Retrospective review of a prospectively collected multisurgeon registry. To determine the correlation between patient-perceived changes in health and patient-reported outcome measures (PROMs) commonly used in cervical spine surgery. Recently, there has been a growing focus on PROMs as important metrics in cervical spine surgery. However, there is little data on how these PROMs correlate with changes in patients' overall perception of health status. Consecutive patients who underwent cervical disc replacement (CDR) or anterior cervical discectomy and fusion (ACDF) from 2017 to 2023 were included. The correlation between the Global Rating Change (GRC) questionnaire, a 5-item Likert Scale, and changes in PROMs (Neck Disability Index [NDI], Visual Analogue Scale [VAS] for neck and arm pain, Short-Form 12 [SF-12 PCS/MCS] and PROMIS physical function [PROMIS-PF]) was assessed using Spearman rank correlation coefficients. Three hundred sixteen patients (109 CDRs, 207 ACDFs) were available for analysis. Most patients in each group described their cervical spine-related health as "slightly better" or "much better" at each postoperative follow-up visit compared with preoperatively and the previous visit. In the CDR cohort, change in PROMs from preoperatively showed a statistically significant but moderate correlation with GRC for multiple PROMs, but change in PROMs from the previous visit did not show any significant correlations with GRC. In the ACDF cohort, change in PROMs from preoperatively were not significantly correlated with GRC, and change in PROMs from the prior visit showed a moderate correlation at one time-point each for NDI and VAS neck, with no other significant correlations. PROMs commonly utilized in cervical spine surgery demonstrated few statistically significant moderate-strength correlations with patient-perceived changes in health. These findings suggest that commonly used PROMs may not adequately assess changes in health that are relevant to patients undergoing cervical spine surgery. Level III.
Although patients often report improvements in pain and functional capacity after endoscopic lumbar spine surgery, objectively measured real-life physical activity may differ from that reported. This multicenter prospective study aimed to assess the correlations between physical activity and patient-reported outcomes (PROs). All adult patients undergoing endoscopic lumbar spine surgery were offered enrollment in the SPINEhealthie smartphone app to assess physical activity. Estimated daily step counts (SCs) and serial PROs, including visual analog scale (VAS) leg pain, VAS back pain, and Oswestry Disability Index (ODI) scores, were collected. Of the 289 patients with pre- and postoperative SC data (mean follow-up 11.4 months), > 70% of patients achieved minimal clinically important difference (MCID) for VAS back and leg pain at 2 weeks and remained stable at 1 year (p < 0.05). Although patients demonstrated substantial improvement in VAS leg (-3.4, p < 0.001) and VAS back (-3.1, p < 0.001) pain scores at 2 weeks, the mean SC decreased significantly at 2 weeks (-632.4, p < 0.001). SC began to increase at 3 months (+265.7, p = 0.004). VAS scores demonstrated minimal further improvement beyond 2 weeks, but SCs continued to improve at all subsequent time points (p < 0.001), as did ODI (-12.2 at 3 months and -13.6 at 1 year, p < 0.001 for both). Preoperative SC was highly predictive of 1-year SC (r = 0.86, p < 0.001) and mildly predictive of ODI at 1 year (r = -0.31, p = 0.006). No preoperative PRO was correlated with PROs or SC at 1 year (r ≤ 0.10, p > 0.2 for all). Quartile analysis of SC revealed that pain scores did not correlate with functional measures. The patient quartiles' recovery patterns remained distinct (p < 0.05 between quartiles at 1 year). ODI improvement was greater in patients with higher baseline SCs (-15.6 vs -13.8 in the lowest quartile at 1 year, p = 0.047). Stratification of patients by baseline scores did not distinguish improvement in SC, or ODI, VAS leg pain, or VAS back pain (p > 0.05 for all) scores, indicative that baseline scores did not predict outcomes. Patients demonstrated immediate reduction in pain but delayed improvement in SC and ODI score. Among preoperative assessments, only SCs were predictive of postoperative outcomes. Furthermore, pain scores did not correlate with disability or activity. SC demonstrated interquartile stability, suggesting that SC may provide a reliable and independent perspective and may be predictive of outcomes.
