Study Design Systematic review and meta-analysis. Objective To evaluate the prevalence, patterns, diagnosis, and management of drug-resistant spinal tuberculosis (TB). Methods We systematically searched PubMed, Embase, Scopus, Web of Science, and the Cochrane database from database inception to 14 February 2026, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Observational and experimental studies reporting drug resistance among patients with spinal TB were included. A random-effects meta-analysis was performed to estimate pooled proportions with 95% confidence intervals (CI). Risk of bias was assessed using the Joanna Briggs Institute checklist. Results Nineteen studies involving 5,475 patients with spinal TB were included. The pooled prevalence of multidrug-resistant (MDR)-TB among spinal TB was 4.69% (95% CI: 3.03-7.20%; 16 studies). Rifampicin resistance was noted in 13.84% (95% CI: 3.07-44.90%; 6 studies). Drug susceptibility testing was most commonly performed after clinical or radiological non-response rather than as routine practice. Treatment approaches were heterogeneous, with MDR spinal TB typically managed using individualized second-line anti-TB regimens, frequently combined with surgical intervention. Low risk of bias was documented in 47.4% of studies. Conclusions The prevalence of MDR-TB among spinal tuberculosis was 4.69%. Considerable heterogeneity exists in drug susceptibility testing, diagnosis, medical treatment, and surgical management. The available evidence remains limited, underscoring the need for prospective studies evaluating the effectiveness of anti-TB regimens in MDR spinal tuberculosis.
Study DesignScoping review.ObjectivesTo map longitudinal evidence on natural history, nonoperative management, progression definitions, clinical decision variables, and multimodal surveillance in mild to moderate degenerative cervical myelopathy (DCM), while distinguishing the treatment implications of mild and moderate disease.MethodsPubMed/MEDLINE, Embase, Web of Science Core Collection, Scopus, and the Cochrane Library were searched from inception to March 22, 2026. The review followed PRISMA-ScR. Eligible studies were adult longitudinal reports of mild or moderate DCM/cervical spondylotic myelopathy, extractable mild/moderate subgroups, or clinically relevant progression-surveillance evidence. Data were charted for design, population, management, follow-up, endpoints, progression definitions, examination findings, imaging variables, CT-relevant pathology, and alignment or motion factors.ResultsOf 6,193 records, 4,137 remained after deduplication and 766 underwent full-text consideration. Thirty-two reports underwent final eligibility assessment; 28 were retained, including 13 main analytic studies, 7 supplementary or conditional studies, and 8 adjunct multimodal narrative studies. Evidence was heterogeneous in severity thresholds, progression definitions, endpoints, and follow-up schedules. Nonoperative and natural-history cohorts showed that mild to moderate disease is not uniformly stable; some patients remained stable, whereas others deteriorated or crossed over to surgery. Objective function, quantitative MRI, electrophysiology, and selected structural measures may detect change more sensitively than symptom scales or conventional MRI alone.ConclusionsMild to moderate DCM represents a surveillance population, but mild and moderate disease should not be treated as having identical indications. Nonoperative cohorts help define progression and escalation risk, and multimodal follow-up appears more informative than single-scale monitoring.
Study DesignRetrospective-prospective multicenter comparative cohort study.ObjectivesPostoperative dysesthesia (POD) is a recognized complication of transforaminal endoscopic lumbar surgery, with reported rates up to 21.5%. Degenerative lumbar deformity may amplify this risk through vertebral rotation displacing the dorsal root ganglion into the transforaminal trajectory. This study compares POD rates and functional outcomes between transforaminal endoscopic lumbar foraminotomy (TELF) and interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) in degenerative lumbar deformity, and explores vertebral rotation as a mechanistic basis for approach selection.MethodsOne hundred patients with degenerative lumbar deformity (Cobb ≥10°) and foraminal stenosis underwent single-level endoscopic foraminotomy across 6 centers in Latin America: a retrospective cohort of 46 patients treated with TELF (2021-2023) and a prospective cohort of 54 patients treated with ICELF (2023-2025). Vertebral rotation was measured by CT using the Aaro-Dahlbornmethod. Primary outcome was POD occurrence; secondary outcomes included VAS, ODI, and modified MacNab criteria at 12 months.ResultsPOD occurred in 8/46 TELF patients (17.4%) versus 1/54 ICELF patients (1.9%; p=0.011, OR=11.16), corresponding to an 89% relative risk reduction (NNT=6.4). Functional outcomes were equivalent at 12 months (MacNab excellent+good: 67.4% vs 70.4%, p=0.376). Within the TELF group, vertebral rotation was significantly higher in POD patients (19.2°±4.7° vs 12.2°±4.3°, p=0.001). ROC analysis identified a 15° threshold (AUC=0.870, sensitivity 88%, specificity 74%).ConclusionsICELF is associated with substantially lower POD rates compared to TELF in degenerative lumbar deformity, with equivalent functional outcomes. Vertebral rotation appears to be a specific, measurable risk modifier for POD in the transforaminal approach, suggesting its role in approach selection.
