Tag: degenerative

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

J Neurosurg Spine 44:693–703, 2026

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

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

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

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

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

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

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

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

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

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

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Utilization of robotic pars repair for early return to activity in adolescents with symptomatic spondylolysis

J Neurosurg Spine 44:349–354, 2026

This case series from a tertiary academic spine center reports outcomes of robot-assisted percutaneous pars repair in nine adolescents with symptomatic lumbar spondylolysis who failed conservative management. The authors describe a single–midline incision technique using CT-based robotic guidance and a single lagged transdefect screw, detailing operative workflow, implant sizes, and a standardized postoperative rehabilitation protocol.

Results show most patients returned to preinjury or higher activity within months, with low complication rates and radiographic evidence of union in those who obtained CT follow-up. The authors conclude that minimally invasive robotic pars repair is a viable option after failed nonoperative care and advocate timely surgical consultation to potentially accelerate return to sport and avoid progressive spondylolisthesis.

Clinical problem Symptomatic lumbar pars interarticularis fractures (spondylolysis) are a common cause of adolescent low-back pain; nonoperative care with activity modification is standard first-line treatment.

Nonunion risk Despite conservative management, about 20% of patients may progress to symptomatic nonunion, and some can later develop spondylolisthesis that may require fusion.

Study aim Robotic surgical guidance was used to enable percutaneous pars screw placement; the series reports the largest cohort of adolescents treated with robot-assisted pars repair to date.

Design & cohort Retrospective review of a prospectively collected database identified 9 adolescents/young adults (13–25 years) treated with a single-screw pars repair technique.

Technique Using Excelsius robotic planning/registration and intraoperative 3D imaging, bilateral screw trajectories were planned to converge so bilateral pars screws could be placed through a single 1–2 cm midline incision; compression was achieved via a “lag-by-technique” preparation without direct pars visualization/grafting.

Postop protocol Patients walked only for 2 weeks, then added stationary biking for 2 weeks, followed by 4 weeks of sport-directed physical therapy; if tolerated symptom-free, they were cleared for activity (cleared to begin return-to-sport training at 4 weeks).

Outcomes Mean preop activity cessation at consultation was 8.6 ± 10.6 months; at mean follow-up 11.4 ± 9.1 months, 78% had returned to baseline activity or were cleared to return to sport.

Safety/efficacy conclusion Robot-assisted pars repair was reported as a safe, effective option after failed nonoperative care, enabling return to activity in as little as 8 weeks; a single lag-style screw may be clinically effective compared with prior open debridement/bone-grafting approaches.

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Cage migration in multilevel stand-alone lateral lumbar interbody fusion: incidence and clinical correlations

J Neurosurg Spine 44:426–435, 2026

This clinical case series compares the incidence and outcomes of lateral interbody cage migration (LCM) following multilevel stand-alone lateral lumbar interbody fusion (LLIF) versus LLIF with posterior pedicle screw instrumentation in 87 age-matched patients. The retrospective analysis reports similar LCM rates (7% vs 5%), no significant differences in complications, and comparable improvements in Oswestry Disability Index and pain scores at ≥1 year follow-up.

The report details patient selection, radiographic assessment methods, operative characteristics, and risk-factor analysis, emphasizing meticulous selection for multilevel stand-alone LLIF. Authors conclude multilevel stand-alone LLIF can be safe in selected patients but call for prospective studies to validate findings and clarify factors contributing to cage migration.

Lateral Cage Migration (LCM) Incidence: LCM occurred in 7% of multilevel stand-alone LLIF cases and 5% of LLIF cases with posterior instrumentation; this difference was not statistically significant.

Patient Selection Criteria: Optimal candidates for multilevel stand-alone LLIF have neutral sagittal and coronal balance, mild to moderate facet arthropathy, stable grade 1 spondylolisthesis, absence of severe central canal stenosis, normal or mildly reduced bone mineral density, and comorbidities or age that increase surgical risk with posterior fixation.

Clinical Outcomes: Both cohorts (stand-alone and posterior instrumentation) showed significant postoperative improvement in Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, with no significant differences between groups.

Complication Rates: Postoperative complication rates were similar between groups (23% stand-alone vs. 20% posterior instrumentation), and no intraoperative complications were reported in either group.

Biomechanical Considerations: Supplemental posterior instrumentation increases construct stability, but clinical significance in preventing LCM in well-selected patients remains unclear; stand-alone LLIF can be safe with meticulous patient selection.

