Abstract Introduction Poor nutrition status has been associated with poor outcomes in the treatment of oncologic disease, however, there are no defined nutritional indicators for patients with metastatic spine disease (MSD). Hypoalbuminemia has been shown to be a potential biomarker for poor nutritional status in other populations, but the role it plays in the treatment of MSD remains unclear. Methods A scoping review of the literature up to December 2022 was conducted using PubMed/ Medline, EMBASE, and Web Science databases. Studies that included patients with MSD, collected albumin levels and reported associated clinical outcomes were included. Baseline health and clinical outcomes data including serum albumin levels, treatments for MSD, ambulatory status, readmission rate, mortality, and complications were collected. Results Thirty-eight studies comprising 21,401 patients were analyzed. The majority of studies defined hypoalbuminemia as a binary variable with a level <3.5 g/dL. Twenty-seven (71%) studies evaluated mortality as a primary outcome and 20 of these studies (74%) demonstrated a significant association between albumin levels and survival. A total of 13 studies (34%) included post-treatment complications, 54% of which reported a significant association between hypoalbuminemia and increased risk of complication. Notably only two studies evaluated hypoalbuminemia with regard to discharge disposition, but both studies found a significant association between albumin level and non-routine discharge. Conclusion The evidence from this scoping review suggests a threshold of 3.5g/dL is an appropriate definition for hypoalbuminemia in patients with MSD. Many studies demonstrated a correlation between hypoalbuminemia and both operative and non-operative outcomes in patients with MSD.

Abstract In patients with metastatic spinal disease (MSD), interhospital transfer has been shown to impact clinical outcomes such as complications, length of stay and nonroutine discharge, but not mortality. Critically, potential benefits of transfer to a higher level of care must be weighed against the negative effects of consequent delay in definitive treatment. The purpose of this study was to examine the impact of transfer status on inhospital mortality and clinical outcomes in patients with MSD. De la Garza Ramos et al. (2021) examined 10,360 National Inpatient Sample (NIS) discharges (2012–2014) and found that transferred patients had higher odds of complications (OR 1.34), prolonged length of stay (OR 1.33), and nonroutine discharge (OR 1.70), but no difference in mortality (OR 1.05, p = 0.662). In a retrospective study using the NIS, we replicated and extended these findings using a larger contemporary cohort with propensity score matching. Adult patients with bone metastasis, metastatic spinal cord compression or pathological vertebral fracture were identified using ICD-9-CM and ICD-10-CM codes. We first replicated the findings of De la Garza Ramos et al. from 2012–2014 (N = 11,132) and found that transferred patients had significantly higher adjusted odds of complications (OR 1.30), prolonged stay (OR 1.34), and nonroutine discharge (OR 1.64), with no mortality difference (OR 1.15, p = 0.230).We then extended this analysis for the years 2012-2022, and after propensity score matching (6,569 pairs), transfer was significantly associated with higher mortality (OR 1.49, 95% CI 1.30–1.70, p < 0.001), prolonged stay (OR 1.66), nonroutine discharge (OR 1.60), and complications (OR 1.16; all p < 0.001). It is also notable that transfer rates increased over the 2012-2014 study period. Given this, our updated results regarding the implications of interhospital transfer in MSD underscore the need to optimize transfer protocols and minimize delays in definitive care for patients with MSD.

