Introduction: Skeletal-related events (SREs), including pathological fractures and spinal cord compression, significantly reduce the quality of life and survival in patients with metastatic spinal tumors. Although multidisciplinary "liaison treatment" has been implemented at our institution to detect and manage all metastatic spinal lesions, some patients still develop SREs. This study aims to analyze the characteristics and circumstances of patients who experienced SREs despite this system, with particular focus on referrals from other hospitals.

Methods: We reviewed patients who developed SREs between December 2013 and December 2023 at our institution. Clinical data including age, sex, performance status (PS), spinal instability neoplastic score (SINS), primary tumor type, spinal lesion level, histologic subtype, epidural spinal cord compression (ESCC) grade, and timing of spine intervention were analyzed. PS at initial and final visits was compared using the Wilcoxon signed-rank test.

Results: Among 1,479 patients with metastatic spinal tumors, 72 (4.8%) developed SREs. Median age was 71 years; 69% were male. PS significantly improved from 3.1 to 2.4 (p = 0.0002). SINS averaged 8.9, with 72.4% of cases showing intermediate instability. Thoracic spine involvement was most frequent (59.7%). Prostate, lung, and breast cancers accounted for over 50% of cases. ESCC grade ≥II was present in 62.5%. Notably, 54.2% (39/72) were referred after the onset of an SRE; 77% of these occurred at other hospitals. Furthermore, 69.5% had no prior cancer diagnosis before the SRE.

Conclusions: Despite an in-house liaison system, SREs frequently occurred in patients referred from external institutions. Early recognition of red-flag symptoms, such as back pain in cancer patients and timely referral for imaging and specialist evaluation are essential. Regional collaboration and education are crucial to prevent avoidable SREs.

Introduction: To compare the prognostic accuracy of eight widely used scoring systems and their Primary Tumor-Independent (PTI) versions in untreated patients with spinal metastases (SPM).

Methods: Data from 108 untreated patients with SPM diagnosed between 2017 and 2023 were retrospectively analyzed. Prognostic accuracy was assessed for eight scoring systems: Skeletal Oncology Research Group (SORG) Nomogram, New Katagiri score, Revised Tokuhashi Score, Tomita Score, New England Metastatic Spinal Score, Modified Bauer Score, Oswestry Spinal Risk Index, and van der Linden Score. PTI versions were also evaluated by excluding primary tumor information. Predictive accuracy was assessed using receiver operating characteristic analysis at 90 days, 180 days, and 1 year.

Results: At 90 days, the New Katagiri score demonstrated the highest predictive accuracy (area under the curve [AUC] = 0.788). The SORG Nomogram exhibited the highest accuracy at 180 days (AUC = 0.759) and 1 year (AUC = 0.749). In PTI analysis, the SORG Nomogram-PTI retained the highest accuracy at 90 days (AUC = 0.728) and 180 days (AUC = 0.719).

Conclusions: The New Katagiri score and the SORG Nomogram demonstrated high prognostic accuracy for untreated SPM patients, with the SORG Nomogram-PTI maintaining strong predictive performance even without primary tumor information. These scoring systems are valuable tools for survival estimation and clinical decision-making in this challenging patient population.

Introduction: Postoperative progression of ossification of the posterior longitudinal ligament (OPLL) has been noted after posterior decompression surgery that does not involve direct resection of OPLL. It appeared that posterior decompression and fusion (PDF) may be more effective in preventing OPLL progression than posterior decompression alone; however, the connection between progression and the extent of fixation remains unclear. This study aimed to identify the ideal fixation range in PDF concerning the progression of OPLL after surgery. We also examined the OPLL progression characteristics post-PDF and the correlation between progression and fixation range.

Methods: This retrospective study included 52 patients with cervical OPLL who underwent PDF and had both pre- and post-operative computed tomography images. We examined OPLL progression in thickness, width, and sagittal extension at each vertebra and intervertebral level. We statistically compared patient demographics and radiological data in patients with and without OPLL progression.

Results: Throughout the average follow-up of 3.0 years, OPLL progression was observed in the fixed segments in one case (1.9%). However, 16 cases (31%) exhibited progression in the adjacent levels to the fusion. In one case (1.9%), reoperation was necessary owing to spinal cord compression resulting from the advanced OPLL. A comparison of patients with and without OPLL progression revealed that those with progression had a notably higher rate of nonbridged OPLL in the adjacent intervertebral space (94.1% versus 31.4%; p < 0.001). A multivariate logistic analysis revealed that fewer fixation levels and nonbridged OPLL adjacent to the fixation were independent risk factors for OPLL progression.

Conclusions: Fixation with instrumentation could prevent OPLL progression in the fixation area in 98% of cases. However, 31% of cases progressed at the adjacent segment to the fixed end. Nonbridged OPLL at the segment adjacent to the fixation and fewer fixation levels were significant risk factors for OPLL progression.

Introduction: Distal adding-on (DA) is a common radiographic complication following selective thoracic fusion for Lenke type 1A adolescent idiopathic scoliosis (AIS). This study aimed to investigate whether intraoperative radiographs can predict postoperative DA in Lenke type 1A AIS.

Methods: A total of 79 patients with AIS and Lenke type 1A (group A) who underwent posterior selective thoracic fusion were retrospectively evaluated. For comparison, another 79 patients with Lenke type 1B and 1C (group BC) were included. The occurrence and factors associated with DA at 2 years postoperatively were investigated using intraoperative radiographs.

Results: Of 158 total cases, eight patients (10%) in group A and 13 (16%) in group BC developed DA at two years postoperatively. Intraoperative radiographs in group A showed that the mean angulation of the first disc below the lowest instrumented vertebra (LIV) was significantly greater in the DA group (−2.3 ± 2.3°) compared to the non-DA group (−0.6 ± 1.7°). Patients with angulation of the first disc below the LIV greater than 3° were significantly associated with DA (odds ratio, 18.0; p < 0.01) in group A, as well as in group BC (odds ratio, 22.0; p < 0.01). In group A, the mean intraoperative LIV tilt angle was greater in the DA group (4.8 ± 7.0°) than in the non-DA group (1.2 ± 3.7°), with greater tilt observed in 1A-L (L4 tilted left) compared to type 1A-R (L4 tilted right). Multivariate analysis revealed that intraoperative LIV tilt was significantly associated with DA in group A, but not in group BC.

Conclusions: Intraoperative radiographs showing angulation greater than 3° at the first disc below the LIV and larger LIV tilt angles were significantly associated with postoperative DA in Lenke type 1A. Surgeons should strive to achieve horizontalization of the LIV intraoperatively, especially in Lenke type 1A-L curves, to avoid postoperative DA.

Background: The study examined sex-specific associations between Schmorl' s nodes (SNs), Modic changes (MC), and osteoporosis (OP) in the low thoracolumbar region (Th10/11-L5/S1) using magnetic resonance imaging (MRI).

Methods: This study included 970 participants (317 males, mean age = 67.2 years; 653 females, mean age = 66.0 years) aged 21-97 years from the Wakayama Spine Study. SN was defined as a small, well-defined herniation pit with a surrounding wall of hypointense signal. MC was defined as a diffuse high-signal change along either endplate. OP was defined according to the Japanese Society for Bone and Mineral Research criteria. We evaluated the prevalence of SN at each level and its detailed distribution in males and females. Univariate logistic regression analysis examined the association between the presence of SN in the low thoracolumbar region and age strata, body mass index (BMI), OP, and MC in males and females. Multiple logistic regression analysis identified independent factors, with significant factors in the univariate logistic regression analysis used as independent variables.

Results: Infemales, but not males, advanced age was significantly associated with SN after adjustment for smoking and alcohol (50-59 years: odds ratio [OR] 3.2; 60-69 years: OR 6.0; 70-79 years: OR 12.1; >80 years: OR 14.8). OP and BMI were not significantly associated with SN in either males or females. MC was significantly associated with SN in females (OR, 1.5).

Conclusions: This study demonstrated that SN was associated with MC, but not OP, in females. These findings may help elucidate the causes and mechanisms of SN.

