Spine[JOURNAL]
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200 papers
Instability in Spinal Infection: Evaluating the Predictive Value of the Spinal Instability Spondylodiscitis Score (SISS).
Neuhoff J, Thavarajasingam SG, Sutherland R … +8 more , McCaughan H, Abdelmaksoud A, Shiban E, Davies B, Kandziora F, Ringel F, Demetriades AK, Kramer A
Spine (Phila Pa 1976) · 2026 Jun · PMID 42202104 · Publisher ↗
STUDY DESIGN: Retrospective observational cohort study. OBJECTIVE: Evaluating the predictive value of the Spinal Instability Spondylodiscitis Score (SISS) for radiologic progression in conservatively treated patients and...
STUDY DESIGN: Retrospective observational cohort study. OBJECTIVE: Evaluating the predictive value of the Spinal Instability Spondylodiscitis Score (SISS) for radiologic progression in conservatively treated patients and its association with functional outcomes in both treatment groups. SUMMARY OF BACKGROUND DATA: The SISS was developed to assess spinal instability in spondylodiscitis and assist in treatment decisions. However, its ability to predict radiologic and functional outcomes has not been validated. METHODS: A total of 176 patients diagnosed with primary pyogenic spondylodiscitis at two centers in Germany and the UK were included. Clinical data, imaging studies, and outcomes were retrospectively collected. SISS scores were calculated pretreatment based on MRI/CT imaging. Functional outcomes were measured using the modified Rankin Scale (mRS). Radiologic progression was assessed in conservatively treated patients. Predictive value analyses, correlation, and multivariate regression were conducted to assess the relationship between SISS and both radiologic and clinical outcomes. RESULTS: On the basis of SISS, patients were classified as stable (14.77%), potentially unstable (44.89%), and unstable (40.34%). In conservatively treated patients (n=54), the "SISS_unstable" category showed moderate predictive value for deformity progression (PPV and NPV both 77.8%, sensitivity 41.2%, specificity 94.5%, AUC=0.68). Vertebral destruction >50% was the strongest predictors of radiologic progression. At a mean follow-up of 121 days correlation between initial SISS scores and unfavorable clinical outcomes (mRS 4-6) was weak (r=0.201, P = 0.002). In multivariate analysis, age, neurological deficits at admission, and systemic inflammatory response syndrome (SIRS) were stronger predictors of poor outcomes, while SISS classification was not significant. DISCUSSION: Patients triaged as "unstable" were very likely to show radiologic progression, indicating a fair predictive value of the score for spinal deformity. However, instability itself did not correlate with functional outcomes. These findings suggest that instability alone may not capture the multifactorial nature of outcome in spinal infections, but must be interpreted with caution due to small subgroup sizes and the use of a global, less granular outcome measure. Future research should focus on integrating broader patient factors to support clinical decision-making in spondylodiscitis.
Coronal Plane Correction in Adults with Patient-Specific Rods.
Sater A, Ho A, Koshak C … +4 more , Noshchenko A, Burger E, Ou-Yang DC, Kleck CJ
Spine (Phila Pa 1976) · 2025 Nov · PMID 42188460 · Publisher ↗
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate radiographic and patient-reported outcomes of adult spinal deformity (ASD) correction using patient-specific rods (PSRs), with emphasis on coronal alignmen...
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate radiographic and patient-reported outcomes of adult spinal deformity (ASD) correction using patient-specific rods (PSRs), with emphasis on coronal alignment. SUMMARY OF BACKGROUND DATA: While the sagittal plane has long been the primary focus in ASD correction, coronal malalignment contributes significantly to pain, disability, and mechanical complications. PSRs have demonstrated utility in improving sagittal alignment, but their impact on coronal deformities remains under-investigated. METHODS: We retrospectively analyzed 118 patients who underwent thoracolumbar or lumbar fusion with UNiD™ PSRs at a single academic center (2014-2021). Inclusion criteria required preoperative radiographic evidence of scoliosis (Cobb angle ≥10°) or coronal imbalance (C7 plumb line deviation ≥30 mm). Radiographic parameters-including maximal coronal Cobb angle, absolute C7PL deviation, sagittal vertical axis (SVA), lumbar lordosis (LL), and pelvic tilt (PT)-as well as patient-reported outcomes (Oswestry Disability Index [ODI] and Numeric Rating Scale [NRS] for back and leg pain) were collected pre- and postoperatively. Patients were followed up to 2 years. Complications and reoperations were documented. Paired t-tests and multivariate regression analyses assessed changes and predictors of postoperative alignment. RESULTS: Preoperative maximal coronal Cobb angle improved from 35.0° to 18.0° postoperatively (P <0.0001). SVA decreased from 62.9 mm to 28.6 mm (P <0.0001). ODI improved from 21.1 to 13.6 and NRS decreased from 6.1 to 2.3 at 9-12 months (both P <0.0001). Coronal correction did not correlate with increased rates of dural tears or blood loss >2500 mL. Reoperation rate due to hardware-related complications was 9.3%. CONCLUSIONS: Significant improvements in coronal and sagittal alignment were observed following surgery incorporating PSRs, along with reductions in disability and pain. These findings demonstrate adequate coronal correction while maintaining sagittal alignment; however, causality cannot be inferred in this retrospective series.
Instrumented vs Non-Instrumented Fusion for Elderly Patients with Lumbar Spondylotic Conditions: A Causal Inference Analysis.
Striano BM, Holly KE, Mukorombindo T … +4 more , Enchill ZA, Cronin PK, Schoenfeld AJ, Kang JD
Spine (Phila Pa 1976) · 2026 May · PMID 42184409 · Publisher ↗
STUDY DESIGN: Retrospective study using causal inference techniques. OBJECTIVE: To apply causal inference techniques and a single-surgeon study design to more effectively address confounding by indication inherent to pri...