OBJECTIVES:This study aimed to identify sociodemographic predictors of stereotactic body radiotherapy (SBRT) use and assess temporal trends in first-line SBRT use among patients with spinal metastatic renal cell carcinoma (mRCC) in relation to National Comprehensive Cancer Network guidelines. METHODS:Using the PearlDiver Database, adults with spinal mRCC were identified. The database includes patients from 2010 to 2023. Patients with documented first-line radiotherapy were grouped as either receiving SBRT or conventional external beam radiation therapy (EBRT). Cohorts were compared using the χ2 tests for categorical variables and independent-samples t tests for continuous variables (P<0.05). Utilization trends were examined before versus after guideline implementation in 2019, and predictors of SBRT utilization were evaluated using multivariate logistic regression. RESULTS:Of 86,482 patients with spinal metastatic RCC, 10,988 met the inclusion criteria (SBRT=453; EBRT=10,535). Cohorts differed significantly by age, sex, insurance coverage, and US region. After multivariate analysis, younger age, male sex, commercial insurance, and Midwest or Northeast residence were associated with higher odds of receiving first-line SBRT (P<0.05). SBRT use decreased after 2019, while EBRT use exceeded SBRT in every study year. CONCLUSIONS:From 2010 to 2023, EBRT remained the predominant first-line radiotherapy for spinal mRCC. Higher commercial insurance rates among SBRT recipients and regional variability in SBRT use suggest that payer mechanisms and institutional variation may influence first-line SBRT use. Policy alignment with contemporary evidence and expansion of SBRT infrastructure may enhance patient access.

Abstract Introduction The nature of osseous metastases to the spine are such that patients can develop pain from spinal instability, pathologic fracture, inflammatory or nocturnal pain, and neuropathic pain from compression of neural elements. We sought to evaluate the current literature regarding pain in patients with metastatic spine disease (MSD) and develop more precise terminology to define varying pain syndromes. Methods We conducted a systematic review of pain terminology relevant to patients with MSD according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendations. Studies were reviewed for distinct classes of pain in patients with MSD. Results A total of 3515 unique citations were reviewed, which was narrowed to 54 full-text citations based on inclusion criteria. Studies were reviewed according to their mention of the International Association for the Study of Pain’s (IASP) comprehensive system to classify pain. Twenty-seven (50%) of studies mentioned IASP Group D (treatment related) pain and 18 (33.3%) describe Group A (nociceptive) pain syndromes. The authors propose that in order to characterize pain for patients with MSD, symptoms should be classified in a way that characterizes whether pain will respond to an intervention using the following framework: 1. Tumor related/ biologic, 2. Mechanical, 3. Radicular, 4. Neuropathic, and 5. Treatment related. This terminology was developed by the members of the AO Knowledge Forum Tumor international group. Conclusion The authors present an approach to nomenclature for neoplastic spinal pain which can be used to communicate the clinical status of patients with MSD between surgeons, radiation oncologists, and medical oncologists.

The management of adult spinal deformity (ASD) has evolved dramatically over the past century, transitioning from external bracing and in situ fusion to complex, technology-driven surgical interventions. This review traces the historical development of spinal deformity correction and highlights contemporary enabling technologies that are redefining the surgical landscape. Advances in stereoradiographic imaging now allow for precise, low-dose three-dimensional assessment of spinopelvic parameters and segmental bone density, facilitating individualized surgical planning. Robotic assistance and intraoperative navigation improve the accuracy and safety of instrumentation, while patient-specific rods and interbody implants enhance biomechanical conformity and alignment precision. Machine learning and predictive modeling tools have emerged as valuable adjuncts for risk stratification, surgical planning, and outcome forecasting. Minimally invasive deformity correction strategies, including anterior column realignment and circumferential minimally invasive surgery (cMIS), have demonstrated equivalent clinical and radiographic outcomes to traditional open surgery with reduced perioperative morbidity in select patients. Despite these advancements, complications such as proximal junctional kyphosis and failure remain prevalent. Adjunctive strategies—including ligamentous tethering, modified proximal fixation, and vertebral cement augmentation—offer promising preventive potential. Collectively, these innovations signal a paradigm shift toward precision spine surgery, characterized by data-informed decision-making, individualized construct design, and improved patient-centered outcomes in spinal deformity care.

