Category: Spine

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Outcomes after cervical disc replacement compared with anterior cervical discectomy and fusion at medium- to long-term follow-up

Neurosurg Focus 61(1):E5, 2026

This retrospective propensity score–matched analysis of 18,916 adults compares long-term functional and surgical outcomes after cervical disc replacement (CDR) versus anterior cervical discectomy and fusion (ACDF) using a large federated EHR network. Results across 6 months to 5 years show consistently lower risks after CDR for anterior reoperation, posterior revision, adjacent segment disease, new-onset cervical pain, ADL dependence, and surgical site infections.

The study emphasizes durable biomechanical advantages of motion-preserving CDR, with sustained reductions in opioid use and functional impairment at 5 years, while acknowledging limitations of EHR-based retrospective study design, potential selection bias, and absence of granular radiographic and patient-reported outcome data.

Objective Compare long-term functional and clinical outcomes of cervical disc replacement (CDR) versus anterior cervical discectomy and fusion (ACDF) for degenerative cervical disc disease, focusing on whether motion preservation reduces adjacent segment disease and reoperation.

Methods Queried TriNetX EHR network for adults (≥18) undergoing CDR or ACDF for degenerative indications; performed 1:1 propensity score matching and assessed outcomes from 6 months to 5 years, including Kaplan–Meier analyses for reoperation/adjacent segment disease.

Cohort After matching, 9458 patients were included in each group (mean age 48 years).

Reoperation & pain Across follow-up time points, CDR was associated with lower risk of anterior reoperation (RR 0.62, 95% CI 0.52–0.74) and new-onset cervical pain (RR 0.64, 95% CI 0.55–0.73) versus ACDF.

Infection At 1-, 2-, and 5-year follow-ups, CDR showed lower surgical site infection risk (RR 0.62, 95% CI 0.48–0.78).

Sagittal alignment No difference between groups in coding for acquired cervical kyphosis/lordosis after 2 years (p > 0.05).

Opioids (5-year) At 5 years, CDR was associated with lower opioid use (RR 0.66, 95% CI 0.54–0.82).

Conclusion & caution Results suggest superior long-term outcomes with CDR versus ACDF, but interpretation should be cautious due to limitations of retrospective EHR-based analyses; CDR is presented as a viable alternative for degenerative cervical pathologies.

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Diabetes as a significant risk factor for postoperative dysphagia following cervical spine surgery

J Neurosurg Spine 45:19–29, 2026

This clinical study evaluates whether preoperative diabetes increases the risk and severity of postoperative dysphagia after cervical spine surgery, using prospectively collected multi-institutional registry data and validated EAT-10 scores at baseline and 1, 3, and 12 months. Multivariable mixed-effects logistic regression identified diabetes as an independent predictor of dysphagia at 1 and 3 months, with higher incidence and worse PROMs in diabetic patients.

The cohort of 2001 patients (20% with diabetes) demonstrated significantly greater new postoperative dysphagia and higher EAT-10 score changes among diabetics, particularly after anterior procedures; however, diabetes did not independently predict dysphagia at 12 months. The authors discuss clinical implications, limitations (lack of HbA1c and neuropathy data), and recommend surgeons counsel patients about elevated short-term dysphagia risk.

Objective Relationship between preoperative diabetes and incidence of postoperative dysphagia after cervical spine surgery, assessed using EAT-10 at baseline and 1, 3, and 12 months post-op

Cohort 2001 cervical spine surgery patients; 400 (20%) had diabetes; baseline dysphagia rates were not significantly different (18% diabetes vs 14% no diabetes)

Higher dysphagia rates Patients with diabetes had higher postoperative dysphagia incidence at 1 month (66% vs 54%), 3 months (39% vs 26%), and 12 months (33% vs 24%)

Independent prediction (all patients) After adjusting for baseline dysphagia and other factors, diabetes independently predicted postoperative dysphagia at 1 month (OR 1.46) and 3 months (OR 1.63), but not at 12 months (OR 1.21)

New dysphagia (no baseline dysphagia) Among patients without baseline dysphagia, diabetes was associated with higher new dysphagia at 1 month (62% vs 50%), 3 months (34% vs 21%), and 12 months (27% vs 18%)

Independent prediction (new dysphagia) In those without baseline dysphagia, diabetes independently predicted new dysphagia at 1 month (OR 1.49) and 3 months (OR 1.81), but not at 12 months (OR 1.31)

Symptom severity change Mean EAT-10 change from baseline to 12 months was worse with preoperative diabetes (2.440 ± 5.013 vs 1.688 ± 4.139) among those without baseline dysphagia

Conclusion Diabetes is a significant risk factor for postoperative dysphagia after cervical spine surgery, with strongest independent effect at early time points (1 and 3 months)

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Multiple-level (≥ 3) cervical artificial disc replacement: illustrative case and systematic review of the literature

Neurosurg Focus 61(1):E8, 2026

This systematic review and illustrative case evaluate outcomes of multilevel (≥3 levels) cervical artificial disc replacement (C-ADR), synthesizing data from five studies and one clinical example to assess pain relief, functional recovery, range-of-motion preservation, complications, and reoperation rates. The review reports consistent, durable improvements in VAS and NDI scores, preserved segmental and global cervical motion, low revision rates, and primarily transient complications across 3- and 4-level cohorts.

The article compares multilevel C-ADR with anterior cervical discectomy and fusion (ACDF), emphasizing motion-preserving biomechanical advantages that may reduce adjacent segment degeneration. Limitations include sparse, mostly retrospective data, heterogeneous reporting, and limited long-term follow-up, prompting a call for larger prospective trials and extended surveillance for implant longevity and ASD risk.

Objective Characterize outcomes and complications after multilevel (≥ 3 levels) cervical artificial disc replacement (C-ADR), including an illustrative 3-level case for technical discussion.