Study DesignProspective international multicenter observational cohort study.ObjectiveTo evaluate the relationships among distal radius and ulna (DRU) classification, growth velocity, and scoliosis progression patterns in adolescent idiopathic scoliosis (AIS) using longitudinal interval-based analyses in a multinational Asian cohort.MethodsPatients aged 10-18 years with AIS were prospectively enrolled from multiple Asian centers. DRU classification, Sanders classification, Risser stage, standing height, and Cobb angle were assessed at approximately 4-6-month intervals. Only observations obtained before brace treatment or surgery were included. Height velocity and Cobb progression velocity were calculated between consecutive visits. Stage-specific patterns were evaluated using boxplots, nonparametric analyses, and mixed-effects models adjusted for age, sex, and baseline Cobb angle.ResultsAmong 329 enrolled patients, 236 patients contributing 618 longitudinal intervals met eligibility criteria. Mean age was 13.5 years, and mean baseline Cobb angle was 24.0°. Height velocity peaked at Radius stage 6 (0.62 cm/month) and Ulnar stage 5 (0.68 cm/month). Cobb progression velocity was greatest at Radius stage 6 (0.31°/month); among adequately represented Ulnar stages, progression velocity was greatest at stage 5 (0.27°/month). Spearman analyses showed only very weak correlations between skeletal maturity stage and Cobb progression velocity. Mixed-effects analyses suggested nonlinear progression patterns, with increased progression velocity at earlier to intermediate maturity stages.ConclusionsDRU classification demonstrated stage-dependent progression patterns, with peak scoliosis progression generally occurring approximately one DRU stage after peak height velocity. These findings suggest that DRU classification may help identify skeletal maturity phases associated with accelerated scoliosis progression in AIS.
Study Design Retrospective Cohort Study. Objective To propose a new technique named “lateral mass gutter” and investigate its role in augmenting spinal canal cross-sectional area (SCA) during laminoplasty. Methods This study included 105 patients who received cervical laminoplasty from February 2021 to February 2024. Patients were allocated to the conventional (CON) group or the lateral mass (LM) group according to the guttering technique used intraoperatively. Propensity score matching with a caliper of 0.2 was utilized to reduce selection bias. Intergroup comparisons encompassed clinical outcomes (Visual Analog Scale (VAS) of neck pain, Japanese Orthopaedic Association (JOA) score), radiographic measurements (SCA, laminoplasty opening angle (LOA), hinge fractures, hinge fusion, C2-7 Cobb angle) and postoperative complications (cerebrospinal fluid leakage, incisional fat liquefaction, C5 nerve root palsy, axial neck pain, cervical spine instability). Results Following propensity score matching, baseline parameters were comparable between the CON and LM groups (37 patients per group, P > 0.05). Compared to the CON group, the LM group exhibited a significantly smaller LOA, a lower incidence of hinge fractures, a higher rate of hinge fusion, greater improvement in JOA and a larger expansion in the SCA (P < 0.05). No statistically significant differences were observed between the two groups regarding VAS of neck pain or postoperative complications (P > 0.05). Conclusion Compared to conventional guttering technique, lateral mass gutter significantly reduces hinge fracture, promotes hinge fusion, enhances spinal canal expansion and optimizes postoperative neurological recovery in posterior cervical laminoplasty.
