Global Spine Journal

Literature Review with clinical recommendations.

To highlight impactful studies on subaxial cervical fractures, identified by the AO Spine Knowledge Forum Trauma and Infection group, with recommendations for their integration into clinical practice.

Four studies on subaxial cervical fractures that have the potential to shape current practice in subaxial cervical fractures were selected and reviewed. Each study was chosen for its contribution to a critical phase in subaxial fractures management: diagnosis and imaging, surgical vs conservative treatment, and selection of approach.

Four studies were highlighted. Article 1: Rutsch et al evaluated the sensitivity and specificity of CT, MRI, plain radiography, and LODOX-Statscan in identifying cervical spine injuries. We strongly recommend the use of CT/MRI as gold standard for radiological workup in cervical spine injuries. Article 2: Cirillo et al performed a systematic review of predictor of failure to conservative treatment for isolated unilateral facet fractures. We conditionally recommend surgical treatment in floating lateral mass and greater fragment size. Article 3: Singh et al evaluated the predictors of failure after stand-alone ACDF in subaxial fractures. We conditionally recommend adding posterior fusion in PLL injury, bilateral facet joint dislocation and age above 60 years. Article 4: Kwon et al prospectively randomized and compared anterior vs posterior approach in unilateral facet joint injury. We conditionally recommend anterior surgical fixation in unilateral facet injuries without spinal cord injury.

This article provides spine surgeons with evidence-based recommendations to enhance standardization and effectiveness of the management of subaxial spine fractures.

Retrospective propensity score–matched cohort study.

To investigate whether the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is associated with a reduced risk of lumbar degenerative disease (LDD) and lumbar spine surgery in patients with type 2 diabetes mellitus (T2DM).

Data were obtained from the TriNetX Global Collaborative Network. Adult patients with T2DM initiating GLP-1 RA therapy were matched 1:1 with non-users based on demographics, comorbidities, and medication use. Patients with pre-existing LDD or prior lumbar spine surgery were excluded. Primary outcome was the incidence of LDD; secondary outcome was lumbar spine surgery. Outcomes were assessed at 3- and 5-year intervals, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

A total of 196 435 matched pairs were analyzed. At 3 years, GLP-1 RA users had a lower incidence of LDD (11.9% vs 13.3%; OR 0.89, 95% CI: 0.87-0.91). At 5 years, this difference widened (14.6% vs 18.7%; OR 0.74, 95% CI: 0.73-0.74). Lumbar spine surgery rates were similar at 3 years (0.4% in both groups; OR 1.03, 95% CI: 0.93-1.14), but significantly lower in GLP-1 RA users at 5 years (0.5% vs 0.6%; OR 0.86, 95% CI: 0.78-0.92).

GLP-1 RA use is associated with a lower long-term risk of developing LDD and undergoing lumbar spine surgery in patients with T2DM. These findings support further investigation of GLP-1 RAs as potential disease-modifying agents in spinal health.

Retrospective study.

To develop and validate a predictive model for cage subsidence (CS) after midline lumbar interbody fusion (MIDLIF) with cortical bone trajectory (CBT) screws.

This retrospective two-center study included patients diagnosed with lumbar degenerative disorders undergoing MIDLIF between January 2018 and October 2023 at two independent hospitals under identical eligibility criteria and variable definitions. Patients were stratified into CS and non-CS groups according to postoperative outcomes. Variables with P < 0.1 in the univariate analysis were subsequently included in multivariate logistic regression to determine independent predictors. Bone mineral density (BMD) was indirectly evaluated using endplate bone quality (EBQ) scores from MRI and Hounsfield units (HU) measurements from CT scans. Inter-rater reliability of EBQ was reported using the intraclass correlation coefficient (ICC) with 95% CIs. The model’s performance was assessed using ROC analysis, calibration curves, and decision curve analysis (DCA).

Across both centers, 316 patients were included, of whom 71 (22.5%) developed CS (development center: 48/216, 22.2%; external center: 23/100, 23.0%). Elevated BMI, higher EBQ scores, lower HU values, and reduced preoperative disc height were found to be independent predictors. The prediction model exhibited favorable discriminative ability, with AUCs of 0.924 in the training set and 0.884 in the internal validation set, and it maintained performance in a geographically external cohort (AUC = 0.842). Calibration curves demonstrated good agreement between predicted and observed outcomes, and DCA indicated strong clinical applicability. Although lower than in the training and internal validation sets, external net benefit stayed positive across a broad clinical threshold range and, for most thresholds, exceeded treat-none and treat-all. EBQ inter-rater reliability (ICC, 95% CIs) was 0.960 (0.945-0.971), 0.940 (0.902-0.964), and 0.920 (0.881-0.946) in the training, internal validation, and external cohorts, respectively. In addition, the nomogram was developed into an online calculator that visually displays the predicted probability of CS following MIDLIF.

The developed nomogram serves as a practical and reliable means to predict the risk of cage subsidence in patients undergoing MIDLIF. An online risk calculator based on this model further enhances its clinical utility, providing clinicians with a valuable reference for tailoring surgical strategies and improving perioperative decision-making.

Prospective Cohort Study.

The aim of this study was to assess how sound pressure levels (SPL) change throughout spine procedures and which phases may place surgeons at higher risk of noise induced hearing loss.

SPL was recorded by a microphone attached to the surgeon’s collar beneath the sterile gown for 6 of each: MI-TLIF, microdiscectomy, decompression. dBA was recorded every second. An overall average (ADL) and maximum (MDL) for each phase of the procedure were calculated and compared across procedure type. The ADL and MDL of two electric burrs and one pneumatic burr were collected and compared.

ADLs were significantly different for all three procedure types. There was no difference in the mean MDL (mMDL) between phases within each procedure type. The irrigation/closure phase had the lowest ADL and mMDL for all three procedure types. In MI-TLIF, facetectomy had a significantly greater ADL than all other phases; the highest mMDL was during the exposure phase. In microdiscectomy, laminotomy had the greatest mMDL, and ADL and was significantly higher than all other phases except exposure. In decompression, the laminectomy phase had the highest ADL and mMDL. The brand A-e burr had a significantly lower ADL and the lowest MDL.

During common spine surgery procedures, phases involving powered instruments such as burrs, electrocautery machines or suction had higher ADL and mMDL. Sound levels in the OR may peak above 85 dBA for short periods despite the average being below dangerous levels. Therefore, while surgeons are not usually at an elevated risk of NIHL, periods of elevated dBA warrant attention for elevated risk.

Retrospective comparative cohort study.

To validate FDA IDE–sponsored trial findings on cervical disc replacement (CDR) and anterior cervical discectomy and fusion (ACDF) by comparing reoperation outcomes with real-world data.

Patients undergoing one- or two-level ACDF or CDR from 2010-2022 were identified in the PearlDiver (PD) database. FDA IDE trials were retrieved through review of databases. Subsequent surgeries and sample sizes were extracted at 2-, 4-, 5-, 7-, and 10-year intervals. Event rates were calculated as reoperations divided by patients at risk, and survival probabilities as S(t) = 1−event rate. Kaplan–Meier–style survival curves were reconstructed using the Guyot algorithm with a monotonicity constraint. Pooled FDA survival probabilities were weighted by number at risk. Hazard ratios (HRs) were derived from log-transformed survival probabilities, and statistical significance was tested using Pearson’s chi-square or Fisher’s exact test. Analyses were stratified by surgical level (1- vs 2-level) and procedure type (CDR vs ACDF).

In total, 277 146 ACDF and 25 957 CDR patients from PD and 46 FDA trials were analyzed. CDR reoperation risks were similar between FDA and PD cohorts, though differences were significant at 2-, 7-, and 10-year follow-up for 1-level procedures. ACDF reoperation risks were consistently and significantly lower in PD (eg, HR 0.4 at 7 years).

Reoperation risks for CDR were broadly comparable, while ACDF outcomes were superior in practice compared with trials. These differences may reflect trial selection bias or stricter adjudication of ACDF outcomes. Validation against real-world data supports long-term safety assessment and personalized surgical decision-making.

A Retrospective real-world study.

This study aimed to investigate whether paraspinal muscle degeneration (PMD) is a predictor of chronic low back pain (CLBP) in elderly patients with lumbar spondylolisthesis after posterior lumbar interbody fusion (PLIF).

A comparative cohort analysis was performed on 86 patients aged >60 with Meyerding grade I–II spondylolisthesis. Patients were stratified into PMD and non-PMD groups based on psoas major muscle index (PMI) and multifidus fat infiltration (MFI). Clinical outcomes were assessed using Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores, alongside lumbosacral sagittal parameters including lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), PI-LL (PL) mismatch. Propensity score matching for listhesis degree and osteoporosis yielded 30 patients per group for analysis. Multivariate analysis identified risk factors for CLBP at 2 years, and a machine learning model was developed as a clinically applicable predictive tool based on an expanded cohort of 649 patients.

The PMD group demonstrated significantly worse outcomes at 2-year follow-up, with higher VAS (2.40 ± 1.55 vs 1.23 ± 1.48) and ODI scores (29.40 ± 6.83 vs 20.57 ± 6.38), and poorer sagittal alignment. PMI and MFI were identified as major risk factors for CLBP both pre- and postoperatively. The Random Forest Model achieved high accuracy (97.1%), sensitivity (95.9%), specificity (90.6%), and an F1 score (88.9%) in predicting postoperative CLBP.

PMD significantly impacts both preoperative symptom severity and postoperative recovery. Assessment of PMD provides valuable prognostic information, and the established predictive model can aid in managing surgical expectations and guiding rehabilitation.

A retrospective case-control design.

This study proposed a novel MRI finding termed the “Flying owl sign” to characterize a specific type of lumbar disc herniation (LDH) and examined the correlation between this image finding and the patient-reported outcomes (PROs) following full-endoscopic lumbar discectomy.

A retrospective case-control study was conducted involving LDH patients who underwent full-endoscopic lumbar discectomy in our institution. The propensity score matching method was employed to categorize patients into a “Flying owl sign” group and a control group. Multivariable logistic regression analysis was performed to evaluate the relationship between the “Flying owl sign” and the PROs.

A total of 431 patients who underwent full-endoscopic lumbar discectomy between November 2015 and October 2022 in our institution were enrolled. After a mean follow-up of 32.24 ± 8.60 months, 377(87.47%) patients were satisfied (NASS score of 1 or 2). 10.21% (44/431) patients exhibited “Flying owl sign”, and experienced significantly greater improvements in VAS(P = 0.022), higher patient satisfaction index (P = 0.016), and a lower incidence of residual low back pain (P = 0.013) than the control group. Propensity score matching produced a final study cohort of 88 patients. The multivariate analysis revealed that “Flying owl sign” was a protective factor for satisfaction (OR = 3.544, P = 0.018).

The presence of “Flying owl sign” reflected a specific LDH type, which was the combination of giant disc herniation and the integrity of the posterior longitudinal ligament. “Flying owl sign” correlated with improved postoperative efficacy and satisfaction in patients with LDH, and may contribute to reducing residual low back pain rates.

A multimethod experimental study.

Spinal cord injury (SCI) has devastating neurological consequences, mainly through secondary injury mechanisms. Chinese medicine-derived flavonoids, including rutin (RUT) and ochnaflavone (OCE), have shown potential in modulating these processes, although their molecular mechanisms are not understood. This study aims to elucidate the neuroprotective mechanisms of RUB and OCE in SCI, with an emphasis on their regulatory function in microglia and the PI3K/AKT and NF-κB signaling pathways.

Single-cell RNA sequencing (scRNA-seq) of SCI mouse models was used to identify the inflammatory microglial subtype and define its molecular signature. Network pharmacology predicted that RUB and OCE targets overlap with SCI pathology. Their anti-inflammatory and anti-apoptotic effects were tested by vitro assays using LPS-stimulated BV2 microglia and a microglia-neuron co-culture system. In vivo validation was conducted using a murine SCI model to test protein expression by western blotting, immunofluorescence, and Enzyme-linked immunosorbent assay (ELISA).

RUB and OCE synergistically inhibited LPS-induced microglial activation with significant downregulation of pro-inflammatory cytokines (TNF-α, IL-1β, and IL-6) and neuronal apoptosis markers (Bax and cleaved Caspase-3) and upregulation of anti-apoptotic B. Mechanistically, the combination therapy suppressed the phosphorylation of PI3K, AKT, IKKβ, and NF-κB p65 without affecting their protein levels. These molecular effects were parallel in vivo, significantly reducing microglial hyperactivation and apoptotic signaling.

Our findings suggest that targeting the PI3K/AKT and NF-κB pathways may be an effective strategy for inhibiting secondary damage post-SCI, offering a novel therapeutic approach to reshape the post-injury environment and restore neural homeostasis.

Delphi study.

Optimal spine trauma care requires extensive resource availability and training. In LMICs, where resources and training are scarcer, spine trauma represents a major source of disability and public health burden. This study aimed to evaluate the highest priority resource needs for spine surgeons in sub-Saharan Africa in order to provide safe, high-quality spine trauma care.

This study utilized a Delphi methodology with three electronic surveys. Participants were identified through the Continental Association of African Neurosurgical Societies (CAANS) and College of Surgeons of East, Central, and Southern Africa (COSECSA) networks. Response collection lasted from August 2024 to May 2025. The initial survey was an open-ended collection of all spine trauma resource priorities. In each subsequent round, participants rated topics on a Likert scale from 1 (most important) to 9 (least important). Consensus was defined as topics ranked 1, 2 or 3 (highly important) by >70% of participants.

Invitations were sent to 75 potential participants, with 36 participating in round one. Thirty-four participants (94.4%) and thirty-five (97.2%) completed the second and third consensus rounds respectively. Fifty-one items reached consensus. The most highly rated items included braces/c-collars, spine training/education of emergency room physicians and surgeons, and access to implants. Items not reaching consensus included microscopes, endoscopes, navigation and specialized auxiliary personnel.

Given the high burden of traumatic spine injury and resource needs in these regions, efforts should be focused on providing essential resources related to timely stabilization of the spine over advanced tools and technologies.

Retrospective cohort study.

Determine if the use of a Wilson kyphosis frame during single level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) at L4-5 or L5-S1 impacts postoperative lumbar lordosis.

A retrospective analysis of patients who underwent a single level MIS TLIF at L4-5 and L5-S1 from 1/1/2016 to 1/1/2021 was performed. Patient demographics were collected, and radiographic measurements preoperatively and 6 months postoperatively were performed. Our primary outcome was “delta lumbar lordosis” (delta LL), or the difference between pre-operative and 6 month postoperative lumbar lordosis. Statistical analysis was performed using step-wise multivariate linear regressions.

A total of 180 patients were included. Mean age was 58.5 ± 11.8 years and 48.3% were female. Mean BMI was 28.6 ± 5.6. Wilson positioning frames were used in 96/180 (53.3%) procedures. Use of a Wilson Frame was independently predictive of 2.5° reduced delta LL (Coeff −2.5, 95% CI -4.1 to −0.9). However, use of a Wilson frame was not found to be independently associated with postoperative mismatch between pelvic incidence and lumbar lordosis.

Use of a Wilson kyphosis frame during single level MIS TLIF at L4-5 and L5-S1 resulted in a loss of 2.5° of lordosis compared with those patients who had a MIS TLIF without a Wilson frame. The clinical impact of this loss over long-term follow-up will be the subject of future studies.

Single-center retrospective cohort study.

To evaluate whether 3D-printed titanium (3DTi) cages reduce the risk of revision surgery compared to polyetheretherketone (PEEK) cages in standalone lateral lumbar interbody fusion (SA-LLIF).

SA-LLIF procedures performed between 09/2018 and 08/2022 were retrospectively reviewed. Minimum follow-up was 2 years. Baseline characteristics and surgical details were compared between those treated with 3DTi and those with PEEK. Univariable, multivariable Poisson, and hierarchical mixed-effects Poisson regression models were performed to identify independent predictors. Secondary analyses examined differences in timing and types of revision surgeries between the 2 implant types.

A total of 233 patients (43.8% female) were included, with a median age of 65 years (IQR: 56-71), BMI of 28.0 (IQR: 24.7-32.1), and a median of 2 levels fused (range 1-4). Overall, 17.6% underwent revision surgery, with a mean time to revision of 26 ± 16 months. Revisions were more frequent after PEEK (26.3%) vs 3DTi (13.0%; P = 0.017). In multivariable analysis adjusting for follow-up and surgical levels, 3DTi was independently associated with reduced revision risk (RR: 0.52, 95% CI: 0.30-0.90; P = 0.027), which remained significant in a hierarchical mixed-effects model accounting for surgeon-level variation (P = 0.042). Early revisions (<2 years) were more common with PEEK (13.8% vs 4.1%; P < 0.05), while late revisions (>2 years) were similar (11.5% vs 8.9%; P = 0.521).

3D-printed titanium cages in SA-LLIF was associated with lower revision risk compared to PEEK, particularly in the early postoperative period. These findings support the implementation of 3Dti implants to improve surgical outcomes in SA-LLIF.

Retrospective Cohort Study.

This study aimed to examine the characteristics of medical malpractice claims related to spinal fracture treatment in our country between 2018 and 2023.

The study utilized our database to analyze 65 closed spinal fracture medical malpractice cases. The inclusion criteria were vertebral fracture, traumatic origin, age >18 years, and available data. The study evaluated patient demographics, fracture characteristics, treatment details, complications, and the nature of the malpractice complaints.

The results showed that 22 out of 65 cases were found to involve malpractice by the committee. The most common complaints were treatment errors, failure to diagnose the condition, and postoperative paralysis. In 22 cases of malpractice, there were twelve cases of failure of diagnosis, 3 cases of misdiagnosis, 6 cases of treatment error, and 1 case of inappropriate postoperative management. Three of the malpractice cases involved orthopedic surgeons, while 19 involved neurosurgeons. The study found no significant differences in any of the parameters between patients with and without malpractice. Five of the 15 defendant orthopaedic surgeons, 5 of the 41 defendant neurosurgeons, 6 of the 24 defendant emergency medicine specialists and 6 of the 8 defendant radiologists were found to be at fault in malpractice lawsuits.

Neurosurgeons receive the most complaints, but radiologists have the highest rate of malpractice, with 6 out of 8 of these cases being malpractice. The findings highlight the importance of accurate diagnosis and treatment in reducing the risk of malpractice claims in spinal fracture cases.

Single-center retrospective comparative study.

While vitamin D (VD) levels are known to correlate with outcomes in lumbar degenerative disease (LDD), it remains unclear whether LDD is related to elevated risk of VD deficiency. This study aimed to compare the prevalence and epidemiological characters of VD deficiency between surgical LDD patients and health screening (HS) populations.

7300 HS participants and 1147 surgical LDD patients were included. All participants accepted serum VD test. In both HS participants and LDD patients, the epidemiological characteristics and influence factors of VD deficiency were analyzed. Propensity score matching was used to create a matched healthy control group, and the prevalence of VD deficiency was further compared.

66.9% of HS participants and 42.9% of LDD patients were with VD deficiency. Age, sex, BMI and season were influence factors of VD deficiency in both groups. As age grows, the VD levels increase in young age and decrease in older age after the peak. Female, high BMI and Winter/Spring season were risk factors of VD deficiency. Compared with matched control group, LDD group exhibited statistically higher median VD levels than controls [median (interquartile range), 21.6 (16.3, 27.9) vs 19.3 (15.0, 25.3), P < 0.001]. However, the prevalence of VD deficiency was not significantly different between the matched groups.

LDD does not appear to be associated with an elevated risk of VD deficiency. Compared with the HS cohort, surgical LDD patients exhibit similar epidemiological patterns of VD levels, including an unusual biphasic relationship with age.

Retrospective cohort study.

Successful bone fusion is crucial for favorable posterior lumbar interbody fusion (PLIF) outcomes. While trabecular bone remodeling (TBR) indicates osseointegration, its interpretation remains uncertain. This study aimed to clarify the clinical significance of distinct TBR types—fine TBR (fTBR) and sclerotic TBR (sTBR)—as seen on computed tomography (CT) scans and to evaluate their predictive value for segment stabilization and complete bone fusion and their relationship with interbody cage materials.

Seventy-one patients who underwent one-level PLIF with follow-up exceeding 5 years were included. Interbody cages were made of carbon fiber-reinforced polymer (CFRP; 37 segments) or titanium-coated polyether-ether-ketone (TiPEEK; 34 segments). CT images were obtained at 3 months, 1 year, and incidentally at 5 years or later. TBR was classified morphologically as fTBR or sTBR.

At 1-year postoperatively, the fTBR positivity rate was significantly higher in the TiPEEK group than in the CFRP group (48.6% vs 73.5%, P = .032). The 33 fTBR-positive segments at 3 months had a significantly higher complete fusion rate than 38 fTBR-negative segments (97.0% vs 57.9%, P < .001). There was no significant difference in fusion rates between 27 sTBR-positive segments at 3 months and 44 sTBR-negative segments (66.7% vs 81.8%, P = .15).

fTBR may serve as a positive indicator for predicting future segment stabilization and bone fusion post-PLIF. sTBR, however, is not associated with future segment stability. This refined TBR classification could enhance postoperative assessment and broaden our understanding of implant-bone integration in spinal fusion.

Retrospective study.

We found that inter-vertebral signal concordance index (ISCI), as a novel factor, was significantly higher in the osteoporotic vertebral compressed fracture (OVCF) patients than non-OVCF patients in our previous retrospective study. In this study, we aim to validate the association between ISCI and OVCF using finite element analysis (FEA).

From the non-fracture cohort of our previous diagnostic study, 18 female patients (50-75 years) with degenerative lumbar disease were selected. To minimize confounding factors affecting bone strength, paired patients were matched under criteria: 1. The same femoral neck T-score; 2. Age caliper of 4 years. FEA was adopted to predict vertebral bone strength under 500N compression and failure load for the paired patients.

Among three ISCI subtypes (T1, T2, STIR), only STIR-ISCI showed significant biomechanical differences: Compared to lower STIR-ISCI group, the higher STIR-ISCI group exhibited increased vertebral deformation (2.62 ± 0.72 mm vs 1.24 ± 0.55 mm, P = .002) and increased stress distribution (10.92 ± 1.98 MP vs 6.49 ± 2.87 MP, P = .002) under 500N load. Moreover, the yield strength in the higher STIR-ISCI group was lower (4443.11 ± 8.99 N vs 4467.67 ± 9.66, P < .001). Consequently, the deformation at yield strength was higher in the higher STIR-ISCI group (21.25 ± 4.73 mm vs 15.55 ± 2.55 mm, P = .027). No differences were observed in the T1-ISCI or T2-ISCI subgroups.

STIR-ISCI is an independent risk factor for OVCF, strongly associated with compromised vertebral biomechanics independent of bone mineral density. This magnetic resonance imaging-derived biomarker offers a promising tool for clinical fracture risk stratification.

Retrospective Study.

Spinal cord injury (SCI) has become a major health threat, and existing diagnostic tools such as MRI and CT have limitations. This study aims to investigate the expression changes of miR-200a-3p and its target PTEN in SCI and explore their potential diagnostic and therapeutic values.

A total of 148 SCI patients were enrolled. An in vitro SCI model was established using PC12 cells treated with LPS. The levels of miR-200a-3p and PTEN were measured using qRT-PCR. The diagnostic value of both for SCI was evaluated using ROC curve analysis. The targeting relationship between miR-200a-3p and PTEN was validated through dual-luciferase reporter assays, and RNA pull-down experiments. Cell viability and apoptosis were analyzed using MTT and flow cytometry. ELISA was used to measure pro-inflammatory cytokines. Levels of ROS, CAT, and SOD were determined using respective kits.

miR-200a-3p was significantly decreased, while PTEN was upregulated in SCI patients. Both miR-200a-3p and PTEN could distinguish SCI patients from individuals with normal neurological function, as well as complete vs incomplete SCI. Furthermore, miR-200a-3p directly targets and suppresses PTEN; overexpression of miR-200a-3p enhanced cell viability, reduced inflammation and oxidative stress, and inhibited apoptosis. Conversely, PTEN overexpression reversed these protective effects.

miR-200a-3p and PTEN have certain diagnostic value for SCI, and miR-200a-3p exerts neuroprotective effects by targeting PTEN to reduce inflammation and oxidative stress. This study provides promising biomarkers and therapeutic targets for the early diagnosis and intervention of SCI.

Literature review.

To systematically review blood biomarker profiles in adolescent idiopathic scoliosis (AIS) and evaluate their pathophysiological implications and clinical potential for diagnosis, prognosis, and therapeutic monitoring.

A comprehensive literature search was conducted to identify studies examining blood-based biomarkers in AIS patients, including alterations in vitamin D, calcium, trace elements, sex hormones, leptin, melatonin, growth hormone, ghrelin, bone metabolism factors, microRNAs, proteomic and metabolomic profiles. Relevant findings were synthesized to elucidate systemic biological alterations associated with AIS.

Consistent vitamin D and calcium deficiencies, hormonal dysregulation (leptin, estrogen, ghrelin), altered trace element levels (selenium), and distinct changes in bone metabolism markers (osteocalcin, P1NP, RANKL) were observed in AIS patients. Emerging evidence supports the involvement of specific microRNAs and proteomic/metabolomic profiles in AIS pathogenesis and curve progression. These blood biomarkers exhibit potential for early diagnosis, risk stratification, and individualized treatment approaches.

Blood biomarkers offer valuable insights into the systemic pathophysiology of AIS and may serve as accessible tools for improving early detection, progression monitoring, and personalized management of AIS. Further longitudinal and multi-omics studies are warranted to validate their clinical utility.

Systematic Review.

Randomized controlled trials (RCTs) on lumbar endoscopic decompression inform treatment decisions for disk disease, radiculopathy, and lumbar spinal stenosis. This study assessed the fragility of statistical outcomes in these RCTs.

PubMed, Embase, and MEDLINE were queried for RCTs reporting dichotomous outcomes with at least 1 endoscopic decompression arm. The fragility index (FI) and reverse FI (rFI) represented the number of event reversals needed to change significance for significant and nonsignificant outcomes, respectively. The fragility quotient (FQ) was calculated by dividing FI by sample size. Subgroup analysis was performed by outcome type.

37 RCTs met the inclusion criteria for analysis. A total of 160 outcomes were analyzed. The median FI was 4 (IQR: 3-5) and FQ 0.038 (IQR: 0.017-0.067). Significant outcomes (n = 23) had a median FI of 7 (IQR: 2-13), FQ 0.024 (IQR: 0.012-0.056); nonsignificant outcomes (n = 137) had FI 4 (IQR: 3-5), FQ 0.041 (IQR: 0.020-0.068). Revisions/reoperations were most robust (FI: 5, FQ: 0.037); microscopic outcomes most fragile (FI: 4, FQ: 0.022). Pain outcomes had FI 4 (FQ: 0.051); complications FI 4 (FQ: 0.038). In 47.5% of outcomes, patients lost to follow-up exceeded FI.

Findings from RCTs on lumbar endoscopic decompression are vulnerable to small changes in outcome events. In nearly half of outcomes, patients lost to follow-up outnumbered the FI. Reporting FI and FQ with P-values may improve interpretation and reliability of trial results.

Systematic Review.

Infection following vertebral augmentation using Percutaneous vertebroplasty (PV) and percutaneous balloon kyphoplasty (PBK) is an exceedingly rare, but potentially life-threatening complication. This systematic review evaluates the microbiological characteristics, risk factors, treatment strategies and outcomes of these infections.

PubMed, Scopus, and Mendeley databases (2000-2025) were systematically reviewed. Inclusion criteria involved case cohorts of more than 5 adult patients with infections following PV or PBK. Data on the initial procedure, demographics, infection biomarkers, neurologic status, comorbidities, causative pathogens, treatment protocols, and outcomes were evaluated.

A total of 102 patients from 8 studies were included (mean follow-up: 22.9 months). Most were female (64.7%) with a mean age of 71.0 years (range: 50-95). The mean time interval from the initial procedure to infection diagnosis was 5.2 months (range: 0.03-85.2). The most common pathogen was Mycobacterium tuberculosis (35.3%). The mean infection biomarkers were CRP 36.77 mg/dL (range: 0.05-343), ESR 56.98 mm/h (range: 6-126), and WBC 8.53 cells/mm³ (range: 2.09-22.35). Seven patients (6.1%) were treated conservatively, while 95 patients (93.1%) underwent revision surgery. Outcomes were reported for 89 patients (87%). Final follow-up showed that 34 patients (38%) achieved normal mobility, 22 patients (25%) had assisted mobility (crutches or walker), and 11 patients (12%) required a wheelchair. The mobility status was unclear for 11 patients (12%). The mortality rate was 12.3%. Post-treatment mobility was strongly dependent on preoperative neurologic status (OR = 6.0, P = 0.001).

Post-augmentation spinal infections are rare but serious. Outcomes are strongly influenced by preoperative neurological status, while pathogen type and patient comorbidities have limited prognostic impact.

Systematic Scoping Review.

Radiographic assessment is crucial for diagnosing symptomatic pseudarthrosis and evaluating spinal fusion outcomes, yet no consensus exists on defining successful lumbar fusion. This scoping review presents criteria for imaging-based assessment after posterolateral and interbody lumbar fusion, aiming to guide consistent evaluation methods.

Following PRISMA guidelines, a comprehensive search of Medline, Embase, and Scopus identified eligible randomized controlled trials and Federal Drug Administration clinical trials involving lumbar fusion. Studies on revision surgeries, non-lumbar fusions, adult spinal deformity, traumatic fractures, tumors, infections, or lacking defined fusion assessment methods were excluded. Data extraction focused on classification and descriptive systems of fusion evaluation, analyzing parameters such as bony bridging, angular motion, translation, hardware failure, cage migration, radiolucency, and cleft within the fusion mass.

A total of 142 articles (1995-2024) were reviewed. Computerized tomography was the most common imaging modality (102, 71.8%), followed by static (96, 67.6%) and dynamic radiographs (88, 62%). Descriptive criteria were used in 108 studies (76.1%) and classification systems in 47 (33.1%). Interbody fusion was assessed in 90 articles (63.4%) and posterolateral fusion in 68 (47.9%). Bony bridging continuity was the most reported descriptive criterion (105, 73.9%), followed by angular motion (72, 50.7%) and translation (43, 30.3%). Radiolucency was reported around the cage (31, 21.8%), pedicle screws (17, 11.9%), and within the fusion mass (36, 25.4%) to describe nonunion. Common classification systems included Bridwell (10 studies), Brantigan (9), and Lenke (9).

This scoping review highlights the variability in lumbar fusion assessment across RCTs and FDA trials. Over time, assessment methods have evolved from static radiographs to greater use of dynamic imaging and classification systems in the mid-2000s, with CT emerging as the dominant modality in the past decade. Despite these advancements, fusion assessment criteria remain inconsistent across studies.

Systematic Review and Meta-Analysis.

Degenerative cervical myelopathy (DCM), the leading cause of spinal cord injury globally, may clinically manifest with hand numbness and tingling, loss of hand dexterity and impaired balance and gait. Biomarkers have been identified as disease indicators with recent studies exploring the role of structural and inflammatory biomarkers in diagnostic and treatment outcome prediction. The review aims to identify relevant cerebrospinal fluid (CSF) and blood-based biomarkers associated with DCM diagnosis and prognostication.

The systematic review was conducted as per PRISMA guidelines. A comprehensive search strategy was devised to identify articles evaluating biomarkers in DCM and comparative control cohorts. The studies were screened by two independent reviewers and discrepancies resolved by a third author. Study characteristics were recorded, and data synthesis was performed to allow for pooled analyses. The quality of included studies and risk of bias were assessed using the QUADAS-2 tool.

A total of 17 studies incorporating 699 individuals with DCM and 475 controls were included. 9 studies evaluated CSF biomarkers while 6 and 2 studies reviewed blood-based and CSF-to-serum quotients, respectively. Pooled analyses revealed significantly higher levels of NF-L and IL-6, albumin-Q, IgA-Q, and IgG-Q in the DCM cohort as compared to the control group.

This systematic review highlights the structural and inflammatory biomarkers that can be potentially used as substitutes for diagnosing and prognosticating outcomes for DCM. The findings further suggest the need for larger prospective studies to assess the clinical relevance of these biomarkers in DCM management.

A systematic review and meta-analysis.

To estimate reoperation rate after lumbar disc herniation surgery and identify associated risk factors.

We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, and Embase to April 2025 for English-language randomized controlled trials and observational studies reporting risk factors and reoperation rates. Two reviewers independently screened studies, extracted data, and assessed quality using the Newcastle–Ottawa Scale and Cochrane Risk of Bias 2.0 tool. Meta-analysis used fixed-effect model.

Twenty-five studies (1,031,348 patients) met the inclusion criteria. The pooled reoperation rate was 8.5% (95% CI: 6.2%-11.6%), rising with follow-up: 4% at ≤1 year, 11.1% at 1-5 years, and 8.8% beyond 5 years (P < 0.0001 for subgroup differences). Smoking (OR 1.39; 95% CI: 1.09-1.78), older age (OR 1.52; 95% CI: 1.25-1.85), and large annular defect size (OR 2.19; 95% CI: 1.07-4.48) were significant risk factors; sex was not (OR 1.22; 95% CI: 0.96-1.55). Diabetes and certain surgical techniques were also linked to higher risk in individual studies. Adjustment for publication bias increased the overall pooled rate to 10.3% (95% CI: 7.6%-14.0%).

Reoperation rates after lumbar disc herniation surgery differ by follow-up duration: 4% at ≤1 year, 11.1% at 1-5 years, and 8.8% beyond 5 years. Smoking, older age, diabetes, and large annular defects were significant risk factors. Recognizing high-risk patients can support decisions for extended conservative care or closer follow-up. Further studies should compare revision techniques to improve long-term outcomes.

Narrative Review.

Recent studies have separated assessment of sarcopenia into two main categories within spine surgery: (1) general sarcopenia assessing systemic muscle degeneration and (2) spine-specific sarcopenia assessing muscle degeneration within the more localized paraspinal musculature. We sought to highlight challenges in optimizing outcomes for adult spinal deformity (ASD) patients with sarcopenia and evaluate the effectiveness of using general and spine-specific sarcopenia metrics for prognostication.

We evaluated the relationship between sarcopenia and surgical outcomes in ASD, explored methods for assessing sarcopenia, and provided recommendations for managing ASD patients with consideration of sarcopenia based on literature review. Global and spine-specific sarcopenia assessment approaches were compared, emphasizing the impact of diagnostic methods, such as MRI and clinical performance tests, on outcome prediction.

The large variability in sarcopenia measurement methods significantly affected its prognostic utility in ASD treatment. Studies using the psoas muscle to define global sarcopenia revealed mixed results for prediction. Meanwhile, assessments focusing on fatty infiltration of paraspinal muscles showed stronger correlations with complications than general sarcopenia markers.

Standardizing sarcopenia assessment in ASD is essential to facilitating its integration into clinical practice. Assessments focusing on paraspinal muscle quality demonstrated stronger associations with complications than general sarcopenia markers, underscoring the dissociation between systemic and spine-specific muscle health. Hence, future studies should refine sarcopenia metrics for spine-specific assessment as opposed to global metrics. Research should also be done to optimize interventions specifically targeting spinal sarcopenia to potentially enhance surgical outcomes. Adopting consistent, targeted sarcopenia evaluation can contribute to safer, more effective treatment pathways for ASD patients.

Systematic Review.

Enhanced Recovery After Surgery (ERAS) is a widely acknowledged approach for improving surgical outcomes. This review aims at analyzing the characteristics of study populations, interventions and outcomes in spine patients.

Embase and Ovid were searched from inception until March 2025. We followed PRISMA guidelines. Study quality and risk of bias were assessed. In addition to a narrative synthesis of the evidence, a meta-analysis of RCTs evaluating length of stay (LOS) for a lumbar spine population was conducted. This review was registered prospectively on PROSPERO (No. CRD42025638293).

1431 records were identified, from which 81 studies were included. Reports of ERAS predominantly exist for degenerative spine pathologies (n = 35/81, 43.2%) and spinal deformities (n = 29/81, 35.8%). Most studied interventions were postoperative analgesia, early mobilisation (both n = 61/81, 75.3%) and patient education (n = 60, 74.1%). The most frequently used outcome measures were LOS (n = 65/81, 92.9%) and complication rates (n = 40/81, 49.4%). The overall median complication rate for ERAS patients was found to be lower (8.8% vs 15.6%). There was a statistically non-significant tendency for ERAS shortening LOS for 1 day in lumbar spine patients [95%CI -2.77, 0.71; P = 0.25].

ERAS in spine surgery appears to be effective in terms of reducing LOS and complication rates. Further efforts at refining pain management and targeted disease-specific interventions are required. Whether ERAS interventions applied to individuals with significant neurological impairment and/or medical frailty, can influence surgical outcomes needs to be further studied.