Methods Systematic review conducted per PRISMA guidelines, querying PubMed and MEDLINE (August 2025) for primary peer-reviewed studies reporting ≥ 3-level C-ADR outcomes, including range of motion (ROM) preservation and complications.

Clinical outcomes Across 5 studies of 3- and 4-level C-ADR, patients had substantial, durable improvements in pain, disability, and quality of life (e.g., neck/arm VAS decreases > 50%) with benefits reported up to 7 years.

Motion preservation Multilevel C-ADR preserved segmental and global cervical ROM, contrasting with near-complete loss of motion reported after multilevel fusion comparators.

Adjacent segment disease No cases of symptomatic adjacent segment degeneration requiring reoperation were reported in the reviewed multilevel C-ADR studies.

Complications/reoperation Complication rates were low and mostly transient; reoperation was required in only 0%–2% of cases across included studies.

Illustrative case A 50-year-old man with progressive cervical myeloradiculopathy underwent 3-level C-ADR (C4–5, C5–6, C6–7) with uncomplicated recovery, immediate symptom relief, and return to unrestricted activity by 6 weeks with preserved motion at 6 months.

Conclusions/limitations 3- and 4-level C-ADR appears safe and effective for appropriately selected patients with durable pain relief and low revision rates, but evidence remains limited (only five stratified studies; largely retrospective) and devices are not FDA-approved for ≥ 3 levels.

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Use of pelvic incidence to predict proximal junctional failure in long-segment spinal fusion

J Neurosurg Spine 45:44–54, 2026

This clinical study evaluates how pelvic incidence (PI) affects spinopelvic correction and proximal junctional failure (PJF) after long-segment thoracolumbar fusion with pelvic fixation in 204 adult spinal deformity patients. Patients were stratified by PI (<55° vs >55°) and analyzed for radiographic outcomes, complications, and PROMs using frequentist and Bayesian models.

Key findings show lower PI independently predicts higher PJF risk (21% vs 9%), with lower thoracic UIV and revision surgery as additional predictors; lower PI patients more often met age-adjusted alignment goals but experienced greater overcorrection relative to individualized morphology.

Objective Evaluate how pelvic incidence (PI) affects spinopelvic correction and complication rates (especially proximal junctional pathology) after long-segment fusion for adult spinal deformity.

Cohort Retrospective analysis of 204 patients undergoing open posterior long-segment thoracolumbar fusion with pelvic fixation (≥ 6 levels) with ≥ 1-year follow-up; grouped by PI cutoff 55° into lower PI (n=108) vs higher PI (n=96).

Primary finding (PJF rates) Lower PI patients had higher proximal junctional failure (PJF) at 1 year than higher PI patients (21% vs 9%, p=0.019).

UIV subgroup With an upper thoracic UIV (T2–5), PJF was 15% in lower PI vs 0% in higher PI (p=0.014).

Independent predictors Multivariate analysis: lower PI (OR 4.3, p=0.006), lower thoracic UIV (T10–12) (OR 6.5, p=0.005), and revision surgery (OR 23.8, p=0.001) independently predicted PJF.

Model confirmation Bayesian mixed-effects modeling also identified lower PI (OR 6.25, posterior probability 0.996) and lower thoracic UIV (OR 7.03, posterior probability 0.997) as significant predictors of PJF.

PJK vs PJF Proximal junctional kyphosis (PJK) rates were similar between PI groups at 1 year (38% vs 41%, p=0.697), despite the PJF difference.

Planning implication Preoperative PI morphology may guide individualized surgical planning to reduce risk of junctional pathology, since lower PI carried higher PJF risk after long-segment fusion.

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Safety and Efficacy of Real-Time Intraoperative Ultrasound-Guided Posterolateral Thoracic Diskectomy

Operative Neurosurgery 31:20–27, 2026

This article reports a single-center retrospective case series evaluating real-time intraoperative ultrasound (IOUS)-guided posterolateral thoracic diskectomy for symptomatic thoracic disk herniation (TDH). The study of 32 patients (41 levels) demonstrates significant reductions in pain and Nurick scores, low blood loss, moderate operative times, no postoperative complications, and high fusion rates at follow-up.

The manuscript details patient selection, surgical technique using IOUS for direct ventral cord visualization during posterolateral diskectomy, perioperative outcomes, and limitations. Authors conclude IOUS-guided posterolateral diskectomy is a safe, effective, and broadly adoptable method that improves decompression while minimizing morbidity compared with traditional anterior or lateral approaches.

Clinical problem: Thoracic disk herniation surgery is technically challenging because the thoracic canal is narrow and the spinal cord blocks direct access/visualization of ventral pathology.

Technique: Real-time intraoperative ultrasound (IOUS) is used during a posterolateral thoracic diskectomy to directly visualize the spinal cord and TDH, guide instrument positioning, and confirm decompression intraoperatively.

Study design: Retrospective single-surgeon series of symptomatic TDH patients treated with IOUS-guided posterolateral diskectomy from May 2020 to Feb 2025 at a major academic center.

Cohort details: 32 patients (41 levels); 50% had calcified disks (n=16), predominantly central lesions (n=13), including 2 “giant” TDHs (>40% canal).

Key operative steps: Laminectomy and partial bony removal (including <¼ pedicle), creation of a cavity by removing small cranial/caudal endplate portions, then using an ultrasound-visualized curette to push the disk fragment ventrally into the cavity for safe removal, with repeat IOUS confirmation of anterior cord decompression.

Clinical outcomes: Significant improvement in pain and neurological/ambulatory function (VAS 5.9±2.0 to 1.8±1.2; Nurick 2.8±0.7 to 1.0±0.8; P<.001 for both).

Perioperative metrics: Mean operative time 132.8±32.9 minutes, mean blood loss 118.1±77.6 mL, and average length of stay 4.7±2.6 days.

Safety/fusion: No postoperative complications were observed; among those with ≥1-year follow-up (30/32), all achieved Lenke-Bridwell Grade A or B fusion without pseudarthrosis or revision surgery.

