BACKGROUND:Factors associated with early re-collapse after posterior fixation of thoracolumbar burst fractures have been sparsely examined in previous studies. Early re-collapse is challenging to predict due to multifactorial risk. Therefore, we aimed to investigate factors associated with vertebral re-collapse within the first 3 months following posterior fixation. METHODS:This retrospective study used data from the Swedish Fracture Register (2015-2019) and included patients aged 18 to 66 years with a single-level thoracolumbar burst fracture between T11 and L3 treated with posterior fixation. Fractures were classified according to the load-sharing classification (LSC) and the 2013 AO Spine Injury Classification System. Bone quality was assessed using Hounsfield unit (HU) values. In addition, postoperative pedicle screw depth within the vertebral body (% depth) and the number of instrumented vertebrae were recorded. To evaluate postoperative vertebral collapse, kyphosis angle, wedge angle, and anterior/posterior vertebral height ratio were measured. Re-collapse was defined as an anterior vertebral height loss of at least 20%, and pedicle screw pull-out was also assessed. Multivariable logistic regression was used to identify factors associated with vertebral re-collapse within 3 months postoperatively. RESULTS:This study comprised 100 patients. Sixteen patients had radiographic vertebral re-collapse, and 15 had pedicle screw pull-out. Lower HU values were significantly associated with vertebral re-collapse (OR 0.97, 95% CI 0.94-0.99, P = 0.01). Higher preoperative LSC scores were also significantly associated with an increased risk of re-collapse (OR: 2.35, 95% CI: 1.07-6.82, P = 0.02). In contrast, neither screw insertion depth nor the number of instrumented vertebrae was associated with re-collapse. CONCLUSION:Lower HU values and higher preoperative LSC scores were associated with an increased risk of early vertebral re-collapse within 3 months after posterior fixation of thoracolumbar burst fractures. However, early re-collapse appears to be multifactorial and remains difficult to predict, warranting further investigation. CLINICAL RELEVANCE:This study provides clinically relevant insights into early re-collapse after posterior fixation of thoracolumbar burst fractures and identifies factors associated with early mechanical failure. LEVEL OF EVIDENCE: 3:
BACKGROUND:Cutibacterium acnes has been identified in excised intervertebral disc tissue in multiple studies; however, contamination remains a persistent limitation, and all prior investigations have relied on excised tissue sampling. No study has evaluated swab-based sampling directly from the disc space. The primary aim of this study was to determine the prevalence of C acnes in intervertebral disc spaces following discectomy but prior to fusion cage or total disc replacement implantation using anaerobic culture and quantitative polymerase chain reaction (qPCR) and to assess concordance between detection methods. METHODS:This prospective cohort registry study included 29 patients (53 discs: 28 cervical, 25 lumbar) undergoing discectomy. Prior to discectomy, deep tissue was irrigated with 0.05% chlorhexidine gluconate (Irrisept) to suppress dermal-origin organisms. Following discectomy and before device implantation, a sterile swab was inserted into the disc space. Swabs were divided for 21-day anaerobic culture with semiquantitative grading and 16S rRNA qPCR (positivity threshold >1.04 copies/reaction). Cohen kappa, McNemar test, and Clopper-Pearson exact 95% confidence intervals were calculated. RESULTS:Overall disc-level prevalence was 43.4% (23/53; 95% CI: 29.8%-57.7%) by culture and 54.7% (29/53; 95% CI: 40.4%-68.4%) by qPCR. Cervical discs demonstrated significantly higher culture positivity than lumbar discs (71.4% vs 12.0%; P < 0.001), while qPCR positivity was similar (50.0% vs 60.0%). When either method was positive, prevalence was 85.7% in cervical and 64.0% in lumbar discs. Inter-method agreement was poor overall (κ = -0.044; 95% CI: -0.31 to 0.22). In lumbar discs, qPCR identified significantly more positive discs than culture (P = 0.003). CONCLUSIONS:Cutibacterium acnes is detectable in intervertebral disc spaces at high rates using swab-based sampling after deep-tissue chlorhexidine gluconate irrigation, particularly in cervical discs. Poor concordance between culture and qPCR suggests each method identifies distinct subsets of positive discs, particularly in lumbar discs. CLINICAL RELEVANCE:This is the first report of disc-space swab analysis for intradiscal C acnes detection at the time of cervical and lumbar surgery. Detection prior to fusion cage or total disc replacement implantation may help characterize the microbiological environment at the implant interface and supports further investigation into strategies to reduce disc-space C acnes burden prior to implantation, particularly in total disc replacement. LEVEL OF EVIDENCE: 3:
Postsurgical lymphocele is a rare complication following anterior lumbar interbody fusion (ALIF), for which ideal management remains controversial. Our study presents a case of a 70-year-old woman who underwent a multilevel anterior and posterior fusion from L3 to the pelvis with direct lateral interbody fusion at L3 to 4 and L4 to S1 ALIF and subsequently developed a persistent left-sided fluid collection, later identified as a retroperitoneal lymphocele. A temporary drainage catheter was initially placed within the collection but did not lead to complete resolution. Our case report presents a novel approach of using a diagnostic lymphangiogram to identify an active lymphatic leak for subsequent successful embolization of the source using n-butyl cyanoacrylate glue in dilution with lipiodol (1:8). Time to complete resolution was 12.5 weeks with 1 repeat aspiration but no additional glue embolization. We introduce lymphatic embolization as a robust alternative to operative management when treating post-ALIF lymphoceles, particularly in cases of high infection risk, or refractory disease.