Background: Lumbar lordosis (LL) varies with posture due to spinal mobility. The difference in LL (DiLL) between supine and standing positions (DiLL: supine LL − standing LL) is a novel dynamic parameter reflecting functional spinal alignment. Recent studies suggest its potential utility in predicting outcomes after lumbar spine surgery.

Methods: A narrative review of the literature was conducted to examine posture-related changes in LL, with a particular focus on DiLL. Recent studies assessing LL in different postures and its association with postoperative outcomes following lumbar decompression and fusion surgeries were included.

Results: Standing LL is typically greater than supine LL in healthy individuals, resulting in negative DiLL. However, elderly individuals and patients with adult spinal deformity (ASD) often show positive DiLL, indicating reduced ability to maintain lordosis when standing. Patients with a positive DiLL value (DiLL [+]) tend to have worse postoperative outcomes than DiLL (−) patients after short-segment fusion or decompression surgeries. Among DiLL (+) patients, those with mild or no vacuum phenomena in non-fused intervertebral discs (retaining postoperative mobility) exhibited better surgical outcomes than those with severe vacuum phenomena in such discs.

Conclusions: DiLL is an easily obtainable dynamic parameter using standard imaging and may serve as a useful predictor of surgical outcomes, particularly in procedures that preserve lumbar mobility. While static parameters like pelvic incidence-LL mismatch remain essential in long-segment fusions, DiLL provides additional insight into functional alignment. In lumbar decompression or short-segment fusion surgeries, DiLL (+) patients who are expected to have non-fused intervertebral discs with severe disc vacuum phenomena postoperatively may experience poorer surgical outcomes. Therefore, if such patients present with severe ASD-specific symptoms, such as fatigue-induced low back pain when standing, we recommend considering long-segment fusion surgery or informing patients about the potential for residual postoperative symptoms and postoperative kyphosis.

Introduction: Patients with adolescent idiopathic scoliosis (AIS) frequently have cervical kyphosis, and, although it can be significantly improved by scoliosis correction surgery, cervical kyphosis remains frequent even after surgery. It has been reported that cervical kyphosis can increase the risk of pain, degenerative disc disease, and reduced quality of life, even in patients with AIS. However, it is unclear what indicators we should aim for during scoliosis correction surgery to prevent residual cervical kyphosis after surgery.

Methods: A total of 45 consecutive patients (41 women, 4 men) with Lenke type 1 or 2 AIS who received posterior corrective surgery and were followed up for a minimum of 2 years were included. Data were extracted from our prospectively collected database. The patients were divided into 2 subgroups: those with cervical hyperkyphosis (cervical lordosis ≤−10°) and those without. We investigated the alignment we should aim for during posterior thoracic correction surgery to prevent postoperative cervical hyperkyphosis. According to the previous study, we focused particularly on upper thoracic kyphosis (TK1-5).

Results: The cervical hyperkyphosis group was characterized by a large preoperative cervical kyphosis, a small preoperative and postoperative TK1-5, and a small postoperative T1 slope. In our multivariate logistic regression analysis, we found that postoperative TK1-5 was an independent associated factor for postoperative cervical hyperkyphosis.

Conclusions: We clarified that during posterior correction surgery for Lenke type 1 and 2 curves AIS, formation of kyphosis in the thoracic spine, especially in the upper thoracic spine, is important for preventing postoperative cervical hyperkyphosis.

Introduction: Intramedullary spinal cord tumors (IMSCTs) are rare lesions associated with significant neurological impairment and decreased quality of life. Surgical resection is the primary treatment option; however, postoperative recovery is often limited and functional outcomes vary considerably. Although cigarette smoking is known to adversely affect outcomes in various spinal disorders, its impact on IMSCT surgery remains unclear. This study aimed to determine the influence of cigarette smoking on surgical outcomes and perioperative complications in patients with IMSCTs.

Methods: This retrospective comparative study included 194 consecutive patients with IMSCTs who underwent surgical resection between 2012 and 2022. Participants were categorized into smoker (n = 35) and nonsmoker (n = 159) groups based on smoking status. Demographic, surgical, and clinical outcomes were compared between the two groups.

Results: The smoker group had significantly lower pre- and postoperative Japanese Orthopaedic Association (JOA) scores for cervical and thoracic lesions than the nonsmoker group, with no significant improvement observed at the final follow-up. However, there were no significant differences between the groups in other demographic data, surgical data, perioperative complications, or postoperative modified McCormick scale grade changes for either cervical or thoracic IMSCTs. In addition, preoperative smoking status (the number of cigarettes smoked/day, years of smoking, total number of smoked cigarettes) showed no significant correlation with pre- or postoperative JOA scores.

Conclusions: Although smoking does not affect the incidence of perioperative complications, it negatively impacts JOA scores in patients with IMSCTs, regardless of the number of cigarettes smoked or the duration of smoking.

Introduction: The application of intraoperative computed tomography (CT) navigation in anterior cervical spine surgery remains limited because of challenges in securing a stable reference frame during supine positioning and the absence of reliable bony landmarks in the anterior cervical region. To overcome these limitations, we propose a novel technique involving reference frame placement on the proximal diaphysis of the clavicle and evaluate its feasibility and navigation accuracy.

Technical Note: Five patients (4 males, 1 female; mean age 59 ± 15 years) underwent anterior cervical surgery for cervical ossification of the posterior longitudinal ligament (n = 2), cervical disc herniation (n = 2), and cervical spondylotic amyotrophy (n = 1).

The reference frame was affixed to the clavicle contralateral to the operating surgeon. Intraoperative CT scans were obtained using a robotic C-arm angiography system and navigation was performed via an optical surgical navigation system. Navigation accuracy was assessed in 3 planes: mediolateral (x), craniocaudal (y), and anteroposterior (z).

Navigation errors (mean ± standard deviation) were 0.29 ± 0.24 mm (x), 0.47 ± 0.31 mm (y), and 0.64 ± 0.59 mm (z), all within clinically acceptable limits. No intraoperative or postoperative complications, including clavicle fracture, subclavian vessel injury, or supraclavicular nerve damage, were observed. Compared with previously reported techniques, this method demonstrated favorable accuracy.

Conclusions: Clavicle-based reference frame placement offers high navigation accuracy and technical feasibility in anterior cervical spine surgery. Larger studies are warranted to confirm its clinical utility and safety.

Introduction: Osteoporotic vertebral fractures (OVFs) are the most common type of fragility fracture in elderly patients with osteoporosis. Bracing is widely used for conservative treatment; however, few studies have objectively assessed patient adherence to prescribed brace usage. This prospective study aimed to evaluate true patient compliance with the Jewett brace for acute OVFs using a temperature logger embedded in the brace.

Methods: Patients aged ≥65 years with an acute OVF diagnosed within two weeks of injury were enrolled between February 2024 and January 2025. After two weeks of bed rest, patients began ambulation while wearing a Jewett brace. A button-type temperature logger was installed on the sternal pad of the brace to record the temperature every 30 minutes for 42 consecutive days. Wearing was defined as temperatures ≥30°C. Based on previous reports, wearing the brace for 15 hours daily was defined as 100% compliance. Compliance was calculated for the entire period, for hospitalization versus post-discharge, and at three 14-day intervals. Correlations between vertebral instability and compliance were also analyzed.

Results: A total of 17 patients were included in the final analysis. The mean overall compliance rate was 85.8%, corresponding to an average wearing time of 12.9 hours per day. Brace compliance was consistently maintained at a high level during hospitalization and after discharge, as well as across the first, second, and last 14-day intervals. The daily wearing rate peaked at approximately 80% around mealtimes and remained above 70% during daytime hours. A significant, moderately positive correlation was observed between vertebral instability and compliance in the last 14 days.

Conclusions: This study objectively demonstrated a remarkably high patient compliance rate of 85.8% (12.9 hours per day) with Jewett braces for OVFs during the 42-day period following the initial two-week hospitalized bed rest.

Introduction: Postoperative shoulder imbalance (PSI) is a cosmetically and psychologically significant complication following surgical correction of adolescent idiopathic scoliosis (AIS). While commonly studied in thoracic curve patterns, its occurrence in Lenke type 5 curves remains under-investigated. This study aimed to identify radiographic predictors of PSI in Lenke type 5 AIS, with particular emphasis on preoperative fulcrum side bending (FSB) flexibility assessment.

