ObjectiveTo describe a surgeon-led workflow for developing customized surgical instruments using computer-aided design (CAD) software and to evaluate the clinical utility of the resulting devices.MethodsUnmet clinical needs in spine surgery were identified by the operating surgeon, who then created three-dimensional (3D) models of five surgical instruments (windowed reamer, retractor blade for retroperitoneal or extrapleural approach, protect-guider, disposable sharp hook and holder, and flexible-tip retractor) using Autodesk Fusion 360®. Patient CT or MRI data were imported to determine key dimensions. Draft 3D models were provided to sales representatives, who relayed them to manufacturers' engineers for assessment of manufacturability and refinement into production drawings. The finished instruments were used in clinical practice for at least 6 months. Three board-certified neurospine surgeons completed a structured usability survey (six Likert-scale items) and reported the frequency of use of each device in eligible cases.ResultsThe windowed reamer and flexible-tip retractor achieved the highest mean satisfaction scores (27.7 ± 1.5 and 27.6 ± 1.5), followed by the retroperitoneal/extrapleural retractor (26.7 ± 1.5). These three devices are now used in almost all relevant procedures, effectively replacing their conventional counterparts at our institution. In contrast, the protect-guider and the disposable sharp hook and holder showed lower satisfaction and remain in mixed use with existing instruments.ConclusionSurgeon-generated 3D CAD models can substantially improve communication with manufacturers, enabling rapid development of customized surgical instruments that address specific intraoperative needs and, in some cases, replace standard tools in routine practice. This approach offers a practical pathway for surgeons to translate unmet clinical needs into manufacturable designs that can be integrated into conventional approval processes.
Occupational dose records in Japan are retained by employers, with no national registry, complicating epidemiological exposure assessments. In the Epidemiological Study on Occupational Radiation Exposure in Medical Staff, the feasibility of a mailed dose record review was evaluated among participants who underwent occupational radiation health surveillance (ORHS) at six annual conferences (November 2020-October 2024). Dose information was obtained for 182 individuals (44.9% of eligible participants). The median cumulative effective dose was 2.3 [25th, 75th percentile: 0.3, 11.7] mSv, and median cumulative duration was 8.5 [3.8, 19.8] years. For the fiscal year prior to ORHS, annualized median values were 0.1 mSv for effective dose (E), 0.6 mSv for equivalent dose to the lens of the eye (Heye), and 0.6 mSv for equivalent dose to the skin (Hskin) (values below the detection limit were set to 0.0 mSv), presented descriptively to characterize data properties in this feasibility study. Interventional radiology physicians tended to show higher cumulative and annualized doses than neuro-spine physicians in this descriptive feasibility analysis.
Full-endoscopic spine surgery (FESS) is increasingly utilized for the treatment of degenerative lumbar spinal disorders, with the aim of minimizing tissue disruption and facilitating recovery. Concurrently, postoperative follow-up is shifting toward digital platforms, enabling high-frequency collection of patient-reported outcome measures (PROMs). The characteristics of postoperative recovery trajectories and the determinants of long-term follow-up adherence in this setting remain incompletely defined. Do postoperative PROM trajectories and follow-up retention differ between full-endoscopic lumbar discectomy and decompression, and does early postoperative engagement predict long-term follow-up compliance? This prospective multicenter cohort study included adult patients undergoing lumbar full-endoscopic discectomy or decompression for degenerative pathology between 2018 and 2025. Postoperative PROMs were collected using a smartphone-based application on a daily basis during the first postoperative week and at predefined intervals up to six months. Outcomes included visual analog scale (VAS) scores for back and leg pain and the Oswestry Disability Index (ODI). Longitudinal PROM trajectories were analyzed, and follow-up retention was assessed using Kaplan-Meier analysis and Cox proportional hazards regression in a baseline-engaged cohort. Early postoperative PROM adherence was evaluated as a predictor of long-term retention. A total of 478 patients were analyzed (279 discectomy, 199 decompression). Both cohorts demonstrated significant and sustained reductions in back and leg pain beginning on postoperative day one and persisting through six months (all p < 0.001). Functional recovery, as measured by ODI, followed a delayed course and exhibited a transient early postoperative increase in the decompression cohort. Six-month complete PROM datasets were available in 31.6% of discectomy patients and 48.4% of decompression patients. Follow-up retention differed significantly between procedures, with decompression associated with a lower hazard of dropout (adjusted HR 0.60, 95% CI 0.50-0.72). Higher PROM completion during the first postoperative week was independently associated with long-term follow-up compliance. High-frequency app-based PROM assessment allows detailed evaluation of early and mid-term recovery following FESS. However, long-term outcome interpretation is constrained by follow-up attrition, which varies by procedure type. Early postoperative engagement appears to be a key determinant of durable follow-up and represents a potential target for improving longitudinal outcome assessment.