Role of Lateral Plates: Adding lateral plates to stand-alone LLIF does not significantly improve stability or reduce cage migration/subsidence in multilevel constructs and may increase cost and risk.

Risk Factors for LCM: No significant demographic, radiographic, or procedural risk factors for LCM were identified in this study; all patients with LCM had normal bone density, and meticulous surgical technique and patient selection are emphasized.

Study Limitations: Retrospective design, single institution, and small sample size may limit generalizability; prospective studies are needed for further validation.

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Postoperative loss in segmental lumbar lordosis following L5–S1 anterior lumbar interbody fusion

J Neurosurg Spine 44:420–425, 2026

This clinical study evaluates predictors and thresholds for postoperative loss of L5–S1 segmental lordosis following anterior lumbar interbody fusion (ALIF) in 94 adults treated for degenerative disc disease. Multivariate analyses identified baseline obesity, absence of posterior fixation, and larger immediate lordotic correction as independent predictors of 6-week to 1-year segmental lordosis loss, which related to higher rates of cage subsidence and revision.

The authors derived 6-week postoperative L5–S1 lordosis thresholds (overall range 21.6°–26.8°, PI-specific: low 19.0°–24.8°, average 21.0°–26.4°, high 24.1°–28.7°) that minimized subsequent loss and need for revision. Findings support targeted preoperative planning to achieve sustainable correction while balancing risks of overcorrection and subsidence.

Segmental Lordosis Restoration: L5–S1 anterior lumbar interbody fusion (ALIF) provides strong and durable correction of segmental lumbar lordosis and disc height, with most correction maintained at 1 year postoperatively.

Predictors of Lordosis Loss: Baseline obesity, lack of posterior fixation, and larger initial correction in L5–S1 lordosis are independent predictors of postoperative segmental lordosis loss within 1 year.

Complications: Loss of segmental lordosis increases the risk of cage subsidence and revision surgery, particularly due to pseudarthrosis.

Optimal Correction Thresholds: Achieving 6-week postoperative L5–S1 segmental lordosis between 21.6° and 26.8° minimizes the risk of lordotic loss and need for revision; PI-specific thresholds are 19.0°–24.8° (low PI), 21.0°–26.4° (average PI), and 24.1°–28.7° (high PI).

Risks of Overcorrection/Undercorrection: Overcorrection (>26.8°) increases risk of cage subsidence and mechanical complications, while undercorrection (<21.6°) may predispose to implant failure and adjacent segment disease.

Surgical Planning Importance: Preoperative planning should target lordosis correction within these thresholds and consider modifiable risk factors to optimize outcomes and reduce complications.

Comparison to Other Techniques: ALIF offers greater segmental correction than other lumbar interbody fusion techniques such as TLIF or XLIF.

Clinical Implications: Nearly half of patients experience some degree of lordosis loss post-ALIF, highlighting the need for careful patient selection, surgical technique, and postoperative monitoring.

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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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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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A survival analysis for predictors of implant subsidence following 1- or 2-level transforaminal lumbar interbody fusion

J Neurosurg Spine 43:42–51, 2025

This study found that after 1- or 2-level TLIF, aggressive disc height restoration and taller interbody implants significantly increase the risk of implant subsidence, especially in patients with poor bone quality. Surgeons should balance correction goals with subsidence risk, particularly in those with low Hounsfield unit measurements.

• This study analyzed predictors of interbody implant subsidence after 1- or 2-level transforaminal lumbar interbody fusion (TLIF) using a time-to-event (survival) analysis.

• Aggressive disc height restoration and use of taller interbody implants significantly increased the risk of subsidence.

• Poor baseline bone quality, measured by lower Hounsfield units (HU) on CT, was a strong independent predictor for significant (≥4 mm) subsidence.

• Longer fusion constructs (more instrumented levels) also increased the risk of significant subsidence.

• No significant association was found between cage material (titanium vs PEEK), device geometry, or lumbopelvic parameters and subsidence risk.

• Subsidence occurred in 38.2% of levels (≥2 mm) and significant subsidence in 10.4% (≥4 mm) by last follow-up.

• Clinical implications suggest balancing correction goals with subsidence risk, especially in patients with poor bone quality.

• Further multicenter and prospective studies are recommended to validate these findings.

