Category: Spine

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Do all patients with adult scoliosis need instrumented fusion from T10 to the pelvis?

J Neurosurg Spine 44:195–204, 2026

This clinical review addresses whether adult scoliosis uniformly requires instrumented fusion from T10 to the pelvis, presenting diagnostic frameworks, radiographic assessment, and surgical decision-making. It contrasts full-length thoracolumbar–pelvic constructs with shorter, focal interventions, emphasizing individualized selection based on pain generators, balance, deformity location, and comorbidities.

The article reviews indications for extending fusions to upper thoracic levels, risks such as proximal junctional kyphosis, and evidence supporting limited fusion or decompression-only strategies when focal pathology (fractional curve, foraminal stenosis, olisthesis) explains symptoms. Multiple case examples illustrate practical application of the decision algorithm and outcomes.

Individualized Treatment: Not all adult scoliosis patients require instrumented fusion from T10 to the pelvis; surgical decisions should be based on the patient’s symptoms, pain generator, spinal balance, and radiographic findings rather than a one-size-fits-all approach.

Pain Source Identification: Careful identification of the pain generator (scoliosis-related, neurogenic, facet, or sacroiliac) is critical; many patients have back pain unrelated to scoliosis and may benefit from focal or limited procedures instead of extensive fusion.

Fusion Level Selection: The choice of upper instrumented vertebra (UIV) depends on curve characteristics, presence of kyphosis, risk of proximal junctional kyphosis (PJK), and patient-specific factors; fusion may end at T10, upper thoracic, or even lumbar levels as appropriate.

Limited/Focal Surgery: In select cases, limited fusion (e.g., of the major curve, concavity, or fractional curve) or even decompression alone can be effective, especially for patients with focal symptoms or significant comorbidities who cannot tolerate extensive surgery.

Fractional Curve Fusion: Fusion of only the fractional curve (typically L4–S1) is effective for radicular pain referable to this segment; careful preoperative assessment of coronal alignment and curve type is necessary to avoid postoperative imbalance.

Radiographic-Clinical Correlation: Surgical planning should integrate both radiographic parameters (sagittal vertical axis, pelvic incidence–lumbar lordosis mismatch, coronal balance) and the patient’s clinical presentation, as discordance may require further investigation.

Risks of Extensive Fusion: Long-segment fusions (T10–pelvis or longer) carry significant morbidity and complication risks; such approaches are best reserved for cases with severe, disabling symptoms, progressive deformity, or global imbalance.

Patient Preferences and Expectations: Surgical decisions must consider patient quality of life, goals, psychological profile, and willingness to accept surgical risks or possible reoperation, with shared decision-making emphasized

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Percutaneous modified iliac screw fixation: technique and clinical experience

Acta Neurochirurgica (2026) 168:20

This study reports clinical experience with a percutaneous modified iliac screw (PMIS) technique for sacropelvic fixation, developed to reduce soft-tissue dissection and avoid limitations of conventional iliac and S2 alar-iliac screws. Ten patients treated between 2014 and 2025 for mainly metastatic spinal disease underwent PMIS under C-arm fluoroscopy with virtual reference lines guiding intra-iliac cancellous screw placement.

Outcomes showed no wound infections, screw prominence complaints, sciatic notch or acetabular violations, or radiographic loosening (except one case requiring removal for progressing infection unrelated to PMIS). Spinopelvic alignment remained stable, and authors conclude PMIS is a safe, minimally invasive alternative warranting larger studies for broader validation.

Percutaneous Modified Iliac Screw (PMIS) Technique: PMIS is a minimally invasive method for sacropelvic fixation that uses fluoroscopic guidance and virtual reference lines to safely insert screws into the intra-iliac cancellous corridor, aiming to overcome drawbacks of conventional iliac screw (CIS) and S2 alar-iliac (S2AI) techniques.

Clinical Outcomes: In a retrospective series of 10 patients, PMIS showed no cases of infection, screw prominence, or screw-related complications, with only one revision required due to unrelated infection progression.

Spinopelvic Stability: Radiographic evaluation demonstrated that spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope) remained stable from preoperative to final follow-up, indicating maintenance of alignment.

Advantages Over Traditional Methods: PMIS avoids the need for offset connectors, reduces soft tissue dissection, minimizes screw head prominence, and potentially lowers infection and wound complication rates compared to CIS and S2AI methods.

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Spinal versus general anesthesia in robotic minimally invasive transforaminal lumbar interbody fusion: a comparative study on surgical outcomes

J Neurosurg Spine 44:99–107, 2026

This clinical study compares spinal anesthesia (SA) versus general anesthesia (GA) for robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA‑MIS TLIF), reporting retrospective outcomes from 209 patients treated 2018–2024. Primary findings show SA patients had significantly shorter operative times, lower immediate postoperative pain scores, reduced estimated blood loss, and shorter hospital length of stay after propensity score matching and regression adjustment.

The authors contextualize results within advances in robotic spinal surgery and awake spine techniques, discuss safety and potential cost and opioid‑reduction benefits, and acknowledge limitations including retrospective design, single‑center data, and reduced matched cohort size. Conclusions support SA as a safe, efficient approach for RA‑MIS TLIF with calls for larger prospective studies and formal patient‑selection guidelines.

