BACKGROUND CONTEXT:High-dose glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly used for obesity management, but their perioperative safety and potential effects on fusion-related outcomes after anterior cervical discectomy and fusion (ACDF) remain unclear. PURPOSE:To compare short-term postoperative outcomes and longer-term fusion-related outcomes after ACDF among patients receiving high-dose versus standard-dose GLP-1 RA therapy. STUDY DESIGN/SETTING:Retrospective cohort study using the TriNetX Research Network. PATIENT SAMPLE:Adult patients undergoing ACDF were identified within TriNetX and stratified into 3 pairwise comparison groups: standard-dose GLP-1 RA versus no GLP-1 exposure, high-dose GLP-1 RA versus no GLP-1 exposure, and high-dose versus standard-dose GLP-1 RA use. A total of 112,065 patients met inclusion criteria across all 3 comparisons. In the primary dose-intensity comparison, 921 patients remained in each cohort after 1:1 propensity score matching. OUTCOME MEASURES:Outcomes included 90-day healthcare utilization (readmission, emergency department visits, outpatient visits, physical therapy utilization), 90-day medical and acute postoperative complications, 90-day opioid exposure, and long-term fusion-related outcomes from 180 to 720 days, including pseudarthrosis and posterior cervical fusion. METHODS:Data were queried on March 9, 2026. Adults undergoing ACDF were identified and stratified by preoperative GLP-1 RA dose intensity. Exposure was defined by recorded GLP-1 RA prescription strength from 1 year to 1 week before the index ACDF procedure. Separate 1:1 propensity score matching was performed for each pairwise comparison. Outcomes were evaluated at 1 to 90 days for healthcare utilization, short-term complications, and opioid exposure, and at 180 to 720 days for long-term fusion-related outcomes. FUNDING/CONFLICTS OF INTEREST:No funding was received for this study. The authors report no study-specific conflicts of interest or associated biases. RESULTS:In the primary high-dose versus standard-dose comparison, 90-day healthcare utilization was similar, including readmission (11.4% vs 10.0%; p = 0.327), emergency department visits (11.4% vs 12.3%; p = 0.564), outpatient visits (49.8% vs 52.1%; p = 0.328), and physical therapy utilization (42.0% vs 44.0%; p = 0.397). Short-term complications were also similar, including composite medical complications (9.6% vs 8.9%; p = 0.629), dysphagia (10.6% vs 11.2%; p = 0.709), hematoma (6.8% vs 6.3%; p = 0.638), dysphonia (1.8% vs 1.6%; p = 0.721), and acute respiratory failure (2.3% vs 1.7%; p = 0.406). Opioid exposure did not differ between cohorts (85.2% vs 83.1%; p = 0.202). Long-term outcomes were likewise similar, including pseudarthrosis (4.0% vs 3.8%; p = 0.822) and posterior cervical fusion (3.0% vs 3.7%; p = 0.398). Compared with matched non-users, both standard-dose and high-dose GLP-1 RA users had lower pseudarthrosis rates, although no additional long-term benefit was observed with higher-dose therapy. CONCLUSIONS:High-dose GLP-1 RA therapy was not associated with increased short-term healthcare utilization, postoperative complications, opioid exposure, or long-term fusion-related risk after ACDF compared with standard-dose therapy. These findings provide reassurance that higher-dose GLP-1 regimens do not appear to confer excess perioperative or fusion-related risk in this population.
BACKGROUND CONTEXT:Postoperative cervical hematoma requiring surgical evacuation after anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) is rare but life-threatening. Risk factor data are limited and inconsistent, largely derived from heterogeneous administrative databases. PURPOSE:To characterize the incidence and independent risk factors for postoperative cervical hematoma in a large single-institution consecutive series, and to evaluate the roles of ENT involvement and drain type. DESIGN:Retrospective cohort study. PATIENT SAMPLE:6,084 consecutive ACDF/CDR patients at a single academic institution; 25 confirmed hematoma cases identified by manual chart review. OUTCOME MEASURES:Cervical hematoma requiring surgical evacuation. METHODS:Univariate and multivariable logistic regression; 1:1 propensity score matching without replacement (caliper 0.2xSD) for ENT involvement and drain type. Post hoc power was assessed for key comparisons. RESULTS:Incidence was 0.41% (25/6,084). On univariate analysis, male sex (80.0% vs 56.6%, p=0.024), clotting disorder (OR 3.78, p=0.017), postoperative antihypertensive use (OR 2.36, p=0.042), and ≥4 surgical levels (OR 4.19, p=0.022) were associated with increased risk. On multivariable analysis, male sex (aOR 2.99, p=0.029) and ≥4 surgical levels (aOR 3.20, p=0.037) were independent predictors. Surgical approach by ENT showed no association after propensity matching (OR 1.00, p=1.000). Penrose drains were associated with higher rates than closed-suction drains (OR 6.08, p=0.001) or no drain (OR 9.15, p<0.001). CONCLUSIONS:Cervical hematoma after ACDF/CDR occurred in 0.41% of cases and was independently predicted by male sex and ≥4 surgical levels. ENT approach did not affect risk after matching. Penrose drains were associated with higher hematoma rates than closed-suction or no drain. These findings inform perioperative risk stratification and surgical decision-making.
