Objective This study aims to compare the risk of subsequent surgery following surgical treatment of clinical adjacent-segment pathology (CASP) after lumbar fusion, specifically evaluating decompression alone versus decompression with extension of the fusion.
Methods Using the Swespine registry, we included patients who had surgical treatment for CASP following index lumbar fusion surgery, 1997–2019. The cohort was divided according to CASP treatment: decompression alone or decompression with extended fusion. A comparison of subsequent surgeries was made with Kaplan-Meier analysis and Cox regressions adjusted for potential confounders (age, sex, body mass index, smoking status, number of operated levels at CASP surgery, number of fused levels at index fusion surgery, and diagnosis for CASP surgery).
Results A total of 2,521 patients were included, 1,176 (47%) in the decompression-group and 1,345 (53%) in the extended fusion group and the mean follow-up was 6.1±4.4 years. Mean age at CASP surgery was 61 years and 1,588 (63%) were females. The median time to subsequent surgery was 1.7 years (range, 0.9–3.7 years). Kaplan-Meier–estimated probability of subsequent surgeries at 5 years was 18% (95% confidence interval [CI], 15%–20%) for the decompression-group and 25% (95% CI, 22%–27%) for the extended fusion group. The hazard ratio was 1.26 (95% CI, 1.02–1.56; p=0.032) for those with extended fusion.
Conclusion Extension of fusion for CASP was associated with significantly higher risk of subsequent surgery, but causality should be interpreted with caution as radiographic information on instability, deformity, or foraminal stenosis could not be verified.
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A Commentary on “How to Treat Adjacent-Segment Pathology Following Lumbar Fusion Surgery: Decompression Alone or Decompression With Extended Fusion Surgery?” Jang W. Yoon Neurospine.2026; 23(3): 564. CrossRef
When Is Fusion Necessary in Addressing Symptomatic Adjacent Level Pathology – A Commentary on “How to Treat Adjacent-Segment Pathology Following Lumbar Fusion Surgery: Decompression Alone or Decompression With Extended Fusion Surgery?” Marc A. Arslanian, Vignessh Kumar, Lee A. Tan Neurospine.2026; 23(3): 561. CrossRef
From the Editor-in-Chief: Featured Articles in the July 2026 Issue Inbo Han Neurospine.2026; 23(3): 513. CrossRef
Objective Advanced age has been proposed as a risk factor for worse outcomes and higher complication rates after spinal surgery. We assessed whether decompression for central lumbar spinal stenosis (CLSS) provided meaningful improvement in patients aged 50–95 years.
Methods We evaluated preoperative and 1-year postoperative Numerical Rating Scale (NRS) leg and back pain, Oswestry Disability Index (ODI), and complications in 17,987 patients aged ≥50 years undergoing decompression without fusion for CLSS without spondylolisthesis from the Swespine register. Meaningful improvement was defined using minimal clinically important difference (MCID) thresholds for NRS leg/back pain and ODI. Across 5-year age groups, we assessed the proportions improving ≥MCID and odds ratios (ORs) with 95% confidence intervals (CIs), using ages 65–69 years as the reference group.
Results Across age groups, 71%–80% improved ≥MCID in ≥1 outcome. Compared with the reference group, ORs (95% CI) for ≥MCID improvement were lower in ages 70–74 (0.8; 0.7–1.0), 75–79 (0.7; 0.6–0.8), 80–84 (0.6; 0.5–0.7), and 85–89 (0.6; 0.5–0.8); no other age groups differed. 5%–12% experienced complications. Compared with the reference group, ORs (95% CI) for complications were higher in ages 75–79 (1.3; 1.1–1.6), 80–84 (1.7; 1.4–2.1), and 85–89 (2.0; 1.5–2.8), and lower in ages 55–59 (0.7; 0.5–0.9).