Methods: A retrospective review was conducted on 21 patients with Lenke type 5C AIS (mean age 14.6 ± 2.6 years) who underwent posterior spinal fusion using all-pedicle screw constructs. Preoperative and postoperative radiographic parameters were analyzed, including Cobb angles of proximal thoracic, main thoracic (MT), and thoracolumbar/lumbar (TL) curves. Flexibility was assessed with active side bending (ASB) and FSB radiographs. ΔASB and ΔFSB were calculated as the difference from the standing Cobb angles. PSI was defined as a coracoid height difference ≥9 mm or a clavicle angle ≥2°.

Results: PSI occurred in 7 patients (33.3%). The PSI group showed significantly greater ΔFSB in the TL curve (41.7° ± 5.7 vs. 35.3° ± 2.2, p = 0.01), smaller ΔFSB in the MT curve (p = 0.04), and a higher TL correction rate (p = 0.03). Logistic regression identified ΔFSB in TL (odds ratio [OR] 1.21, p = 0.03) and TL correction rate (OR 1.15, p = 0.04) as independent predictors of PSI.

Conclusions: Preoperative FSB radiographs are valuable not only for estimating curve flexibility but also for identifying patients at risk of PSI in Lenke type 5 AIS. Surgeons should consider not only the absolute flexibility of each curve but also the relative flexibility between TL and MT segments when determining correction magnitude; intraoperative moderation of TL correction may be warranted when the MT segment demonstrates limited compensatory flexibility.

Objective: To present 3 cases of spontaneous cervical epidural hematoma (SCEH) with acute neurological deterioration that achieved excellent functional recovery after surgical decompression, and to evaluate the influence of surgical timing on outcomes through a literature review.

Methods: We report on 3 patients diagnosed with SCEH via cervical magnetic resonance imaging (MRI) following acute-onset neck pain, followed by hemiparesis or hemiplegia. Surgical decompression was performed at 19, 6, and 10 hours after symptom onset, respectively. A comprehensive literature review was also conducted to assess the relationship between surgical timing and neurological outcomes in SCEH.

Literature Search Strategy: We performed a literature search using PubMed as the primary database, complemented by Google Scholar, covering the period from January 1980 to March 2025. Keywords included "spinal epidural hematoma," "cervical," "spontaneous," and "surgery." Inclusion criteria were case reports, case series, or reviews describing SCEH with surgical or conservative management and reported outcomes.

Results: All 3 patients demonstrated complete neurological recovery despite presenting with severe motor deficits and undergoing surgery at different times. Their recovery periods ranged from 11 to 90 days. Our literature review, which included 158 cases, consistently indicated that surgical timing is a critical factor influencing outcomes. Specifically, 83.2% of patients showed neurological improvement with surgery within 12 hours, while 68.9% improved when operated on between 12 and 24 hours¹⁾. Another study reported 91% favorable outcomes with ultra-early intervention (within 6 hours), compared to 33% when delayed beyond 48 hours²⁾.

Limitations: The proposed treatment algorithm is based on a small number of institutional cases combined with data from a narrative literature review. A formal meta-analysis or quantitative pooled analysis was not performed; therefore, the generalizability of the algorithm should be interpreted with caution.

Conclusions: Prompt surgical decompression, ideally within 12-24 hours, can result in excellent functional recovery in SCEH, even in patients with severe initial neurological deficits. Early recognition of stroke-mimicking symptoms and urgent MRI evaluation are crucial for achieving optimal outcomes.

Background: Dialysis-related spondyloarthropathy (DRSA) is a rare but serious spinal pathology among patients on long-term dialysis, most commonly affecting the cervical spine. DRSA often requires surgical intervention by means of fusion when accompanied by substantial neurological and/or clinical symptoms, although available data are limited. This systematic review investigates the collated outcomes after cervical fusion in patients with DRSA to inform surgical decision-making and improve dialysis-related spine surgery care.

Methods: A pre-registered systematic review, conducted through June 20, 2025, searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online, and Web of Science for studies with outcome data on patients with DRSA undergoing cervical fusion. To determine study quality, the Methodological Index for Non-Randomized Studies scale was applied, and outcome certainty grading was performed. Demographics, operative details, functional recovery, and complications were extracted. Descriptive statistics were used for narrative evidence synthesis.

Results: Nine retrospective observational studies (six "moderate", three "low" quality) with "very low" outcome certainty were included out of 91 retrieved.

Patients: Patients (n = 88; 39.8% female; frequency-weighted mean [FWM] age = 60.0 ± 8.3 years; follow-up = 50.3 ± 42.3 months) were on dialysis for a FWM of 17.1 ± 7.0 years, with 3.2 ± 1.4 intervertebral levels fused (67.0% posterior-utilizing approach). Most studies (88.9%) reported that at least 80% of their cohort experienced improvements in symptoms after fusion, and the FWM postoperative Japanese Orthopaedic Association score improvement was 4.5. Pseudoarthrosis occurred at a pooled rate of 15.0%, and total complications occurred at a pooled rate of 36.3%. Infections (16.1%) were the most common complication. Complication-related mortality was reported at a pooled rate of 9.1%.

Conclusions: Cervical fusion in patients with DRSA appears to provide considerable functional improvement, though concerns remain regarding complications and mortality. Future high-quality studies of greater outcome quality and certainty are warranted to further advance evidence-based surgical decision-making in this complex yet rapidly growing dialysis-reliant population.

Background: The 25-item Geriatric Locomotive Function Scale (GLFS-25) is often used to assess locomotive syndrome stage in older adults with lumbar spinal stenosis (LSS). However, locomotive syndrome stage three encompasses a wide score range, potentially masking clinically meaningful improvements. This study aimed to establish the minimal clinically important difference (MCID) for the GLFS-25 and determine whether MCID-based assessment better reflects surgical outcomes than stage-based evaluation.

Methods: This study included 314 patients aged 65 years and older with LSS who were preoperatively classified as having locomotive syndrome stage three. Patient-reported outcome measures, including the GLFS-25, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), and Zurich Claudication Questionnaire (ZCQ), were administered before and at six months and 1 year after surgery. The MCID for the GLFS-25 was calculated using an anchor-based method, with the satisfaction item from the ZCQ at 1 year after surgery serving as the anchor. Patients were then categorized into four groups based on whether they achieved improvements in locomotive syndrome stage and/or the GLFS-25 MCID.

Results: A 19-point improvement in the GLFS-25 was determined to be the MCID, with an area under the receiver operating characteristic curve, sensitivity, and specificity of 0.80, 65.8%, and 90.2%, respectively. Based on postoperative changes, 129, 49, 33, and 103 patients achieved both stage and MCID improvement (group C), improvement in MCID alone (group M), improvement in stage alone (group S), and no improvement, respectively. Group C showed significantly better surgical effectiveness across all JOABPEQ domains. Group M showed significant improvements in four domains, whereas group S showed significant improvement in only one domain.

Conclusions: The newly established 19-point MCID for the GLFS-25 more accurately represented clinically meaningful improvement than stage-based evaluation. The combined use of MCID and stage classification may enhance outcome assessment after LSS surgery in older adults.

Introduction: Chronic low back pain (CLBP) is a complex condition significantly impacting global health. While non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for treatment, factors influencing their efficacy remain poorly understood. This study investigated the therapeutic effects of systemically acting diclofenac sodium patches in patients with CLBP and factors influencing their efficacy, focusing on psychiatric factors and neuropathic pain components in short-term (4 weeks) and long-term (12 weeks) outcomes.

Methods: This multicenter retrospective observational study included 196 patients with CLBP treated with diclofenac sodium patches (150 mg/day). The visual analog scale (VAS) evaluated the intensity of LBP. Psychiatric factors were assessed using the Brief Scale for Psychiatric Problems in Orthopedic Patients (BS-POP), and neuropathic pain was evaluated using the short form of the Spine painDETECT questionnaire (SF-SPDQ). Multiple regression analyses were performed to identify predictive factors.