STUDY DESIGN: Retrospective study using causal inference techniques. OBJECTIVE: To apply causal inference techniques and a single-surgeon study design to more effectively address confounding by indication inherent to prior research on instrumented vs non-instrumented fusion in elderly patients. We hypothesized that non-instrumented fusion would be associated with lower rates of reoperation at two years. SUMMARY OF BACKGROUND DATA: There has been renewed interest in non-instrumented approaches in the context of payment reform and increased sensitivity to the impact of high intensity surgery on elderly patients and those with frailty. Previously published randomized trials on instrumented vs non-instrumented procedures are not informative for elderly individuals and those with frailty. METHODS: We identified individuals 65 and older who received instrumented, or non-instrumented, decompression and fusion for degenerative lumbar indications in a single surgeon practice. The primary outcome was reoperation within two years of surgery. The primary predictor was instrumented versus non-instrumented fusion. To account for confounding by indication in the decision to use instrumentation, we used propensity-score weighting that accounted for age, biologic sex, body mass index, co-morbidities, the number of levels decompressed and the number of levels fused. RESULTS: This study included 248 patients; 181 who underwent instrumented fusion and 67 who received non-instrumented fusion. Following propensity-score weighting, non-instrumented fusion was significantly associated with increased odds of reoperation (OR 1.83; 95% CI 1.05, 3.25; P=0.04). When limiting consideration to reoperations performed for mechanical failure, adjacent segment degeneration or symptom recurrence/incomplete resolution there was no significant difference in reoperation (OR 0.86; 95% CI 0.39, 1.84; P=0.69). CONCLUSIONS: When accounting for selection and indication bias, instrumented fusion results in a significantly lower rate of reoperation even in those with more advanced age and frailty. We believe that the use of instrumentation represents the preferred approach when fusion is indicated except in rare situations. LEVEL OF EVIDENCE: III.
Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) to Prevent Symptomatic Pseudarthrosis in Posterolateral Lumbar Fusion: A Break-Even Cost-Effective Analysis.
Martinazzi BJ, Mathew J, Farooqi A … +17 more , Lee Y, Dalton J, Ng M, Toci GR, Henry TW, Giakas A, Green W, Baek G, Hitchner M, Eichbaum Y, Cha TD, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Rihn JA, Kepler CK
Spine (Phila Pa 1976) · 2026 May · PMID 42184396 · Publisher ↗
STUDY DESIGN: A break-even cost-effective analysis. OBJECTIVE: To evaluate the cost-effectiveness of recombinant human bone morphogenetic protein-2 (rh-BMP-2) for preventing symptomatic pseudarthrosis requiring revision...
STUDY DESIGN: A break-even cost-effective analysis. OBJECTIVE: To evaluate the cost-effectiveness of recombinant human bone morphogenetic protein-2 (rh-BMP-2) for preventing symptomatic pseudarthrosis requiring revision surgery in posterolateral lumbar fusion. SUMMARY OF BACKGROUND DATA: Spinal fusion rates differ across surgical techniques and are influenced by approach, graft selection, and patient factors. Although rh-BMP-2 has been shown to improve fusion rates, its widespread use remains limited by high upfront costs and uncertainty regarding cost-effectiveness. METHODS: A break-even analysis framework was used to determine the absolute risk reduction (ARR) in symptomatic pseudarthrosis required for rh-BMP-2 to be cost-effective. Model inputs were derived from published literature and included low (2%) and high (15%) baseline symptomatic pseudarthrosis rates requiring revision surgery, rh-BMP-2 costs before and after surgeon cost awareness, and two-year costs of treating pseudarthrosis using combined direct and indirect cost models. Base-case and one-way sensitivity analyses were performed to assess the impact of baseline pseudarthrosis risk, rh-BMP-2 cost, revision surgery cost, and surgeon cost awareness, defined as adjusting rhBMP-2 dosages to reduce surgical costs. Break-even number needed to treat (NNT) values were calculated. RESULTS: Rh-BMP-2 was cost-effective only at high baseline symptomatic pseudarthrosis rates across both cost models. Using surgical-only revision costs, rh-BMP-2 was cost-effective at high baseline pseudarthrosis rates with an ARR of 14.32% (NNT = 7) prior to surgeon cost awareness and 7.89% (NNT = 13) after cost awareness. At low baseline pseudarthrosis rates, rh-BMP-2 was not cost-effective regardless of product cost. Sensitivity analyses demonstrated that surgeon cost awareness and higher revision costs expanded scenarios in which rh-BMP-2 was cost-effective. CONCLUSION: Rh-BMP-2 is most likely to be cost-effective in posterolateral lumbar fusion among patients with a high baseline risk of pseudarthrosis, particularly with substantial revision costs and surgeon cost awareness. These findings support a selective, risk-stratified approach to rh-BMP-2 utilization. LEVEL OF EVIDENCE: III.
Letter to the Editor. Validation of a surgical timing threshold for spinal cord CH.
Mo F, He S
J Neurosurg Spine · 2026 May · PMID 42172675 · Publisher ↗
Abstract loading — click title to view on PubMed.
Performance comparison between a deep learning model and spine surgeons in detecting cervical spinal cord compression on radiographs.
Chen R, Liang M, Zhang Y … +11 more , Liu X, Wang T, Wang A, Fan N, Yuan S, Du P, Ma Z, Xi Y, Gu Z, Fei Q, Zang L
J Neurosurg Spine · 2026 May · PMID 42172670 · Publisher ↗
OBJECTIVE: This study aimed to develop a deep learning (DL) model for the detection of cervical spinal cord compression on cervical radiographs and compare its performance with spine surgeons. METHODS: The authors conduc...
OBJECTIVE: This study aimed to develop a deep learning (DL) model for the detection of cervical spinal cord compression on cervical radiographs and compare its performance with spine surgeons. METHODS: The authors conducted a retrospective study on consecutive hospitalized patients who underwent cervical spine radiography and MRI at their center. Data from 600 patients were randomly divided into the training (n = 480), validation (n = 60), and internal test (n = 60) sets. Additionally, patients from another center were included as an external test set (n = 60). MR images were used as the gold standard for determining the presence of cervical segmental compression. The model was trained on cervical radiographs, where a segmentation-based localization algorithm was first developed to identify cervical segments, followed by a binary classification to diagnose spinal cord compression. Furthermore, the gradient-weighted class activation mapping (Grad-CAM) was used to visualize the area with high feature densities extracted by the model. Model performance was evaluated based on accuracy, sensitivity, specificity, F1 score, and area under the receiver operating characteristic curve (AUC), and compared to the diagnoses of two spine surgeons. RESULTS: In the internal test set, the model achieved 94.67% accuracy and an AUC of 0.9911, significantly outperforming the two spine surgeons (69.09% and 71.18% accuracy, p < 0.05). In the external test set, the model achieved 93.33% accuracy with an AUC of 0.9868. Compared to the reference standard, the kappa coefficients for the model, reader 1, and reader 2 were 0.893, 0.378, and 0.422, respectively. Grad-CAM showed high feature density in the intervertebral discs, intervertebral foramina, and facet joints. CONCLUSIONS: The DL model developed in this study achieved binary classification of cervical spinal cord compression and localized the affected segments on cervical radiographs, demonstrating superior diagnostic performance to that of spine surgeons. This DL model ensures high detection rates for cervical spinal cord compression and holds promise for clinical diagnosis, particularly in resource-limited or remote settings.