BACKGROUND:Postoperative drain use after transforaminal full-endoscopic spine surgery (TF-FESS) remains controversial, and procedure-specific criteria are not well defined. This study aimed to determine whether postoperative bleeding risk-quantified by postoperative drain output and intraoperative endoscopic bleeding findings-differs by TF-FESS procedure and whether these metrics can inform a procedure-specific drainage strategy. METHODS:We retrospectively reviewed 100 consecutive TF-FESS cases: 65 managed with postoperative drains, and 35 managed without drains after an institutional policy change (limited to full-endoscopic discectomy [FED] and lumbar foraminotomy). Procedures included FED, full-endoscopic lumbar foraminotomy (FELF), full-endoscopic ventral facetectomy (FEVF), transforaminal full-endoscopic lumbar undercutting laminectomy (TELUL), and pars crisscross decompression (pars crisscross). Postoperative drain output was analyzed in the drain group. Intraoperative endoscopic bleeding was assessed at 3 standardized steps: approach/foraminoplasty (step 1), procedure-specific decompression (step 2), and final hemostasis (step 3). Multivariable analysis identified predictors of higher drain output. RESULTS:Drain output differed significantly among procedures (analysis of variance, P < 0.001). FED and FELF showed low drain output, whereas FEVF, TELUL, and pars crisscross showed higher drain output. Invisible bleeding during step 2 was more frequent in TELUL and pars crisscross. On multivariable analysis, TELUL and FEVF independently predicted higher drain output. In the drain-free subgroup (n = 35; FED/FELF), no patient developed neurological deterioration or symptoms requiring emergent hematoma evacuation. CONCLUSIONS:Bleeding risk in TF-FESS is strongly procedure dependent. Drain-free management was implemented only in a selected low-risk subgroup after a policy change; given the small sample size and the low baseline incidence of symptomatic hematoma, this cohort is not powered to assess safety outcomes, and drain-free observations should be interpreted as descriptive feasibility data. Postoperative drainage should be considered for advanced procedures involving epidural venous plexus manipulation and/or extensive cancellous bone exposure (FEVF/TELUL/pars crisscross). Given the nonrandomized, procedure-dependent drain policy, these findings are hypothesis generating. CLINICAL RELEVANCE:A procedure-specific, risk-stratified drainage approach may help optimize postoperative management and patient safety in TF-FESS. LEVEL OF EVIDENCE: 3:
BACKGROUND:Celiac artery compression syndrome (CACS) is a rare but potentially life-threatening complication of spinal deformity correction. Although prior reports have suggested an association between spinal correction and vascular compression, the underlying anatomical mechanisms remain unclear. This study aimed to investigate the positional changes in the celiac artery and median arcuate ligament (MAL) during spinal corrective procedures using a cadaveric model. METHODS:A human cadaver preserved using the Thiel method was used to simulate anterior extension correction via Smith-Petersen osteotomy (SPO) at the T12/L1 and L3/L4 levels and posterior shortening via pedicle subtraction osteotomy (PSO) at L1, each with a 30° correction angle. The T12/L1 and L3/L4 levels were located proximal and distal to the origin of the diaphragmatic crura, respectively. Pre- and postoperative computed tomography was conducted to measure the vertical and anteroposterior distances between the celiac artery and the MAL, with the anterior-inferior border of the 12th thoracic vertebra as a fixed reference point. RESULTS:The vertical distances between the celiac artery and the MAL were 8.8 mm before correction, 2.6 mm after T12/L1 SPO, 9.3 mm after L3/L4 SPO, and 11.5 mm after L1 pedicle subtraction osteotomy. The corresponding horizontal distances were 6.6 mm, 11.3 mm, 8.2 mm, and 5.8 mm. Notably, SPO at T12/L1-proximal to the origin of the diaphragmatic crus-resulted in the greatest reduction in vertical distance. CONCLUSION:Anterior extension correction at the thoracolumbar junction significantly reduced the distance between the celiac artery and the MAL. These positional changes may contribute to the development of iatrogenic CACS. Surgeons should exercise caution when performing anterior correction near the diaphragmatic crus to minimize this vascular risk. CLINICAL RELEVANCE:Anterior correction at the thoracolumbar junction, particularly at T12/L1, significantly shortens the distance between the MAL and the celiac artery, increasing the risk of vascular compression. Patients with a short MAL-celiac artery distance may be more susceptible to developing CACS. To prevent this potentially fatal complication, preoperative imaging and anatomically informed surgical planning are essential. LEVEL OF EVIDENCE: 5:
BACKGROUND:Spinal epidural abscess is a rare but potentially devastating infection that may cause irreversible neurological injury. Although acupuncture is generally considered safe, serious infectious complications have been reported. CASE:A previously healthy 54-year-old woman developed neck pain, diffuse paresthesia, and urinary retention 10 days after acupuncture. Magnetic resonance imaging revealed a posterior epidural abscess from C5 to T2 with severe spinal cord compression, together with paravertebral and retropharyngeal abscesses. Within 36 hours, her neurological status deteriorated, progressing to quadriparesis with minimal motor function in all 4 limbs. An urgent decompression and abscess evacuation was performed. Blood and intraoperative cultures grew penicillin-sensitive Staphylococcus aureus. Repeat imaging showed an anterior epidural abscess with C5 to C6 discitis-osteomyelitis, requiring a second anterior decompression and fixation. LITERATURE REVIEW:A review of the published literature revealed 22 reported cases of spinal epidural abscess following acupuncture. Patients ranged from 12 to 89 years old; symptoms typically developed within 2 weeks. S aureus was the predominant pathogen, and 59.1% required surgery. CONCLUSION:Although acupuncture is generally safe, in rare cases, it may lead to severe spinal infection. Early diagnosis and prompt treatment are essential to prevent neurological sequelae.