Spinal Anesthesia (SA) vs General Anesthesia (GA): In robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA-MIS TLIF), SA significantly reduces operative times, postoperative pain, and hospital length of stay compared to GA, with no increase in complications or adverse outcomes.

Robotic Assistance Benefits: Robotic technology in spine surgery improves pedicle screw placement accuracy, reduces radiation exposure, and is associated with lower complication and revision rates, enhancing surgical safety and efficiency.

Study Design: A retrospective analysis of 209 patients (31 SA, 178 GA) from 2018–2024, with propensity score matching applied to control for confounders, allowing fair comparison between SA and GA cohorts for single-level procedures.

Key Outcomes (After Matching): SA cohort had shorter median total OR time (159 vs 283 min), procedure time (115 vs 201 min), lower intraoperative blood loss (25 vs 50 mL), lower first postoperative pain scores (median VAS 0 vs 5), and reduced mean length of stay (0.90 vs 2.64 days) compared to GA.

Patient Selection: The choice between SA and GA was based on patient preference and eligibility, with all SA cases being single-level procedures and comparable baseline demographics after matching.

Safety Profile: No increase in intraoperative or postoperative complications was observed with SA; screw placement accuracy remained high with robotic assistance.

Implications for Practice: Combining SA with RA-MIS TLIF offers a safe, efficient, and patient-centered approach that may lower healthcare costs and opioid requirements by reducing pain and hospitalization.

Limitations: Single-center, retrospective design with a relatively small matched cohort may limit generalizability; further prospective, multicenter studies are needed to validate these findings.

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Erector spinae plane block during standalone anterior lumbar surgery: impact on early ambulation, length of stay, and inpatient opioid use

J Neurosurg Spine 44:90–98, 2026

This clinical retrospective study assesses the impact of erector spinae plane block (ESPB) as an adjunct to multimodal analgesia in standalone anterior lumbar procedures (ALIF and lumbar TDR). Outcomes compared between ESPB and non-ESPB cohorts include in-hospital pain scores, opioid consumption (MME), time to ambulation, length of stay (LOS), and opioid-related complications.

Results show ESPB associated with lower day-of-surgery pain scores, earlier ambulation, and shorter LOS, with reduced in-hospital oral MME in univariate analysis; preoperative opioid use predicted higher perioperative opioid consumption and urinary retention despite ESPB. The authors emphasize ESPB as a component of enhanced recovery protocols and note limitations of retrospective design and sample size.

Erector Spinae Plane Block (ESPB): ESPB is a regional analgesic technique used as an adjunct in anterior-only lumbar surgeries, such as ALIF and total disc replacement, aiming to improve perioperative pain control and recovery outcomes.

Reduced Pain and Opioid Use: ESPB significantly lowers pain scores on the day of surgery and reduces in-hospital opioid use, especially oral morphine milligram equivalents (MMEs), compared to patients not receiving ESPB.

Shorter Hospital Stay: Patients receiving ESPB experience a significantly shorter hospital length of stay (LOS) and are more likely to be discharged earlier, including same-day discharge, than those without ESPB.

Faster Ambulation: ESPB is associated with a significantly shorter time to first ambulation after surgery, facilitating earlier rehabilitation.

Predictors of Opioid Use: Baseline (preoperative) opioid use is the strongest predictor of higher perioperative opioid requirements and is also linked to a higher incidence of postoperative urinary retention, regardless of ESPB administration.

Subgroup Benefits: Among ESPB patients, those with a shorter LOS (<2 days) had earlier ambulation, lower opioid use, and lower pain scores on postoperative day 1, indicating enhanced early recovery.

Multimodal Pain Management: ESPB should be considered as one component within a comprehensive multimodal pain management strategy (such as ERAS protocols), rather than as a standalone intervention.

Study Limitations: The findings are limited by the retrospective design, potential selection bias, lack of randomization, and incomplete data on preoperative opioid use, highlighting the need for larger, prospective studies

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Does segmental alignment matter? A novel understanding of segmental compensation and reciprocal change following single-level lumbar reconstruction

J Neurosurg Spine 44:72–79, 2026

This clinical study analyzes segmental compensation and reciprocal changes after single-level L5–S1 anterior lumbar interbody fusion in 100 adults with normal preoperative lumbar lordosis. Using intradiscal angle, motion segment angle, and disc heights, the authors show significant index-level lordosis restoration and correlated increases in overall lumbar lordosis at 1 month and 1 year.

The paper documents consistent reciprocal decreases in lordosis at adjacent L4–5 and L3–4 levels, provides predictive linear equations for adjacent-level change based on index-level IDA change, and argues that restoring segmental lordosis may prevent maladaptive compensation and reduce adjacent segment disease risk, while noting limitations and need for longer follow-up.

Segmental Compensation: Adjacent lumbar spine segments compensate for loss of lordosis at a pathologic segment by increasing their own segmental lordosis to maintain overall lumbar lordosis (LL) within the normal range.

Reciprocal Change After Fusion: Restoration of lordosis at the L5–S1 level via anterior lumbar interbody fusion (ALIF) leads to a significant, measurable decrease in segmental lordosis at adjacent levels (L4–5 and L3–4), demonstrating a reciprocal relationship.