Lumbar spine instability is often cited as a contributor to chronic low back pain and radiculopathy, however there is no consensus definition or standardized diagnostic criteria across clinical practice. This lack of consolidated criteria complicates patient management and surgical planning. To identify commonly used clinical, radiological, and patient-reported questionnaire criteria for defining lumbar instability and to highlight trends in the evolution of these definitions to guide clinical practice. Systematic review of published literature PATIENT SAMPLE: Studies evaluating adult patients for lumbar instability using clinical examination, radiographic imaging, or patient questionnaires. Self-report Measures: Lumbar Spine Instability Questionnaire (LSIQ) PHYSIOLOGIC MEASURES: Flexion-extension radiography, magnetic resonance imaging FUNCTIONAL MEASURES: Reported symptom provocation with movement, activity-related functional limitations METHODS: A comprehensive search of MEDLINE, Embase, CENTRAL, and Web of Science was conducted using MeSH terms and keywords including "spine instability," "radiographic instability," "neurologic instability," and "biomechanical instability." Eligible studies included adult patients evaluated for lumbar instability using at least one of the three domains: clinical examination, radiographic imaging, or patient-reported questionnaires. Studies were excluded if they involved pediatric populations, non-lumbar regions, instability of other joints, or non-clinical models. The search yielded 1,043 records, of which 32 met inclusion criteria after screening. Clinical instability was most often described as a constellation of symptoms and signs (e.g., episodic pain triggered by movement, instability catch sign) rather than a single exam maneuver such as the lumbar rocking test. Radiographic definitions varied, though >3 mm sagittal translation on flexion-extension radiographs were historically common. Recent literature emphasized multifactorial assessment, incorporating advanced imaging findings and contextual factors such as degenerative changes and patient positioning. Questionnaire-based definitions, particularly using the LSIQ, demonstrated reliability and captured the patient's subjective experience of instability. Lumbar instability is a multifactorial diagnosis that cannot be adequately defined by a single clinical test, radiographic threshold, or questionnaire alone. A standardized diagnostic framework incorporating at least two of the three domains of clinical signs, imaging findings, and patient-reported symptoms may optimize specificity and sensitivity and balance both biomechanical and patient-centered perspectives. These criteria could improve diagnostic accuracy and consistency in treatment planning.
Large language models (LLMs) are transforming medicine, yet their use has been largely confined to back-end administrative tasks, leaving their potential for real-time patient interaction critically unexplored. This study aimed to address this gap by developing and evaluating Spine-GPT, a novel AI assistant built on multi-layered prompt engineering to conduct pre-consultation interviews in the field of spine surgery and enhance clinical decision-making. A two-phase study was conducted. Phase 0 involved simulation-based evaluation using 24 fictional clinical scenarios assessed by three board-certified spine surgeons across seven domains (adaptive questioning, complaint comprehension, diagnostic accuracy, justification clarity, investigation appropriateness, red-flag recognition, and professional tone) on 5-point Likert scales. Phase 1 was a prospective clinical pilot study involving 60 patients, allocated to a control group (n = 30) receiving conventional consultations and an intervention group (n = 30) using Spine-GPT before face-to-face appointment. The primary outcome was active surgeon history-taking time. Secondary outcomes included information completeness, red-flag detection, surgeon and patient satisfaction. In simulations, Spine-GPT demonstrated high performance, with mean scores exceeding 4.0 out of 5 across all evaluation domains. In the clinical study, the AI-assisted group achieved a 31.3% reduction in active surgeon history-taking time (11.47 min vs. 7.88 min; p < 0.001). This efficiency gain was achieved alongside a significant increase in information completeness (11.7%-point increase; p < 0.001). All three predefined red-flag cases were correctly identified. Surgeon and patient satisfaction were significantly higher in the intervention cohort (p < 0.001), with 70% of the AI-generated summaries requiring no edits. This study provides proof-of-concept that a prompt-engineered LLM can safely increase clinical efficiency while simultaneously improving the quality of data collection in a specialized surgical practice. By structuring its reasoning process to be transparent, the system functions as an explainable "probabilistic partner" rather than an uninterpretable "black box," helping to bridge the gap between automated inference and clinician trust. This work ultimately positions the clinician not as a passive bystander to automation, but as a critical editor and beneficiary of machine-reasoning, supporting the new paradigm for human-AI collaboration in clinical care.