BACKGROUND:Selection of the upper instrumented vertebra (UIV) in posterior cervical decompression and fusion remains variable, and its influence on junctional mechanics and clinical outcomes is not fully defined. Extending fixation to C2 may offer mechanical advantages but introduces additional operative complexity. This study compared radiographic alignment, proximal junctional complications, and patient-reported outcomes between constructs terminating at C2 vs C3. METHODS:A retrospective cohort analysis was conducted on consecutive patients undergoing posterior cervical fusion from 2021 to 2023 with distal fixation at T1. Patients were stratified by UIV: C2 or C3. Demographic, operative, and radiographic data were collected. Cervical alignment parameters, proximal and distal junctional complications, and patient-reported outcomes (visual analog scale, Neck Disability Index, and 36-item Short Form physical component score and mental component score) were evaluated at baseline and at 6 and 24 months. Group comparisons used t and χ2 tests, with significance set at P < 0.05. RESULTS:A total of 104 patients were included (C2: n = 63; C3: n = 41) with comparable baseline demographics and clinical characteristics. Estimated blood loss was higher in the C2 group. Both groups demonstrated significant postoperative improvement in cervical alignment and patient-reported outcomes through 24 months, with no significant differences between groups for visual analog scale, Neck Disability Index, or physical component score. Constructs ending at C3 exhibited a significantly larger UIV - UIV + 1 angle and higher rates of proximal junctional failure (9.7% vs 0%), whereas distal junctional complication rates and overall revision rates were similar. CONCLUSIONS:Termination at C2 reduces proximal junctional complications and results in a smaller transition angle without compromising midterm clinical outcomes; however, it involves greater operative burden. UIV selection should be individualized, favoring C2 when anatomical feasibility and junctional risk profiles support cranial fixation. Longer-term prospective studies are needed to determine whether mechanical advantages translate into durable clinical benefit. CLINICAL RELEVANCE:These findings suggest that selecting C2 rather than C3 as the upper instrumented vertebra may reduce proximal junctional complications in posterior cervical fusion extending to T1, although the greater operative burden of C2 fixation should be considered when individualizing surgical planning. LEVEL OF EVIDENCE: 3:
BACKGROUND:Unilateral laminectomy bilateral decompression with unilateral biportal endoscopy (UBE-ULBD) is widely used for lumbar spinal stenosis (LSS). This study introduces a modified UBE-ULBD technique, the "look-back" technique, aiming to reduce postoperative complications. METHODS:This retrospective study enrolled 88 lumbar spinal stenosis patients, with 45 undergoing conventional UBE-ULBD surgery and 43 undergoing the look-back technique. Baseline characteristics, surgical level distribution, operative time, hemoglobin level, hematocrit level, blood loss, hospital stay, complications, visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index, and modified MacNab criteria were assessed. RESULTS:Demographics, comorbidities, and American Society of Anesthesiologists classifications showed no significant differences between the groups. The calculated blood loss in the look-back group was significantly less than that in the UBE-ULBD group (302 mL [Q1, Q3 166, 424 mL] vs 384 mL [Q1, Q3 267.5, 524 mL], P < 0.05). The VAS for leg pain at 1 day after surgery in look-back group was significantly lower than that in UBE-ULBD group (1.72 ± 0.96/2 [1, 2] vs 2.27 ± 1.25/2 [2, 3], P < 0.05). No significant difference was observed in surgical level distribution, surgical time, preoperative/postoperative hemoglobin or hematocrit level, complications, hospital stay, VAS back pain score at 1 day after surgery, VAS low back/leg pain scores at 1 month and 6 months, Oswestry Disability Index scores at 1 month and 6 months, or MacNab outcome at 6 months. CONCLUSIONS:The look-back technique significantly reduces intraoperative blood loss and early leg pain after UBE-ULBD, although it does not significantly lower the overall complication rate. LEVEL OF EVIDENCE: 3:
BACKGROUND:Thoracic disc herniation extruding into the dorsal epidural space is exceptionally rare and is frequently mistaken for an epidural tumor, abscess, or hematoma. We aimed to characterize its clinicoradiological features, identify imaging features that may favor a disc fragment over a neoplasm, and report surgical outcomes. METHODS:We retrospectively present 2 histologically confirmed cases treated by posterior decompression at our institution. To contextualize these cases, a focused literature review was performed, limited to thoracic-only cases, excluding cervical, lumbar, and other epidural pathologies that mimic this condition. The primary outcome (neurological recovery) was prespecified using the modified Frankel grade, with "complete recovery" defined as full motor strength (5/5) plus the patient's preinjury independent ambulation. RESULTS:The pooled cohort comprised 16 patients (14 men, 2 women; median age 56.5 years; T10-T11 most common, 38%). All presented with thoracic myelopathy, most with rapid neurological deterioration. In