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This study aims to evaluate the clinical and radiological outcomes of posterior reduction and fusion strategies, with or without interfacet joints distraction and cage implantation, based on reducibility, in the surgical management of atlantoaxial dislocation (AAD). Patients who underwent posterior reduction and fusion surgery for AAD in our institution were included. They were categorized into 2 groups based on reducibility. Japanese Orthopaedic Association (JOA), visual analogue scale (VAS), and patient-reported satisfaction scores were collected. The atlantodental interval, distance of the tip of the odontoid to Chamberlain's line (DOCL), clivus-axial angle (CXA) and mean obliquity of the atlantoaxial articular facet (OAAF) were measured on computed tomography (CT) images. Fusion was evaluated using CT and dynamic x-rays. A total of 90 patients (45 males and 45 females) were included. Among them, 54 patients in the reducible group underwent direct posterior reduction and fusion, and 36 patients in the irreducible group were treated with additional interfacet joint distraction and cage implantation. All patients showed significant improvements in JOA and VAS scores postoperatively. In the irreducible group, the preoperative CXA was smaller, whereas the OAAF was greater. Receiver operating characteristic curve analysis identified optimal cutoff value of OAAF in predicting reducibility was 32.4° (sensitivity: 86.1%, specificity: 81.5%). Postoperative changes in DOCL and CXA were more pronounced in irreducible group. The fusion rates were comparable in the 2 groups (92.6% vs. 94.4%, p=0.730). The reducibility-based posterior reduction fusion strategy achieves satisfactory clinical and radiological outcomes in the surgical management of AAD. For reducible cases, direct reduction under continuous intraoperative skull traction is preferred to minimize surgical trauma. In contrast, interfacet joints distraction and cage implantation are essential for irreducible cases. Preoperative OAAF may act as a potential predictor of reducibility.
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. 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. 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. 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.
Idiopathic normal pressure hydrocephalus is a disease of unknown cause that occurs in people aged 60 years or older and causes gait disturbance, cognitive decline, and urinary problems. A 63-year-old man with untreated diabetes presented with unsteady gait and amnesia. Head magnetic resonance imaging revealed disproportionately enlarged subarachnoid-space hydrocephalus and brain herniation into the para-superior sagittal sinus arachnoid granulation. Although the patient experienced generalized convulsions immediately before surgery, a lumbo-peritoneal shunt was performed, and symptoms improved. These brain herniations into the arachnoid granulation might accelerate the pathology, and idiopathic normal pressure hydrocephalus with brain herniation into the arachnoid granulation of the lateral lacuna of the superior sagittal sinus is extremely rare and has not been reported previously.
Maintaining the occipito-axial (O-C2) angle following occipitocervical fusion is crucial to prevent postoperative complications. Although automated O-C2 measurement has been reported, practical methods that provide rapid results for routine practice remain limited. This study aimed to develop a deep learning model using the YOLO (You Only Look Once) object detection algorithm to automatically identify anatomical landmarks and rapidly calculate the O-C2 angle. A retrospective analysis was conducted using cervical spine radiographs from 2 independent facilities. The internal dataset comprised 574 lateral cervical radiographs from 271 patients for model development, while the external validation dataset included 100 radiographs from 100 patients. Model performance was evaluated against manual measurements by 3 expert raters. The model demonstrated excellent detection performance, achieving perfect metrics for the hard palate (F1 score: 1.00) and high performance for the occipital bone (F1 score: 0.97), anteroinferior corner of C2 (F1 score: 0.99), and posteroinferior corner of C2 (F1 score: 0.99). For O-C2 angle estimation, the mean absolute error was 2.35° and root mean squared error was 2.98°, with an accuracy of 94.7% for determining the presence or absence of the O-C2 angle (i.e., whether all 4 anatomical landmarks were simultaneously detected). Bland-Altman analysis revealed minimal bias (0.57°; 95% confidence interval, -0.06° to 1.12°) with limits of agreement from -5.19° to 6.33°. Inference time was approximately 0.14 s per image. Our deep learning model enables rapid and accurate O-C2 angle measurement on lateral cervical radiographs, demonstrating performance comparable to expert raters and potential clinical utility.