Effect of same-day physical therapy on length of hospital stay and discharge disposition following single-level lumbar fusion.
Ogura Y, Nakatsuka M, Ogelle K … +4 more , Maglaras C, Protopsaltis T, Raman T, Goldstein J
J Neurosurg Spine · 2026 May · PMID 42172669 · Publisher ↗
OBJECTIVE: The aim of the study was to evaluate the safety and efficacy of initiating physical therapy (PT) on the day of surgery (i.e., postoperative day 0 [POD0]) in patients undergoing single-level lumbar fusion surge...
OBJECTIVE: The aim of the study was to evaluate the safety and efficacy of initiating physical therapy (PT) on the day of surgery (i.e., postoperative day 0 [POD0]) in patients undergoing single-level lumbar fusion surgery, with a focus on hospital length of stay (LOS) and early postoperative outcomes. METHODS: The authors conducted a retrospective review of prospectively collected data from a single institution. Patients undergoing single-level lumbar fusion between August 2022 and December 2024 were included. Those with revision surgery, tumors, or infections were excluded. POD0 PT was implemented in January 2024. Patients treated prior to this date received POD1 PT. Demographic, surgical, and postoperative data were compared between the POD0 and POD1 PT groups. RESULTS: A total of 586 patients were analyzed (POD0, n = 84; POD1, n = 502). Baseline demographics and surgical characteristics were similar between the groups. The POD0 group had a significantly shorter LOS (mean 3.4 ± 1.6 vs 4.0 ± 2.7 days, p = 0.016), and the patients were more likely to be discharged home. No significant differences were found in postoperative complications, including cardiac, pulmonary, neurological, gastrointestinal, urinary, infectious, or mechanical issues. Rates of 30- and 90-day emergency department visits, readmissions, or reoperations were also comparable between the groups. CONCLUSIONS: Initiating PT on the day of surgery is associated with reduced LOS and an increased likelihood of home discharge, without increasing complications or worsening clinical outcomes. These findings support the safety and potential benefits of POD0 PT in enhancing early recovery following single-level lumbar fusion surgery.
The Clinical Usefulness of Bone Maturity Indicators for Bracing Adolescents with IdiopathicScoliosis: Signs Along the Road While Driving in a "Heavily Foggy Night".
Negrini S, Zaina F
Spine (Phila Pa 1976) · 2026 May · PMID 42166650 · Publisher ↗
Abstract loading — click title to view on PubMed.
Longer Symptom Duration Is Associated With Worse Absolute Outcomes but Similar MCID Achievement After ACDF.
Ng M, Baek G, Lee Y … +13 more , Hitchner M, Eichbaum Y, Green WA, Mathew J, Dalton J, Giakas A, Baidya J, Mastrokostas PG, Hilibrand A, Vaccaro A, Cha T, Schroeder G, Kepler C
Spine (Phila Pa 1976) · 2026 May · PMID 42166639 · Publisher ↗
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare clinical outcomes and patient-reported outcome measures between patients with preoperative symptoms greater than or less than 12 months undergoing primary a...
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare clinical outcomes and patient-reported outcome measures between patients with preoperative symptoms greater than or less than 12 months undergoing primary anterior cervical discectomy and fusion (ACDF) for the indication of radiculopathy. SUMMARY OF BACKGROUND DATA: While ACDF is a well-established treatment for cervical radiculopathy, the impact of preoperative duration of symptoms (DOS) on postoperative recovery remains unclear. Prior lumbar and myelopathy studies suggest longer DOS correlates with poorer outcomes, but data regarding isolated cervical radiculopathy remains inconclusive. METHODS: Adult patients undergoing elective primary ACDF for radiculopathy between 2014 and 2020 were identified. Patients with incomplete preoperative or 1-year postoperative PROMs were excluded. Patient demographics, preoperative nonoperative treatment, surgical characteristics, and clinical outcomes were collected from patient charts. PROMs, including SF-12, VAS Neck/Arm, mJOA, and NDI, were assessed preoperatively and at 3, 6, and 12 months postoperatively. MCID achievement was determined using pre-established thresholds. Patients were divided into two cohorts: DOS <1 year and DOS >1 year. RESULTS: Of 170 patients, 107 (62.9%) had symptoms <1 year, and 63 (37.1%) had symptoms >1 year. Cohorts were comparable at baseline. The DOS >1 year cohort had a greater proportion of patients who received preoperative epidural steroid injections (58.7% vs. 41.1%, P=0.039). Postoperatively, there were no significant differences in rates of inpatient complications, including dysphagia, LOS, readmissions, or reoperations. While the <1-year cohort achieved higher absolute scores in MCS, PCS, and mJOA at 12 months, the rates of achieving MCID for all PROMS were comparable between groups. CONCLUSION: Although patients with shorter symptom duration may reach higher absolute PROM scores at one year, both groups experienced similar rates of clinical improvement and MCID achievement. A delay in surgical intervention for isolated radiculopathy may not adversely affect the patient's perceived benefit of the procedure.
Development and Validation of a Predictive Model Incorporating Paravertebral Muscle Quality for Progressive Kyphosis After Percutaneous Kyphoplasty: A Retrospective Cohort Study.
Li X, Liu L, Xie Z … +4 more , Tao Y, Li X, Fan P, Wang Y
Spine (Phila Pa 1976) · 2026 May · PMID 42166634 · Publisher ↗
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate risk factors for progressive kyphosis (PK) following percutaneous kyphoplasty (PKP) and develop a validated nomogram for individualized risk prediction....
