Waeel O. Hamouda, Stipe Ćorluka, Sathish Muthu, Luca Ambrosio, Carla Cunha, Stjepan Ivandic, Mohamed A.R. Soliman, Fabrizio Russo, Sibylle Grad, In Ho Han, Gianluca Vadala, Hans-Jorg Meisel, Sam K. Cho, Tim S. Yoon, Jeffrey C. Wang, Amit Jain, Zorica Buser, AO Spine Knowledge Forum Degenerative
Neurospine 2026;23(1):109-116. Published online January 31, 2026
Objective Bracing after lumbar discectomy surgery (LDS) is a controversial topic with paucity of related scientific literature. Previous surveys on spine surgeons’ preferences were limited both in geographical coverage and number of respondents. The aim of this study is to fill this gap in the literature.
Methods An international online survey among AO Spine members regarding the postoperative recommendations for bracing (PoBr), activity restriction (AR), and associated factors, was performed.
Results A total of 703 spine surgeons participated in the survey of which 34% recommended PoBr, with half of them reported usage for 4 weeks. Main influencing variables were being from Europe/South Africa region, greater extent of bony decompression, and larger amount of excised disc material. Seventy-nine percent of the respondents recommended postoperative AR. Prolonged standing, prolonged sitting, and driving were usually restricted for 2 weeks. Bending, twisting, lifting, and low-intensity physical activities for 3 months, while high-intensity physical activities and direct contact sports for 6 months were restricted.
Conclusion Despite recent literature insights showing limited evidence of efficacy, 34% and 80% of a large cohort of international surgeons practice bracing and recommend AR after LDS for variable durations. Extensive bony decompression and radical discectomy significantly influenced the decision to brace, similarly endoscopic approaches and radical discectomy influenced the decision to restrict activity. These findings emphasize the persistent evidence-practice gap and the wide variability on the global level. More randomized controlled trials are warranted on this topic to reach an evidence-based recommendation.
Objective This systematic review and meta-analysis aimed to compare endoscopic discectomy (ED) with microdiscectomy (MD) for lumbar disc herniation, evaluating patient-reported outcomes, perioperative parameters, and complications to determine if ED could replace MD as the gold standard.
Methods Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, we searched PubMed, Embase, Scopus, and Web of Science (January 2000–June 2025) for randomized controlled trials (RCTs) and prospective cohort studies comparing MD with ED subtypes (transforaminal endoscopic lumbar discectomy [TELD], interlaminar endoscopic lumbar discectomy [IELD], and unilateral biportal endoscopy [UBE]). Outcomes included Oswestry Disability Index (ODI), visual analogue scale (VAS) for pain, operative time, hospital stay, complications, and recurrence. Pooled mean differences and odds ratios (ORs) were calculated using random-effects models, with subgroup analyses by ED subtype. Risk of bias was assessed using RoB 2.0 and ROBINS-I tools.
Results Seventeen studies (9 RCTs, 8 cohorts; n=3,115) were included. ED significantly reduced hospital stay (mean difference, -2.43 days; 95% CI, -3.62 to -1.23; p<0.05) and showed greater short-term ODI improvement (mean difference, 2.13; 95% CI, 0.58–3.67). No differences were observed in operative time, long-term ODI, or VAS scores. ED had lower wound complications but a higher recurrence risk with TELD (OR, ~2.0). High heterogeneity (I²>95%) and limited long-term data (>2 years) were noted.
Conclusion ED offers perioperative advantages and comparable efficacy but does not surpass MD due to TELD’s increased recurrence risk. IELD and UBE are promising alternatives, but MD remains the benchmark. Long-term RCTs are needed.
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Letter to Editor: Practice preference of revision surgery for recurrent lumbar disc herniation: an international survey of AO spine members Borriwat Santipas, Jin-Sung Kim European Spine Journal.2026;[Epub] CrossRef
Luca Ambrosio, Sathish Muthu, Patrick C. Hsieh, S. Tim Yoon, Jeffrey C. Wang, Gianluca Vadalà, Hans Jörg Meisel, Stipe Ćorluka, Zorica Buser, AO Spine Knowledge Forum Degenerative
Neurospine 2026;23(1):31-39. Published online January 31, 2026
Objective This study aimed to characterize international practice patterns in the surgical management of primary lumbar disc herniation (LDH) among AO Spine surgeons.
Methods A cross-sectional online survey was distributed in September 2024 to AO Spine members. The questionnaire collected detailed information on demographic characteristics, surgical indications, preferred techniques, and approaches for primary LDH treatment. Data on specialty, practice setting, fellowship training, and surgical case volume were analyzed using univariate and multivariate logistic regression to identify significant associations between surgeon characteristics and treatment preferences.
Results A total of 714 surgeons participated, representing diverse regions: North America (9.0%), Latin America (18.7%), Europe & Southern Africa (34.7%), Middle East & Northern Africa (12.8%), and Asia Pacific (24.8%). Neurological status was the most critical factor influencing early operative treatment in nonurgent cases, while bladder/bowel dysfunction and severe motor deficits were the primary indications in urgent scenarios. The majority of respondents (54.2%) preferred a mini-open technique—using either a surgical microscope or loupes—with partial laminotomy (58.1%) and partial discectomy (63.2%) being the most frequently performed procedures. Regional variations and differences in surgeon training were significantly associated with the choice of surgical approach and overall case volume.
Conclusion The findings reveal substantial variability in the surgical management of primary LDH across regions and specialties. This comprehensive dataset underscores the need for standardized, evidence-based guidelines to harmonize treatment strategies and optimize patient outcomes.
Objective The upper lumbar region has distinctive anatomical characteristics that contribute to the challenges of performing discectomy. We introduce far-lateral transforaminal unilateral biportal endoscopic (UBE) lumbar discectomy for central or paracentral disc herniations in the upper lumbar region.
Methods We conducted retrospective review of the patients who underwent a far-lateral transforaminal UBE lumbar discectomy at our institution from January 2018 to September 2024. The electronic medical records, operative records, and radiologic images of the patients were reviewed.
Results A total of 27 patients underwent far-lateral transforaminal UBE lumbar discectomy for central or paracentral disc herniations in the upper lumbar region. The patient had a mean age of 54.0 ± 13.7 years. Operation was performed at the L1–2 level in 3 patients (11.1%), L2–3 in 9 patients (33.3%), and L3–4 in 15 patients (55.6%). The patients were followed-up for a mean of 27.7 ± 19.3 months. The Oswestry Disability Index was significantly decreased from 36.3 ± 6.8 preoperatively to 3.7 ± 3.3 at last follow-up (p < 0.001). The visual analogue scale (VAS) back was significantly decreased from 7.8 ± 0.9 preoperatively to 3.1 ± 0.6 postoperative day 2 (p < 0.001). The VAS leg was significantly decreased from 8.1 ± 0.8 preoperatively to 2.3 ± 0.7 postoperative day 2 (p < 0.001).
Conclusion The far-lateral transforaminal UBE lumbar discectomy would be a viable surgical option for upper lumbar disc herniations.
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Objective To analyze costs and cost-effectiveness of transforaminal endoscopic thoracic discectomy (TETD) for the treatment of symptomatic thoracic disc herniation (TDH) and compare it with open microdiscectomy (MD).
Methods This retrospective cohort study included patients who underwent TETD or MD for symptomatic TDH and had a minimum follow-up of 1 year. Cost analysis included direct costs (primary and secondary hospital costs), indirect costs (lost wages due to work absence), total costs (direct + indirect), and cost-effectiveness (cost per quality-adjusted life year [QALY] and incremental cost-effectiveness ratio [ICER]). Clinical outcomes included patient-reported outcome measures (Oswestry Disability Index [ODI], 36-item Short Form health survey [SF-36]), QALY gained, and reoperation and readmission rates at 1 year. TETD and MD groups were compared for outcome measures.
Results A total of 111 patients (57 TETD, 54 MD) were included. The direct ($6,270 TETD vs. $7,410 MD, p < 0.01), indirect costs ($1,250 TETD vs. $1,450 MD, p < 0.01), total costs ($7,520 TETD vs. $8,860 MD, p < 0.01), and cost per QALY ($31,333 TETD vs. $44,300 MD, p < 0.01) were significantly lower for TETD compared to MD. ICER of TETD was found to be -$33,500. At 1 year, TETD group showed significantly greater improvement in ODI (46% vs. 36%, p < 0.01) and SF-36 (64% vs. 53%, p < 0.01) and significantly greater QALY gained (0.24 vs. 0.2, p < 0.01) compared to MD group. No significant difference was found in reoperation and readmission rates.
Conclusion TETD demonstrated significantly better clinical outcomes, lower overall costs, and better cost-effectiveness than MD in appropriately selected patients of symptomatic TDH.
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Objective This study aims to investigate the anatomical relationship among the nerve roots, intervertebral space, pedicles, and intradural rootlets of the cervical spine for improving operative outcomes and exploring neuroventral decompression approach in posterior endoscopic cervical discectomy (PECD).
Methods Cervical computed tomography myelography imaging data from January 2021 to May 2023 were collected, and the RadiAnt DICOM Viewer Software was employed to conduct multiplane reconstruction. The following parameters were recorded: width of nerve root (WN), nerve root-superior pedicle distance (NSPD), nerve root-inferior pedicle distance (NIPD), and the relationship between the intervertebral space and the nerve root (shoulder, anterior, and axillary). Additionally, the descending angles between the spinal cord and the ventral (VRA) and dorsal (DRA) rootlets were measured.
Results The WN showed a gradual increase from C4 to C7, with measurements notably larger in men compared to women. The NSPD decreased gradually from the C2–3 to the C5–6 levels. However, the NIPD showed an opposite level-related change, notably larger than the NSPD at the C4–5, C5–6, and C7–T1 levels. Furthermore, significant differences in NIPD were observed between different age groups and genders. The incidence of the anterior type exhibited a gradual decrease from the C2–3 to the C5–6 levels. Conversely, the axillary type exhibited an opposite level-related change. Additionally, the VRA and DRA decreased as the level descended, with measurements significantly larger in females.
Conclusion A prediction of the positional relationship between the intervertebral space and the nerve root is essential for the direct neuroventral decompression in PECD to avoid damaging the neural structures. The axillary route of the nerve root offers a safer and more effective pathway for performing direct neuroventral decompression compared to the shoulder approach.
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We present a novel technique to approach far lateral lumbar pathologies using a bitubular, biportal endoscopic system and a paramedian approach. Background: Conventional approaches for lumbar far lateral discectomy range from open approaches to newer minimally invasive approaches such as tubular discectomy and single portal endoscopic discectomy. We present a case of a patient suffering with a left L3–4 and left L4–5 extraforaminal disc herniation who was treated successfully with a left sided bitubular, biportal endoscopic 2 level far lateral discectomy. A paramedian ‘bitubular’ biportal endoscopic approach is safe and effective for far lateral lumbar pathologies with excellent visualisation due to good outflow of irrigation fluid.
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Objective Lumbar disc herniation (LDH) represents an increasingly encountered condition in patients with rheumatoid arthritis (RA). The aim of the present study is to assess the progress of health-related quality of life following transforaminal endoscopic lumbar discectomy (TELD) for LDH in patients suffering from RA.
Methods Seventy-four patients, scheduled to undergo elective TELD for LDH, were prospectively enrolled in the study. Group A included 36 otherwise healthy individuals and group B 38 patients complementarily diagnosed with RA according to the 2010 ACR/EULAR (American College of Rheumatology/European League Against Rheumatism) criteria. The Medical Outcomes Study 36-item Short Form health survey (SF-36) was selected for the outcome assessment at baseline and postoperatively, at selected intervals at 6 weeks, 3, 6, and 12 months postoperatively.
Results Group A presented statistically significantly higher scores in all SF-36 domains and all selected intervals (p<0.001), except for mental health parameter. All aspects of SF-36 questionnaire significantly improved postoperatively (p<0.001) and in each group independently. Nevertheless, the absolute improvement between consecutive time intervals did not differ significantly between the 2 groups.
Conclusion Patients diagnosed with RA who undergo TELD for LDH demonstrate statistically significant improvement in their health status, as measured by SF-36 questionnaire, one year after the procedure. This improvement is comparable with normal individuals.
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Objective Anterior cervical discectomy and fusion (ACDF) with anterior plating is a commonly performed procedure for cervical disc diseases. While the clinical outcomes of most reported multilevel ACDF cases are excellent, symptomatic pseudarthrosis remains a challenge, often requiring revision surgeries. This study aims to present the radiological characteristics of multilevel ACDF constructs, which can be considered during intraoperative management to prevent pseudarthrosis.
Methods This retrospective cohort study included patients who underwent multilevel (3 or 4 levels) ACDF with anterior plating between June 2010 and August 2022. Patients were regularly followed at 4 months, 12 months, and then annually postoperation. Fusion rates and characteristic radiological patterns, such as the formation of bony buttresses underneath the anterior plate, were graded and evaluated.
Results A total of 163 patients were included in the study. Overall fusion rates were 26.38%, 64.34%, and 81.58% at 4-month, 1-year, and the final follow-up, respectively. Nonunions at 4-month follow-up with tightly engaged anterior plate with bony buttress formation were more likely to fuse in the later period (Buttress grade 0 vs. 1; p=0.01, odds ratio [OR], 5.70, Buttress grade 1 vs. >2; p<0.01, OR, 12.00).
Conclusion This study emphasizes the significance of pseudarthrosis following multilevel ACDF. Pseudarthrosis predominantly occurs in the caudal-most segment of the construct, particularly when it terminates at C7. Constructs that are not tightly engaged and lack bony buttress formation in the caudal part of multilevel ACDF are more likely to develop pseudarthrosis.
Objective To compare the long-term clinical and radiographic outcomes of transforaminal endoscopic lumbar discectomy (TELD) versus microdiscectomy (MD).
Methods The data of 154 patients with lumbar disc herniation (LDH) who underwent TELD (n = 89) or MD (n = 65) were retrospectively analyzed. The patients’ clinical outcomes were evaluated using visual analogue scales for leg and low back pain, the Japanese Orthopaedic Association (JOA) score, and the Oswestry Disability Index (ODI). The evolution of radiographic manifestations was observed during follow-up. Potential risk factors for a poor clinical outcome were investigated.
Results During a mean follow-up of 5.5 years (range, 5–7 years), the recurrence rate was 4.49% in the TELD group and 1.54% in the MD group. All scores significantly improved from preoperatively to postoperatively in both groups (p < 0.01). The improvement in the ODI and JOA scores was significantly greater in the TELD than MD group (p < 0.05). Forty-seven patients (52.8%) in the TELD group and 32 (49.2%) in the MD group had Modic changes before surgery, most of which showed no changes at the last follow-up. The degeneration grades of 292 discs (71.0%) were unchanged at the last follow-up, while 86 (20.9%) showed improvement, mostly at the upper adjacent segment. No significant difference was observed in the intervertebral height index or paraspinal muscle-disc ratio.
Conclusion Both TELD and MD provide generally satisfactory long-term clinical outcomes for patients with LDH. TELD can be used as a reliable alternative to MD with less surgical trauma. Modic type II changes, decreased preoperative intervertebral height, and a high body mass index are predictors of a poor prognosis.
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Objective To introduce a technique of laminotomy using a common trephine to enlarge the interlaminar space at L4/5 segment for interlaminar endoscopic lumbar discectomy (IELD) and report the anatomical basis of this procedure, technical details, as well as primary clinical outcomes of a consecutive patient cohort with L4/5 lumbar disc herniation (LDH).
Methods On anteroposterior fluoroscopy, the intersection of the medial edge of the inferior articular process and the inferior endplate of L4 vertebra was taken as the target. Using a common trephine, laminotomy was performed to remove a big portion of the posterior wall of the canal under the guidance of endoscopy. From June 2018 to December 2021, the consecutive patients who underwent L4/5 IELD were prospectively studied. Clinical outcomes were assessed at the day before surgery, 1 day, 1 month, 3 months, 12 months after surgery, and the last follow-up. Numerical Rating Scale, Roland-Morris Disability Questionnaire (RMDQ), and MacNab criteria were used to evaluate back and leg pain, the quality of life, and clinical efficacy, respectively.
Results There were 64 men and 44 women, with an age of 50.3 ± 14.9 years. The operating time was 74.54 ± 17.42 minutes. The mean follow-up time was 32.7 ± 18.6 months (range, 12–64 months). The complications of IELD included numbness, neck pain, and recurrence. Both leg pain (6.2 ± 1.9 vs. 1.8 ± 0.8, p < 0.001) and back pain (3.1 ± 2.3 vs. 1.7 ± 0.9, p < 0.001) quickly improved after this procedure and maintained (1.1 ± 1.5, 1.1 ± 1.3) at final follow-up. Physical disability due to back pain, as assessed using RMDQ, was improved remarkably after surgery (15.0 ± 5.8 vs. 2.9 ± 4.1, p < 0.001). In addition, MacNab outcome grade was evaluated as good-to-excellent in 96 cases (88.9%).
Conclusion A convenient technique of laminotomy using a common trephine was proposed for the L4/5 IELD. It can efficiently enlarge the interlaminar entry to perform endoscopic discectomy. This procedure is particularly suitable for treating LDH with concomitant lumbar spinal stenosis and migrated herniated disc.
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Objective Cervical myelopathy (CM) describes the compressive cervical spinal cord state, often accompanied by serious clinical condition, by herniated disc or hypertrophied spurs or ligament. Anterior cervical discectomy and fusion (ACDF) has been frequently employed as conventional surgical solution for this CM despite its inherent biomechanical handicap. Alternatively, an artificial disc replacement (ADR) preserves cervical motion while still decompressing the spinal canal and neural foramen. This analysis elaborated to clarify the potential benefits of ADR application to CM over ACDF from the conglomerated results of the past references.
Methods A literature search was performed using MEDLINE, Embase, Cochrane review, and KMbase databases from the studies published until March 2023. Six studies (3 randomized controlled study [RCTs] and 3 non-RCTs) were included in a qualitative and quantitative synthesis. Data were extracted and analyzed using a random effects model to obtain effect size and its statistical significance. Quality assessment and evidence level were established in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.
Results Among 6 studies, 2 studies showed that ADR group achieved significantly better clinical improvement than the ACDF group, while the rest 4 studies revealed no significant difference. A meta-analysis showed better clinical outcomes with or without statistical significance. The level of evidence was low because of inconsistency and imprecision.
Conclusion ADR was superior or at least, not inferior to ACDF in terms of functional recovery. However, its application to the CM patients is merely empowered with weak strength due to low level of evidence.
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Objective The aim of this study was to emphasize on the interaction of spatial and temporal gait parameters and analyse the gait asymmetry in the patients with lumbar disc herniation (LDH) before and after microdiscectomy.
Methods This was a prospective, observational study conducted on 59 cases of LDH planned for lumbar microdiscectomy, and healthy control group with 54 participants for analysis was performed prior to surgery and 15 days after surgery. The spatiotemporal gait parameters were measured using a “Win-Track” gait analysis platform system. All the participants walked barefoot for 10 times with their normal walking speed in the same day. The 3 flawless walking data were recorded and the arithmetic means were computed. The gait symmetry index was used to calculate the walking asymmetry. The pain intensity of the patients was recorded shortly before performing the analysis by a visual analogue scale.
