Tag: fusion

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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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Impact of lateral plate and screw fixation on long-term radiographic subsidence in lateral lumbar interbody fusion

J Neurosurg Spine 44:493–497, 2026

This clinical study evaluates long-term radiographic subsidence after lateral lumbar interbody fusion (LLIF), comparing stand-alone procedures with those augmented by lateral plate and screw fixation. Retrospective analysis of 146 patients (219 levels) with ≥1-year CT follow-up shows lateral plating significantly reduced subsidence odds, while 3D-printed porous titanium cages trended toward lower subsidence than PEEK.

Results note similar reoperation rates between groups, no grade III subsidence, and rare adverse events including one delayed vertebral fracture with plating; methodology included multivariate logistic regression and Marchi subsidence grading. Conclusions support lateral plate and screw fixation, particularly with porous titanium cages, as protective against severe radiographic subsidence.

Objective Assess whether adding lateral plate and screw fixation changes the long-term rate/grade of radiographic cage subsidence after LLIF (excluding posterior instrumented fusion).

Design/Population Retrospective review (2014–2022) of degenerative lumbar spondylosis LLIF cases at two centers; required ≥1-year postoperative CT; 146 patients/219 levels (45% plated, 55% stand-alone).

Subsidence grading Long-term imaging graded by Marchi criteria (grade 0: 0%–24% disc height loss; I: 25%–49%; II: 50%–74%; III: 75%–100%); no intraoperative subsidence included.

Main finding (plating effect) Lateral plate + screws was significantly associated with reduced long-term radiographic subsidence (multivariable OR 0.484, p = 0.006).

Severity pattern All grade II (severe) subsidence cases occurred in the stand-alone LLIF group (4 patients); no grade III subsidence observed.

Cage material trend 3D-printed porous titanium cages trended toward lower subsidence versus PEEK but did not reach statistical significance (OR 0.401, p = 0.071).

Reoperation/fusion No significant difference in reoperation rate between plated and stand-alone groups; radiographic fusion rates were similar (83.1% plated vs 86.4% stand-alone; p = 0.58).

Noted complications/implant details One lateral-plate patient had a delayed vertebral body fracture; plated cases used 18-mm-wide cages, while nearly all stand-alone cases used 22-mm-wide cages.

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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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Risk Factors Associated With Revision Microdiscectomy or Subsequent Spinal Fusion Within Two Years of Index Lumbar Microdiscectomy

Spine 2025;50:1392–1399

This large retrospective study found that within two years of lumbar microdiscectomy, 5.5% required revision surgery and 6.6% required spinal fusion. Age 40–59, female sex, and at least one Charlson Comorbidity Index (CCI) comorbidity significantly increased the risk of subsequent fusion, but not revision microdiscectomy.

Revision microdiscectomy rates after index lumbar microdiscectomy were 3.5% at one year and 5.5% at two years.

• Lumbar fusion rates were 2.9% at one year and 6.6% at two years after index surgery.

• Age 40–59, female sex, and presence of at least one Charlson Comorbidity Index (CCI) comorbidity significantly increased risk of lumbar fusion, but not revision microdiscectomy.

• Having ≥1 CCI comorbidity increased the likelihood of needing fusion by about 80%.

• Specific comorbidities (e.g., congestive heart failure, peripheral/cerebrovascular disease, diabetes) were strong predictors for time-to-fusion.

• Age, sex, and CCI score were not predictive of time-to-revision microdiscectomy.

• Results suggest CCI may help identify patients at higher risk for spinal fusion after microdiscectomy.

• Findings may guide surgeons in perioperative decision-making and patient counseling.

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Development of a unified and comprehensive definition of successful spinal fusion: a systematic review

J Neurosurg Spine 42:403–412, 2025

The document discusses a systematic review aimed at creating a unified definition of successful spinal fusion by integrating clinical symptoms, imaging modalities, and bone healing processes. It proposes a clinical algorithm for evaluating fusion success, emphasizing the need for standardized assessment criteria.