BACKGROUND:Erector spinae plane block (ESPB) is increasingly used to improve perioperative analgesia after lumbar spine surgery, but its comparative effectiveness versus alternative strategies and different delivery modalities remains uncertain. PURPOSE:To compare ESPB with analgesic comparators evaluated in eligible ESPB-containing studies and to assess whether analgesic efficacy differs by ESPB delivery modality. STUDY DESIGN:Systematic review and dual network meta-analysis. PATIENT SAMPLE:Adults undergoing lumbar spine surgery receiving ESPB, modified thoracolumbar interfascial plane block (mTLIP), wound infiltration, sham ESPB, or control/usual care. OUTCOME MEASURES:Primary outcomes were 0-24 h opioid consumption (intravenous morphine equivalents), 24 h postoperative pain scores, and postoperative nausea/vomiting (PONV); secondary comparisons evaluated ultrasound-guided, fluoroscopy-guided, and freehand ESPB techniques. METHODS:Electronic databases were searched for eligible trials and two complementary network meta-analyses were performed: a treatment-comparison network including ESPB, mTLIP, wound infiltration, sham, and control, and a modality-comparison network contrasting ultrasound-guided, fluoroscopy-guided, and freehand ESPB with sham, wound infiltration, and control. Random-effects models generated comparative treatment effects alongside frequentist network estimates and Bayesian ranking metrics. RESULTS:ESPB reduced 0-24 h opioid consumption versus control/usual care and was superior to wound infiltration and sham. Modified thoracolumbar interfascial plane block (mTLIP) often ranked highest for opioid sparing, although inferences were limited by sparse direct evidence. ESPB showed favourable effects on 24 h pain and reduced PONV versus control, with no clear differences versus mTLIP or sham for PONV. Modality analyses indicated broadly similar reductions in opioid use and pain with ultrasound- and fluoroscopy-guided ESPB. CONCLUSIONS:ESPB is an effective opioid-sparing adjunct after lumbar spine surgery and appears superior to sham and wound infiltration for several outcomes, while apparent advantages of mTLIP require cautious interpretation; ultrasound- and fluoroscopy-guided ESPB demonstrate comparable analgesic performance, supporting modality choice based on local expertise and resources.
This scoping review was conducted in accordance with PRISMA guidelines to synthesize available literature evaluating return-to-sport rates, timing of return, functional recovery, performance outcomes, and career durability following spine surgery in ice hockey players. Ice hockey is a high-velocity collision sport associated with substantial axial loading, repetitive flexion-extension, and rotational forces across the spinal column, making spine injuries that require surgical intervention potentially career-altering. Despite this, hockey-specific postoperative outcome data remain fragmented and are often extrapolated from mixed-sport cohorts. Electronic database searches identified studies reporting postoperative outcomes following spine surgery in hockey athletes, with extracted variables including return-to-sport rates, time to return, performance outcomes, functional recovery metrics, surgical characteristics, complications, and career longevity. Among 441 hockey athletes, return-to-sport rates following spine surgery ranged from 75% to 90% across cervical and lumbar procedures. Lumbar microdiscectomy permitted earlier return compared with fusion procedures, whereas anterior cervical discectomy and fusion demonstrated return timelines approaching 9-12 months. Despite high return participation rates, several studies demonstrated postoperative declines in games played, scoring productivity, and performance indices. Career longevity following lumbar pathology averaged approximately three to four years, while cervical-specific longevity data remain limited, with mixed-sport cohorts suggesting similar durations. Overall, available evidence suggests that lumbar and cervical spine surgery can permit return to hockey participation in a majority of athletes; however, existing data are predominantly retrospective and frequently derived from mixed-sport cohorts. Performance decline and variable recovery timelines are commonly observed, and standardized criteria guiding return-to-play clearance, particularly following spinal fusion, are poorly defined and inconsistently reported. Prospective, sport-specific investigations incorporating standardized functional, radiographic, and performance metrics are needed to better guide surgical decision-making and postoperative rehabilitation.
BACKGROUND CONTEXT:Due to an aging population, incidences of Anderson Type 2 Odontoid fractures (T2OF), a type of spinal fragility fracture, are increasing. Elderly populations have high rates of sarcopenia, an age-related condition characterized by loss of muscle mass and function, which has been tied to outcomes after spine surgery and has been related to worse functional status and worse fracture healing. PURPOSE:No prior studies have explored the relationship between cervical sarcopenia and outcomes following T2OF, which may aid with surgical decision-making in this complex patient population. STUDY DESIGN:This study was a retrospective single-center cohort analysis. PATIENT SAMPLE:Adult patients presenting with acute T2OF after trauma from 2013-2025 were included. OUTCOME MEASURES:Demographics, comorbidities, surgical data, and clinical outcome and imaging data were collected. Cervical skeletal muscle measurements were performed both 2-dimensionally at the C3 level, which was then converted to lumbar skeletal muscle index and then stratified as sarcopenic or non-sarcopenic, and 3-dimentionally via skeletal volume measurements from the top of C1 to the bottom of C7 (cSMV). METHODS:Univariable analyses were performed using χ² or Fisher exact tests for categorical variables and analysis of variance or Kruskal-Wallis tests for continuous variables, and multivariable outcomes were assessed using Cox proportional hazards regression models and survival functions by the Kaplan-Meier method. RESULTS:Sarcopenic patients were significantly older, more likely to be female, had lower BMI, were more likely to have T2OF from a fall, and had significantly lower cSMV. Patients with sarcopenia and lower cSMV were less likely to fail non-operative management, and we did not detect an association between sarcopenia and cSMV and 1-year mortality. CONCLUSIONS:Sarcopenia and cSMV both seem to carry valuable prognostic information regarding success of non-operative management of T2OF, encoding information about patient frailty and functional status beyond age and comorbidity burden. This warrants further exploration in larger multi-center cohorts.
