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.
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: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: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.
BACKGROUND CONTEXT Factors driving financial disparities such as operative time and etiology have been explored in other orthopaedic subspecialties but are understudied in spinal deformity surgery. We hypothesized that increased operative time and differing etiology are associated with compensation decrease. PURPOSE To identify factors associated with compensation differences in spinal deformity surgery. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 31,739 patients. OUTCOME MEASURES Total Work Relative Value Units-per-Hour (wRVU/hr) and Dollars-per-Hour. METHODS The 2016–2021 Pediatric NSQIP database was queried for posterior spinal fusion cases (CPT 22800, 22802, 22804) for spinal deformity. Cases lacking operative time or wRVU data were excluded. ICD-10 codes were used to determine etiology. Total wRVUs (TwRVU) were calculated by combining primary and additional billed CPT codes. TwRVU-per-hour and Dollars-per-hour were derived using CMS conversion rates. Linear regression assessed operative time effects, and ANOVA compared etiologies. RESULTS A total of 31,739 patients were included (70.0% idiopathic, 18.0% neuromuscular, 0.6% syndromic, 4.5% congenital, 3.3% kyphosis, 3.6% other; mean age 13.8 ± 2.7 years; 68.2% female). Longer operative time was associated with decreased compensation, with each additional hour associated with a reduction of 2.38 TwRVUs ($79.87; p<0.001). In neuromuscular cases, each additional hour resulted in a $56.28 decrease, while in kyphosis cases the decrease was $144.91 per hour. Compensation rates also varied by etiology (p=0.002), with neuromuscular cases reimbursed at $429.13/hour and kyphosis cases at $554.42/hour. CONCLUSIONS Increased operative time and surgical etiology are associated with decreased compensation per hour. Current reimbursement models do not adequately reflect operative complexity or duration, highlighting disparities in financial compensation for spinal deformity surgery. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT Intraoperative ultrasound (IOUS) has been increasingly utilized in spine trauma, primarily for prognostication of spinal cord injury. It also offers real-time visualization of neural elements within the dura and may serve as a useful adjunct for intraoperative decision-making. However, its adoption remains limited, and evidence supporting routine use is still evolving. PURPOSE To evaluate the clinical utility of intraoperative ultrasound in spine trauma surgery, with a focus on its role in assessing decompression and guiding intraoperative decision-making. STUDY DESIGN/SETTING Retrospective chart review at a Level 1 trauma center. PATIENT SAMPLE Patients undergoing surgery for acute traumatic spine injuries between January 2020 and December 2024 in whom intraoperative ultrasound was utilized. OUTCOME MEASURES Intraoperative changes in surgical management based on ultrasound findings. METHODS Operative reports from patients undergoing surgery for acute spine trauma over a 5-year period were reviewed. Demographic and injury characteristics were collected. Cases utilizing intraoperative ultrasound were identified, and operative reports were analyzed to determine whether ultrasound findings resulted in modifications to the surgical approach. Descriptive statistics and chi-square testing were performed. RESULTS A total of 525 patients underwent surgery for acute spine trauma, of whom 143 (27.2%) had documented use of intraoperative ultrasound (113 cervical, 15 thoracic, 15 lumbar). Laminectomy was performed in all cases. Indications included spinal cord or conus compression (n=136), acute cauda equina syndrome (n=4), and nerve root compression (n=3). Ultrasound confirmed adequate decompression in 120 cases (83.9%). In 23 cases (16.1%), ultrasound findings altered surgical management: laminectomy extension in 16 (11.2%), expansile duraplasty in 4 (2.8%), transpedicular decompression in 1, and cervical realignment to improve lordosis in 1 case. There were no significant differences in ultrasound-guided intervention based on spinal region or presence of bony injury (p=0.784 and p=0.243, respectively). CONCLUSIONS Intraoperative ultrasound is a useful adjunct in spine trauma surgery, particularly for confirming adequacy and guiding the extent of decompression. Given its low cost and ease of use, it may enhance intraoperative decision-making and improve surgical precision in selected cases. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT Sarcopenia has emerged as a potential risk factor for vertebral fractures; however, its independent contribution remains unclear due to confounding by osteoporosis and obesity, which frequently coexist in aging populations. PURPOSE To evaluate the independent and combined effects of sarcopenia, osteoporosis, and obesity on vertebral fracture risk using component network meta-analysis. STUDY DESIGN/SETTING Systematic review and component network meta-analysis of observational studies (PROSPERO registration: CRD420251266964). PATIENT SAMPLE Adults with vertebral fractures from cross-sectional and cohort studies published through January 2026. OUTCOME MEASURES Occurrence of vertebral fractures reported as odds ratios (ORs) with 95% confidence intervals. METHODS PubMed, EMBASE, and Cochrane Library were searched. Of 391 identified records, 306 were screened after duplicate removal, and 16 studies met inclusion criteria. Studies involving refracture after vertebral augmentation, mixed fracture types, or specific disease populations (e.g., rheumatoid arthritis, HIV) were excluded. Component network meta-analysis using weighted least squares regression decomposed combined conditions into individual component effects under an additive model assumption. Publication bias was assessed using Egger’s test, Begg’s test, and trim-and-fill analysis. RESULTS Sixteen studies were included. Pooled analysis demonstrated significant associations for sarcopenia alone (OR 2.43; 95% CI 1.88–3.15; I2=40%), osteoporosis alone (OR 2.90; 95% CI 1.85–4.55), and osteosarcopenia (OR 6.92; 95% CI 4.80–9.98; I2=0%). Component network meta-analysis confirmed independent effects of sarcopenia (OR 2.58; 95% CI 1.91–3.48; p<0.0001) and osteoporosis (OR 2.61; 95% CI 1.59–4.29; p=0.0002), while obesity was not independently associated with fracture risk (OR 0.73; 95% CI 0.31–1.73; p=0.47). The additive model demonstrated good fit (R2=0.1462), with predicted effects aligning with observed outcomes. Egger’s test suggested funnel plot asymmetry (p=0.032), but trim-and-fill analysis did not identify missing studies, indicating heterogeneity rather than publication bias. CONCLUSIONS Sarcopenia and osteoporosis independently and additively increase vertebral fracture risk, resulting in substantially higher risk when combined. Obesity does not independently contribute to fracture risk. These findings support integrated assessment of muscle and bone health in fracture prevention strategies. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT Patients with degenerative lumbar spinal stenosis (LSS) often experience limited long-term relief from conservative therapies, with many progressing to surgery. Limaprost, a prostaglandin E1 analog, may improve symptoms by enhancing microcirculation in compressed neural tissues. This multicenter prospective study evaluates its real-world effectiveness and safety. PURPOSE To evaluate the effectiveness and safety of limaprost in degenerative LSS and to identify predictors of subsequent surgical intervention. STUDY DESIGN/SETTING Multicenter prospective observational cohort study. PATIENT SAMPLE A total of 1,139 patients with degenerative lumbar spinal stenosis. OUTCOME MEASURES Primary outcomes included changes in Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) subjective symptom scores. Secondary outcomes included visual analog scale (VAS) scores for pain and numbness, EuroQol-5 Dimension (EQ-5D), and walking capacity. METHODS Patients were categorized into four groups: limaprost monotherapy (n=308), standard combination (n=234), other combination (n=531), and non-limaprost control (n=66). Outcomes were assessed at 2 weeks and at 1, 3, and 6 months. Changes from baseline were compared across groups. Odds ratios (OR) with 95% confidence intervals (CI) were used to assess risk of subsequent surgical intervention. RESULTS Compared with controls, the limaprost monotherapy group demonstrated significantly greater improvement in ODI at 3 months (p=0.0123). Improvements in JOA subjective scores were greater in the monotherapy group beginning at 1 month (all p<0.05). At 6 months, all limaprost groups showed significantly greater improvements than controls in ODI and JOA scores (all p<0.05), as well as superior outcomes in pain and numbness VAS, EQ-5D, and walking capacity. Among patients without prior LSS surgery, limaprost monotherapy was associated with a significantly reduced risk of subsequent surgery (OR 0.07, 95% CI 0.01–0.39; p=0.003). Adverse event rates were low across all groups (0.9%–2.2%). CONCLUSIONS Limaprost-containing regimens are associated with improved symptoms, functional outcomes, and quality of life in patients with degenerative LSS compared with non-limaprost therapy. Limaprost monotherapy may also reduce the likelihood of subsequent surgical intervention in patients without prior surgery. FDA Device/Drug Status Limaprost (limaprost alfadex) (Investigational/Not Approved).
