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 Transforaminal lumbar interbody fusion (TLIF) has become a mainstay technique for interbody fusion, allowing for large contact area between implant and endplate, and providing increased stability and greater area for fusion. The development of 3-dimensional (3D)-expandable implants that provide multidimensional (3D) expansion has shown to provide better height restoration and clinical outcomes when compared to static implants. Comparison of the endplate coverage between 3D-expandable and static TLIF implants has yet to be studied. This study compares endplate coverage achieved with static TLIF, 3D-expandable TLIF, and anterior lumbar interbody fusion (ALIF) implants.
Methods A retrospective review of patients undergoing interbody fusion with either static TLIF, 3D-expandable TLIF, or ALIF between the years 2014 and 2022 was conducted. Postoperative computed tomography (CT) imaging was used to measure endplate and implant dimensions. 3D-expandable TLIF interbody device areas were calculated using diameter measurements on postoperative CT. The coverage ratio was defined as the ratio of twice the area of the implant and the sum of the superior and inferior endplate areas at the operative level.
Results A total of 53 patients per cohort were included. The average endplate coverage ratios for static TLIF, 3D-expandable TLIF, and ALIF implants were 0.19±0.04, 0.35±0.06, and 0.46±0.13, respectively. Subgroup analysis showed comparable coverage of 3D-expandable TLIF to ALIF implants at L3–4 and L4–5, while ALIF remained superior at L5–S1.
Conclusion 3D-expandable TLIF interbody devices provide greater endplate coverage when compared to static TLIF devices and approach comparable coverage to ALIF implants.
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From the Editor-in-Chief: Featured Articles in the December 2025 Issue Inbo Han Neurospine.2025; 22(4): 877. CrossRef
Objective Unilateral biportal endoscopic (UBE) spine surgery is a minimally invasive technique that uses continuous irrigation to improve visualization and control bleeding. Effective water pressure management is crucial for patient safety, particularly at the cervical and thoracic levels where spinal cord injury risk is higher. However, real-time pressure monitoring remains underexplored. This study evaluates the impact of real-time water pressure monitoring on safety during UBE surgery.
Methods A prospective study was conducted involving 20 patients undergoing UBE lumbar spine surgery. Patients were divided into 2 groups based on the irrigation system: gravity-based or infusion pump. Real-time water pressure was monitored using a digital sensor throughout surgery. Each procedure was categorized into 3 phases: phase I, working space preparation; phase II, laminectomy; phase III, flavectomy, dura exposure, and discectomy. Data was analyzed according to the type of irrigation system and surgical phase.
Results The mean water pressure in the surgical field during UBE spine surgery was 17.98± 8.07 mmHg, with no significant differences between surgical phases. However, the infusion pump system maintained significantly lower mean pressure (12.10±3.51 mmHg) compared to the gravity-based system (23.86±6.97 mmHg, p=0.001). The infusion pump system consistently maintained a significantly lower mean water pressure compared to the gravity-based system.
Conclusion Real-time water pressure monitoring during UBE surgery enhances safety by enabling improved control of pressure within the surgical field. Both the gravity-based and infusion pump systems safely maintained working space pressure, with the pump system showing significantly lower pressure levels.
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Metastatic spine disease represents a growing therapeutic challenge that demands a balance between incorporating emerging technologies while respecting the fundamental principles during clinical decision-making. Advances in adjuvant therapies, including stereotactic body radiotherapy (SBRT) and chemotherapy, have significantly improved long-term patient survival. Surgical decision-making should be guided by well-established frameworks such as the NOMS (neurologic, oncologic, mechanical, systemic) criteria, the ESCC (epidural spinal cord compression) scale, and the SINS (spinal instability neoplastic score), ensuring a structured and evidence-based approach to treatment. The integration of minimally invasive techniques, including percutaneous instrumentation, ablation techniques, and biportal endoscopic approaches, has reduced surgical morbidity and facilitated faster recovery. Additionally, carbon fiber implants are revolutionizing spinal stabilization by allowing better postoperative visualization of any local recurrence and easier radiation planning. SBRT has emerged as a critical modality, offering precise, high-dose radiation with minimal toxicity to the spinal cord, improving local tumor control and patient outcomes. A multidisciplinary approach remains paramount, requiring collaboration between spine surgeons, radiation oncologists, and medical oncologists. In this narrative review, we aim to provide a comprehensive overview of the current state of metastatic spine tumor management, focusing on: (1) fundamentals of metastatic spine care, (2) minimally invasive surgical techniques, (3) the use of carbon fiber screws, (4) SBRT, and (5) ways to maximize patient safety.
