Retrospective radiographic study. Forward head posture (FHP) is commonly observed in individuals with prolonged screen exposure and may affect spinal alignment. Because the craniovertebral angle (CVA) alone does not fully capture how sagittal balance is distributed across the spine, this study evaluated head-to-pelvis sagittal alignment patterns in individuals with and without FHP, with particular attention to the upper cervical region. This study evaluated head-to-pelvis sagittal balance (SB) patterns in individuals with and without FHP using standing whole-body EOS radiographs. A total of 201 adults were referred for evaluation of low back pain (LBP) and classified into FHP and non-FHP groups using a predefined CVA threshold as a pragmatic stratification criterion. Sixteen SB parameters spanning the cranio-cervical, thoracic, lumbo-pelvic, and global regions were analysed using group comparisons, age-adjusted regression, and correlation analyses. Individuals with FHP showed greater upper cervical extension and higher values of cervical sagittal vertical axis, T1 slope, thoracic kyphosis, and global sagittal vertical axis, while lumbar lordosis and spinopelvic parameters remained comparable between groups. In non-FHP individuals, subaxial cervical alignment (C2–C7) was associated with global alignment. However, these relationships were absent in the FHP group, with correlations shifting toward the upper cervical parameters (C0-C1, C0-C2) including associations with pelvic parameters, and the T1 slope, which showed stronger associations across cervical and global alignment. These findings suggest a redistribution of sagittal alignment relationships toward the upper cervical and cervico-thoracic regions in FHP, while lumbar structural alignment remains preserved, highlighting the limitations of CVA-centric frameworks for capturing whole-spine postural adaptations.

Abstract Background and objective Vertebral hemangiomas are common benign spinal lesions. But studies of lumbar vertebral hemangiomas (LVHs) are still relatively limited. In this work, we assessed the distribution of LVHs within the study population, and explored their relationships with different categories of low back pain (LBP), pain- and health-related outcomes, and lumbar spine morphology. Methods A retrospective cross-sectional study recruited 1,021 participants with or without LBP. Magnetic resonance imaging was used to assess the location, size as well as types of LVHs. Clinical data were collected from well-designed questionnaires and clinical examination. Results LVHs were identified in 8.3% of the recruited participants, and their prevalence increased with advancing age. The prevalence of LVHs differed across back pian categories, with rates of 12.4% in intermittent LBP groups, 10.0% in chronic LBP group, and 6.3% in the no back pain group. No statistically significant associations were observed between LVHs and either intermittent LBP (OR 1.96, p = 0.061) or chronic LBP (OR 1.40, p = 0.312). Additionally, pain intensity (p = 0.401), functional impairment (p = 0.110), and quality of life (p = 0.670) did not differ significantly between the no-LVHs and LVHs groups. Across different LBP categories, no significant difference in LVHs size, type, or number were observed among participants. Following age- and sex-adjusted propensity score matching, greater lumbar disc degeneration (p = 0.004) and a trend toward a higher prevalence of Modic changes (p = 0.060) were observed in participants with LVHs. No significant differences were found in facet joint degeneration, disc herniation, spinal canal width, or Schmorl’s nodes between the LVHs and matched groups. Conclusion In our study, LVHs were not associated with differences in LBP categories or health-related indicators. Additionally, participants with LVHs showed more severe lumbar disc degeneration but no other morphological abnormalities. Level of evidence Level 3.

