Study Design: Systematic review and meta-analysis. Objective: To evaluate whether preoperative depression is associated with differences in improvement of PROs following ACDF by comparing improvement-from-baseline outcomes between depressed and nondepressed patients. Background of Summary Data: Depression has been associated with worse baseline and postoperative patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF). However, most studies emphasize absolute postoperative scores rather than improvement from baseline, which more directly reflects the treatment effect. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. MEDLINE, PubMed, Cochrane Library, and Google Scholar were searched for comparative studies evaluating PROs after ACDF in patients with and without preoperative depression. Outcomes included Neck Disability Index (NDI), visual analog scale (VAS) neck pain, VAS arm pain, and SF-12 Physical and Mental Component Scores (PCS, MCS). Mean improvement from preoperative baseline to 6-month and ≥1-year follow-up was analyzed separately for depressed and nondepressed cohorts. Results: A total of 6 studies encompassing 930 patients met inclusion criteria. At baseline and at all postoperative time points, depressed patients demonstrated worse absolute PROs compared with nondepressed patients. However, when improvement from baseline was analyzed, depressed patients demonstrated significantly greater improvement in disability and pain outcomes. Perioperative outcomes, including operative time, blood loss, and length of stay, did not differ between groups. Conclusions: Although patients with preoperative depression experience worse absolute postoperative PROs following ACDF, they demonstrate comparable or greater improvement in disability and pain from baseline. These findings highlight the importance of distinguishing final health status from treatment effect and suggest that depression alone should not be considered a contraindication to surgical intervention but rather a factor for preoperative counseling and expectation management. Levels of Evidence: Level III.

Systematic review and meta-analysis. To compare perioperative, radiographic, and functional outcomes between open and percutaneous posterior fixation following anterior or lateral lumbar interbody fusion (ALIF/LLIF). Posterior fixation enhances construct stability after ALIF or LLIF, yet the optimal approach, open versus percutaneous, remains debated. While minimally invasive surgery (MIS) reduces tissue disruption, open fixation may offer superior sagittal correction, particularly in adult spinal deformity (ASD). Prior meta-analyses have not isolated ALIF/LLIF procedures. Following PRISMA guidelines, PubMed, Embase, and Google Scholar were searched (January 2000–January 2025). Comparative studies evaluating open versus percutaneous posterior fixation after ALIF/LLIF were included. Outcomes included sagittal parameters, perioperative variables, postoperative events and patient-reported outcomes. Meta-analyses were performed using random- or fixed-effects models depending on heterogeneity (I² >50%). Thirteen studies (912 patients; 454 open, 458 percutaneous) met inclusion criteria. For radiographic outcomes: No overall difference in Δ Lumbar Lordosis(LL), Δ Pelvic Incidence–LL, or Δ Sacral Slope; however, open fixation achieved greater sagittal correction in ASD (ΔLL=12.9° [95% CI 0.01 – 25.87, P =0.05] , PI–LL=−4.1° [95% CI -7.88 – -0.38, P =0.03] , SS=+2.5° [95% CI 0.38 – 4.58, P =0.02]). For perioperative outcomes, percutaneous fixation reduced EBL (−387 mL [95% CI -575.72 - -197.71, P <0.0001]), OR time (−65 min [95% CI -93.90 - -15.82, P =0.006]), LOS (−1.7 d [95% CI -2.42 -1.01, P < 0.00001]), and transfusion risk (OR 0.26 [95% CI 0.11 – 0.58, P =0.001]). For postoperative outcomes, no significant differences in reoperation, fusion, or adjacent segment disease incidence; percutaneous fixation improved pain-medication independence (OR 4.29 [95% CI 1.20 – 15.36, P =0.03]). For patient-reported outcomes, percutaneous fixation yielded superior ODI (−7.1 [95% CI -11.07 – -3.21, P =0.0004]) improvements early; at two years, it maintained minimally better VAS Back (−0.31 [95% CI -0.54 – -0.08, P =0.009]) and ODI (−2.9 [95% CI -5.04 – -0.68, P =0.01]) scores. Percutaneous posterior fixation after ALIF/LLIF offers clear perioperative advantages, reduced blood loss, operative time, LOS, and transfusion need, without compromising fusion or long-term outcomes. Open fixation remains preferable for ASD cases requiring extensive sagittal realignment. Surgical approach should therefore be individualized based on deformity rigidity and alignment goals.