Predictive Model: The degree of reciprocal loss of lordosis at adjacent levels can be predicted using linear equations based on the lordosis gain at the fused segment (e.g., 1-year adjacent level decrease in IDA = −0.195 × [index level 1-year IDA change] + 0.332).

Global Alignment Maintenance: Despite significant increases in lordosis at the surgical level, total lumbar lordosis does not increase by the same amount due to compensatory decreases at adjacent levels, maintaining global alignment.

Clinical Implication: Proper restoration of segmental lordosis at the surgical level may help prevent negative consequences of persistent compensation at adjacent segments, potentially reducing the risk of adjacent segment disease.

Study Population: Findings are based on 100 adults with normal preoperative LL (PI–LL < 10°) who underwent single-level L5–S1 ALIF and achieved ≥5° increase in segmental lordosis postoperatively.

Correlation With Outcomes: Changes in lordosis at the surgical segment positively correlate with changes in overall lumbar lordosis at both 1 month and 1 year postoperatively.

Long-Term Impact: The persistence of reciprocal changes at adjacent segments up to 1 year suggests that segmental compensatory mechanisms are durable and may influence long-term spinal health and surgical planning.

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Minimally invasive lumbar decompression versus open decompression for lumbar spinal stenosis: a propensity score–matched analysis

J Neurosurg Spine 44:55–61, 2026

This propensity score–matched retrospective study compares minimally invasive lumbar decompression (mild) with open decompression for lumbar spinal stenosis at a tertiary multisite center from 2005–2024. Primary outcomes included pain change (NRS), reoperation, and perioperative complications, with MCID defined as 30% NRS improvement.

Results show open decompression yielded greater pain improvement, higher MCID attainment, and lower overall reoperation rates, while mild had fewer durotomies but more neurological deficits. The authors recommend independent prospective studies to validate comparative efficacy and cost-effectiveness and note limitations including retrospective design and incomplete radiographic severity data.

Open decompression is more effective than the mild (minimally invasive lumbar decompression) procedure for achieving clinically significant pain improvement in patients with symptomatic lumbar spinal stenosis (43.1% vs 22.2% reached MCID; p < 0.001).

Reoperation rates are higher after the mild procedure compared to open decompression (46.2% vs 29.3%; p = 0.008), indicating less durable symptom relief with mild.

Pain outcomes favor open decompression, with patients reporting lower pain scores at last follow-up (mean NRS 2.3 vs 5.4; p < 0.001) and greater overall improvement from baseline.

Complication profiles are similar overall, but mild is associated with higher rates of postoperative neurological deficits (6.3% vs 0.6%; p = 0.003), while open decompression has a higher rate of durotomy (2.9% vs 0%; p = 0.024).

Procedure characteristics: The mild procedure is performed percutaneously through a small incision, typically by pain medicine physicians, and targets debulking the ligamentum flavum without muscle dissection.

Study limitations include retrospective design, incomplete matching for stenosis severity and baseline pain, and missing data on some outcomes, suggesting a need for prospective studies.

Existing literature on mild is often industry-sponsored and lacks direct comparison to open decompression; independent studies show mild may be less effective and more likely to require further surgery.

Clinical recommendation: Open decompression remains the gold standard for patients with symptomatic lumbar spinal stenosis who fail conservative management, while the mild procedure may offer less pain relief and higher reoperation risk.

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Comparative Effectiveness of Conservative Management Versus Surgical Fixation in Acute Type II Odontoid Fractures

Neurosurgery 98:61–72, 2026

This retrospective single-center study compares radiological and functional outcomes of conservative versus surgical management for acute type II odontoid fractures in an elderly cohort treated from 2015–2023. Results show surgical fixation markedly increases radiographic union rates, while conservative bracing predominated and delivered superior early pain control with similar long-term functional independence.

Multivariable modeling identified surgery as the strongest positive predictor of union, whereas age ≥80, smoking, osteoporosis, higher frailty, and angulation ≥11° reduced union odds and lowered likelihood of surgical selection. Complication rates and hospital stays were higher after surgery, supporting individualized treatment decisions balancing union probability, pain, frailty, and perioperative risk.

Surgical fixation increases the odds of fracture union in acute type II odontoid fractures (adjusted OR = 6.6), but does not improve long-term functional independence or survival compared to conservative management.

Conservative management (mainly rigid collars) is preferred for elderly or frail patients and achieves similar functional outcomes (modified Rankin Scale ≤2: 75% vs 73%) and better early pain control (75% vs 47%) than surgery, despite lower union rates.

Fracture union rates are significantly higher after surgery (44% vs 10% with conservative treatment, P < .01), but most conservatively managed patients achieve stable nonunion without adverse functional impact.

Advanced age (≥80 years), frailty, smoking, osteoporosis, and fracture angulation ≥11° are all strong negative predictors of fracture union, regardless of treatment approach.

Surgical patients are typically younger, less frail, and have greater fracture displacement or posterior displacement, reflecting selection bias in surgical decision-making.

Complication rates are higher with surgery (40% vs 2% for conservative), and surgical patients have longer hospital stays (median 11 vs 3 days), but most complications do not require reoperation.

Mortality rates at five years are similar between conservative and surgical groups (52% vs 53%), indicating no survival advantage with operative intervention.