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Adjacent segment disease treated with stand-alone lateral lumbar interbody fusion: an analysis of domino adjacent segment revisions

J Neurosurg Spine 44:884–893, 2026

This clinical study compares stand-alone lateral lumbar interbody fusion (LLIF) with circumferential LLIF plus posterior instrumentation for treating adjacent segment disease (ASD) after prior posterior lumbosacral fusion. Primary outcome focused on “domino” proximal ASD revisions, with secondary measures including cage subsidence, radiographic alignment, and perioperative metrics.

Results from 236 patients show stand-alone LLIF had significantly lower 5-year domino ASD revision rates, shorter operative times and hospital stays, and comparable alignment despite higher rates of moderate-to-severe cage subsidence. Multivariable and competing-risk analyses supported stand-alone LLIF’s protective association against subsequent adjacent-segment reoperations.

Objective Assess whether stand-alone LLIF is a durable ASD revision strategy with lower risk of subsequent “domino” adjacent-segment revision compared with circumferential LLIF (LLIF + posterior fusion extension).

Design/Methods Single-center retrospective cohort (Jan 2008–Aug 2023) of patients with prior posterior lumbosacral fusion undergoing ASD revision via stand-alone vs circumferential LLIF; primary outcome was domino ASD revision; survival analysis and multivariable Cox regression used, adjusting for alignment, stenosis severity, and fused levels.

Cohort 236 patients included (131 stand-alone; 105 circumferential); baseline demographics/treated levels similar; preop MRI showed more severe central stenosis in the circumferential group (more Schizas grade D).

Primary outcome Stand-alone LLIF had a lower 5-year incidence of domino ASD revision (13.7% vs 28.6%, p = 0.005).

Adjusted association After multivariable adjustment, stand-alone LLIF remained independently associated with fewer domino ASD revisions (HR 0.43, 95% CI 0.23–0.79; p = 0.007).

Radiographic outcomes Overall radiographic alignment was comparable between groups, but stand-alone LLIF had higher cage subsidence (Marchi grade ≥ II: 22.9% vs 9.5%, p = 0.019), and subsidence was not associated with increased revision risk.

Perioperative outcomes Stand-alone LLIF had significantly shorter operative time and hospital stay than circumferential LLIF (with lower blood loss also reported).

Conclusion Stand-alone LLIF is supported as a treatment option for ASD after prior posterior fusion, with less domino ASD revision and similar radiographic alignment, at the cost of higher subsidence rates.

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Ventral Spinal Cord Displacement: A Guide to Differentiating Spinal Cord Herniation From Dorsal Arachnoid Web

Operative Neurosurgery 30:977–984, 2026

This article reviews imaging and operative distinctions between spinal arachnoid webs (SAW) and spinal cord herniation (SCH), using two detailed case illustrations with narrated 2-D operative videos. It highlights diagnostic imaging features, intraoperative findings, and tailored surgical techniques to optimize differentiation and management.

Focusing on technical nuance, the paper contrasts midline-sparing unilateral laminectomy and arachnoid lysis for SAW with bilateral laminectomy, cord mobilization, and ventral alloderm sling reconstruction for SCH, and emphasizes intraoperative ultrasound and neuromonitoring for safe reduction and decompression.

Problem: Spinal arachnoid web (SAW) and spinal cord herniation (SCH) can present similarly (myelopathy/radiculopathy) and both often look like focal anterior cord displacement on MRI, yet require very different operative strategies.

Definitions: SAW is abnormally thickened arachnoid tissue in the subarachnoid space that can tether/compress the cord and disrupt CSF flow (edema/syrinx), while SCH is cord displacement through an opening in the dura/arachnoid (often ventral).

Imaging workup: CT myelography is recommended to evaluate/confirm suspected findings because its resolution can outperform MRI for distinguishing these entities.

Key imaging clues: Visible ventral CSF between cord and ventral dura argues against herniation, while absence of ventral CSF supports SCH; cord twisting at the abnormal level is a more specific sign for SCH; the “scalpel sign” is commonly linked to SAW but can occur in both.

Limits of imaging: Arachnoid webs are below MRI/CT resolution, and diagnostic patterns are imperfect (reported SAWs can lack the scalpel sign or mimic SCH on CT myelogram).

SAW surgery: Definitive treatment is lysis/excision of the thickened arachnoid band, often via laminectomy with ultrasound localization; dentate ligament division can help inspect the ventral compartment to exclude ventral pathology.

SCH surgery: Management typically uses wider exposure (often bilateral laminectomy), spinal cord mobilization/rotation (sectioning dentate ligaments ± dorsal rootlets), reduction of the herniation, and placement/suturing of a ventral alloderm sling to span the dural defect, with close neuromonitoring and ultrasound confirmation.

Outcomes in cases: SAW case showed postoperative normalization of cord position and complete syrinx regression after web excision/lysis; SCH case showed complete reduction of herniation on postoperative MRI with substantial functional improvement (including near-resolution of bowel/bladder symptoms).

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The posterior approach for removal of all thoracic disc herniations

J Neurosurg Spine 44:876–883, 2026

his single-surgeon series evaluates a posterior partial transpedicular approach for symptomatic thoracic disc herniation augmented by intraoperative ultrasound (IOUS) and ultrasonic aspiration (UA). Over 108 patients (137 discs) treated from 2012–2024, the technique produced significant neurological improvement with an acceptable complication and reoperation profile.

The report details patient selection, operative steps, radiographic grading, neuromonitoring use, outcomes (Frankel grade improvements), and multivariate predictors, highlighting the method’s versatility for giant and calcified herniations and its accessibility to general spine surgeons.

Clinical problem Thoracic disc herniation is surgically challenging due to ventral location, frequent calcification, and risk of severe neurologic compromise; anterior/lateral approaches can be effective but carry substantial morbidity and technical demands.

Study aim Evaluated safety, efficacy, and versatility of a posterior partial transpedicular discectomy augmented with intraoperative ultrasound (IOUS) and ultrasonic aspiration (UA) for symptomatic TDH.