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate risk factors for progressive kyphosis (PK) following percutaneous kyphoplasty (PKP) and develop a validated nomogram for individualized risk prediction. SUMMARY OF BACKGROUND DATA: PK after PKP significantly impacts patient outcomes, yet its pathogenesis remains incompletely understood. While paravertebral muscle (PVM) degeneration has been implicated in spinal pathology, its independent contribution to PK after PKP has not been systematically quantified, and no clinical prediction model incorporating muscle quality exists. METHODS: This study enrolled 330 elderly patients (aged ≥60 y) who underwent single-level PKP for acute or subacute osteoporotic vertebral compression fractures (2013-2022), with a minimum follow-up of 24 months (median 39 mo). PK was defined as an increase in local Cobb angle >10° from immediate postoperative to final follow-up. Patients were randomly divided into training (n=231, 70%) and validation (n=99, 30%) sets. LASSO regression was used for variable selection, followed by multivariable logistic regression to identify independent risk factors and construct a nomogram. PVM fat infiltration (FI) was quantified on axial T2-weighted MRI at the L4/5 level using ImageJ. Model performance was assessed by AUC, calibration plots, and decision curve analysis. RESULTS: Four independent predictors were identified: age (OR=1.107, P=0.012), preoperative paravertebral muscle fat infiltration (OR=1.116, P<0.001), preoperative Cobb angle (OR=1.227, P=0.001), and black line signal on MRI (OR=3.251, P=0.015). The nomogram showed excellent discrimination in training (AUC=0.885) and validation (AUC=0.881) sets, with good calibration and net benefit. An online dynamic nomogram was developed for clinical use (https://dynamicnomogramlee.shinyapps.io/DynNomApp/). CONCLUSION: The nomogram incorporating age, paravertebral muscle fat infiltration, preoperative Cobb angle, and black line signal provides accurate, individualized prediction of progressive kyphosis after kyphoplasty, enabling early identification of high-risk patients for targeted preventive strategies.
Two-Year Outcomes Following Treatment of Painful Lumbar Degenerative Disc Disease with a Percutaneous Polymer-Based Hydrogel Intradiscal Augmentation Implant.
Clerk-Lamalice O, Spath A, Carcary K … +3 more , Amirdelfan K, Nunley PD, Beall DP
Spine (Phila Pa 1976) · 2026 May · PMID 42166623 · Publisher ↗
STUDY DESIGN: Prospective, single arm, multicenter, feasibility study. OBJECTIVE: To determine implant and patient-reported outcomes of percutaneous implantation of an intervertebral disc augmentation hydrogel for treatm...
STUDY DESIGN: Prospective, single arm, multicenter, feasibility study. OBJECTIVE: To determine implant and patient-reported outcomes of percutaneous implantation of an intervertebral disc augmentation hydrogel for treatment of chronic low back pain (CLBP) secondary to degenerative disc disease at 24 months follow-up. SUMMARY OF BACKGROUND DATA: A feasibility study recently demonstrated a novel polymer- based hydrogel was safely and successfully implanted in 83 lumbar intervertebral discs in 60 patients with CLBP. Secondary patient-reported outcome measures indicated clinically significant improvements in function, low back pain, and lower limb pain within one month post-procedure through 12 months. METHODS: Patients with CLBP >6 months duration, Modified Pfirrmann grades 4-8 disc degeneration, Numeric Rating Scale (NRS) ≥4, Oswestry Disability Index (ODI) ≥30, and a competent outer annulus were enrolled in three outpatient clinics. The single-use hydrogel implant was heated to 65°C and delivered intradiscally to the nucleus pulposus with a 17G cannula using fluoroscopic guidance, under local anesthesia. ODI and NRS were collected at 1, 3, 6, 12, and 24 months. The primary outcome was ODI and NRS scores at 24 months. RESULTS: Sixty patients (36 female, mean age 49.0±9.3 y) received 83 implants. ODI scores improved from 57.5±1.5 (baseline) to 10.2±1.8 (24 mo, P <0.001). NRS Back Pain scores improved from 7.3±0.2 (baseline) to 1.6±0.3 (24 mo, P <0.001). NRS Lower Limb Pain scores improved from 5.5±0.4 (baseline) to 1.5±0.3 (24 mo, P <0.001). All mean improvements surpassed minimal clinically important differences. CONCLUSION: Patients reported that clinically meaningful improvements in function and reductions in pain observed at 1 and 12 months post-intervention were maintained through 24 months following percutaneous intradiscal implantation of a polymer-based hydrogel. These outcomes suggest a sustained positive outcome, but should be confirmed in a randomized controlled trial. LEVEL OF EVIDENCE: III, prospective cohort study.
Outcomes of Outpatient Cervical Disc Replacement in an Ambulatory Surgical Center: An Analysis of 1,007 Patients.
Hirpara A, Scheitler S, Hirsch B … +7 more , Shifflett G, Melikian R, Jain N, Macyszyn L, Beckett J, Bray R, Girdler S
Spine (Phila Pa 1976) · 2026 May · PMID 42166620 · Publisher ↗
STUDY DESIGN: Retrospective cohort. OBJECTIVE: To evaluate the efficacy, peri-discharge safety, and reimbursement of single-level and multi-level cervical disc replacements (CDRs) performed in a freestanding ambulatory s...