Results In the postoperative assessment LDH patients had significantly shorter temporal parameters, longer spatial parameters, faster walking speed, and more cadence than the preoperative assessment (p < 0.05). There were improvements in the asymmetry values of the postoperative gait parameters compared to the preoperative values, but these differences were not significant (p > 0.05). In addition, there was a significant difference in all parameters in terms of gait asymmetry between the postoperative assessment and the healthy controls (p < 0.05).
Conclusion These results can guide the patient-specific evaluating and implementation of gait rehabilitation programs, and design protocols before or after surgery in the LDH patients.
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Objective Spine surgery rates are increasing in the elderly population due to social aging, and it is known that prognoses related to surgery are worse for the elderly compared to younger individuals. However, minimally invasive surgery, such as full endoscopic surgery, is considered safe with low complication rates due to minimal damage to surrounding tissues. In this study, we compared outcomes of transforaminal endoscopic lumbar discectomy (TELD) in elderly and younger patients with disc herniation in the lumbosacral region.
Methods We retrospectively analyzed the data of 249 patients who underwent TELD at a single center between January 2016 to December 2019, with a minimum follow-up of 3 years. Patients were allocated to 2 groups: a young group aged ≤ 65 years (n = 202) or an elderly group aged > 65 years (n = 47). We evaluated baseline characteristics, clinical outcomes, surgery-related outcomes, radiological outcomes, perioperative complications, and adverse events during the 3-year follow-up period.
Results Baseline characteristics, including age, general condition based on American Society of Anesthesiologist physical status classification grade, age-Charlson Comorbidity Index, and disc degeneration, were worse in elderly group (p < 0.001). However, except for leg pain at 4 weeks after surgery, overall outcomes, including pain improvement, radiological change, operation time, blood loss, and hospital stay, were not different between the 2 groups. Furthermore, the rates of perioperative complications (9 patients [4.46%] in the young group and 3 patients [6.38%] in the elderly group, p = 0.578) and adverse events over the 3-year follow-up period (32 patients [15.84%] in the young group and 9 patients [19.15%] in the elderly group, p = 0.582) were comparable in the 2 groups.
Conclusion Our findings suggest that TELD produces similar outcomes in both elderly and younger patients with a herniated disc in the lumbosacral region. TELD can be considered a safe option for appropriately selected elderly patients.
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Objective We attempted to investigate the potential risk factors of recurrent lumbar disc herniation (rLDH) after tubular microdiscectomy.
Methods We retrospectively analyzed the data of patients who underwent tubular microdiscectomy. The clinical and radiological factors were compared between the patients with and without rLDH.
Results This study included 350 patients with lumbar disc herniation (LDH) who underwent tubular microdiscectomy. The overall recurrence rate was 5.7% (20 of 350). The visual analogue scale (VAS) score and Oswestry Disability Index (ODI) at the final follow-up significantly improved compared with those preoperatively. There was no significant difference in the preoperative VAS score and ODI between the rLDH and non-rLDH groups, while the leg pain VAS score and ODI of the rLDH group were significantly higher than those of the non-rLDH group at final follow-up. This suggested that rLDH patients had a worse prognosis than non-rLDH patients even after reoperation. There were no significant differences in sex, age, body mass index, diabetes, current smoking and drinking, disc height index, sagittal range of motion, facet orientation, facet tropism, Pfirrmann grade, Modic changes, interdisc kyphosis, and large LDH between the 2 groups. Univariate logistic regression analysis revealed that rLDH was associated with hypertension, multilevel microdiscectomy, and moderate-severe multifidus fatty atrophy (MFA). A multivariate logistic regression analysis indicated that MFA was the sole and strongest risk factor for rLDH after tubular microdiscectomy.
Conclusion Moderate-severe MFA was a risk factor for rLDH after tubular microdiscectomy, which can serve as an important reference for surgeons in formulating surgical strategies and the assessment of prognosis.
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