Cohort & design Retrospective single-surgeon series of 108 consecutive patients (137 TDHs) treated from 2012–2024; outcomes tracked with Frankel grades preop, 3–6 months, and final follow-up; multivariate regression used to identify predictors of improvement.

Key technique Posterior midline exposure with laminectomy, <50% medial facetectomy, and superomedial caudal pedicle removal using UA to create a corridor; IOUS used after laminectomy, during ventral work, and after resection to confirm decompression and detect residual/migrated fragments; IONM used in all cases.

Case mix severity Most patients presented with myelopathy (86.1%); many discs were giant (>40% stenosis, 68.6%) and frequently calcified (complete 38.7%, incomplete 21.2%).

Neurologic outcomes Mean Frankel grade improved from 3.77 preop to 4.54 at last follow-up (p < 0.001); 61.1% improved by ≥1 Frankel grade; follow-up for the primary outcome was 100%.

Safety & complications IOUS and UA enabled safe decompression in all cases; reoperation-requiring complications occurred in 9.3% (most commonly reherniation 4.6%); no postoperative CSF leaks through the wound were reported.

Predictors & conclusion Less neurologic improvement was associated with diabetes and obesity (and heart disease); overall conclusion: posterior partial transpedicular approach with IOUS and UA is safe, effective, and broadly applicable for TDH (including large/calcified lesions) and can be adopted by general spine surgeons.

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A novel interpretable classification of lumbar spinal stenosis using a cascade deep learning approach and T2-weighted MRI

J Neurosurg Spine 44:847–857, 2026

This clinical article presents a fully automated, interpretable three-stage deep learning pipeline for detecting and grading lumbar spinal stenosis (LSS) using axial T2-weighted MRI. The framework integrates region classification, YOLO-based ROI detection, and CNN-based severity grading, validated on internal (640 patients, 17,440 slices) and external (515 patients, 8,000 slices) datasets with high accuracy and explainability via Grad-CAM.

The study details dataset curation, model architectures (ResNet-18, RegNetX-400MF, EfficientNet-B0, YOLOv5/8), training protocols, evaluation metrics, and clinical implementation pathways, highlighting strengths, limitations (single-rater labels, class imbalance, 2D slice analysis), and future directions toward volumetric and multi-expert validation.

Objective Standardize and automate lumbar spinal stenosis (LSS) identification, classification, and grading from axial T2-weighted lumbar MRI to reduce diagnostic variability.

Pipeline Three-stage cascade: (1) classify slices into sacral/lumbar/thoracic regions, (2) detect and crop anatomical ROIs, (3) grade LSS as binary or multiclass severity.

Datasets Internal training set: 640 patients with 17,440 retained axial T2 slices; external validation set: 8000 preprocessed, neurosurgeon-graded axial slices from an open-access dataset (515 patients).

Grading scheme Labels follow Schizas central canal stenosis grades A–D; a binary version groups A+B as nonstenotic and C+D as clinically significant stenosis.

Models Lightweight CNN backbones (ResNet-18, RegNetX-400MF, EfficientNet-B0) used for stages 1 and 3; YOLOv5/YOLOv8 used for ROI detection.

Validation approach Patient-level splits with 10-fold cross-validation to reduce overfitting and data leakage; an independent internal test set (62 patients, 1679 slices) reserved for final evaluation.

Performance Achieved 97.87% accuracy for binary LSS grading and 95.52% accuracy for multiclass grading, outperforming prior models in this setting.

Interpretability & clinical aim Grad-CAM heat maps highlight regions influencing predictions to support trust and potential workflow integration as an interpretable decision-support tool.

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Using the Quality Outcomes Database to Identify Minimum Clinically Important Differences for Patients With Cervical Spondylotic Myelopathy

Neurosurgery 98:1347–1358, 2026

This multicenter retrospective analysis of 1,141 surgical cases from the Quality Outcomes Database defines optimal minimum clinically important differences (MCIDs) for commonly used patient-reported outcome measures (PROMs) in cervical spondylotic myelopathy (CSM). The study compares several MCID calculation methods using AUCs anchored to patient satisfaction at 3- and 24-month follow-ups to identify the most predictive thresholds.

Key findings report a ≥30% improvement from baseline as the preferred MCID for NDI and neck/arm NRS, severity-adjusted point increases for mJOA, and absolute numeric cutoffs for EQ-5D (0.065 at 3 months; 0.149 at 24 months). Achievement rates and implications for clinical decision-making and benchmarking across centers are provided.

Aim Identify the most appropriate MCID thresholds for common PROMs in surgical cervical spondylotic myelopathy (CSM) using the Quality Outcomes Database (QOD) cohort.

Cohort Analyze 1141 CSM surgical cases across 14 sites (enrolled 2016–2018) with a 24-month follow-up rate of 87.6% (excluding 2.5% deaths).

PROMs Use baseline, 3-month, and 24-month outcomes for NDI, EQ-5D (QALYs), mJOA, and neck/arm pain NRS, with patient satisfaction as the anchor.

Anchor/AUC method Define “satisfied” using the NASS satisfaction scale (responses 1–2) vs “not satisfied” (3–4), then compare MCID methods by AUC for predicting satisfaction.

NDI & pain MCID A ≥30% improvement from baseline is the preferred/optimal MCID benchmark for NDI and neck/arm pain NRS (close to the best-performing ROC-derived percentage cutoffs).

EQ-5D MCID Absolute numeric cutoffs outperform other methods for EQ-5D: +0.065 QALYs (3 months) and +0.149 QALYs (24 months).

mJOA MCID A severity-adjusted approach performs best for mJOA: improvement of ≥1 (mild), ≥2 (moderate), or ≥3 (severe) points.

MCID achievement (24 months) MCIDs are achieved by 63% (NDI), 59% (neck pain NRS), 61% (arm pain NRS), 52% (EQ-5D), and 59% (mJOA) of patients.

