Category: Spine

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Achieving Alignment and Implant-Specific Goals in Anterior Lumbar Interbody Fusion, and Predictors of Postoperative Intradiscal Lordosis

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.

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Spinal meningiomas: histopathological grading using a benchmark radiomics model with notes on disease control

Neurosurg Focus 61(3):E8, 2026

Could preoperative imaging help anticipate the biological behavior of spinal meningiomas?
This study applies radiomics—quantitative analysis of imaging features—to distinguish tumor pathology groups.
The model showed promising discrimination using open-source tools and internal validation.
Its potential role is to inform counselling, but clinical adoption requires independent testing.

Objective

To develop a preoperative radiomics classifier for spinal meningioma pathology and explore factors associated with disease control.

Methods

Investigators retrospectively reviewed institutional surgical records from 2012–2025. Manually segmented contrast-enhanced images underwent PyRadiomics feature extraction. An ensemble classifier used 10 features and nested cross-validation.

The study’s “high-grade” category combined WHO grade 2 tumors with grade 1 tumors showing atypia; this is not equivalent to conventional WHO high-grade classification.

Main results

Among 74 patients, the model achieved an area under the receiver-operating-characteristic curve of 0.879 and a mean F1 score of 0.748.

The clinical analysis included 55 patients, with median radiographic follow-up of 22.2 months and four recurrences. Subtotal resection was associated with poorer progression-free survival than gross-total resection: HR 10.62 (95% CI 1.46–77.05; P=.019). Institutional abstract

Interpretation

The imaging approach merits further investigation, but discrimination within one institution does not establish performance across scanners, imaging protocols or patient populations. An AUC of 0.879 should not be described as “87.9% diagnostic accuracy.”

The recurrence analysis is exploratory. Its wide confidence interval signals considerable uncertainty, and it does not justify pursuing complete resection at the expense of neurological function.

Limitations

The small retrospective cohort and internal validation limit generalizability. The unconventional pathology grouping complicates comparison with other grading studies. Four recurrence events provide limited support for prognostic modelling.

Publisher and PubMed retrieval failed; verification relied on the authors’ institutional abstract. Full methodological details and supplementary material could not be assessed.

Clinical takeaway

Radiomics is a promising research adjunct for preoperative assessment of spinal meningiomas. This model should not yet determine resection extent, radiation treatment or surveillance schedules without external validation and confirmation of clinical utility.

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Surgical Versus Nonoperative Treatment for Adult Spinal Deformity: A Multicenter Propensity Score–Matched Study of Two-Year Patient-Reported Outcomes

Spine 2026;51:1197–1208

Choosing between reconstruction and nonoperative care for adult spinal deformity demands a realistic estimate of benefit rather than radiographic enthusiasm alone. This multicenter analysis uses propensity matching to compare patients with similar measured baseline characteristics. At 2 years, surgery produced substantially greater improvement in disability and scoliosis-specific quality of life. Clinically meaningful benefit was achieved by a much larger proportion of surgical patients, although the cohort was relatively young and only mildly to moderately impaired at baseline. The results strengthen comparative-effectiveness evidence but do not replace individualized discussion of complications and residual confounding.

Objective

To compare 2-year patient-reported outcomes after surgical and nonoperative management of adult spinal deformity while reducing measured treatment-selection bias through propensity-score matching.

Methods

The retrospective comparison used prospectively collected data from an adult spinal-deformity registry at six centers. Of 580 eligible patients, 338 underwent surgery and 242 received nonoperative care. Propensity scores incorporated demographic variables, radiographic alignment measures and baseline Oswestry Disability Index (ODI) and Scoliosis Research Society–22 (SRS-22) scores. One-to-one matching produced 160 balanced pairs.

Main results

At 2 years, mean ODI improvement was −19.4 ± 14.2 points after surgery and −4.2 ± 12.3 with nonoperative care (p<0.001). A clinically meaningful ODI improvement of at least 15 points was achieved by 72% of surgical patients versus 29% of nonoperative patients.

The mean 2-year SRS-22 total score was 3.95 ± 0.67 after surgery and 3.46 ± 0.75 after nonoperative care (p<0.0001). The minimum clinically important difference for the SRS-22 total score was reached by 81.3% and 36.9%, respectively.

Interpretation

Among matched patients, reconstruction was associated with a large and clinically visible improvement beyond that observed with nonoperative management. Propensity matching makes the groups more comparable but cannot recreate randomization. The magnitude of benefit should therefore be presented alongside the patient’s operative risk, deformity phenotype, frailty, goals and probability of complications or revision.

Limitations

Treatment was not randomized, and unmeasured factors such as surgeon judgment, symptoms, patient preference and socioeconomic context may still influence both selection and outcome. The matched cohort had a mean age of about 45 years and mild-to-moderate baseline impairment, limiting extrapolation to older or frailer patients. Two-year follow-up does not capture late mechanical failure, revision burden or durability.

Clinical takeaway

For an appropriately selected adult with symptomatic deformity, surgery offers a substantially greater chance of meaningful 2-year improvement than continued nonoperative care. Use those probabilities in shared decision-making, but pair them with center-specific complication and revision estimates rather than presenting benefit in isolation.