BACKGROUND CONTEXT:Sagittal malalignment in adult spinal deformity (ASD) is associated with disability and reduced quality of life. Although paraspinal muscle degeneration has been implicated in spinal alignment changes, longitudinal predictors of ASD progression remain unclear. PURPOSE:To determine whether MRI-defined erector spinae fatty infiltration and pelvic tilt predict sagittal malalignment progression in a population-based cohort. STUDY DESIGN/SETTING:Prospective longitudinal cohort study. PATIENT SAMPLE:A total of 533 community-dwelling adults from the Wakayama Spine Study with baseline whole-spine MRI and 6-year radiographic follow-up. OUTCOME MEASURES:Progression of sagittal malalignment defined as an increase in C7 sagittal vertical axis (SVA) ≥50 mm over 6 years. METHODS:Fatty infiltration ratio (FIR) of the erector spinae and multifidus was quantified on MRI. Multivariable logistic regression models were constructed, adjusting for age, sex, body mass index (BMI), and baseline C7 SVA. FIR was expressed per 5% increase to improve clinical interpretability. RESULTS:Sagittal malalignment progression occurred in 56 participants (10.5%). In univariable analysis, baseline C7 SVA did not differ significantly between groups, whereas pelvic tilt was significantly higher in the progression group. In multivariable models, pelvic tilt independently predicted progression (OR 1.13 per 1° increase, 95% CI 1.08-1.18, p<0.001). Fatty infiltration of the erector spinae at T12/L1 was also an independent predictor (OR 2.01 per 5% increase, 95% CI 1.40-3.05, p<0.001), whereas multifidus fatty infiltration was not statistically significant after adjustment. Baseline C7 SVA was inversely associated with progression (OR 0.82 per 10 mm increase, 95% CI 0.81-1.00, p=0.0085). In model discrimination analysis, the AUC improved from 0.700 in the base model to 0.806 after adding pelvic tilt and erector spinae FIR. CONCLUSIONS:MRI-defined fatty infiltration of the erector spinae was independently associated with sagittal malalignment progression in the general population. Increased pelvic tilt and lower baseline SVA may reflect a compensated state prone to subsequent decompensation. These findings highlight the importance of early identification of latent sagittal imbalance and suggest that paraspinal muscle quality may serve as a target for preventive strategies in ASD. LEVEL OF EVIDENCE:Level II.
BACKGROUND CONTEXT:Medicare physician reimbursement, even while adjusting for inflation, for lumbar spine surgery has decreased over the past two decades. No systematic review has measured these declines or separated out their differences by procedure. PURPOSE:This review's main question asked how inflation-adjusted U.S. Medicare physician reimbursement for common lumbar spine surgery CPT codes changed over time. Secondary questions explored how these changes differed across procedure categories and their relationship to surgical volume. DESIGN:Systematic review following PRISMA 2020 guidelines. The protocol was put together prior to beginning the search but was not registered; no quantitative meta-analysis was performed. PATIENT SAMPLE:Eleven retrospective studies (published between 2018 and 2026) were selected. These studies looked at Medicare physician reimbursement for lumbar spine surgery from 2000 to 2024. OUTCOME MEASURES:The primary variable this review was focused on was the Compound Annual Growth Rate (CAGR) of Medicare physician reimbursement adjusted for inflation. Secondary outcomes were nominal reimbursement, work relative value unit trends, and procedure volume. METHODS:We searched PubMed/MEDLINE, Scopus, and Web of Science from January 2014 to March 2026. Supplemental citation chaining was also done on included studies. Studies were eligible if they reported Medicare physician reimbursement for at least one of 15 lumbar CPT codes (6 decompression, 5 fusion, 4 instrumentation), with at least 3 years of data including one year inside our required range. Risk of bias was measured using the JBI Critical Appraisal Checklist with two review-specific items. Findings were combined as a narrative synthesis. We verified reported estimates by directly analyzing Physician Fee Schedule payment data for all 15 codes (2017-2025). This review received no specific grant funding. Records were screened in duplicate by two independent reviewers. No investigational drug or device was evaluated. RESULTS:The 11 included studies used data from Physician Fee Schedule look-up tools (n=5), Medicare claims (n=5), and a surgical registry (n=1). Six studies were rated low risk of bias, four moderate, and one high. The median study-level CAGR was -2.00% per year (interquartile range, -2.62% to -1.27%; range, +0.38% to -2.77%). Cumulative declines approached 33% over two decades. In our fee schedule analysis, inflation-adjusted payment for all 15 codes declined from 2017 to 2025, showing a median regression slope of -4.62% per year, with every 95% confidence interval remaining below zero. Decompression codes declined most sharply on average. Among fusion codes, anterior lumbar interbody fusion declined the most (CAGR -2.26% to -2.47%), while posterior lumbar interbody fusion was essentially stable (CAGR -0.01%). Anterior lumbar interbody fusion volume rose 798% even as payment fell 37.8%; total fusion volume increased 94.6% while reimbursement dropped 25%. Studies of post-2017 periods reported greater annualized declines, though shorter observation windows may inflate these rates. CONCLUSIONS:Medicare physician reimbursement for lumbar spine surgery has fallen at roughly 2% per year, with cumulative losses approaching one-third, even as surgical volumes have continued to rise. The growing gap between rising volume and falling payment may threaten practice sustainability, workforce participation, and access to lumbar spine procedures for Medicare beneficiaries.
BACKGROUND:Accurate pedicle screw placement is essential to prevent neurovascular injury, revision surgery, and excess healthcare costs. While navigation and robotic systems enhance accuracy over freehand or fluoroscopic techniques, they remain limited by high cost and patient radiation exposure. Three-dimensional printed (3DP) patient-specific guides offer comparable accuracy with potentially reduced intraoperative time and radiation. PURPOSE:To compare the accuracy, safety, and operative efficiency of 3DP- guides (3DPG) with navigation (NAV) and robotic-assisted (RA) platforms for pedicle screw placement using network meta-analysis. STUDY DESIGN:Systematic review and network meta-analysis of published clinical studies (randomized control studies, prospective and retrospective cohort studies). PATIENT SAMPLE:A total of 133 studies encompassing 15,946 adults (aged 18+) undergoing pedicle screw placement were included. PHYSIOLOGIC OUTCOME MEASURES: pedicle screw breach rates, estimated blood loss, operative time, radiation exposure, and complications. FUNCTIONAL OUTCOME MEASURES: postoperative pain (Visual Analog Scale) and functional outcomes (Oswestry Disability Index). METHODS:A systematic search of PubMed, MEDLINE, Embase and Cochrane was performed on September 27, 2025, comparing 3D-printed guides, computer navigation systems, and robotic-assisted platforms against conventional techniques (freehand or fluoroscopy-guided). Primary outcomes included pedicle screw breach rates, total operative time, estimated blood loss, overall and neurological complications, and pain and functionality scores. Binary outcomes were pooled as odds ratios (ORs) and continuous outcomes as mean differences (MDs), each with 95% confidence intervals. Radiation exposure, reported using heterogeneous metrics, was synthesized as ratios of means (RoM). Random-effects models were used throughout to account for between-study heterogeneity, with statistical significance set at p < 0.05. Risk of bias was assessed using ROBINS-I and RoB. RESULTS:Compared with conventional techniques, 3DPG achieved the lowest overall breach risk (OR 0.21, 95%CI: 0.16-0.28, p <0.001) and outperformed both RA and NAV. All advanced methods reduced odds of a major breach compared to the conventional method with no differences between them (p > 0.2). 3DPG placement produced the lowest blood loss (mean difference (MD) -79.6 mL, 95%CI: -101.1, -58.1, p < 0.001). Operative time was shortest with 3DPG with RA (+32.4 min, 95%CI: 28.3-36.5, p <0.001) and NAV (+34.8 min, 95%CI: 30.5-39.1, p <0.001) procedures taking significantly longer than 3DPG. Moreover, patient radiation exposure was significantly reduced compared to NAV and RA (ROM 0.21, 95% CI 0.08-0.50, p < 0.01 and ROM 0.35, 95% CI 0.15-0.82, p < 0.05, respectively). No significant differences were observed in postoperative pain (VAS) or neurological complication rates among advanced systems (all p > 0.1). CONCLUSIONS:3DPG demonstrated the lowest breach rates, lowest blood loss, shortest operative time and least radiation exposure compared to the other advanced guidance technologies. However, because this review synthesizes data from studies with variable designs, populations, and reporting methods, direct head-to-head comparisons between newer technologies remain limited. Given their lower per-unit cost, ease of implementation, and lack of reliance on capital-intensive equipment, 3DPG may represent a particularly accessible and cost-effective option, especially for smaller centres . Nevertheless, formal cost-comparison studies among these technologies are warranted.