Results: LBP VAS scores significantly improved from baseline (72.4 ± 15.4) to 12 weeks (42.6 ± 23.5). Among the participants, 112 (57.1%) had comorbid pain, defined as chronic musculoskeletal pain in sites other than low back and radiating leg pain. Multiple regression analysis revealed that psychiatric factors (BS-POP score; regression coefficient = −1.10, p = 0.026) and presence of comorbid pain (regression coefficient = −9.50, p = 0.021) were significant negative predictors at 4 weeks, with their impact increasing at 12 weeks (BS-POP score: regression coefficient = −2.51, p < 0.001; comorbid pain: regression coefficient = −11.73, p = 0.020). Neuropathic pain components negatively affected only short-term outcomes.

Conclusions: Psychiatric factors and comorbid pain significantly influence the efficacy of diclofenac sodium patches in CLBP treatment, with their impact increasing over time. These findings emphasize the importance of comprehensive patient assessment before initiating NSAID treatment and suggest the need for early multifaceted intervention in patients with psychiatric factors and comorbid pain.

Background: Low back pain (LBP) in children of school age has become an increasingly recognized health concern. Moreover, poor posture among children has emerged as a significant problem. However, large-scale studies evaluating the relationship between LBP prevalence and objectively measured spinal alignment using Spinal Mouse technology remain limited. This study aimed to determine the prevalence of LBP in children of school age and identify associated factors.

Methods: This cross-sectional study included 899 children (451 males, 448 females, mean age 10.6 years) who participated in the 2023 Katsuragi Integrated Defense for Locomotive Syndrome in Children (KID Locomo) study. LBP was assessed through questionnaires. Body composition and spinal alignment parameters including lumbar lordosis and sacral inclination were measured using Spinal Mouse. Associations between these parameters and LBP were evaluated considering age, sex, physical activity time, muscle mass, and postural awareness. Statistical analysis was performed using Student's t-test.

Results: LBP was present in 45 children (5.0%), with no significant sex difference (p = 0.17). The LBP group showed significantly higher values for age (12.6 vs. 10.5 years), longer weekly physical activity time (385.5 minutes vs. 219.3 minutes), appendicular skeletal muscle mass (16.0 kg vs. 12.6 kg), trunk muscle mass (18.3 kg vs. 14.9 kg), and skeletal muscle index (all p < 0.05). In addition, the LBP group had significantly higher rates of neck stiffness (46.7% vs. 7.5%), parental awareness of poor posture (75.6% vs. 52.9%), student awareness of poor posture (77.8% vs. 51.3%), and lower sitting sacral inclination (14.1° vs. 16.5°) (p < 0.05).

Conclusions: The prevalence of LBP in children of school age was 5.0%. Associated factors included older age, longer weekly physical activity time, increased muscle mass, decreased sacral inclination in sitting position, and awareness of poor posture. LBP may increase owing to growth-related changes, lifestyle factors, and postural influences.

Introduction: Intramedullary spinal cord tumors (IMSCTs) are rare tumors, with ependymoma being the most common type. Surgical resection is the main treatment, but gross total resection (GTR) carries a risk of morbidity, while subtotal resection (STR) increases the risk of recurrence. The role of adjuvant radiotherapy is debated, and chemotherapy is rarely used except for recurrence. This study aims to investigate and compare the clinical characteristics, management, and outcomes of intramedullary spinal cord ependymomas (ISCEs) comprehensively.

Methods: This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, analyzing clinical characteristics, management, and outcomes of ISCEs. Studies were screened using Population, Intervention, Comparison, Outcome, and Study design criteria, quality-assessed with Newcastle-Ottawa Scale and Risk Of Bias In Non-randomized Studies Of Interventions, and statistically analyzed with Review Manager 5.4.1 and R software, evaluating treatment efficacy and prognostic factors.

Results: GTR improves neurological function, reduces recurrence, and improves survival in IMSCTs, while STR increases the risk of recurrence, which often requires radiotherapy. The meta-analysis indicates that patients who received optimal management strategies had significantly better neurological outcomes (odds ratio: 4.65; 95% confidence interval: 1.77-12.23; p = 0.0018). Meta-analysis also showed that based on the management approach, the rate of complication, improvement, recurrence, and overall survival was 16%, 71%, 7%, and 18%, respectively.

Conclusions: Surgical strategies, individualized treatment, and advanced monitoring optimize IMSCT outcomes. Future research should standardize protocols, conduct large-scale studies, and refine adjuvant therapies to improve prognosis and quality of life.

Background: Multi-level lumbar fusion carries exceptionally high pseudarthrosis risk, with reported rates reaching 35% in contemporary series; however, the impact of proton pump inhibitors (PPIs) on fusion outcomes remains underexplored in this high-risk population. Recent evidence associates PPIs with increased pseudarthrosis in single-level cervical and lumbar fusions, given their established links to impaired bone metabolism. This study is the first to evaluate their association, specifically in multi-level lumbar fusion, where extended fusion constructs and heightened biomechanical demands amplify biological vulnerability to pseudarthrosis.

Methods: This retrospective cohort study analyzed 9,608 adults undergoing elective ≥2-level posterior lumbar interbody fusion/transforaminal lumbar interbody fusion from the TriNetX database. The exposed cohort comprised patients with sustained postoperative PPI use (≥3 months), while controls had no PPI prescriptions. Rigorous 1:1 propensity score matching (PSM) balanced 15 covariates, including demographics (age, sex, race), comorbidities (diabetes, osteoporosis, gastroesophageal reflux disease), body mass index categories, and medication exposures (nonsteroidal anti-inflammatory drugs) between cohorts. Pseudarthrosis incidence was assessed at standardized 6-month, 1-year, and 3-year postoperative intervals. Statistical significance was defined as p < 0.05.

Results: After PSM (n = 2,739 per cohort), PPI users did not demonstrate a significantly elevated pseudarthrosis risk at 6 months (17.9% vs. 16.2%; risk ratio [RR] = 1.10, p = 0.136). However, significant risk increases emerged at 1 year (20.3% vs. 16.5%; RR = 1.23, p < 0.001) and 3 years (22.0% vs. 18.9%; RR = 1.16, p < 0.01), revealing a time-dependent effect.

Conclusions: This large-scale analysis demonstrated that postoperative PPI use is significantly associated with increased long-term pseudarthrosis risk following multi-level lumbar fusion, with absolute risk elevations of 3.8% (1 year) and 3.1% (3 years), a notable finding given baseline nonunion rates reported to exceeding 35% in multilevel constructs. PPIs may thus represent a modifiable perioperative risk factor, and careful evaluation of prolonged PPI therapy is warranted to minimize the risk of compromised fusion. Optimizing perioperative PPI management may offer surgeons a tangible opportunity to improve spinal fusion outcomes.

Introduction: Although percutaneous kyphoplasty (PKP) is widely recognized as an effective treatment for osteoporotic vertebral compression fractures (VCFs), there is growing concern about the risk of subsequent VCF after the procedure. Prior studies suggest that the timing between primary VCF and PKP may affect future VCF, but there are limited data evaluating this timing, and no studies use data-driven methods to derive precise thresholds. Therefore, the aim of this study was to determine (1) the optimal time interval that minimizes the risk of 2-year subsequent VCF and (2) the impact of this interval on 90-day medical complications after PKP.

Methods: A retrospective cohort analysis in patients who underwent PKP for primary thoracic VCF from 2010 to 2022 was identified using a national administrative claims database. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between primary thoracic VCF and PKP that minimized the likelihood of subsequent VCF within 2 years of the index PKP procedure. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven association with 2-year VCF rates and compare the likelihood of various 90-day medical complications.

Results: In total, 16,197 patients who underwent PKP after primary VCF were included in this study. SSLR analysis identified two timing thresholds: 0 weeks (Same-Day cohort) and 1 to 30 weeks (Delayed cohort). The Same-Day cohort was significantly less likely to experience 2-year subsequent VCF than was the Delayed cohort (odds ratios: 0.52; 95% confidence interval: 0.47-0.56; p < 0.001).

Discussion: Early PKP significantly reduces the risk of 2-year subsequent VCFs compared with delayed intervention by nearly 50%. During this preoperative period, patient optimization should be prioritized to enhance management outcomes, allowing a careful balance between timely intervention and comprehensive patient evaluation.