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Objective Endoscopic spine surgery implies possibly severe complications of the central nervous system, from headache to seizures and autonomic dysreflexia. These adverse events might be due to increased intracranial pressure (ICP), presumably induced by increased spinal intra-/epidural pressure caused by fluid irrigation. This study was designed to perform interlaminar endoscopic lumbar discectomy (IELD) at different irrigation fluid settings while monitoring its effect on intra-/epidural and ICPs, with and without dural tears.
Methods Spinal intradural pressures were measured by introducing catheters through a sacral approach to human cadavers’ lumbar, thoracic, and cervical levels. Additionally, an epidural probe was placed at L3–4. ICP was measured by an intraventricular probe. IELD was performed at L3–4, and the effect of varying irrigation pressures by different endoscopic pump systems and gravity-based irrigation on intra-/epidural and ICP pressures was measured before and after durotomy at L3–4.
Results Intradural pressure at L3–4 correlated linearly with increasing irrigation pressure, irrespective of the used pump system (median pressure increase at 100-mmHg irrigation pressure: system I: 7 mmHg, r=0.94, p=0.002; system II: 7 mmHg, r=0.89, p=0.017) or gravity (8 mmHg, r=0.93, p=0.242). This effect was also seen intradurally at the thoracic/cervical spine, epidural, and intracranial level, and was even more pronounced with the maneuver of outflow-occlusion and a dural tear present.
Conclusion While performing IELD, pump pressures correlated linearly to intra-/epidural pressures and ICPs. Pressures did not rise to concerningly high levels without outflow-occlusion, even with increased pump pressures. In the presence of a dural tear, higher pump pressures exacerbated by occlusion may lead to deleterious intradural and ICP elevations.
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Postoperative pain is an inevitable consequence of spine surgery, yet there remains no universal consensus on the optimal pain management strategy. The complexity of spine procedures, coupled with patient variability, necessitates a multifaceted approach to pain control. Over time, numerous strategies have emerged, each with varying levels of effectiveness. Pharmacological approaches, including multimodal analgesia, local anesthetic infusions, and gabapentinoids, provide relief for both acute and chronic pain. Additionally, perioperative strategies such as enhanced recovery after surgery (ERAS) protocols have demonstrated benefits in optimizing pain control and recovery outcomes. Beyond pharmacological interventions, physical therapy has become a cornerstone of postoperative pain management, aiding in functional recovery and reducing reliance on medications. For patients with refractory or chronic pain, neuromodulatory techniques such as spinal cord stimulation and intrathecal injections offer alternative solutions. Despite the breadth of evidence-based strategies available, limitations persist, including opioid dependence, the complexity of multimodal regimens leading to suboptimal compliance, and cases of refractory pain. These challenges underscore the importance of tailoring pain management approaches to individual patient needs, ensuring a balance between effectiveness and safety. This narrative review of evidence seeks to explore the multifaceted nature of pain management following spine surgery, highlighting the challenges and evolving strategies in optimizing patient outcomes.
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Objective Preoperative opioid misuse is associated with worse postoperative outcomes. This prospective longitudinal cohort study evaluated the association between preoperative opioid misuse and prolonged pain and opioid use after elective spine surgery; and examined postoperative trajectories of patient-reported outcomes over one year.
Methods Fifty-two patients undergoing elective spine surgery completed presurgical and weekly postoperative longitudinal assessments of pain and opioid use and monthly assessments of depression, anxiety, sleep disturbance, and physical function. Cox regression analyzed the effect of preoperative opioid misuse on time to pain and opioid cessation while linear mixed-effects models examined longitudinal changes in postoperative outcomes.
Results Adjusting for age, sex, operative region, number of spinal levels, and any preoperative opioid use, preoperative opioid misuse (COMM-Positive) was associated with a delayed return to baseline opioid dose (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.14–0.88; p=0.02) and delayed opioid cessation (HR, 0.25; 95% CI, 0.09–0.59; p=0.008). All patients experienced comparable reductions in current and average pain intensity, and pain interference over time. COMM-Positive patients reported a normalization of postoperative anxiety and depression 1 month after surgery with a rebound at 3 months while patients without preoperative opioid misuse remained stable over time.
Conclusion Preoperative opioid misuse is a significant risk factor for delayed opioid cessation even after adjusting for preoperative opioid use, and is associated with a transient normalization of anxiety and depressive symptoms with a rebound 3 months following spine surgery. Targeted screening and risk reduction strategies are needed for patients reporting preoperative opioid misuse before spine surgery.
Objective This study aimed to determine the rates, causes, and predictive factors of readmissions at different periods following spine surgery, up to 180 days.
Methods This study utilized data from the 2018 to 2019 Nationwide Readmissions Database and included four postoperative periods: 0 to 7 days, 8 to 30 days, 31 to 90 days, and 91 to 180 days. The causes of readmissions and potential predictive factors were systematically identified. All analyses were performed for each period.