BACKGROUND CONTEXT:Low back pain (LBP) is a leading cause of disability worldwide, yet population-level stratification of LBP risk remains limited. Unsupervised machine learning offers a data-driven approach to identify latent subgroups with distinct biopsychosocial profiles. PURPOSE:To identify population groups within a nationally representative survey using machine learning-based clustering algorithms and describe their LBP prevalence and associated factors. STUDY DESIGN/SETTING:Cross-sectional secondary analysis of the Chilean National Health Survey 2016-2017 (ENS 2016-2017). PATIENT SAMPLE:A total of 6,233 individuals aged 15 years and older completed the main forms, and 5,520 of these individuals also completed laboratory measurements. OUTCOME MEASURES:Weighted means and prevalence of LBP, sociodemographic characteristics, psychosocial factors (depression suspicion), and clinical biomarkers (metabolic, cardiovascular, and musculoskeletal profiles). Feature importance was assessed to determine the primary drivers of cluster assignment and LBP risk. METHODS:A machine learning pipeline was applied, using the K-prototypes clustering algorithm for mixed-type variables. The optimal number of clusters was determined using the elbow method and silhouette score. Cluster interpretability and feature importance were assessed using SHAP (SHapley Additive explanations) values analysis. Weighted prevalence estimates and descriptive comparisons were calculated across clusters using survey expansion factors. One-way ANOVA and Chi-square tests were conducted to identify differences among clusters (P = .05), and Odds Ratios (ORs) were calculated and adjusted for age and sex. RESULTS:Three clusters emerged: (A) healthy young adults, (B) middle-aged adults with higher depressive symptom burden, and (C) socioeconomically disadvantaged older adults with multimorbidity. Cluster B exhibited the highest weighted prevalence of LBP (26.86%; 95% confidence interval [CI], 24.77 to 29.06), followed by Cluster C (24.38%; 95% CI, 22.32 to 26.56) and Cluster A (10.78%; 95% CI, 9.72 to 11.93) (P<.001). Pain intensity (mean [SD], 7.1 (1.97); 95% CI, 6.97 to 7.23) and depressive symptoms (37.48%, 95% CI, 35.03 to 40.00) were key differentiators for Cluster B, while Cluster C showed increased cardiometabolic risk (High CV risk, 60.53%; 95% CI, 57.41 to 63.57), the longest pain exposure (103.74 months [191.89]; 95% CI, 89.64 to 117.84) and highest multisite pain burden (2.47 sites [1.61]; 95% CI 2.34 to 2.60). CONCLUSIONS:Unsupervised learning identified distinct subgroups within the population with heterogeneous LBP patterns. These findings contribute to a stratified understanding of population-level patterns of low back pain, highlighting the relevance of psychosocial and metabolic factors.
BACKGROUND CONTEXT:Cervical spine injuries related to non-traditional modes of transportation represent an emerging source of morbidity in the United States, particularly among younger populations. Although cervical spine trauma has been extensively studied in traditional motor vehicle crashes, epidemiologic data regarding injuries associated with non-traditional vehicles remain limited. PURPOSE:To characterize the epidemiology, mechanisms, demographics, and temporal trends of cervical spine injuries associated with non-traditional vehicles presenting to United States emergency departments. STUDY DESIGN/SETTING:Descriptive epidemiological study utilizing the National Electronic Injury Surveillance System (NEISS), a nationally representative database of emergency department visits in the United States. PATIENT SAMPLE:A total of 1,410 sampled NEISS records representing approximately 66,750 estimated emergency department visits for cervical spine injuries associated with non-traditional vehicles between January 1, 2015, and December 31, 2024. OUTCOME MEASURES:Primary outcomes included injury diagnosis, mechanism of injury, patient demographics, vehicle type, injury location, disposition, and temporal trends in annual injury estimates. METHODS:The NEISS database was queried for cervical spine injuries occurring between 2015 and 2024. Cases were identified using the neck body-part code and relevant diagnosis codes in combination with product codes for all-terrain vehicles (ATVs), dirt bikes, electric bicycles, go-carts, mopeds, minibikes, power-assisted cycles, and utility vehicles. Injury narratives were reviewed to confirm cervical spine involvement and classify mechanisms. National estimates and weighted percentages were calculated by summing the sampling weights provided for eligible NEISS records. No funds were received in support of this work ($0), and no study-specific conflicts of interest were identified. RESULTS:The 1,410 sampled NEISS records represented approximately 66,750 estimated emergency department visits nationally. Cervical strain or sprain was the most common diagnosis (45.7% of the weighted national estimate), followed by cervical fracture (21.4%). Males accounted for 62.4% of the weighted estimate. Four-wheel off-road ATVs were the most frequently involved vehicle type (30.6%), followed by two-wheeled powered off-road vehicles (17.7%). Patients aged 11-20 years represented the largest age group (25.7%). Weighted annual estimates increased significantly during the study period, with an average increase of 564 visits per year (P = 0.011). Non-contact mechanisms, including loss of control, rollover events, and falls from vehicles, predominated across age and sex groups. Most estimated visits resulted in treatment and release from the emergency department (76.0%). CONCLUSIONS:Non-traditional vehicles were associated with a substantial estimated burden of cervical spine injuries treated in United States emergency departments, particularly among adolescent and young adult males. ATVs and dirt bikes accounted for the largest shares of the weighted national estimate, and non-contact mechanisms predominated across demographic groups. These findings identify opportunities for targeted injury-prevention and safety interventions.