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Segmental and overall lumbar lordosis after single-level minimally invasive transforaminal lumbar interbody fusion: a systematic review and meta-analysis

J Neurosurg Spine 43:70–82, 2025

This systematic review and meta-analysis found that single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) generally preserves segmental and overall lumbar lordosis, with preoperative alignment and use of expandable cages predicting postoperative lordosis. Greater segmental lordosis improvement was associated with reduced leg pain, but clinical outcome correlations were otherwise limited.

• Single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) generally preserves or slightly increases segmental and overall lumbar lordosis.

• Meta-analysis of 35 studies (1935 patients) showed significant but modest increases in segmental lordosis (mean +2.2°) and lumbar lordosis (mean +2.8°) postoperatively.

• Preoperative alignment and use of expandable cages are significant predictors of postoperative lordosis change.

• Greater improvement in segmental lordosis was associated with larger reductions in postoperative leg pain, but no strong correlation with other clinical outcomes was found.

• Most included studies were retrospective case series, with high heterogeneity in surgical technique and reporting.

• No significant association was found between facetectomy type, operative bed, or fixation technique and changes in lordosis.

• The main goal of MI-TLIF is neural decompression and fusion, not alignment correction; alternative approaches may be needed for major lordosis restoration.

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Surgical outcomes of unilateral painful foot drop secondary to lumbar disc herniation

J Neurosurg Spine 42:727–736, 2025

This multicenter retrospective study of 75 patients found that prompt surgical intervention for unilateral painful foot drop due to lumbar disc herniation improves outcomes, especially in younger and less frail patients. Delays in surgery reduced the likelihood of recovery, but no specific timing cutoff was identified.

• This multicenter retrospective study analyzed surgical outcomes for unilateral painful foot drop caused by lumbar disc herniation, excluding cauda equina syndrome cases.

• 75 adult patients were included; improvement in muscle strength (MRC grade) was seen in 55%, with 23% achieving full resolution of foot drop.

• Earlier surgery, younger age, and lower frailty scores were associated with better outcomes; for each day surgery was delayed, chance of improvement dropped by 0.2%.

• No specific surgical timing cutoff was identified, but delays reduced likelihood of recovery.

• Patients with more severe initial weakness (lower MRC grade) were more likely to show some improvement, but less likely to achieve full resolution.

• Radicular pain (sciatica) improved in most patients regardless of time to surgery.

• Study limitations include small sample size, retrospective design, and variability between centers.

• Authors recommend early surgical consideration and call for larger prospective studies to refine guidelines.

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Technique and outcomes of the trans-superior articular process approach for endoscopic thoracic discectomy

J Neurosurg Spine 42:775–783, 2025

The trans-superior articular process (SAP) approach for endoscopic thoracic discectomy enables safe, minimally invasive treatment of symptomatic thoracic disc herniation, particularly in challenging upper/mid-thoracic regions, with significant improvements in pain and disability, short operative time, and low complication rates in a 38-patient series.

• Trans-superior articular process (trans-SAP) approach for endoscopic thoracic discectomy is described for symptomatic thoracic disc herniation (TDH).

• This technique creates a controlled corridor through the SAP using a Jamshidi needle and manual bone drills, minimizing facet removal and neural injury.

• Study included 38 patients (mean age 48.9), mostly with central or middle thoracic herniations.

• Mean operative time was 42 minutes, hospital stay 1.3 days, and follow-up 11.5 months.

• Significant improvements in pain (VAS) and disability (ODI) scores were observed at all follow-up points.

• Only one complication (2.6%, recurrent herniation) was reported.

• Trans-SAP approach is safe, effective, and minimally invasive, but has a steep learning curve and is not suitable for hard disc, severe myelopathy, or ossified ligament cases.

• Technique enables treatment of central and paramedian TDH and can be performed under local anesthesia.

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Comparison of outcomes between cervical disc arthroplasty and anterior cervical discectomy and fusion for the treatment of cervical spondylotic myelopathy