Study Design. Retrospective single-center cohort study. Objective. To investigate whether postoperative T4-L1PA mismatch (T4 pelvic angle minus L1 pelvic angle) predicts mechanical revision within 5 years after multilevel fusion to the upper lumbar and lower thoracic spine, versus other alignment parameters. Summary of Background Data. T4-L1PA mismatch is an established predictor of mechanical failure after upper thoracic fusion to the sacropelvis. Its value in lower thoracic spine and upper lumbar constructs remains unclear. Methods. We retrospectively analyzed 204 patients who underwent posterior spinal fusion of 3 to 10 instrumented levels (upper instrumented vertebra [UIV] T8-L3) with distal fixation to the sacrum or ilium (2006-2024). Alignment was assessed preoperatively, at the first postoperative timepoint, and at 1 year: T4-L1PA mismatch, PI-LL mismatch, sagittal vertical axis, L1PA deviation, lordosis distribution index, and distal lordosis. The primary outcome was mechanical revision within 5 years. Cox regression, ROC, Kaplan-Meier, and combined-risk analyses were performed. Results. Thirty-three patients (16.2%) underwent mechanical revision within 5 years. On first postoperative radiographs, T4-L1PA mismatch predicted revision (hazard ratio [HR] 1.10, P =0.012), as did PI-LL (HR 1.03, P =0.027). Adjusted for PI-LL, age, and levels fused, T4-L1PA remained significant (HR 1.09, P =0.028) while PI-LL did not ( P =0.070). At 1 year (n=148, 16 events), T4-L1PA had an HR of 1.17 ( P =0.001; PI-LL P =0.171). Other parameters were non-significant. Five-year cumulative revision incidence rose from 6% with neither parameter malaligned to 19% with one and 39% with both (log-rank P =0.003). Conclusions. Postoperative T4-L1PA mismatch was the most consistent alignment predictor of mechanical revision over 5 years in thoracolumbar and upper lumbar fusions (UIV T8-L3) to the sacropelvis and remained independently prognostic at 1 year, with most revisions attributable to proximal junctional failure. PI-LL contributed early risk but weakened over time. Combined assessment identified a high-risk subgroup.

To determine the correlation between quantitative HU values derived from DECT collagen maps and the MRI-based Pfirrmann grade. We retrospectively reviewed IVDs in patients who underwent both spinal DECT and MRI within one year. CT scans were acquired using single-source DECT at 80 and 135-kVp with automatic exposure control. Three readers scored IVDs according to Pfirrmann et al. on T2-weighted MRI images. Quantitative evaluation involved placing three standardized regions of interest in each IVD in DECT-based cMaps; in corresponding 135-kVp DECT scans and MRI images. Mean density measurements of AF and NP were compared with PF-grades using linear mixed model analysis. We included 339 IVDs of 97 patients [mean age 59.1 years]; (53 women [mean age 63.5 years] and 44 men [mean age 53.8 years]). cMap analysis revealed a significant difference of AF and NP collagen and chondroitin density between PF-grade I and V(AF: MD = - 31.1HU (95% CI - 59.5 to - 2.7), p = 0.032;NP:MD = - 37.8HU (95% CI - 73.6 to - 2.0), p = 0.038). 135-kVp DECT showed no IVD density reduction corresponding to PF-grades. MRI showed significant reduction of signal intensities in AF and NP with increasing PF-grades. IVD collagen and chondroitin density declined with increasing PF-grade in DECT-based cMaps, suggesting DECT-based cMaps as an additional tool for IVD classification.

Modern spine care is increasingly fragmented across operative and nonoperative disciplines, with inconsistent terminology, variable procedural standards, and uneven referral thresholds. These limitations can lead to duplicated services, delayed escalation when structural disease is present, premature escalation when operative targets are absent, and prolonged episodes of low-value care. This manuscript presents an implementation-oriented conceptual framework designed to improve transition reliability across the spine-care continuum. The framework was developed through targeted narrative synthesis of representative multisociety position statements, guideline-based procedural standards, value-oriented literature, and implementation-focused clinical policy analyses relevant to spine-care transitions. We propose four practical elements: (I) functional role definitions and accountability interfaces, with operative care anchored to biomechanics-informed accountability and rescue/revision capability, and nonoperative care anchored to evidence-based, goal-directed, time-bound care episodes; (II) explicit bidirectional handoff triggers for escalation to surgical evaluation and return to nonoperative management; (III) standardized procedural language and minimum expectations, including route-specific injection terminology, structured follow-up, and response-based repetition logic; and (IV) coordinated management of boundary-zone interventions, particularly those associated with durable biomechanical consequences or evolving evidence. This framework is intended to reduce care drift, improve safety and consistency, and support timely escalation and appropriate de-escalation. By standardizing terminology, clarifying accountability, and operationalizing bidirectional transitions, it offers a practical pathway to improve coordination, patient navigation, and value across multidisciplinary spine care.