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Same-day spine surgery at an ambulatory surgical center versus hospital outpatient department

J Neurosurg Spine 44:835–846, 2026

This clinical study compares safety, complications, and patient-reported outcomes for same-day anterior cervical arthrodesis/arthroplasty and lumbar decompression performed in ambulatory surgical centers (ASC) versus hospital outpatient departments (HOPD) using a propensity-matched statewide registry. Primary outcomes included complication rates, return to OR, ED visits, and readmissions; secondary outcomes assessed PROMs and return-to-work at 90 days and 1 year.

Matched analysis of 3,351 lumbar decompressions and 806 anterior cervical procedures found no differences in PROs between ASC and HOPD, comparable safety for anterior cervical surgery, but a slightly higher rate of return to OR—driven by reherniation—for lumbar decompression performed in ASCs. Authors recommend future cost-effectiveness and patient-selection research.

Objective Compare safety and outcomes of same-day discharge anterior cervical arthrodesis/arthroplasty (1–2 levels) and lumbar decompression performed in an ambulatory surgical center (ASC) versus a hospital outpatient department (HOPD).

Design/Data source Retrospective, propensity-matched comparative cohort analysis using the statewide Michigan Spine Surgery Improvement Collaborative (MSSIC) registry for cases from Jan 1, 2021 to Jun 30, 2023.

Matching approach HOPD:ASC cohorts matched 4:1 using BMI, ASA class, and number of operative levels to improve comparability and power.

Primary outcomes Assessed any complication, return to operating room (OR) within 90 days, and ED visit or readmission within 30 and 90 days; secondary outcomes included PROs at 90 days/1 year and return to work.

Sample size (matched) Included 3351 lumbar decompressions (2679 HOPD, 672 ASC) and 806 anterior cervical cases (644 HOPD, 162 ASC).

Cervical results No significant ASC vs HOPD differences for complications, PROs at 90 days or 1 year, or return to work at 90 days or 1 year (p > 0.05).

Lumbar results (safety) ASC had higher rates of any complication (8% vs 5.5%) and return to OR (4.9% vs 2.1%) than HOPD in univariate analysis, and this persisted in multivariate analysis (IRR 1.5 for any complication; IRR 2.3 for return to OR).

Lumbar results (driver & outcomes) Elevated return-to-OR risk in ASC was driven primarily by lumbar reherniation requiring reoperation (3.2% ASC vs 1.0% HOPD), while PROs at 90 days and 1 year were otherwise similar between settings.

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How much do patients benefit in quality of life after surgery for cervical spondylotic myelopathy? A Spine CORe™ analysis of QOD data

Neurosurg Focus 60(5):E2, 2026

This multicenter Quality Outcomes Database analysis evaluates long-term quality of life after surgery for cervical spondylotic myelopathy (CSM), using EQ-5D scores at baseline and 3, 12, 24, and 60 months. The study reports significant, durable postoperative EQ-5D improvements and a mean gain of 0.72 QALYs at five years across a large surgical cohort.

The analysis identifies predictors of clinically meaningful improvement: worse baseline EQ-5D increased odds of improvement, while greater baseline neck pain severity and undergoing anterior cervical corpectomy and fusion (ACCF) decreased those odds. Complication and mortality rates were low, supporting sustained quality-of-life benefits of CSM surgery.

Objective Assess long-term postoperative quality-of-life benefit after surgery for cervical spondylotic myelopathy (CSM) and identify factors linked to meaningful improvement.

Methods Post hoc analysis of a prospectively collected, 14-site QOD CSM cohort using EQ-5D at baseline and 3, 12, 24, and 60 months; MCID for EQ-5D defined as 0.11; multivariable logistic regression used to find predictors of 60-month MCID achievement.

Cohort At 60 months, follow-up status was available for 895/1085 patients (82.4%); 788 patients had 60-month EQ-5D data for the main EQ-5D analysis.

Quality-of-life gains Mean EQ-5D improved from 0.58 ± 0.22 preop to 0.76 ± 0.22 at 60 months (p < 0.001), with improvements evident by 3 months and sustained through 5 years.

Clinically meaningful benefit 58.7% of patients achieved the EQ-5D MCID at 60 months.

Negative predictors Greater baseline neck pain severity and undergoing ACCF (anterior cervical corpectomy and fusion) were independently associated with lower odds of achieving the 60-month EQ-5D MCID.

Positive predictor Worse baseline quality of life (lower baseline EQ-5D) was associated with increased odds of achieving long-term (60-month) MCID improvement.

QALYs Mean gain after surgery was 0.72 ± 1.11 QALYs over 60 months (calculated via area-under-the-curve with baseline-projected QALYs subtracted).

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Incidence and risk factors of adjacent segment degeneration in lumbosacral or lumbo-iliac fusion with L2 as the uppermost instrumented vertebra

J Neurosurg Spine 44:693–703, 2026

This clinical retrospective study evaluates the incidence and risk factors for symptomatic adjacent segment degeneration (ASD) after instrumented fusion from L2 to the sacrum or ilium in 89 adults treated for diffuse lumbar degeneration or mild–moderate deformity. Over a mean 38.6-month follow-up, 40% developed symptomatic L1–2 ASD and 23.6% required revision, with Kaplan-Meier ASD-free rates of 79% at 1 year and 59% at 3 years.

Multivariate analysis identified L2–3 decompression, preexisting advanced L1–2 disc degeneration, greater postoperative PI–LL mismatch, and higher lordosis distribution index as independent ASD risk factors; distal failures (13.5%) were linked to male sex, younger age, and absence of iliac screws. The authors recommend careful selection of L2 as UIV, balanced lordosis restoration, and consideration of pelvic fixation to mitigate proximal and distal complications.

Aim Quantify incidence of symptomatic adjacent segment degeneration (ASD) after instrumented fusion from L2 (UIV) to sacrum or ilium and identify associated risk factors.