Conclusion 77% of patients aged 50–95 years improved ≥MCID after decompression without fusion for CLSS without spondylolisthesis. Although outcomes were slightly worse and complication rates higher in older than younger patients, decompression without fusion remains effective across this age range.
Objective Parkinson disease (PD) is frequently characterized by a forward-bent posture that increases biomechanical stress on the lumbar spine, which increases the rate of subsequent lumbar surgeries after spinal fusions. This study aimed to evaluate the rates of additional lumbar surgeries following spinal fusion in patients with PD.
Methods Data from the Health Insurance Review and Assessment Service of the Republic of Korea were retrospectively analyzed. PD was identified using the International Classification of Diseases, 10th Revision code G20. Patients with PD were matched with those without PD in a 3:1 ratio based on sex, age, and Charlson Comorbidity Index using the greedy nearest neighbor matching method. The primary outcome was the rate of subsequent lumbar surgeries following spinal fusion within the 7-year follow-up period. The timing of these reoperations was also assessed.
Results A total of 2,287 patients with PD and 6,861 matched patients without PD were included in this study. The prevalence of PD among patients undergoing lumbar fusion surgery remained stable throughout the study period. Patients with PD had 1.6-fold higher odds to undergo reoperation compared with the non-PD cohort. No significant difference was observed in the timing of additional surgeries between the groups.
Conclusion Patients with PD faced 1.6-fold higher odds of subsequent lumbar surgeries following spinal fusion compared to those without the disease. This finding suggests the need for a cautious treatment approach and thorough preoperative optimization when considering lumbar fusion in this population.
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A Commentary on “Rates of Subsequent Lumbar Surgery Following Spinal Fusion in Patients With Parkinson Disease: A Propensity-Score Matched Nationwide Cohort Analysis” Yusuke Nishimura Neurospine.2026; 23(3): 547. CrossRef
From the Editor-in-Chief: Featured Articles in the July 2026 Issue Inbo Han Neurospine.2026; 23(3): 513. CrossRef
Objective To compare perioperative burden, hardware outcomes, and oncologic control between sagittal vertebral resection (SVR) and total vertebral resection (TVR) for thoracolumbar tumors, and to propose a practical framework for SVR surgical decision making.
Methods Clinical data, operative parameters, and follow-up outcomes were retrospectively analyzed. To address baseline imbalances in tumor volume and preoperative embolization, a 1:1 propensity score matching was performed based on 5 critical covariates, resulting in a matched cohort of 78 patients (39 per group). Groups were compared using Student t-test or Mann-Whitney U-test for continuous variables and chi-square/Fisher exact test for categorical variables.
Results In the total cohort (39 SVR vs. 84 TVR), SVR significantly reduced blood loss (median 1,200 mL vs. 1,500 mL, p=0.016), transfusion (800 mL vs. 1,200 mL, p<0.001), complication rate (51.3% vs. 77.4%, p=0.004), and hospital stay (13.7 days vs. 19.0 days, p=0.012). Bilateral nerve root sacrifice was less frequent in SVR (41.0% vs. 69.0%, p<0.001). Negative surgical margins (71.8% vs. 73.8%, p=0.814) and local recurrence (12.8% vs. 13.1%, p=0.965) were comparable. Postmatching analysis (n=78) confirmed that even after balancing for tumor volume and embolization, the SVR group maintained significant advantages in blood loss (p=0.035) and operation time (p=0.041). Hardware failure occurred in 3 TVR patients (3.6%) but in none after SVR.
Conclusion SVR significantly reduces perioperative morbidity while maintaining comparable oncologic outcomes relative to TVR. The superiority of SVR remains robust after propensity score adjustment for tumor complexity. By formalizing a type-based surgical decision-making framework, this study provides practical guidance for when and how SVR may be safely adopted as a standardized alternative to TVR in appropriately selected thoracolumbar tumors.
Objective To evaluate early postoperative mobility after lumbar decompression using real-time location system (RTLS)-derived objective metrics and to explore differences in mobility patterns between biportal endoscopic decompression and open decompression.