Introduction: The Japanese Scoliosis Society conducted a survey on the complications of pediatric spinal deformity surgeries in 2012, 2014, and 2017. However, a registry-based survey was necessary to systematically and comprehensively identify complications, and a web-based registry system was established. This study aimed to investigate the frequency of pediatric spinal deformity surgeries and perioperative complications in Japan in 2022, using a web-based registry.

Methods: Of the 158,263 cases collected from 1,032 institutions, 1,945 (485 boys and 1,460 girls) were included in the study. The diagnoses were idiopathic scoliosis (64.9%), congenital scoliosis (10.1%), neuromuscular scoliosis (7.4%), congenital kyphoscoliosis (1.1%), and others (16.5%). The intraoperative, postoperative (within 30 days), and systemic (within 30 days postoperatively) complications were investigated.

Results: The overall complication rate was 6.0% (intraoperative, 2.5%; postoperative, 2.4%; and systemic, 2.0%). The complication rates by diagnosis were highest in congenital kyphosis (25.0%), followed by congenital kyphoscoliosis (18.2%) and neuromuscular scoliosis (13.3%), whereas idiopathic scoliosis (10-18 years old) had a complication rate of 3.7%. The most common intraoperative complications were massive bleeding (>2,000 mL) in 0.9%, dural tears in 0.7%, and nerve injury in 0.2% of the patients. The most frequent postoperative complications were neurologic deficits (0.8%), surgical site infections (0.8%), and implant failure (0.5%). The most frequent postoperative systemic complications were respiratory (0.6%) and urinary (0.4%).

Conclusions: This nationwide web-based registry study provides a highly comprehensive report on pediatric scoliosis surgery in Japan in 2022. The complication rates were notably high for congenital kyphosis, congenital kyphoscoliosis, and neuromuscular scoliosis. These findings may help improve patient and family understanding of the risks associated with various spinal deformities and support shared decision-making in pediatric surgical care.

Introduction: Some adult patients with spinal deformities show a sloping spine, not kyphosis, with severe global malalignment and deterioration of patient-reported outcome measures (PROMs). The purpose of this study was to elucidate sloping-type deformities on the basis of radiographic parameters and PROMs.

Methods: This study included participants from a health screening program with sagittal vertical axis (SVA) >40 mm. The sloping-type deformity (S group) was defined as the deformity in which all posterior vertebral walls were positioned anteriorly to the vertical line extending from the posterior end of the sacrum on standing whole-spine lateral radiographs. SVA, thoracic kyphosis (TK), lumbar lordosis (LL), L4-S angle, pelvic incidence (PI), and pelvic tilt (PT) were measured. PROMs were evaluated using the Oswestry Disability Index (ODI).

Results: A total of 348 participants (142 men and 206 women; average age 75.8 years) were included in the study, and 50 participants (14.4%) were classified into the S group. The mean age and measured variables of the S and non–sloping-type (non-S) group were 76.1, 72.6 years; SVA 111, 79 mm; TK 24, 35°; L4-S 15, 30°; PI 58, 49°; PT 27, 21°; PI-LL 28, 14°; and ODI 22, 15%, respectively. There were 30 participants (60%) with evident lumbar anterolisthesis in the S group and 76 (25.5%) in the non-S group (p < 0.001). The S group had larger SVA, PI, PT, and PI-LL (all p < 0.001) and lower TK and L4-S angle (both p < 0.001) than did the non-S group. The S group showed an inferior ODI to that of the non-S group (p = 0.012).

Conclusions: The sloping-type deformity showed a significantly higher PI, and worse spinopelvic alignment and PROMs. The significant factors contributing to the incidence of sloping-type deformities were higher PI, prevalence of lumbar anteriolisthesis, and lower TK and L4-S angle.

Introduction: Pedicle screw placement can be technically challenging in anatomically narrow pedicles, such as those in the thoracic spine or in older patients. Although smaller screws preserve cortical integrity, they may compromise fixation strength. Conversely, oversized pedicle screws that breach the pedicle cortex may enhance anchorage but raise concerns about potential neurovascular injury.

Methods: We performed a cadaveric biomechanical study using 36 thoracic and lumbar vertebrae harvested from five older donors. Each vertebra received an oversized screw that intentionally breached the pedicle cortex on one side and a smaller intracortical screw on the contralateral side. Four vertebrae were excluded owing to fracture during testing, leaving 32 vertebrae for analysis. After cyclic loading, pullout strength was measured. Subgroup and multivariate analyses were conducted based on pedicle diameter, vertebral level, and insertion side.

Results: Oversized screws indicated superior pullout strength in 20 of the 32 analyzed vertebrae. When the breach percentage exceeded 40%, oversized screws generally outperformed intracortical screws. Subgroup analysis revealed a significant advantage of oversized screws in narrow pedicles (<5 mm), where they increased pullout strength. In contrast, a decrease in strength was observed in wide pedicles (≥5 mm). Multivariate analysis identified pedicle diameter as the only independent predictor of strength improvement.

Conclusions: Oversized screws provide stronger fixation than do intracortical screws, particularly in anatomically narrow pedicles where cortical contact is limited. These findings suggest a potential biomechanical advantage of oversized screws in selected patients. However, careful consideration of anatomical risk and patient-specific factors is essential to minimize neurological complications.

Introduction: Double crush syndrome (DCS) refers to compressive neuropathy at multiple sites along a peripheral nerve (PN), yet its relevance in the lower extremity remains poorly defined. This study aimed to (1) determine the prevalence of PN lesions in patients undergoing surgery for lumbosacral radiculopathy (LR), (2) identify commonly affected nerves, (3) assess associated risk factors, and (4) evaluate the DCS hypothesis by comparing the incidence of PN lesions in patients undergoing surgery for LR versus matched controls.

Methods: A retrospective cohort study was conducted using the PearlDiver database (2010-2022) to identify adult patients who underwent lumbar decompression and/or fusion for LR. PN lesions diagnosed within two years before or after surgery were categorized by nerve. Univariate logistic regression was used to identify risk factors. A matched control cohort without LR was created using propensity score matching to evaluate the DCS hypothesis.

Results: Of 650,562 patients undergoing surgery for LR, 32,909 (5.1%) were diagnosed with a PN lesion, with 60.6% occurring before and 38.4% after surgery. The most commonly affected nerves were the sciatic (31.7%), plantar (16.1%), and peroneal (11.2%). Risk factors for PN lesions included female gender (odds ratio [OR]: 1.22), age 50-59 years (OR: 1.23) and 60-69 years (OR: 1.17), and higher comorbidity burden with Elixhauser Comorbidity Index ≥5 (OR: 1.50). Comorbid conditions associated with increased risk included complex regional pain syndrome (OR: 3.33), fibromyalgia (OR: 1.73), and osteoarthritis (OR: 1.61). Compared to matched controls, patients with LR were significantly more likely to develop a PN lesion (OR: 3.10).

Conclusions: PN lesions affect over 5% of patients undergoing surgery for LR and are significantly more common than in controls, supporting the DCS hypothesis in the lower extremity. Clinicians should maintain a broad differential diagnosis when evaluating radicular symptoms, especially in patients with high comorbidity burden or recurrent postoperative pain.

Introduction: Double-door laminoplasty is a common surgical approach; however, implant displacement and hinge fractures can cause lamina closure, leading to unfavorable outcomes. A novel clip-type implant has been introduced to improve rigid fixation safely; however, its biomechanical stability, compared with that of hydroxyapatite (HA) spacers, has not yet been evaluated. Therefore, the aim of this study was to compare the mechanical stability of polyetheretherketone clip implants versus that of HA spacers in freshly frozen cadaveric cervical spines.

Methods: Seven freshly frozen cervical spines were used in this study. Double-door laminoplasty was performed at the C3-C6 cervical vertebral level. Clip-type implants and HA spacers were alternately placed on each specimen. Strain gauges were used to measure lamina displacement and reaction force at 0-mm to 2.5-mm lateral displacement. The reaction forces between the clip implant and HA spacer groups were compared.