Conservative treatment is a safe, effective option for most elderly or frail patients with type II odontoid fractures, reserving surgery for younger, medically fit individuals or those with unstable fracture patterns

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Spatial patterns of fat within the deep multifidus as a biomarker for chronic low back pain

The Spine Journal 26 (2026) 106−118

This clinical study maps spatial fat infiltration (FI) within the lumbar multifidus (MF) of 230 chronic low back pain (cLBP) patients using 3T IDEAL MRI and statistical parametric mapping to identify level- and region-specific FI patterns. The authors introduce a novel “fat-map” method and define a deep15 FI% (deepest 15% of MF) to compare regional FI with overall whole‑muscle FI across L1L2–L5S1.

Key results show elevated FI in the deep MF at L4L5 and L5S1 is associated with higher pain (PEG scores) and adjacent disc degeneration independent of age, sex, and BMI, while overall FI% is more strongly linked to demographic factors. The deep15 FI% emerges as a potential biomarker for cLBP, suggesting regional MF degeneration may better explain pain mechanisms than whole‑muscle summary measures.

Deep multifidus fat infiltration (FI): Elevated fat content in the deepest regions (deepest 15%) of the multifidus muscle at the lower lumbar spine (L4L5, L5S1) is more strongly associated with chronic low back pain (cLBP) symptoms and adjacent disc degeneration than overall muscle FI%.

Regional specificity: FI in the deep multifidus at lower lumbar levels is less influenced by age, sex, and BMI compared to overall FI%, making it a more specific biomarker for cLBP.

Novel biomarker (deep15 FI%): The “deep15 FI%” (mean fat fraction in the deepest 15% of the multifidus at L4L5/L5S1) is a regionally specific muscle quality measure, showing a stronger association with pain and disc degeneration than traditional whole-muscle FI% measures.

Demographic factors: Older age and female sex are associated with increased FI throughout the multifidus, while higher BMI mainly affects FI in the superficial 60% of the muscle, not the deep region at lower lumbar levels.

Pain association: Higher deep15 FI% at the lower lumbar levels is significantly associated with higher pain and pain interference scores (PEG survey), while overall FI% is not.

Disc degeneration link: Adjacent disc degeneration is the only degenerative spine feature consistently associated with increased deep multifidus FI at lower lumbar levels; other features (e.g., Modic changes, facet osteoarthritis) do not show this association when controlling for age, sex, and BMI.

Clinical implications: Deep multifidus FI could serve as a more precise imaging biomarker for cLBP and may guide future targeted interventions, though further longitudinal and interventional studies are needed to confirm causality and reversibility.

Limitations: The study’s spatial FI analysis is limited to radial (deep-to-superficial) direction and cross-sectional design; further research is needed to clarify causal mechanisms and intervention effects.

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Segmental Lordosis After Open Transforaminal Lumbar Interbody Fusion Using Expandable Oblique Versus Static Anterior Banana Cages

Operative Neurosurgery 30:78–89, 2026

This clinical research article compares segmental and lumbar lordosis outcomes after open transforaminal lumbar interbody fusion (TLIF) with posterior column osteotomy using either static anterior “banana” cages or obliquely placed expandable cages. In a single-surgeon retrospective cohort of 210 patients (327 segments), expandable cages produced a significantly greater median change in segmental lordosis (ΔSL) by 2.0° at six months, persisting after multivariate adjustment and propensity matching.

The study also reports inconsistent effects of cage type on overall lumbar lordosis (ΔLL), with subgroup and matched analyses yielding differing results, and found no difference in subsidence or complication rates. Findings emphasize the influence of preoperative segmental lordosis, segment level (notably L5–S1), and construct length on achieved correction, while noting limitations including retrospective design and lack of clinical outcomes.

Expandable Cages: Expandable obliquely placed cages in open transforaminal lumbar interbody fusion (TLIF) with posterior column osteotomy (PCO) produce a significantly greater median increase in segmental lordosis (ΔSL) of 2.0° compared to static anteriorly placed banana cages, representing a 50% increase.

Statistical Robustness: The greater segmental lordosis achieved with expandable cages remained significant after multivariate regression analysis and propensity score matching, confirming the reliability of the finding.

Overall Lumbar Lordosis (ΔLL): No clear advantage was found between cage types regarding the change in overall lumbar lordosis, with results varying depending on the statistical method used.

Surgical Technique Consistency: All surgeries were performed open with a full PCO using a consistent technique, minimizing confounding variables related to surgical approach or technique.

Preoperative Segmental Lordosis Impact: Segments with lower preoperative segmental lordosis (<15°) experienced the greatest increase in lordosis postoperatively, regardless of cage type.

L5-S1 Segment Benefit: Expandable cages were especially favorable at the L5-S1 segment, likely due to anatomical constraints that make insertion of large static cages more challenging at this level.

Complication and Subsidence Rates: No significant differences were observed between cage types in rates of complications, cage subsidence, or spondylolisthesis correction.

Clinical Outcomes Unclear: The study did not assess clinical outcomes, so the impact of the observed radiographic differences on patient-reported outcomes remains unknown.