J Neurosurg Spine 42:705–717, 2025

This systematic review and meta-analysis evaluates the outcomes of cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) in treating cervical spondylotic myelopathy (CSM). Based on 12 randomized controlled trials including 2,612 patients, the study found that CDA shows superior clinical effectiveness and a more favorable safety profile than ACDF. Neck pain improvement (VAS) with CDA was clinically meaningful within the first postoperative year. CDA also had lower reoperation rates and reduced incidence of adjacent segment disease (ASD), although with slightly longer operative times. Further high-quality, large-scale trials are needed to confirm these findings.
Key Points
• • Objective: Compare the efficacy and safety of CDA vs. ACDF in CSM patients through meta-analysis.
• • Methods: 12 RCTs with 2,612 patients (1,464 CDA, 1,148 ACDF); outcomes included NDI, VAS, ROM, SF-36, complications, and reoperations.
• • Overall success: Higher in CDA group (RR 1.21; p = 0.004).
• • Neck pain (VAS): Significantly improved in CDA up to 12 months post-op; clinically meaningful.
• • Arm pain (VAS): Slight improvement at 3 and 12 months; not clinically significant.
• • NDI scores: Statistically better in CDA, though often below MCID thresholds.
• • ROM: Better preserved in CDA; data limited and heterogeneous.
• • Quality of life (SF-36): No significant differences between groups.
• • Operative time: Longer in CDA (MD 18.75 min; p < 0.00001).
• • Complications: Similar blood loss and adverse event rates; lower ASD and reoperation rates in CDA.
• • Limitations: Limited CSM-specific data, inconsistent surgical protocols, and risk of bias in several trials.
• • Conclusion: CDA offers better early clinical outcomes and fewer mechanical complications than ACDF, but broader validation is needed.

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Buttock pain in lumbar disc herniation: clinical characteristics, risk factors, and surgical outcomes

J Neurosurg Spine 42:572–578, 2025

The study investigates buttock pain in patients with lumbar disc herniation (LDH), identifying it as a common, independent symptom. It found that buttock pain is associated with contained herniation and an intact annulus fibrosus, and can be effectively treated with endoscopic discectomy.

• Buttock pain is common in patients with lumbar disc herniation (LDH), particularly in the L3–S1 segments, and is often independent of back and leg pain.

• The study examined 321 patients with single-level LDH who underwent endoscopic discectomy, finding that 75.4% experienced buttock pain.

• Buttock pain is more prevalent in patients with contained LDH and an intact annulus fibrosus.

• Endoscopic discectomy is effective in treating buttock pain, with significant improvements observed shortly after surgery and at the 1-year follow-up.

• The occurrence of buttock pain is not associated with age, sex, or specific spinal levels, indicating it as an independent symptom.

• The study suggests that altered intradiscal pressure may be a pathogenic factor for buttock pain in contained LDH.

• Residual buttock pain was more likely in L3–4 LDH, though the sample size for this segment was limited.

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Outcome prediction following lumbar disc surgery: a longitudinal study of outcome trajectories, prognostic factors, and risk models

J Neurosurg Spine 42:33–42, 2025

This study aimed to 1) describe the 2-year postoperative trajectories of leg pain and overall clinical outcome after surgery for radiculopathy, 2) identify the preoperative prognostic factors that predict trajectories representing poor clinical outcomes, and 3) develop and internally validate multivariable prognostic models to assist with clinical decision-making.

METHODS This retrospective cohort study included patients enrolled in the Canadian Spine Outcomes and Research Network who were diagnosed with lumbar disc pathology and radiculopathy and had undergone lumbar discectomy at one of 18 spine centers. Potential outcome predictors included preoperative demographic, health-related, and clinical prognostic factors. Clinical outcomes were 1) 2-year univariable latent trajectories of leg pain intensity (numeric pain rating scale) and 2) overall outcomes comprising multivariable trajectories showing the combined postoperative courses of leg and back pain intensity (numeric pain rating scale) together with pain-related disability (Oswestry Disability Index). Each outcome model identified a subgroup of patients classified as experiencing a poor outcome based on minimal change in their clinical status after surgery. Multivariable risk model performance and internal validity were evaluated with discrimination and calibration statistics based on bootstrap shrinkage with 500 resamplings.

RESULTS The authors included data from 1142 patients (47.6% female). The trajectory models identified 3 subgroups based on the patients’ postoperative courses of pain or disability: 88.6% of patients in the leg pain model and 71.9% in the overall outcome model experienced a good-to-excellent outcome. The models classified 11.4% (leg pain outcome) and 28.2% (overall outcome) of patients as experiencing a poor clinical outcome, which was defined as minimal improvement in pain or disability after surgery. Eleven individual demographic, health, and clinical factors predicted patients’ poor leg pain and overall outcomes. The performance of the multivariable risk model for leg pain was inadequate, while the overall outcome model had acceptable discrimination, calibration, and internal validity for predicting a poor surgical outcome.