Design/definition Retrospective review (Jan 2016–Dec 2023) of adults undergoing first-time L2–S1/ilium fusion; symptomatic ASD defined by new/worsening pain or neurologic symptoms with L1–2 degenerative/junctional changes (e.g., disc degeneration/stenosis progression, listhesis, junctional kyphosis, fracture, or UIV fixation failure).

Cohort 89 patients (mean age 68.5 years) with mean follow-up 38.6 months.

ASD incidence 36/89 (40%) developed symptomatic ASD at L1–2; mean time to ASD 21 months; 21/89 (23.6%) required reoperation.

ASD-free survival Kaplan-Meier ASD-free rates: 79% at 1 year, 68% at 2 years, 59% at 3 years (mean ASD-free period 52.8 months).

ASD risk factors Higher ASD risk associated with simultaneous decompression at L2–3, preexisting advanced L1–2 disc degeneration, greater postoperative PI-LL mismatch, and higher lordosis distribution index (LDI).

Distal failure incidence 12/89 (13.5%) developed distal failure (including 9 L5–S1 pseudarthroses, 2 sacral fractures, 1 rod fracture); mean time 19 months.

Distal failure risk factors Male sex, younger age, and lack of iliac screws increased risk of distal failure.

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Disruptive technologies in spine surgery: current trends, outcomes, and ethical implications

J Neurosurg Spine 44:756–768, 2026

Disruptive technologies in spine surgery—AR/VR, robotics, neuronavigation, endoscopy, and patient-specific implants—are examined for their roles in enhancing precision, training, and patient outcomes. The review summarizes evidence for preoperative simulation, AR-assisted planning, and 3D segmentation, highlighting improvements in accuracy, reduced fluoroscopy, and trainee confidence.

Intraoperative advances such as robot-assisted techniques, computer-assisted navigation, and endoscopic approaches offer minimally invasive alternatives with favorable recovery profiles but face challenges of cost, learning curves, and equitable access. The authors emphasize ethical considerations, need for standardized outcomes, and strategies to expand accessibility and training.

Scope Disruptive spine-surgery technologies emphasized include AR/VR (XR), advanced navigation, robotics, patient-specific implants/3D printing, and endoscopic spine surgery.

XR definitions VR provides a fully immersive digital environment, AR overlays digital content onto the real world, and MR blends both; all fall under XR.

Training impact VR simulation in spine training improved trainee comfort and autonomy and reduced fluoroscopy use in lateral lumbar interbody fusion simulations; VR-trained learners also made fewer pedicle-screw placement errors than traditional instruction.

Preop planning VR-based planning can reduce fluoroscopy/localization time and improve puncture accuracy in endoscopic lumbar discectomy; segmented 3D models support rehearsal, trajectory planning, and risk assessment around critical structures.

AR navigation outcomes Wearable AR navigation (e.g., FDA-cleared xvision) has shown high pedicle-screw placement accuracy (reported ~96.7% thoracic and ~99.1% lumbosacral) and may reduce operative time and radiation exposure.

Patient-specific surgery Segmentation + 3D printing/predictive modeling enable personalized approaches and implants (e.g., patient-specific rods, templates, custom cages), with early reports of high accuracy for template-guided instrumentation and promising feasibility for custom interbody devices.

Endoscopic techniques ESS supports minimally invasive treatment across multiple pathologies and can match conventional outcomes for lumbar disc herniation while improving recovery (e.g., shorter stays/earlier return to work), but broader adoption is constrained by learning curve and reimbursement challenges.

Implementation ethics/costs High acquisition/maintenance costs and limited reimbursement risk widening access disparities; recommended mitigations include subsidized training, shared equipment models, and reimbursement policies to support equitable implementation alongside standardized outcomes and training.

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The Timing of Diskectomy as a Predictor of Outcomes in Patients With Lumbar Disk Herniation

Neurosurgery 98:1051–1062, 2026

This prospective cohort study evaluates how the duration of preoperative symptoms influences outcomes after microdiskectomy for lumbar disk herniation. Outcomes measured include radicular pain, low back pain, disability (ODI), and motor and sensory deficits, with follow-up at 6 weeks, 6, 12, and 24 months in 1,120 analyzed patients.

Key finding: surgical intervention within one month of symptom onset yields faster, more pronounced pain relief and neurological recovery, whereas symptoms persisting beyond two years associate with the highest rates of residual motor and sensory deficits at 24 months.

Objective Evaluate how the preoperative duration of low back pain, disability, radicular leg pain, and motor/sensory deficits relates to postoperative outcomes after microdiskectomy for lumbar disk herniation (LDH).

Design/setting Prospective cohort (April 2015–October 2022) of adults undergoing microdiskectomy for symptomatic LDH with imaging-confirmed herniation consistent with symptoms.

Assessments & follow-up Pain measured by NRS, disability by ODI, motor deficit by MRC grading, sensory deficit as present/absent; assessed pre-op and at 6 weeks, 6, 12, and 24 months post-op.

Cohort size 1222 patients enrolled; 69 recurrences and 33 lost to follow-up excluded, leaving 1120 for statistical analyses.

Symptom-duration grouping Patients categorized by symptom duration thresholds ≤1, ≤6, ≤24, and ≥25 months for LDH-related symptoms (pain/disability/neurologic symptomatology).

Key outcome (timing) Surgery performed within 1 month of symptom onset was associated with more favorable outcomes than longer symptom duration, including faster improvement in neurological deficit and more significant radicular pain relief.

Residual deficits at 2 years Residual motor and sensory deficits at 24 months were least common when preoperative neurological symptoms lasted ≤1 month, and more common when symptoms exceeded 1 month.

Worst outcomes with long duration LDH symptoms persisting beyond 2 years were associated with the least favorable postoperative outcomes, including the highest residual motor and sensory deficits at 2 years.