BACKGROUND:Prior studies of transforaminal lumbar interbody fusion (TLIF) have primarily focused on older populations, with limited evaluation of younger adults as a distinct cohort. Whether presumed biologic advantages in younger patients translate into superior long-term outcomes remains unclear. This study aimed to assess whether younger age (≤50 years) is associated with improved clinical, radiographic, and patient-reported outcomes following TLIF. METHODS:Adults undergoing TLIF for degenerative lumbar pathology at a single center (2018-2022) with ≥2-year follow-up were retrospectively analyzed. Patients were stratified by age (≤50 vs >50 years). A 1:2 propensity score match was performed using sex, BMI, age-independent comorbidity index, prior fusion, and number of levels fused. Outcomes included complications, reoperation, radiographic parameters, and patient-reported outcomes (ODI, VAS back/leg pain). Univariate and multivariable analyses adjusted for covariates. RESULTS:From 854 patients, propensity matching yielded 89 aged ≤50 years and 178 aged >50 years. Complication rates were comparable between groups (reoperation: 19.1% vs 22.5%, p = 0.53; pseudarthrosis: 3.4% vs 5.6%, p = 0.42; subsidence: 12.4% vs 19.1%, p = 0.17; ASD: 10.1% vs 15.7%, p = 0.21). On multivariable analysis, age >50 was not associated with reoperation, pseudarthrosis, or subsidence, but independently predicted adjacent segment disease (OR 2.08, 95% CI 1.02-4.66; p = 0.044). Radiographic outcomes were comparable. Older age was independently associated with greater 2-year improvement in ODI, VAS back, and leg pain (all p < 0.05). CONCLUSIONS:Younger age was not associated with reduced complications, reoperation, or radiographic failure after TLIF. Older patients demonstrated greater patient-reported improvement despite similar surgical outcomes. This suggests that age alone should not be considered a predictor of superior TLIF outcomes and highlights the importance of individualized patient counseling regarding expected functional benefit.

STUDY DESIGN:Retrospective cohort study. OBJECTIVE:To compare sagittal alignment, reoperation rates, and patient-reported outcomes between anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) in patients ≤50 years. SUMMARY OF BACKGROUND DATA:ALIF and TLIF are commonly used lumbar fusion techniques with known differences in alignment restoration and complication profiles. However, comparative outcomes in younger patients, who have greater long-term biomechanical demands, remain poorly defined. METHODS:A single-institution retrospective analysis was performed on patients ≤50 years undergoing 1-2 level ALIF (stand-alone or with posterior instrumentation) or TLIF at L4-S1. Radiographic parameters (lumbar lordosis [LL], PI-LL mismatch, pelvic tilt [PT]) were assessed preoperatively and up to 2 years postoperatively. Reoperation rates and indications were recorded, with Kaplan-Meier and Cox regression analyses evaluating reoperation-free survival. Patient-reported outcomes included PROMIS Global Mental Health (GMH) and Physical Health (GPH). Multivariable regression adjusted for age, BMI, CCI, and multilevel fusion. RESULTS:A total of 218 patients were included (ALIF stand-alone: n=60; ALIF+posterior (ALIF +P): n=47; TLIF: n=111). At 2 years, ALIF+P demonstrated greater LL and lower PI-LL mismatch compared to TLIF (P≤0.02). Reoperation rates were highest in TLIF (20.7%) versus ALIF stand-alone (10.0%) and ALIF+P (8.5%) (P=0.03). TLIF was associated with increased reoperation risk compared to ALIF+P (HR 2.13, 95% CI 1.62-2.71). Adjacent segment disease was more common in TLIF (P=0.040). Early (6-week) GMH and GPH favored TLIF (P<0.001), whereas final GPH was highest in ALIF+P (P=0.001). Subsidence rates were similar across groups (P=0.627). CONCLUSION:In patients ≤50 years, ALIF with posterior instrumentation provides superior and durable sagittal alignment, lower reoperation rates, and improved long-term physical health compared to TLIF. Although TLIF demonstrates favorable early recovery, circumferential ALIF may offer greater long-term biomechanical and clinical benefit in younger patients.