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Clinical Outcomes of Decompressive Spine Surgery for Painless Cervical Myelopathy

Neurosurgery 98:161–173, 2026

This multicenter retrospective study analyzes 407 patients from the Michigan Spine Surgery Improvement Collaborative who underwent decompressive surgery for cervical spondylotic myelopathy presenting without neck or arm pain. Patient-reported outcomes (mJOA, PROMIS PF, EQ-5D) and clinical endpoints were assessed at baseline, 90 days, 1 year, and 2 years to quantify functional and quality-of-life changes after surgery.

Results show modest but clinically meaningful improvements in function and quality of life for a subset of patients, with peak MCID rates at one year and sustained patient satisfaction above 80% at two years. Severe preoperative myelopathy predicted worse immediate disposition and higher readmission, although some severe cases still achieved early functional gains.

Painless Cervical Myelopathy (CSM) Surgery: Decompressive spine surgery in patients with CSM but without neck or arm pain led to clinically significant improvements in myelopathic symptoms and physical function for a modest proportion of patients.

Quality of Life Gains: Surgery resulted in increased quality of life, with mean EQ-5D scores higher at all postoperative time points compared to baseline, and over 80% of patients reported sustained satisfaction up to two years after surgery.

Severity-Dependent Outcomes: Patients with severe myelopathy had worse immediate surgical outcomes (lower rates of discharge to home, higher 90-day readmission) and lower quality of life at two years compared to those with mild myelopathy.

Incidence of Postoperative Pain: Despite presenting without pain, 20% of patients developed persistent postoperative neck pain and 14% developed arm pain at two years, rates comparable to those seen in typical CSM surgery cohorts.

Functional Improvement Metrics: At one year, 49% achieved clinically meaningful improvement in physical function (PROMIS PF), 36% in mJOA, and 42% in quality of life (EQ-5D); these improvements were most pronounced at one year and declined by two years for some metrics.

Surgical Approach Differences: Anterior approaches were associated with higher postoperative satisfaction and lower rates of complications like dysphagia compared to posterior or combined approaches.

Study Limitations: Limitations include lack of radiological data, possible misclassification of myelopathy severity, and significant loss to follow-up, affecting long-term outcome interpretation.

Clinical Implication: Surgery may halt progression and provide functional and quality of life benefits even in painless CSM, but patient selection remains challenging and further objective, randomized studies are needed.

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Lumbar Multifidus Intramuscular Fat Concentrations are Associated With Recovery Following Decompressive Surgery for Lumbar Spinal Stenosis

Spine 2026;51:25–33

This longitudinal cohort study investigates whether preoperative intramuscular fat (IMF) in lumbar paraspinal muscles predicts five-year recovery and surgical success after decompressive surgery for lumbar spinal stenosis causing intermittent neurogenic claudication. Using automated MRI segmentation and quantitative IMF thresholds, outcomes included global perceived effect, Zurich Claudication Questionnaire-based surgical success, pain VAS, and disability scores.

Key findings show lower preoperative multifidus IMF (but not erector spinae IMF) was associated with higher rates of perceived recovery, surgical success, and reduced long-term disability over five years. No consistent relationship was found between IMF and leg or back pain trajectories; results were adjusted for age, BMI, sex, smoking, reoperation, and surgical technique.

Lumbar multifidus intramuscular fat (IMF): Lower preoperative IMF in the lumbar multifidus muscle is associated with higher rates of perceived recovery and surgical success after decompression surgery for lumbar spinal stenosis (LSS) over a five-year period.

Erector spinae IMF: Preoperative IMF levels in the erector spinae muscle are not significantly associated with recovery or surgical success following LSS surgery.

Disability outcomes: Patients with nonsevere IMF in the right lumbar multifidus experience less postoperative disability for up to five years compared to those with severe IMF.

Pain outcomes: No significant association exists between preoperative paraspinal IMF (either muscle) and the clinical course of leg or back pain intensity after surgery.

IMF quantification method: Automated MRI-based quantification and categorization of IMF (<50% = nonsevere, ≥50% = severe) using computer vision models enables objective assessment of paraspinal muscle health.

Prognostic value: Assessing lumbar multifidus IMF preoperatively can improve prediction of which patients are at risk for poor recovery and help tailor individual interventions.

Study limitations: Missing data (up to 32% at five years), dichotomized IMF classification, and limited field-of-view for some muscles may affect precision; more detailed and larger studies are needed.

Clinical implication: Routine IMF assessment may enhance clinical decision-making and rehabilitation strategies for patients undergoing lumbar decompressive surgery.

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A pilot randomized control trial comparing posterior paramedian versus midline incisions for interbody fusions of the lumbar spine

The Spine Journal 26 (2026) 85−93

This single-center pilot randomized controlled trial compares posterior midline versus posterior paramedian (Wiltse/minimally invasive) approaches for 1–2 level lumbar interbody fusions, assessing feasibility, infection rates, and reoperation. One hundred-one patients were randomized, with reported differences: higher deep infection (9.6% vs 4.1%) and greater reoperation rates (25% vs 6.1%) in the midline group, alongside improvements in PROMs for both groups.

Methods, perioperative care, and outcome measures are detailed, including CDC-defined deep infection, PROMs (ODI, SF-12, EQ-5D, VAS), and feasibility metrics for a multicenter RCT. The authors conclude the pilot supports a larger trial, recommend an interim analysis for reoperation differences, and outline limitations related to single-surgeon data, recruitment disruptions, and clustering effects.