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Long-Term Clinical Benefits of Age-Adjusted Sagittal Correction in Adult Spinal Deformity Surgery

Neurosurgery 98:1040–1050, 2026

This study evaluates long-term clinical outcomes of age-adjusted sagittal alignment correction in adult spinal deformity (ASD) surgery by integrating PI–LL, pelvic tilt, T1 pelvic angle, and SVA. Using hierarchical cluster analysis on 386 patients with long-segment fusion, three postoperative alignment patterns emerged—undercorrected, matched, and overcorrected—correlated with differing radiographic trajectories and complication rates.

Patients in the matched-correction cluster achieved the best balance of clinical improvement (ODI and SRS-22r) and minimized proximal junctional kyphosis/failure, while overcorrection increased mechanical complications despite stronger radiographic correction. The results support a multi-parameter, age-adjusted strategy and propose cluster-derived offset ranges as practical surgical benchmarks.

Aim Evaluate long-term benefits of age-adjusted sagittal alignment in adult spinal deformity surgery by integrating PI–LL, PT, TPA, and SVA using hierarchical cluster analysis.

Cohort Retrospective review of 386 ASD patients undergoing ≥5-level fusion including sacrum/pelvis, with minimum 2-year follow-up (mean follow-up 36.6 months).

Targeting method Postoperative offsets (target − current) for PI–LL, PT, TPA, and SVA were computed using published age-adjusted formulas from 6-week radiographs (or immediate postop if early PJK).

Clustering outcome Patients stratified into 3 clusters (A: 72, B: 211, C: 103) with cluster A undercorrected, cluster B balanced/matched, and cluster C overcorrected trends across all parameters.

Mechanical complications PJK/PJF rates differed by cluster, highest in cluster C (37.9%) vs cluster B (27.5%) and cluster A (20.9%) (P = .046).

Patient-reported outcomes At final follow-up, cluster B had significantly better ODI and SRS-22r outcomes than clusters A and C.

Parameter relationships Offsets showed strong correlations: PI–LL with PT (r = 0.77) and PI–LL with TPA (r = 0.79); weaker with SVA (r = 0.43).

Practical implication A balanced multi-parameter alignment profile (cluster B) best optimized outcomes while reducing complications, supporting integrating multiple sagittal targets rather than relying on a single parameter.

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The effect of paraspinal sarcopenia on postoperative sagittal balance: a multivariate analysis following multilevel lumbar fusion surgery

The Spine Journal 26 (2026) 709−719

This clinical study examines how paraspinal sarcopenia influences long-term sagittal alignment and functional outcomes after multilevel posterior lumbar interbody fusion. Using preoperative MRI/CT and serial radiographs, muscle cross-sectional area, fat infiltration, and spinopelvic parameters were measured to compare sarcopenic and nonsarcopenic patients over at least two years.

Results show multifidus atrophy and fatty infiltration, plus inadequate preoperative lumbar and segmental lordosis, independently predict postoperative sagittal imbalance and worse pain and disability. The authors recommend preoperative paraspinal muscle assessment, nutritional and rehabilitation optimization, and tissue-sparing techniques to improve long-term outcomes.

Study aim: Assessed how paraspinal sarcopenia affects long-term sagittal alignment and persistent pain/disability after multilevel posterior lumbar interbody fusion (PLIF), and identified risk factors for postoperative sagittal imbalance.

Design & cohort: Retrospective single-institution study of 213 multilevel PLIF patients with imaging follow-up through ≥2 years; sarcopenic (n=69) vs nonsarcopenic (n=143/144) groups were compared.

Sarcopenia definition: Grouping based on psoas muscle index (MI) at L3 with thresholds <6.36 cm²/m² (men) and <3.92 cm²/m² (women).

Key measurements: Quantified L3 psoas/erector spinae/multifidus muscle MI, fat infiltration (Goutallier grading), and muscle density (CT HU); tracked spinopelvic parameters including LL, SL, PT, PI-LL, SVA plus VAS and ODI outcomes.

Muscle differences by group: Sarcopenic patients had lower muscle indices and higher fat infiltration (especially erector spinae and multifidus), with no significant difference in muscle density reported.

Alignment & outcomes: Sarcopenic patients showed worse long-term sagittal alignment at final follow-up (differences in LL, SL, PT, PI-LL, SVA) and worse long-term VAS and ODI scores, despite similar preoperative clinical scores.

Independent risk factors: Multifidus atrophy (lower MMI) and multifidus fat infiltration plus insufficient preoperative LL and SL were independent predictors of long-term postoperative sagittal imbalance; psoas, erector spinae, and other balance parameters were not independently associated.

Practical implication: Better sagittal-balance maintenance was associated with larger paraspinal MI, reduced fat infiltration, and favorable preoperative LL/SL, supporting preoperative evaluation of muscle health, nutritional status, and alignment.

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Risk Factors and Reoperation Rate in Revision Lumbar Disc Herniation Surgery: A Systematic Review and Meta-Analysis of 1,031,348 Patients

Global Spine Journal 2026, Vol. 16(3) 1633-1647

This systematic review and meta-analysis examines reoperation rates and associated risk factors following primary lumbar disc herniation surgery across 25 studies totaling 1,031,348 patients. Pooled reoperation rate was 8.5% overall (adjusted to 10.3% for publication bias), with rates varying by follow-up: 4% at ≤1 year, 11.1% at 1–5 years, and 8.8% beyond 5 years.

Key risk factors identified include smoking, older age, diabetes, and large annular defects, while sex was not significant. The review highlights heterogeneity across study designs and follow-up durations, recommends careful patient selection, extended conservative management or closer surveillance for high-risk patients, and calls for trials comparing revision techniques.

Objective Estimate the reoperation rate after lumbar disc herniation surgery and identify associated risk factors.

Evidence base 25 studies (including observational studies and 3 RCTs) totaling 1,031,348 patients were included.

Overall reoperation rate Pooled reoperation rate was 8.5% (95% CI 6.2%–11.6%); after trim-and-fill adjustment for publication bias it was 10.3% (95% CI 7.6%–14.0%).