Full-endoscopic spine surgery performed under local anesthesia offers clinical advantages, particularly for elderly patients. However, its reliance on fluoroscopy raises concerns about occupational radiation exposure. Although several studies have evaluated cumulative radiation dose, real-time data identifying specific high-risk phases of surgery remain limited. This study aimed to clarify phase-dependent scatter radiation patterns and identify targets for effective protection. We analyzed real-time personal dose equivalent, Hp(10), measured over the protective apron (over-apron Hp(10)) in 28 FESS cases using RaySafe i3 dosimeters across four staff roles: operator, assistant, supervisor, and scrub nurse. Surgical procedures were divided into three phases: Phase 1 (Marking), Phase 2 (Setup), and Phase 3 (Check). The operator showed the highest median total over-apron Hp(10) per case (0.244 mSv), significantly exceeding other staff (p < 0.001), with an operator-to-nurse over-apron Hp(10) ratio of approximately 51.9:1. Phase-based analysis demonstrated that the operator's over-apron Hp(10) was heavily concentrated in Phase 2 (Setup) (median 0.194 mSv), significantly higher than Phase 1 and Phase 3 (p < 0.001). No significant difference in total over-apron Hp(10) was found among surgical approaches. In conclusion, although FESS is minimally invasive for patients, the Setup phase represents a critical target for radiation safety. These anatomical and spatial observations suggest that further investigation into behavioral modifications, such as the use of single-shot fluoroscopy and maximizing operator distance during sheath placement, is warranted to reduce occupational radiation risk.
Surgical site infections (SSIs) are a major complication of spinal surgery. The influence of tattoos overlying the operative incision has not been previously evaluated as a risk factor in this context. Retrospective cohort study of 1,578 consecutive spinal procedures performed by a single senior surgeon (November 2015-December 2025). Presence of a tattoo overlying or crossing the planned incision, ASA score, and standard demographics were prospectively recorded. SSI diagnosis applied CDC/NHSN criteria. Sixty-four SSIs were recorded (overall rate: 4.06%; 95% CI [3.1-5.0%]). Among 98 tattooed patients (6.2%), 10 (10.2%) developed an SSI versus 54/1,480 (3.65%) non-tattooed patients (OR = 3.00 [95% CI: 1.48-6.09]; p = 0.005). Infected tattooed patients had a mean ASA score of 1.8 (80% were ASA 1-2), suggesting that poor general health status is unlikely to be a major confounding driver in this subgroup, although residual confounding cannot be fully excluded. The median tattoo-to-surgery delay was 3.0 years (range: 2-7), ruling out any acute tattooing effect. Advancing age was also significant (66.0 vs. 61.3 years; p = 0.010). Staphylococcus aureus was the predominant pathogen (55.4%). No significant association was found for sex, diabetes, BMI, or smoking. Tattooed skin at the operative site was significantly associated with an increased risk of SSI in spine surgery, with a nearly 3-fold increased risk. These findings support consideration of systematic preoperative documentation and individualized perioperative protocols.
Separation surgery has emerged as a key surgical strategy for metastatic spinal cord compression (MSCC), aiming to create a circumferential decompressive margin that allows safe delivery of postoperative radiotherapy. However, despite its widespread adoption, the clinical value of objectively confirming separation on early postoperative magnetic resonance imaging (MRI) remains unclear. To evaluate whether separation success confirmed by MRI at 2-3 weeks postoperatively is associated with improved neurological recovery, functional outcomes, and survival in patients with MSCC. Retrospective cohort study. Fifty-nine patients who underwent posterior separation surgery for MSCC between 2020 and 2023 were included. All patients underwent metal artifact-reduced MRI at three weeks postoperatively and were classified into a separation group (Group S; n = 26, 44.1%) or a non-separation group (Group NS; n = 33, 55.9%) based on MRI findings. Primary outcomes included neurological recovery (motor grade and ambulation status), overall survival, and length of hospital stay. Secondary outcomes included radiologic parameters (Bilsky grade and Spinal Instability Neoplastic Score), postoperative complications, and radiotherapy administration. Successful separation was defined as a cerebrospinal fluid margin ≥2 mm between the tumor and spinal cord. Baseline characteristics were compared using appropriate parametric and nonparametric tests. Logistic regression was used to identify predictors of separation success. Survival outcomes were analyzed using the Kaplan-Meier method with log-rank testing and Cox proportional hazards regression. Baseline characteristics were comparable between groups except for Bilsky grade distribution. Group NS had a significantly higher proportion of Bilsky grade 3 lesions (28/33 vs. 16/26, p = 0.041). Compared with Group NS, Group S demonstrated significantly higher postoperative motor grades (4.54 vs. 3.67, p = 0.015), higher ambulation rates (92.3% vs. 69.7%, p = 0.032), and shorter hospital stays (15.81 vs. 23.94 days, p = 0.042). Overall survival was significantly longer in Group S (13.31 vs. 6.02 months, p = 0.001). Logistic regression identified preoperative Bilsky grade as the only independent predictor of separation failure (OR = 0.248, 95% CI: 0.069-0.888, p = 0.032). Cox regression demonstrated that separation failure was associated with a 2.63-fold increased risk of mortality (p = 0.006). Separation success confirmed on early postoperative MRI obtained 2-3 weeks after surgery was associated with early neurological recovery, higher postoperative ambulation rates, and prolonged survival in patients with MSCC. Despite technical limitations, early postoperative MRI provides a practical and objective means of assessing decompression adequacy and may support postoperative evaluation and treatment planning following separation surgery for MSCC.