• A systematic review was conducted to develop a unified definition of successful spinal fusion, incorporating clinical symptoms and imaging modalities.

• The review involved 20 studies evaluating 1,324 spinal fusion procedures, resulting in a clinical algorithm for determining fusion success.

• The algorithm stratifies patients as symptomatic or asymptomatic, using specific imaging techniques based on pain type.

• Successful fusion for asymptomatic patients is considered after 12 months, while persistent symptoms indicate failure regardless of radiographic findings.

• Limitations include reliance on imaging and heterogeneous study data, but the algorithm aims to standardize fusion evaluation and improve outcomes.

• Future directions suggest using AI and machine learning for predictive algorithms and evaluating regional differences in fusion assessment.

• The proposed algorithm aims to improve diagnostic accuracy and provide a shared understanding of successful spinal fusion among clinicians.

• Implementation of the algorithm can enhance outcomes research and assess new developments in spinal fusion.

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Interbody cages versus structural bone grafts in lumbar arthrodesis: a systematic review and meta-analysis

J Neurosurg Spine 41:188–198, 2024

The role of interbodies in lumbar arthrodesis has been insufficiently supported by evidence, impacting clinical decision-making and occasionally insurance coverage. This study aimed to compare clinical and radiological outcomes between lumbar arthrodesis with a synthetic interbody spacer (cage) versus structural bone graft alone (autograft or allograft) in patients with degenerative spine disease.

METHODS A systematic review of the literature was performed to identify studies directly comparing outcomes of lumbar interbody arthrodesis with and without interbody cage use. The outcomes of individual studies were synthesized in meta-analyses using random-effects models.

RESULTS Twenty studies with 1508 patients (769 with an interbody cage and 739 without an interbody cage) were included. Interbody cage placement was associated with a significantly greater increase in disc height after surgery (4.0 mm vs 3.4 mm, p < 0.01). There was a significantly greater reduction of back pain (visual analog scale [VAS] score) in cases in which an interbody cage was used (5.4 vs 4.7, p = 0.03). Fusion rates were 5.5% higher in the cage group (96.3% vs 90.8%) and reached statistical significance (p = 0.03). No statistically significant differences were identified between the two groups regarding all-cause reoperation rates, complication rates, or improvement in Oswestry Disability Index score or leg pain (VAS score).

CONCLUSIONS These results suggest that implantation of an interbody cage is associated with higher rates of fusion, more effective maintenance of disc height, and greater improvement of back pain. This study underlines the clinical value of interbody cages in lumbar arthrodesis for patients with degenerative spine disease.

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Postoperative Measurement of the Retropharyngeal Space Predicts the Risk of Dysphagia After Anterior Cervical Diskectomy and Fusion

Neurosurgery 94:1116–1121, 2024

Postoperative dysphagia is a common complication of anterior cervical diskectomy and fusion (ACDF), although its pathophysiology remains poorly understood. Patients with severe dysphagia may suffer from serious complications such as aspiration pneumonia, in addition to difficulty with oral intake or malnutrition; therefore, a prompt indicator for postoperative management would be helpful. We quantitatively evaluated the retropharyngeal space (RS) after ACDF and investigated its association with postoperative dysphagia.

METHODS: This multicenter retrospective study analyzed the clinical data of 82 consecutive patients who underwent ACDF. The anteroposterior distance (APD) of the RS was measured at the C2 level using a lateral radiographic view on postoperative day 1. Postoperative dysphagia was subjectively assessed using the Bazaz-Yoo Dysphagia Severity Scale. We statistically evaluated the association between the APD of the RS and postoperative dysphagia.

