Aims and Scope The Journal of Spine Surgery (JSS, J Spine Surg, Print ISSN: 2414-469X; Online ISSN: 2414-4630) is an open access, peer-reviewed journal dedicated to the field of spine surgery, science and clinical outcomes. Published quarterly from December 2015 to December 2025, JSS will transition to a monthly publication model, starting in January 2026. JSS has been indexed by Web of Science [Emerging Sources Citation Index (ESCI)], PubMed/PubMed Central and Scopus, and received its first impact factor of 2.3 for the year 2025. The primary objective of JSS is to provide critical analysis and a comprehensive overview of contemporary topics within the field of spine surgery. Each issue will welcome relevant spine topics through the categorized sections: Original Article, Review Article, Case Reports, Editorial Commentary, Guidelines, and Evidence Update. The second objective of the JSS is to facilitate and stimulate the discussion and sharing of pertinent clinical information amongst surgeons and physicians concerned with the surgical treatment of spinal disorders. Articles will be published both in print and online, which will be featured with surgical videos. The aim of the Journal is to provide a forum for the dissemination of progresses in all areas related to spinal disorders and surgical techniques worldwide. JSS is published by AME Publishing Company, with support from Wolters Kluwer (the journal content will be made available on Wolters Kluwer Health’s Lippincott and Ovid platforms). Indexing Journal of Spine Surgery is indexed and covered by Web of Science [Emerging Sources Citation Index (ESCI)] PubMed PubMed Central (PMC) Scopus Google Scholar Ovid Information for Authors JSS is a member of Committee on Publication Ethics (COPE) and it follows the Committee on Publication Ethics (COPE)'s guidelines and the ICMJE recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journal. Manuscripts submitted must be the original work of the author(s) and must not be published previously or under consideration for publication elsewhere. Submission Turnaround Time In-house review: 1-3 weeks. External peer review: 1-3 months. Publication Ahead of Print: within 1 month after being accepted (with APC payment received). Formal publication: within 1-3 months after being accepted (with APC payment received). Original Articles are listed as priority. Publication Schedule Published quarterly from December 2015 to December 2025, JSS will transition to a monthly publication model, starting in January 2026. Open Access Statement This journal is a peer reviewed, open access journal. All content of the journal is published under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0). All articles published open access will be immediately and permanently free for all to read, download, copy and distribute as defined by the applied license. Free access and usage Permitted third party reuse is defined by the CC BY-NC-ND 4.0 license. This license allows users to copy and distribute the article, provided: this is not done for commercial purposes and further does not permit distribution of the Article if it is changed or edited in any way. the user gives appropriate credit (with a link to the formal publication through the relevant DOI) and provides a link to the license but not in an any way implying that the licensor is endorsing the user or the use of the work. no derivatives including remix, transform, or build upon the material was allowed for distribution. The full details of the license are available at https://creativecommons.org/licenses/by-nc-nd/4.0/ Copyright For open access publishing, this journal uses an exclusive licensing agreement. Authors will transfer copyright to AME Publishing Company, but will have the right to share their article in the same way permitted to third parties under the relevant user license, as well as certain scholarly usage rights. For any inquiry/special circumstance on the copyright, commercial usage or adaptation of JSS articles, please contact: permissions@amegroups.com For reprint order, please contact: sales@amegroups.com Support for Authors to Comply with Funding Body Mandates We work with authors of research articles supported by funding bodies with open access mandates to ensure that authors can meet their funders’ requirements for public access to research results. In addition, we offer further support for authors who are required to comply with funding body mandates, including but not limited to: All articles published open access will be immediately and permanently free for everyone to read, download, copy and distribute. If a specific open access license is needed, please contact the editorial office for confirmation before submission. Example of statements in a published article: https://jgo.amegroups.org/article/view/76355/html. No copyright is claimed for any work of the U.S. government. Example of statements in published articles: https://actr.amegroups.org/article/view/8875; https://med.amegroups.org/article/view/8358/html. Contact with Editorial Office Suki Tang, Corresponding Editor, Journal of Spine Surgery Email: jss@amegroups.com Hong Kong Office: Flat/RM C 16F, Kings Wing Plaza 1, NO. 3 on Kwan Street, Shatin, NT, Hong Kong, China. Publisher Information JSS is published by AME Publishing Company. Addresses: Hong Kong branch office: Flat/RM C 16F, Kings Wing Plaza 1, NO. 3 on Kwan Street, Shatin, NT, Hong Kong, China. Updated on June 18, 2026