Follow-up pattern Reoperation rates differed by follow-up duration: 4% at ≤1 year, 11.1% at 1–5 years, and 8.8% at >5 years (significant subgroup differences).

Smoking risk Smoking was associated with higher odds of reoperation (OR 1.39, 95% CI 1.09–1.78).

Age risk Older age was associated with higher odds of reoperation (OR 1.52, 95% CI 1.25–1.85).

Annular defect risk Larger annular defect size was associated with higher odds of reoperation (OR 2.19, 95% CI 1.07–4.48).

Other factors Diabetes and certain surgical techniques were linked to higher reoperation risk in individual studies; sex was not a significant predictor (OR 1.22, 95% CI 0.96–1.55).

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Which spine surgeries belong in the ambulatory surgical center?

Neurosurg Focus 60(4):E2, 2026

This study uses time-driven activity-based costing (TDABC) to quantify true costs of common cervical and lumbar spine procedures performed in an outpatient hospital setting and compares these costs to Medicare ambulatory surgical center (ASC) reimbursement. Findings show microdiscectomy, lumbar laminectomy/decompression, and ACDF most often fall below Medicare ASC reimbursement, while endoscopic discectomy and posterior lumbar fusion frequently exceed reimbursement.

The analysis identifies supplies and personnel as primary cost drivers, highlights heterogeneity in Medicare ASC facility fees that do not reflect procedural complexity or number of levels, and argues that reimbursement reform is needed to expand the range of spine procedures economically feasible in ASCs.

Objective Identify spine procedures that are economically suitable to move from an outpatient hospital setting to an ambulatory surgical center (ASC) by comparing true costs (via TDABC) with Medicare ASC reimbursement.

Methods Retrospective cohort (2020–2024) of outpatient hospital spine cases with length of stay ≤ 1 day; procedures: cervical disc arthroplasty, ACDF, lumbar laminectomy/decompression, microdiscectomy, endoscopic discectomy, and posterior lumbar fusion; primary outcomes were total costs and proportion of cases with cost below Medicare reimbursement; regression adjusted for age, sex, BMI, and number of levels.

Costing approach (TDABC) Episode mapped across preop, intraop (wheels-in to wheels-out), and recovery phases; costs included supplies (consumables, implants, meds), personnel time (per-minute rates by role), and overhead.

Key cervical finding ACDF was more often below corresponding ASC reimbursement than cervical disc arthroplasty (71.8% vs 40.0%); adjusted odds favored ACDF (OR 5.3, 95% CI 3.0–9.4).

Key lumbar cost levels Mean lumbar episode cost was $4,640 ± $6,475; posterior lumbar fusion had the highest mean cost ($25,042 ± $15,645) and microdiscectomy the lowest ($3,233 ± $2,142).

Key lumbar viability finding Microdiscectomy (95.3%) and laminectomy/decompression (94.5%) most often cost less than reimbursement; endoscopic discectomy (31.0%) and posterior lumbar fusion (30.0%) were least often below reimbursement; adjusted odds were higher for laminectomy/decompression (OR 6.0) and microdiscectomy (OR 4.7), and far lower for endoscopic discectomy (OR 0.01) and fusion (OR 0.02).

Conclusions (procedures best suited for ASC under current payments) Microdiscectomy, lumbar laminectomy/decompression, and ACDF appear most economically suitable for transition from hospital outpatient to ASC in existing payment structures.

Reimbursement implication Broader feasibility in ASCs likely requires reimbursement reform, given mismatches between procedural complexity/resource use and Medicare ASC payment patterns.

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Low Posterior Electromyographic Threshold and Functional Outcomes After L4-5 Lateral Lumbar Interbody Fusion

Operative Neurosurgery 30:566–570, 2026

This single-institution retrospective study evaluates whether low posterior electromyography (EMG) stimulation thresholds during lateral L4-5 lumbar interbody fusion (LLIF) correlate with postoperative femoral nerve motor or sensory neurapraxia. Forty-two lateral-position single-level L4-5 LLIFs with neuromonitoring data showed no significant association between posterior EMG threshold or retractor time and transient postoperative anterior thigh numbness or weakness.

The cohort experienced transient sensory neurapraxia in 38% at six weeks that resolved by six months; only one patient had temporary motor neurapraxia. Limitations include small sample size, retrospective design, and short follow-up, leading authors to conclude no demonstrable link between posterior EMG threshold and plexus injury in this series.

Context: In L4-5 transpsoas LLIF, the retractor is placed near the lumbar plexus; directional EMG stimulation thresholds are used intraoperatively to estimate nerve proximity and potentially reduce injury risk.

Objective: Assessed whether posterior EMG stimulation threshold was associated with lumbar plexus injury/neurapraxia after single-level L4-5 LLIF performed in the lateral position.

Design/criteria: Retrospective, single-institution review of single-level L4-5 LLIF (Jan 2019–May 2022) with available neuromonitoring thresholds and retractor time; excluded cases with additional levels or missing monitoring data.

Cohort/intraop metrics: 42 patients (mean age 66 years); mean retractor time 12.4 minutes; mean posterior EMG threshold 10.4 mA.

Neurologic outcomes: Femoral motor neurapraxia occurred in 1 patient (2%); sensory neurapraxia (anterior thigh numbness) occurred in 16 patients (38%) at 6 weeks and resolved to 0% by 6 months.

Main finding: Posterior EMG threshold was not associated with postoperative motor neurapraxia or sensory neurapraxia at 6 weeks (including logistic regression showing OR 1.00; P=.98 for thigh numbness).

Other associations: No significant correlation between posterior EMG threshold and retractor time (Spearman ρ=0.11; P=.50) or postoperative ODI (ρ=0.17; P=.33).

Notable case/interpretation: The single motor neurapraxia case had 27-minute retractor time with posterior EMG 5 mA and recovered by 6 months; median retractor time in the cohort was low (10.8 minutes), limiting conclusions about longer retraction durations.

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