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.
Coccydynia is a painful condition of the coccyx that is frequently misdiagnosed and managed inconsistently. This review summarizes and grades the current evidence on diagnostic strategies and treatment options. We systematically searched the literature and included 42 studies covering conservative, interventional, and surgical management. Based on these data, we propose a current best framework for diagnostic evaluation and therapeutic management. Initial assessment should include detailed history and focused examination with palpation for localized coccygeal tenderness and symptom provocation. Standard anteroposterior and lateral radiographs are recommended mainly to exclude serious pathology, while dynamic sitting-standing radiographs can be considered when mechanical pain is suspected and symptoms persist. Cross-sectional imaging with magnetic resonance imaging or computed tomography (CT) should be reserved for trauma, red-flag features, suspected neoplasm or infection, or inconclusive basic imaging. First-line treatment should consist of education, ergonomic advice, offloading strategies, nonsteroidal anti-inflammatory drugs or other simple analgesics, and physiotherapy, with extracorporeal shock wave therapy having the strongest support. In patients with persistent pain, image-guided diagnostic and therapeutic injections and radiofrequency procedures can provide substantial relief and help select candidates for more invasive treatment. Coccygectomy should be reserved for patients with chronic, function-limiting pain who have failed conservative and interventional care and show concordant findings on assessment, imaging, and diagnostic blocks, while modified incision strategies and minimally invasive techniques may be considered in selected cases.
Paulina Cewe, Victor E. Staartjes, Victor Gabriel El-Hajj, Ihab Ahmad Al-Rikabi, Basel Musmar, Joana M Roy, Dennis Troung, Mats Beckman, Marcus Ohlsson, Pascal Jabbour, Adrian Elmi-Terander, Erik Edström
Neurospine 2025;22(4):905-915. Published online December 31, 2025
Objective Traumatic vertebral artery injuries (tVAIs) are uncommon but potentially devastating if missed. While computed tomography angiography (CTA) is routinely used for diagnosis, data on the number needed to image (NNI) remain limited. We hence analyzed tVAI epidemiology and imaging practices at a major Scandinavian level 1 trauma center.
Methods A retrospective study (2013–2020) was performed based on a single-center trauma registry. Patients were grouped based on CTA imaging protocol used; selective screening (2013–2017) and universal screening (2018–2020). Imaging protocols, treatment strategies, and outcomes were analyzed.
Results Among 2,843 patients admitted with level 1 trauma and receiving CTA imaging, 62 had a tVAI (2.2%) yielding a NNI of 46 patients to diagnose 1 tVAI. Twenty-five of these patients (40.3%) were found to have a posterior circulation stroke, resulting in an incidence of 0.9%, and a NNI of 114 to diagnose 1 stroke on CTA. NNIs for both tVAI and stroke detection increased with adoption of universal screening (tVAI: 35→65; stroke: 90→149). However, the detection rate of tVAI during the universal screening period was not significantly higher than during the selective screening period (p=0.261).
Conclusion In our level 1 trauma cohort, the incidence of tVAI was 2.2% and stroke rate 0.9%. The NNI rose with universal screening, yet detection rates did not improve. These findings suggest that selective screening based on risk factors may be more efficient than a universal approach. Further research is needed to balance diagnostic accuracy with resource use in trauma care.
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Optimizing Diagnostic Yield: Evidence Against Universal Computed Tomography Angiography for Traumatic Vertebral Artery Injury Screening – A Commentary on “Epidemiology and Screening of Traumatic Vertebral Artery Injuries at a Large Scandinavian Level 1 Tr Jae Taek Hong Neurospine.2025; 22(4): 916. CrossRef
From the Editor-in-Chief: Featured Articles in the December 2025 Issue Inbo Han Neurospine.2025; 22(4): 877. 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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Artificial intelligence in spine surgery: a scoping review Anis Choucha, Morgane Evin, Matteo de Simone, Guillaume Dannhoff, Henry Dufour, Valentin Avinens, Kaissar Farah, Florian Saby, Stephane Fuentes Neurochirurgie.2026; 72(1): 101764. CrossRef
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Objective Virtual and augmented reality have enjoyed increased attention in spine surgery. Preoperative planning, pedicle screw placement, and surgical training are among the most studied use cases. Identifying osseous structures is a key aspect of navigating a 3-dimensional virtual reconstruction. To automate the otherwise time-consuming process of labeling vertebrae on each slice individually, we propose a fully automated pipeline that automates segmentation on computed tomography (CT) and which can form the basis for further virtual or augmented reality application and radiomic analysis.
Methods Based on a large public dataset of annotated vertebral CT scans, we first trained a YOLOv8m (You-Only-Look-Once algorithm, Version 8 and size medium) to detect each vertebra individually. On the then cropped images, a 2D-U-Net was developed and externally validated on 2 different public datasets.
Results Two hundred fourteen CT scans (cervical, thoracic, or lumbar spine) were used for model training, and 40 scans were used for external validation. Vertebra recognition achieved a mAP50 (mean average precision with Jaccard threshold of 0.5) of over 0.84, and the segmentation algorithm attained a mean Dice score of 0.75 ± 0.14 at internal, 0.77 ± 0.12 and 0.82 ± 0.14 at external validation, respectively.
Conclusion We propose a 2-stage approach consisting of single vertebra labeling by an object detection algorithm followed by semantic segmentation. In our externally validated pilot study, we demonstrate robust performance for our object detection network in identifying individual vertebrae, as well as for our segmentation model in precisely delineating the bony structures.
Artificial intelligence in spine surgery: a scoping review Anis Choucha, Morgane Evin, Matteo de Simone, Guillaume Dannhoff, Henry Dufour, Valentin Avinens, Kaissar Farah, Florian Saby, Stephane Fuentes Neurochirurgie.2026; 72(1): 101764. CrossRef
Deep Learning-Based Projection Angle Estimation for Lumbar Oblique Radiography: A Two-Stage Object Detection Approach Using Vertebral–Pedicle Ratio Analysis Riria Yamamoto, Kaori Tsutsumi, Takaaki Yoshimura, Hiroyuki Sugimori Applied Sciences.2026; 16(6): 2800. CrossRef
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Objective Computed tomography (CT) imaging is a cornerstone in the assessment of patients with spinal trauma and in the planning of spinal interventions. However, CT studies are associated with logistical problems, acquisition costs, and radiation exposure. In this proof-of-concept study, the feasibility of generating synthetic spinal CT images using biplanar radiographs was explored. This could expand the potential applications of x-ray machines pre-, post-, and even intraoperatively.
Methods A cohort of 209 patients who underwent spinal CT imaging from the VerSe2020 dataset was used to train the algorithm. The model was subsequently evaluated using an internal and external validation set containing 55 from the VerSe2020 dataset and a subset of 56 images from the CTSpine1K dataset, respectively. Digitally reconstructed radiographs served as input for training and evaluation of the 2-dimensional (2D)-to-3-dimentional (3D) generative adversarial model. Model performance was assessed using peak signal to noise ratio (PSNR), structural similarity index (SSIM), and cosine similarity (CS).
Results At external validation, the developed model achieved a PSNR of 21.139 ± 1.018 dB (mean ± standard deviation). The SSIM and CS amounted to 0.947 ± 0.010 and 0.671 ± 0.691, respectively.
Conclusion Generating an artificial 3D output from 2D imaging is challenging, especially for spinal imaging, where x-rays are known to deliver insufficient information frequently. Although the synthetic CT scans derived from our model do not perfectly match their ground truth CT, our proof-of-concept study warrants further exploration of the potential of this technology.
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Artificial intelligence in spine surgery: a scoping review Anis Choucha, Morgane Evin, Matteo de Simone, Guillaume Dannhoff, Henry Dufour, Valentin Avinens, Kaissar Farah, Florian Saby, Stephane Fuentes Neurochirurgie.2026; 72(1): 101764. CrossRef
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Objective The 5-repetition-sit-to-stand (5R-STS) test is an objective test of functional impairment- commonly used in various diseases, including lumbar degenerative disc diseases. It is used to measure the severity of disease and to monitor recovery. We aimed to evaluate reference values for the test, as well as factors predicting 5R-STS performance in healthy adults.
Methods Healthy adults ( > 18 years of age) were recruited, and their 5R-STS time was measured. Their age, sex, weight, height, body mass index (BMI), smoking status, education level, work situation and EuroQOL-5D Healthy & Anxiety category were recorded. Linear regression analysis was employed to identify predictors of 5R-STS performance.