Pilot RCT Findings: A single-center pilot randomized controlled trial compared posterior paramedian and midline incisions for lumbar interbody fusion, finding potential differences in deep infection and reoperation rates, with both groups showing improvement in patient-reported outcomes.

Infection Rates: Deep infection occurred in 9.6% of midline patients versus 4.1% in the paramedian group within 3 months post-surgery.

Reoperation Rates: 25% of midline patients required revision surgery compared to 6.1% in the paramedian group during follow-up.

Patient Outcomes: Both surgical approaches led to improvements in disability, pain, and quality of life scores at 6–18 weeks and 1 year postoperatively, with slightly greater improvements noted in the paramedian group.

Intraoperative Metrics: The paramedian group had lower average blood loss (268ml vs. 313ml) and a shorter average hospital stay (3.3 vs. 4.2 days) compared to the midline group.

Feasibility: The trial demonstrated high protocol adherence, low loss to follow-up, and good participant acceptance, supporting the feasibility of a larger multicenter RCT.

Limitations: The pilot was limited by single-center design, small sample size, protocol violations, and short follow-up; results may not be generalizable until confirmed by a larger trial.

Next Steps: The pilot data will inform sample size calculations and study design for a multicentered RCT to clarify whether paramedian approaches offer significant clinical advantages over midline incisions.

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Randomized controlled trials comparing cervical disc arthroplasty and anterior cervical discectomy and fusion outcomes in degenerative spine disease: a systematic review and meta-analysis

J Neurosurg Spine 43:703–716, 2025

This systematic review and meta-analysis synthesizes randomized controlled trials comparing cervical disc arthroplasty (CDA) with anterior cervical discectomy and fusion (ACDF) for degenerative cervical disc disease. Across 25 RCTs (4530 patients), CDA demonstrated higher overall and neurological success, reduced adjacent-segment disease and fewer reoperations, but increased heterotopic ossification and longer operative times.

The authors performed multilevel meta-analysis and meta-regression to explore heterogeneity, finding myelopathy inclusion and follow-up completeness influenced results; sensitivity analyses excluding industry-funded trials showed consistent findings. Conclusions emphasize CDA’s potential benefits for selected patients while recommending longer-term and subgroup-specific trials.

Cervical Disc Arthroplasty (CDA) vs. Anterior Cervical Discectomy and Fusion (ACDF): CDA shows comparable or potentially greater overall and neurological success rates compared to ACDF for degenerative cervical spine disease.

Motion Preservation: CDA preserves cervical spine range of motion at the operated level, while ACDF is associated with loss of motion and potentially increased risk of adjacent segment degeneration (ASD).

Adjacent Segment Disease (ASD): CDA is associated with a significantly lower rate of ASD compared to ACDF, suggesting a protective effect against degeneration of adjacent spinal segments.

Reoperation Rates: CDA results in lower total reoperation rates compared to ACDF, indicating fewer subsequent surgical interventions.

Heterotopic Ossification (HO): CDA has a significantly higher rate of HO, a complication where bone forms in soft tissue, which can potentially reduce the motion-preserving benefit of the procedure.

Operative Time: CDA procedures are associated with significantly longer operative times than ACDF, with no significant difference in blood loss or hospital length of stay between the two techniques.

Pain and Disability Outcomes: No significant differences were found between CDA and ACDF in terms of improvement in arm pain, neck pain, or disability scores (Neck Disability Index) as measured by patient-reported outcomes.

Patient Selection: The benefits of CDA over ACDF are most applicable to patients with 1-2 level degenerative disease, preserved cervical alignment, and no significant instability or deformity; findings may not generalize to more complex cases.

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The impact of Roussouly sagittal profile changes on postoperative outcomes

J Neurosurg Spine 43:609–615, 2025

This clinical study examines postoperative changes in Roussouly sagittal spinal profiles among 525 adult spinal deformity (ASD) patients and evaluates how shifts between Roussouly types influence mechanical complications and patient-reported outcomes up to two years after fusion surgery. Methods include radiographic classification (current SS-based and theoretical PI-based), HRQOL measures (ODI, SRS-22r, EQ-5D), and multivariate regression to link type changes with PJK/PJF and MCID attainment.

Key findings show 39–59% of patients experienced postoperative Roussouly shape changes, with certain transitions (R1→R2, R2→R4, R3→R4) associated with higher proximal junctional kyphosis/failure risk and R4→R3 linked to greatest mechanical complication risk. R2-mismatched patients had poorer ODI improvement and higher pelvic nonresponse, suggesting Roussouly matching should inform ASD surgical planning.

Roussouly Classification Changes: Postoperative changes in Roussouly sagittal profile are common after adult spinal deformity (ASD) surgery, with 39% of patients experiencing a change in Roussouly type at 6 weeks post-op; type 1 (R1) patients had the highest rate of change (59%) and type 4 (R4) the lowest (26.7%).

Mechanical Complication Risk: Certain Roussouly type changes significantly increase the risk of proximal junctional kyphosis (PJK) and mechanical complications, especially transitions from R1 to R2, R2 to R4, R3 to R4, and R4 to R3.