BACKGROUND CONTEXT The decision to undergo spinal fusion is multifactorial and highly individualized. Surgical success is often defined by absence of complications and patient satisfaction; however, patients may remain dissatisfied despite technically successful procedures. While patient-reported outcomes are widely used, the validity of minimal clinically important difference (MCID) thresholds has been questioned. Understanding patient-specific preoperative goals and their attainment may provide a more comprehensive measure of surgical success. PURPOSE To evaluate the relationship between attainment of preoperative patient goals and postoperative pain, satisfaction, and patient-reported outcomes following lumbar fusion. STUDY DESIGN/SETTING Retrospective cohort study at a tertiary referral specialty hospital. PATIENT SAMPLE A total of 668 patients aged 30–85 years who underwent elective lumbar fusion between January and December 2025. OUTCOME MEASURES Primary outcomes included Oswestry Disability Index (ODI), pain scores, and patient satisfaction assessed at 3 and 6 months postoperatively. METHODS Patients reported preoperative goals and rated goal attainment during recovery on a scale from 0% to 100%. Goals were categorized into nine groups: recreation, pain, mobility, mobility and pain, independence, health, quality of life, family, and “before” (return to pre-symptom state). Relationships between goal categories and outcomes were analyzed using Pearson correlation and regression analyses. RESULTS The most common goals were pain (26%), mobility (17%), and recreation (15%). Patients with family, recreation, and mobility-related goals demonstrated the greatest improvements, while those with “before,” independence, and work-related goals showed the least improvement. Goal attainment at 3 months was moderately correlated with pain, satisfaction, and ODI (r = -0.558, -0.569, -0.598, respectively), and similar correlations were observed at 6 months (r = -0.571, -0.489, -0.553). Patients with “before” goals were significantly less likely to be satisfied (OR 0.16; p<0.001; 95% CI 0.03–0.80), whereas patients with family-related goals (OR 6.1; p=0.028; 95% CI 1.3–29.3) and mobility-related goals (OR 4.3; p=0.019; 95% CI 1.6–10.5) were more likely to report satisfaction. CONCLUSIONS Attainment of preoperative goals is strongly associated with postoperative pain, function, and satisfaction. The type of goal influences perceived recovery, suggesting that setting realistic and patient-centered goals preoperatively may improve outcomes following lumbar fusion. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT Finite element models (FEMs) of the spine are commonly used to predict biomechanical behavior following posterior fusion with pedicle screws and rods (PSR). However, variation in how posterior column bone is represented may significantly influence predicted stress distributions, potentially leading to misleading conclusions. PURPOSE To evaluate how different representations of posterior column bone affect predicted stress distributions in a lumbar FEM with PSR under multi-directional loading. STUDY DESIGN/SETTING In vitro computational modeling study with validation against specimen-specific experimental strain data. PATIENT SAMPLE N/A.. OUTCOME MEASURES Range of motion (ROM), compressive stiffness, and stress/strain distributions across bone and instrumentation. METHODS A specimen-specific L4–L5 FEM was developed with three posterior bone representations:(1) cancellous bone with cortical shell (FE-Post1),(2) homogeneous bone interfacing anterior structures (FE-Post2), and(3) homogeneous bone with cortical wall interface (FE-Post3).Models were subjected to multi-directional bending (7.5 Nm) and 400 N axial compression. Predicted ROM, stiffness, and strain distributions were compared to experimental data from intact and instrumented (PSR) conditions. RESULTS Posterior bone representation had minimal effect on intact ROM and compressive stiffness but influenced anterior bone strain predictions. FE-Post2 and FE-Post3 predicted substantially lower cancellous bone stresses compared to FE-Post1. Following PSR, all models predicted ROM and stiffness within acceptable ranges of experimental values. However, FE-Post1 most accurately matched experimental surface strains (8 of 10 comparisons), while FE-Post2 showed the greatest deviation. Although peak instrumentation (PSR) stresses were similar across models, stress distributions within bone varied significantly depending on posterior bone representation. CONCLUSIONS FEMs incorporating non-homogeneous posterior bone representation (cancellous bone with cortical shell) provide more accurate predictions of stress distribution following PSR. Simplified homogeneous models may underestimate bone stress and produce unrealistic results. Careful consideration of posterior bone modeling is essential for reliable biomechanical analysis. FDA Device/Drug Status Pedicle screws (approved for this indication).
BACKGROUND CONTEXT Obstructive sleep apnea (OSA), characterized by recurrent upper airway collapse during sleep, has been increasing in prevalence worldwide and is associated with adverse postoperative outcomes across surgical disciplines; however, its impact in spine surgery remains incompletely characterized. PURPOSE To evaluate the association between OSA and postoperative complications in patients undergoing spine surgery through a systematic review and meta-analysis. STUDY DESIGN/SETTING Systematic review and meta-analysis. PATIENT SAMPLE Patients with obstructive sleep apnea undergoing spine surgery. OUTCOME MEASURES Deep vein thrombosis (DVT), pulmonary embolism (PE), urinary tract infection (UTI), pneumonia, respiratory failure, septic shock, renal failure, and cardiac complications. METHODS This review was conducted according to PRISMA guidelines. A comprehensive search of PubMed, Google Scholar, and Embase was performed through October 2025. Eligible studies included comparative cohorts of OSA patients undergoing spine surgery reporting postoperative complications. Two independent reviewers screened and extracted data, with disagreements resolved by consensus. Meta-analyses were performed using STATA 18.0. RESULTS Seven studies including 2,698,835 patients without OSA and 207,140 patients with OSA were analyzed. OSA was associated with significantly increased odds of DVT (OR 2.29; 95% CI 1.45–3.60; p=0.010), pneumonia (OR 3.26; 95% CI 1.37–7.77; p=0.020), PE (OR 2.21; 95% CI 1.05–4.67; p=0.041), renal failure (OR 2.63; 95% CI 1.77–3.90; p=0.009), and respiratory failure (OR 6.48; 95% CI 1.58–26.7; p=0.030). No significant associations were observed for mortality, myocardial infarction, other cardiac complications, 90-day readmission, emergency department visits, septic shock, or UTI (p>0.05). CONCLUSIONS OSA is associated with increased risk of thromboembolic, pulmonary, and renal complications following spine surgery. These findings support enhanced perioperative risk stratification and monitoring in this population, though heterogeneity and limited study numbers warrant further prospective investigation. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT Osteoporosis is highly prevalent among patients undergoing posterior spinal fusion (PSF) and is associated with increased risk of postoperative complications, including pseudarthrosis, implant failure, vertebral fracture, infection, and reoperation. As PSF volume increases in older osteoporotic populations, optimization of perioperative bone health has become increasingly important. While anabolic agents improve fusion biology and bone microarchitecture, their impact on clinically meaningful postoperative outcomes remains unclear. Additionally, romosozumab, a newer anabolic agent, has rarely been compared with other osteoporosis therapies in PSF patients. PURPOSE To compare postoperative complications and surgical outcomes in osteoporotic patients undergoing PSF treated with antiresorptive versus anabolic osteoporosis therapies. STUDY DESIGN/SETTING Retrospective cohort study using the TriNetX Research Collaborative Network. PATIENT SAMPLE Patients aged ≥50 years undergoing PSF between 2015 and 2025 who received at least one prescription for osteoporosis pharmacotherapy ≥3 months preoperatively. OUTCOME MEASURES Pseudarthrosis, surgical site infection (SSI), wound complications, vertebral fracture, hardware complications, revision fusion surgery, readmissions, and 1-year postoperative pain scores. METHODS Patients were stratified into antiresorptive and anabolic cohorts, with subgroups including teriparatide, bisphosphonates, denosumab, and romosozumab. Exclusion criteria included Paget’s disease, active malignancy, chemotherapy, radiation, or hormonal cancer therapy. Propensity score matching (1:1) was performed based on demographics, Charlson Comorbidity Index (CCI), DEXA T-scores, prior spine surgery, and relevant medication use. RESULTS A total of 10,258 patients met inclusion criteria (9,080 antiresorptive; 1,178 anabolic). After matching, 1,163 patients remained in each cohort with no significant baseline differences. Antiresorptive therapy was associated with lower rates of SSI (1.4% vs 3.8%, p<0.001), wound dehiscence (2.3% vs 4.0%, p=0.019), and postoperative vertebral fracture (4.2% vs 9.1%, p<0.001), while other outcomes were similar. Subgroup analyses demonstrated lower readmission rates with denosumab compared to romosozumab, lower pseudarthrosis rates with romosozumab compared to teriparatide, and lower vertebral fracture rates with bisphosphonates compared to denosumab (p<0.05). CONCLUSIONS In osteoporotic patients undergoing PSF, antiresorptive therapy was associated with fewer 1-year postoperative complications compared with anabolic therapy, while fusion-related outcomes were similar. These findings suggest that suppression of bone turnover and preservation of bone mass may provide clinically meaningful perioperative benefits. Although anabolic therapies may improve fusion biology and remain valuable in select high-risk patients, these advantages did not consistently translate into reduced complication rates. Agent-specific differences highlight the importance of individualized therapy selection. Further prospective studies are needed to define optimal osteoporosis management following PSF. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.