Accuracy of a high-resolution augmented reality (AR) guidance system with novel 3D stereoscopic targeting for spinal surgery
Background: Augmented reality (AR) is increasingly transforming the landscape of spine surgery by offering enhanced visualization of anatomical structures in real time, directly overlaid onto the surgical field. The study objective was to determine the accuracy of a novel high-resolution AR system with novel three-dimensional (3D) stereoscopic targeting in pedicle screw insertion and to compare it with published studies on existing AR, navigation, and robotic systems. Methods: Eighty pedicle screws were inserted using a novel high-resolution AR system (minimally invasive 55, open 25; thoracic 34, lumbosacral 46). Heary and Gertzbein-Robbins grading was applied, assessing the degree of pedicle breaches on postoperative CT scans. 3D measurements of positional error (PE) and angular error (AE) were performed by comparing post-operative CT scans of implanted screws with planned trajectories. Results: Seventy-six screws placed had Heary grade I. Four screws had a larger diameter than the pedicle and were planned with an in-out-in technique with an intended Heary grade II. Screw placement accuracy rate defined as the percentage of implantations with Heary grades I and II and Gertzbein-Robbins grades A and B was 100%. PE and AE (mean ± standard deviation) for the novel AR system were 1.1±0.5 mm and 1.3°±0.5°, respectively. Percent increment in PE and AE for different navigation, robotic, and AR systems compared to the novel AR system ranged between 23.7–80.6% and 40.6–79.5%, respectively, with the differences being highly significant for all comparisons. Conclusions: PE and AE for placing pedicle screws are 2–5× smaller for the high-resolution AR system with novel 3D stereoscopic targeting compared to published studies on existing navigation, robotic and AR systems. A PE of 1.1 mm and AE of 1.3° makes this technology particularly suited for small pedicles and challenging anatomy.
45S5 bioglass graft decreases surgical site infection after posterior transforaminal lumbar interbody fusion reconstruction compared to alternative graft materials
Background: 45S5 bioglass synthetic bone graft is an established bone graft material with known intrinsic antimicrobial material properties well documented in the in vitro setting. However, 45S5 bioglass graft has not been studied clinically to determine if these antimicrobial properties translate to decreased surgical site infection (SSI) rates. This study sought to determine whether synthetic 45S5 bioglass graft decreases the risk of SSI in posterior transforaminal lumbar interbody fusion (TLIF) compared to other non-bioglass bone graft materials in the clinical setting. Methods: This multi-center retrospective review included all patients undergoing open TLIF procedures from 2017–2022. The minimum follow-up period was 1-year. The final included cohort consisted of 1,376 patients (470 bioglass and 906 non-bioglass). Patient demographic, comorbidity, perioperative, and acute postoperative variables were obtained for each patient and compared between groups. The primary outcome measure was SSI at 1-year postoperatively. Multivariable regression analysis was performed to compare outcomes of interest between the groups, controlling for variables with P<0.05 on univariate analysis. Results: The use of 45S5 bioglass synthetic graft for posterior TLIF was associated with a decreased risk of SSI within one year compared to patients who received non-bioglass grafts [0.6% vs. 2.7%, odds ratio (OR) =0.19, 95% confidence interval (CI): 0.04–0.68, P=0.02], when adjusting for covariates. Conclusions: Results of this multicenter retrospective analysis support an association between 45S5 bioglass graft use and a reduced risk of SSI in the setting of posterior TLIF, consistent with the intrinsic antimicrobial properties of 45S5 demonstrated in prior in vitro work. Causation cannot be established from a retrospective design; prospective, randomized trials are warranted to confirm these findings. This association uniquely expands the recognized clinical properties of 3rd-generation 45S5 bioglass bone graft, which is both an established synthetic osteobiologic graft material and, in this series, associated with a significantly decreased SSI risk.