OBJECTIVE:The Risk Assessment and Prediction Tool (RAPT) has been utilized to anticipate discharge needs after procedures such as total joint arthroplasty. Its usefulness for spine patients, particularly those undergoing transforaminal lumbar interbody fusion (TLIF), has not been clearly established. This study evaluated the relationship between the preoperative RAPT score and 3 postoperative outcomes: discharge destination, hospital length of stay (LOS), and 30-day readmission. METHODS:A retrospective cohort study was conducted of adults who underwent elective TLIF with a recorded preoperative RAPT score. RAPT was analyzed as a continuous variable. Home discharge and 30-day readmission were modeled with logistic regression, and LOS with linear regression. Multivariable models adjusted for age, sex, Charlson Comorbidity Index (CCI), and insurance type. Discrimination for facility discharge was assessed by receiver operating characteristic (ROC) analysis at literature-aligned thresholds (RAPT scores 9.5 and 8.5: balanced and conservative, respectively). RESULTS:Among 116 patients, the mean age was 62.2 years and 50.9% of patients were female; the mean BMI was 29.9, and the mean CCI was 5.64. The mean RAPT score was 9.65, and the mean LOS was 3.14 days. Discharge to a skilled nursing or rehabilitation facility occurred in 6.9% of patients, and 30-day readmission occurred in 6.0%. Each 1-point increase in the RAPT score was associated with higher odds of home discharge (univariate: OR 1.74, 95% CI 1.11-2.73, p = 0.016; multivariable: OR 2.17, 95% CI 1.24-3.80, p = 0.007) and a shorter LOS (β = -0.38 days, 95% CI -0.71 to -0.05, p = 0.025; adjusted β = -0.39, bootstrap 95% CI -0.76 to -0.10, p = 0.038). The RAPT score was not associated with 30-day readmission (adjusted OR 0.93, 95% CI 0.52-1.65; p = 0.798). ROC analysis for predicting facility discharge showed moderate discrimination with an area under the curve of 0.709 (95% CI 0.543-0.876, p = 0.049), with sensitivity 63% and specificity 62% at 9.5, and sensitivity 38% and specificity 82% at 8.5. Youden's index revealed an optimal cutoff of 10.5, with sensitivity 100% and specificity 29.6%. CONCLUSIONS:In patients undergoing TLIF, higher preoperative RAPT scores were associated with greater odds of home discharge and shorter LOS. RAPT may serve as a practical preoperative tool to support discharge planning and resource allocation in spine surgery.

Study DesignRetrospective cohort study.ObjectiveTo evaluate the impact of age ≥75 years on postoperative complications and sagittal alignment following open transforaminal lumbar interbody fusion (TLIF).MethodsA retrospective review was performed for patients undergoing primary open TLIF from 2017 to 2021. Patients were divided into 2 cohorts: age <75 and ≥75 years. Groups were 1:1 propensity score matched based on gender, body mass index (BMI), hypertension, diabetes, and Charlson Comorbidity Index (CCI). Radiographic sagittal parameters were analyzed preoperatively and at 1 year postoperatively. Complication rates, including reoperations, adjacent segment disease, and subsidence, were compared between matched cohorts.ResultsPrior to the PSM, a total of 489 patients fit the initial exclusion criteria with 448 in the younger (18-75 years) cohort and 40 in the older (≥75 years) cohort. After matching, 80 patients were included (40 per group) with no significant differences in demographics or perioperative variables. Postoperative radiographic parameters were similar between groups. The overall complication rates were comparable (P = 0.546). However, elderly patients experienced significantly higher rates of revision surgery (27.5% vs 5.7%, P = 0.013).ConclusionPatients ≥75 years old achieved similar radiographic alignment and experienced comparable complication rates following open TLIF. However, they may be at greater risk for revision surgery. These findings support the safety and effectiveness of open TLIF in elderly patients, though larger and longer-term studies are needed to further define outcomes in this population.Level of EvidenceIII.

Background/Objectives: Irritable bowel syndrome (IBS) is among the most prevalent disorders of gut-brain interaction, yet its implications for spine surgery remain poorly characterized. This narrative review examines how IBS influences symptom presentation and postoperative outcomes in spine surgery patients. Methods: We synthesized the neurobiologic, epidemiologic, and perioperative literature linking IBS with musculoskeletal pain, spine-related symptomatology, and surgical outcomes, drawing on spine-specific data where available and on related surgical and chronic-pain populations where it was not. Results: IBS is characterized by central sensitization, impaired descending inhibition, increased temporal summation, autonomic dysregulation, and a high prevalence of psychiatric comorbidity, which manifest as widespread hyperalgesia and symptom amplification that overlap with pain mechanisms common in spine surgery patients. Epidemiologic studies indicate that patients with IBS undergo musculoskeletal and spinal procedures at disproportionately high rates, reflecting both symptom burden and diagnostic uncertainty from viscerosomatic overlap. These same factors have been associated with greater postoperative pain, elevated opioid requirements, slower functional recovery, and reduced satisfaction after spine surgery, although direct IBS-specific spine data remain limited. IBS may also confound preoperative assessment by mimicking radicular, discogenic, or sacroiliac pain. Conclusions: IBS represents an under-recognized potential modifier of symptom localization, perioperative pain trajectories, and functional recovery in spine surgery. Greater awareness of IBS-related nociplastic and psychosocial mechanisms may improve preoperative evaluation, risk stratification, perioperative management, and the design of future outcome studies.