BACKGROUND CONTEXT:Long-term outcomes after cauda equina syndrome (CES) are commonly reported using isolated endpoints such as bladder recovery, which may underestimate the true burden of disease. CES affects multiple functional domains, yet its cumulative long-term impact remains poorly characterised. PURPOSE:To evaluate long-term outcomes after CES using a multidomain framework, quantify cumulative functional burden, examine discordance between residual deficits and patient-perceived recovery, and identify factors associated with adverse outcome. STUDY DESIGN/SETTING:Retrospective cohort study with prospective long-term follow-up conducted at a tertiary spinal referral centre. PATIENT SAMPLE:Seventy-two patients with degenerative CES confirmed by multidisciplinary team consensus and clinical-radiological correlation. OUTCOME MEASURES:Long-term patient-reported outcomes across seven domains: bladder, bowel, sexual function, mobility, pain, mental health, and activities of daily living. An unweighted multidomain burden score was constructed from 0 to 7, with extensive burden defined as four or more affected domains. Global outcomes included perceived symptomatic improvement, satisfaction, and willingness to undergo surgery again. METHODS:Patients with confirmed degenerative CES were identified from a tertiary spinal centre cohort and contacted for structured long-term follow-up. Outcomes were assessed using a domain-based patient-reported questionnaire. Residual dysfunction was recorded across seven functional domains and combined into a multidomain burden score. Comparative analyses were performed between clinically relevant subgroups, including CES-retention versus CES-incomplete status and presence versus absence of persistent bladder dysfunction. Exploratory regression analyses were performed to identify predictors of high multidomain burden and persistent bladder dysfunction. RESULTS:Seventy-two patients were included, with a mean age of 49.3 ± 14.8 years and median follow-up of 5.2 years (IQR 2.9-7.2). Residual dysfunction was common: bladder dysfunction persisted in 51.4%, bowel dysfunction in 37.5%, sexual dysfunction in 54.2%, and mobility limitation in 58.3%. Overall, 90.3% of patients had impairment in at least one domain, 72.2% in three or more domains, and 61.1% demonstrated extensive multidomain burden. Despite this, 79.2% reported symptomatic improvement, 86.1% would choose surgery again, and 70.8% reported high satisfaction, demonstrating discordance between persistent deficits and perceived benefit. Persistent bladder dysfunction was associated with more extensive multidomain burden compared with no bladder dysfunction (5.65 ± 1.32 vs 2.37 ± 1.75, p<0.001) and greater functional limitation. CES-retention versus CES-incomplete status did not significantly differentiate long-term outcomes. Increasing age was associated with both multidomain burden and persistent bladder dysfunction. CONCLUSIONS:Long-term outcomes after CES are characterised by persistent multidomain disability rather than isolated deficits. Most patients experience residual impairment across multiple functional domains, yet many still report symptomatic improvement, satisfaction, and willingness to undergo surgery again, highlighting a satisfaction-deficit paradox. Persistent bladder dysfunction appears to be a key driver of long-term outcome. These findings support a shift from single-domain endpoints toward multidimensional outcome assessment, comprehensive long-term follow-up, and more realistic patient counselling.
BACKGROUND CONTEXT:Spinal deformity surgery is among the most resource-intensive inpatient procedures in the United States. Despite increased transparency in commercial pricing, the structural drivers of cost variation for complex spine surgery remain unclear. PURPOSE:To characterize hospital-, market-, and community-level factors associated with variation in commercially negotiated prices for thoracolumbar spinal deformity surgery. STUDY DESIGN / SETTING:Cross-sectional analysis PATIENT SAMPLE: A total of 6,253 commercially negotiated prices for surgical thoracolumbar spinal deformity treatment (MS-DRG 456-458) were analyzed from 2,449 U.S. hospitals across five major commercial payers. OUTCOME MEASURES (FUNCTIONAL MEASURES):The primary outcome measure was the log-transformed commercially negotiated price for thoracolumbar spinal deformity surgery. METHODS:Hospital-level variables included bed size, teaching status, ownership, Case-Mix Index (CMI), and system affiliation. Market-level variables included wage index and concentration (Herfindahl-Hirschman Index). Community-level variables encompassed uninsured rate, Social Deprivation Index (SDI), racial composition, and population health metrics. Prices were log-transformed to address skewness. Multivariable linear regression utilized a hospital-payer-DRG contract-level dataset (n = 6,253 contracts from 2,449 hospitals), reflecting 30.5% attrition from the initial 3,526 hospitals due to complete-case exclusion for missing covariates (e.g., wage index and CMI). RESULTS:The fully specified model, inclusive of state and insurer fixed effects (adjusted R² = 0.244), revealed that system affiliation was the strongest predictor of higher prices, with affiliated hospitals charging 21.1-41.8% more (p < 0.001). Larger bed count (p = 0.008) and higher CMI (p = 0.015) were also associated with higher prices, whereas non-teaching hospitals (p = 0.042) had lower prices. Higher labor costs (p < 0.001) and lower market competition (7.5-7.8% higher prices, p < 0.05) were each associated with higher prices. At the community level, higher uninsured rates (+13.4% per SD, p = 0.020) correlated with higher prices, whereas poorer health (-6.9% per SD, p = 0.045) and lower SDI (-4.1% per SD, p = 0.048) were linked to lower prices. CONCLUSION:Hospital system size, labor costs, market concentration, and community context were associated with substantial variation in negotiated prices for surgical spinal deformity treatment.