Results: Polyetheretherketone clip-type implants had significantly higher reaction force values than HA spacers at all displacement levels (p < 0.001). Clip-type implants exhibited a 1.5- to 1.7-times higher reaction force than that of spacers at the middle of the lamina and a 1.9- to 2.0-times higher reaction force than that of spacers at the tip of the lamina.

Conclusions: Novel clip-type implants provide greater stability than HA spacers. To the best of our knowledge, this study is the first to demonstrate the superior biomechanical stability of clip implants.

Background: Spinal deformities occur in 10 to 77% of neurofibromatosis type 1 (NF1) cases. The dystrophic type of NF1 progresses rapidly and can cause severe neurological complications if left untreated. Surgical intervention is necessary, as bracing is ineffective. Although the joint anterior-posterior (AP) approach provides better correction than single approaches, it carries higher surgical risks, leading to an ongoing debate about optimal treatment strategies.

Methods: A systematic search was conducted across the Scopus, Embase, PubMed, and Google Scholar databases from inception to June 2024. Data on clinical characteristics, treatment approaches, radiological and functional outcomes, and complications were systematically collected and synthesized in a narrative format.

Results: Six studies involving 124 patients were analyzed, comprising five case series and one retrospective observational study. The AP approach showed better correction outcomes than the anterior-only (AO) and posterior-only approaches. All surgical approaches resulted in significant functional improvements, as reflected by increased Japanese Orthopaedic Association/modified Japanese Orthopaedic Association scores, decreased Visual Analog Scale scores, and reduced Neck Disability Index scores. However, the AP approach was associated with a higher incidence of complications, while the AO approach had the lowest incidence.

Conclusions: Existing evidence demonstrates that the AP approach leads to a better degree of correction than the AO or posterior-only approaches, despite higher complication rates. The dual mechanism of anterior reconstruction and posterior stabilization effectively addresses the challenges associated with dystrophic cervical kyphosis in patients with NF1.

Introduction: Brace treatment is an essential nonoperative strategy to prevent curve progression in adolescent idiopathic scoliosis (AIS), yet it can cause substantial psychological stress. However, few studies have investigated factors associated with brace-related psychological stress. This study aimed to evaluate the association between pre-bracing health-related quality of life (HRQOL) and brace-related psychological stress during treatment.

Methods: This study retrospectively analyzed female patients with AIS aged 10-15 years who initiated brace treatment at a single center. Inclusion criteria were a baseline Cobb angle of 20-40°, initiation of full-time bracing, and completion of standardized questionnaires. Baseline assessments included demographic and radiographic data, as well as patient-reported outcomes: the Scoliosis Research Society-22r and the Scoliosis Japanese Questionnaire-27 (SJ-27). Brace-related psychological stress was assessed at multiple time points during the first year using the Japanese version of the Bad Sobernheim Stress Questionnaire-Brace (JBSSQ-Brace). A linear mixed-effects model was used to identify baseline factors associated with higher stress levels over time.

Results: A total of 151 patients (mean age 12.4 ± 1.1 years) were included. At one month, 32.5% of patients reported moderate to severe stress (JBSSQ-Brace ≤16), and 11.8% of the total cohort experienced worsening stress during the first six months. In multivariable analysis, a higher baseline SJ-27 score was significantly associated with increased brace-related psychological stress over time (β = −0.15 ± 0.04, p < 0.001). Other factors, including age, skeletal maturity, pre-bracing Cobb angle, and in-brace correction rate, were not significant.

Conclusions: Lower pre-bracing HRQOL, as measured by the SJ-27, was independently associated with increased psychological stress during brace treatment. Early psychological screening using AIS-specific HRQOL tools may help identify high-risk patients and provide timely support to improve compliance and treatment outcomes.

Introduction: High rates of postoperative rod fracture at the lumbosacral junction have been reported after long spinopelvic fixation. In the prevention of rod fractures, supplemental accessory rods (ARs) and lateral interbody fusion are commonly used and reportedly effective. However, the optimal AR placement to mitigate rod stress at the lumbosacral junction is unclear.We therefore used a synthetic bone model and a finite element model concurrently to address their respective shortcomings.

Methods: Both models included the lumbar spine (L1-L5) and the pelvis, and were instrumented with a screw and rod system and lateral interbody fusion cages to closely resemble actual surgical procedures. The four different constructs were: two primary rods (PRs) without ARs, PRs + contoured long ARs, PRs + short ARs, and PRs + straight long ARs. In our synthetic model, we applied vertical load to the constructs and measured rod strain at L5-S1 using strain gauges. We calculated a mean value of the five rods in each construct. In our finite element model, we measured maximum principal stresses at L5-S1 after the application of flexion/extension, lateral bending, and axial rotation loads.

Results: In our synthetic bone model, there was significant reduction of rod strain by 52% in PRs + straight long ARs compared with PRs without ARs (p= 0·023). A reduction of average principal stress in the finite element model was observed in PRs + straight long ARs by up to 44·2% (highest against flexion load) compared with PRs without ARs.

Conclusions: We conducted concurrent biomechanical analyses using a synthetic bone model and a finite element model. We recommend straight long ARs to prevent rod fracture at the lumbosacral junction in long spinopelvic fixation.

Introduction: Ultrasound-guided cervical nerve root block (US-CNRB) is increasingly recognized as a safer alternative to fluoroscopy-guided procedures for treating cervical radiculopathy, owing to its ability to visualize neural and vascular structures in real time and to avoid exposure to radiation and contrast media. However, its clinical adoption remains limited due to concerns regarding inadvertent vascular puncture and misidentification of cervical levels. This study focuses on anatomical anomalies at the C6 and C7 levels, which are critical to the accuracy and safety of US-CNRB, and investigates the prevalence of morphological variations using cervical computed tomography (CT).

Methods: This retrospective observational study included patients who underwent cervical CT between April 2018 and March 2020. Patients with tumors, rheumatoid arthritis, infectious spondylitis, destructive spondyloarthropathy, or a history of cervical spine surgery were excluded.

Axial and sagittal CT images were analyzed to assess two specific anatomical variants: absence of the anterior tubercle at C6 and presence of the anterior tubercle at C7. Two board-certified orthopedic spine surgeons independently assessed the images. Descriptive statistics and Cohen' s kappa coefficient were used for analysis, with a p < 0.05 considered statistically significant.

Results: We included 671 patients (359 females, 312 males; mean age: 62.1 years). Anatomical variants were observed in 1.34% (9/671) of cases: absence of the anterior tubercle at the C6 vertebra in 0.45% and presence of the anterior tubercle at C7 in 0.89%. No patient had both anomalies. Interobserver agreement was high, with disagreement in only one case. The Cohen' s kappa coefficient for interobserver reliability was 0.97.

Conclusions: Although rare, anatomical anomalies at C6 and C7 can obscure critical landmarks during US-CNRB, increasing the risk of level misidentification and procedural errors. Recognizing these variants through preprocedural imaging is essential to improve the safety and precision of cervical spine interventions.

Introduction: Anterior cervical discectomy and fusion (ACDF) is a common procedure for cervical degenerative disc disease, with a growing shift toward outpatient surgery. Despite advancements enabling shorter hospital stays, same-day discharge remains a complex decision influenced by factors such as case timing and surgeon-specific practices. This study aims to identify patient and operational factors associated with same-day discharge following ACDF.

Methods: We retrospectively analyzed all elective ACDF procedures performed by 24 different surgeons across 3 affiliated hospitals within a large urban health system between January 2021 and December 2022. Patient and clinical factors, case timing, and surgeon-specific practices were compared between patients who received same-day discharge and those who were admitted on the same day following ACDF.

Results: Among the 530 elective ACDF procedures analyzed, 18.5% resulted in same-day discharge. Same-day discharge occurred significantly more frequently in procedures involving fewer operative levels, no surgical drain, and lower estimated blood loss (EBL). In contrast, factors such as age, Charlson Comorbidity Index, American Society of Anesthesiologists score, and preoperative antiplatelet or anticoagulation use did not significantly impact discharge rates. Earlier case completion times were strongly associated with same-day discharge, with 69.4% of such discharges occurring in cases completed before 14:00. Surgeon preference emerged as a key determinant, with the 15 surgeons who performed 10 or more procedures falling into 3 distinct categories: those who never, rarely, or routinely discharged patients on the same day.

