STUDY DESIGN:Nonrandomized, quantitative study. OBJECTIVE:The goal of this study is to determine whether the prevalence and severity of spinal epidural lipomatosis (SEL) in patients undergoing lumbar spine decompression surgery have increased over the past decade. SUMMARY OF BACKGROUND DATA:There are no reports on whether the incidence of symptomatic spinal stenosis due to epidural lipomatosis has changed over time. This study assesses whether the prevalence and characteristics of spinal epidural lipomatosis have changed over 10 years. METHODS:This retrospective cohort study assesses consecutive patients who underwent lumbar decompression surgery (laminotomy/laminectomy, with or without fusion) for treatment of degenerative stenosis in the calendar years of 2013 and 2023 by a single surgeon. Patient demographic factors, surgical details, SEL grade, body mass index, and smoking status were analyzed. Statistical analyses were conducted using the χ2 tests to compare demographic and surgical variables. Binary logistic regressions were used to model the prediction of SEL, adjusting for age, BMI, and smoking status. RESULTS:The prevalence of SEL at multiple levels in the lumbar spine increased significantly from 2013-2023, rising from 47.5%-63% (P=0.028). Elevated Body Mass Index (BMI) was associated with an increased odds of SEL (OR=1.03, P=0.021). Cigarette smoking had a significant association with higher SEL grades, including a 3-fold increase in odds for SEL ≥60%. CONCLUSIONS:This study found a significant increase in multilevel SEL involvement from 2013-2023. Smoking and elevated BMI were associated with significantly increased odds of SEL, underscoring their impact as modifiable risk factors. These results support continued efforts to minimize smoking and obesity, while suggesting that additional, unmeasured factors may also be contributing to the increased prevalence of SEL over time.
STUDY DESIGN:Retrospective study. OBJECTIVE:To determine the prevalence of vitamin D deficiency in patients undergoing spine surgery and to evaluate its distribution across demographic characteristics, bone mineral density (BMD), and spine disease categories. A secondary objective was to examine the associations between serum 25-hydroxyvitamin D (25(OH)D) levels and bone turnover markers (BTMs). SUMMARY OF BACKGROUND DATA:Vitamin D is essential for musculoskeletal health. Although previous studies have reported a high prevalence of vitamin D deficiency among patients undergoing spinal surgery, most have been limited by small sample sizes, and large-scale investigations remain scarce. METHODS:Patients aged ≥40 years who underwent spine surgery between January 2021 and March 2024 were retrospectively reviewed. Preoperative evaluation included BMD measured by dual-energy X-ray absorptiometry and serum measurements of 25(OH)D and BTMs, including β-cross-linked C-telopeptide of type I collagen (β-CTX), procollagen type I N-terminal propeptide (PINP), and osteocalcin. Patients were stratified by age, sex, BMD status, and spine disease category. The correlation between serum 25(OH)D and BTMs was evaluated. RESULTS:A total of 1388 patients were included. Vitamin D deficiency was present in 43.4% of patients, and 39.2% had insufficient levels. Deficiency was more common in females (50.1%) than males (29.9%) and was most prevalent among patients aged 40-59 years. Patients with osteoporosis had the lowest mean 25(OH)D levels and the highest β-CTX, PINP, and osteocalcin levels. Among disease categories, patients with osteoporotic vertebral fractures showed the lowest vitamin D levels and the highest β-CTX and PINP levels. Serum 25(OH)D levels were negatively correlated with β-CTX and PINP. CONCLUSIONS:Vitamin D deficiency remains highly prevalent among patients undergoing spine surgery, particularly in females and younger individuals. Lower vitamin D levels are associated with increased bone turnover activity, suggesting that routine assessment and management of vitamin D status may help optimize bone health. LEVEL OF EVIDENCE:Level III.