Methods This retrospective cohort study included 323 patients who underwent lumbar decompression for degenerative lumbar spinal stenosis between March 2020 and May 2024. RTLS sensors embedded in wristbands continuously recorded patient mobility during postoperative days (PODs) 1–4. Primary RTLS-derived outcomes included total walking distance, mean walking speed, and active movement ratios (top 20% and top 50%). Between-group comparisons were performed using nonparametric tests. Propensity score matching and multivariable median quantile regression adjusting for age, American Society of Anesthesiologists physical status, and preoperative mobility were conducted.
Results RTLS identified differences in early postoperative activity patterns between surgical approaches. In adjusted analyses, activity-intensity–based metrics, particularly the top 20% activity ratio, remained significantly higher in the biportal endoscopic decompression group across multiple PODs. Subgroup analyses demonstrated minimal differences after single-level decompression, whereas activity-based differences were more frequently observed in multilevel procedures.
Conclusion RTLS-based continuous monitoring detected differences in early postoperative activity patterns following lumbar decompression. These findings support the role of RTLS as an objective tool for assessing early functional recovery in spine surgery.
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
Objective Lumbar fusion surgery serves as a crucial option for treating lumbar degenerative diseases. However, patient heterogeneity contributes to suboptimal surgical outcomes in a substantial proportion of cases. Therefore, an accurate classification may provide a powerful tool for personalized treatment and enable the identification of individuals at increased risk for unfavorable surgical outcomes (USO). The study aimed to develop a risk stratification model for USO using cluster analysis.
Methods Consecutive patients diagnosed with degenerative lumbar disease who underwent lumbar fusion between April 2019 and January 2023 were enrolled. The outcome of interest was the USO, defined as failure to achieve a minimal clinically important difference in the 36-Item Short Form Health Survey physical component summary score, with the presence of complications. Three machine learning algorithms were employed to identify risk factors associated with USO. Based on these risk factors, we conducted a data-driven clustering analysis to develop a risk stratification model. Furthermore, based on 6 machine learning models, we developed a classification classifier capable of accurately identifying the risk cluster of individual patients.
Results A total of 662 patients were enrolled for risk stratification model, 219 patients were classified as having an USO. Six features were identified as key prognostic predictors, including frailty, depression, PI–LL (pelvic incidence minus lumbar lordosis) match, surgical levels, functional independence measure, and the relative functional cross-sectional area. The K-prototypes clustering algorithm successfully identified 3 distinct clusters. Furthermore, we developed a classification classifier, in which LightGBM (light gradient boosting machine) demonstrated the highest predictive performance (area under the receiver operating characteristic curve, 0.951; 95% confidence interval [CI], 0.814–0.974; area under the precision-recall curve, 0.927; 95% CI, 0.769–0.969).
Conclusion Based on data-driven clustering analysis, we developed a risk stratification model for predicting USO following lumbar fusion surgery, which demonstrated high predictive accuracy. Further studies in larger and more diverse cohorts are warranted to validate the clinical applicability of clustering analysis in USO risk stratification.
Spinal arthroplasty aims to preserve or reconstruct the normal biomechanical functions of the spine with motion-preserving implants. Although fusion is a proven technique to stabilize the spine, it is nonphysiologic with known limitations such as loss of mobility and risk of adjacent segment disease. This paper focuses on the main areas of spinal arthroplasty including cervical disc replacement, lumbar disc replacement, and lumbar facet arthroplasty. We review the biomechanics, history, outcomes, and future directions for each of these over the last 30 years. Although today spinal arthroplasty is only used in very specific degenerative settings, as innovation in spinal arthroplasty progresses, this will lead to wider adoption and a future where spine surgery is truly reconstructive and motion-preserving.
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A Commentary on “A Comprehensive Review of Spinal Arthroplasty” Sonja Häckel, Fabienne Pohle Neurospine.2026; 23(2): 273. CrossRef
From the Editor-in-Chief: Featured Articles in the April 2026 Issue Inbo Han Neurospine.2026; 23(2): 227. CrossRef
Objective To develop and externally validate a dual-mechanism deep learning (DL) model that integrates vertebral segmentation and lesion detection for automated evaluation of lumbar degeneration and structured report generation on plain radiographs.
Methods In this retrospective study, 5,964 patients who underwent standing anteroposterior and lateral lumbar radiographs at a single institution and 600 patients from a public dataset (BUU-Spine) were included. Vertebral corners from T11–L5 (and S1 on lateral views) and 7 degenerative findings (scoliosis, straightened/preserved lordosis, spondylolisthesis, disc space narrowing, osteophytes, vertebral compression, and abdominal aortic calcification) were annotated by 3 spine surgeons. Two independently trained, parallel networks were developed, including a ResNet-based segmentation network and a YOLOv8-based detection network. A rule-based integration strategy reconciled both outputs and generated structured diagnostic reports. Segmentation accuracy, quantitative measurement agreement, diagnostic performance, and clinical acceptability of reports were evaluated.
Results Intra- and interobserver landmark distances within 3 mm reached 96% and >95%, respectively. On the internal test set, the percentage of correct keypoints within 3 mm was 95.7%–98.6%, with intraclass correlation coefficients of 0.84–0.89 and Pearson correlation coefficient (r) of 0.90–0.94 for key radiographic parameters. The segmentation- and detection-based models achieved precision of 92.2%–96.9% and 91.7%–95.5%, and recall of 91.6%–94.8% and 93.3%–95.2%, respectively. Under the dual-positive condition, the integrated model yielded the highest precision (93.8%–97.3%), whereas the any-positive condition achieved the highest recall (94.1%–97.6%). Of 596 automatically generated structured reports, 557 (93.4%) were deemed clinically acceptable.
Conclusion The proposed dual-mechanism DL framework enables accurate, multilesion assessment of lumbar degeneration and generation of clinically acceptable structured reports from plain radiographs, supporting workflow optimization in lumbar spine imaging.
Objective Lumbar disc herniation is among the most common and disabling spinal disorders, driven by the interplay of mechanical overload, structural failure, and cellular dysfunction. Despite advances in surgical interventions, achieving true biological repair of herniated discs remains a major clinical challenge. This review aims to critically examine the biomechanical landscape of disc herniation, focusing on how altered load transmission, tissue stiffness, and structural disruption influence cellular behavior and tissue regeneration. It further explores mechanobiological mechanisms governing repair and highlights emerging biomimetic models and technologies that integrate mechanical and biological insights to promote functional disc restoration.
Methods A comprehensive literature review was conducted using the Web of Science Core Collection, PubMed (National Library of Medicine), and ScienceDirect databases. The search was limited to peer-reviewed journal articles published in English and focused on studies related to lumbar disc herniation.
Results While decades of research have elucidated the biomechanical factors contributing to disc herniation, recent advances in mechanobiology have uncovered how mechanical cues influence cellular behavior, tissue repair, and degeneration. Evidence suggests that true disc regeneration cannot be achieved through biological replacement or mechanical stabilization alone; rather, it requires restoring functional biomechanics, specifically, the disc’s ability to sense, adapt to, and sustain physiological loading.
Conclusion Viewing disc herniation through a mechanobiological lens offers new opportunities to develop targeted therapies aimed at restoring both tissue integrity and load-bearing functionality, paving the way for more effective regenerative interventions.
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Integrating Structures and Biology: Cellular and Molecular Interactions with Functionally Graded Spinal Cage Designs Yuen Ho Cheng, Amy Libing Fu, Jessica Gaff, Gianluca Vadala, Amit Jain, Javad Tavakoli International Journal of Molecular Sciences.2026; 27(10): 4531. CrossRef
From mechanotransduction to manual therapy: advances in piezo/TRP channels and lumbar degeneration Zhennan Liu, Tianzhong Peng, Wenli Li, Manhua Zhu Frontiers in Physiology.2026;[Epub] CrossRef
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.
Luca Ambrosio, Jordy Schol, Stone Sima, Clara Ruiz-Fernandez, Victor Chen, Fabrizio Russo, In-Ho Han, Daisuke Sakai, Gianluca Vadalà, Vincenzo Denaro, Ashish D. Diwan, AO Spine Knowledge Forum Degenerative
Neurospine 2026;23(1):3-28. Published online January 31, 2026
Lumbar disc herniation (LDH) is one of the most common causes of low back and leg pain. While mechanical and degenerative factors have long been considered the main contributors, persistent or recurrent symptoms in many patients suggest additional biological mechanisms. Recent research has highlighted the microbiome as a potential modulator of inflammation, immune response, and pain sensitization, introducing the “gut-spine axis” concept. This scoping review summarizes the current evidence on the role of both gut and local disc microbiota in LDH. A systematic search of PubMed/MEDLINE and Scopus was conducted up to June 2025, following PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Twenty-six studies were included, encompassing preclinical and clinical investigations. Animal models showed that LDH may alter gut microbial composition and that microbiome-targeted interventions can reduce inflammation, neuroinflammatory signaling, and pain sensitivity. In human studies, low-virulence bacteria, particularly Cutibacterium acnes, were frequently detected in surgically excised intervertebral discs, although results were inconsistent due to methodological heterogeneity and potential contamination. Some studies reported associations between bacterial colonization and Modic changes, disc height loss, or chronic pain. Additionally, genetic and metabolomic data suggest that gut dysbiosis and related microbial metabolites may influence systemic immune and metabolic pathways implicated in disc degeneration and pain perception. Overall, the current evidence suggests the biological plausibility of microbiome involvement in LDH pathophysiology, acting through both systemic and local mechanisms. However, the available data remain preliminary, and no mechanistic study has confirmed the observed correlations to date. Further standardized, contamination-aware studies are required to clarify causality and explore microbiome-targeted therapeutic strategies.
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Lost in Translation: Why Biologic Therapies for Intervertebral Disc Degeneration and Low Back Pain Have Not Reached the Clinic (Yet) Luca Ambrosio, Jordy Schol, Clara Ruiz‐Fernandez, Vincenzo Denaro, Gianluca Vadalà, Daisuke Sakai JOR SPINE.2026;[Epub] CrossRef
Gut‐Intervertebral Disc Axis: Gut Microbiome‐Driven Immune‐Metabolic Imbalance and Intervertebral Disc Degeneration Xinhui Cui, Wenjia Du Journal of Cellular Physiology.2026;[Epub] CrossRef
Objective To quantify the effect of different hip positions on lumbar lordosis (LL) and spinopelvic parameters in the right lateral decubitus position (RLDP) and identify the configuration that most closely replicates physiologic standing alignment during lateral lumbar interbody fusion in minimally invasive spinal surgery.
Methods Thirty healthy volunteers (15 males, 15 females; mean age, 27.8±8.6 years) underwent lateral lumbar radiographs in standing position and 5 RLDP configurations: neutral hips (NN), 30° flexion of both hips (30FF), 30° flexion of the right hip with left hip neutral (30FN), 60° flexion of both hips (60FF), and 60° flexion of the right hip with left hip neutral (60FN). LL, pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI) were measured. Each position was compared to standing using paired t-tests. Intra- and interobserver reliability were evaluated using intraclass correlation coefficients (ICCs).
Results LL decreased significantly in all RLDP positions compared with standing (51.1°±3.8°). The 30FN position showed the smallest change (ΔLL=-4.9°, p<0.001), whereas 60FF showed the greatest (ΔLL=-15.0°, p<0.001). In 30FN, PT decreased (p=0.013) and SS increased (p=0.003), indicating mild anterior pelvic rotation. PI showed minimal variation across positions. Intra- and interobserver ICCs ranged from 0.92 to 0.99, confirming high measurement reliability.
Conclusion Hip position significantly influences lumbar and pelvic alignment in RLDP. Among tested configurations, the 30FN position (right hip flexed 30°, left neutral) showed the smallest numerical deviation from standing alignment and spinopelvic harmony relative to standing in RLDP.
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Reply Letter: Reconsidering Intraoperative Hip Positioning in Single-Position Lateral Lumbar Interbody Fusion – A Commentary on “Optimal Positioning for
Single-Position Lateral Lumbar Interbody Fusion” Worawat Limthongkul, Natavut Prasertkul, Pakawas Praisarnti, Maruay Tanayavong, Surachat Jaroenwareekul, Wicharn Yingsakmongkol, Weerasak Singhatanadgige, Vit Kotheeranurak Neurospine.2026; 23(3): 756. CrossRef
Reconsidering Intraoperative Hip Positioning in Single-Position Lateral Lumbar Interbody Fusion – A Commentary on “Optimal Positioning for Single-Position Lateral Lumbar Interbody Fusion” Jiayi Chen Neurospine.2026; 23(3): 754. CrossRef
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
Domain-Adapted Foundation Models for Single-Click Surgical Instrument Segmentation in Spinal Endoscopy Bong-Su Mun, Zhi Zhao, Sang-Min Park, Jiwon Park, Hyun-Jin Park, Hyung Rae Lee, Ho-Joong Kim, Jin S. Yeom Neurospine.2026; 23(3): 633. CrossRef
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Objective To evaluate long-term bone quality changes within the fusion construct (FC) after 2- to 3-level lumbar fusion using computed tomography (CT)-derived Hounsfield units (HUs).
Methods Among 520 screened patients, 222 who underwent 2- to 3-level posterior lumbar interbody fusion met the inclusion criteria. HU values were measured on CT scans preoperatively, at 1-year postoperative, and at final follow-up. The percentage change in HU (HU [final–pre]%) was calculated for each vertebral level.
Results At the final follow-up, the FC demonstrated a significant decline in HU compared to preoperative values (median [10th–90th percentile], 132.0 [86.5–220.4]; 95% confidence interval [CI], 116.0–142.5 vs. 124.5 [71.0– 210.0]; 109.8–135.1; HU (final–pre)%: -11.0 [-62.0 to 48.5]; -19.9 to -6.1; p<0.001). In contrast, HU increased significantly at the uppermost instrumented vertebra (HU (final–pre)%: median [10th–90th percentile], 28.3 [-19.9 to 102.9]; 95% CI, 21.1–36.4; p<0.001), likely reflecting increased mechanical demands. Subgroup analysis revealed a more pronounced decline in HU in patients with longer follow-up durations, particularly in the FC group (p=0.003).
Conclusion CT-derived HU revealed progressive trabecular bone loss within FC over time after lumbar fusion. In patients with longer postoperative intervals, clinicians should remain aware of the potential weakening of the FC, which has important implications when considering implant removal or planning revision surgery.
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A Commentary on “Disuse Bone Loss in Fusion Constructs After Multilevel Lumbar Fusion: A Computed Tomography Hounsfield Unit Analysis” Jiajun Deng, Hongsheng Lin Neurospine.2026; 23(2): 504. CrossRef
Reply Letter: A Commentary on “Disuse Bone Loss in Fusion Constructs After Multilevel Lumbar Fusion: A Computed Tomography Hounsfield Unit Analysis” Hyun-Jun Jang, Dongkyu Kim, Bong-Ju Moon, Kyung-Hyun Kim, Jeong-Yoon Park, Sung-Uk Kuh, Keun-Su Kim, Dong-Kyu Chin Neurospine.2026; 23(2): 506. CrossRef
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