Conclusions: Surgeon preference plays a critical role in shaping discharge decisions following ACDF. Alongside case complexity, EBL, drain usage, and timing, surgeon preference strongly influences whether a patient is discharged on the same day. Identifying and understanding the concerns underlying variable surgeon practice patterns will help promote standardization of discharge criteria, optimize selection for same-day discharge, and improve healthcare resource utilization.

Introduction: Intradiscal therapy with condoliase is becoming one of the minimally invasive treatment options for lumbar disc herniation (LDH). However, evidence regarding its efficacy in elderly populations remains scarce. The purpose of this study is to reveal the efficacy of condoliase treatment for LDH in patients over the age of 70 years.

Methods: The patients with LDH who received condoliase treatment in our institution with a follow-up period of 1 year were enrolled in this study. The patients were divided into two groups according to age: group E (>70 years) and group C (20-70 years). To assess clinical outcomes, visual analog scale (VAS) scores for leg and back pain and the Oswestry Disability Index (ODI) were obtained. Disc height and degeneration were evaluated using magnetic resonance imaging. Treatment was considered effective if the VAS scores for leg pain improved by ≥50% at 1 year and surgery was avoided.

Results: A total of 121 patients were enrolled in the study. The therapy was effective in 12 of 17 patients (70.6%) in group E and 79 of 104 patients (76.0%) in group C. The deterioration rate of Pfirrmann grade was significantly higher in group C than in group E (53.9% vs. 7.1%). Improvements in VAS scores and ODIs were comparable between the two groups. There were no significant differences in disc height reduction or herniation reduction rates between the groups. Despite disc degeneration, herniation reduction was observed, accompanied by a decrease in disc height.

Conclusions: Chemonucleolysis with condoliase is effective in treating LDH in patients over 70 years of age, affording outcomes comparable to those in younger patients. Despite disc degeneration, herniation reduction was observed accompanied by a decrease in disc height. Condoliase offers a less invasive alternative for treating elderly patients with multiple comorbidities. Careful patient selection is critical for ensuring optimal clinical results.

Introduction: To evaluate the differences in anterior spinal bridging and sagittal spinal parameters between patients with diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) using whole-spine computed tomography (CT).

Methods: This retrospective study included patients with DISH (n = 111) and AS (n = 27). The number of anterior spinal bridges and sagittal spinal parameters was evaluated. The sagittal vertical axis (SVA) evaluated by whole-spine CT was defined as sup-SVA. Patients were further evaluated by matching their age and sex.

Results: Anterior spinal bridging frequently occurred in the thoracic spine in DISH and AS. In AS, bridging occurred in the lumbar spine according to the number of anterior spinal bridges. Sup-SVA and T5-T12 thoracic kyphosis (TK) were significantly greater in AS, and lumbar lordosis (LL) was significantly smaller in AS. TK was greater according to the number of anterior spinal bridges in both DISH and AS. Sup-SVA in DISH was greater according to the number of anterior spinal bridges, especially in the thoracic spine, whereas it was greater according to the lumbar in AS. LL in AS was smaller according to the number of lumbar bridges. Sup-SVA in DISH correlated with TK, whereas it correlated with both TK and LL in AS.

Conclusions: In patients with AS, the spine tends to bridge from the lumbar to the thoracic spine, causing kyphosis in the thoracolumbar spine. In patients with DISH, the spine tends to bridge from the thoracic spine, causing kyphosis in the thoracic spine. Thus, sup-SVA is greater in AS than in DISH.

Background: Low back pain (LBP) is a leading cause of disability worldwide, particularly in aging populations. While the Oswestry Disability Index (ODI) is widely used to assess LBP-related disability, few studies have evaluated its long-term trajectory and predictive factors in general populations.

Methods: This 7-year longitudinal study included 553 community-dwelling adults (mean age 66.3 years) from the Wakayama Spine Study, a population-based sub-cohort of the Research on Osteoarthritis/Osteoporosis against Disability (ROAD) study. Participants completed whole-spine magnetic resonance imaging and responded to the ODI questionnaire at baseline and follow-up. Disability levels were classified as mild (0%-20%), moderate (21%-40%), or severe (41%-60%). Longitudinal transitions in disability categories were analyzed descriptively. Multiple linear regression was used to identify predictors of ODI deterioration.

Results: The mean ODI score significantly increased from 9.6 ± 11.5 at baseline to 12.2 ± 14.2 after 7 years (p < 0.001), although the change did not reach clinical significance. Among participants initially classified as mildly disabled (n = 468), 88.0% remained stable, while 12.0% worsened. Of those with moderate disability (n = 73), 35.6% improved, 44.0% remained unchanged, and 20.5% worsened. No participant with severe disability (n = 40) improved to mild. Female sex, older age, higher body mass index, and vertebral fractures (semiquantitative grade ≥2) were significant predictors of worsening disability (p < 0.05). Higher baseline ODI was inversely associated with deterioration.

Conclusions: In this population-based cohort, LBP-related disability modestly worsened over 7 years. Older adults, women, individuals with obesity, and those with vertebral fractures were at greatest risk. These findings support early intervention and screening strategies to prevent disability progression in at-risk populations.

Background: Surgical decompression is necessary for anterior paradiscal-type thoracic spine tuberculosis with a neurological deficit; nevertheless, if pedicle screw fixation is unsuccessful, laminectomy may result in pan-vertebral instability. No available studies compare traditional anterolateral decompression (ALD) with the convenient, less extensive technique of transpedicular decompression (TPD).

Methods: This randomized comparative study of 20 cases of thoracic spine tuberculosis (T2-T12) used a posterior midline surgical approach with pedicle screw instrumentation. Diseased pedicle removal by eggshell technique (TPD) was compared with decompression by removal of the posterior part of the rib, transverse process, pedicle, and posterolateral part of the diseased vertebral body (ALD).

Results: Both groups had similar lengths of skin incision, intraoperative blood loss, and blood transfusion, but the duration of surgery was significantly less (p -value 0.019) in the TPD (156.5 minutes) than in the ALD group (184.5 minutes). Additional hemi-laminotomy was needed in two cases of TP, in the absence of liquid pus. Both groups showed similar neurological recovery except for one case of multidrug resistance in the ALD group. Improvements in the modified Japanese Orthopedics Association score (p = 0.719); visual analog scale (p = 0.259) and Nurick scale (p = 0.387) had no statistical difference between the two groups. Mean kyphosis correction of 6.64⁰ and 6.45⁰ and mean loss of correction at 2-years were 4.74⁰ and 1.98⁰ in the TPD and ALD groups, respectively. Complications included one case of superficial and deep infection in each group.

Conclusions: Similar outcomes of both approaches. TPD is quicker but may need hemi-laminotomy in the absence of liquid pus. ALD enables thick organized pus removal without compromising lamina in paradiscal-tuberculosis.

Introduction: Endoscopic spine surgery (ESS) presents advantages over traditional microscopic techniques but faces limitations in terms of field of view and depth perception. Virtual reality (VR) devices offer solutions by integrating real-time digital images into the surgical field, enabling magnification and teleproctoring.

Methods: The study was conducted in two phases. In the first phase, 55 surgeons completed a pre-use questionnaire. In the second phase, 19 surgeons participated in cadaveric practical training using the device and completed a post-use survey. Data were analyzed using R software.

Results: Following device use, surgeon confidence in magnification increased significantly (from 21% to 57%), with improved perception of image quality. Acceptance of teleproctoring rose from 33% to 94.7%. The device was considered superior to the operating microscope in both image quality and ergonomics.

Conclusions: VR head-mounted devices enhance visualization in ESS, allow intraoperative access to imaging, and support remote guidance via teleproctoring. Their adoption may contribute to improved training, planning, and surgeon ergonomics. However, additional controlled studies are required to determine their effects on clinical outcomes and operative performance.

Introduction: This study aimed to identify the factors associated with the postoperative deterioration of sagittal balance after surgery for adult spinal deformity (ASD), focusing on preoperative alignment and pelvic incidence (PI).