STUDY DESIGN:Retrospective cohort study. OBJECTIVE:The purpose of this study was to (1) evaluate recent trends in the use of intraoperative neuromonitoring (IONM) for anterior cervical discectomy and fusion (ACDF) in the United States, (2) assess regional variations in the use of IONM, and (3) assess the association between IONM and clinical outcomes. SUMMARY OF BACKGROUND DATA:IONM is frequently used during anterior cervical procedures to mitigate the risk of neurological injury. Prior studies have demonstrated decreasing utilization of IONM in ACDFs. However, no recent studies have re-assessed these trends. METHODS:Cases of cervical myelopathy and radiculopathy that underwent ACDF from 2011 to 2021 were identified through the PearlDiver Patient Record Database. Rates of IONM were compared based on patient age, gender, income, and region. Complications, 30-day readmissions, and reimbursement rates were also assessed. RESULTS:We identified 285,939 patients undergoing isolated ACDF, with 45,943 (16.1%) of these cases using IONM. There was a significant increase in the use of IONM for ACDFs over the study period ( R2 =0.87, P <0.001). Significant regional variability was observed in the utility of IONM (Northeast; 21.2%, Midwest; 16.3%, South; 14.7%, West; 14.2%; P <0.001). Younger age and higher patient income were associated with increased utility of IONM ( P <0.001). IONM was associated with significantly higher costs but no reduction in rates of postoperative neurological complications ( P <0.001 and 0.29, respectively). CONCLUSION:This study demonstrates a significant increase in IONM utilization during ACDFs over the past decade. Considerable differences exist in IONM use concerning patient demographics, income, and geographic region, with the highest utilization in the Northeast. Notably, despite the association of IONM with over a 20% increase in reimbursement rates, its implementation was not associated with a reduction in rates of neurological complications.

INTRODUCTION: Although 90% of spine tumors develop metastases with debilitating sensorimotor complications and spinal instability, spine tumor patients have limited eligibility to participate in clinical trials and continuously lack therapeutic targets and prognostication markers of disease. Thus, there is a distinct need for molecular profiling of spine tumors. METHODS: Patients undergoing spine surgery with the Department of Neurosurgery at Duke University were consented (IRB Protocol #Pro00101198) for tissue collection. Vertebral osseous metastases and adjacent normal tissue were confirmed histologically (H&E, immunohistochemistry) and radiologically (MRI, PET, CT, and x-ray). Tissues were manually and enzymatically homogenized in serum-free media with collagenase A and DNAse I to obtain a single cell suspension. Cells were then filter sterilized, erythrolyzed, counted to determine live-death ratio, resuspended to 10-20 million cells per mL, then cryopreserved for downstream standard library preparation for single-cell sequencing using the 10X genomics platform. Downstream analysis was performed using Seurat pipeline, InferCNV analysis, and SingleR. RESULTS: P404S and PSA expression confirmed tumor was prostate in origin. Radiological imaging and H&E staining confirmed the presence of T7 osseous metastasis. Uniform manifold approximation and project (UMAP) plots identified 12 unique clusters of immune cell subpopulations between normal and tumorous vertebrae, with their own subsets of differentially expressed genes, emphasizing metabolic enzyme UDP-6-glucose-dehydrogenase (UGDH). CONCLUSIONS: We validate a protocol to generate granular single cell molecular profiling in other metastatic spine tumor cancer types. Applications of this protocol can aid in identifying cancer-specific therapeutic targets, molecular predictors of disease, and potentiate increased eligibility of patients for clinical trials.

BACKGROUND:Non-malignant primary tumors of the spine (NMPTS) patients in rural areas face unique barriers that may limit their capacity to receive optimal care. With a lower geographical distribution of neurosurgical specialists and limited healthcare infrastructure, rural NMPTS patients may receive certain treatments at a lower frequency than metropolitan patients. NMPTS We sought to examine the association between residential urbanicity, race-ethnicity, treatment patterns, and survival outcomes for cases diagnosed with NMPTS. METHODS:Cases of NMPTS diagnosed between 2004 and 2019 were identified from the Central Brain Tumor Registry of the United States (CBTRUS), a combined dataset of CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology and End Results (SEER) data. Using multivariable logistic regression, we evaluated the association between urbanicity and treatment (including surgery and radiation), adjusted for age at diagnosis, sex, and race-ethnicity. Patient-level all-cause survival data were obtained from the NPCR Survival Analytical Database (2004-2018). RESULTS:A total of 38,414 cases were identified, 33,097 of whom lived in metropolitan and 5317 of whom lived in non-metropolitan regions. Nerve sheath tumors and meningiomas were the most common tumor histopathologies across both regions, with no clinically significant difference in other histopathologies (p<0.001). There were statistically significant differences between the frequency and type of surgery received by urbanicity (p<0.001). Overall all-cause survival was significantly lower for NH Blacks residing in non-metropolitan areas when compared to NH Blacks residing in metropolitan areas (p<0.0001). CONCLUSION:Our data demonstrates significant differences in the incidence of NMPTS across both race-ethnicity and urbanicity. However, a wider analysis of all-cause mortality reveals disparities in health outcomes across both race-ethnicity and urbanicity for Black and Hispanic populations. To address the disparity in health outcomes, policymakers and health providers need to work with local communities in rural areas to improve access to equitable and quality healthcare.