STUDY DESIGN:Retrospective comparative study. OBJECTIVE:This study evaluated the radiologic and clinical outcomes of minimally invasive versus open fusion surgery using a computer-assisted image analysis tool. BACKGROUND:Lumbar spondylolisthesis, isthmic in nature, tends to interfere with sagittal balance and results in chronic back pain and disability. Operationally, the primary aim is to correct sagittal imbalance and restore functional stability. METHODS:Patients with single-level mild isthmic lumbar spondylolisthesis who underwent treatment with minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) or open posterior lumbar fusion were evaluated retrospectively. Sagittal spinopelvic parameters, such as pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), disc height (DH), and spondylolisthesis degree (SD), were measured preoperatively and postoperatively at 3 months with quantitative image-processing software. Functional outcomes were assessed using the Oswestry Disability Index (ODI), and the connection between radiographic and clinical changes was analyzed. RESULTS:Both methods significantly restored PT, SS, LL, DH, and SD (all P=0.021-0.038), without changing PI (P=0.412). Greater restoration of LL and DH was associated with improved ODI scores (r=0.64 and 0.59; P=0.001 and 0.003, respectively). Clinical outcomes were comparable between groups (P=0.284); however, the minimally invasive group demonstrated shorter hospital stay and faster early recovery (P=0.018). Quantitative imaging showed high reproducibility (ICC=0.93). CONCLUSION:Minimally invasive and open fusion methods both restored sagittal spinopelvic parameters and improved functional outcome in mild isthmic spondylolisthesis. Minimally invasive fusion provided similar radiographic correction at decreased perioperative morbidity. Quantitative image-based evaluation offers a consistent method for assessing spinal alignment and improving surgical planning. LEVEL OF EVIDENCE:Level II.
STUDY DESIGN:Retrospective study. OBJECTIVES:To evaluate whether adding cross-links during single-level lumbar interbody fusion (LIF) improves fusion rates, segmental alignment, and clinical outcomes. SUMMARY OF BACKGROUND DATA:Biomechanical studies suggest cross-links enhance rotational stability in single-level posterior lumbar interbody fusion, but clinical evidence for their benefit in degenerative lumbar spine diseases remains limited. No previous clinical study has investigated how cross-link addition affects LIF outcomes. METHODS:One hundred thirty-one patients underwent single-level LIF for degenerative lumbar spine diseases (2012-2022) and were categorized into cross-link (CL, n=64) and non-cross-link (NCL, n=67) groups. Researchers assessed CT-based fusion parameters (interbody and facet fusion rates), segmental alignment measurements (segmental lordosis, disk height, and coronal tilt), and clinical outcomes (JOA and VAS scores) over a minimum 1-year follow-up. Propensity score matching minimized selection bias. RESULTS:One-year interbody fusion rates were comparable between groups (CL: 72.1% vs. NCL: 69.1%, P=0.839). No significant differences were found in facet fusion rates (CL: 37.7% vs. NCL: 30.9%, P=0.558), pedicle screw loosening (CL: 8.2% vs. NCL: 16.4%, P=0.254), or cage subsidence (CL: 9.8% vs. NCL: 9.1%, P=1.000). Clinical outcomes improved similarly in both groups based on final JOA scores (CL: 26.0±6.8 vs. NCL: 25.3±4.3, P=0.47) and VAS back pain scores (CL: 21.8±20.8 vs. NCL: 22.9±22.7, P=0.79). Propensity score-matched analysis of 32 patients per group confirmed these findings. CONCLUSIONS:Routine use of cross-link in single-level LIF does not improve radiographic or clinical outcomes after 1 year. A selective approach could reduce costs while maintaining excellent patient outcomes.
STUDY DESIGN:A total of 20 patients with degenerative cervical myelopathy (DCM) and a plan for surgical decompression were recruited in this pilot study to assess a new outcome measure. Patients were evaluated preoperatively and 3 months, 6 months, and 1 year postoperatively using a 3-dimensional motion-tracking application (reachable workspace) to calculate an upper extremity (UE) relative surface area (RSA) and standard measurements [modified Japanese Orthopedic Association (mJOA), 12-Item Short Form Health Survey (SF-12), and visual analog pain (VAP) score]. Baseline demographic data were collected. OBJECTIVE:To assess the validity and comparativeness of a new measurement tool in DCM. SUMMARY OF BACKGROUND DATA:Currently, no universally accepted outcome measure exists for DCM. Traditionally used assessment scales are subjective and lack sensitivity. The reachable workspace, a graphical representation of UE spatial surface area using motion-sensor technology, can be used as an objective adjuvant assessment tool in DCM. METHODS:The Welch t test was performed to assess UE RSA differences between DCM patients and healthy controls (HC). Concurrent validity and effect size of the RSA were compared to the standard measurements. A P=0.05 was accepted as statistically significant. RESULTS:DCM patients had significantly reduced RSA of all quadrants compared to controls, with the largest reductions in the upper quadrants (P<0.0001). Total RSA was significantly associated with total mJOA score (ρ=0.48, P<0.0001), upper extremity mJOA score (ρ=0.44, P<0.0002), VAP score during movement (ρ=-0.40, P<0.0007), and the SF-12 mental component (ρ=0.34, P<0.005). Patients with symptoms <1 year before surgery showed improved function via significant increases in total RSA and mJOA score. A stronger effect size was seen with RSA. CONCLUSION:The reachable workspace shows potential to track DCM UE function with accuracy, reliability, and sensitivity to change. Given the promise of this pilot study, a larger study to increase power and substantiate our results will be performed in the future.