Osteolipoma is an uncommon benign lipomatous tumor characterized by the presence of mature adipose tissue intermixed with lamellar bone. We present a unique case of a 22-year-old female with an osteolipoma in the upper cervical paraspinal region, closely associated with the vertebral artery. The patient exhibited atypical symptoms, including intermittent dizziness and numbness around the right eye, which were previously unreported in similar spinal cases. Diagnosis was confirmed through multimodal imaging and CT-guided biopsy. Surgical excision was performed without complications, and the patient experienced complete symptom resolution at follow-up. This report contributes novel clinical and anatomical insights to the limited literature on spinal osteolipomas, emphasizing the importance of individualized evaluation and multidisciplinary management for optimal outcomes.
Aim and objective Low back pain (LBP) is increasingly prevalent among pediatric patients but often lacks a definitive diagnosis. Kissing Spine Syndrome (KSS), or Baastrup's Disease, is well-described in adults but understudied in children. This study characterizes the clinical and radiographic features of pediatric and adolescent patients with LBP suggestive of KSS. Methods We conducted a retrospective comparative study, wherein we reviewed 131 patients aged 10-22 years presenting with LBP to a pediatric orthopedic clinic in 2021. Inclusion criteria were lumbar spine radiographs and clinical examination. Exclusions included prior spine surgery, inadequate imaging, spondylolysis, spondylolisthesis, degenerative disc disease, and congenital anomalies. Patients were classified into a KSS group (n=23), defined by sclerosis on adjacent spinous processes, or a non-KSS group (n=108). Data were analyzed using non-parametric statistics. Results The KSS group had a higher mean age (16.5±1.8 vs 15.0±2.4 years; p=0.006) and greater female predominance (84% vs 57%; p=0.020). Pain with lumbar extension occurred in 67% of KSS and 53% of non-KSS patients (p=0.217). Patients with KSS had higher pelvic incidence (53.0°±11.5 vs 45.6°±11.3; p=0.039) and reduced interspinous distances at L2-L3 (7.5±3.3 vs 10.0±4.5 mm; p=0.015) and L4-L5 (5.1±3.1 vs 6.9±3.6 mm; p=0.013). MRI demonstrated higher frequencies of spinous process edema (22% vs 5%) and interspinous ligament edema (44% vs 24%), though differences were not statistically significant. Conclusions KSS is an identifiable cause of pediatric LBP, particularly in adolescent female subjects and patients performing extension-based activities. Key indicators include pain with lumbar extension, adjacent spinous process sclerosis, and reduced interspinous distances. MRI trends suggest early inflammatory changes, but larger studies are needed to define its diagnostic role.
Percutaneous endoscopic lumbar discectomy (PELD) is a preferred minimally invasive surgery for lumbar disc herniation (LDH); however, postoperative recurrence, nerve root damage, and hyperesthesia continue to present key clinical challenges. Chitosan represents a novel preventive approach against postoperative complications. This study aimed to assess the clinical efficacy of ultrasound-guided percutaneous endoscopic interlaminar discectomy (PEID) plus medical chitosan in treating lumbar 4-5 disc herniation (L4-5 LDH). Totally, 200 L4-5 LDH patients were prospectively recruited and randomly divided into the control group (ultrasound-guided PEID) and observation group (ultrasound-guided PEID plus medical chitosan). Low back and leg pain and lumbar dysfunction were assessed preoperatively and postoperatively using Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopaedic Association (JOA). Efficacy and postoperative complications were evaluated according to the modified MacNab criteria. Logistic regression analyses identified the risk factors. Mann-Whitney U test was used for inter-group comparisons, and the Kruskal-Wallis test for timepoint comparisons. The two groups showed significant differences in pre-treatment Pfirrmann classification and operation time. As time progressed, patients exhibited reduced VAS and ODI scores and increased JOA scores postoperatively. Significant differences were observed in VAS, JOA, and ODI scores in the observation group at 2 weeks postoperatively. The observation group demonstrated superior treatment efficacy and a lower complication incidence than the control group. Age, disease course, and postoperative bleeding were independent risk factors affecting clinical efficacy of ultrasound-guided PEID plus chitosan. Ultrasound-guided PEID plus medical chitosan reduces postoperative pain and perioperative complications, demonstrating superior clinical efficacy.