Health-Related Quality of Life (HRQOL): Overall, Roussouly type changes were not associated with significant differences in minimum clinically important difference (MCID) achievement for SRS-22r scores up to 2 years, except for a lower rate of ODI MCID attainment in R2-mismatched patients.

Surgical Invasiveness and Deformity Severity: R1 patients had the most severe baseline deformity and underwent more extensive surgery, which may contribute to higher rates of postoperative Roussouly type changes.

Matching Theoretical Roussouly Type: Only 48% of patients matched their theoretical (PI-based) Roussouly type postoperatively; those who matched, especially in the R2 group, had better functional outcomes and lower rates of pelvic nonresponse (PNR).

Clinical Implications: Maintaining or restoring the original Roussouly type during ASD surgery may reduce the risk of mechanical complications and improve early functional outcomes, particularly for R2 patients.

Limitations: The study was retrospective, single-center, and limited to 2-year follow-up, which may affect generalizability and long-term conclusions.

Surgical Planning: Accounting for Roussouly type changes and known risk factors (e.g., osteoporosis, advanced age) during surgical planning may help decrease postoperative complications.

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The Association of Area Deprivation Index and Spine Surgery Outcomes: A Systematic and Narrative Review

Operative Neurosurgery 29:775–784, 2025

This systematic review examines the relationship between neighborhood-level socioeconomic disadvantage, measured by the Area Deprivation Index (ADI), and outcomes after various spine surgeries. Ten North American observational studies (56,925 patients) indicate higher ADI is associated with increased readmissions, emergency visits, longer lengths of stay, higher costs, and worse patient-reported outcomes for cervical and lumbar procedures.

The review outlines potential mechanisms—limited health literacy, barriers to follow-up, comorbidity control, and access deficits—and proposes targeted interventions across education, income/employment, housing, and household support to mitigate disparities and improve perioperative optimization and outcomes.

Area Deprivation Index (ADI): ADI is a validated, neighborhood-level measure of socioeconomic disadvantage, incorporating 17 variables across education, income/employment, housing, and household characteristics, with scores ranked from 0 (least disadvantaged) to 100 (most disadvantaged).

Association with Spine Surgery Outcomes: High ADI is linked to worse outcomes after spine surgery, including higher rates of postoperative readmissions, complications, emergency room visits, longer hospital stays, and poorer patient-reported outcomes (PROs).

Cervical Spine Surgery: Increased ADI is associated with higher costs of care, increased surgical utilization, and longer hospital length of stay after anterior cervical discectomy and fusion (ACDF); some studies also report increased likelihood of 30-day readmission, though not always statistically significant.

Lumbar Spine Surgery: High ADI predicts worse preoperative pain, function, depression, and anxiety scores; patients with high ADI experience greater rates of complications (e.g., respiratory failure), longer hospital stays, increased emergency visits, higher costs, and are less likely to achieve clinically meaningful improvements postoperatively.

Mechanisms of Disparity: Poor health literacy, reduced access to primary and follow-up care, barriers to transportation, and poor control of comorbidities are key mechanisms by which high ADI leads to worse surgical outcomes.

Potential Interventions: Targeted interventions addressing education (health literacy outreach, transitional care), income/employment (public assistance, nutrition programs), housing (medical-legal partnerships, transitional housing), and household resources (home health, internet access, transportation assistance) may help mitigate disparities for high ADI patients.

Limitations: Evidence is limited by heterogeneity of included studies, moderate risk of bias, small sample sizes for some subgroups, and lack of generalizability across all spine surgery types.

Future Directions: ADI can serve as a prognostic tool for identifying at-risk patients; further research should validate these associations and evaluate the effectiveness of targeted interventions to improve spine surgery outcomes in disadvantaged populations.

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To fuse or not to fuse: surgical strategies for recurrent lumbar disc herniation from a 16-nation study

J Neurosurg Spine 43:681–692, 2025

This international survey examines variability in surgical management of recurrent lumbar disc herniation across 515 spine surgeons from 16 countries, comparing redo discectomy versus various fusion techniques for six clinical scenarios. Findings reveal substantial inter- and intranational differences, specialty-related tendencies, and consensus only for simple first recurrences without back pain.

The study identifies key decision drivers—lumbar pain with radiculopathy and inflammatory disc disease—highlights gaps in high-level evidence, and calls for standardized research, registries, and improved training to harmonize indications and reduce practice heterogeneity.

Significant International Variability: Surgical strategies for recurrent lumbar disc herniation (LDH) vary widely among spine surgeons internationally, especially beyond the first recurrence without low back pain or instability, where decisions are more homogeneous.

Decision-Making Factors: Key factors influencing the choice for fusion over redo discectomy include the presence of low back pain with radiculopathy, radiological evidence of inflammatory disc disease, and the occurrence of second recurrences.

Surgeon Specialty Impact: Orthopedic surgeons are significantly more likely to propose procedures involving implants (fusion) compared to neurosurgeons, regardless of other demographic factors.

Country-Specific Patterns: Countries with low variability (e.g., Portugal, China, UK, Germany) favor posterior lumbar interbody fusion (PLIF/TLIF) and redo discectomy, while countries with high variability (e.g., France, Tunisia, US, Brazil) show more diverse approaches, including anterior and combined procedures.