STUDY DESIGN:Retrospective cross-sectional study. OBJECTIVE:The objective of our study is to assess the relationship between carotid artery stenosis (CAS) and muscle morphology. SUMMARY OF BACKGROUND DATA:Paraspinal muscle degeneration, marked by fatty infiltration (FI) and reduced functional cross-sectional area (fCSA), contributes to spine instability, chronic pain, and disc degeneration. While abdominal aortic calcification is linked to lumbar muscle atrophy, cervical vascular-muscle associations remain underexplored. METHODS:Sixty-five patients undergoing primary cervical spine surgery between 2009 and 2018 with preoperative cervical MRI and CTA exams (≤12 mo apart) were included. T2-weighted axial MRIs at C3 were used to measure FI and fCSA in 5 bilateral muscle groups: sternocleidomastoid (SCM), anterior, posteromedial (PM), posterolateral (PL), and trapezius (TP). Carotid stenosis was measured on CTA using semiautomated software. Correlations between muscle parameters and stenosis were analyzed with Spearman correlation and multivariable regression, adjusted for age, BMI, and sex. RESULTS:Mean stenosis was significantly associated with FI in all muscle groups, including SCM (P=0.001), anterior (P=0.022), PL (P=0.031), PM (P=0.003), and TP (P=0.001). Maximum stenosis was associated with reduced fCSA in SCM (P=0.032) and anterior (P=0.032), as well as FI in SCM (P=0.005), TP (P=0.006), and PM (P=0.001). CONCLUSIONS:This is the first study linking CAS with cervical muscle atrophy, pointing toward vascular health's potential role in muscle degeneration and the need for further research into vascular and musculoskeletal health interplay.
STUDY DESIGN:Controlled experimental biomechanical study using a sheep cervical spine model. OBJECTIVE:To biomechanically evaluate and compare skip laminectomy and laminoplasty in the lower cervical spine, focusing on their influence on spinal stability. SUMMARY OF BACKGROUND DATA:Skip laminectomy and laminoplasty are 2 posterior cervical surgical techniques widely used for spinal canal decompression. Although their clinical outcomes have been compared, no previous study has biomechanically analyzed and compared these techniques in the cervical region. METHODS:Twenty-eight C2-T1 cervical spine specimens obtained from merino sheep were used in this study. Seven specimens underwent preliminary fracture testing to establish nondestructive loading parameters. The remaining specimens were assigned to 3 groups: intact control, laminoplasty, and skip laminectomy (n=7 per group). Bone mineral density (BMD) was measured to ensure baseline equivalence across specimens. Biomechanical testing was performed using an electromechanical actuator to evaluate displacement during flexion, extension, lateral bending, and axial rotation under standardized loading conditions. Statistical analysis was conducted to compare biomechanical behavior among the groups. RESULTS:No statistically significant differences were observed among the control, laminoplasty, and skip laminectomy groups with respect to displacement during flexion (P=0.755), extension (P=0.546), right lateral bending (P=0.359), left lateral bending (P=0.415), or axial rotation (P=0.690). Both surgical techniques demonstrated biomechanical behavior comparable to that of intact cervical spine specimens under the tested loading conditions. CONCLUSION:This study represents, to our knowledge, the first direct biomechanical comparison of skip laminectomy and laminoplasty in the cervical spine. Both procedures preserved immediate postoperative mechanical stability in this experimental ovine model, with no significant biomechanical differences identified between the techniques. Further biomechanical and long-term clinical studies are needed to determine the clinical relevance of these findings.
STUDY DESIGN:Retrospective review. OBJECTIVE:To analyze the clinical and radiologic outcomes of biportal endoscopic cervical laminectomy (BECL) for cervical myelopathy. SUMMARY OF BACKGROUND:Cervical myelopathy is a progressive disease caused by spinal cord compression that significantly impacts quality of life. While open posterior surgeries have been utilized, they carry risks such as postoperative instability, kyphosis, and muscle damage. BECL has emerged as a minimally invasive technique designed to minimize damage. METHODS:Fifteen patients without cervical kyphosis or segmental instability underwent BECL for myelopathy. The endoscopic approach was designed to preserve the multifidus muscle. Clinical outcomes were measured using the Neck Disability Index (NDI) and Visual Analog Scale (VAS) preoperatively and at least 1-year postoperatively. Radiologic outcomes were assessed to evaluate changes in alignment. RESULTS:The mean follow-up period was 18.9±4.4 months. All clinical outcomes showed statistically significant improvement (P<0.05). VAS Neck, VAS Arm, and NDI all demonstrated clinical improvement. Radiologically, there were no statistically significant changes in sagittal alignment. CONCLUSION:In appropriately selected patients, BECL is a safe and effective alternative treatment for myelopathy. It provides excellent clinical outcomes for pain relief and functional recovery while preserving preoperative cervical sagittal alignment in the short term.