ObjectiveTo evaluate whether preoperative testosterone replacement therapy (TRT) use is associated with increased risks of pseudarthrosis and reoperation following single-level anterior cervical discectomy and fusion (ACDF).MethodsThe TriNetX Research Network was queried to identify adult males aged 18 to 89 years who underwent single-level ACDF. Patients were separated into a TRT exposure group within 1 year before initial ACDF procedure as well as comparator cohort without TRT exposure that was matched 1:1 using propensity score matching based on age, race, and relevant medical comorbidities. Patients were followed longitudinally for 2 years from the index procedure to assess postoperative outcomes. The primary outcomes were pseudarthrosis and reoperation. Risk ratios and time-to-event hazard ratios were calculated along with 95% confidence intervals.ResultsAfter propensity score matching, 494 matched pairs reached balance across all baseline characteristics. Patients receiving TRT demonstrated a 70% increased risk of pseudarthrosis (RR 1.70, CI 1.20-2.39; HR 1.71 CI 1.19 - 2.46) compared to the non-TRT cohort. TRT use was not associated with an increased risk of reoperation (RR 0.92 CI 0.59-1.43; HR 0.87, CI 0.55-1.38) following ACDF.ConclusionsPreoperative testosterone replacement therapy was associated with increased risk of pseudarthrosis, but not reoperation following ACDF. These findings suggest that TRT may represent an important patient-specific risk marker in patients undergoing ACDF. Given the observational design and potential for residual confounding, these findings should not be interpreted as evidence of a causal effect.
Study DesignRetrospective study.ObjectivesTo develop and validate a computer-assisted model for planning screw trajectories to support modified cortical bone trajectory (MCBT), cortical bone trajectory (CBT), and pedicle screw (PS) techniques, based on iterative closest point (ICP) registration and weighted k-nearest neighbors (kNN) algorithms.MethodsCT data from 110 patients undergoing lumbar surgery were analyzed, comprising an internal set of 50 younger patients with normal bone density and an external set of 60 patients including younger and older individuals with or without bone loss. L4-L5 segments were reconstructed using Mimics 21.0. Two surgeons manually planned MCBT, CBT, and PS trajectories bilaterally in the internal set to serve as reference standards. A personalized computer-assisted screw planning model was developed using ICP registration and weighted kNN, where the template library consisted of manually generated screw plans. Accuracy was evaluated by comparing algorithm-generated screw trajectories against expert manually planned trajectories to calculate deviations in sagittal inclination (α), axial inclination (β), screw head, pedicle entry point, pedicle crossing point, and screw tip. Hounsfield unit (HU) values along screw trajectories were also measured.ResultsIn the external set (total of 720 screws: 240 PS, 240 CBT, 240 MCBT), deviations for CBT weresagittal inclination (α) 4.117 (2.028, 7.251)°, axial inclination (β) 3.714 (1.901, 6.316)°, screw head 3.382 (2.514, 4.803) mm, pedicle entry point 3.0 (1.999, 4.149) mm, pedicle crossing point 1.511 (1.008, 2.443) mm, screw tip 3.586 (2.465, 4.542) mm. Those for MCBT were 4.865 (2.126, 7.547)°, 3.801 (1.658, 6.147)°, 4.153 (3.14, 5.658) mm, 3.818 (2.43, 6.209) mm, 1.545 (1.061, 2.222) mm, 3.777 (2.768, 5.241) mm, respectively. Computational acceptance rates for PS were 97.06% (HU: 238.4±67.71) in younger normal bone group, 92.71% (173.6±53.83) in older normal bone group, and 97.37% (113.3±58.68) in older bone loss group. For CBT, rates were 100% (477.2±168.6 HU), 100% (338.5±125.8 HU), and 100% (178.1±99.75 HU), respectively. For MCBT, rates were 100% (475.8±131 HU), 98.96% (376.8±104.9 HU), and 97.37% (213.4±106 HU), respectively. MCBT and CBT achieved significantly higher HU values than PS (P < 0.05).ConclusionThe ICP registration and weighted kNN-based planning model demonstrates high computational acceptance rates and excels in planning cortical bone screw trajectories with low breach rates and high HU values.
Study DesignRetrospective analysis of a prospectively maintained multicenter cohort.ObjectivesTo identify clinical characteristics associated with clinically meaningful improvement in neuropathic pain and to evaluate its relationship with postoperative functional outcomes in patients with degenerative cervical myelopathy (DCM).MethodsAmong 816 patients with complete Neuropathic Pain Symptom Inventory (NPSI) data, 597 with baseline total NPSI scores ≥7 were included in the primary analysis because they were eligible to achieve the predefined minimal clinically important difference (MCID) of a 7-point reduction. Patients were classified as responders or non-responders according to MCID achievement at 2 years postoperatively. Clinical outcomes included the cervical Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS), Short Form-36 (SF-36), and JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ).ResultsOf the 597 patients, 323 (54.1%) achieved the NPSI MCID. Responders had significantly higher preoperative total NPSI scores than non-responders, whereas no significant differences were observed in baseline JOA, VAS, or SF-36 scores. Responders demonstrated greater improvement in upper-extremity pain and numbness and in the SF-36 mental component summary score. They also showed significantly higher effectiveness rates in the upper-extremity, lower-extremity, bladder, and quality-of-life domains of the JOACMEQ.ConclusionsClinically meaningful improvement in neuropathic pain after surgery for DCM was associated with broader postoperative recovery across pain-related, functional, mental health, and quality-of-life outcomes. Assessment of neuropathic pain may provide clinically relevant information complementary to conventional measures of neurological function.