BACKGROUND/OBJECTIVE:Intracranial gunshot wounds (GSW) are often fatal, with most patients dying before intervention can occur. Surgical management, when indicated, results in decreased mortality. We sought to assess the neurosurgical outcomes and economic costs of intracranial GSW. METHODS:We conducted a retrospective analysis using the longitudinal claims Truven MarketScan® database (IBM) from 2000 to 2016. Mortality was the primary outcome of interest. Complications, length of stay, and payment were secondary outcomes. Multivariable logistic and linear regression analyses were performed to assess the relationship between age, gender, insurance type, and the number of comorbidities in the outcomes measured. RESULTS:We identified 315 patients (median age 34.0 years; interquartile range (IQR)=24, 48; 32.06% female) who received craniotomy or craniectomy for intracranial GSW. Mortality occurred in 44 patients (13.97%) and 234 patients (74.29%) experienced complications. The median length of stay was 13 days (IQR=5, 25 days), and the median cost was $70,624.00 (IQR=$32,378.00; $163,437.00). Increases in the Elixhauser index by one-comorbidity increments were associated with increased length of stay (risk ratio (RR)=1.207; 95% confidence interval (CI)=1.106-1.317) and payment (RR=1.135; 95% CI=1.036-1.243). Patients with respiratory complications, excluding infection, experienced an increased risk of mortality (odds ratio (OR)=3.486; 95% CI=1.623-7.485), length of stay (RR=1.649; 95% CI=1.321-2.060), and payment (RR=2.085; 95% CI=1.652-2.631). CONCLUSIONS:Although these findings must be interpreted in the context of the limitations inherent to studies using national administrative data, the current study provides additional insight into the relationship between patient characteristics and outcomes after surgery for intracranial GSW.

Perioperative vision loss (POVL) is a devastating surgical complication that impacts both the recovery from surgery and quality of life, most commonly occurring after spine surgery. With rates of spine surgery dramatically increasing, the prevalence of POVL will increase proportionately. This scoping review aims to aggregate the literature pertinent to POVL in spine surgery and consolidate recommendations and preventative measures to reduce the risk of POVL. There are several causes of POVL, and the main contribution following spine surgery is ischemic optic neuropathy (ION). Vision loss often manifests immediately following surgery and is irreversible and severe. Diffusion weighted imaging has recently surfaced as a diagnostic tool to identify ION. There are no effective treatments; therefore, risk stratification for counseling and prevention are vital. Patients undergoing prone surgery of long duration and/or with significant expected blood loss are at greatest risk. Future research is necessary to develop effective treatments.

Background: Palliative care (PC) has been shown to benefit patients with metastatic cancer by managing symptoms, improving quality of life, and facilitating advance care planning. Despite this, PC is often misunderstood and underutilized. Objective: To deepen our understanding of PC barriers seen among the spine metastasis population. Design/Setting: Between March 2021 and August 2022, people with metastatic spine tumors (MSTs) at a multidisciplinary oncology clinic were administered a survey on PC prior to their scheduled appointment. These responses were compared with the Health Information National Trends Survey 5 (HINTS 5), which is a validated survey created by the National Cancer Institute between February and June of 2020. Chi-squared statistical analysis was used. Results: Fifty-six people with MST were compared with 3795 patients from the HINTS 5 database. People with MST reported a significantly higher baseline understanding of PC when compared with the general population (GP) (chi-squared = 34.4, p = <0.0001). People with MST had a higher frequency of disagreement with the statement "PC is equivalent with death" when compared with the GP (chi-squared = 12.8, p = 0.0124). Over 25% of the MST group reported no understanding of PC. Conclusion: MST patients are often referred to PC services due to the extreme symptom burden of their disease. Based on this study, in comparison to the GP, people with MST tended to have a more accurate and well-adjusted perception of the goals and functions of PC. Although reassuring, there remains a high proportion of patients who have no knowledge of PC, and groups erroneously associated PC with hospice status.