STUDY DESIGN:Retrospective study. OBJECTIVES:To describe technique of medial pedicle wall referencing extra-pedicular (EP) screw insertion method. To compare the EP chord length of this technique with the conventional technique in adolescent idiopathic scoliosis (AIS) patients and report the accuracy of this technique based on computed tomography (CT) assessment. SUMMARY OF BACKGROUND DATA:Conventional EP screw technique has a high medial convergence angle, which increases the difficulty of entry into vertebral body, increasing the risk of anterior perforations. Lateral entry point requires more extensive dissection. A lateral starting point leads to malalignment of the screw heads when placed next to intra-pedicular screws. METHODS:A total of 103 AIS patients who had undergone posterior spinal fusion (PSF) from 2018 to 2023 were recruited. A total of 2472 thoracic pedicles were analyzed on preoperative CT scans and the pedicle morphometry were classified based on the Chiu et al classification. The EP chord length of both techniques was measured for narrow dysplastic pedicles (grade C and D). Postoperative CT scans were used to assess for medial perforations (Gertzbein and Robbins classification modified by Rao et al) and anterior perforations (Hansen-Algenstaedt et al grading) . RESULTS:The longest chord length in conventional technique was in left T8 (53.7±3.5 mm) and T9 (53.7±3.7 mm) versus medial pedicle referencing technique which recorded 38.6±3.2 mm and 38.3±3.2 mm, respectively (P<0.001). A total of 434 EP screws were inserted using this technique in narrow dysplastic pedicles. The prevalence of grade 1 medial perforations were 11.3% and for grade 1 anterior perforations were 4.1%. There were only 0.7% grade 2 (critical) perforations [medial: 0.2%, anterior: 0.5%]. None of the perforations were symptomatic and no grade 3 perforations were observed. CONCLUSION:The medial pedicle wall referencing EP screw technique is a safe alternative method, especially in narrow dysplastic pedicles. This technique has a shorter chord length and a less convergent trajectory with an acceptable critical perforation rate (0.7%).
STUDY DESIGN:Retrospective cohort. OBJECTIVE:To investigate the relationship between GLP-1 receptor agonist exposure and incidence of vertebral fracture and surgical intervention for these injuries in patients with osteoporosis. SUMMARY OF BACKGROUND DATA:Vertebral fractures are relatively common in patients with osteoporosis and frequently result in substantial morbidity, such as persistent pain and functional deficit. Although primarily indicated for the management of type 2 diabetes mellitus and obesity, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have demonstrated positive effects on bone mineral density (BMD) in the lumbar spine. However, it remains unknown if this effect translates to positive clinical outcomes for patients with osteoporosis. METHODS:This study utilized the TriNetX database to identify female patients aged over 50 years diagnosed with osteoporosis without a current pathologic fracture within the 10-year period ended January 1, 2025. The study group included patients with a history of GLP-1 RA use after osteoporosis diagnosis compared with a control group with no GLP-1 RA exposure. Cohorts were propensity-matched based on baseline demographic characteristics, BMI, HbA1c, eGFR, medical comorbidities, osteoporotic medication use, and serum calcium, phosphate, and vitamin D levels. Primary outcomes included incidence of vertebral collapse and vertebral augmentation within the 10-year study period. RESULTS:There were 56,142 matched pairs. The rate of vertebral fracture in the experimental group was ∼1.9% compared with 4.3% in the control group (RR: 0.434, 95% CI: 0.404-0.467, P<0.001). In addition, GLP-1 RA exposure was associated with a lower incidence of kyphoplasty or vertebroplasty (RR: 0.453, 95% CI: 0.381-0.538, P<0.001). CONCLUSION:Glucagon-like peptide-1 receptor agonist use is associated with a lower incidence of vertebral fracture and osteoporotic fracture intervention in female patients aged 50+ with osteoporosis. These findings underscore the potential protective effects of GLP-1 receptor agonists in patients with poor bone quality. LEVEL OF EVIDENCE:Level III.