Results We included 172 individuals with mean age of 39.4 ± 14.1 years and mean BMI of 24.0 ± 4.0 kg/m2. Females constituted 57%. Average 5R-STS time was 6.21 ± 1.92 seconds, with an upper limit of normal of 12.39 seconds. In a multivariable model, age (regression coefficient [RC], 0.07; 95% confidence interval [CI], 0.05/0.09; p < 0.001), male sex (RC, -0.87; 95% CI, -1.50 to -0.23; p = 0.008), BMI (RC, 0.40; 95% CI, 0.10–0.71; p = 0.010), height (RC, 0.13; 95% CI, 0.04–0.22; p = 0.006), and houseworker status (RC, -1.62; 95% CI, -2.93 to -0.32; p = 0.016) were significantly associated with 5R-STS time. Anxiety and depression did not influence performance significantly (RC, 0.82; 95% CI, -0.14 to 1.77; p = 0.097).
Conclusion The presented reference values can be applied as normative data for 5R-STS in healthy adults, and are necessary to judge what constitutes abnormal performance. We identified several significant factors associated with 5R-STS performance that may be used to calculate individualized expected test times.
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Objective There have been no clinical studies comparing different robotic techniques. We compare minimally invasive, robot-guided transforaminal lumbar interbody fusion (RGTLIF) and mini-open robot-guided posterior lumbar interbody fusion (RG-PLIF).
Methods Using data from a prospective institutional registry, we identified 38 patients who underwent RG-PLIF. Propensity score matching using a nearest-neighbor algorithm was implemented to select RG-TLIF controls. Twelve-month patient-reported outcome measures are presented. A reduction of ≥ 30% from baseline was defined as the minimum clinically important difference (MCID).
Results Among the 76 included patients, there was no difference between RG-TLIF and RG-PLIF in surgical time (132.3 ± 29.4 minutes vs. 156.5 ± 53.0 minutes, p = 0.162), length of stay (55.9 ± 20.0 hours vs. 57.2 ± 18.8 hours, p = 0.683), and radiation dose area product (310.6 ± 126.1 mGy × cm2 vs. 287.9 ± 90.3 mGy × cm2, p = 0.370). However, while there was no difference among the 2 groups in terms of raw postoperative patient-reported outcome measures scores (all p > 0.05), MCID in leg pain was greater for RG-PLIF (55.3% vs. 78.9%, p = 0.028), and MCID in Oswestry Disability Index was greater for RG-TLIF (92.1% vs. 68.4%, p = 0.009). There was no difference concerning back pain (81.6% vs. 68.4%, p = 0.185).
Conclusion Our findings suggest that both RG-TLIF and RG-PLIF are viable and equally effective techniques in robotic spine surgery.
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Objective While it has been established that surgery for lumbar disc herniation, excluding emergent indications, should only be performed after weeks of conservative treatment, it has also been established that late surgery is associated with poorer outscomes in terms of leg pain. However, nothing is known concerning the timinig and functional outcome. We quantify the association of time to surgery (TTS) with functional impairment outcome and identify a maximum TTS cutoff.
Methods A consecutive series of patients who underwent tubular microdiscectomy for lumbar disc herniation was included. A reduction of ≥ 30% in the Oswestry Disability Index from baseline to 12 months was defined as the minimum clinically important difference (MCID). TTS was defined as time of symptom onset to surgery in weeks. The maximum TTS cutoffs were derived both quantitatively by an area under the curve (AUC) analysis, as well as qualitatively based on cutoff-specific MCID rates.
Results Inclusion was met by 372 patients, among which 327 (87.9%) achieved MCID. MCID achievement was associated with lower TTS (hazard ratio, 0.725; 95% confidence interval, 0.557–0.944; p = 0.014). The optimum maximum TTS based on AUC was 21.5 weeks. The qualitative analysis showed a continuous drop of MCID rates with increasing TTS, with values > 80% until week 14.
Conclusion Our findings suggest that longer TTS is associated with a poorer patient-reported outcome in terms of functional impairment, and that—depending on the calculation method and according to the literature—a maximum TTS of between 14 to 22 weeks should likely be aimed for.
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