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Opioid and Neuropathic Pain Medication Use After ACDF for Degenerative Cervical Spine Disease

Spine 2026;51:1223–1232

Anterior cervical discectomy and fusion often relieves radicular or myelopathic symptoms, but medication use provides an additional real-world measure of recovery. This nationwide Finnish study links a spine registry with comprehensive outpatient prescription-purchase data. Around seven in ten preoperative users stopped repeatedly purchasing opioids or gabapentinoids after surgery, while new sustained strong-opioid use was uncommon. Nevertheless, approximately one in six patients continued repeated purchases during the first postoperative year. Preoperative medication exposure and modifiable factors such as smoking helped identify patients at risk.

Objective

To describe opioid and neuropathic-pain medication use after primary ACDF for degenerative cervical disease and identify independent predictors of repeated postoperative purchases.

Methods

The longitudinal study linked the nationwide FinSpine registry to Finland’s prescription database and included 4,366 consecutive patients operated between 2017 and 2022. Repeated postoperative use was defined as at least two purchases of the same drug class during months 2–12. New strong-opioid users had no strong-opioid purchase in the 6 months before surgery but met the repeated-purchase definition afterward. Multivariable logistic regression evaluated associated factors.

Main results

Before surgery, 41.9% purchased opioids and 41.2% gabapentinoids. During months 2–12 after ACDF, 16.5% made repeated opioid purchases and 15.6% made repeated gabapentinoid purchases. Among preoperative users, 69.5% stopped repeated opioid purchasing and 70.9% stopped repeated gabapentinoid purchasing.

Only 2.2% of previously strong-opioid-naïve patients became new repeated strong-opioid purchasers. Independent predictors of repeated postoperative purchases included pain lasting more than 1 year, smoking, greater baseline Neck Disability Index, central canal stenosis, unfavorable employment status and preoperative purchase of the same medication class.

Interpretation

Most previous users reduced sustained analgesic purchasing after ACDF, and surgery rarely initiated new repeated strong-opioid use. Yet persistent medication use in roughly one sixth of patients indicates that decompression and fusion do not address every contributor to pain, disability or pharmacological dependence. Dispensing is an objective outcome but is not synonymous with consumption or inappropriate use.

Limitations

Registry data cannot confirm whether purchased medication was taken, why it was prescribed or whether prescriptions related to cervical symptoms. Residual confounding from mental health, pain at other sites and prescriber behavior is possible. The Finnish healthcare and prescribing environment may limit international generalizability.

Clinical takeaway

Review opioid and gabapentinoid exposure before ACDF and set explicit postoperative deprescribing expectations. Patients who smoke, have symptoms exceeding 1 year, greater baseline disability or established medication use merit closer follow-up and coordinated pain management rather than automatic prescription renewal.

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Impact of Symptom Duration on Surgical Outcomes and Functional Recovery in Degenerative Cervical Myelopathy: Insights From a Prospective Multicenter Study

Spine  2026;51(16):1123–1129

The optimal timing of surgery for degenerative cervical myelopathy remains important because neurological decline may be slow and apparently tolerable. This large prospective multicenter cohort relates symptom duration to neurological recovery and patient-reported physical health. Surgery produced clinically meaningful neurological improvement even after prolonged symptoms. However, patients operated within two years were more likely to achieve meaningful improvement in physical quality of life. The study supports timely referral without implying that patients with longstanding disease no longer benefit.

Objective

To determine how symptom duration before surgery influences neurological, functional and patient-reported recovery after operative treatment for degenerative cervical myelopathy.

Methods

The prospective cohort included 874 patients treated at 10 institutions and followed for 2 years. Symptom duration was categorized as less than 6 months, 6 months to 2 years, 2–5 years or at least 5 years. Outcomes included the Japanese Orthopaedic Association score, SF-36, pain and neuropathic-pain scales, and JOACMEQ domains. Minimum clinically important differences were 2.5 points for JOA and 4 points for the SF-36 physical component.

Main results

Every symptom-duration group exceeded the minimum clinically important improvement in JOA score, including patients symptomatic for at least 5 years. In contrast, only patients with symptoms for less than 2 years exceeded the clinically important threshold for improvement in the SF-36 physical component.

After adjustment for relevant covariates, shorter symptom duration was associated with better recovery of extremity and bladder function and better quality-of-life outcomes on the JOACMEQ.

Interpretation

Delayed surgery does not eliminate the possibility of neurological improvement, but it may reduce the probability that recovery translates into a patient-perceived gain in physical health. The two-year point is a prognostic association rather than a rigid biological deadline.

Limitations

Patients were not randomized to early or delayed surgery, so symptom duration may correlate with access to care, disease phenotype or unmeasured severity. Recall of symptom onset can be imprecise. The cohort and instruments were predominantly Japanese, and the results do not identify ideal timing for an individual patient with mild or stable disease.

Clinical takeaway

Refer and evaluate degenerative cervical myelopathy promptly. Surgery can still be worthwhile after years of symptoms, but counseling should explain that intervention within two years is associated with a better chance of meaningful physical and quality-of-life recovery.