STUDY DESIGN:Retrospective cohort study. OBJECTIVE:Evaluate the effect of smoking on complication rates, radiographic parameters, and patient-reported outcomes (PROs) after anterior cervical disc replacement (ACDR). SUMMARY OF BACKGROUND DATA:ACDR is a motion-preserving procedure used to treat cervical radiculopathy and myelopathy. Although tobacco use is known to adversely affect outcomes after fusion-based procedures, its impact on ACDR remains underexplored. METHODS:Patients who underwent ACDR for myelopathy or radiculopathy between 2017 and 2025 at a single institution were identified and categorized as smokers or non-smokers. Outcomes included complication rates, global and segmental radiographic parameters (i.e. Cobb angle, range of motion [ROM]), and PROs (neck and arm Visual Analog Score, Neck Disability Index). Univariate analyses used chi-square and t-tests, and Firth logistic regression was applied for multivariate analysis of binary variables. RESULTS:A total of 102 patients were included (19 smokers, 83 non-smokers). Baseline characteristics, including age, sex, BMI, and comorbidities, were similar between groups. Postoperatively, smokers demonstrated a significantly higher rate of reoperation than non-smokers (15.8% vs. 1.2%; P=0.003), all due to loosening or migration of the arthroplasty device. No significant differences were found in radiographic alignment or PROs, though smokers exhibited greater segmental ROM (9.5° vs. 6.8°; P=0.04). CONCLUSIONS:While ACDR appears to preserve functional outcomes in smokers, tobacco use is associated with an increased risk of reoperation, likely resulting from reduced implant stability. Surgeons should monitor smokers closely postoperatively and consider enhanced follow-up for this at-risk population.

STUDY DESIGN:Retrospective cohort study. OBJECTIVE:To evaluate the impact of patient age on complication rates, radiographic alignment, and patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA:ACDF is one of the most common and effective spinal procedures in the United States. However, as a rising number of elderly patients undergo ACDF, age-related differences in outcomes such as subsidence, adjacent segment disease, and PROs remain poorly defined. METHODS:A retrospective review was conducted on 302 patients who underwent ACDF between 2020 and 2022 at a single academic institution. Patients were stratified into 4 age groups: younger than 50, 50-59, 60-69, and 70 years or older. Univariate regression analyses compared cervical sagittal alignment and PROs, while multivariate analyses assessed perioperative characteristics and complications. RESULTS:Compared with the younger-than-50 cohort, patients aged 50-59 exhibited a significantly higher rate of subsidence (29.6% vs. 13.7%, P=0.001). The 60-69 group showed a similar outcome (24.6%, P=0.033) and a significantly longer length of stay (1.34 vs. 0.96 d, P=0.023). Patients aged 70 years or older experienced the most pronounced changes: subsidence occurred in 42.1% (P=0.044), LOS increased to 1.74 days (P=0.001), and SVA increased by an average of 0.83 cm preoperatively, unlike younger cohorts, in whom SVA stabilized. In addition, patients aged 70 years or older reported a significant resurgence of neck pain at 1- and 2-year follow-ups. In contrast, this group also exhibited the greatest improvement in brief resilience scale scores, ultimately reporting the highest resilience at 1 year postoperatively (P=0.0162). CONCLUSIONS:Advanced age is associated with increased subsidence, sagittal imbalance, longer hospitalization, and recurrence of neck pain following ACDF. These findings are important to consider when planning ACDF, particularly in patients aged 70 years or older. Nonetheless, improvements in resilience among older patients highlight their capacity for meaningful recovery. LEVEL OF EVIDENCE:Level III.