Proximal junctional kyphosis (PJK) is a well-recognized complication of adult spinal deformity (ASD) surgery. However, traditional proximal junctional angle (PJA) thresholds (15°) and revision-predictive thresholds (28°) may represent distinct clinical entities with unique etiologies. To analyze and compare predictive risk factors for moderate (PJA ≥15°) and severe (PJA ≥28°) PJK using machine learning. Retrospective study PATIENT SAMPLE: A total of 374 patients who underwent ASD surgery with a minimum 2-year follow-up. Development of moderate (PJA ≥ 15°) and severe (PJA ≥ 28°) PJK. Five machine learning algorithms (Logistic Regression, SVM, RF, XGBoost, AutoGluon) were trained to predict moderate and severe PJK. Feature stability analysis identified robust predictors across models, and SHAP analysis elucidated the feature directionality. The incidence of moderate and severe PJK was 17.4% (65 patients) and 11.0% (41 patients), respectively. BMI and L1 tilt were universally selected for moderate PJK. SHAP analysis showed that high RLL (relative hyperlordosis) and L1 tilt were associated with increased predicted risk, whereas iliac screws were protective. The maldistributed LDI and number of rods were consensus predictors of severe PJK. SHAP associated maldistributed LDI, excessive postoperative LL, and high cement volume with an increased predicted risk of severe PJK. Moderate PJK appears to be driven by geometric stress concentration (e.g., L1 tilt and relative hyperlordosis), whereas severe PJK stems from structural/distributional mismatch (e.g., lordosis maldistribution and construct rigidity). Prevention strategies should be stratified according to these distinct mechanisms.
A descriptive study investigating ligamentum flavum (LF) hypertrophy in individuals with and without lumbar spinal stenosis (LSS). To elucidate the relationship between LF hypertrophy and spinal degeneration in the lumbar spine based on magnetic resonance imaging. LF thickening plays a major role in LSS pathogenesis, initiated by mechanical stress that induces chronic inflammation, tissue damage, scarring, and fibrosis. However, whether LF thickening arises solely from mechanical stress remains uncertain. The connection between spinal degeneration and LF hypertrophy continues to be debated. LF hypertrophy was defined using a threshold based on the mean and SD of the flavum canal ratio (FCR) measured from MRI images of 1086 young individuals. FCR was measured from L1/2 to L5/s in 1266 patients with LSS and 1000 non-LSS cases. Endplate and disc degeneration were evaluated using Modic changes and the Pfirrmann classification. LF hypertrophy and disc degeneration were significantly more prevalent in the LSS group than in the non-LSS group, with the highest prevalence observed at the L4/5 level in both groups. In spinal degeneration, endplate and disc degeneration were significantly less prevalent at the L1/2 level compared with other levels. The trend analysis revealed a statistically significant pattern: the lower the intervertebral level, the higher the incidence of degeneration in LF hypertrophy. LF thickening occurred in the lower lumbar spine, accompanied by spinal degeneration, whereas thickening in the upper lumbar spine occurred without spinal degeneration. These findings suggested the involvement of different mechanisms in the development of LF hypertrophy. Level III.
Intervertebral disc degeneration (IVDD) is a leading cause of chronic back pain and long-term disability, imposing a substantial burden on healthcare systems worldwide. At the core of this degenerative process lies oxidative stress, a pathological condition driven by excessive accumulation of reactive oxygen species (ROS). This redox imbalance initiates a destructive cascade within the intervertebral disc, resulting in injury, premature senescence, and death of nucleus pulposus cells. The loss of these critical cells subsequently provokes inflammatory responses and degradation of the extracellular matrix, ultimately compromising the structural integrity of the disc. Although conventional clinical interventions effectively alleviate symptoms, they typically fail to target the underlying biological mechanisms or halt disease progression. This unmet therapeutic need has spurred growing interest in antioxidant materials, which offer a more proactive approach by directly neutralizing ROS and restoring redox homeostasis. Beyond mere ROS scavenging, these materials also mitigate inflammation and foster a microenvironment supportive of tissue regeneration. Current research efforts are increasingly focused on the rational design of such antioxidant systems, particularly their integration with advanced cell-based therapies to enhance regenerative outcomes. A detailed assessment of how these materials modulate specific pathological pathways is essential to clarify their practical utility and inherent limitations. Translating promising laboratory results into clinical practice remains a major challenge, necessitating rigorous evaluation of their performance in complex biological settings. Refining these antioxidant strategies may ultimately pave the way for a paradigm shift, from symptomatic relief to genuine functional restoration in patients with IVDD.