RESULTS: The mean APD of the RS in all 82 patients was 3.6 mm preoperatively and significantly increased to 8.2 mm postoperatively (P < .0001). Twenty-two patients (26.8%) had postoperative dysphagia. Multivariable analysis revealed that the postoperative APD was associated with postoperative dysphagia (odds ratio 1.27, 95% CI 1.10-1.50, P = .0007). The receiver operating characteristic curve (area under the curve 0.70, 95% CI 0.58-0.83) demonstrated that the postoperative APD of the RS cutoff value was 6.1 mm, with a sensitivity of 100% and a specificity of 35%. With this cutoff value, the positive and negative predictive values for postoperative dysphagia were 36% and 100%, respectively.

CONCLUSION: Our data demonstrate that a value of 6.1 mm for the APD of the RS is an effective indicator for dysphagia after ACDF, which contributes to optimizing the patient management in the acute postoperative period.

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Health Care Costs Following Anterior Cervical Discectomy and Fusion or Cervical Disc Arthroplasty

Spine 2024;49:530–535

Study Design. Observational cohort study.

Objective. To describe the postoperative costs associated with both anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) in the two-year period following surgery.

Summary of Background Data. CDA has become an increasingly common alternative to ACDF for the treatment of cervical disc disorders. Although a number of studies have compared clinical outcomes between both procedures, much less is known about the postoperative economic burden of each procedure.

Materials and Methods. By analyzing a commercial insurance claims database (Marketscan, Merative), patients who underwent one-level or two-level ACDF and CDA procedures between January 1, 2017 and December 31, 2017 were identified and included in the study. The primary outcome was the cost of payments for postoperative management in the two-year period following ACDF or CDA. Identified postoperative interventions included in the study were: (i) physical therapy, (ii) pain medication, (iii) injections, (iv) psychological treatment, and (iv) subsequent spine surgeries.

Results. Totally, 2304 patients (age: 49.0 ± 9.4 yr; male, 50.1%) were included in the study. In all, 1723 (74.8%) patients underwent ACDF, while 581 (25.2%) underwent CDA. The cost of surgery was similar between both groups (ACDF: $26,819 ± 23,449; CDA: $25,954 ± 20,620; P = 0.429). Thirty-day, 90-day, and two-year global costs were all lower for patients who underwent CDA compared with ACDF ($31,024 vs. $34,411, $33,064 vs. $37,517, and $55,723 vs. $68,113, respectively).

Conclusion. Lower two-year health care costs were found for patients undergoing CDA compared with ACDF. Further work is necessary to determine the drivers of these findings and the associated longer-term outcomes.

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Comparison of minimally invasive decompression alone versus minimally invasive short-segment fusion in the setting of adult degenerative lumbar scoliosis:

J Neurosurg Spine 39:394–403, 2023

Patients with degenerative lumbar scoliosis (DLS) and neurogenic pain may be candidates for decompression alone or short-segment fusion. In this study, minimally invasive surgery (MIS) decompression (MIS-D) and MIS short-segment fusion (MIS-SF) in patients with DLS were compared in a propensity score–matched analysis.

METHODS The propensity score was calculated using 13 variables: sex, age, BMI, Charlson Comorbidity Index, smoking status, leg pain, back pain, grade 1 spondylolisthesis, lateral spondylolisthesis, multilevel spondylolisthesis, lumbar Cobb angle, pelvic incidence minus lumbar lordosis, and pelvic tilt in a logistic regression model. One-to-one matching was performed to compare perioperative morbidity and patient-reported outcome measures (PROMs). The minimal clinically important difference (MCID) for patients was calculated based on cutoffs of percentage change from baseline: 42.4% for Oswestry Disability Index (ODI), 25.0% for visual analog scale (VAS) low-back pain, and 55.6% for VAS leg pain.