this highly selected cohort, posterior decompression was followed by neurological improvement in all reported cases, with no major complications. Documented complete recovery was identified in 5 of 16 patients (31%), using a conservative proxy definition, at a median follow-up of 4.5 months (range 0.1-30 months). Contrast enhancement (rim, peripheral, or diffuse) did not reliably distinguish disc fragments from tumor; features favoring a disc fragment were continuity with a degenerated disc space, absence of a dural tail, and absence of a homogeneous markedly high T2 signal. CONCLUSIONS:Dorsal thoracic disc extrusion should be considered when a posterior thoracic epidural mass causes acute or rapidly progressive myelopathy. In the reported thoracic cases, posterior decompression was followed by neurological improvement in all patients, but complete recovery was documented in only 31% under a conservative proxy definition. These findings remain limited by short follow-up, small sample size, level 4 evidence, and significant publication and selection bias. CLINICAL RELEVANCE:A high index of suspicion for dorsal disc extrusion is warranted whenever a posterior thoracic epidural mass is encountered, even when imaging suggests neoplasm. Continuity with a degenerated disc space, absence of a dural tail, and absence of homogeneous markedly high T2 signal are clues that may support early surgical decompression when the clinical presentation is consistent with compressive myelopathy. LEVEL OF EVIDENCE: 4:
BACKGROUND:The US population is aging, with the number of individuals aged 85 or older expected to triple by 2060. As such, spine surgeons are operating on an increasing number of elderly patients. This propensity score-matched retrospective analysis aimed to determine whether 30-day postoperative outcomes from spinal fusion surgery differ between super-elderly patients (aged ≥85 years) and younger patients (≤65 years). METHODS:Patients in the 2015 to 2023 National Surgical Quality Improvement Program datasets were included if they were treated by an orthopedic or neurological surgeon with a primary Current Procedural Terminology code corresponding to spinal fusion at any level. Patients were separated into a younger cohort (≤65 years) and a super-elderly cohort (≥85 years). Propensity score matching was performed to balance demographics, comorbidities, surgical indications, and specific surgical procedures. Univariate statistical analysis followed by false-discovery rate correction was performed using Python 3.10.16. RESULTS:Following matching, there were 1298 patients in each cohort. There was a 2.6% higher rate of pneumonia (P < 0.01), a 1.8% greater risk of reintubation (P < 0.01), a 1.2% increase in failure to wean from the ventilator after 48 hours (P < 0.01), a 1.9% higher rate of urinary tract infection (P < 0.01), a 1.2% higher risk of myocardial infarction (P < 0.01), and a 1.2% increase in mortality rate (P < 0.01) in the super-elderly compared with younger patients. Older patients were also more likely to be discharged to a skilled care facility (P < 0.01) and had a shorter operative duration (P < 0.01) and longer hospital stay (P < 0.01) relative to younger patients. CONCLUSIONS:Although we identified statistically significant increases in the risk of several adverse outcomes in the super-elderly population, the magnitude of these differences ranged from 1.2% to 2.6%, implying minimal clinical significance. Considering the increased risk of medical complications independent of surgical intervention in the super-elderly population, the minor increase in the risk of complications observed in this study can be considered acceptable, suggesting that advanced age alone is not a contraindication to surgery. CLINICAL RELEVANCE:The results of this study provide insights into the safety of spinal arthrodesis in the growing super-elderly population. LEVEL OF EVIDENCE: 4:
BACKGROUND:Image-guided pedicle screw placement improves accuracy over fluoroscopy, but level-specific performance and independent predictors in routine care remain incompletely defined. This study aims to compare intraoperative computed tomography (iCT)-navigated vs fluoroscopy-assisted (FA) lumbar screw placement, while quantifying level-specific performance and exploring independent predictors of optimal (grade A) placement. METHODS:We performed a single-center retrospective, noncontemporaneous cohort study of 229 adults who underwent primary lumbar pedicle screw fixation, including 131 iCT navigated and 98 FA. In total, 1304 lumbar screws were graded on postoperative computed tomography (CT) using the Gertzbein-Robbins scale. Mixed-effects logistic regression estimated odds of Grade A placement with fixed effects for technique, pathology, level, side, and age. RESULTS:iCT was associated with higher accuracy than FA (grade A 97% vs 86%), with no grade C breaches under iCT (vs 2% with FA). The advantage was level dependent and most pronounced at L5 (grade A 97.3%-98.2% with iCT vs 79.3%-85.7% with FA); additional statistically significant differences favored iCT at L2 left, L3 left, and L4 left, while L3 right showed a nonsignificant trend. In adjusted analyses, FA was associated with markedly lower odds of grade A placement. Trauma was independently associated with a reduced likelihood of grade A placement, whereas revision surgery served as