BACKGROUND CONTEXT:The optimal number of fixation levels in cervical open-door laminoplasty remains controversial. A recent randomized controlled trial (RCT) demonstrated that alternate-level instrumentation (skip-fixation) achieved non-inferior improvement in the Japanese Orthopaedic Association (JOA) score compared with instrumentation at every level (all-fixation). Skip-fixation requires instrumentation at approximately half of the laminar levels and may therefore theoretically reduce implant-related costs. However, the economic impact of fixation strategy has not been formally evaluated. PURPOSE:To evaluate the cost-effectiveness of skip-fixation compared with all-fixation using two-year direct medical costs and health-related quality-of-life (HRQoL) data within the Japanese public health insurance system. STUDY DESIGN/SETTING:A secondary cost-effectiveness analysis conducted alongside a prospective, multicenter randomized controlled trial at four hospitals in Japan. PATIENT SAMPLE:Patients aged ≥60 years who underwent C3-C6 open-door cervical laminoplasty for degenerative cervical myelopathy in a multicenter randomized controlled trial. OUTCOME MEASURES:Two-year cumulative direct medical costs, including surgery-related inpatient costs, postoperative outpatient costs, and costs associated with complications or reoperations, were evaluated from the payer's perspective. HRQoL was measured using the EQ-5D-5L at baseline and at 3, 12, and 24 months postoperatively, and quality-adjusted life-years (QALYs) were calculated. METHODS:Incremental net monetary benefit (INMB) was calculated at a willingness-to-pay (WTP) threshold of JPY 5,000,000 (USD 45,900) per QALY. Uncertainty was assessed using 10,000 bootstrap replications to generate cost-effectiveness planes and acceptability curves. RESULTS:A total of 129 patients with complete two-year cost and utility data were analyzed (66 skip-fixation; 63 all-fixation). No statistically significant difference in two-year QALYs was observed between groups (ΔQALY = 0.035; 95% CI, -0.083 to 0.152). Mean two-year total direct medical costs were lower in the skip-fixation group (ΔCost = USD -1,460; 95% CI, -2,834 to -173). At the WTP threshold of USD 45,900, the mean INMB was USD 3,061 (95% CI, -2,481 to 8,569). The probability that skip-fixation was cost-effective was 86.3%. Scenario analyses demonstrated greater economic advantage when higher-cost plate fixation was assumed. CONCLUSIONS:Skip-fixation was cost-effective compared with all-fixation in cervical open-door laminoplasty over a two-year period. This economic advantage was more pronounced when high-cost implants were used.
BACKGROUND CONTEXT:Incidental durotomy (IDT) is a frequent intraoperative complication in spine surgery. While most cases are managed successfully with primary repair, management failure leads to persistent symptoms and necessitates secondary intervention, resulting in significantly poorer clinical outcomes. PURPOSE:To identify independent risk factors for management failure following IDT through a comprehensive analysis of patient demographics, pathological conditions, and surgical approaches. STUDY DESIGN/SETTING:A retrospective cohort study at a single tertiary institution. PATIENT SAMPLE:A total of 1,180 patients with confirmed IDT, identified from a continuous series of 24,438 spinal procedures performed between 2011 and 2024. OUTCOME MEASURES:The incidence of IDT and the rate of management failure, defined as the requirement for secondary surgical intervention. METHODS:To evaluate factors contributing to IDT management failure, the cohort was categorized into three distinct surgical subgroups based on the surgical approach used: anterior cervical, posterior thoracic OPLL (ossification of the posterior longitudinal ligament)/OLF (ossification of the ligamentum flavum), and general posterior approaches. A comparative evaluation of clinical, anatomical, and operative variables was performed between the success and failure groups to derive independent predictors of surgical failure. RESULTS:The overall incidence of IDT was 4.8% (1,180/24,438), with a management failure rate of 3.22% (38/1,180). Failure rates varied by procedure, peaking in anterior cervical corpectomy and fusion (13.3%) and posterior thoracic OPLL/OLF surgery (9.5%). In the thoracic OPLL/OLF subgroup, revision surgery (42.9% vs 5.4%, p = 0.015) and a higher OPLL occupying ratio (55.9% vs 16.3%, p < 0.001) were significantly associated with management failure. In minimally invasive procedures, 74.7% of IDTs were successfully managed without primary sutures. In the general posterior approach subgroup, multivariate analysis identified radiotherapy history (OR 14.82, 95% CI 3.12-70.45, p < 0.001), dural patch use (OR 5.32, 95% CI 2.05-13.84, p < 0.001), long-segment surgery (≥ 4 levels) (OR 3.12, 95% CI 1.28-7.62, p = 0.012), and higher body weight (OR 1.04, p = 0.019) as independent predictors of failure. CONCLUSIONS:Management failure after IDT is driven by patient-specific and anatomical factors. High-risk scenarios-specifically previous radiotherapy, revision thoracic procedures, and severe OPLL-starkly increase this risk, necessitating proactive surgical strategies. To prevent secondary interventions, surgeons must move beyond primary repair alone, optimizing the local environment by obliterating anatomical dead space and ensuring adequate extrinsic tamponade.