Background Hollow viscus perforation following spine surgery is uncommon but associated with substantial morbidity and mortality when diagnosis is delayed. Early recognition is challenging because presenting symptoms frequently overlap with expected postoperative bowel dysfunction and imaging findings may initially be subtle. Despite its clinical significance, the literature remains fragmented across case reports and small series, and a consolidated, mechanism-based framework specific to spine surgery is lacking. Methods We performed a single-institution case series of five patients who developed hollow viscus perforation or significant postoperative intra-abdominal pathology after spine surgery, combined with a comprehensive review of the published literature. Data were analyzed to identify common mechanisms of injury, clinical presentation patterns, diagnostic pathways, management strategies, and preventive considerations. Results Hollow viscus perforation after spine surgery occurred through four principal mechanisms: direct mechanical injury, functional distension related to acute colonic pseudo-obstruction physiology, delayed hardware or graft migration, and medication-associated ulceration or diverticular perforation. Early clinical findings frequently overlapped with expected postoperative bowel dysfunction, contributing to delayed recognition. Diagnosis depended on identifying deviations from expected recovery trajectories and obtaining timely computed tomography imaging. Preventive strategies included recognition of preoperative abdominal risk factors, meticulous exposure-specific surgical technique, optimization of postoperative bowel function, and judicious use of medications that impair gastrointestinal motility or tissue integrity. Conclusions Hollow viscus perforation following spine surgery is an uncommon but potentially catastrophic complication arising from distinct mechanical, functional, hardware-related, and medication-associated pathways. Because early signs are often nonspecific, a low threshold for imaging and general surgical evaluation is essential. Improved preoperative risk stratification, intraoperative vigilance, and structured postoperative monitoring may reduce delays in diagnosis and improve outcomes in this high-risk population.

Retrospective cohort study. To evaluate whether elevated 6-week postoperative pelvic tilt (PT) is associated with reduced 1-year age-adjusted sagittal alignment target achievement after TLIF, independent of baseline alignment and patient/surgical factors. Elevated postoperative PT has been associated with poor sagittal alignment, but prior analyses in degenerative TLIF cohorts have been criticized for reliance on simplified thresholds and limited adjustment for baseline alignment phenotype. The clinical importance of persistent or newly developed postoperative compensation remains incompletely defined. A retrospective analysis of 817 primary TLIF patients was performed. Patients were stratified by 6-week PT into high PT (≥ 25°) and low PT (< 25°) groups. The primary endpoint was 1-year age-adjusted PI–LL target achievement (Lafage age-specific thresholds). The primary multivariable logistic model adjusted for preoperative PT, preoperative PI–LL mismatch, age, sex, BMI, CCI, and number of fused levels; 6-week age-adjusted target status was not included, as it lies on the causal pathway between exposure and outcome, and the corresponding over-adjusted model is reported as a supplementary analysis. A prespecified sensitivity model used continuous 6-week PT. Supportive transition-phenotype analyses (Low→Low, Low→High, High→Low, High→High) were performed in patients with both preoperative and postoperative PT data. High PT was present in 306/817 patients (37.5

STUDY DESIGN:Systematic review and meta-analysis. OBJECTIVE:To compare perioperative, radiographic, and functional outcomes between open and percutaneous posterior fixation following anterior or lateral lumbar interbody fusion (ALIF/LLIF). BACKGROUND:Posterior fixation enhances construct stability after ALIF or LLIF, yet the optimal approach, open versus percutaneous, remains debated. While minimally invasive surgery (MIS) reduces tissue disruption, open fixation may offer superior sagittal correction, particularly in adult spinal deformity (ASD). Prior meta-analyses have not isolated ALIF/LLIF procedures. MATERIALS AND METHODS:Following PRISMA guidelines, PubMed, Embase, and Google Scholar were searched (January 2000-January 2025). Comparative studies evaluating open versus percutaneous posterior fixation after ALIF/LLIF were included. Outcomes included sagittal parameters, perioperative variables, postoperative events and patient-reported outcomes. Meta-analyses were performed using random- or fixed-effects models depending on heterogeneity ( I2 >50%). RESULTS:Thirteen studies (912 patients; 454 open, 458 percutaneous) met inclusion criteria. For radiographic outcomes: No overall difference in Δ lumbar lordosis (LL), Δ pelvic incidence-LL, or Δ sacral slope; however, open fixation achieved greater sagittal correction in ASD (ΔLL=12.9° [95% CI: 0.01-25.87, P =0.05], PI-LL=-4.1° [95% CI: -7.88, -0.38, P =0.03], SS=+2.5° [95% CI: 0.38-4.58, P =0.02]). For perioperative outcomes, percutaneous fixation reduced EBL (-387 mL [95% CI: -575.72, -197.71, P <0.0001]), OR time (-65 min [95% CI: -93.90, -15.82, P =0.006]), LOS (-1.7 d [95% CI: -2.42, -1.01, P < 0.00001]), and transfusion risk (OR: 0.26 [95% CI: 0.11-0.58, P =0.001]). For postoperative outcomes, no significant differences in reoperation, fusion, or adjacent segment disease incidence; percutaneous fixation improved pain-medication independence (OR: 4.29 [95% CI: 1.20-15.36, P =0.03]). For patient-reported outcomes, percutaneous fixation yielded superior ODI (-7.1 [95% CI: -11.07, -3.21, P =0.0004]) improvements early; at 2 years, it maintained minimally better VAS back (-0.31 [95% CI: -0.54, -0.08, P =0.009]) and ODI (-2.9 [95% CI: -5.04, -0.68, P =0.01]) scores. CONCLUSIONS:Percutaneous posterior fixation after ALIF/LLIF offers clear perioperative advantages, reduced blood loss, operative time, LOS, and transfusion need, without compromising fusion or long-term outcomes. Open fixation remains preferable for ASD cases requiring extensive sagittal realignment. Surgical approach should therefore be individualized based on deformity rigidity and alignment goals.