Study DesignRetrospective Cohort.ObjectivesAccurate, midline artificial disc placement is crucial when performing cervical disc replacement (CDR). Although cervical spinous processes (SPs) are considered midline structures, clinical experience has often shown noticeable deviation at times. This study aims to quantitatively characterize this known observation to better understand the utility of SPs as midline indicators during CDR.MethodsPatients who underwent anterior cervical discectomy and fusion with preoperative cervical spine computerized tomography (CT) scans were retrospectively identified, excluding those with previously surgically altered spines. Angular and lateral SP deviations from C3-C7 were collected from these CTs. Statistical analysis was conducted using one-way ANOVA with post-hoc testing using Tukey's test.ResultsThe average angular SP deviations at C3-C7 were 2.94 ± 2.06 degrees, 3.52 ± 2.19 degrees, 3.50 ± 2.13 degrees, 4.31 ± 2.15 degrees, and 3.53 ± 2.86 degrees, respectively. The average lateral SP deviations at C3-C7 relative to vertebral body widths were 5.43%, 6.10%, 6.14%, 8.17%, and 7.52%, respectively. Angular deviation at C6 was greater than C3 (p = 0.009). Relative lateral deviation at C6 was greater than at C3 (p = 0.027). Neither angular nor lateral deviation differed by sex at any level (p > 0.05 for all).ConclusionsGiven significant variation in cervical SP deviation between patients and by level, surgeons should hesitate to solely rely on them for determining vertebral midline during CDR. The C6 and C7 SPs especially should be used cautiously as they show relatively higher magnitudes and variations of deviation. However, the C3-C5 SPs may be of use if viewed in conjunction with other radiographic landmarks, such as the uncinate processes or medial borders of the pedicles.
Study DesignScoping review.ObjectiveTo systematically map and characterize the literature on the use of polymethyl methacrylate (PMMA) cement as an interbody spacer in the surgical management of pyogenic spondylodiscitis.MethodsA comprehensive search of MEDLINE, EMBASE, Web of Science, and Cochrane Library databases was conducted from their inception through February 2026. Studies reporting PMMA cement used as an interbody for pyogenic spondylodiscitis were included. Postoperative surgical site infections were excluded. Data were synthesized descriptively following scoping review framework (PRISMA-ScR).ResultsEight studies involving 203 patients (2013-2024) were identified. Common surgical indications included neurological deficit, instability, epidural abscess, and failure of medical management. Antibiotic-impregnated PMMA was used in seven studies (most commonly vancomycin + tobramycin or gentamicin). No major PMMA-related complications were reported, although one study mentioned a case of PMMA implant dislocation, requiring revision surgery during the same admission. Infection recurrence was low (1.4-1.6%). Fusion rates ranged from 95.9% to 100% when assessed (n=150). Fusion was commonly observed despite permanent PMMA implantation. Patient-reported outcomes were infrequently assessed but reported improvements in pain scores.ConclusionsLimited level IV evidence suggests that antibiotic-impregnated PMMA interbody placement is associated with high rates of infection control and fusion in pyogenic spondylodiscitis, particularly when significant endplate destruction is present and anterior column support is needed. No major PMMA-related complications were reported in the available literature. Well-designed comparative studies are warranted to clarify optimal patient selection, long-term durability, and the relative advantages of PMMA, if any, over contemporary reconstructive techniques.