Coccydynia is a painful condition of the coccyx that is frequently misdiagnosed and managed inconsistently. This review summarizes and grades the current evidence on diagnostic strategies and treatment options. We systematically searched the literature and included 42 studies covering conservative, interventional, and surgical management. Based on these data, we propose a current best framework for diagnostic evaluation and therapeutic management. Initial assessment should include detailed history and focused examination with palpation for localized coccygeal tenderness and symptom provocation. Standard anteroposterior and lateral radiographs are recommended mainly to exclude serious pathology, while dynamic sitting-standing radiographs can be considered when mechanical pain is suspected and symptoms persist. Cross-sectional imaging with magnetic resonance imaging or computed tomography (CT) should be reserved for trauma, red-flag features, suspected neoplasm or infection, or inconclusive basic imaging. First-line treatment should consist of education, ergonomic advice, offloading strategies, nonsteroidal anti-inflammatory drugs or other simple analgesics, and physiotherapy, with extracorporeal shock wave therapy having the strongest support. In patients with persistent pain, image-guided diagnostic and therapeutic injections and radiofrequency procedures can provide substantial relief and help select candidates for more invasive treatment. Coccygectomy should be reserved for patients with chronic, function-limiting pain who have failed conservative and interventional care and show concordant findings on assessment, imaging, and diagnostic blocks, while modified incision strategies and minimally invasive techniques may be considered in selected cases.
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. 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. 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. 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.
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. 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. 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). 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.
Instability of the craniocervical junction is a potentially life-threatening condition requiring surgical stabilization. Traditional occipital plate fixation carries risks of construct loosening and intracranial complications due to variable skull thickness, particularly after posterior fossa decompression where plate fixation is challenging. Occipital condyle screws (OCS) provide direct fixation into the occipital condyles (OCs). However, comprehensive outcome data remains sparse. This systematic review and meta-analysis evaluated anatomical parameters, technical aspects, and surgical outcomes of OCS fixation in craniocervical stabilization. Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, PubMed/MEDLINE, Embase, and Scopus were searched for studies reporting techniques and outcomes of occipitocervical fixation using OCS. Two reviewers independently extracted data, and study quality was assessed using the Newcastle-Ottawa Scale, when possible. Random-effects meta-analysis was performed. The primary endpoint was to characterize the technical aspects of craniocervical fixation using OCS and to ascertain its overall feasibility, defined by morphometric suitability, technical success rates, and complication rates. Thirty studies met inclusion: 12 cadaveric (618 specimens), 10 imaging (1,604 participants), and 8 surgical (284 patients). Morphometry consistently showed larger OC in male populations. Bicortical screw placement achieved 100% technical success. Standard 3.5-mm screws (18-24 mm) were commonly used. Recommended trajectories varied (sagittal with 18°-28° angulation; axial with 22°-37° angulation). No major symptomatic vascular or permanent neurological complications occurred. Meta-analytic data revealed significant differences in morphometric measurements of the OC and differences in the OCS length and angulation parameters. OCS fixation appears to be an anatomically feasible and technically promising fixation strategy in selected patients when anatomy and technique are carefully evaluated. Population-specific morphometric variability mandates individualized preoperative assessment. Future comparative studies should define long-term outcomes, fusion rates, and optimize region-specific surgical parameters.
To establish an adult-lifespan segment-specific normative atlas of cervical spinal cord morphometry as a physiologically adjusted reference and to explore its application in degenerative cervical myelopathy (DCM). We included 829 healthy volunteers and 210 surgically treated DCM patients undergoing cervical magnetic resonance imaging (MRI) from 2019 to 2023. Follow-up MRI was obtained in a stratified random sample of 207 healthy volunteers and 42 patients. Axial T2-weighted images at C2-3 to C6-7 were segmented semiautomatically. Cross-sectional area (CSA) was the primary morphometric measure; right-left and anteroposterior diameters (APDs) were complementary measures. In healthy volunteers, sex-stratified, level-specific models including age, age², magnetic field strength, and scanner manufacturer were used to construct the atlas and compute z-scores. In DCM, z-scores were summarized as CompMinZ and NonCompMinZ and explored in relation to clinical outcomes. In healthy volunteers, CSA showed a nonlinear pattern, with smaller values at older ages. Longitudinal changes were age dependent: CSA, right-left diameter, and APD increased in younger adults, were stable in midlife, and declined in older adults. In DCM, z-scores were most negative at compressed levels, while noncompressed segments also frequently fell below the normative mean. Z-score metrics showed exploratory associations with neurological status and postoperative outcomes. In the postoperative subset, CompMinZ showed the strongest association with recovery rate, whereas maximum spinal cord compression was not significantly associated with recovery rate. An adult-lifespan, segment-specific normative atlas of cervical spinal cord morphometry provides a physiologically adjusted reference for interpreting cervical cord morphologic variation and deviation, with exploratory application in surgically treated DCM.