CONCLUSIONS Patients with lumbar radiculopathy experience heterogeneous postoperative trajectories of pain and disability after lumbar discectomy. Individual preoperative factors are associated with postoperative outcomes and can be combined within a multivariable risk model to predict overall patient outcome. These results may inform clinical practice but require external validation before confident clinical implementation.

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Comparison of biportal endoscopic and microscopic tubular paraspinal approach for foraminal and extraforaminal lumbar disc herniation

J Neurosurg Spine 41:473–482, 2024

Foraminal and extraforaminal lumbar disc herniation (FELDH) is an important pathological condition that can lead to lumbar radiculopathy. The paraspinal muscle–splitting approach introduced by Reulen and Wiltse is a reasonable surgical technique. Minimally invasive procedures using a tubular retractor system have also been introduced. However, surgical treatment is considered more challenging for FELDH than for central or subarticular lumbar disc herniations (LDHs). Some researchers have proposed uniportal extraforaminal endoscopic lumbar discectomy through a posterolateral approach as an alternative for FELDH, but heterogeneous clinical results have been reported. Recently, the biportal endoscopic (BE) paraspinal approach has been suggested as an alternative. The aim of this study was to compare the clinical outcomes of BE and microscopic tubular (MT) paraspinal approaches for decompressive foraminotomy and lumbar discectomy (paraLD) in patients with FELDH.

METHODS Ninety-one consecutive patients with unilateral lumbar radiculopathy and FELDH underwent paraLD. Demographic and perioperative data were collected. Clinical outcomes were evaluated using the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI) for spinal disability, and the modified Macnab criteria for patient satisfaction. Postoperative complications and reoperation rates were also evaluated.

RESULTS In total, 76 patients were included in the final analysis. Among them, 43 underwent BE paraLD (group A) and the remaining 33 underwent MT paraLD (group B). The demographic and preoperative data were not statistically different between the groups. All patients showed significant improvements in VAS back, VAS leg, and ODI scores compared with baseline values (p < 0.05). The improvement in VAS back scores was significantly better in group A than in group B on postoperative day 2 (p < 0.001). However, all clinical parameters were comparable between the two groups after postoperative year 1 (p > 0.05). According to the modified Macnab criteria, 86.1% and 72.7% of the patients had excellent or good outcomes in groups A and B, respectively. No intergroup differences were observed (p = 0.367). In addition, there were no differences in the total operation time or amount of surgical drainage. Postoperative complications were not significantly different between the two groups (p = 0.301); however, reoperation rates were significantly higher in group B (p = 0.035).

CONCLUSIONS BE paraLD is an effective treatment for FELDH and is an alternative to MT paraLD. In particular, BE paraLD has advantages of early improvement in postoperative back pain and low reoperation rates.

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Full-endoscopic lumbar discectomy for lumbar disc herniation in young adults: 199 consecutive cases treated by a single surgeon with a mean 3.7-year follow-up

J Neurosurg Spine 41:369–377, 2024

Lumbar disc herniation (LDH) is rare in young adults. The present study aimed to evaluate the clinical outcomes of full-endoscopic lumbar discectomy (FELD) for LDH in young adults and to determine the risk factors that predict unfavorable outcomes of FELD for LDH in young adults.

METHODS A retrospective two-center cohort study was performed between January 2015 and October 2021 at the authors’ institutions. Clinical outcomes were assessed using the visual analog scale (VAS) for low-back pain and leg pain and the Oswestry Disability Index (ODI). The modified Macnab criteria were used to evaluate clinical efficacy at the last follow-up, and the global outcomes were classified into 4 groups, namely excellent, good, fair, and poor. The fair and poor groups were defined as unfavorable outcomes.

RESULTS One hundred ninety-nine patients were analyzed in this study (mean age 18.5 years, mean BMI 25.1 kg/m 2 , male/female sex ratio 2.8). The duration from the onset of symptoms to the operation was in general prolonged with age. The VAS and ODI scores significantly improved after surgery. A total of 17 of 195 single-segment cases had unfavorable outcomes based on the modified Macnab criteria. Lateral disc herniation (OR 3.72, 95% CI 1.14–12.12, p = 0.029) and high preoperative VAS score (OR 1.98, 95% CI 1.13–3.46, p = 0.017) were identified as risk factors for unfavorable outcomes after FELD.

CONCLUSIONS FELD for LDH in young adults is safe and effective. Preoperative VAS score and lateral disc herniation are risk factors of nonfavorable outcomes after surgery and may be a useful index for surgical procedure selection.

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