Limited Influence of Experience and Practice Type: Duration of practice, annual surgical volume, and type of institution (public vs. private) generally do not significantly affect procedure choice, except in some first recurrence cases where public practitioners favor redo discectomy.

Lack of High-Level Evidence: There is a lack of strong, consistent evidence or guidelines favoring one surgical approach over another for recurrent LDH, contributing to the observed variability.

Patient and Surgeon Preferences: Decision-making is influenced by patient preferences, surgeon familiarity with techniques, desire for low-morbidity procedures, and adherence to literature, though economic factors play a lesser role.

Call for Standardization and Research: The findings highlight the need for high-quality studies, improved training, and international collaboration to reduce variability and improve decision-making in recurrent LDH surgery.

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Radiation exposure in XLIF surgery utilizing ultra-low radiation imaging with image enhancement software: a randomized controlled trial

The Spine Journal 25 (2025) 2692−2700

This randomized controlled trial evaluates ultra-low radiation imaging with image enhancement (mFluoro) versus conventional fluoroscopy during single-level XLIF lateral interbody fusion in 57 analyzed patients. Results show marked reductions in OR staff exposure (surgeon −72.1%, assistant −76.1%, scrub nurse −67.5%), lower patient DAP (−66.1%), fewer images, and shorter procedure times without increased complications.

The study used live dosimeters, standardized protocols, and optical reposition-assist technology (LessRay/PULSE) with Cios Spin. Findings support ULRI+IE as an effective strategy to decrease occupational and patient radiation during minimally invasive lateral spine surgery, noting limitations including lack of surgeon blinding and early learning-curve crossovers.

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Masseter Sarcopenia and Mortality After Type II Odontoid Fractures in the Elderly: A 5-Year Follow-Up Study

Neurosurgery 97:1297–1307, 2025

This clinical retrospective study evaluates whether masseter sarcopenia, measured on routine head CT scans, predicts mortality after Type II odontoid fractures in elderly patients. Using masseter cross-sectional area (MCSA) thresholds, the authors found that lower MCSA is independently associated with increased 1-year mortality, while frailty indices and age drive longer-term risk.

The paper details methods, cohort characteristics (n=72, mean age 80.9), imaging measurement technique, multivariate Cox models, and Kaplan-Meier analyses. Results support MCSA as a practical prognostic marker to inform postinjury management and targeted interventions in high-risk geriatric trauma patients.

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Fusion Sequence and Risk Factors for Pseudarthrosis in Multilevel Anterior Cervical Discectomy and Fusion

Neurosurgery 97:1153–1161, 2025

This clinical study evaluates fusion rates, fusion timing, and pseudarthrosis risk factors in 119 patients undergoing 2-level versus 3-level anterior cervical discectomy and fusion (ACDF) with minimum two-year follow-up. Fusion was assessed via angular and linear interspinous motion on dynamic radiographs, with Kaplan-Meier and Cox regression analyses.

Key findings show higher and faster fusion in 2-level ACDF; middle levels fuse earliest while caudal levels have lowest rates. Polyetheretherketone (PEEK) cages and multilevel constructs associate with increased pseudarthrosis risk, highlighting material choice and level-specific biomechanics as critical for surgical planning and future research.

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Modic Change Edema in Chronic Low Back Pain Treated With Infliximab or Placebo

Spine 2025;50:1091–1101

This randomized, double-blind clinical trial evaluated whether infliximab reduces Modic type 1 (MC1) edema on STIR MRI and whether baseline edema or ADC values modify its effect on disability and low back pain (LBP). Patients with chronic LBP and MC1 received four infliximab or placebo infusions; MRI and clinical outcomes (ODI, pain) were assessed at five and six months.

Results showed no clinically relevant edema reduction by infliximab in the primary per-protocol analysis, and baseline STIR edema or MC-related ADC did not modify treatment effects or prognosticate ODI or LBP. Sensitivity analyses yielded a modest edema signal in the full analysis set, but overall findings do not support infliximab for chronic LBP with MC1.

• Infliximab: Did not have a clinically relevant effect in reducing Modic change (MC) edema at six months in patients with chronic low back pain and MC type 1 (MC1) compared to placebo.

• Disability and Pain: Infliximab did not improve disability (Oswestry Disability Index) or low back pain intensity at five or nine months follow-up versus placebo.

• Edema as Modifier: Baseline MC edema and apparent diffusion coefficient (ADC) values did not modify the effect of infliximab on disability or low back pain.

• Prognostic Value: Baseline MC edema and ADC values did not predict disability or low back pain outcomes, regardless of treatment group.

• Statistical Findings: The odds ratio for reduced MC edema at six months with infliximab versus placebo was not statistically significant in the per protocol analysis (OR 2.2, 95% CI: 0.8–5.8; P = 0.12), but reached statistical significance in the full analysis set (OR 2.1, 95% CI: 1.02–4.5; P = 0.04), though the clinical benefit was limited.

• Clinical Relevance: Any observed difference in clinical improvement between patients with and without reduced edema was near or below the threshold for clinical relevance (10 ODI points, 1.5–2.0 pain points).

• Reliability: MRI assessment methods for MC and edema (using STIR imaging and ADC) showed good to very good inter-rater reliability.

• Recommendation: These results do not support the use of infliximab as a treatment for chronic low back pain with MC1.

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