Computer-assisted spine surgery has evolved from fluoroscopy-based techniques to advanced navigation and robotic systems. These technologies aim to improve intraoperative precision, enhance instrument guidance, and increase reproducibility of surgical workflows. Modern platforms integrate preoperative planning, intraoperative imaging, and real-time tracking to support surgical decision-making. As adoption increases, their role in clinical practice continues to be critically evaluated. This review provides an overview of the development and current state of computer-assisted and robotic spine surgery, outlining key technological principles and clinical applications. In addition, it addresses current challenges, including workflow integration, resource requirements, and limitations of existing systems. Finally, emerging developments such as automation, improved imaging integration, and data-driven approaches are discussed to contextualize the potential future impact of these technologies on spine care.

Chronic low back pain (cLBP) is a major contributor to global disability. This study examined the association between paraspinal muscle morphology and spinal mobility and alignment in individuals with and without cLBP. In this cross-sectional study, participants were prospectively recruited from the general population. Magnetic resonance imaging (MRI) was used to assess morphological characteristics, namely fatty infiltration (FI) and functional cross-sectional area (fCSA) of the multifidus (MF), erector spinae (ES), and psoas muscles at all lumbar levels individually and averaged. Lumbar mobility (flexion, extension, side-bending) was assessed with a skin surface measurement device. Associations between both parameters were evaluated using multivariable regression models adjusted for demographic, structural, and clinical confounders. 721 participants (56.9

STUDY DESIGN:Secondary analysis of a prospective cross-sectional study at an academic tertiary spine care center. OBJECTIVES:To examine the prevalence and risk factors for preoperative Vitamin D (VitD) deficiency and secondary hyperparathyroidism (SHPT), and to assess the seasonal variation of metabolic bone laboratory parameters in patients undergoing lumbar fusion surgery (LFS). SUMMARY OF BACKGROUND DATA:LFS relies on adequate connective tissue quality and bone healing capacity. VitD deficiency and SHPT significantly impact bone metabolism and are linked to lower fusion rates and poorer bone quality. However, their seasonal variation in LFS patients remains unexplored. METHODS:Patients undergoing LFS for degenerative conditions received preoperative VitD, parathyroid hormone (PTH), and bone turnover markers laboratory routinely from December 2014 to December 2023. Descriptive and comparative statistics, logistic regression, and univariable and multivariable cosinor regression models were used to evaluate VitD status, SHPT prevalence, their risk-factors and seasonal variations in VitD, PTH, and bone turnover markers. RESULTS:Data from 431 patients (49% female, median age 64 y) was analyzed. VitD insufficiency (<30 ng/mL) was observed in 34% of patients, ranging from 48% in winter to 25% in summer. SHPT was present in 24%, with winter prevalence at 28%. Surgery during winter and spring was associated with a 7.5-fold increased risk of VitD deficiency and a 2.1-fold increased risk of SHPT. Seasonal changes with peaks for VitD, PTH, and bone-specific alkaline phosphatase were observed in July, February, and November, respectively, with no significant annual variation in other bone metabolism markers. CONCLUSIONS:The prevalence of VitD deficiency and SHPT in LFS patients is high, especially during winter and spring. Seasonal variations in VitD and bone metabolism markers suggest that single-timepoint laboratory evaluations may not reflect bone metabolism throughout the year, highlighting the need for further studies investigating whether seasonal factors in preoperative assessments could affect outcomes.

STUDY DESIGN:Secondary analysis of two prospective single-center studies. OBJECTIVE:To evaluate the effectiveness of guideline-recommended osteoporosis screening age cutoffs in lumbar fusion surgery (LFS) patients and identify optimized thresholds for osteoporosis and osteopenia detection. BACKGROUND:Poor bone quality impacts lumbar fusion surgery (LFS) outcomes. Current general population screening guidelines recommend starting at 65 years for women and 70 years for men in the absence of other risk factors. This study evaluates their effectiveness and refines age-based screening strategies for LFS patients. METHODS:This post-hoc analysis included patients ≥50 years of two prospective studies enrolling patients undergoing LFS for degenerative conditions. Patients with unsuitable imaging for quantitative CT (qCT) bone mineral density measurements were excluded. Osteoporosis and osteopenia status was determined by medical history and qCT in all patients. Uni- and multivariable logistic regression and ROC analysis to optimize age cut-offs for BMD screening were performed. The number needed to screen (NNS) for age cut-offs to detect one case was calculated. RESULTS:Among 515 patients (56% female, median age 66 years), impaired bone quality was present in 70%. Osteoporosis was found in 34%, with 38% of cases previously undiagnosed. Age was the only significant risk factor for low BMD for both sexes. Guideline age cutoffs yielded a sensitivity of 78% in females (NNS 1.8) and 58% in males (NNS 2.4) for osteoporosis and 68% (NNS 1.2) and 39% (NNS 1.2), respectively, for impaired bone status. Sensitivity-optimized screening for osteoporosis required lowering the age threshold to 58 for men (NNS 4) and 62 for women (NNS 2). Screening all patients for impaired bone status had an NNS of 1.4. CONCLUSIONS:General population age cutoffs inadequately detect osteoporosis in LFS patients. We propose individualized osteoporosis screening with sensitivity-optimized age thresholds and osteopenia screening for higher-risk procedures in patients aged ≥50 years.