The fascia iliaca compartment is a potential interfascial space deep to the fascia iliaca and superficial to the iliacus and psoas muscles. Compared with infrainguinal techniques, the suprainguinal approach is anatomically favorable for cephalad spread beneath the fascia iliaca. Although this approach is well established in perioperative analgesia, detailed procedural descriptions adapted for ultrasound-guided fascial hydrodissection and interventional pain practice remain limited. This technical report describes an anatomy-based, ultrasound-guided suprainguinal fascia iliaca plane injection using the anterior inferior iliac spine (AIIS) as a practical sonographic landmark. With the patient supine, a high-frequency linear transducer is used to identify the AIIS and is then rotated into an oblique plane directed toward the umbilicus. In this orientation, the iliacus muscle, overlying fascia iliaca, and adjacent abdominal wall musculature can be visualized. The procedural target is the plane between the fascia iliaca and the iliacus muscle. Under in-plane ultrasound guidance, an echogenic needle is advanced from caudad to cephalad into the interfascial plane. Correct needle-tip placement is confirmed with a small test injectate, followed by incremental delivery of the remaining injectate under continuous visualization. This report emphasizes sono-anatomical orientation, needle trajectory, confirmation of correct fascial plane separation, expected injectate spread, and safety considerations. The manuscript is intended as a technical and educational description rather than as evidence of clinical efficacy. By presenting a reproducible AIIS-based workflow, this report may support clinician training, procedural standardization, and future prospective studies.
Suprascapular neuropathy caused by nerve compression or tension at the suprascapular notch is an uncommon but often underappreciated source of shoulder pain and weakness, with limited reporting of presentation types, diagnostic algorithms, and outcomes of surgical treatment. (1) How does suspected suprascapular nerve compression without rotator cuff tear or space-occupying lesion present in a predominantly young and active military population? (2) How does arthroscopic suprascapular nerve decompression affect VAS pain scores, shoulder motor grading, and return to military duty or sport in this population? Between 2013 and 2020, two surgeons treated 29 patients for symptoms attributed to suprascapular nerve lesions with arthroscopic suprascapular nerve decompression. The diagnosis was made by a combination of history, physical examination, MRI, and selective use of EMG and diagnostic injection. Ultrasound-guided suprascapular nerve injection at the suprascapular notch with local anesthetic was performed in all patients presenting predominantly with pain to support the diagnosis. Patients who had positive findings from this work-up were offered surgical decompression, with patients presenting predominantly with pain having completed at least 7 months of nonoperative treatment at the time of final diagnosis. Although we do not have the exact numbers, the large majority of patients whose work-up suggested the presence of these nerve lesions underwent surgical decompression. We excluded nine of the original 29 patients because they had concomitant procedures and/or were over the age of 60 years. The remaining 20 patients (median [IQR] age 23 years [21 to 28]; 15 were men) were treated with isolated arthroscopic suprascapular nerve decompression at the suprascapular notch with necessary concomitant subacromial decompression, and all of them had follow-up of a minimum of 2 years (median [range] 6 years [2 to 10]) with respect to the endpoint of VAS pain, motor grading, and return to duty or sport. To answer our first research question, we characterized the patients' presentations descriptively based on whether they presented principally with pain or with weakness. Patients presenting predominantly with pain had VAS pain scores ranging from 4 to 8 with motor grades no worse than 4+ of 5, while patients presenting predominantly with weakness had a motor grading of 4 of 5 or worse and VAS pain scores ranging from 0 to 5 (median and mode 0). To answer our second research question, we collected the following outcome measures: return to active-duty military service, shoulder abduction and external rotation strength (by motor grade), and VAS pain score (worst level at rest or activity). These outcomes were compared with Wilcoxon rank sum tests. We found two clinical patterns. A primary symptom of weakness was present in 10 of 20 patients, and pain was the main symptom in 10 of 20 patients. Supraspinatus and/or infraspinatus edema and/or atrophy were present on MRI in 10 of 10 patients with weakness and 0 of 10 patients with pain. EMG had denervation changes in 8 of 8 patients with weakness and 0 of 4 patients with pain. Postoperatively, patients who primarily reported pain had improvement in median (IQR) VAS scores (6 [4 to 7] to 1 [0 to 1]; p = 0.009), whereas those who primarily reported weakness had improvement in abduction and external rotation motor grading (4.0 [3.6 to 4.0] to 5.0 [4.8 to 5.0] and 3.3 [3.0 to 3.9] to 4.3 [4.0 to 5.0], respectively; p = 0.004 and p = 0.008). Return to duty or sport occurred in 8 of 10 patients presenting predominantly with pain and 9 of 10 patients presenting predominantly with weakness at a median (IQR) of 13 weeks (13 to 17) and was maintained past at least 1-year follow-up. In this young, active cohort, suspected suprascapular neuropathy caused by compression at the suprascapular notch presented with one of two primary symptoms: pain or weakness. Diagnosis can be supported by concordant findings on history, physical examination, and MRI, with selective use of EMG for weakness and diagnostic injection for pain. Outcomes after arthroscopic suprascapular nerve release with necessary concomitant subacromial decompression involved successful pain relief and strength improvement in patients presenting with pain and weakness, respectively. Future studies could provide valuable insight into the epidemiology of suprascapular neuropathy and further define thresholds for surgical treatment, especially for patients presenting predominantly with pain. Level III, therapeutic study.