Spinal column tumors can be difficult to process for single-cell omic studies, given the heterogeneity in tissue. Here, we present a protocol for operating room-to-benchtop single-cell processing of clinical specimens from a prostate cancer patient. We describe steps for sample homogenization, red blood cell lysis, cryopreservation, and single-cell sequencing analysis. This protocol can be used to identify prognostic markers and therapeutic targets for patients with osseous spine metastases and better inform eligibility for clinical trials.

Study Design: Retrospective cohort study. Objective: The purpose of this study was to (1) evaluate recent trends in the use of intraoperative neuromonitoring (IONM) for anterior cervical discectomy and fusion (ACDF) in the United States, (2) assess regional variations in the use of IONM, and (3) assess the association between IONM and clinical outcomes. Summary of Background Data: IONM is frequently used during anterior cervical procedures to mitigate the risk of neurological injury. Prior studies have demonstrated decreasing utilization of IONM in ACDFs. However, no recent studies have re-assessed these trends. Methods: Cases of cervical myelopathy and radiculopathy that underwent ACDF from 2011 to 2021 were identified through the PearlDiver Patient Record Database. Rates of IONM were compared based on patient age, gender, income, and region. Complications, 30-day readmissions, and reimbursement rates were also assessed. Results: We identified 285,939 patients undergoing isolated ACDF, with 45,943 (16.1%) of these cases using IONM. There was a significant increase in the use of IONM for ACDFs over the study period (R 2=0.87, P<0.001). Significant regional variability was observed in the utility of IONM (Northeast; 21.2%, Midwest; 16.3%, South; 14.7%, West; 14.2%; P<0.001). Younger age and higher patient income were associated with increased utility of IONM (P<0.001). IONM was associated with significantly higher costs but no reduction in rates of postoperative neurological complications (P<0.001 and 0.29, respectively). Conclusion: This study demonstrates a significant increase in IONM utilization during ACDFs over the past decade. Considerable differences exist in IONM use concerning patient demographics, income, and geographic region, with the highest utilization in the Northeast. Notably, despite the association of IONM with over a 20% increase in reimbursement rates, its implementation was not associated with a reduction in rates of neurological complications.

The use of intraoperative neuromonitoring (IONM) has recently increased in popularity among spinal surgery to reduce rates of postoperative neurological complications. However, its utility has been mixed, especially in elective surgeries, due to increased healthcare spending and limited guidelines. In this study, we investigated the associations between IONM and clinical outcomes, as well as both financial and demographic factors, for patients with primary non-malignant spine tumors (PNMT) undergoing surgery. A retrospective review was performed using the PearlDiver Patient Record Database to identify cases of PNMT patients who underwent surgery from 2011 to 2021. Rates of IONM usage were compared based on patient age, sex, family income, and region. Complications and 30-day readmissions were also assessed. 5,692 patients undergoing surgery with PNMTs were identified, with 1,914 (33.6%) of these utilizing IONM. Younger age (p < 0.001) and male sex (p < 0.05) were both significantly associated with IONM usage and there was significant regional variability in utilization observed (Midwest: 33.8%; Northeast: 24.6%; South: 29.0%; West: 12.6%; p < 0.001). Among clinical outcomes, nerve injury (p < 0.001), surgical complications (p < 0.001), and 30-day readmission rates (p < 0.001) were all significantly associated with IONM usage. Both mean family income (p < 0.005) and reimbursement amounts were not clinically significant in association with IONM usage. Among patients with PNMTs, this study demonstrates significant differences in IONM usage across geographic regions, sex, and age as well as a positive association with 30-day readmission rates with use. While associations between IONM and family income have been observed previously, neither income nor reimbursement measures were clinically significant in our cohort. Given the growing usage of IONM in spinal surgeries, these results provide important insights into the utility of IONM among patients with non-malignant spinal tumors.