Cost-effectiveness of three-level cervical disc arthroplasty vs. anterior discectomy and fusion: a comparative single-system analysis
Background: Cervical degenerative disc disease is a common indication for surgical intervention to stabilize vertebral segments and alleviate symptomatic radiculopathy or myelopathy. While anterior cervical discectomy and fusion (ACDF) has long been a standard procedure for these cases, more recently, cervical disc arthroplasty (CDA) has offered a motion preserving alterative to potentially reduce adjacent segment degeneration (ASD). Although cost-effectiveness data exist for single- and two-level procedures, there remain no direct comparisons for three-level CDA constructs. This study retrospectively evaluates admission costs and 3-month clinical outcomes between three-level CDA and ACDF to evaluate each procedure’s relative cost-effectiveness. Methods: In this single-system retrospective study, patients receiving elective three-level CDA (n=10) or ACDF (n=10) for degenerative cervical pathology were compared. Exclusion criteria included acute trauma, infection, or tumors. Data collected included patient demographics, comorbidities, symptoms, radiological findings, procedural details, postoperative complications, and 3-month clinical outcomes. Financial metrics, normalized to institutional cost units, included total admission costs and subcategories [e.g., equipment cost, operating room (OR) cost]. Statistical comparisons employed Kruskal-Wallis and chi-square tests (P<0.05 threshold). Results: Cohorts exhibited comparable baseline characteristics, including age (CDA: 52.3±9.6 years; ACDF: 58.7±7.4 years), comorbidities, symptoms, and diagnoses (P>0.05). Operative times trended longer for CDA (268.6±40.7 min) vs. ACDF (222.8±84.4 min; P=0.08). No intraoperative complications occurred in either cohort, and postoperative complications were not significantly higher for CDA vs. ACDF (30% vs. 10%; P=0.58). There were no significant differences in 3-month symptom resolution and readmission/reoperation rates between procedures (P>0.40). Total admission costs were markedly elevated for CDA (78.04 units) compared to ACDF (46.25 units; +68.75%, P<0.001), driven predominantly by equipment costs (+152.34%, P<0.001), with lesser increases in OR (+32.97%, P=0.006), anesthesia (+56.0%, P=0.008), and radiology costs (+74.56%, P=0.005). Conclusions: Three-level CDA incurs substantially higher admission costs than ACDF without short-term clinical superiority. These findings highlight equipment-driven cost differences amid comparable clinical efficacy, suggesting ACDF may be superior to CDA in three-level cases where motion preservation is not essential and cost is a significant consideration. However, further cost-utility analyses are necessary to evaluate how differences in long-term ASD rates and reoperations may compensate for the higher short-term admission costs of CDA.
Tumor-specific outcomes in spinal metastases: a systematic review and meta-analysis
Background: Spinal metastases (SMs) are common, debilitating, and often associated with severe pain and neurologic disability. Treatment decisions hinge on anticipated life expectancy, yet survival and recurrence outcomes remain poorly defined across primary tumor types. This study is to systematically review and meta-analyze outcomes of SM stratified by primary cancer, with focus on survival, recurrence, and treatment patterns. Methods: PubMed, Scopus, Web of Science Core Collection, and Embase (Ovid) were searched from inception to April 16, 2025. Eligible studies reported outcomes in patients with SM from any primary tumor. Random-effects meta-analyses were performed for survival and recurrence. Study quality was assessed with ROBINS-I. Results: One hundred twenty-three studies (38,780 patients) across nine primary tumors were included; 61 studies (9,222 patients) contributed to meta-analysis. Lung cancer accounted for the largest cohort (n=26,918), followed by gynecologic (n=3,679), breast (n=1,961), and renal (n=1,732). Pooled 1-year survival ranged from 46% in lung SM to 74% in prostate SM. Median survival was shortest for liver (8.2 months) and lung (12.1 months), and longest for thyroid (59.9 months) and melanoma (57.9 months). Recurrence rates were consistently low (<5%), though thyroid SM carried a slightly higher long-term risk. Conclusions: Outcomes in SMs are strongly influenced by primary tumor biology. These data provide benchmarks for clinical decision-making and highlight the need for prospective studies integrating molecular and functional outcomes.
Clinical outcome 24 months after cervical disc arthroplasty with a new articulating and viscoelastic disc prosthesis
Background: Various cervical disc prosthesis and implant designs for motion preservation are routinely used in cervical disc arthroplastic (CDA) surgery. One of the newest implant designs combines features of an articulating gliding surface with those of a viscoelastic flexible core. This should allow for absorption of compressive loads in the axial direction, whereas the gliding surface at the inner surface is intended to allow a physiological range of motion with a progressive increase of resistance in six degrees of freedom (DOF). The aim of this study was to evaluate the safety and efficacy of a new cervical disc prosthesis in a mono-centric clinical setting. Methods: This observational study analyzes the first clinical and radiological results over a period of up to 24 months and evaluates the safety and efficacy of the novel CDA design. Subjects with one- or two-level degenerative cervical disc disease were enrolled. Radiographic assessments were performed pre-operatively, as well as at the 12- and 24-month follow-ups. Clinical data including pain scores [visual analog scale (VAS), Denis Pain Scale, pharmacological treatment], function scores [Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA)], outcome scores (mMacnab) and complication rates were monitored. Results: Forty-five subjects (21 male/24 female) with a mean age of 43.4 years (30–62 years) were operated on the levels C4/5 (7.0), C5/6 (22.0) and C6/7 (23.0) between 01/2021 and 01/2025. A total of 52 implants with sizes between 5 mm ×16 mm and 8 mm ×18 mm were used. Clinically, all subjects reported significant improvements in pain and functional outcomes; however, VAS arm improved better than VAS neck, whereas NDI and mJOA improved at all time points over baseline. No serious adverse events were monitored. Heterotopic ossification (McAfee grades 3 and 4) was observed in 17.3% after 2 years, subsidence with migration into the endplates >2 mm in 11.5%. There were no re-operations due to mechanical problems or implant malfunction. Conclusions: The clinically tested articulating and viscoelastic design concept demonstrated both safety and effectiveness for the treatment of degenerative cervical disc disease. Compared to baseline, all subjects demonstrated significantly improved quality of life and reduced pain, as well as a decreased need for analgesics.
Intraoperative measurement of hinge reaction force using strain gauge and predictability of postoperative hinge fracture in open-door cervical laminoplasty: a prospective study with mid-term follow-up
Background: Open-door cervical laminoplasty relies on greenstick fracture at the hinge side to maintain laminar elevation. The hinge reaction force secures hydroxyapatite (HA) spacers without additional fixation, but has never been quantitatively measured. This study aimed to quantify hinge reaction force using a strain gauge system, to identify factors correlated with it, to evaluate its predictive value for early postoperative hinge fracture, and to investigate mid-term bone healing of fractured hinges. Methods: This prospective study included 50 patients (173 laminae) who underwent open-door laminoplasty with stand-alone HA spacers [2015–2017]. Hinge reaction force was measured using a strain gauge-equipped Penfield dissector. Computed tomography (CT) images were evaluated at postoperative day 1 and delayed phase (mean 2.5 years). Results: Mean hinge reaction force was 0.70 kgf (6.87 N). Early hinge fracture occurred in 24/173 laminae (13.9%). The fracture group showed significantly lower force than the non-fracture group (0.46 vs. 0.74 kgf, P<0.001). Receiver operating characteristic (ROC) analysis revealed area under the curve (AUC) of 0.798 with optimal cutoff of 0.59 kgf. At delayed phase, 62% of early fractures (13/21) demonstrated bone healing, and the overall fracture rate decreased to 8.2%. No lamina showed subsidence exceeding 1 mm. Neither Japanese Orthopaedic Association (JOA) recovery rate (P=0.63) nor postoperative pain visual analog scale (VAS) scores differed between groups. Conclusions: This study provides the first quantitative characterization of greenstick fracture reaction force in cervical laminoplasty. The established force benchmarks and predictive threshold (0.59 kgf) offer foundational biomechanical data for developing simplified clinical assessment devices, force-guided selective fixation strategies, and objective surgical training standards.
