify predictors of postoperative intradiscal lordosis and its change from baseline after one- or two-level ALIF, and to evaluate the relationship between intraoperative supine alignment and early postoperative standing measurements.

Methods

This retrospective, single-center study included 204 adults treated between 2019 and 2023 at 258 levels: 80 at L4–5 and 178 at L5–S1. Ninety patients underwent stand-alone ALIF and 114 received supplementary posterior instrumentation. Patients with prior lumbar interbody fusion, surgery for trauma, tumor or infection, combined interbody approaches, or pelvic fixation were excluded.

The authors reviewed standing preoperative radiographs, intraoperative images and postoperative standing radiographs, obtained a median of two days after surgery. Measurements included intradiscal lordosis, disc height, spinopelvic alignment, implant dimensions and cage position. Separate regression models evaluated the final intradiscal angle and the change from baseline. Median overall follow-up was 12.4 months, although the principal alignment comparisons concerned the early postoperative period.

Main results

Tables 2 and 3 report a median intradiscal lordosis of 6.7° before surgery and 17.8° postoperatively, with a median individual change of 10.4°. The median gain was 8.1° after stand-alone ALIF and 11.5° with posterior instrumentation. The between-construct difference was significant at L5–S1, but not at L4–5.

Greater cage lordosis, greater baseline intradiscal lordosis, L5–S1 implantation and posterior instrumentation independently predicted a larger postoperative angle. Each additional degree of implant lordosis was associated with 0.62° greater postoperative intradiscal lordosis (95% CI 0.44–0.79). This coefficient describes the adjusted association with the final angle, not the correction gained from baseline.

The separate change model showed that greater preoperative lordosis was associated with less additional correction. Thus, achieving a larger final angle and gaining more lordosis are distinct outcomes.

Intraoperative imaging showed no significant additional increase in intradiscal lordosis after posterior instrumentation compared with the preceding post-ALIF measurement. The authors considered differences in initial correction and maintenance of alignment on standing as possible explanations for the better results in the circumferential group, rather than attributing them solely to posterior corrective maneuvers.

Interpretation — operative relevance

The most useful planning distinction is between the intended final segmental angle and the additional correction required to reach it. A cage’s stated lordosis should not be presented as the expected angular gain. A segment with relatively preserved baseline lordosis may reach a larger final angle while requiring less correction than a more collapsed disc space.

The operative description emphasizes trial selection that provides contact with both vertebral endplates without excessive distraction. This is relevant to the balance between restoring alignment and avoiding an unnecessarily aggressive increase in disc height. The study does not establish a numerical distraction limit or demonstrate that selecting the tallest or most lordotic available implant improves clinical outcomes.

Posterior fixation was associated with greater correction, particularly at L5–S1, but the intraoperative comparisons do not show that the posterior stage itself reliably adds lordosis. The decision to supplement the anterior construct therefore requires the broader stabilization and decompression assessment; the reported group difference is not, by itself, an indication for instrumentation. In the described practice, an open posterior approach was generally used when decompression was also needed, whereas percutaneous fixation was favored when stabilization alone was required.

Finally, intraoperative alignment should be interpreted in relation to postoperative standing measurements. The study supports attention to this transition, but does not provide a validated patient-specific formula for predicting standing correction from a supine image.

Limitations

The retrospective design and nonrandom selection of constructs prevent causal conclusions. Baseline alignment differed between groups, and implant selection and endplate preparation depended on surgeon judgment. The heterogeneous indications also limit the ability to isolate the influence of individual anatomical features or technical maneuvers. Patient-reported outcomes were not available, so greater radiographic correction cannot be equated with better pain relief, function or long-term clinical benefit.

There are internal numerical discrepancies between the abstract, narrative and tables. The overall descriptive values above follow the concordant entries in Tables 2 and 3; conflicting subgroup estimates have not been used to define a quantitative treatment target.

Clinical takeaway

Define the required correction before selecting the implant, distinguish angular gain from final lordosis, and consider the treated level and fixation strategy together. This study supports anatomically informed ALIF planning and assessment of achieved alignment, rather than maximizing cage dimensions or assuming that posterior instrumentation will automatically produce further correction.