Isthmic lumbar spondylolisthesis (ILS) results from a defect of the pars interarticularis, leading to anterior vertebral displacement. We hypothesize that paraspinal muscle atrophy contributes to the degree of vertebral slippage in symptomatic ILS. This retrospective cross-sectional study included 78 patients (46 females, 32 males). Fat infiltration (FI) and height-adjusted functional cross-sectional area (HI) of the multifidus (MF), erector spinae (ES), and psoas (PS) muscles were quantified applying the Otsu thresholding method. Multivariable linear regression was used to analysis the association between the paraspinal musculature and vertebral slippage. Confounding variables such as sex, age, body mass index (BMI), disc (Pfirrmann classification) and facet joints degeneration (Weishaupt classification) were included. The median age was 48.5 (interquartile range [IQR]: 31.5–55) years, median BMI was 26.4 (IQR: 22.8–29.4) kg/m², and the median translation was 33 (IQR: 24–47)

Even though adult degenerative scoliosis (ADS) is an increasingly relevant pathology in the aging spine, its pathophysiology has yet to be fully understood. As some previous studies have shown degeneration of the paraspinal muscles to be associated with ADS, this study aimed to examine side-specific degeneration of the erector spinae (ES), multifidus (MF), and psoas (PS) along the concave and convex aspects of the curvature. This retrospective study included patients with adult degenerative scoliosis (Cobb > 10°) and a defined apex at L3 who underwent spinal fusion surgery of at least 2 levels at a tertiary academic center. Paraspinal muscle morphology was assessed on preoperative axial T2-weighted MRIs, including fatty infiltration (FI) and height-adjusted functional cross-sectional area (fCSA). Measurements were performed bilaterally from L1/2 to L5/S1 using standardized segmentation and Otsu thresholding. Spinopelvic parameters, including Cobb angle, sagittal vertical axis (SVA), lumbar lordosis (LL), and sacral slope (SS), were measured on standing radiographs. Differences between the concave and convex sides were assessed using Wilcoxon signed-rank tests. Associations with spinopelvic alignment were analyzed using multivariable linear regression adjusted for age, sex, and BMI. A total of 51 patients with median age of 82 (IQR 72 – 85) and 70.6

DesignRetrospective study.ObjectiveTo evaluate the predictive performance of a simplified, MRI-derived vertebral bone quality score (VBQ) using measurements at L1/2 (VBQL1/2) for opportunistic bone quality screening, compared to the established VBQL1-4.MethodsIn patients undergoing lumbar surgery for degenerative spondylolisthesis, VBQL1/2 was assessed using circular regions of interest on sagittal T1-weighted sequences in L1 and L2, while VBQL1-4 included measurements from L1 through L4. Measurements were normalized to cerebrospinal fluid intensity at L2/3. Bone mineral density (BMD) was measured by opportunistic qCT, with osteoporosis defined as BMD < 80 mg/cm3 and impaired bone quality (osteoporosis or osteopenia) as BMD < 120 mg/cm3. Agreement between VBQL1/2 and VBQL1-4 was determined using the intraclass correlation coefficient (ICC), and predictive performance was evaluated using receiver operating characteristic analysis with Youden's index optimization.ResultsAmong 144 patients included ((39% male, n = 56) the median age was 69 years (interquartile range 64-67). Osteopenia was present in 47% and osteoporosis in 22%, yielding 69% impaired bone quality. VBQL1/2 and VBQL1-4 showed excellent agreement (ICC: 0.988, 95% CI: 0.982-0.991). Predictive performance was comparable for osteoporosis (AUC: VBQL1/2 0.71 vs. VBQL1-4 0.69) and impaired bone quality (AUC: 0.68 vs. 0.67). For osteoporosis detection, VBQL1/2 showed a higher sensitivity (94% vs 71%) but a lower specificity (45% vs 64%), as well as for detecting impaired bone quality (sensitivity 77% vs. 47%, 56%, vs 82%).ConclusionsVBQL1/2 offers a simplified alternative to VBQL1-4 for MRI-based bone quality assessment. Further validation and threshold refinement are warranted.