the reference category and was not an independent predictor; age, level, and side were not independent predictors. CONCLUSIONS:In this retrospective cohort, iCT navigation was associated with superior radiographic accuracy compared with fluoroscopy and higher rates of optimal screw placement. Traumatic pathology was associated with lower odds of optimal placement. CLINICAL RELEVANCE:iCT-based navigation was associated with an increased likelihood of achieving optimal (Gertzbein-Robbins grade A) lumbar pedicle screw placement compared with fluoroscopy in routine clinical practice. The advantage appears particularly pronounced at L5 and in anatomically challenging scenarios. However, these findings are based on radiographic accuracy only and should be interpreted cautiously, as no direct conclusions on clinical outcomes or complication reduction can be drawn. LEVEL OF EVIDENCE: 3:
BACKGROUND:Lumbar discal cysts are a rare phenomenon that may result in clinical symptoms of back pain and lumbar radiculopathy. The natural history of these cysts and best practices are not well established in the literature. OBJECTIVE:To report an illustrative case series of the diagnosis, management, and outcomes of a rare clinical/radiological entity known as lumbar discal cyst. METHODS:Three patients were included in the case series. Patient 1 is a 36-year-old man who presented with lumbar radiculopathy, initially diagnosed as a lumbar herniated disc. The patient underwent a successful microdiscectomy; however, symptoms returned within 6 weeks. Repeat imaging showed enlargement of a previously undiagnosed discal cyst. The patient underwent a subsequent computed tomography (CT)-guided discogram followed by cyst fenestration/rupture, with good resolution of his symptoms. Patient 2 is a 32-year-old man who presented with symptoms of lumbar radiculopathy and a known diagnosis of lumbar discal cyst. This patient was treated successfully with a CT-guided interlaminar cyst fenestration/rupture; however, symptoms returned within 3 months. Repeat imaging showed a persistent/recurrent cyst in the same location. Patient 2 subsequently underwent laminotomy and cyst excision with durable resolution of his symptoms. Patient 3 is a 47-year-old man who presented with lumbar radiculopathy that was diagnosed with a discal cyst extending into the neuroforamen. He underwent CT-guided interlaminar cyst aspiration with early and durable resolution of symptoms. RESULTS:Patient 1 first underwent successful microdiscectomy with return of symptoms within 6 weeks. He went on to CT-guided fenestration/rupture of the discal cyst with durable relief at 6 months. Patient 2 was first treated with CT-guided interlaminar cyst aspiration with return of symptoms within 3 months. He went on to laminotomy and cyst excision with durable relief of symptoms at 6 months. Patient 3 underwent CT-guided interlaminar cyst aspiration with resolution of symptoms, with follow-up imaging showing resolution of the discal cyst. CONCLUSIONS:We present our experience with lumbar distal cysts here, treated with initial success via different means and 2 patients subsequently requiring revision due to recrudescence of symptoms, ultimately resulting in excellent clinical outcomes. Due to their rarity and paucity of high-quality data, these entities should be treated on a case-by-case basis. Where appropriate or applicable, a multidisciplinary approach between spine surgeons and interventional radiologists may afford patients reasonable options to use a tailored approach to care. CLINICAL RELEVANCE:A multidisciplinary, patient-tailored approach to lumbar discal cysts can afford satisfactory outcomes while minimizing patient morbidity. LEVEL OF EVIDENCE: 4:
BACKGROUND:Multifidus muscle tears are uncommon injuries, and herniation of muscle tissue into the spinal canal has not been previously reported. This report presents a rare case of traumatic multifidus muscle herniation into the spinal canal, leading to cauda equina syndrome. The primary research question is whether a specific sequential injury mechanism can explain this unusual pattern of intraspinal muscle herniation. METHODS:An 18-year-old woman presented with back pain, bilateral lower limb and perineal numbness, lower extremity weakness, and urinary retention after a fall from height. Magnetic resonance imaging demonstrated an intraspinal soft tissue mass at the L2 level causing thecal sac compression, consistent with cauda equina syndrome. The patient underwent urgent decompressive laminectomy with pedicle screw fixation from T12 to L3 and underwent posterolateral bone graft fusion at L1 to L2. Intraoperative findings and histopathological examination confirmed the nature of the compressive mass. RESULTS:Preoperative imaging, intraoperative visualization, and postoperative pathology confirmed that the intraspinal mass represented herniated multifidus muscle tissue. At 6-month follow-up, the patient demonstrated complete neurological recovery without residual symptoms. The proposed mechanism involves sequential hyperflexion and hyperextension forces during the traumatic event, potentially creating a transient osseous gap allowing muscle herniation. CONCLUSIONS:This rare case demonstrates that traumatic hyperflexion-hyperextension injury can result in intraspinal herniation of the multifidus muscle, leading to cauda equina syndrome. Recognition of this potential mechanism may aid in diagnosis and timely surgical intervention. CLINICAL RELEVANCE:Clinicians should consider soft tissue herniation, including muscle, in the differential diagnosis of traumatic intraspinal masses causing neurological compromise. Prompt surgical decompression can achieve excellent neurological outcomes. LEVEL OF EVIDENCE: 4:
BACKGROUND:Lumbar total disc replacement (TDR) is an alternative to interbody fusion for treating symptomatic degenerative disc disease. This approach involves replacing deteriorated lumbar discs with a prosthetic device to alleviate pain and maintain spinal mobility. This review maps the current findings on migration or dislocation related to TDR, identifies contributing factors, and summarizes reported treatment approaches and their results. METHODS:A systematic search was conducted across MEDLINE, Embase, Scopus, Web of Science, and CENTRAL to identify relevant studies. The search identified 7 pertinent studies. The extracted data included study design, patient demographics, type of prosthesis used, direction of migration or dislocation, risk factors, and treatment methods. RESULTS:The review of 7 articles on TDR indicated that significant migration or dislocation requiring surgical intervention was reported in approximately 1% to 2% of cases, typically within weeks to months after the procedure. A higher occurrence of clinically relevant subsidence was reported, which correlated with poorer patient outcomes. Anterior migrations predominated, while posterior and lateral migrations were rare. Risk factors observed included selecting an undersized or improperly positioned implant, surgical technique, and trauma. Treatment strategies ranged from conservative monitoring to revision arthroplasty for early malposition when the endplates were still intact and conversion to fusion. CONCLUSIONS:Clinically significant implant migration following lumbar TDR is rare but remains an important complication. Reported events most commonly occur early after surgery and are associated with heterogeneous factors, including implant sizing, surgical technique, and trauma. Management strategies vary, with conversion to fusion most frequently reported. The current literature remains limited by heterogeneous and inconsistently reported outcomes, highlighting the need for more standardized reporting of migration characteristics, risk factors, management strategies, and clinical outcomes in future studies. CLINICAL RELEVANCE:Mapping the currently reported patterns, risk factors, and management strategies associated with implant migration following lumbar TDR may help inform surgical technique, postoperative surveillance, and future research reporting standards. LEVEL OF EVIDENCE:Not applicable; scoping review.
BACKGROUND:The optimal management of neurologically intact thoracolumbar burst fractures remains controversial. Although surgical treatment may provide earlier stabilization and deformity correction, nonsurgical management avoids surgical morbidity and health care costs. Return to work (RTW) is a clinically meaningful outcome that reflects both functional recovery and socioeconomic reintegration. We aimed to compare RTW outcomes following surgical vs nonsurgical treatment of neurologically intact thoracolumbar burst fractures. METHODS:We systematically searched PubMed, Scopus, and Web of Science from inception to March 2026 for comparative studies evaluating RTW outcomes after surgical and nonsurgical treatment of adult patients with AO Spine A3/A4 thoracolumbar burst fractures without neurological deficits. Primary outcomes included time to RTW, overall RTW rate, and return to the same or modified work. Secondary outcomes included pain, disability, and quality of life (QoL). Random-effects meta-analyses were performed. RESULTS:Ten studies involving 632 patients (324 surgical and 308 nonsurgical) were included, of which 8 were eligible for meta-analysis. Surgical treatment was associated with a significantly shorter time to RTW (mean difference [MD] -104.11 days; 95% CI -178.14 to -30.08; P = 0.006), although heterogeneity was substantial (I² = 96%). No significant difference was observed in the overall RTW rate between treatment groups (OR 0.62; 95% CI 0.25-1.56; P = 0.31). Subgroup analysis demonstrated a lower odds of RTW in the surgical group at 6 months (OR 0.22; 95% CI 0.07-0.70; P = 0.01), whereas no difference was observed at final follow-up. Similarly, there were no significant differences in return to the same work (OR 1.04; P = 0.98) or modified work (OR 1.47; P = 0.56). Pain (MD 0.03; P = 0.93), disability (MD 1.28; P = 0.80), and QoL (MD 2.79; P = 0.46) were comparable between groups. CONCLUSIONS:Among neurologically intact patients with thoracolumbar burst fractures, surgical treatment may facilitate an earlier RTW; however, it does not improve long-term work participation, occupational reintegration, pain, disability, or QoL compared with nonsurgical management. Given the comparable long-term functional outcomes, treatment decisions should be individualized and guided by fracture characteristics, patient preferences, and shared decision-making rather than expectations of superior long-term recovery with surgery alone. CLINICAL RELEVANCE:Surgical treatment may facilitate earlier return to work in neurologically intact thoracolumbar burst fractures but does not improve long-term work participation, pain, disability, or quality of life. Treatment decisions should therefore be individualized based on fracture characteristics, patient priorities, and shared decision-making. LEVEL OF EVIDENCE: 2:
PURPOSE:To define directly visualized endoscopic posterior sensory network interruption (endoscopic transection/neurectomy of targeted dorsal ramus tributaries) as surgically distinct from percutaneous fluoroscopy-guided radiofrequency lesioning, and to propose a bounded, physiology-informed pathway that positions it after functional confirmation, and before structural reconstruction in selected phenotypes. STUDY DESIGN:Narrative, mechanism-informed perspective. METHODS:Selective synthesis of peer-reviewed evidence on dorsal root ganglion (DRG) neurobiology, functional diagnostics, imaging-symptom noncorrelation, and endoscopic posterior sensory procedures; and development of an operational decision framework specifying pragmatic diagnostic anchors, exclusion thresholds, reassessment expectations, and stopping rules. RESULTS:Axial and radiating/appendicular symptoms frequently coexist along a continuum influenced by DRG excitability rather than separating cleanly into "facet" vs "compression" categories. In imaging-noncorrelative presentations, magnetic resonance imaging noncorrelation is treated as a diagnostic classification rather than an indication: directly visualized endoscopic neurectomy is considered only when a suspected level/pathway is physiologically localized using predefined functional confirmation (eg, concordant diagnostic testing with clinically meaningful immediate relief) and when competing dominant mechanisms (instability, deformity, or predominant neuromuscular failure) are reasonably excluded. The framework constrains procedural "dose" and retreatment through explicit safety boundaries, including conservative multilevel use, interval objective neuromuscular reassessment, and stopping rules-particularly in patients with multifidus compromise, sarcopenia/frailty phenotypes, extensor-compartment vulnerability, or radiographic instability. CONCLUSIONS:Directly visualized endoscopic interruption of medial branch and related dorsal ramus tributaries is a surgical procedure with verified anatomic access under endoscopic visualization and should be distinguished from needle-based fluoroscopic radiofrequency lesioning when interpreting technique, reach, outcomes, and risk. Within a restricted, auditable selection framework requiring functional confirmation and defined safety boundaries, it may serve as a motion-preserving, escalation-friendly option in selected DRG-dominant axial-radiating pain phenotypes, while preserving escalation pathways to decompression or fusion when structural progression becomes dominant. CLINICAL RELEVANCE:A DRG-centered, endoscopic framework may address a common treatment gap-function-limiting symptoms with noncorrelative routine imaging-by pairing functional diagnostics with directly visualized posterior sensory network interruption while maintaining longitudinal accountability for neuromuscular and biomechanical risk. LEVEL OF EVIDENCE: 5:
BACKGROUND:Current techniques for instrumented posterolateral lumbar fusion include the use of titanium rods and pedicle screws to provide mechanical fixation, while autograft and/or allograft bone is used to promote osseous union across the fusion site. Although bone graft substitutes may be used for this purpose, they can resorb before a solid fusion is established, leading to nonunion. Tetracalcium phosphate-phosphoserine (TTCP-PS) is a novel, bioresorbable, osteoconductive, wet-field mineral-organic bone adhesive and bone graft substitute that has been previously shown to promote bone healing in a number of applications, including cranial bone flap fixation. OBJECTIVE:The goal of this study was to investigate the use of TTCP-PS for fusion in a posterolateral lumbar ovine model and to compare it to a commercially available bone graft substitute. STUDY DESIGN:An ovine lumbar fusion model was used to evaluate the safety and efficacy of TTCP-PS mineral-organic bone adhesive compared with a currently marketed bone graft substitute as a control (Actifuse ABX) over 1 year. These substances were implanted bilaterally in 20 sheep between the L3-L4 and L4-L5 transverse processes, stabilized with a pedicle screw fixation system. METHODS:Postoperative x-ray images, computed tomography scans, and histological findings were assessed at 12, 26, and 52 weeks after implantation to evaluate lumbar fusion across groups and time points. RESULTS:After euthanasia at 12 weeks, no statistically significant differences in the bone deposition region of interest at any of the substance implantation sites were observed. At 26 weeks, histologic analysis demonstrated new bone formation percentage to be significantly greater (P = 0.001) in the TTCP-PS sites (57%) than in the control group sites (31%). By 52 weeks, no statistically significant difference was found between groups, although the mean percentage bone growth area remained higher for the bone adhesive (52%) compared with the control (45%). CONCLUSIONS:TTCP-PS was safe and effective in an ovine posterolateral lumbar fusion model. TTCP-PS promoted earlier and greater (26 weeks) bone bridging in this study than a currently marketed bone graft substitute (Actifuse ABX) while producing greater levels of bone formation at 1 year after surgery. This accelerated healing may aid implant stabilization and reduce the risk of nonunion in posterolateral lumbar fusions in humans. CLINICAL RELEVANCE:TTCP-PS was demonstrated to be safe and effective as a bone graft substitute in this large animal posterolateral spinal fusion model. Its use resulted in superior new bone volume, greater mineral density of the fusion mass, and more rapid bone ingrowth than the control. These properties of TTCP-PS bone adhesive may improve the reliability and success of spinal fusion procedures. LEVEL OF EVIDENCE: 2:
BACKGROUND:Navigation of spinal instrumentation is heavily dependent on maintaining an accurate registration of the local anatomy to the navigation software. Any motion of the anatomy reduces accuracy. Historically, navigation in the cervical spine has been limited by the mobile nature of the anatomy. Here, we describe the development and testing of a novel stabilizer clamp designed to reduce motion and improve stability for navigated-instrumentation accuracy. METHODS:Testing was completed both on a flat-top table and separately on a Jackson table. On both tables, the cadaveric specimen was positioned prone with a Mayfield clamp. A total of 30 trials were completed as 3 repeats over 10 applications with force in the anteroposterior (AP) direction, and 30 additional trials with force in the medial-lateral (ML) direction. Displacement was recorded using a digital motion indicator for each trial. The experiment was then repeated after the addition application of a novel cranial stabilization system (Caption device). RESULTS:The Caption cranial stabilizer significantly reduced both AP motion (45%-53% reduction) and ML motion (69%-92% reduction; P < 0.05 for each). The result was consistent when the cadaver was positioned both on the flat-top table (50.3% AP and 79.6% ML reduction) and on the Jackson table (53.5% AP and 92.5% ML reduction). With the device attached to the extended bed rails, the Caption cervical stabilization system reduced deflections by 45% AP and 69% ML when compared to deflections without the use of the stabilization system. CONCLUSIONS:The addition of a supplementary cranial stabilization system significantly reduces cranial motion compared with the use of only a Mayfield clamp. CLINICAL RELEVANCE:Increased stability of the cranial and cervical anatomy may allow for a reduction in malposition of navigated cervical instrumentation. Particular benefit may be seen in minimally invasive cases where the bony anatomy cannot be directly visualized, and in placement of cervical pedicle screws where the anatomic tolerances required are very high. LEVEL OF EVIDENCE: 5:
BACKGROUND:Minimally invasive spine surgery (MISS) has gained popularity owing to improved short-term outcomes and technological advances despite comparable risks and similar long-term results with open surgery. The gold standard hence remains an ongoing debate among spine surgeons, heavily influencing the surgical techniques offered. However, the patients' perspective of MISS has remained grossly underexplored, despite buzzwords like "keyhole" and limited patient education possibly influencing their decision-making for surgery. This study aims to evaluate patients' current perception of spine surgery with a focus on MISS and whether this perception changes with "keyhole" surgery mentioned. METHODS:A 5-section anonymous questionnaire was conducted from June to November 2024 a a tertiary hospital in Singapore. The questionnaire collected patients' biodata, perspective of spine surgery, and knowledge, perspective, and demand for "keyhole" spine surgery. We included symptomatic surgical candidates with degenerative lumbar pathologies indicated for decompression and/or fusion surgery. All patients with lumbar pathologies secondary to trauma, infection, inflammation, or tumors were excluded. RESULTS:A total of 50 patients participated in the study. All 50 patients understood that "keyhole" meant MISS. Of these, 92% chose "keyhole" surgery over open surgery, citing lower complication risks (67%) and better outcomes (65%) as primary reasons. Most patients viewed "keyhole" surgery as a minor (44%) rather than a major surgery (18%), with 74% believing most to all patients are suitable candidates. As a result, more than 50% were willing to wait longer, pay more, and travel further for MISS. Despite this strong demand, most (90%) were unaware of the difference between endoscopic, tubular approaches, and MISS, and 100% were unaware of uniportal and biportal terminology. CONCLUSION:The term "keyhole" transforms patients' perspectives of spine surgery. Many who initially perceived spine surgery as high-risk view MISS as a safer alternative, associating it with fewer complications and better outcomes than open surgery. While demand for MISS is high, misconceptions about its complexity and limitations remain. CLINICAL RELEVANCE:Addressing patients' misconceptions requires effective patient education to ensure expectations align with clinical realities, fostering trust and satisfaction from the preoperative stage. Furthermore, the preference for MISS underscores the importance of surgeons being proficient in both open and minimally invasive approaches, enabling adaptation to individual patient needs. LEVEL OF EVIDENCE: 4:
