Mateo Tomas Fariña Nuñez, Sven Theiler, Inka Berglar, Massimo Barbagallo, Massimo Bottini, Victor Gabriel El-Hajj, Stefanos Voglis, Nicolai Maldaner, Tamas F. Fekete, Daniel Haschtmann, Markus Loibl, Dezsö J. Jeszenszky, Maria L. Gandía-González, Menno R. Germans, David Bellut, Carlo Serra, Luca Regli, Erik Edström, Adrian Elmi-Terander, Victor E. Staartjes
Neurospine 2026;23(3):703-719. Published online July 31, 2026
Instability of the craniocervical junction is a potentially life-threatening condition requiring surgical stabilization. Traditional occipital plate fixation carries risks of construct loosening and intracranial complications due to variable skull thickness, particularly after posterior fossa decompression where plate fixation is challenging. Occipital condyle screws (OCS) provide direct fixation into the occipital condyles (OCs). However, comprehensive outcome data remains sparse. This systematic review and meta-analysis evaluated anatomical parameters, technical aspects, and surgical outcomes of OCS fixation in craniocervical stabilization. Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, PubMed/MEDLINE, Embase, and Scopus were searched for studies reporting techniques and outcomes of occipitocervical fixation using OCS. Two reviewers independently extracted data, and study quality was assessed using the Newcastle-Ottawa Scale, when possible. Random-effects meta-analysis was performed. The primary endpoint was to characterize the technical aspects of craniocervical fixation using OCS and to ascertain its overall feasibility, defined by morphometric suitability, technical success rates, and complication rates. Thirty studies met inclusion: 12 cadaveric (618 specimens), 10 imaging (1,604 participants), and 8 surgical (284 patients). Morphometry consistently showed larger OC in male populations. Bicortical screw placement achieved 100% technical success. Standard 3.5-mm screws (18–24 mm) were commonly used. Recommended trajectories varied (sagittal with 18°–28° angulation; axial with 22°–37° angulation). No major symptomatic vascular or permanent neurological complications occurred. Meta-analytic data revealed significant differences in morphometric measurements of the OC and differences in the OCS length and angulation parameters. OCS fixation appears to be an anatomically feasible and technically promising fixation strategy in selected patients when anatomy and technique are carefully evaluated. Population-specific morphometric variability mandates individualized preoperative assessment. Future comparative studies should define long-term outcomes, fusion rates, and optimize region-specific surgical parameters.
Objective To longitudinally analyze smartphone-based real-life activity data and compare it with established clinical outcome measures in patients undergoing lumbar spine surgery for sciatica, focusing on identifying divergence in recovery trajectories.
Methods Fifty patients were assessed preoperatively and at 6 weeks (6W), 3 months (3M), and 6 months (6M). Outcomes included smartphone-derived daily Step Count, objective capacity (6-minute walking test [6WT]), and subjective disability (visual analogue scale [VAS] leg/back, Core Outcome Measures Index [COMI] back, and Oswestry Disability Index [ODI]). All metrics were standardized into z-scores relative to baseline. Piecewise linear mixed-effects (LME) models compared recovery slopes across 2 segments: phase I (early: 0–6 weeks) and phase II (late: 6 weeks–6 months).
Results The cohort (mean age, 50.7 years; 24 females) included 33 patients with lumbar disc herniation and 17 with lateral recess stenosis. All measures improved significantly during phase I (all p<0.05). However, LME modeling revealed a significant interaction between time segment and measurement type in phase II. Daily Step Count was the only metric maintaining a significant, linear upward recovery slope during the late phase (β=0.31 Z/mo). Conversely, slopes for 6WT, ODI, and COMI were significantly flatter (p<0.001 vs. Step Count), indicating a statistical plateau or “ceiling effect.” Spearman correlations between Step Count and traditional metrics weakened from strong at baseline to weak at 6 months.
Conclusion Smartphone-derived real-life activity data detect continuous functional improvement up 6 months postoperatively, whereas conventional objective and subjective measures plateau by 6 weeks. Real-world activity monitoring provides a more sensitive assessment of long-term surgical success.
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From the Editor-in-Chief: Featured Articles in the April 2026 Issue Inbo Han Neurospine.2026; 23(2): 227. CrossRef
Real-World Effectiveness Versus Efficacy in a Study Environment: How Smartphones Help Capture Meaningful Patient Recovery Trajectories – A Commentary on “Physical Performance Continues to Improve After Surgery for Sciatica, Exceeding Recovery Periods of P Victor E. Staartjes Neurospine.2026; 23(2): 239. CrossRef
This paper analyzes the regulatory frameworks for artificial intelligence/machine learning AI/ML-enabled medical devices in the European Union (EU), the United States (US), and the Republic of Korea, with a focus on applications in spine surgery. The aim is to provide guidance for developers and researchers navigating regulatory pathways. A review of current literature, regulatory documents, and legislative frameworks was conducted. Key differences in regulatory bodies, risk classification, submission requirements, and approval pathways for AI/ML medical devices were examined in the EU, US, and Republic of Korea. The EU AI Act (2024) establishes a risk-based framework, requiring regulatory review based on device risk, with high-risk devices subject to stricter oversight. The US applies a more flexible approach, allowing multiple submission pathways and incorporating a focus on continuous learning. The Republic of Korea emphasizes possibilities of streamlined approval and with growing use of real-world data to support validation. Developers must ensure regulatory alignment early in the development process, focusing on key aspects like dataset quality, transparency, and continuous monitoring. Across all regions, the need for technical documentation, quality management systems, and bias mitigation are essential for approval. Developers are encouraged to adopt adaptable strategies to comply with evolving regulatory standards, ensuring models remain transparent, fair, and reliable. The EU’s comprehensive AI Act enforces stricter oversight, while the US and Korea offer more flexible pathways. Developers of spine surgery AI/ML devices must tailor development strategies to align with regional regulations, emphasizing transparent development, quality assurance, and postmarket monitoring to ensure approval success.
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Neurospine 2024;21(2):633-641. Published online June 30, 2024
Objective In the digital age, patients turn to online sources for lumbar spine fusion information, necessitating a careful study of large language models (LLMs) like chat generative pre-trained transformer (ChatGPT) for patient education.
Methods Our study aims to assess the response quality of Open AI (artificial intelligence)’s ChatGPT 3.5 and Google’s Bard to patient questions on lumbar spine fusion surgery. We identified 10 critical questions from 158 frequently asked ones via Google search, which were then presented to both chatbots. Five blinded spine surgeons rated the responses on a 4-point scale from ‘unsatisfactory’ to ‘excellent.’ The clarity and professionalism of the answers were also evaluated using a 5-point Likert scale.
Results In our evaluation of 10 questions across ChatGPT 3.5 and Bard, 97% of responses were rated as excellent or satisfactory. Specifically, ChatGPT had 62% excellent and 32% minimally clarifying responses, with only 6% needing moderate or substantial clarification. Bard’s responses were 66% excellent and 24% minimally clarifying, with 10% requiring more clarification. No significant difference was found in the overall rating distribution between the 2 models. Both struggled with 3 specific questions regarding surgical risks, success rates, and selection of surgical approaches (Q3, Q4, and Q5). Interrater reliability was low for both models (ChatGPT: k = 0.041, p = 0.622; Bard: k = -0.040, p = 0.601). While both scored well on understanding and empathy, Bard received marginally lower ratings in empathy and professionalism.
Conclusion ChatGPT3.5 and Bard effectively answered lumbar spine fusion FAQs, but further training and research are needed to solidify LLMs’ role in medical education and healthcare communication.
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Neurospine 2020;17(1):270-280. Published online January 26, 2020
Objective The patient-reported outcome measure (PROM)-based evaluation in lumbar degenerative disc disease (DDD) is today’s gold standard but has limitations. We studied the impact of lower extremity motor deficits (LEMDs) on PROMs and a new objective outcome measure.
Methods We evaluated patients with lumbar DDD from a prospective 2-center database. LEMDs were graded according to the British Medical Research Council (BMRC; 5 [normal] –0 [no movement]). The PROM-based evaluation included pain (visual analogue scale), disability (Oswestry Disability Index [ODI] & Roland-Morris Disability Index [RMDI]), and health-related quality of life (HRQoL; Short-Form 12 physical component summary/mental component summary & EuroQol-5D index). Objective functional impairment (OFI) was determined as age- and sex-adjusted Timed-Up and Go (TUG) test value.
Results One hundred five of 375 patients (28.0%) had a LEMD. Patients with LEMD had slightly higher disability (ODI: 52.8 vs. 48.2, p = 0.025; RMDI: 12.6 vs. 11.3, p = 0.034) but similar pain and HRQoL scores. OFI T-scores were significantly higher in patients with LEMD (144.2 vs. 124.3, p = 0.006). When comparing patients with high- (BMRC 0–2) vs. low-grade LEMD (BMRC 3–4), no difference was evident for the PROM-based evaluation (all p > 0.05) but patients with high-grade LEMD had markedly higher OFI T-scores (280.9 vs. 136.0, p = 0.001). Patients with LEMD had longer TUG test times and OFI T-scores than matched controls without LEMDs.
Conclusion Our data suggest that PROMs fail to sufficiently account for LEMD-associated disability, which is common and oftentimes bothersome to patients. The objective functional evaluation with the TUG test appears to be more sensitive to LEMD-associated disability. An objective functional evaluation of patients with LEMD appears reasonable.
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Standardizing Physical Activity Monitoring in Patients With Degenerative Lumbar Disorders Nicolai Maldaner, Megan Tang, Parastou Fatemi, Chris Leung, Atman Desai, Christy Tomkins-Lane, Corinna Zygourakis Neurosurgery.2024; 94(4): 788. CrossRef
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Understanding the challenges of rapid digital transformation: the case of COVID-19 pandemic in higher education Irawan Nurhas, Bayu R. Aditya, Deden W. Jacob, Jan M. Pawlowski Behaviour & Information Technology.2022; 41(13): 2924. CrossRef
XR (Extended Reality: Virtual Reality, Augmented Reality, Mixed Reality) Technology in Spine Medicine: Status Quo and Quo Vadis Tadatsugu Morimoto, Takaomi Kobayashi, Hirohito Hirata, Koji Otani, Maki Sugimoto, Masatsugu Tsukamoto, Tomohito Yoshihara, Masaya Ueno, Masaaki Mawatari Journal of Clinical Medicine.2022; 11(2): 470. CrossRef
External Validation of the Minimum Clinically Important Difference in the Timed-up-and-go Test After Surgery for Lumbar Degenerative Disc Disease Nicolai Maldaner, Marketa Sosnova, Michal Ziga, Anna M. Zeitlberger, Oliver Bozinov, Oliver P. Gautschi, Astrid Weyerbrock, Luca Regli, Martin N. Stienen Spine.2022; 47(4): 337. CrossRef
Expanding the indications for measurement of objective functional impairment in spine surgery: A pilot study of four patients with diseases affecting the spinal cord Gregor Fischer, Vincens Kälin, Oliver P. Gautschi, Oliver Bozinov, Martin N. Stienen Brain and Spine.2022; 2: 100915. CrossRef
Patients undergoing surgery for lumbar degenerative spinal disorders favor smartphone-based objective self-assessment over paper-based patient-reported outcome measures Marketa Sosnova, Anna Maria Zeitlberger, Michal Ziga, Oliver P. Gautschi, Luca Regli, Astrid Weyerbrock, Oliver Bozinov, Martin N. Stienen, Nicolai Maldaner The Spine Journal.2021; 21(4): 610. CrossRef
Assessment of the Minimum Clinically Important Difference in the Smartphone-based 6-minute Walking Test After Surgery for Lumbar Degenerative Disc Disease Anna M. Zeitlberger, Marketa Sosnova, Michal Ziga, Luca Regli, Oliver Bozinov, Astrid Weyerbrock, Martin N. Stienen, Nicolai Maldaner Spine.2021; 46(18): E959. CrossRef
Longitudinal smartphone-based self-assessment of objective functional impairment in patients undergoing surgery for lumbar degenerative disc disease: initial experience Marketa Sosnova, Anna Maria Zeitlberger, Michal Ziga, Oliver P. Gautschi, Astrid Weyerbrock, Martin N. Stienen, Nicolai Maldaner Acta Neurochirurgica.2020; 162(9): 2061. CrossRef
Subjective and Objective Measures of Symptoms, Function, and Outcome in Patients With Degenerative Spine Disease Nicolai Maldaner, Martin Nikolaus Stienen Arthritis Care & Research.2020; 72(S10): 183. CrossRef
Evaluation of the 6-minute walking test as a smartphone app-based self-measurement of objective functional impairment in patients with lumbar degenerative disc disease Nicolai Maldaner, Marketa Sosnova, Anna M. Zeitlberger, Michal Ziga, Oliver P. Gautschi, Luca Regli, Astrid Weyerbrock, Martin N. Stienen, _ _ Journal of Neurosurgery: Spine.2020; 33(6): 779. CrossRef
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