STUDY DESIGN:Retrospective study. OBJECTIVE:To evaluate the long-term clinical and radiologic outcomes of adolescent idiopathic scoliosis (AIS) patients with Lenke 1B, 1C, 2B, and 2C curves treated with selective thoracic fusion (STF) using an all-pedicle screw construct. SUMMARY OF BACKGROUND DATA:STF has been reported in the literature to achieve better perioperative outcomes, including shorter operative duration, reduced blood loss, and lower operative risks. However, complications such as coronal decompensation (CD) and the adding-on (AO) phenomenon persist, even with strict selection criteria. Long-term data on the outcomes of STF using all-pedicle screw constructs remain limited. METHODS:This retrospective study included 59 AIS patients who underwent single-staged posterior spinal fusion with an all-pedicle screw construct, with a minimum follow-up of 5 years. Radiologic outcomes and SRS-22r scores were analyzed. Complications, including AO, CD, lumbar decompensation (LD), and junctional kyphosis, were assessed. RESULTS:At a mean follow-up of 5.8 years, the main thoracic (MT) curve correction was 60.3%. Spontaneous lumbar curve correction improved from 49.9% immediately postoperatively to 53.5% at the final follow-up (P=0.046). Coronal balance (CB) shifted significantly from 1.8±12.7 mm preoperatively to -6.9±9.9 mm at the final follow-up (P<0.001). SRS-22r scores improved significantly across all domains except pain, which remained stable. AO and CD occurred in 8.5% of cases each, and LD in 1.7%, with no instances of junctional kyphosis or revision surgery. CONCLUSION:This study demonstrates excellent long-term correction and clinical improvement in AIS patients treated with STF using an all-pedicle screw construct.
STUDY DESIGN:Retrospective matched-cohort study. OBJECTIVE:To evaluate the clinical efficacy, safety, and economic impact of a novel cellular bone allograft (PrimaGen Advanced Allograft; CBA-P) used in combination with recombinant human bone morphogenetic protein-2 (rhBMP-2) for short-segment lumbar interbody fusion. SUMMARY OF BACKGROUND DATA:Osteobiologic grafts are increasingly used to optimize lumbar interbody fusion outcomes. Recombinant human bone morphogenetic protein-2 (rhBMP-2) improves fusion rates but is costly and associated with complications. Cellular bone allografts (CBAs) aim to enhance fusion by providing a bony scaffold, growth factors, and viable cells, but their clinical and economic benefit remains unclear. METHODS:We retrospectively assessed 100 adults who underwent 1- or 2-level posterior or transforaminal lumbar interbody fusion between 2017 and 2023. Fifty patients received CBA-P with rhBMP-2 (experimental cohort), and 50 matched controls received rhBMP-2 with standard-of-care demineralized bone matrix and/or allograft bone powder. Matching was based on age decade, sex, and fusion level. The primary outcome was interbody fusion at 12 and 24 months, assessed using a validated radiograph measurement platform. Secondary outcomes included revision surgery, complications, pain scores, and per-case osteobiologic cost. RESULTS:Fusion rates were similar between cohorts at 12 months (95.7% vs. 89.1%, P=0.27) and 24 months (100% vs. 89.5%, P=0.49), with comparable revision and complication rates. Estimated blood loss (364.4 vs. 232.9 mL, P<0.001) and 6-month pain scores (P=0.03) were higher in the experimental cohort. CBA-P use significantly increased per-case osteobiologic cost ($9478 vs. $5252, P<0.0001). CONCLUSIONS:Use of CBA-P with rhBMP-2 did not improve fusion rates, reduce complications, or enhance pain outcomes, yet markedly increased surgical cost. These findings do not clearly support the routine use of CBA-P alongside rhBMP-2 in short-segment lumbar interbody fusion and highlight the need for well-designed prospective studies to define its standalone clinical value. LEVEL OF EVIDENCE:Level III.