STUDY DESIGN:Systematic review and meta-analysis. OBJECTIVE:To evaluate whether preoperative depression is associated with differences in improvement of PROs following ACDF by comparing improvement-from-baseline outcomes between depressed and nondepressed patients. BACKGROUND OF SUMMARY DATA:Depression has been associated with worse baseline and postoperative patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF). However, most studies emphasize absolute postoperative scores rather than improvement from baseline, which more directly reflects the treatment effect. METHODS:A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. MEDLINE, PubMed, Cochrane Library, and Google Scholar were searched for comparative studies evaluating PROs after ACDF in patients with and without preoperative depression. Outcomes included Neck Disability Index (NDI), visual analog scale (VAS) neck pain, VAS arm pain, and SF-12 Physical and Mental Component Scores (PCS, MCS). Mean improvement from preoperative baseline to 6-month and ≥1-year follow-up was analyzed separately for depressed and nondepressed cohorts. RESULTS:A total of 6 studies encompassing 930 patients met inclusion criteria. At baseline and at all postoperative time points, depressed patients demonstrated worse absolute PROs compared with nondepressed patients. However, when improvement from baseline was analyzed, depressed patients demonstrated significantly greater improvement in disability and pain outcomes. Perioperative outcomes, including operative time, blood loss, and length of stay, did not differ between groups. CONCLUSIONS:Although patients with preoperative depression experience worse absolute postoperative PROs following ACDF, they demonstrate comparable or greater improvement in disability and pain from baseline. These findings highlight the importance of distinguishing final health status from treatment effect and suggest that depression alone should not be considered a contraindication to surgical intervention but rather a factor for preoperative counseling and expectation management. LEVELS OF EVIDENCE:Level III.

BACKGROUND:Testosterone replacement therapy (TRT) use has increased substantially in recent years, yet its impact on outcomes following posterior lumbar fusion remains unclear. Given testosterone's known effects on bone metabolism, coagulation, and musculoskeletal physiology, understanding its relationship with postoperative complications and long-term reoperation is critical for perioperative risk stratification. This study evaluates the association between preoperative TRT use and short- and long-term outcomes following posterior lumbar fusion. METHODS:A retrospective cohort study was conducted using the PearlDiver Mariner165 database (2010-2020). Adult male patients undergoing posterior lumbar fusion were identified using CPT codes and stratified by preoperative TRT use, defined as ≥3 months of therapy with ≥2 prescriptions. Patients with major systemic or neurologic diseases were excluded. TRT and non-TRT cohorts were matched 1:1 using propensity scores based on age, Charlson Comorbidity Index (CCI), diabetes, and tobacco use. Outcomes included 90-day postoperative complications and reoperation rates at 2 and 5 years. Multivariable logistic regression was performed adjusting for relevant comorbidities. RESULTS:A total of 5068 patients were identified, including 955 TRT users. After propensity matching, 904 well-balanced pairs were analyzed. There were no significant differences in 90-day complications between cohorts, including acute kidney injury, thromboembolic events, surgical site complications, readmissions, or persistent pain (all p > 0.05). However, TRT use was independently associated with increased long-term reoperation risk. On multivariable analysis, TRT patients demonstrated higher odds of reoperation at 2 years (adjusted OR 2.36, 95% CI 1.78-3.12, p < 0.001) and 5 years (adjusted OR 2.18, 95% CI 1.70-2.80, p = 0.005). CONCLUSIONS:Preoperative TRT use was not associated with increased short-term postoperative complications following posterior lumbar fusion but was independently associated with a significantly higher risk of long-term reoperation. These findings suggest that TRT may serve as a marker for patients with more complex postoperative trajectories rather than directly increasing perioperative risk. While TRT should not be considered a contraindication to surgery, its presence may warrant closer longitudinal surveillance and more nuanced preoperative counseling regarding long-term expectations. Further prospective studies incorporating radiographic and hormonal data are needed to clarify underlying mechanisms.