Results For the 180,281 patients (mean age, 65.4 years) included, 2.4% were readmitted between 0 and 7 days, 3.5% between 8 and 30 days, 3.7% between 31 and 90 days, and 4.3% between 91 and 180 days (cumulative rates: 2.4%, 5.9%, 9.3%, and 12.1%, respectively). The causes of readmissions varied across different periods: surgical site-related causes predominated within the first 30 days, whereas nonsurgical site-related causes were more prevalent from 31 to 180 days; other surgical care complication (e.g., infection) was the most prevalent cause between 0 and 7 days (10.7%) and between 8 and 30 days (29.2%), while spondylopathies/spondyloarthropathy (e.g., spinal stenosis) were the leading causes between 31 and 90 days (12.6%) and between 91 and 180 days (17.5%). The predictive factors associated with readmissions also varied across different periods. For example, patients who underwent fusion was associated with a decreased risk of readmissions between 31 and 180 days (e.g., between 91 and 180 days: odds ratio [OR], 0.79; 95% confidence interval [CI], 0.72–0.86; p<0.001), rather than between 0 and 30 days (e.g., between 0 and 7 days: OR, 0.99; 95% CI, 0.90–1.08; p=0.81).
Conclusion About 6% of patients with lumbar spinal stenosis who underwent spine surgery were readmitted within 30 days and 12% by 180 days. The causes of readmissions and predictive factors varied by period, providing valuable insights for quality improvement efforts and the burden of readmission reductions.
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Neurospine 2025;22(1):3-13. Published online March 31, 2025
Objective While minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF) has shown superiority in key clinical metrics over the open approach, evidence regarding patient-reported outcomes remains limited. This study compared postoperative recovery trajectories and symptomatic improvement phases between MIS and open TLIF.
Methods This retrospective review included patients who underwent single-level MIS or open TLIF. Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS) for back and leg pain were collected preoperatively and postoperatively. Segmented regression analysis with mixed-effects modeling, allowing for identification of distinct recovery phases, compared symptomatic trends between approaches.
Results Of 324 patients (268 MIS, 56 open), baseline demographics were similar except for greater preoperative leg pain in the MIS group (NRS: 6.0 vs. 5.0, p = 0.027). A segmented regression model identified 4 ODI recovery phases: postoperative disability phase (PDP, day 0 to 13), early improvement phase (day 13 to 28), late improvement phase (day 28 to 110), and plateau phase (later than day 110). The MIS group exhibited significantly lower disability exacerbation during PDP (β = 0.93 vs. 1.42 points per day, p = 0.008). Additionally, the plateau of NRS back occurred significantly earlier in the MIS group than in the open group (MIS, 26.7 ± 2.6 days vs. open, 51.7 ± 6.6 days, p < 0.001).
Conclusion MIS-TLIF resulted in lower postoperative disability during the first 2 weeks compared to the open approach. Furthermore, low back pain achieved an earlier plateau in back pain by about 4 weeks in the MIS approach.
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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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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
Applications of Raman Spectroscopy in Pandemic Virology: A Comprehensive Review Hulya Yilmaz, Anuradha Ramoji, Andreea Winterfeld, Hamideh Salehi, Aykut Ozkul, Jürgen Popp ACS Photonics.2026; 13(6): 1568. CrossRef
Current Applications and Future Directions of Technologies Used in Adult Deformity Surgery for Personalized Alignment: A Narrative Review Janet Hsu, Taikhoom M. Dahodwala, Noel O. Akioyamen, Evan Mostafa, Rami Z. AbuQubo, Xiuyi Alexander Yang, Priya K. Singh, Daniel C. Berman, Rafael De la Garza Ramos, Yaroslav Gelfand, Saikiran G. Murthy, Jonathan D. Krystal, Ananth S. Eleswarapu, Mitchell Journal of Personalized Medicine.2025; 15(10): 480. CrossRef
Objective Full endoscopic cervical surgery (FECS) is an evolving minimally invasive approach for treating cervical spine disorders. This systematic review synthesizes current evidence on the clinical outcomes and patient perspectives associated with FECS, specifically evaluating its safety, efficacy, and overall patient satisfaction.
Methods A systematic search of the PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies published between January 2000 and September 2024 that reported on clinical outcomes or patient perspectives related to FECS were included. Risk of bias was assessed using the ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) tool and the Cochrane Risk of Bias tool. Inclusion criteria encompassed randomized controlled trials, prospective cohort studies, retrospective studies, and observational studies focused on adult populations undergoing FECS for cervical spine surgery.