Background/Objectives: Sagittal spinal alignment is a key determinant of function and quality of life in degenerative spinal disorders. While age is an established determinant of sagittal balance, the independent contribution of BMI remains insufficiently characterized, particularly in degenerative scoliosis cases. This study aimed to investigate the association between BMI and sagittal alignment, quantify its effect relative to age, and explore potential sex-specific differences. Methods: This retrospective single-center study included 293 adults with degenerative scoliosis who underwent standing full-spine EOS imaging. Multivariable linear regression models assessed the association between BMI and sagittal vertical axis (SVA), adjusting for age, sex, diabetes mellitus, and osteoporosis. Secondary analyses examined associations with coronal deformity (Cobb angle) and lumbar degeneration (Wilke score). Sex-stratified analyses and Receiver Operating Characteristic (ROC) analyses for sagittal decompensation were also performed. Results: The cohort had a median BMI of 26.2 kg/m2 (56% female; median age 71 years). Median SVA measured 56.4 mm (interquartile range 30.6-87.1), and 58% of patients exhibited sagittal decompensation. In sex-stratified analyses, higher BMI was independently associated with greater SVA in women (p = 0.015), whereas no significant association was observed in men (p = 0.061). ROC analysis demonstrated limited overall discrimination; however, a BMI ≥ 35 kg/m2 showed high specificity and positive predictive values exceeding 80% for sagittal decompensation. Conclusions: BMI is independently associated with sagittal alignment in degenerative scoliosis and contributes to sagittal decompensation to a degree comparable to age. These findings suggest that body weight represents a clinically relevant biomechanical factor that should be considered alongside age and spinopelvic parameters when interpreting sagittal alignment, although BMI's limited discriminatory performance for sagittal decompensation precludes its use as a standalone screening tool.

Background: ChatGPT is a large language model (LLM) online chatbot developed by OpenAI and launched in November 2022. Early adoption studies have shown high readiness to use this technology for health-related questions and self-diagnosis. However, the quality and clinical adequacy of health-related responses remain incompletely characterized. This study aimed to explore responses generated by ChatGPT-3.5 and ChatGPT-4.0 to common patient questions regarding scoliosis. Methods: Ten scoliosis-related frequently asked questions (FAQs) were selected from a larger pool of over 250 patient-facing questions compiled from 17 publicly available FAQ webpages and informed by a Google Trends analysis. Questions were harmonized, grouped by theme, and then reduced by rule-based expert review to a final set intended to represent common patient concerns. Results: The median ratings of ChatGPT-3.5 and ChatGPT-4.0 responses ranged from satisfactory, requiring minimal (2) to moderate clarification (3). Across the ten matched questions, no statistically detectable difference was found between models in this study setting (W = 8.0, p = 0.59; Cliff's δ = -0.12 [95% CI -0.58, 0.40]); however, given the small question set, unblinded rating process, and poor inter-rater reliability, this should not be interpreted as evidence of equivalence, non-inferiority, or comparable model performance. The results apply only to the 10-15 April 2024, online snapshots of ChatGPT-3.5 and ChatGPT-4.0 and should not be generalized to later model iterations. Conclusions: This study should be interpreted as a clinically oriented observational report, intended to inform physician awareness and patient-physician communication rather than validate chatbot accuracy or safety. In this 10-15 April 2024, sample, both model outputs frequently required clinician clarification. Given the small FAQ set, low inter-rater reliability, unblinded design, and single-sample outputs, the findings do not establish equivalence or superiority and apply only to the specific 10-15 April 2024, model snapshots and evaluated questions.