Erectile dysfunction (ED) is prevalent after traumatic cervical spinal cord injury (CSCI), yet predictive tools for postoperative recovery remain underdeveloped. This study aimed to develop a clinical prediction model for erectile function recovery in male patients undergoing posterior cervical surgery for incomplete traumatic CSCI (iCSCI). In this retrospective cohort study, 207 male patients (aged 18-60 years) with iCSCI (ASIA grades B-D) who underwent posterior cervical decompression between 2018 and 2023 were included. Erectile function was assessed using the International Index of Erectile Function-5 (IIEF-5) at protocol-defined 3-month and 2-year postoperative follow-up visits. Improvement was defined as an increase of ≥ 1 severity category. Candidate predictors were screened via univariate analysis (P ≤ 0.20) and correlation assessment, followed by forward stepwise logistic regression. Model performance was evaluated using area under the receiver operating characteristic (ROC) curve (AUC) and internally validated via bootstrapping. Median total follow-up was 41.00 months. Overall, 72.5% of patients showed erectile function improvement. The final prediction model included four independent predictors: preoperative ASIA grade (OR for grade D vs. B: 30.519, P < 0.001), injury level (C0-C3 vs. C4-C7; OR: 5.749, P = 0.012), injury to surgery interval (OR per day: 0.858, P = 0.018), and spinal cord compression ratio (OR per 1%: 0.937, P = 0.002). The model demonstrated robust discrimination (AUC: 0.881) and good calibration (Hosmer-Lemeshow P = 0.194). Bootstrap internal validation yielded an optimism-corrected AUC of 0.850. A nomogram was constructed to facilitate individualized risk estimation. In male iCSCI patients, erectile function demonstrates significant potential for recovery following posterior cervical surgery. The validated four-factor model-presented as a clinical nomogram-enables personalized preoperative risk stratification to guide counseling and rehabilitation planning. External validation is required before widespread clinical implementation.
Break-even cost analysis. This study uses a break-even cost-effectiveness model to assess whether enoxaparin is cost-effective for venous thromboembolism (VTE) prophylaxis in patients undergoing posterior lumbar fusion (PLF). A 7-day course of enoxaparin 40 mg daily was evaluated using average retail drug costs and literature-based treatment costs for symptomatic VTE. VTE rates after PLF at 2, 3-6, and 7-12 vertebral segments were identified in the TriNetX Diamond database (2018-2023) for patients without prophylaxis. A break-even model calculated the absolute risk reduction and number needed to treat (NNT) for cost-effectiveness. The 7-day enoxaparin course cost $411.34, and treating a symptomatic VTE cost $20,461.32. The overall VTE rate was 0.49%; rates were 0.38% (2-segment), 0.65% (3-6 segments), and 2.7% (7-12 segments). Enoxaparin was cost-effective only for 7-12 segment fusions (NNT=50). Sensitivity analyses demonstrated cost-effectiveness for all PLF and 3-6 segment fusions if drug cost is ≤$100.00, or for 2-segment fusions if ≤$50.00. Alternatively, it is cost-effective if VTE treatment costs ≥$100,000 (all PLF, 2-segment) or ≥$75,000 (3-6 segments). Enoxaparin is cost-effective for PLF of 7-12 segments but not for PLF of fewer than 7 segments. Lower drug costs or higher treatment costs could make prophylaxis cost-effective for PLF of fewer segments.
Patients with multiple myeloma undergoing dorsal spinal instrumentation for malignant spinal lesions remain at high risk for postoperative complications and limited survival. Acute kidney injury (AKI) is common in myeloma and after major surgery, but its prognostic relevance in surgically treated myeloma patients and its association with subsequent CT-based body composition and bone density trajectories, remains insufficiently defined. We performed a retrospective cohort study of consecutive multiple myeloma patients undergoing dorsal spinal instrumentation between 2011 and 2024 at a tertiary referral center. Postoperative AKI was defined and staged according to KDIGO criteria based on serum creatinine changes within 7 postoperative days. Clinical outcomes included overall survival (OS), surgical site infection (SSI), and length of hospital stay (LOHS). CT-based morphometry was assessed on non-contrast whole-body CT at L3 level on a preoperative baseline scan (tCT1) and a postoperative follow-up scan. The follow-up CT scan (tCT2) was obtained approximately 9 months postoperatively as part of routine oncologic follow-up or clinical indication rather than a fixed imaging schedule, reflecting real-world clinical practice. The mean interval between tCT1 and tCT2 was 9.1 ± 1.2 months. Analysis included skeletal muscle index (SMI), skeletal muscle density (SMD), visceral adipose tissue (VAT), and vertebral trabecular bone status assessed by Hounsfield Units (HU). Multivariable Cox regression, logistic regression, and log-linear regression were used to evaluate the independent association of AKI with OS, SSI, and LOHS, adjusting for clinically relevant covariates. 59 patients were included (median age 69.0 years; 40.7% female); postoperative AKI occurred in 16 patients (27.1%). AKI was associated with significantly worse OS (median 224 vs. 396 days without AKI; log-rank p = 0.01), with progressively shorter OS across KDIGO stages. In multivariable Cox regression, AKI remained independently associated with worse OS (adjusted hazard ratio 2.35, 95% CI 1.22-4.54; p = 0.011). AKI was also associated with higher SSI rates (63% vs. 12%; p < 0.01) and longer LOHS (median 29 (IQR 8) vs. 19 (IQR 9) days; p < 0.001). After adjustment for age, sex, preoperative ECOG, and Charlson Comorbidity Index, AKI remained independently associated with higher SSI rates (adjusted odds ratio 3.20, 95% CI 1.11-9.26; p = 0.031) and prolonged hospitalization (LOS ratio 1.34, 95% CI 1.06-1.69; p = 0.014). Longitudinal CT analyses demonstrated significantly greater postoperative declines in the AKI group versus no AKI for SMI (median - 44.6% vs. -18.5%; p < 0.001), SMD (- 20.5% vs. -9.2%; p = 0.02), VAT (- 29.1% vs. -24.1%; p < 0.001), and HU (- 46.2% vs. -37.7%; p < 0.001). In multiple myeloma patients undergoing dorsal spinal instrumentation, postoperative AKI is independently associated with reduced survival, increased postoperative morbidity, and accelerated loss of muscle quantity, muscle quality, visceral fat, and vertebral bone density. These findings highlight AKI as a clinically meaningful systemic event with downstream catabolic consequences and support intensified perioperative nephroprotective and multidisciplinary supportive strategies in this high-risk population.
To provide an evidence-based framework for healthcare professionals to use neuromodulation technologies to restore neuromuscular function and relieve pain. An expert panel, convened by the American Academy of Pain Medicine Foundation, conducted a literature review of English-language studies published between 2015 and 2025 using PubMed, the Cochrane Library, Web of Science, and Scopus (detailed in Supplement 2). The panel screened abstracts, extracted key data, and evaluated evidence quality using a modified United States Preventive Services Task Force criteria. A Delphi process was used to achieve expert consensus on clinical recommendations for various neuromodulation technologies: Artificial intelligence-guided and robotic rehabilitation systems, virtual/augmented reality interfaces, brain-computer interfaces, electrical nerve stimulation (encompassing peripheral nerve stimulation transcutaneous electrical stimulation), vagus nerve stimulation, multifidus neurostimulation, surgery (eg,, regenerative peripheral nerve interface), scrambler therapy, spinal cord stimulation for motor restoration, and transcranial magnetic stimulation. The panel provided clinical recommendations and discussed mechanisms of action, evidence, and clinical considerations for each intervention. Evidence for these technologies is evolving, with some showing promising results in areas like improving upper limb function post-stroke, improving functional spine-related outcomes, and reducing chronic pain. Neuromodulation technologies offer a promising approach for neuromuscular restoration, focusing on interventions that promote functional recovery rather than solely providing symptomatic care. Areas for future research include more high-quality, large-scale studies with consistent outcome measures.