STUDY DESIGN:Systematic review. OBJECTIVE:To compare clinical outcomes of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) in studies without industry influence. SUMMARY OF BACKGROUND DATA:Both CDA and ACDF are appropriate options for cervical degenerative disc disease. However, most studies investigating this have significant industry influence due to either industry sponsorship or conflicts of interest among authors. METHODS:A systematic review of all studies investigating CDA versus ACDF in the Cochrane and PubMed/EMBASE databases was performed. Studies were excluded if they were supported by industry without investigator independence, had a minimum follow-up <2 years, or were performed outside the United States or Europe. Revision rates, adjacent segment degeneration (ASD) rates, and patient-reported outcomes (PROMs), including Neck Disability Index (NDI) and visual analog scale (VAS) Neck, were extracted. Funnel plots were used to exclude biased studies for each specific outcome measure. Meta-analyses were conducted using random effects modeling and forest plot analysis. RESULTS:Thirteen studies were included with 18,473 patients, of whom 12,270 underwent ACDF and 6203 underwent CDA. Minimum follow-up ranged from 24 to 132 months. Overall, 12/13 (92.3%) of studies were considered high quality. On random effects modeling, patients undergoing ACDF demonstrated higher rates of ASD [risk ratio (RR), 1.70; 95% CI: 1.02-2.84] but there were no differences in subsequent revision (RR, 1.29; 95% CI: 0.99-1.67), VAS Neck [(weighted mean differences (MD), 0.26; 95% CI: -0.38 to 0.90), or NDI (weighted MD, 1.81; 95% CI: -3.54 to 7.15)]. CONCLUSIONS:In this first meta-analysis of all comparative studies between ACDF and CDA without industry influence, we demonstrate that despite a higher rate of ASD among patients undergoing ACDF, there are no long-term differences in revision rates or patient-reported outcomes between CDA and ACDF.
STUDY DESIGN:Retrospective cohort study. OBJECTIVE:This study aimed to forecast national trends in anterior cervical discectomy and fusion (ACDF) and posterior cervical fusion (PCF) through 2035 in the US Medicare population using comprehensive, procedure-specific modeling approaches. SUMMARY OF BACKGROUND DATA:Cervical spinal fusion is widely performed for degenerative cervical spine disease. ACDF remains the most common procedure, while PCF is indicated for multilevel disease, deformity, and revision cases. Despite the high-utilization, up-to-date, procedure-specific forecasts for the Medicare population are lacking. Updated forecasts are required to guide workforce planning, policy development, and resource allocation for an aging population. METHODS:National Medicare Part B data were analyzed from 2005 to 2022 to identify ACDF and PCF procedures using Current Procedural Terminology (CPT) codes. Procedure volumes were adjusted for Medicare Advantage enrollment. Ordinary least squares (OLS) regression models were developed to project volumes through 2035, excluding data from 2020 and 2021 to minimize bias from COVID-19-related disruptions. Model performance was assessed using R2, slope estimates, and 5-fold cross-validation. RESULTS:Estimated ACDF volumes increased from 57,765 in 2011 to 101,019 in 2022. ACDF volumes are projected to increase to about 170,102 procedures by 2035 (95% CI: 139,912-200,291). Estimated PCF volumes increased from 9659 in 2005 to 42,400 in 2022 and are projected to reach 68,901 procedures by 2035 (95% CI: 66,108-71,693). The models demonstrated strong fit for both procedures (ACDF R2=0.8382, PCF R2=0.9892). CONCLUSIONS:National volumes of cervical spinal fusion are expected to continue rising through 2035 among Medicare beneficiaries. These trends likely reflect an aging population, broader surgical indications, and the continued shift toward outpatient spine surgery. Our findings have important implications for surgical workforce needs, reimbursement policy, and resource allocation across inpatient and ambulatory care settings.
STUDY DESIGN:Retrospective cohort study. OBJECTIVE:To describe a multicenter cohort of patients with type III occipital condyle avulsion fractures, emphasizing mechanical stability and treatment strategies. SUMMARY OF BACKGROUND DATA:Occipital condyle avulsion fractures are rare, potentially unstable, and historically underreported. METHODS:A retrospective study was performed across 4 spine centers, including patients with acute traumatic occipital condyle avulsion fractures treated between June 2017 and April 2024. Clinical and imaging variables were reviewed. RESULTS:Thirty-two patients with Anderson-Montesano type III fractures were identified, predominantly male (81.3%), with a mean age of 36.6 years. High-energy trauma accounted for most cases (96.9%), mainly motor vehicle accidents (78.1%). Craniocervical instability was present in 9 patients (28.1%), all treated with posterior occipitocervical fusion; the remaining were managed nonoperatively. CT confirmed fusion in 20 patients (80%), with a mean healing time of 99.2 days. Median follow-up was 702 days. Instability was significantly associated with severe head trauma, unstable C1-C2 injuries, and MRI-documented ligamentous or soft tissue injury. CONCLUSION:Most occipital condyle avulsion fractures are stable and suitable for conservative management, but a relevant subset demonstrates craniocervical instability requiring surgical stabilization. MRI and dynamic radiographs help identify high-risk cases.