RESULTS A total of 113 patients were included in the propensity score calculation, resulting in 31 matched pairs. Perioperative morbidity was significantly reduced for the MIS-D group, including shorter operative duration (91 vs 204 minutes, p < 0.0001), decreased blood loss (22 vs 116 mL, p = 0.0005), and reduced length of stay (2.6 vs 5.1 days, p = 0.0004). Discharge status (home vs rehabilitation), complications, and reoperation rates were similar. Preoperative PROMs were similar, but after 3 months, improvement was significantly higher for the MIS-SF group in the VAS back pain score (−3.4 vs −1.2, p = 0.044) and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) score (+10.3 vs +1.9, p = 0.009), and after 1 year the MIS-SF group continued to have significantly greater improvement in the VAS back pain score (−3.9 vs −1.2, p = 0.026), ODI score (−23.1 vs −7.4, p = 0.037), 12-Item Short-Form Health Survey MCS score (+6.5 vs −6.5, p = 0.0374), and VR-12 MCS score (+7.6 vs −5.1, p = 0.047). MCID did not differ significantly between the matched groups for VAS back pain, VAS leg pain, or ODI scores (p = 0.38, 0.055, and 0.072, respectively).

CONCLUSIONS Patients with DLS undergoing surgery had similar rates of significant improvement after both MIS-D and MIS-SF. For matched patients, tradeoffs were seen for reduced perioperative morbidity for MIS-D versus greater magnitudes of improvement in back pain, disability, and mental health for patients 1 year after MIS-SF. However, rates of MCID were similar, and the small sample size among the matched patients may be subject to patient outliers, limiting generalizability of these results.

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Outcomes following anterior odontoid screw versus posterior arthrodesis for odontoid fractures

J Neurosurg Spine 39:196–205, 2023

Odontoid fractures can be managed surgically when indicated. The most common approaches are anterior dens screw (ADS) fixation and posterior C1–C2 arthrodesis (PA). Each approach has theoretical advantages, but the optimal surgical approach remains controversial. The goal in this study was to systematically review the literature and synthesize outcomes including fusion rates, technical failures, reoperation, and 30-day mortality associated with ADS versus PA for odontoid fractures.

METHODS A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching the PubMed, EMBASE, and Cochrane databases. A random-effects meta-analysis was performed and the I 2 statistic was used to assess heterogeneity.

RESULTS In total, 22 studies comprising 963 patients (ADS 527, PA 436) were included. The average age of the patients ranged from 28 to 81.2 years across the included studies. The majority of the odontoid fractures were type II based on the Anderson-D’Alonzo classification. The ADS group was associated with statistically significantly lower odds to achieve bony fusion at last follow-up compared to the PA group (ADS 84.1%; PA 92.3%; OR 0.46; 95% CI 0.23–0.91; I 2 42.6%). The ADS group was associated with statistically significantly higher odds of reoperation compared to the PA group (ADS 12.4%; PA 5.2%; OR 2.56; 95% CI 1.50–4.35; I 2 0%). The rates of technical failure (ADS 2.3%; PA 1.1%; OR 1.11; 95% CI 0.52–2.37; I 2 0%) and all-cause mortality (ADS 6%; PA 4.8%; OR 1.35; 95% CI 0.67–2.74; I 2 0%) were similar between the two groups. In the subgroup analysis of patients > 60 years old, the ADS was associated with statistically significantly lower odds of fusion compared to the PA group (ADS 72.4%; PA 89.9%; OR 0.24; 95% CI 0.06–0.91; I 2 58.7%).

CONCLUSIONS ADS fixation is associated with statistically significantly lower odds of fusion at last follow-up and higher odds of reoperation compared to PA. No differences were identified in the rates of technical failure and all-cause mortality. Patients receiving ADS fixation at > 60 years old had significantly higher and lower odds of reoperation and fusion, respectively, compared to the PA group. PA is preferred to ADS fixation for odontoid fractures, with a stronger effect size for patients > 60 years old.

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Artificial intelligence in predicting early‑onset adjacent segment degeneration following anterior cervical discectomy and fusion

European Spine Journal (2022) 31:2104–2114

Anterior cervical discectomy and fusion (ACDF) is a common surgical treatment for degenerative disease in the cervical spine. However, resultant biomechanical alterations may predispose to early-onset adjacent segment degeneration (EO-ASD), which may become symptomatic and require reoperation. This study aimed to develop and validate a machine learning (ML) model to predict EO-ASD following ACDF.