Introduction:Degenerative lumbar spondylolisthesis (DLS) is a major indication for lumbar surgery. Surgical decision-making, particularly regarding the need for fusion, often depends on radiographic detection of segmental instability. Flexion-extension (FE) radiographs remain the reference standard but are limited by radiation exposure, motion-related discomfort, and poor reproducibility, whereas upright-supine (US) imaging - combining upright lateral radiographs with supine MRI - may offer a comparable, low-radiation alternative using routinely acquired images. Research question:To compare segmental motion at L4/5 between FE and US imaging and evaluate their respective abilities to identify patients with radiographic signs of instability. Material and methods:In this retrospective cross-sectional study, 128 patients surgically treated for isolated L4/5 DLS were included. Segmental motion was analyzed using FE and US imaging by determining relative slippage, dynamic slip angle, and radiographic instability, defined as sagittal translation ≥8% and/or a dynamic slip angle ≥10°. Results:Relative slippage was comparable between US and FE imaging (US: 7.43 ± 5.10%; FE: 7.29 ± 4.57%; p = 0.994). The dynamic slip angle was significantly higher in US imaging compared to FE imaging (US: 6.42 ± 4.20°; FE: 4.03 ± 2.98°; p < 0.001). US imaging identified more patients with radiographic signs of instability compared to FE imaging (US: n = 68, 53.1%; FE: n = 42, 32.8%; p < 0.001). Discussion and conclusion:US imaging identified a higher proportion of patients meeting established thresholds for radiographic instability compared to FE radiographs. Although FE imaging remains the diagnostic standard, US imaging may offer a practical, low-radiation alternative for preoperative assessment. Prospective investigations are warranted to confirm its clinical utility.

Introduction:Bone quality is crucial for satisfactory spinal surgery outcomes. Abdominal aortic calcification (AAC) has been linked to lower bone mineral density (BMD) and increased fracture risk, but its association with bone microarchitecture and extracellular matrix (ECM) quality remains underexplored. Research question:Is AAC independently associated with bone quality beyond BMD in patients undergoing lumbar fusion surgery? Material and methods:In 139 patients undergoing lumbar fusion surgery, AAC was evaluated on lateral lumbar radiographs using the Kauppila score. BMD was measured by quantitative CT, and iliac crest biopsies were analyzed by micro-CT for microarchitecture and by Fourier-transform infrared imaging (FTIRI) for ECM parameters. Associations were examined using correlation and multivariable regression analyses adjusted for BMD or confounders (age, sex, BMI, smoking, diabetes). Results:Higher AAC severity correlated with lower BMD (r = -0.37, p < 0.001), higher trabecular (r = 0.40, p < 0.001) and cortical tissue mineral density (TMD) (r = 0.29, p = 0.001), lower cortical mineral maturity/crystallinity (MMC, r = -0.26, p = 0.003), and greater cortical (r = 0.27, p = 0.002) and trabecular (r = 0.24, p = 0.005) MMC heterogeneity. In multivariable models, AAC remained independently associated with lower BMD (p = 0.001), higher trabecular TMD (p = 0.02), and higher trabecular MMC heterogeneity (p < 0.001). Discussion and conclusion:Preoperative AAC assessment could be representative for altered bone quality characteristics independently of BMD. Accordingly, AAC scoring could refine preoperative risk assessment and trigger osteologic workup to mitigate complication risk in spinal fusion surgery.

In adolescent idiopathic scoliosis (AIS), the choice of upper and lowest instrumented vertebrae and related complications remain debated. Bone quality is a relevant factor in this context. The vertebral bone quality (VBQ) score has recently been proposed as a radiation-free magnetic resonance imaging (MRI)-based measure of bone quality. However, the role of the VBQ score in AIS and its relationship with the severity of scoliosis characteristics has not yet been explored. We hypothesize that the VBQ score is associated with key features of AIS, including curve type, Cobb angle, lumbar modifier, and thoracic kyphosis. This retrospective study included AIS patients who underwent posterior spinal fusion between 2011 and 2025 at a university hospital. The lumbar VBQ score was determined using preoperative MRI, and the Lenke classification was assessed based on preoperative radiographs. To ensure comparability, curve types were categorized based on the flexibility of the lumbar curvature into non-structural (Lenke types 1 and 2) and structural (Lenke types 3 to 6) groups. The association between VBQ and curve type, Cobb angle, lumbar modifier, and thoracic kyphosis—while considering MRI field strength, age, sex, and body mass index (BMI)—was analyzed using multiple linear regression analyses. This single-center study included 60 patients (male: 15