Endoscopic spine surgery (ESS) has expanded rapidly, but existing spine registries do not consistently capture ESS-specific technical variables, ultra-early recovery trajectories, selective imaging validation, or dissemination-related learning-curve effects. This review synthesizes established spine registry models, contemporary consensus initiatives, and digital follow-up approaches to propose a candidate ESS-specific registry framework and preliminary Minimum Data Set (MDS) for future validation. A structured narrative review was conducted on national and multinational spine registries, relevant consensus initiatives, and digital follow-up models. Sources were reviewed with emphasis on governance, data architecture, workflow design, patient-reported outcome measures (PROMs) integration, follow-up structure, data linkage, validation strategies, and implementation feasibility. Established registries provide a methodological foundation for benchmarking, complication surveillance, longitudinal PROM capture, and real-world evidence generation. However, ESS requires modular augmentation of existing registry infrastructures to capture approach-specific operative details, early recovery, selective imaging phenotypes, and governance-controlled maturity indicators. The proposed candidate MDS is organized into 4 domains: (1) baseline case-mix and phenotyping, (2) procedure-specific technical and perioperative variables, (3) selective quantitative imaging and morphometric validation, and (4) structured longitudinal outcome surveillance. The framework prioritizes an essential core dataset while separating recommended, optional, research-oriented, and governance-controlled modules, including digitally enabled early follow-up, opioid-related outcomes, radiation exposure, advanced imaging, and learning-curve variables. A candidate ESS-specific registry framework may support harmonized data capture, real-world evidence generation, quality feedback, and future registry-based research. Formal Delphi consensus, multicenter feasibility testing, and staged integration into existing spine registry infrastructures are required before broader implementation.
Interbody fusion cages are widely used to restore spinal stability, yet conventional designs often exhibit mechanical mismatch and limited biological integration. Functionally graded spinal cages incorporate spatial variations in composition and structure to better align mechanical properties with the surrounding bone environment. Although these designs have been extensively studied from an engineering perspective, their biological implications remain less clearly defined. This review examines how graded material composition, surface characteristics, porosity, and lattice architecture are associated with cellular and molecular responses relevant to bone regeneration. Reported biological responses include protein adsorption, immune modulation, angiogenesis, and osteogenic differentiation. Evidence from orthopaedic implants and tissue engineering systems suggests that such design features may influence mechanobiological pathways; however, direct experimental validation in spinal applications remains limited. Previous reviews primarily focus on material properties or mechanical performance of functionally graded spinal cages. This review presents a structured design-to-biology perspective linking graded implant features with biological responses relevant to spinal fusion. By integrating findings across biomaterials, mechanobiology, and implant design, this review presents a structured design-to-biology perspective and highlights current evidence, translational limitations, and key knowledge gaps in the field. Functionally graded spinal cages represent a promising but still evolving strategy, and further spine-specific mechanobiological and clinical studies are required to establish their impact on fusion outcomes.
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Sacral slanting-defined as the oblique tilt of the upper sacral endplate measurable on standing anteroposterior whole-spine radiographs-is a distinctive and clinically underappreciated finding in adolescent idiopathic scoliosis (AIS). Its etiology is multifactorial and incidence among AIS patients reaches 40%. The direction and degree of sacral slanting interact with the distal lumbar curve type (L4-left vs. L4-right) to influence the pattern of postoperative radiographic changes at the distal spine and shoulder. In patients with L4-left curves and left-sided slanting, stopping fusion at L3 generally prevents coronal decompensation. Furthermore, 5-year data show that the disc wedge angle below the lowermost instrumented vertebra (LIV) does not progress when LIV is L3, and patient-reported outcomes are preserved without revision surgery. When fusion extends to L4 in patients with high sacral slanting, coronal decompensation is more frequent, yet functional outcomes remain comparable and no revision has been required in published series to date, indicating that the decompensation observed is radiographically significant but clinically tolerable within the medium term. In Lenke 1A patients with right-sided sacral slanting (L4-right type), the slanting lowers the last touching vertebra and may facilitate distal adding-on. In Lenke 2A patients with right-sided slanting, distal adding-on serves as a natural shoulder-rebalancing mechanism and may be reasonably monitored conservatively rather than reflexively treated, pending further validation in independent cohorts, unless progressive or symptomatic. Across all scenarios, the optimal distal fusion level remains an unresolved dilemma requiring further long-term prospective study. This review synthesizes the available literature to characterize sacral slanting as a promising radiographic parameter that may serve as a potentially useful adjunct in distal fusion level planning, while highlighting the need for prospective multicenter validation before its routine incorporation into surgical decision-making in AIS.