STUDY DESIGN: Retrospective cohort. OBJECTIVE: To evaluate the efficacy, peri-discharge safety, and reimbursement of single-level and multi-level cervical disc replacements (CDRs) performed in a freestanding ambulatory surgical center (ASC). SUMMARY OF BACKGROUND DATA: CDR is performed to treat spinal stenosis, disc degeneration, disc herniation, and other degenerative pathologies. Recently, there has been a shift from performing CDRs in inpatient settings to ASCs. However, there is limited literature analyzing the outcomes, safety, and economic implications of this transition. METHODS: A retrospective analysis was performed on patients over 18 years old who underwent single-level and multi-level CDR at an ASC between 2018 and 2024. Demographics, surgical characteristics, peri-operative data, insurance type, peri-discharge complications, and reimbursement data were collected. Comparative analyses were conducted between one-, two-, three-, and four-level cohorts using one-way analysis of variance for continuous variables and chi-square or Fisher's exact tests for categorical variables. RESULTS: This study included 1,007 patients (n=576 males, n=430 females, n=1 undisclosed) who underwent 1,043 CDRs. Of the CDRs, 433 were single-level, 579 were two-level, 28 were three-level, and 3 were four-level. The average surgical time for all CDRs was 85.6±29.1 minutes (single-level: 70.6±24.9 minutes, two-level: 94.2±26.0 minutes, three-level: 128.3±24.0 minutes, four-level: 157.7±15.5 minutes) (P<0.001). The average reimbursement for all CDRs was $27,460.91±$9,773.70 (single-level: $24,550.39±$9,297.89, two-level: $29,217.12±$9,517.75, three-level: $34,057.19±$8,630.15, four-level: $47,033.33±$577.35) (P<0.001). There were no complications in the immediate peri-discharge period, and no patients required hospital transfer. All patients were discharged within 24 hours. CONCLUSION: Single-level and multi-level CDRs may be performed in an ASC with a favorable peri-discharge safety profile. CDR in an ASC may also be cost-efficient compared to inpatient surgery. Future studies with longer-term follow-up are needed to better characterize post-discharge outcomes. LEVEL OF EVIDENCE: III.
Aberrant hypothalamic-cortical functional connectivity in spinal cord injury: a neuroimaging-transcriptomic study for motor recovery prognostication.
Qin J, Du J, Yu T … +1 more , Xu H
J Neurosurg Spine · 2026 May · PMID 42139741 · Publisher ↗
OBJECTIVE: Spinal cord injury (SCI) disrupts supraspinal projections to spinal motor circuits, resulting in sensorimotor deficits. While emerging evidence implicates hypothalamic engagement in post-SCI locomotor recovery...
OBJECTIVE: Spinal cord injury (SCI) disrupts supraspinal projections to spinal motor circuits, resulting in sensorimotor deficits. While emerging evidence implicates hypothalamic engagement in post-SCI locomotor recovery, the integrity of hypothalamic-cortical functional connectivity (FC) and its prognostic utility remain uncharacterized. METHODS: Here, the authors employed voxelwise resting-state functional MRI (fMRI) and multivariate pattern analysis to map hypothalamic-cortical FC alterations in 30 incomplete SCI patients relative to 30 demographically matched healthy controls (HCs). Longitudinal assessments at 6-month follow-up integrated clinical metrics (American Spinal Injury Association [ASIA] motor/sensory scores) and transcriptomic decoding via spatial correlation with Allen Human Brain Atlas gene expression profiles. RESULTS: Mass univariate comparisons revealed reduced FC between the hypothalamus and key motor regions, supplementary motor area (SMA), precentral gyrus, and cerebellar crus in SCI patients versus HCs (cluster-level family-wise error-corrected p < 0.05). Baseline hypothalamic-SMA FC strength positively predicted initial motor impairment (Pearson's r = 0.76, p < 0.001). Longitudinal analysis demonstrated FC reorganization paralleling motor recovery (ΔFC vs ΔASIA motor score, r = 0.36, p = 0.04), and searchlight classification identified the precuneus with high classification accuracy for stratifying recovery trajectories. Transcriptomic mapping implicated dysregulated synaptic signaling genes in regions exhibiting FC abnormalities. CONCLUSIONS: The authors' investigation delineated a critical role for hypothalamic-cortical circuits in post-SCI motor recovery. The dynamic reconfiguration of hypothalamic-SMA connectivity, coupled with its prognostic value, positions this pathway as a biomarker for monitoring neuroplasticity in SCI.
Too much of a good thing? Association between high preoperative L4-S1 lordosis and outcomes after adult spinal deformity surgery.
Jain H, Younus I, Zakieh O … +9 more , De Oliveira N, Chanbour H, Ahluwalia R, Zeoli T, Wegner AM, Lugo-Pico JG, Abtahi AM, Stephens BF, Zuckerman SL
J Neurosurg Spine · 2026 May · PMID 42139737 · Publisher ↗
OBJECTIVE: The authors sought to determine the impact of preoperative and postoperative L4-S1 lordosis on 1) mechanical complications, 2) reoperations, and 3) patient-reported outcomes (PROs) using PRO metrics in patient...
OBJECTIVE: The authors sought to determine the impact of preoperative and postoperative L4-S1 lordosis on 1) mechanical complications, 2) reoperations, and 3) patient-reported outcomes (PROs) using PRO metrics in patients undergoing adult spinal deformity (ASD) surgery. METHODS: A retrospective cohort study (2011-2021) was performed for patients undergoing ASD surgery with ≥ 5-level fusion, instrumentation to the ilium, and ≥ 2-year follow-up. Primary exposures were preoperative/postoperative L4-S1 lordosis trichotomized into < 35°, 35°-45°, and > 45°. Primary outcomes were mechanical complications and reoperations. Secondary outcomes included PROs. Multivariable analysis controlled for age, BMI, T-score, pelvic incidence, and postoperative alignment. RESULTS: In 153 patients (mean age 69.0 ± 11.3 years; 75.8% female) undergoing ASD surgery, the mean L4-S1 lordosis was similar in the preoperative and postoperative states (28.1° ± 15.2° vs 28.1° ± 12.5°, p = 0.993). L4-S1 lordosis distribution changed significantly from preoperatively to postoperatively: hypolordosis < 35°, from 66.0% to 69.9%; normal lordosis 35°-45°, from 19.0% to 22.2%, and hyperlordosis > 45°, from 15.0% to 7.8%. In patients with preoperative L4-S1 hyperlordosis, 3 (13.0%) had further increase in lordosis while 20 (87.0%) had a decrease. Overall mechanical complications were similar between the groups based on preoperative (61.4% vs 51.7% vs 82.6%, p = 0.065) and postoperative (65.4% vs 50.0% vs 75.0%, p = 0.177) L4-S1 lordosis; however, when controlling for confounders, preoperative hyperlordosis independently increased the risk of mechanical complications (OR 5.34, 95% CI 1.02-27.89; p = 0.047) compared with preoperative hypolordosis. A higher preoperative L4-S1 lordosis (> 45°) was associated with spinopelvic complications (32.7% vs 20.7% vs 56.5%, p = 0.023), spinopelvic complications requiring reoperation (21.8% vs 10.3% vs 39.1%, p = 0.045), and rod fractures (23.8% vs 13.8% vs 52.2%, p = 0.005). There was no significant association between postoperative L4-S1 lordosis and individual mechanical complications (p > 0.05). No significant difference was found between preoperative or postoperative L4-S1 and PROs (p > 0.05). CONCLUSIONS: In the current single-center study over 10 years, most patients undergoing ASD surgery presented with L4-S1 lordosis < 35°, with no significant change from the preoperative to postoperative condition. Interestingly, high preoperative L4-S1 lordosis (> 45°) was independently associated with increased mechanical complications, rod fracture/pseudarthrosis, and spinopelvic complications. Moreover, half of the patients with L4-S1 hyperlordosis lost lordosis and were downgraded to the normal lordosis group (35°-45°). Complications were lowest in the preoperative group with L4-S1 lordosis of 35°-45°. Special attention should be given to patients presenting with a high L4-S1 lordosis, as they are likely compensating for upper lumbar and thoracic kyphosis and are more likely to lose L4-S1 lordosis during surgery, which could place them at a higher risk for certain mechanical complications.