Study Design.Retrospective cohort study.Objective.To compare intraoperative complications, 90-day medical complications, and 2-year surgical reoperation rates between endoscopic discectomy (ED) and open discectomy (OD).Background.Symptomatic lumbar disc herniation is common, with discectomy serving as a common surgical intervention. Previous studies comparing ED and OD show inconsistent findings regarding complications and long-term outcomes, often limited by small sample sizes and study heterogeneity.Materials and Methods.Patients undergoing ED (CPT-62380) and OD (CPT-63030) from 2010 to 2022 were identified using PearlDiver database. Propensity score matching (1:1) controlled for age, sex, and Charlson Comorbidity Index (CCI). Outcomes included intraoperative complications such as dural tears and nerve injuries, 90-day medical complications including deep vein thrombosis (DVT), surgical site infections (SSI), dura repair, and urinary tract infections (UTI), and 2-year reoperations. Statistical analyses utilized chi 2 tests, t tests, and multivariate logistic regression adjusting for comorbidities. Odds ratios (OR) with 95% CIs were reported.Results.A total of 2618 patients were identified and examined (1309 ED, 1309 OD). On multivariate analysis, ED was associated with a significantly lower risk of dural tears (0.15% vs. 1.15%, OR: 0.179, P = 0.006), surgical site infections (0.08% vs. 1.15%, OR: 0.082, P = 0.001), wound complications (0.38% vs. 1.07%, OR: 0.342, P = 0.023), and dura repair (0.08% vs. 0.69%, OR: 0.091, P = 0.021). ED was also associated with lower odds of persistent pain (2.22% vs. 2.83%, OR: 0.665, P = 0.048). No significant differences were observed in nerve injuries, DVT, UTI, or readmissions.Conclusion.ED is associated with fewer dural tears, surgical site infections, wound complications, and dura repairs, along with lower odds of persistent pain compared with OD. Rates of DVT, UTI, and reoperations were not significantly different between groups.

STUDY DESIGN:Systematic review and meta-analysis. OBJECTIVE:To systematically evaluate the impact of perioperative vitamin D supplementation and bisphosphonate therapy on spinal fusion outcomes, patient-reported disability and pain, postural stability, and vertebral fracture risk. BACKGROUND:Bone health optimization is critical for successful spinal fusion. While vitamin D and bisphosphonate supplementation have been studied individually, their comparative and combined effects remain unclear. METHODS:A PRISMA-compliant systematic review and meta-analysis were performed (PubMed, Embase, and Google Scholar; through January 2025). Eligible randomized controlled and prospective comparative trials evaluated: (1) vitamin D versus placebo/no supplement and (2) bisphosphonates versus vitamin D. Primary outcomes were fusion rates and vertebral compression fractures (VCFs). Secondary outcomes included functional scores (ODI), VAS, postural stability, bone turnover markers (P1NP), and BMD. Risk ratios (RR) and mean differences (MD/SMD) with 95% CI were pooled. RESULTS:For the vitamin D versus placebo analysis, increased fusion at one year (RR: ∼1.25), improved ODI at six months and one year (MD: ∼6.90, 8.56), and provided a small early VAS benefit (MD: 1.14). OSI improved significantly (SMD: 0.93). For Bisphosphonates versus vitamin D analysis, bisphosphonate therapy accelerated early fusion, but by one year, outcomes were similar. ODI favored vitamin D at one year, while VAS showed no difference. Bisphosphonates suppressed P1NP and reduced fracture risk (RR: 0.10). CONCLUSIONS:Vitamin D accelerates early fusion and modestly improves long-term function and bisphosphonates provide fracture protection and turnover suppression. These findings support a tailored, multimodal approach to perioperative bone health optimization in spinal fusion. LEVEL OF EVIDENCE:Level II.