BACKGROUND AND OBJECTIVE:Chronic low back pain (CLBP) is clinically heterogeneous and generates substantial symptom burden, functional limitation, psychological distress, work disability, and health-care utilization. Existing phenotyping approaches often describe subgroups but do not specify how subgroup assignment changes routing, conservative-care dose, imaging, interventional escalation, surgical evaluation, or outcome monitoring. The objective of this narrative review was to define operational phenotyping as a practical method for developing routable, auditable spine-care pathways and to distinguish this methodology from descriptive subgrouping, Subgroups for Targeted Treatment Back Screening Tool (STarT Back)-style risk stratification, and machine-learning phenotyping. METHODS:We conducted a narrative review using structured methods. PubMed/MEDLINE was the primary database, supplemented by Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus/Web of Science when available, guideline and trial-registry review, and reference-list screening. Searches covered January 2000 through January 2026. Studies were synthesized using an Inputs-Decision-Pathway-Outcome (IDPO) framework. The Berlin deep-phenotyping program was used as a contextual exemplar of multidomain measurement, not as evidence of treatment efficacy. KEY CONTENT AND FINDINGS:The synthesis yielded five operational findings. First, phenotype labels are implementation-ready only when linked to explicit pathway decisions. Second, minimal universal inputs should be separated from targeted add-ons. Third, escalation gates require illustrative thresholds and safety overrides rather than open-ended care drift. Fourth, diagnostic procedures, including diagnostic medial branch blocks, may themselves define a pain generator phenotype and should not be treated only as downstream treatment. Fifth, surgical referral should be framed as entry into shared decision-making evaluation rather than an automatic indication for surgery. CONCLUSIONS:Operational phenotyping is best understood as a methodology for developing a field guide rather than a completed field guide for all settings. It translates deep phenotyping and stratified-care concepts into locally deliverable pathways by requiring the same four elements for each phenotype: feasible inputs, explicit decision logic, an actionable pathway, and measurable outcomes.

Background/Objectives: Total en bloc spondylectomy (TES) remains one of the most invasive and selectively used procedures in spine oncology. Its role has become more selective in the modern era of stereotactic body radiotherapy, separation surgery, targeted systemic therapy, immunotherapy, and multidisciplinary cancer care. This study evaluated long-term survival, imaging-defined systemic disease burden, operative morbidity, patient-reported outcomes, and frailty-related variables after TES in a rare single-center cohort, with the goal of identifying selection-relevant survival and treatment-burden signals rather than developing a validated decision algorithm. Methods: We performed a retrospective single-center cohort study of consecutive adults who underwent TES for spinal tumors between 2011 and 2022. Of the 36 screened patients, 30 had sufficient clinical and survival data for analysis; patients without reliable survival or last-contact data were not included. Contrast-enhanced CT and PET-CT were reviewed for extraspinal metastases, lymphadenopathy, pleural effusion, and soft-tissue extension. Survival was analyzed using Kaplan-Meier methods, log-rank testing, and exploratory univariate Cox regression. Patient-reported outcomes included the Oswestry Disability Index (ODI) and SF-36 when available; frailty was summarized with the modified frailty index-5 (mFI-5) when component data were present. Results: The cohort included 13 men and 17 women with a mean age of 54.8 ± 15.2 years. At final follow-up, 18 patients had died, and 12 were alive. Five-year overall survival was approximately 76% in the full cohort. Extraspinal metastases were present in 72.2% of deceased patients compared with 8.3% of survivors and showed the clearest exploratory association with increased mortality (HR 3.46, 95% CI 1.23-9.78; p = 0.019). Metastatic disease demonstrated inferior survival compared with primary bone or soft-tissue tumors. Perioperative blood loss and transfusion burden were substantial but were not associated with survival in univariate analysis. ODI and SF-36 data were available only in small subsets and were therefore interpreted as descriptive signals of treatment burden. Conclusions: TES remains relevant in modern spine oncology, but only as an increasingly selective intervention. In this rare cohort, systemic disease burden, particularly extraspinal metastases, was the clearest selection-relevant survival signal, while blood loss, transfusion requirements, complications, and limited patient-reported outcomes illustrated substantial treatment burden. These findings do not establish a validated selection algorithm but support a contemporary decision threshold that integrates tumor biology, systemic disease status, anticipated margins, physiologic reserve, operative morbidity, and patient goals.