Role of α1-antagonists in postoperative urinary retention following lumbar spine surgery: a propensity score-matched analysis.
Atchley TJ, Gross E, Estevez-Ordonez D … +1 more , Hadley MN
J Neurosurg Spine · 2026 May · PMID 42139734 · Publisher ↗
OBJECTIVE: Postoperative urinary retention (POUR) commonly occurs following elective lumbar spine surgery. POUR can result in prolonged admission, urinary tract infection (UTI), and patient morbidity. Prophylactic α1-ant...
OBJECTIVE: Postoperative urinary retention (POUR) commonly occurs following elective lumbar spine surgery. POUR can result in prolonged admission, urinary tract infection (UTI), and patient morbidity. Prophylactic α1-antagonist therapy is often used to reduce the risk of this complication. The aim of this study was to identify the incidence of POUR in this population and determine the effect of prophylactic α1-antagonists using a propensity score (PS)-matched model. METHODS: This retrospective review included patients who underwent elective lumbar spine surgery at a single institution between 2015 and 2021. PSs were generated for the likelihood of receiving prophylactic α1-antagonists immediately after surgery. PS matching was performed using 1:1 nearest-neighbor matching (0.01 caliper) without replacement. From this matched cohort, a random-effects model accounting for variation in surgeon practice was used to assess factors associated with POUR. RESULTS: Overall, 2326 patients were identified and 506 were successfully PS matched. The overall incidence of POUR was 8.8%. Immediately postoperatively, 422 patients (18.1%) received prophylactic α1-antagonist therapy (treatment group) and 1904 patients did not (controls). Prior to matching, there were significant differences between the control and treatment groups. In the multivariable random-effects model of the 506 matched patients, POUR was associated with the use of prophylactic α1-antagonists after surgery (RR 1.94, 95% CI 1.07-3.52), female sex (RR 1.83, 95% CI 1.41-2.39), intraoperative Foley catheter use (RR 0.25, 95% CI 0.12-0.52), the normalized duration of surgery (RR 0.42, 95% CI 0.20-0.88), patient-controlled anesthesia use (RR 2.63, 95% CI 1.47-4.70), and postoperative UTI (RR 3.52, 95% CI 1.34-9.21). CONCLUSIONS: Prophylactic α1-antagonist use immediately after surgery did not reduce POUR, and patients who received prophylaxis were at greater risk of POUR in this large PS-matched analysis. Female sex was associated with a greater incidence of POUR while intraoperative Foley catheter use and a longer operative duration were associated with reduced risk of POUR. Potentially modifiable risk factors, such as patient-controlled anesthesia use and UTI, significantly increased the risk of POUR and thus should be addressed in the early postoperative setting.
Determinants of cost-effectiveness in minimally invasive surgery for adult spinal deformity correction.
Alan N, Mir JM, Uribe JS … +15 more , Turner JD, Fessler RG, Okonkwo DO, Kanter AS, Wang MY, Fu KG, Anand N, Nunley PD, Eastlack RK, Mundis GM, Bess S, Chou D, Le VP, Mummaneni PV, Passias PG
J Neurosurg Spine · 2026 May · PMID 42139730 · Publisher ↗
OBJECTIVE: The substantial financial implications of minimally invasive surgery for adult spinal deformity (ASD) necessitate a thorough assessment of its inherent value and efficacy. Factors contributing to protracted co...
OBJECTIVE: The substantial financial implications of minimally invasive surgery for adult spinal deformity (ASD) necessitate a thorough assessment of its inherent value and efficacy. Factors contributing to protracted cost-effectiveness (CE) have not been examined in the context of minimally invasive spine surgery (MIS) for ASD (MIS-ASD). Investigating these determinants can yield pivotal insight to optimize the efficacy of such surgical interventions while concurrently moderating associated expenditures. METHODS: MIS-ASD patients who underwent fusion > 2 levels with lateral lumbar interbody fusion or anterior lumbar interbody fusion and 4-year (4Y) follow-up were included. Published methods were used to determine the costs based on the Centers for Medicare & Medicaid Services definitions and average diagnosis-related group (DRG) reimbursement rates. Utility was calculated using quality-adjusted life years (QALYs), with a 3% discount applied for decline with life expectancy. Cost-utility (CU) was determined by dividing costs by total utility gained. Those who met CE at 4 years (CE4+) were evaluated relative to those who did not (CE4-). RESULTS: Eighty-six patients were included. Revision surgery occurred in 27% of patients. The overall mean cost was $73,000. CU at 4 years was $233,000, with 44% meeting CE4+ and a cumulative mean ± SD QALY gain of 0.8 ± 0.7. Among patients without revision, 54% met CE4+, while 76% met CE at life expectancy. There were no differences in length of stay, ICU admission rates, or time in ICU. Those with greater baseline disability (OR 1.1, p < 0.05) and frailty (OR 1.8, p < 0.05) had a higher likelihood of achieving CE4+. Lower comorbidity burden (i.e., lower Charlson Comorbidity Index score) was associated with increased odds of achieving CE4+ (OR 1.8, p < 0.05). Improved correction of pelvic incidence-lumbar lordosis mismatch was associated with achieving CE4+ (OR 3.8, p < 0.05). Those patients with major complications had 6× higher odds of failure to achieve CE4+, whereas those who underwent reoperation had 12× odds (both p < 0.05). CONCLUSIONS: MIS-ASD achieves CE in a significant subset of patients, particularly those with higher baseline disability, lower comorbidity burden, and better correction of spinal deformities. However, major complications and reoperations significantly hinder CE, underscoring the importance of optimizing patient selection and surgical techniques.
Percutaneous navigation-assisted versus open posterior fixation for thoracolumbar fractures in ankylosing spinal diseases: a single-institution 15-year cohort analysis.
Golubovsky JL, Rajan A, Gu BJ … +5 more , Chen HI, Petrov D, Ali ZS, Shammassian BH, Schuster JM
J Neurosurg Spine · 2026 May · PMID 42139724 · Publisher ↗
OBJECTIVE: Ankylosing spinal pathologies including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) predispose patients to long bone-type unstable fractures after even low-velocity mechanis...
OBJECTIVE: Ankylosing spinal pathologies including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) predispose patients to long bone-type unstable fractures after even low-velocity mechanisms of injury. These fractures often require long-segment pedicle screw fixation. Patients with AS and DISH tend to be elderly and have significant comorbidity burdens, emphasizing the importance of minimizing surgical complications. Therefore, the authors investigated outcomes of patients undergoing percutaneous minimally invasive (MIS) pedicle screw fixation versus traditional open pedicle screw fixation with arthrodesis. METHODS: This study was a retrospective cohort analysis of patients undergoing posterior fixation surgery for AS and DISH thoracolumbar fractures from 2010 to 2025 at a tertiary academic level 1 trauma center. Use of MIS or open techniques was determined according to surgeon preference. Intraoperative, in-hospital, 90-day, and 1-year outcomes and variables were evaluated for both groups. The initial univariate analysis was performed using the Wilcoxon rank-sum test for continuous variables and Fisher's exact test for categorical variables. Multivariable linear regression analysis was performed for continuous variables, while logistic regression analysis was performed for categorical variables. RESULTS: A total of 98 patients underwent spinal fixation for AS and DISH thoracolumbar fractures, including 73 undergoing MIS fixation and 25 undergoing open fixation with arthrodesis. Patients undergoing MIS fixation had greater Charlson Comorbidity Index scores. MIS fixation resulted in significantly lower estimated blood loss (EBL) and intraoperative transfusion volumes. No significant differences were found between approaches in terms of operative time, length of stay, 90-day complications, and 1-year reoperations. CONCLUSIONS: MIS fixation for patients with AS and DISH thoracolumbar fractures is feasible, with similar long-term outcomes to traditional open fixation with arthrodesis. Additionally, the MIS approach was associated with lower EBL and transfusion requirements despite these patients being more ill, which is vitally important in the already medically frail and older AS and DISH populations.
A validation defense of the 10-item PROMIS Global Health scale in lumbar decompression surgery.
Milne CM, Tippins NP, Foreit AM … +2 more , Potts EA, Alentado VJ
J Neurosurg Spine · 2026 May · PMID 42139723 · Publisher ↗
OBJECTIVE: To date, the 10-item Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale has not been validated for use in lumbar decompression surgery. Therefore, this study was performed...
OBJECTIVE: To date, the 10-item Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale has not been validated for use in lumbar decompression surgery. Therefore, this study was performed to validate the scale and identify minimum clinically important differences (MCIDs) in PROMIS GH global physical health (GPH) and global mental health (GMH) domain scores in this patient population. METHODS: A prospectively collected quality improvement registry was retrospectively reviewed. PROMIS GH scores were obtained at baseline and 12 months postoperatively from patients undergoing lumbar decompression surgery between 2016 and 2023. Other validated, spine-specific patient-reported outcome measures (PROMs) assessing quality of life were also collected, including the Oswestry Disability Index (ODI), EuroQol visual analog scale (EQ-VAS), EQ-5D-3L (3-level version of the 5-dimension EuroQol health survey), and numeric rating scale for back pain (NRS-BP) and leg pain (NRS-LP). Pearson correlation coefficients assessed the relationship between PROMIS GH and other PROMs at baseline (r0) and 12 months (r12), as well as changes from baseline to 12 months (rΔ12). Cronbach's alpha was used to evaluate the internal consistency of GPH and GMH at each time point (α0, α12, and αΔ12). MCIDs were calculated for GPH and GMH using four established anchor-based methods, with North American Spine Society patient satisfaction index scores as the anchor. RESULTS: A total of 1134 patients completed baseline and 12-month PROMIS GH questionnaires. GPH scores demonstrated strong correlations with ODI (r0 = -0.72, r12 = -0.78, rΔ12 = -0.68), EQ-5D-3L (r0 = 0.67, r12 = 0.74, rΔ12 = 0.60), and EQ-VAS (r0 = 0.55, r12 = 0.64, rΔ12 = 0.53) and moderate correlations with NRS-BP (r0 = -0.45, r12 = -0.67, rΔ12 = -0.47) and NRS-LP (r0 = -0.47, r12 = -0.56, rΔ12 = -0.47) scores. GMH scores had moderate to weak correlations with ODI (r0 = -0.53, r12 = -0.62, rΔ12 = -0.51), EQ-5D-3L (r0 = 0.55, r12 = 0.67, rΔ12 = 0.52), EQ-VAS (r0 = 0.50, r12 = 0.58, rΔ12 = 0.46), NRS-BP (r0 = -0.26, r12 = -0.49, rΔ12 = -0.30), and NRS-LP (r0 = -0.29, r12 = -0.43, rΔ12 = -0.33) scores. Good to questionable internal consistency was observed in GPH (α0 = 0.66, α12 = 0.78, αΔ12 = 0.63) and GMH (α0 = 0.75, α12 = 0.85, αΔ12 = 0.74). Based on 12-month score changes, MCID thresholds ranged from 5.04 to 12.77 for GPH and from 4.49 to 9.79 for GMH. The receiver operating characteristic (ROC) curve analysis was deemed most appropriate for calculating MCIDs. CONCLUSIONS: The GPH and GMH components of PROMIS GH have strong validity and reliability, with moderate to strong correlations to established PROMs and acceptable internal consistency. Based on the ROC approach, MCID thresholds were 11.05 for GPH and 4.90 for GMH. The current findings define and defend clinically significant thresholds for score improvement in PROMIS GH and thereby bolster its clinical utility for patients undergoing lumbar decompression surgery.
Dysphagia rates between long-segment anterior versus posterior cervical fusion.
Narayanan AM, Tippins NP, Foreit AM … +7 more , Hannon KM, Rezner AC, Alentado VJ, Bisson EF, Porche K, Foley KT, Potts EA
J Neurosurg Spine · 2026 May · PMID 42139721 · Publisher ↗
OBJECTIVE: Dysphagia is a common postoperative adverse outcome of cervical spinal fusion surgery and frequently associated with anterior surgical approaches and multilevel fusions. However, postoperative dysphagia has al...
OBJECTIVE: Dysphagia is a common postoperative adverse outcome of cervical spinal fusion surgery and frequently associated with anterior surgical approaches and multilevel fusions. However, postoperative dysphagia has also been observed following posterior approaches, despite the absence of esophageal manipulation with this technique, thereby leaving the underlying mechanism unclear. This study aimed to investigate the impact of surgical approach on the incidence of new-onset postoperative dysphagia following long-segment (≥ 3 levels) anterior cervical fusion (ACF) and posterior cervical fusion (PCF) surgical procedures at 1, 3, and 12 months postoperatively. Patient-reported outcomes (PROs) were also compared between surgical approaches. METHODS: A prospectively collected multi-institutional quality registry was retrospectively reviewed. Patients who underwent long-segment cervical surgery were categorized on the basis of anterior or posterior approach received, and correlations with preoperative and postoperative Eating Assessment Tool-10 (EAT-10) dysphagia questionnaire scores and PROs were examined. Mixed-effects logistic regressions were performed to examine the impact of surgical approach on new-onset postoperative dysphagia. RESULTS: Of the 328 patients who met the inclusion criteria, there were 208 ACF patients and 120 PCF patients. ACF patients experienced significantly greater improvement in Neck Disability Index score from baseline to 12 months postoperatively (-10.8 ± 9.4 vs -7.5 ± 8.6, p = 0.010) with no significant difference in baseline scores (19.0 ± 9.9 for ACF patients vs 17.6 ± 9.8 for PCF patients, p = 0.20). ACF patients also reported greater baseline visual analog scale-arm pain scores (5.7 ± 3.1 vs. 4.3 ± 3.4, p < 0.001) and experienced significantly greater improvement at 12 months postoperatively (-3.8 ± 3.5 vs. -2.2 ± 3.6, p = 0.001). A similar degree of improvement from baseline to 12 months was observed in other PROs regardless of surgical approach. Multivariable regressions indicated that the anterior surgical approach for long-segment cervical surgery was associated with significantly higher odds of experiencing new-onset postoperative dysphagia at 1 month (OR 15.0, 95% CI 1.89-120, p = 0.010) and 3 months (OR 3.25, 95% CI 1.20-8.74, p = 0.020) after cervical spine surgery but not at 12 months (OR 0.75, 95% CI 0.23-2.46, p = 0.6). CONCLUSIONS: Patients who underwent anterior cervical surgery were significantly more likely to develop new-onset dysphagia as long as 3 months after surgery. However, long-term dysphagia rates were similar between cohorts. While initial dysphagia may be related to surgical approach, similar long-term rates suggest that persistent dysphagia may be related to the intraoperative and postoperative factors shared between surgical approaches.
Contrast-Enhanced MRI-Based Grading of Nuchal Ligament Failure in Dropped Head Syndrome Caused by Isolated Neck Extensor Myopathy.
Endo K, Nishimura H, Sawaji Y … +6 more , Yamauchi H, Uehara T, Ueshima T, Aihara T, Suzuki H, Yamamoto K
Spine (Phila Pa 1976) · 2026 May · PMID 42118530 · Publisher ↗
STUDY DESIGN: Retrospective observational cohort study. OBJECTIVE: To establish a contrast-enhanced MRI-based grading system for imaging-defined nuchal ligament disruption in dropped head syndrome (DHS) caused by isolate...
STUDY DESIGN: Retrospective observational cohort study. OBJECTIVE: To establish a contrast-enhanced MRI-based grading system for imaging-defined nuchal ligament disruption in dropped head syndrome (DHS) caused by isolated neck extensor myopathy (INEM), and to evaluate its association with sagittal head alignment, cervical extension function, pain, and quality of life. METHODS: A total of 130 patients with INEM-related DHS who underwent contrast-enhanced cervical MRI were retrospectively analyzed, along with 21 non-DHS controls. Nuchal ligament findings were classified into four grades (Grade 0-3) based on contrast enhancement patterns and ligament continuity. Clinical parameters included chin-brow vertical angle (CBVA), pain severity assessed using the Numerical Rating Scale (NRS), health-related quality of life assessed using EuroQol 5 Dimensions (EQ-5D), and the ability to actively achieve cervical extension in the prone all-fours position. Associations among MRI grades were evaluated using one-way analysis of variance and multivariable regression adjusted for age and sex. RESULTS: All patients with INEM-related DHS demonstrated intraligamentous contrast enhancement, whereas non-DHS controls showed no such findings. CBVA differed significantly across MRI grades, with higher values observed in patients with advanced-grade disruption. However, when MRI grade was treated as an ordinal variable, a strictly linear association with CBVA was not observed. Active cervical extension was rare in patients with Grade ≥2 disruption. Pain severity did not differ among grades. In contrast, EQ-5D scores were significantly lower in higher grades and remained independently associated with MRI grade after adjustment for age and sex. Interobserver reliability was moderate (weighted κ=0.62). CONCLUSIONS: Contrast-enhanced MRI-based grading of imaging-defined nuchal ligament disruption provides a structural marker associated with sagittal head alignment and cervical extension dysfunction in INEM-related DHS. This classification may serve as a clinically useful adjunctive tool for severity assessment and stratification in selected patients.
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