To characterize spine-related research publication output, geographic distribution, and citation-based influence using a Scopus-based bibliometric analysis of 28 orthopedic, neurosurgical, and spine-focused journals from 2014 to 2025. Articles and reviews in 28 ISSN-defined source journals were identified in Scopus (search date February 2026). 15 journals were spine specific, while 13 were multidisciplinary orthopedic or neurosurgical journals. To ensure spine specificity across the 13 multidisciplinary journals, records were filtered using prespecified spine-related title terms. We extracted total document count, annual publication volume, distribution by country, journal, and funding sponsor. Journal CiteScore and the most cited documents were also extracted. A composite influence metric (CiteScore × articles published) was computed per journal to assess influence. Descriptive statistics and linear regression of annual publication counts were used. A total of 34,529 research publications met eligibility criteria. Annual output increased from 2,327 in 2014 to 3,349 in 2025 (43.9

STUDY DESIGN:Single-center, retrospective cohort study (level III). OBJECTIVE:This study evaluates alignment changes and outcomes after C5-C7 ACDF and examines whether the degree of segmental correction is associated with reoperation. BACKGROUND:The C5-6 and C6-7 segments are frequently affected in cervical degenerative disc disease due to their mobility and transitional anatomy. Two-level anterior cervical discectomy and fusion (ACDF) is commonly performed at these levels. Although global cervical alignment restoration has been associated with improved functional outcomes and reduced adjacent-segment disease, the specific impact of postoperative lordotic correction at C5-C7 on clinical measures and revision risk remains poorly defined. METHODS:A retrospective cohort study was conducted at a single institution. Patients undergoing 2-level C5-C7 ACDF were evaluated for demographics, sagittal alignment parameters, and complications through 1 year postoperatively. Multivariate logistic regression, controlling for age, sex, Charlson comorbidity index (CCI), and baseline cervical deformity, was used to assess the association between segmental correction and reoperation. RESULTS:A total of 92 patients underwent C5-C7 ACDF. Mean age was 51.7 years, 57% were female, and mean CCI was 0.5. Significant improvements were observed in C2-C7 lordosis (2.4-7.3 deg.), fused segment alignment (-4.3 to 2.1 deg.), and T1-CL (23.8-20.9 deg.) (all P<0.01). Average correction at fused levels was 6.5 degrees (SD 7.4 deg.). Overall, 12% (11/92) underwent reoperation. Inadequate correction increased reoperation odds 7.2-fold (P=0.028). CONCLUSIONS:C5-C7 ACDF yields significant sagittal correction. However, limited segmental improvement may increase reoperation risk. Achieving sufficient correction is important to optimize outcomes and reduce complications.

Study Design: Retrospective cohort study. Objective: To assess the epidemiology, procedural risk factors, and associated complications of postoperative footdrop following posterior lumbar fusion. Summary of Background Data: Footdrop is an uncommon complication following spine surgery that is associated with functional impairments. Understanding the epidemiology and risk factors of postoperative footdrop may allow for early implementation of preventive measures before and during surgery. Methods: Adults who underwent posterior lumbar fusion were identified using PearlDiver. Eligible patients were stratified by the development of footdrop within 90 days of surgery. Epidemiological trends in footdrop were evaluated by age groups and year between 2010 and 2022. Patient demographics, comorbidities, procedural characteristics, hospital outcomes, and occurrence of intraoperative and postoperative complications were compared. Results: In total, 2988 (0.6%) footdrop and 473,129 (99.4%) no footdrop patients were included, with a mean age of 60.9 years and 57.6% female sex. Postoperative footdrop rates increased from 0.4% to 0.8% between 2010 to 2022 and increased with age. Preoperatively, footdrop patients more frequently reported prior posterior spine surgery and medical comorbidities (all P <0.05). Intraoperatively, they had higher rates of 2 or more level fusion, osteotomy, dural tear, and nerve injury (all P <0.01). Postoperatively, they had higher rates of acute kidney injury, deep venous thrombosis, urinary tract infection, wound-related, hematoma, transfusion, and site-related complications, as well as higher rates of 90-day readmissions (all P <0.001). Conclusion: Patients developing footdrop following lumbar spinal fusion were older, had more comorbidities, and frequently underwent complex multilevel procedures. They also had other postoperative complications, higher hospital readmissions, and increased health care expenditures. This data provides valuable insights into the risk factors and associated adverse outcomes for postoperative footdrop after lumbar spinal fusion.