Methods: We retrospectively reviewed the medical records of 87 patients who underwent corrective surgery for ASD (2017-2020). Sagittal balance was assessed using the sagittal balance classification (SBC). The patients were classified as balanced (maintained SBC grade 1 or 2) or imbalanced (deteriorated to grade 3). Radiographic parameters, clinical outcomes (Japanese Orthopedics Association scores and mechanical complications), and bone mineral density were analyzed.

Results: In 15 patients (17.2%), the sagittal balance deteriorated to grade 3 (imbalanced group). Factors significantly associated with postoperative deterioration of sagittal balance included preoperative grade 3 SBC (73.3% vs. 23.6%, p < 0.001), steroid use (26.7% vs. 2.8%, p < 0.01), pelvic fusion (80% vs. 51.4%, p = 0.049), higher preoperative PI, sacral slope, and sagittal vertical axis. At 2 years, the imbalanced group showed a significantly greater corrective loss of the lumbar spine. Receiver operating curve analysis identified preoperative PI ≥52.1° as predictive of postoperative imbalance (sensitivity 86.7%, specificity 66.7%). The clinical outcomes were similar, but the reoperation rates were higher in the imbalanced group (20.0% vs. 2.8%, p = 0.03).

Conclusions: High preoperative PI, severe sagittal imbalance, steroid use, and pelvic fusion were predictive of postoperative sagittal balance deterioration, underscoring the need for personalized preoperative planning.

Background: Although spine surgery has a high number of patented technologies, there has been little prior application of bibliometric analyses to effectively evaluate the technological literature in the cervical spine field. The aim of this review is to summarize and identify current patent trends in technologies for the stabilization and surgical management of cervical spine pathologies.

Methods: Multiple databases were systematically queried using Lens.org to identify technology patents designed to stabilize or surgically manage cervical spine injury or disease. The patents were then ordered by forward citation count, and the top 50 unique patents were included and organized into five categories: fusion/stabilization/fixation devices, external brace/supporter devices, arthroplasty implants, surgical instruments, and spacer/expansion devices. Subsequent assessments included patent priority year, publication year, priority region, legal status, and rank.

Results: The search results on March 11, 2024, yielded 440 patents published between 1973 and 2014. Of the top 50 most-cited patents, fusion/stabilization/fixation devices were the most common (27), followed by external brace/support devices (18). Patents for fusion/stabilization/fixation devices were more recent, peaking in 2001. The most common patents in the first to third quintiles were for fusion/stabilization/fixation devices.

Conclusions: Most patents before 1995 were for cervical brace and supporter devices. Since the turn of the 21st century, patented surgical fusion/fixation/stabilization devices have markedly increased. Further analysis of trends in cervical spine device technology can assist in guiding future innovation efforts.

Background: Prolapsed lumbar intervertebral disc (IVD) is a prevalent spinal cause of low back pain associated with radicular pain. Platelet-rich plasma (PRP) has emerged as a potential alternative to epidural steroid injections. This review aimed to compare the efficacy of epidural PRP and epidural steroid injections in treating low back pain due to prolapsed lumbar IVD, assessed using a pain scale and Oswestry' s disability index (ODI).

Methods: A systematic search of 4 databases (PubMed, Scopus, ScienceDirect, and Cochrane Central Register of Controlled Trials) up to July 2024 for randomized controlled trials comparing epidural PRP with steroids. Risk of Bias 2 was used for bias assessment. Pain and ODI mean differences (MDs) were calculated using RevMan v5.4. Heterogeneity was measured using I², with random or fixed effects applied accordingly. The combined outcome progression of pain and ODI scores were computed using STATA/MP 17.0 software.

Results: Three trials (n = 132) were included. At 1 month, epidural steroid injections showed lower pain scores than PRP (standard MD = 1.04, 95% confidence interval [CI]: 0.63-1.46, p< 0.00001, I² = 0%). At 6 months, epidural PRP injection demonstrated greater pain relief (MD = −1.51, 95% CI: −1.98 to −1.05, p < 0.00001, I² = 0%) and lower ODI (MD = −9.71, 95% CI: −16.63 to −2.78, p = 0.006, I² = 75%). Epidural steroids showed significant worsening in pain score (1 vs 3 months, p = 0.001; 3 vs 6 months, p = 0.003).

Conclusions: Epidural PRP provides sustained and gradual improvement of pain and ODI for patients with prolapsed lumbar IVD over months of follow-up, while steroids provide initial relief at 1 month but are associated with worsening at later follow-ups.

Background: Symptomatic lumbar foraminal stenosis (LFS) occurs when the neuroforamen narrows, compressing the exiting spinal nerve, leading to symptoms such as radicular pain, paresthesias, and potentially weakness. Although cross-sectional imaging studies are used for diagnostic purposes, there is no clear consensus as to which grading system best evaluates LFS, predisposing to inconsistencies in care. This systematic review aimed to evaluate and compare existing published grading systems for LFS to identify (1) systems most used within the literature and (2) the most effective and reliable method for classifying anatomic severity and clinical symptom correlation.

Methods: This study is a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, analyzing available literature on grading systems for LFS, level of evidence IV. A comprehensive search of PubMed, Embase, and Cochrane Trials was conducted from inception through July 2024. Eligible studies were evaluated for methods, bias, sample size, patient demographics, imaging modalities, and grading systems. Bias was assessed using the Methodological Index for Non-Randomized Studies. Data were synthesized narratively and descriptively.

Results: The review included 35 studies, most using magnetic resonance imaging (88.6%). Seven grading systems have been identified. The original Lee et al. grading system was the most frequently used LFS grading system (69%), followed by Wildermuth et al. (14.3%). Notably, artificial intelligence (AI) grading systems were included in two studies (5.7%). Findings regarding symptom correlation were mixed.

Conclusions: The Lee et al. grading system remains the most used grading system for LFS in the literature and is reliable. Several small studies found an association between the Lee et al. system and clinical symptoms/treatment outcomes; however, this was not universally found. Further investigation is needed to validate the newer grading. The introduction of AI may offer promise for refining the diagnostic and clinical utility of published LFS grading systems.

Lumbar disc herniation (LDH) is one of the main causes of low back pain, and far lateral lumbar disc herniation is a specific type of LDH. Owing to the limitation of the bony structure and surrounding ligaments in the foraminal area, the closer the protrusion inside and outside the foramen is to the exiting nerve root ganglia, the more severe the compression. Therefore, the clinical symptoms of this type of LDH are more pronounced, and timely diagnosis and treatment are required. Some patients can experience pain relief through conservative treatment, whereas others require surgical intervention. Spine surgeons can choose different surgical options according to the patient's condition and their own surgical habits, such as traditional surgery, microendoscopic discectomy, percutaneous endoscopic lumbar discectomy, and unilateral biportal endoscopy. There are different characteristics between traditional surgery and minimally invasive surgery, and there are also different characteristics between different minimally invasive surgeries. This article reviews the anatomical structure, clinical manifestations, and various treatment approaches.

Introduction: Proximal junctional kyphosis (PJK) in patients undergoing instrumented deformity correction surgery for adult spinal deformity (ASD) is found to be multifactorial. This review aims to provide comprehensive information on which factors affect PJK in ASD correction surgery including prevention strategies.

Materials and Methods: A literature review was conducted through a web search on PubMed with the following combination keywords: "proximal junctional kyphosis," "adult spinal deformity," and "risk factor" between January 2001 and June 2024. Primary outcomes of interest were divided into two groups: non-radiological parameters including patient characteristics and surgical techniques, and radiological parameters.

Results: The non-radiological parameters associated with PJK included age, body mass index, comorbidities, low bone quality, muscle degeneration, combined anterior–posterior surgical approach, rigid proximal instrumentation, upper instrumented vertebrae (UIV) selection in the junctional zone, long-segment fusion, and overcorrection. Moreover, lumbar lordosis, spinopelvic parameter, thoracic tilt, upper instrumented vertebra–femoral angle, fused spinopelvic angle, and UIV inclination were found to be the radiological parameters that influence the incidence of PJK in patient with ASD correction surgery.

Conclusion: Understanding the multifactorial aspects of PJK could aid in the preoperative planning and assessment for patients with ASD. Furthermore, the proposed correction should be based on an individualized approach.