Methods Retrospective review of prospectively collected data of patients undergoing ACDF at a quaternary referral medical center was performed. Patients > 18 years of age with > 6 months of follow-up and complete pre- and postoperative X-ray and MRI imaging were included. An ML-based algorithm was developed to predict EO-ASD based on preoperative demographic, clinical, and radiographic parameters, and model performance was evaluated according to discrimination and overall performance.

Results In total, 366 ACDF patients were included (50.8% male, mean age 51.4 ± 11.1 years). Over 18.7 ± 20.9 months of follow-up, 97 (26.5%) patients developed EO-ASD. The model demonstrated good discrimination and overall performance according to precision (EO-ASD: 0.70, non-ASD: 0.88), recall (EO-ASD: 0.73, non-ASD: 0.87), accuracy (0.82), F1-score (0.79), Brier score (0.203), and AUC (0.794), with C4/C5 posterior disc bulge, C4/C5 anterior disc bulge, C6 posterior superior osteophyte, presence of osteophytes, and C6/C7 anterior disc bulge identified as the most important predictive features.

Conclusions Through an ML approach, the model identified risk factors and predicted development of EO-ASD following ACDF with good discrimination and overall performance. By addressing the shortcomings of traditional statistics, ML techniques can support discovery, clinical decision-making, and precision-based spine care.

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Hounsfield Unit as a Predictor of Adjacent-Level Disease in Lumbar Interbody Fusion Surgery

Neurosurgery 91:146–149, 2022

Bone density has been associated with a successful fusion rate in spine surgery. Hounsfield units (HUs) have more recently been evaluated as an indirect representation of bone density. Low preoperative HUs may be an early indicator of global disease and chronic process and, therefore, indicative of the need for future reoperation.

OBJECTIVE: To assess preoperative HUs and their association with future adjacent segment disease requiring surgical intervention through retrospective study.

METHODS: Patients who underwent lumbar interbody fusion at a single institution between 2007 and 2016 were retrospectively reviewed. Hounsfield unit values were measured from preoperative computed tomography (CT) using sagittal images, encircling cancellous portion of the vertebral body. Patient charts were reviewed for follow-up data and adjacent-level disease development.

RESULTS: A total of 793 patients (age: 56.1 ± 13.7 years, 54.4% female) were included in this study. Twenty-two patients required surgical intervention for adjacent segment disease. Patients who underwent lumbar interbody fusion and did not subsequently require surgical intervention for adjacent-level disease were found to have a higher mean preoperative HU than patients who did require reoperation (180.7 ± 70.0 vs 148.4 ± 8.1, P = .032). Preoperative CT HU was a significant independent predictor for the requirement of adjacent-level surgery after spinal arthrodesis (odds ratio = 0.891 [0.883-0.899], P = .029).

CONCLUSION: Patients who underwent lumbar interbody fusion that did not require reoperation for adjacent-level degeneration were found to have a higher mean preoperative HU than patients who did require surgical intervention. Lower preoperative CT HU was a significant independent predictor for the requirement of adjacent-level surgery after spinal arthrodesis.

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Unilateral approach with two‑cage insertion for full endoscopic transforaminal lumbar interbody fusion: technical report

Acta Neurochirurgica (2022) 164:1521–1527

The advantages of performing a transforaminal lumbar interbody fusion (TLIF) with two cages rather than a single cage include a larger cage-bone contact area and higher interbody stability.

Methods A customized cage guide is docked in the disc space created after a total facet resection. The first cage is inserted deeply into the contralateral disc space. The second cage is then inserted using the cage guide device while protecting the exiting and traversing nerve roots.

Conclusion We successfully inserted two cages from unilateral side during full endoscopic TLIF. This technique is recommended for L4–L5 and L5–S1 levels.