Study DesignCross-sectional survey study.ObjectivesTo identify clinical knowledge gaps in spinal trauma and infection and assess use of AO Spine tools and recommendations.MethodsA 33-item online survey was distributed to AO Spine members by email and nonmembers through social media. Responses addressed demographics, case volume, knowledge gaps, and preferred educational formats. Descriptive statistics and regional comparisons using chi-squared or Fisher's exact tests were performed. Signficance was at the P < 0.05 level.ResultsOf 431 respondents, 412 completed at least one survey section and were included; the overall response rate could not be determined because the number of individuals who received or viewed the survey invitation was unavailable. Most respondents were orthopedic (61.2%) or neurosurgical (35.4%) surgeons. Leading priorities were osteoporotic spinal fractures (49.0%), spinal infection (48.3%), and fragility-associated low-energy sacropelvic fractures (40.3%). Regional variation was significant for sacropelvic fragility fractures (P = 0.038) and osteoporotic fractures (P = 0.028). Key gaps included bone quality optimization and surgical treatment for sacropelvic fragility fractures, comparison of techniques for osteoporotic fractures, and spinal infection algorithms. AO Spine Injury Classifications were routinely used by 89.5% of respondents. Use of the separate AO Spine-DGOU Osteoporotic Fracture Classification and AO Spine Primary Spine Infection Classification was reported by 35.7% and 18.7%, respectively, while PROST and CROST use was reported by 17.4% and 14.5%.ConclusionsSurgeons reported a need for standardized, evidence-based algorithms and accessible educational resources for osteoporotic fractures, spinal infection, and fragility-associated low-energy sacropelvic fractures.
Study DesignProspective multicenter observational cohort study.ObjectiveTo redefine mild degenerative cervical myelopathy (DCM) using a patient-reported severity framework derived from Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) and to compare surgical outcomes with the conventional clinician-reported definition.MethodsPatients with DCM undergoing surgery at 10 spine centers were enrolled. Mild DCM was defined using two criteria: a clinician-reported definition based on Japanese Orthopaedic Association (JOA) score (≧ 14.5) and a patient-reported definition derived from principal component analysis of JOACMEQ domains and Numerical Rating Scale (NRS) pain scores. Patients were categorized into four groups: Dual-Mild, Clinician-Mild, Patient-Mild, and Non-Mild. Postoperative outcomes were assessed using achievement of minimum clinically important difference (MCID) for JOA score, JOACMEQ, NRS, and Short Form-36 (SF-36). Multivariable logistic regression models were used to estimate adjusted probabilities of MCID achievement.ResultsAmong 930 eligible patients, 122 met criteria for mild DCM by each definition. Patients classified as Patient-Mild demonstrated higher baseline function and lower pain scores but showed significantly lower adjusted probabilities of achieving MCID in pain-related outcomes and SF-36 physical component summary (PCS) (odds ratio for PCS, 0.346 [0.196-0.589]; p < 0.001). In contrast, Clinician-Mild status was associated with sustained postoperative improvement.ConclusionDefinitions of mild DCM differ substantially between clinician- and patient-reported criteria. Patients who perceive their disease as mild exhibit limited postoperative improvement. Incorporating patient-reported severity into preoperative assessment may better inform expectations and shared decision-making regarding surgery in mild DCM.
Study DesignRetrospective cohort study.ObjectiveThe incidence of cervical radiculopathy is expected to increase by over 30% by 2050. ACDF, CDA, and PCF are established surgical options, each with distinct risk-benefit profiles. The objective of the present investigation is to compare long-term outcomes and complications among anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), and posterior cervical foraminotomy (PCF).MethodsA retrospective analysis was conducted using TriNetX. Adult patients undergoing single-level ACDF, CDA, or PCF for cervical radiculopathy were identified. 1:1 propensity matching was performed. Outcomes included perioperative complications, reoperation rates, and new cervical pathology at 30 days, 90 days, 6 months, 1 year, 2 years, and 5 years. Statistical significance was set at p<0.05.ResultsMatched cohorts included ACDF vs. PCF (N=2,659), ACDF vs. CDA (N=3,749), and CDA vs. PCF (N=2,143). PCF demonstrated significantly higher reoperation rates at all timepoints compared to both ACDF and CDA in pairwise comparisons, (5-year: PCF 9.5 vs. ACDF 4.4%; PCF 10.0% vs. CDA 2.8%, p<0.001). ACDF patients demonstrated increased reoperation rates at 5 years (CDA 3.2% vs. ACDF 4.5%, p=0.01). ACDF was associated with higher early emergency department visits and ICU admissions compared to CDA.ConclusionsPCF was associated with higher rates of subsequent cervical reoperation compared with ACDF and CDA in the matched cohorts. Differences in early postoperative complications and healthcare utilization were also observed between procedures. These findings should be interpreted in the context of differences in surgical indications and unmeasured clinical and radiographic factors that may influence procedure selection.