BACKGROUND CONTEXT:ACDF is performed by both orthopedic and neurosurgery-trained surgeons, but prior studies comparing outcomes across specialties are limited to 30-day endpoints and multi-institution databases. PURPOSE:To compare outcomes between orthopedic and neurosurgery-performed ACDF at a single institution. DESIGN:Retrospective propensity score-matched cohort study. PATIENT SAMPLE:662 pairs (N=1,324) undergoing ACDF at a single academic medical center from 2016-2023. OUTCOME MEASURES:Operative and hospital course duration, 30- and 90-day readmission, 90-day complications, opioid fills at 31-180 days, and one-year complications. METHODS:Adults undergoing ACDF (CPT 22551) were identified from an institutional database. Surgeons below the 50th percentile of annual volume (<5.2 cases/year) were excluded. Matching (1:1) incorporated age, sex, BMI, ASA class, Van Walraven Elixhauser comorbidity score, procedure setting, insurance type, fusion levels, myelopathy, and surgeon volume. RESULTS:Neurosurgery cases had longer surgery duration (3.38 vs. 2.71 h) and anesthesia time (4.22 vs. 3.40 h; both p<0.001). Length of stay was longer in neurosurgery (2.84 vs. 2.05 days; p<0.001), as were 30-day (9.8% vs. 5.9%; p=0.008) and 90-day (13.7% vs. 8.6%; p=0.003) postoperative readmission rates. The 90-day complication rate was higher in neurosurgery (22.1% vs. 16.9%; p=0.018). Neurosurgery cases had higher opioid fill rates at 31-90 days (25.8% vs. 19.6%; p=0.007) and 91-180 days (19.6% vs. 14.2%; p=0.008) post-operatively. CONCLUSIONS:The pattern of short-term differences and long-term convergence suggests differences in perioperative management instead of surgical proficiency. Hospitals performing ACDF across both specialties should standardize perioperative protocols.
BACKGROUND CONTEXT:Generative artificial intelligence (AI) is increasingly used in spine care; however, concerns remain regarding citation hallucinations and reliability. ChatGPT may generate inaccurate or fabricated references, whereas OpenEvidence (OE) prioritizes verified, peer-reviewed literature. This is the first study comparing OE and ChatGPT using cervical spine clinical guideline (CSCG) queries. PURPOSE:To compare guideline alignment, citation validity, sourcing, and prompt-engineering effects between OE and ChatGPT using CSCGs. STUDY DESIGN/SETTING:Cross-sectional comparative analysis. PATIENT SAMPLE:No patient population was included. OUTCOME MEASURES:Primary outcomes were guideline alignment score and citation validity (fully correct, partially hallucinated, or fully hallucinated). Secondary outcomes included source type, publication year, proportion published after CSCG release, and prompt-engineering effects. METHODS:A total of 110 evidence-based clinical questions derived from 10 CSCGs authored by 6 academic societies were submitted to OE (v2.0) and ChatGPT-4o from June 1 to July15, 2025. A subset of prompts was repeated to evaluate prompt-engineering effects. RESULTS:OE generated 999 citations with 100% accuracy, whereas only 184/393 (46.8%) ChatGPT citations met accuracy criteria (p<0.001). OE demonstrated higher guideline alignment than ChatGPT (4.6 ± 0.8 vs 4.1 ± 0.7; p = 0.03), with almost perfect interrater agreement (weighted Cohen's κ = 0.88; 95% CI, 0.80-0.97). . ChatGPT produced 88 partially hallucinated citations (22.4%), most commonly due to incorrect hyperlinks, author names, or publication years. OE cited more peer-reviewed literature (79.8% vs 60.1%; p<0.001) and more recent studies (2018±5.6 vs 2012±7.4; p<0.001). Prompt-engineering analysis showed OE maintained higher citation validity and fewer hallucinations, although accuracy declined when outputs were reformatted through ChatGPT, suggesting cross-model contamination. CONCLUSION:OE demonstrated superior CSCG concordance and substantially lower susceptibility to hallucinations than ChatGPT. Nonetheless, physician oversight remains essential for safe AI integration into clinical practice.
BACKGROUND CONTEXT:Accurate Current Procedural Terminology (CPT) coding is essential for compliant revenue cycle management in spine surgery. However, increasing documentation burdens and the complexity of bundling rules often lead to significant revenue leakage or audit risk. PURPOSE:To evaluate the baseline efficacy of three state-of-the-art Large Language Models (LLMs) in generating accurate CPT codes compared to the "Gold Standard" North American Spine Society (NASS) Common Coding Scenarios, and to quantify the downstream financial impact. STUDY DESIGN/SETTING:Comparative artificial intelligence performance analysis. PATIENT SAMPLE:Twenty standardized clinical vignettes selected from the NASS Common Coding Scenarios guide, representing a broad spectrum of spine pathology including cervical decompression/fusion, lumbar decompression, lumbar fusion, and complex deformity. OUTCOME MEASURES:Exact match accuracy, error of omission (under-coding), error of commission (over-coding/unbundling), and net financial variance utilizing 2026 Medicare Physician Fee Schedule (MPFS) Work RVU (wRVU) values mapped to a standardized commercial conversion factor of $60/wRVU. METHODS:Each vignette was input into three LLMs: GPT-4o (OpenAI), Gemini 1.5 Pro (Google), and Claude 4.6 Sonnet (Anthropic). Under isolated zero-shot conditions, the models were prompted to function as certified professional coders and generate the appropriate CPT codes and modifiers. Outputs were scored against the official NASS answer key, and subsequent financial variances were calculated. RESULTS:Gemini 1.5 Pro achieved an exact match rate of 65%, followed by ChatGPT-4o (55%) and Claude 4.6 Sonnet (40%), though these differences in overall performance were not statistically significant (p = 0.28). However, performance varied substantially by procedure type; notably, both ChatGPT and Claude achieved a 0% exact match rate for Lumbar Fusion constructs, frequently failing to correctly bundle interbody and posterior instrumentation codes. Financially, Gemini 1.5 Pro was the most stable, resulting in a negligible mean net revenue variance of -$2.16 per case. In contrast, ChatGPT and Claude demonstrated a strong tendency toward over-coding and high financial volatility, resulting in mean net revenue overcharges of +$75.60 and +$104.07 per case, respectively. CONCLUSIONS:While no statistically significant difference in overall accuracy was detected between models, qualitative deficits remain severe in handling complex fusion hierarchies. This study evaluates baseline performance under isolated zero-shot conditions; the tendency of Claude and ChatGPT to create unbundled billable codes presents a severe audit risk, while Gemini demonstrated a lower mean financial variance. Currently, LLMs should function only as adjunctive tools requiring strict human supervision.