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Robot-assisted pedicle screw insertion in pediatric spine surgery: an institutional experience and meta-analysis

Operative Neurosurgery. 2026;31(2):202–222

Objective
To assess the accuracy and safety of robotic pedicle-screw placement in pediatric spinal surgery.

Methods
The study combined a seven-patient institutional series with a systematic review and meta-analysis including approximately 900 pediatric patients. Most patients had adolescent idiopathic scoliosis.

Main results
Across 11,434 screws, mean placement accuracy was 97.2%, the malposition rate was 2.67% and the reported revision rate was 0.79%. In the institutional cohort, accuracy was 91.7%, with one intraoperative screw revision. Meta-regression suggested improving accuracy and decreasing durotomy rates over time.

Interpretation
Robotic guidance can provide high pedicle-screw accuracy in pediatric deformity surgery. The evidence supports feasibility and safety but does not establish superiority over modern navigation or carefully performed freehand techniques.

Limitations
The institutional cohort was very small. Included studies were predominantly observational and heterogeneous in robotic platforms, deformity complexity and accuracy definitions.

Clinical takeaway
Robotics is a useful adjunct for complex pediatric instrumentation, but its benefit depends on planning, registration quality, surgeon oversight and the ability to recognize navigation error.

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Percutaneous navigation-assisted versus open posterior fixation for thoracolumbar fractures in ankylosing spinal diseases

Journal of Neurosurgery: Spine. 2026;45(2):160–169

Objective
To compare minimally invasive percutaneous fixation with conventional open fixation for thoracolumbar fractures in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis.

Methods
Retrospective 15-year cohort from a tertiary level I trauma center. Ninety-eight patients were included: 73 underwent navigation-assisted percutaneous fixation and 25 underwent open fixation with arthrodesis.

Main results
Patients treated percutaneously had greater baseline comorbidity but significantly lower estimated blood loss and transfusion requirements. Operative time, hospital stay, 90-day complications and one-year reoperation rates were not significantly different between groups.

Interpretation
Navigation-assisted percutaneous fixation may reduce the physiological burden of surgery without an evident increase in complications or reoperations—an important advantage in this medically fragile population.

Limitations
Retrospective, nonrandomized study with unequal groups. Technique selection reflected surgeon preference, creating a risk of selection bias.

Clinical takeaway
When anatomy and resources permit, percutaneous long-segment fixation is a reasonable strategy for ankylosed-spine fractures, particularly in patients with substantial medical comorbidity.

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Use of an expert panel for symptomatic patients with grade I degenerative lumbar spondylolisthesis: a randomized clinical trial

Neurosurgery. 2026;99(2):285–294

Objective
To determine whether multidisciplinary expert review improves outcomes by guiding the decision to add fusion to decompression in grade I degenerative lumbar spondylolisthesis.

Methods
Randomized trial conducted at 14 North American hospitals. A total of 663 patients were randomized to expert-panel review or usual surgical decision-making. Outcomes were available for 523 operated patients at one year.

Main results
The overall rate of surgical failure measured with EQ-5D was 16.7% after expert review and 17.4% without review (p=0.92). Therefore, the primary comparison was negative. However, when more than 80% of panelists recommended fusion, failure occurred in 8.4% of reviewed patients versus 18.4% of controls. The between-group difference was 10 percentage points (95% CI 2–18; p=0.03).

Interpretation
Routine panel review did not improve overall outcomes. The favorable result in cases with strong expert agreement is interesting but should be considered a secondary subgroup finding.

Limitations
The potentially beneficial signal emerged in a selected subgroup rather than in the primary analysis. Panel composition and recommendations may not be reproducible in other systems.

Clinical takeaway
Expert review should not be routinely required, but strong consensus may help identify selected patients more likely to benefit from fusion.

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Postoperative ketorolac administration and pseudoarthrosis following multilevel posterior cervical decompression and fusion

Spine. 2026;51(15):1101–1107

Objective
To determine whether ketorolac administered within 48 hours of multilevel posterior cervical decompression and fusion increases the risk of pseudoarthrosis.

Methods
Retrospective TriNetX database study covering 2002–2024. Propensity matching produced two cohorts of 1,376 patients treated with ketorolac or acetaminophen alone.

Main results
Pseudoarthrosis rates were similar at one year (6.3% in both groups) and four years (8.1% versus 8.4%). There were also no significant differences in reoperation, hardware complications, infection, bleeding or thromboembolic events. Ketorolac was associated with a modest reduction in later opioid prescriptions (RR 0.909; 95% CI 0.834–0.980).

Interpretation
Short-term postoperative ketorolac was not associated with impaired fusion in this matched cohort. This supports its cautious inclusion in multimodal analgesia after posterior cervical fusion.

Limitations
Retrospective database study dependent on diagnostic and medication coding. Dose, duration, adherence, imaging confirmation of fusion and over-the-counter NSAID exposure could not be fully assessed.

Clinical takeaway
A limited postoperative ketorolac regimen does not appear to produce a clinically meaningful increase in pseudoarthrosis following multilevel posterior cervical fusion.

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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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