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PEEK versus titanium‑coated PEEK cervical cages: fusion rate

Acta Neurochirurgica (2022) 164:1501–1507

Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed procedures for degenerative cervical disease. The evaluation of fusion status is still not fully standardized, and a variety of measurement methods are used. This study presents our own evaluation of fusion by comparing two types of implants.

Methods A total of 170 disc spaces were operated on in 104 patients using PEEK (polyetheretherketone) cages and titaniumcoated (TC) PEEK cages. Patients were assigned to a specific implant using a randomisation table. Fusion status was evaluated based on functional radiographs and CT scans obtained at 12 months post-surgery. Multivariate mixed-effects logistic regression models were performed to assess the association of type of implant with different fusion rates.

Results At 12 months post-surgery, CT scans were performed in 86 patients (a total of 144 disc spaces) and conventional radiographs were obtained in 102 (a total of 166 disc spaces). Complete fusion was demonstrated in 101 cases (71.1%), partial fusion in 43 cases (29.9%). There were no cases of absence of fusion. A total of 85 PEEK cages (59%) and 59 TCPEEK cages (41%) were implanted. For PEEK cages, complete fusion was seen in 75 (88.2%) disc spaces, compared to 26 (44.1%) achieved with TC-PEEK cages. A significantly higher proportion of complete fusions (B = 15.58; P < 0.0001) after 12 months was observed with PEEK implants compared to TC-PEEK implants.

Conclusion Complete fusion was noted at 12 months post-surgery significantly more frequently with PEEK implants compared to TC-PEEK implants.

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Decompression alone versus decompression and instrumented fusion for the treatment of isthmic spondylolisthesis: a randomized controlled trial

J Neurosurg Spine 35:687–697, 2021

The most advocated surgical technique to treat symptoms of isthmic spondylolisthesis is decompression with instrumented fusion. A less-invasive classical approach has also been reported, which consists of decompression only. In this study the authors compared the clinical outcomes of decompression only with those of decompression with instrumented fusion in patients with isthmic spondylolisthesis.

METHODS Eighty-four patients with lumbar radiculopathy or neurogenic claudication secondary to low-grade isthmic spondylolisthesis were randomly assigned to decompression only (n = 43) or decompression with instrumented fusion (n = 41). Primary outcome parameters were scores on the Roland Disability Questionnaire (RDQ), separate visual analog scales (VASs) for back pain and leg pain, and patient report of perceived recovery at 12-week and 2-year follow-ups. The proportion of reoperations was scored as a secondary outcome measure. Repeated measures ANOVA according to the intention-to-treat principle was performed.

RESULTS Decompression alone did not show superiority in terms of disability scores at 12-week follow-up (p = 0.32, 95% CI −4.02 to 1.34), nor in any other outcome measure. At 2-year follow-up, RDQ disability scores improved more in the fusion group (10.3, 95% CI 3.9–8.2, vs 6.0, 95% CI 8.2–12.4; p = 0.006, 95% CI −7.3 to −1.3). Likewise, back pain decreased more in the fusion group (difference: −18.3 mm, CI −32.1 to −4.4, p = 0.01) on a 100-mm VAS scale, and a higher proportion of patients perceived recovery as showing “good results” (44% vs 74%, p = 0.01). Cumulative probabilities for reoperation were 47% in the decompression and 13% in the fusion group (p < 0.001) at the 2-year follow-up.

CONCLUSIONS In patients with isthmic spondylolisthesis, decompression with instrumented fusion resulted in comparable short-term results, significantly better long-term outcomes, and fewer reoperations than decompression alone. Decompression with instrumented fusion is a superior surgical technique that should in general be offered as a first treatment option for isthmic spondylolisthesis, but not for degenerative spondylolisthesis, which has a different etiology. Clinical trial registration number: NTR1300 (Netherlands Trial Register)

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Posterior fusion for fragility type 2 odontoid fractures

J Neurosurg Spine 35:644–650, 2021

The purpose of this study was to evaluate the outcomes of elderly patients with type 2 odontoid fractures treated with an instrumented posterior fusion.