BACKGROUND CONTEXT:Spinal stenosis (SS) has a multifactorial background. PURPOSE:This nationwide study aimed to determine the familial risks of hospital treated SS in first-, second-, and third-degree relatives in Sweden. STUDY DESIGN:The Swedish Multigeneration register was linked to the National Patient Register to investigate the heredity of hospital treated SS between 1997 and 2018. PATIENT SAMPLE:Offspring born to Swedish-born parents were included. OUTCOME MEASURES:Familial hazard ratios (HRs) for SS were calculated for relatives of individuals who had a diagnosis of SS compared with relatives of individuals unaffected by SS as the reference group. The adjusted familial hazard ratios (afHRs) with 95% confidence interval (CI) were determined for SS among pairs of twins, full-siblings, half-siblings, and cousins. METHODS:Adjustments were made for birth year, sex, education, occupation, and comorbidities including amyloidosis. RESULTS:A total of 6,548,565 individuals (48.77% women) were included with a mean age of 41 years (range 0-87 years) at the end of follow-up. 36,958 (0.56%) individuals were affected with hospital treated SS. The afHR for SS were for twins 5.12 (95%CI 3.33-7.89), siblings 2.47 (95%CI 2.35-2.60), half-siblings 1.49 (95%CI 1.28-1.73), and cousins 1.10 (95%CI 0.85-1.43). Among full siblings, afHRs were 5.38 (95%CI 2.02-14.33) for cervical SS and 3.01 (95%CI 2.69-3.67) for lumbar SS. A total of 0.27% SS patients had amyloidosis. Patients with amyloidosis had an adjusted HR of 2.03 (95%CI 1.67 - 2.48) for SS. CONCLUSIONS:Heredity is associated with higher risk of hospital treated SS in the Swedish population.
BACKGROUND CONTEXT Transforaminal lumbar interbody fusion (TLIF) is widely used to treat degenerative lumbar spine disease. Recombinant human bone morphogenetic protein-2 (rhBMP-2) on an absorbable collagen sponge (ACS) is approved for select fusion procedures; however, its use in one- or two-level TLIF remains investigational. PURPOSE To evaluate the safety and efficacy of two doses of rhBMP-2/ACS (2.1 mg/level and 4.2 mg/level) compared to autograft in 1- or 2-level TLIF. STUDY DESIGN/SETTING Global, multicenter, prospective, randomized, controlled, and blinded investigational device exemption (IDE) trial. PATIENT SAMPLE Adults with symptomatic degenerative lumbar disease at one or two adjacent levels (L2–S1) unresponsive to nonoperative treatment. Interim analysis was pre-specified after enrollment of 480 patients. OUTCOME MEASURES Primary endpoints included overall success and radiographic fusion at 24 months. Secondary endpoints included time to fusion, pain, disability, and neurological outcomes. METHODS Patients were randomized to receive TLIF with rhBMP-2/ACS at one of two doses or autograft. All patients underwent interbody fusion with posterior instrumentation. Overall success was defined as a composite endpoint including fusion, improvement in ODI, neurological success, absence of treatment-related serious adverse events, and no related secondary surgeries. A Bayesian adaptive design was used for interim analysis. RESULTS At interim analysis, both rhBMP-2/ACS dose groups met criteria for early success. Posterior probability of noninferiority for overall success versus autograft exceeded 0.999 for both doses, with superiority probabilities of 0.977 and 0.999. Fusion success demonstrated posterior probabilities of superiority >0.999 for both dose groups. Odds ratios for overall success were 1.87 and 2.60, and for fusion success were 3.48 and 5.16, with credible intervals above 1. Secondary outcomes demonstrated noninferiority in time to fusion, pain, disability, and neurological outcomes. Median time to fusion was shorter in the rhBMP-2/ACS groups. Adverse event rates were similar across groups, with no meaningful differences in serious adverse events or secondary surgeries. The autograft group had higher rates of incomplete fusion, while sciatica was more frequently reported in the rhBMP-2/ACS groups. CONCLUSIONS Interim results demonstrate that rhBMP-2/ACS is noninferior to autograft for overall success and superior for fusion success in one- or two-level TLIF, with comparable safety at 24 months. Continued follow-up will further define long-term outcomes and safety. FDA Device/Drug Status rhBMP-2/ACS (approved for this indication).
BACKGROUND CONTEXT Acute traumatic spinal cord injury (SCI) requires timely, evidence-based management to optimize neurological recovery and minimize secondary injury. Updated clinical practice guidelines are needed to reflect evolving evidence and standardize care. PURPOSE To present the 2024 AO Spine/Praxis Spinal Cord Institute Clinical Practice Guidelines for the acute management of traumatic SCI. STUDY DESIGN/SETTING Evidence-based clinical practice guidelines. PATIENT SAMPLE N/A. OUTCOME MEASURES N/A. METHODS Recommendations were developed through systematic review and meta-analysis of the literature, with expert panel consensus to formulate evidence-based and consensus-driven guidance. RESULTS The guidelines emphasize early surgical decompression within 24 hours of injury when medically feasible, supported by evidence demonstrating improved neurological outcomes. Blood pressure management is conditionally recommended, with mean arterial pressure targets of 75–80 mmHg to 90–95 mmHg for 3 to 7 days post-injury, based on associations between hypotension, hypertension, and neurological outcomes. A novel addition includes guidance on intraoperative SCI, including formal definition, risk factors, and recommendations for intraoperative neurophysiological monitoring (IONM) in high-risk procedures such as intramedullary tumor resection and complex deformity correction. A care pathway and checklist for intraoperative monitoring changes are also introduced. CONCLUSIONS The 2024 AO Spine/Praxis guidelines provide updated, evidence-based recommendations for the management of acute SCI, incorporating new data on early surgery and hemodynamic targets while introducing guidance for intraoperative SCI. These guidelines serve as a framework to optimize patient care globally while highlighting areas requiring further research, including ultra-early intervention, management of milder injury patterns, and spinal cord perfusion monitoring. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.