STUDY DESIGN:Propensity-matched retrospective cohort. OBJECTIVE:The objective of this study was to determine whether lumbar disc replacement (LDR) can provide radiographic indirect decompression as effectively as anterior lumbar interbody fusion (ALIF). SUMMARY OF BACKGROUND DATA:Isolated lumbar foraminal stenosis can often be treated with indirect decompression via ALIF. More recently, LDR has emerged as a motion-preserving treatment option for lumbar disease; however, its ability to provide indirect decompression has not been studied. METHODS:All patients undergoing 1-level ALIF and LDR over a 7-year period were queried. A propensity-matched cohort was then identified utilizing patient-specific factors. This yielded 23 patients undergoing LDR and 44 undergoing ALIF. The primary outcome of this study was the change in radiographic foraminal height (FH) and segmental lordosis (SL) from pre- to postoperatively. All measurements were performed by 2 independent reviewers, and intraclass correlation coefficients (ICC) were calculated. Patient-reported outcome measures, including visual analog scale (VAS) back and leg scores, were collected for comparison at early and late postoperative timepoints. Intercohort comparisons were performed via Mann-Whitney U tests. P-values <0.05 were deemed significant. RESULTS:Patients undergoing LDR had shorter operative time (98.9 vs. 136.7 min, P<0.01). FH and SL showed good ICCs (>0.75) across both reviewers. Preoperatively, ALIF patients had smaller radiographic FH (13.8 vs. 15.6 mm, P=0.01), but no other differences were seen. Both ALIF and LDR provided significant increases in FH (ALIF: 3.5 mm and LDR: 3.7 mm) and SL (ALIF: 8.0 degrees and LDR: 8.0 degrees). There were no differences in the mean ΔFH (P=0.56) or ΔSL (P=0.85) between cohorts. Both groups showed significant improvement in postoperative VAS leg scores at early and late time points. CONCLUSIONS:LDR can provide indirect decompression and segmental lordosis restoration as effectively as ALIF.
STUDY DESIGN:Technical note. OBJECTIVE:Biportal endoscopic spine surgery commonly employs a single-handed technique despite the presence of dual portals. An endoscopic self-retractor attached to the viewing trocar enables true bimanual manipulation. The adoption of this 2-handed technique enables safer, more effective resection of the thoracic ossification of the ligamentum flavum (OLF). METHODS:We describe the surgical method of the bimanual biportal endoscopic approach and its clinical application. A 74-year-old woman presented with bilateral leg weakness, radiating pain, and paresthesia. Preoperative magnetic resonance imaging revealed severe T11-T12 spinal cord compression due to OLF. She underwent decompression using the 2-handed biportal endoscopic technique. An endoscopic self-retractor mounted on the viewing portal trocar facilitated soft-tissue dissection and safe separation of the ossified ligamentum flavum (OLF) from the dura, enabling circumferential decompression through stepwise laminotomy, medial facetectomy, and controlled drilling under continuous saline irrigation. This technique allowed effective bilateral OLF removal while minimizing direct manipulation of the dura or spinal cord. CONCLUSION:The use of an endoscopic self-retractor for 2-handed manipulation enhances surgical precision and facilitates safer, more effective OLF removal. This technique improves control and safety during complex thoracic decompression.
STUDY DESIGN:Retrospective cohort study. OBJECTIVE:This study aims to assess the agreement and differences between EOS imaging and conventional cervical radiographs (cXR) in measuring cervical alignment, and to identify factors associated with their differences. SUMMARY OF BACKGROUND DATA:Accurate assessment of cervical spine alignment is essential for effective surgical planning. While cXR has been widely used for this purpose, the EOS imaging system provides a full-body, low-radiation alternative that captures global spinal alignment in a standing position. Despite its advantages, the agreement between EOS and cXR in evaluating cervical alignment parameters remains unclear. METHODS:Patients who had both preoperative EOS and cXR images within a 6-month interval were included. The primary outcome measures included cervical alignment parameters in EOS and standing cXR, including C0-C2 Cobb angle, C2-C7 Cobb angle, C2-C7 sagittal vertical axis (SVA), and T1 slope. The humerus angle was measured on EOS imaging as the angle between the humerus and a plumb line to account for arm positioning during imaging. Bland-Altman analysis was used to evaluate the agreement between EOS and cXR. Multiple linear regression identified predictors of measurement differences of cervical alignment. RESULTS:A total of 171 patients were included, with a mean age of 58 years, of which 56% were male. Significant differences were observed in C0-C2 Cobb (EOS, 27.5° versus cXR, 26.6°; P=0.020), C2-C7 SVA (20.9 mm versus 26.3 mm, P<0.001), and T1 slope (26.7° versus 25.2°, P=0.016), while no significant difference was observed for C2-C7 Cobb (EOS, 11.3° versus cXR, 10.4°; P=0.065). The Bland-Altman analysis suggested significant variability for C2-C7 SVA. Multiple linear regression identified humerus angle (B=-0.159, P=0.026), height (B=-0.153, P=0.036), and C2-C7 SVA on cXR (B=-0.515, P<0.001) as significant predictors of C2-C7 SVA measurement differences. CONCLUSIONS:EOS and cXR are generally interchangeable for cervical alignment assessment. However, C2-C7 SVA measurements require cautious interpretation due to variability stemming from the humerus angle and the patient's height.