METHODS Ninety-three consecutive patients older than 65 years of age in whom a type 2 odontoid fracture had been treated with a variety of C1–2 posterior screw fixation techniques were retrospectively reviewed.

RESULTS The average age was 78 years (range 65–95 years). Thirty-seven patients had an additional fracture, 30 of which involved C1. Three patients had cervical spinal cord dysfunction due to their injury. All patients had comorbidities. The average total hospitalization was 9.6 days (range 2–37 days). There were 3 deaths and 19 major complications, the most common of which was pneumonia. No patient suffered a vertebral artery injury. Imaging studies were obtained in 64 patients at least 12 months postsurgery (mean 19 months). Fusion was assessed by dynamic radiographs in all cases and with a CT scan in 80% of the cases. Four of the 64 patients did not achieve fusion (6.25% overall). All patients in whom fusion failed had undergone C1 lateral mass fixation and C2 pars (1/29, 3.4%) or laminar (3/9, 33.3%) fixation.

CONCLUSIONS Instrumented posterior cervical fusions may be performed in elderly patients with acceptable morbidity and mortality. The fusion rate is excellent except when bilateral C2 translaminar screws are used for axis fixation.

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Intrawound vancomycin application after spinal surgery: a propensity score–matched cohort analysis

J Neurosurg Spine 34:788–798, 2021

Surgical site infection (SSI) following spine surgery is associated with increased morbidity and healthcare costs. In an effort to reduce SSI rates, the application of intrawound vancomycin powder has gained popularity. However, there is limited high-quality evidence to support the safety and efficacy of this practice. The authors sought to determine if intrawound application of vancomycin powder improves 90-day overall SSI rates.

METHODS The authors performed a retrospective, vancomycin exposure–matched cohort study at a single tertiary care hospital over 21 months. They included all patients undergoing elective spinal surgery and stratified the patients into two groups: those who received intrawound vancomycin powder application and those who received no application of vancomycin powder. The primary outcome of interest was the 90-day overall SSI rate. Secondary outcomes included rates of superficial SSI, deep SSI, wound disruption, and a post hoc analysis of the microbiology and minimum inhibitory concentrations. Baseline patient demographics, clinical presentation, comorbidities, perioperative factors, and 90-day postoperative outcomes were manually abstracted from patient charts. To mitigate bias, we performed 1:1 matching after calculating propensity scores and identified 1 patient from the no-vancomycin cohort for each patient in the vancomycin cohort.

RESULTS A total of 997 patients met our inclusion criteria (473 patients receiving vancomycin and 524 patients not receiving vancomycin). Propensity score matching produced 221 matched pairs. Risk-adjusted analysis demonstrated similar overall SSI rates between the groups (OR 1.9, p = 0.329). On unadjusted analysis, the overall 90-day SSI rate was greater in the vancomycin group (n = 10 [4.5%]) than in the no-vancomycin group (n = 5 [2.3%]) (p < 0.001), as were the superficial SSI rate (7 [3.2%] vs 4 [1.8%], p < 0.001), deep SSI rate (3 [1.4%] vs 1 [0.5%], p < 0.001), and wound disruption rate (5 [2.3%] vs 1 [0.5%], p < 0.001). No cultured isolate demonstrated vancomycin resistance.

CONCLUSIONS The authors observed no difference in SSI rates after the intrawound application of vancomycin powder during spine surgery. Vancomycin use did not contribute to antimicrobial resistance; however, it may select out gram negative bacteria and increase rates of wound disruption.

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Modified far lateral endoscopic transforaminal lumbar interbody fusion using a biportal endoscopic approach

Acta Neurochirurgica (2021) 163:1205–1209

Endoscopic transforaminal lumbar interbody fusion (TLIF) has the disadvantage of the small cage size and by consequence risk for cage subsidence. We succeeded to insert a large oblique lumbar interbody fusion (OLIF) cage during biportal endoscopic TLIF.