Results The final synthesis included 30 studies. FECS was associated with significant reductions in both cervical and radicular pain, as well as meaningful functional improvements, measured by standardized clinical scales such as the Neck Disability Index and visual analogue scale. Patient satisfaction rates were consistently high, with most studies reporting satisfaction exceeding 85%. Complication rates were low, primarily involving transient neurological deficits that were typically resolved without the need for further intervention. Nonrandomized studies generally presented a moderate risk of bias due to confounding and selection, whereas randomized controlled trials exhibited a low risk of bias.
Conclusion FECS is a safe and effective minimally invasive surgical option for cervical spine disorders associated with substantial pain relief, functional improvement and high levels of patient satisfaction.
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Response to the letter to the editor: Inconsistencies in obesity criteria: implications for systematic reviews on endoscopic spine surgery Wongthawat Liawrungrueang, Watcharaporn Cholamjiak, Peem Sarasombath, Yudha Mathan Sakti, Pang Hung Wu, Meng-Huang Wu, Yu-Jen Lu, Lo Cho Yau, Zenya Ito, Sung Tan Cho, Dong-Gune Chang, Kang Taek Lim Asian Spine Journal.2026; 20(1): 211. CrossRef
Full-Endoscopic Posterior Cervical Foraminotomy and Discectomy for Cervical Disc Hernia With Unilateral Radiculopathy Idris Gurpinar, Mehmet Yigit Akgun, Furkan Almas, Ozkan Ates Journal of Minimally Invasive Spine Surgery and Technique.2026; 11(1): 149. CrossRef
Current Trends and Future Directions in Lumbar Spine Surgery: A Review of Emerging Techniques and Evolving Management Paradigms Gianluca Galieri, Vittorio Orlando, Roberto Altieri, Manlio Barbarisi, Alessandro Olivi, Giovanni Sabatino, Giuseppe La Rocca Journal of Clinical Medicine.2025; 14(10): 3390. CrossRef
Navigated Minimally Invasive Cervical and Cervicothoracic Fixation: A Technical Note on Surgical Technique and Proposed Classification Spyridon Komaitis, Konstantinos Zygogiannis, Sotirios Karatzoglou, Dimitrios Klitsinikos, Dritan Pasku, Khalid Salem Cureus.2025;[Epub] CrossRef
Luca Ambrosio, Sathish Muthu, Samuel K. Cho, Micheal S. Virk, Juan P. Cabrera, Patrick C. Hsieh, Andreas K. Demetriades, Stipe Ćorluka, S. Tim Yoon, Gianluca Vadalà, AO Spine Knowledge Forum Degenerative
Neurospine 2025;22(1):40-47. Published online March 31, 2025
Objective This study aims to assess global trends in the use of open surgery versus minimally invasive surgery (MIS) for the treatment of single-level L4–5 degenerative lumbar spondylolisthesis (DLS).
Methods A cross-sectional online survey issued by the AO Spine Knowledge Forum Degenerative was conducted among AO Spine members between July and September 2023. Participants were presented with 3 clinical cases of L4–5 grade 1 DLS, each with varying degrees of stenosis and instability. The survey captured surgeon demographics and preferences for open versus MIS approaches. Statistical analysis, including chi-square tests and logistic regression, was performed to explore associations between surgical choices and surgeon demographics.
Results A total of 943 surgeons responded, with 479 completing the survey. Open surgery was the preferred approach in all 3 cases (58.8%, 57.3%, and 42.4%, respectively), particularly in cases involving central and bilateral foraminal stenosis. MIS was the second most common choice, particularly for unilateral foraminal stenosis with mild instability (38.8%). Surgeons’ preferences varied significantly by region, age, and fellowship training, with younger and fellowship-trained surgeons more likely to prefer MIS.
Conclusion The study highlights the continued predominance of open surgery for DLS, especially in complex cases, despite the growing acceptance of MIS. Significant regional and demographic variations in surgical preferences suggest the need for tailored guidelines and standardized training protocols to optimize patient outcomes. Future research should focus on the long-term efficacy of these approaches and the impact of evolving technologies on surgical decision-making.
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Minimally Invasive Options for Spondylolisthesis Chibuikem A. Ikwuegbuenyi, Mousa Hamad, Ibrahim Hussain, Roger Härtl Neurosurgery Clinics of North America.2026; 37(1): 39. CrossRef
Long-term comparative study of Open-TLIF, MIS-TLIF, and UBE-TLIF in single-level degenerative lumbar spondylolisthesis Jian Luo, Lihua Shen, Changshen Bao, Zhichao Gao European Journal of Medical Research.2026;[Epub] CrossRef
Current Trends and Future Directions in Lumbar Spine Surgery: A Review of Emerging Techniques and Evolving Management Paradigms Gianluca Galieri, Vittorio Orlando, Roberto Altieri, Manlio Barbarisi, Alessandro Olivi, Giovanni Sabatino, Giuseppe La Rocca Journal of Clinical Medicine.2025; 14(10): 3390. CrossRef
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