Background Prognostic indices for patients with brain metastases (BM) are needed to individualize treatment and stratify clinical trials. Two frequently used tools to estimate survival in patients with BM are the recursive partitioning analysis (RPA) and the diagnosis-specific graded prognostic assessment (DS-GPA). Given recent advances in therapies and improved survival for patients with BM, this study aims to validate and analyze these 2 models in a modern cohort.Methods Patients diagnosed with BM were identified via our institution's Tumor Board meetings. Data were retrospectively collected from the date of diagnosis with BM. The concordance of the RPA and GPA was calculated using Harrell's C index. A Cox proportional hazards model with backwards elimination was used to generate a parsimonious model predictive of survival.Results Our study consisted of 206 patients diagnosed with BM between 2010 and 2019. The RPA had a prediction performance characterized by Harrell's C index of 0.588. The DS-GPA demonstrated a Harrell's C index of 0.630. A Cox proportional hazards model assessing the effect of age, presence of lung, or liver metastases, and Eastern Cooperative Oncology Group (ECOG) performance status score of 3/4 on survival yielded a Harrell's C index of 0.616. Revising the analysis with an uncategorized ECOG demonstrated a C index of 0.648.Conclusions We found that the performance of the RPA remains unchanged from previous validation studies a decade earlier. The DS-GPA outperformed the RPA in predicting overall survival in our modern cohort. Analyzing variables shared by the RPA and DS-GPA produced a model that performed analogously to the DS-GPA.

Abstract BACKGROUND Given the complex nature of surgical resection and the potential for neural injury in spinal tumor surgery, the use of intraoperative neuromonitoring (IONM) could improve clinical outcomes and injury prevention in surgeries for patients diagnosed with primary malignant spine tumors (PMTs). While IONM has been growing in usage, especially during spinal procedures, its utility has been mixed due to undefined guidelines and potentially high costs. In this study, we examined trends in IONM use in surgeries for PMT patients, regional variations in IONM usage, and associations between IONM and clinical outcomes. METHODS A retrospective review was performed using the PearlDiver Patient Record Database to identify cases of PMTs that underwent surgery from 2011 to 2021. Rates of IONM usage were compared based on patient age, sex, family income, and region. Complications and 30-day readmissions were also assessed. RESULTS 4,551 patients undergoing surgery for PMTs were identified, with 1,643 (36.1%) of these utilizing IONM. Significant regional variability was observed in IONM usage (Midwest: 32.6%; Northeast: 28.1%; South: 26.4%; West: 12.5%; p < 0.001) and those using IONM were more likely to be in inpatient settings, compared to outpatient (p < 0.001). Both younger age and mean family income were associated with IONM usage (p < 0.001, p < 0.01, respectively), although, clinically insignificant. 30-day readmission rates and complication rates were significantly higher for patients undergoing PMT surgery with IONM (both p < 0.001). CONCLUSIONS This study demonstrates significant differences in IONM usage across geographic regions, sex, and operation settings among PMT patient surgeries. Differences in family income were observed to be significant but not clinically relevant. Notably, IONM was associated with higher 30-day post-operative readmission rates and complication rates. Given the increased adoption of IONM, these trends provide valuable insights in assessing its value and applicability across diverse settings.