Methods Unilateral total facetectomy was performed to expose the exiting and traversing nerve roots. The distance between the exiting and traversing nerve roots was measured before OLIF cage insertion. We inserted an OLIF cage instead of a TLIF cage.

Conclusion We successfully performed modified far lateral biportal endoscopic TLIF using large OLIF cages. Modified far lateral biportal endoscopic TLIF is usually suitable for the L4-5 and L5-S1 levels.

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Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study

J Neurosurg Spine 34:27–31, 2021

Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures.

METHODS The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma.

RESULTS Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not.

CONCLUSIONS Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.

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Perioperative complications with multilevel anterior and posterior cervical decompression and fusion

J Neurosurg Spine 32:9–14, 2020

Cervical spondylotic myelopathy (CSM) is a progressive degenerative pathology that frequently affects older individuals and causes spinal cord compression with symptoms of neck pain, radiculopathy, and weakness. Anterior decompression and fusion is the primary intervention to prevent neurological deterioration; however, in severe cases, circumferential decompression and fusion is necessary. Published data regarding perioperative morbidity associated with these complex operations are scarce. In this study, the authors sought to add to this important body of literature by documenting a large single-surgeon experience of single-session circumferential cervical decompression and fusion.

METHODS A retrospective analysis was performed to identify intended single-stage anterior-posterior or posterioranterior- posterior cervical spine decompression and fusion surgeries performed by the primary surgeon (V.C.T.) at Rush University Medical Center between 2009 and 2016. Cases in which true anterior-posterior cervical decompression and fusion was not performed (i.e., those involving anterior-only, posterior-only, or delayed circumferential fusion) were excluded from analysis. Data including standard patient demographic information, comorbidities, previous surgeries, and intraoperative course, along with postoperative outcomes and complications, were collected and analyzed. Perioperative morbidity was recorded during the 90 days following surgery.

RESULTS Seventy-two patients (29 male and 43 female, mean age 57.6 years) were included in the study. Fourteen patients (19.4%) were active smokers, and 56.9% had hypertension, the most common comorbidity. The most common clinical presentation was neck pain in 57 patients (79.2%). Twenty-three patients (31.9%) had myelopathy, and 32 patients (44.4%) had undergone prior cervical spine surgery. Average blood loss was 613 ml. Injury to the vertebral artery was encountered in 1 patient (1.4%). Recurrent laryngeal nerve palsy was observed in 2 patients (2.8%). Two patients (2.8%) had transient unilateral hand grip weakness. There were no permanent neurological deficits. Dysphagia was encountered in 45 patients (62.5%) postoperatively, with 23 (32%) requiring nasogastric parenteral nutrition and 9 (12.5%) patients ultimately undergoing percutaneous endoscopic gastrostomy (PEG) placement. Nine of the 72 patients required a tracheostomy. The incidence of pneumonia was 6.9% (5 patients) overall, and 2 of these patients were in the tracheostomy group. Superficial wound infections occurred in 4 patients (5.6%). Perioperative death occurred in 1 patient. Reoperation was necessary in 10 patients (13.9%). Major perioperative complications (permanent neurological deficit, vascular injury, tracheostomy, PEG tube, stroke, or death) occurred in 30.6% of patients. The risk of minor perioperative complications (temporary deficit, dysphagia, deep vein thrombosis, pulmonary embolism, urinary tract infection, pneumonia, or wound infection) was 80.6%.

CONCLUSIONS Single-session anterior-posterior cervical decompression and fusion is an inherently morbid operation required in select patients with cervical spondylotic myelopathy. In this large single-surgeon series, there was a major perioperative complication risk of 30.6% and minor perioperative complication risk of 80.6%. This overall elevated risk for postoperative complications must be carefully considered and discussed with the patient preoperatively. In some situations, shared decision making may lead to the conclusion that a procedure of lesser magnitude may be more appropriate.

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