STUDY DESIGN:Retrospective cohort study. OBJECTIVE:To evaluate the association between paraspinal interfascial plane (PIP) block use and postoperative outcomes and resource utilization in posterior lumbar spine surgery. SUMMARY OF BACKGROUND DATA:The PIP block is a regional anesthesia technique that may improve pain control after posterior spine surgery, but its impact on outcomes remains underreported in large cohorts. METHODS:We retrospectively reviewed 327 age-matched adult patients who underwent posterior lumbar surgery between October 2020 and June 2024. Of these, 164 received a PIP block, and 163 did not. Primary outcomes included postoperative opioid consumption and pain scores. Secondary outcomes included hospital length of stay, ICU admission, postoperative nausea and vomiting, and estimated blood loss. RESULTS:The PIP group had lower opioid use in the first 24 hours postoperatively (median: 0.83 vs. 0.98 MME/kg, P=0.046) and a trend toward reduced use from 24-48 hours (median: 0.39 vs. 0.46 MME/kg, P=0.067). The median pain scores at 0-24 hours were similar (7.0 vs. 7.5, P>0.9), but were significantly lower at 24-48 hours (P=0.03). Hospital length of stay was shorter in the PIP group (median: 4.0 vs. 5.0 d, P<0.001), and postoperative nausea and vomiting were less frequent (8.8% vs. 21%, P=0.002). The time to first analgesic request was delayed within the first 250 minutes postoperatively in the PIP group (P=0.042). ICU admission and estimated blood loss did not differ between groups. CONCLUSIONS:Use of the paraspinal interfascial plane block in posterior lumbar spine surgery was associated with reduced early postoperative opioid consumption, decreased length of stay, and less postoperative nausea and vomiting. These findings support the potential value of the PIP block as an adjunct to multimodal analgesia protocols in posterior lumbar spine surgery. LEVEL OF EVIDENCE:Level III.
STUDY DESIGN:Retrospective cohort study, level III evidence. OBJECTIVES:This study aimed to evaluate the relationship between anti-inflammatory use and mortality and complications, including pseudoarthrosis, in patients undergoing spinal fusion. SUMMARY OF BACKGROUND DATA:Postoperative pain control after spine surgery frequently requires large doses of narcotics. Opioid complications adversely affect patient outcomes and increase health care costs. In orthopedics, alternative methods of analgesia, including nonsteroidal anti-inflammatory drugs (NSAIDs), have gained momentum with the hope of minimizing postoperative opioids. There remains conflicting and limited evidence regarding the effect of NSAIDs on fusion within the perioperative period, and whether other factors, such as NSAID choice or timing of administration, have an effect. METHODS:Data from the Centers of Medicare and Medicaid Services were used to identify patients aged 65 years or older who underwent spinal fusion surgery between 2016 and 2021 and were eligible for Part D (pharmacy) benefits. Patients were divided into 2 cohorts: no NSAIDs (n=169,712) and NSAIDs (n=130,029), based on a Part D claim indicating filling of a prescription within 90 days before the surgical date through 1 year postfusion surgery. Logistic regression was used to compare mortality, pseudoarthrosis, complications, and readmission at 1-year. RESULTS:The NSAID user cohort was younger with lower Hierarchical Conditions Classification Count scores. Compared with patients treated without NSAIDs, NSAID use in the perioperative period was associated with a statistically significant reduction in 1-year mortality, and significantly greater rates of 1-year readmissions, pseudoarthrosis, and overall complications. CONCLUSIONS:Our observations found that NSAIDs are associated with higher overall complication rates. Further analysis regarding NSAID use in spinal fusion surgery is warranted to understand their full effects.