OBJECTIVE: To analyze the extant literature describing the application of gene therapy to spinal fusion. METHODS: A systematic review of the English-language literature was performed. The search query was designed to include all published studies examining gene therapy approaches to promote spinal fusion. Approaches were classified as ex vivo (delivery of genetically modified cells) or in vivo (delivery of growth factors via vectors). The primary endpoint was fusion rate. Random effects meta-analyses were performed to calculate the overall odds ratio (OR) of fusion using a gene therapy approach and overall fusion rate. Subgroup analyses of fusion rate were also performed for each gene therapy approach. RESULTS: Of 1179 results, 35 articles met criteria for inclusion (all preclinical), of which 26 utilized ex vivo approaches and 9 utilized in vivo approaches. Twenty-seven articles (431 animals) were included in the meta-analysis. Gene therapy use was associated with significantly higher fusion rates (OR 77; 95% confidence interval {CI}: [31, 192]; P < 0.001); ex vivo strategies had a greater effect (OR 136) relative to in vivo strategies (OR 18) ( P = 0.017). The overall fusion rate using a gene therapy approach was 80% (95% CI: [62%, 93%]; P < 0.001); overall fusion rates were significantly higher in subjects treated with ex vivo compared to in vivo strategies (90% vs. 42%; P = 0.011). For both ex vivo and in vivo approaches, the effect of gene therapy on fusion was independent of animal model. - CONCLUSIONS: Gene therapy may augment spinal fusion; however, future investigation in clinical populations is necessary.

Background Traumatic thoracolumbar fracture fixation without neurological injury can be performed using the traditional open, mini-open Wiltse, and percutaneous approaches. This systematic review and meta-analysis aims to compare perioperative outcomes between these approaches. Methods PubMed, Web of Science, Scopus, Embase, and the Cochrane Library were searched for all relevant observational comparative studies. Results 5 randomized trials and 22 comparative cohort studies were included. Compared to the traditional open approach (n = 959), the Wiltse approach (n = 410) was associated with significantly lower operative time, intraoperative estimated blood loss (EBL), and length of stay (LOS). There was no significant difference between the two in terms of postoperative visual analog scale (VAS) and Cobb angle. Compared to the percutaneous approach (n = 980), the Wiltse approach was associated with shorter operative and fluoroscopy time, as well as significantly improved Cobb and vertebral body angles. The percutaneous approach was associated with improved vertebral body height. There was no significant difference between the two for blood loss, postoperative VAS, or LOS. Compared to the traditional open approach, the percutaneous approach was associated with shorter operative time, lower EBL, shorter LOS and better postoperative VAS and Oswestry Disability Index. There was no difference between the two in postoperative Cobb angle, vertebral angle, or vertebral body height. Overall study heterogeneity was high. Conclusions Utilization of minimally invasive surgical approaches holds great promise for lowering patient morbidity and optimizing care. A prospective trial is needed to assess outcomes and guide surgical decision making.

-BACKGROUND: High-energy traumatic sacral fractures, particularly U-type or AOSpine classification type C frac-tures, may lead to significant functional deficits. Tradi-tionally, spinopelvic fixation for unstable sacral fractures was performed with open reduction and fixation, but robotic-assisted minimally invasive surgical methods now present new, less invasive approaches. The objective here was to present a series of patients with traumatic sacral fractures treated with robotic-assisted minimally invasive spinopelvic fixation and discuss early experience, con-siderations, and technical challenges. -METHODS: Between June 2022 and January 2023, 7 consecutive patients met the inclusion criteria. Intra-operative fluoroscopic images were merged with intra-operative computed tomography images using a robotic system to plan the trajectories for placement of bilateral lumbar pedicle and iliac screws. Intraoperative computed tomography was performed after pedicle and pelvic screw insertion to confirm appropriate placement before insertion of rods percutaneously without the need for a side connector.-RESULTS: The cohort consisted of 7 patients (4 female, 3 male) with ages ranging from 20 to 74. Intraoperatively, the mean blood loss was 85.7 +/- 84.0 mL, and mean operative time was 178.4 +/- 63.9 minutes. There were no complications in 6 patients; 1 patient experienced both a medially breached pelvic screw and a complicated rod pullout. All patients were safely discharged to their homes or an acute rehabilitation facility.-CONCLUSIONS: Our early experience reveals that robotic-assisted minimally invasive spinopelvic fixation for traumatic sacral fractures is a safe and feasible treatment option with the potential to improve outcomes and reduce complications.