Early clinical outcomes of simultaneous biportal endoscopic decompression for tandem spinal stenosis: a single-center retrospective study
Background: Tandem spinal stenosis (TSS), defined as simultaneous spinal canal narrowing at noncontiguous levels, most commonly involves the cervical and thoracolumbar regions and presents substantial challenges in surgical planning. Although staged decompression has traditionally been favored to reduce perioperative risk, simultaneous decompression may shorten overall treatment duration and accelerate neurological recovery. However, evidence regarding the safety and effectiveness of simultaneous minimally invasive decompression remains limited. Therefore, this study aimed to evaluate the feasibility and early clinical outcomes of simultaneous biportal endoscopic spine surgery (BESS) for TSS. Methods: This retrospective single-center case series included 11 patients with TSS who underwent simultaneous BESS between January 2024 and June 2025. All patients presented with cervical spondylotic myelopathy (CSM) accompanied by clinically significant lower-extremity neurological symptoms. Nine patients had concurrent lumbar radiculopathy, while two had additional thoracic spinal cord compression. Clinical outcomes were evaluated using the modified Japanese Orthopaedic Association (mJOA) score and Visual Analog Scale (VAS) for leg pain. Perioperative parameters and complications were recorded. Neurological recovery was assessed using the Hirabayashi recovery rate. Results: Simultaneous multiregional BESS decompression was successfully completed in all patients without conversion to open surgery. The mean follow-up duration was 10.2±2.7 months. Mean operative time and estimated blood loss were 307.7±48.5 minutes and 286.4±86.9 mL, respectively. No major perioperative complications, including dural tears, neurological deterioration, or surgical site infection, were observed. Significant clinical improvement was achieved, with mJOA scores improving from 9.9±1.1 preoperatively to 14.2±0.9 at final follow-up and VAS leg pain scores decreasing from 7.3±0.7 to 2.4±0.5 (both P<0.001). The mean Hirabayashi recovery rate was 52.9%±7.5%. Conclusions: Simultaneous BESS decompression appears to be a feasible minimally invasive approach for TSS, with encouraging short-term neurological improvement, highlighting its potential for broader application in complex spinal pathology.
The impact of COVID-19 on spine surgery: temporal trends in complications and patient-reported outcomes across a statewide cohort
Background: The coronavirus disease 2019 (COVID-19) pandemic substantially disrupted spine surgery worldwide, with widespread deferral of elective procedures, shifts in patient selection, and reallocation of perioperative resources. Existing studies have produced conflicting findings on whether complication rates and patient-reported outcomes (PROs) worsened during the pandemic, and most are limited to single centers or short timeframes. The aim of this study was to evaluate the impact of the COVID-19 pandemic on patient characteristics, adverse events (AEs), and PROs following cervical and lumbar spine surgery across four prospectively defined pandemic phases in a statewide multicenter cohort. Methods: This retrospective cohort study used the Michigan Spine Surgery Improvement Collaborative (MSSIC) to analyze patients undergoing lumbar or cervical spine surgery during pre-COVID (January 2019–February 2020), onset-COVID (March 2020–September 2020), active-COVID (October 2020–February 2022), and post-COVID (March 2022–December 2022) phases. Patient demographics, surgical characteristics, 30- and 90-day AEs, and PROs were compared across cohorts using Chi-squared or Fisher’s exact tests for categorical variables and analysis of variance (ANOVA) or Kruskal-Wallis tests for continuous variables. Results: Among 47,831 patients (33,532 lumbar; 14,299 cervical), demographics remained stable across phases. Lumbar onset-COVID patients had higher durotomy, urinary retention, and return-to-operating room (OR) rates, while cerebrospinal fluid (CSF) leak and 30-day readmissions declined during active-COVID. Cervical surgery showed increased dysphagia during active-COVID and higher return-to-OR and readmissions during onset and post-COVID, with cerebrovascular accident (CVA) and urinary retention rates decreasing over time. PROs were consistent, though lumbar patients more often achieved back pain minimal clinically important difference (MCID) during onset-COVID. Cervical patients reported higher 1-year satisfaction during onset, active, and post-COVID compared with pre-COVID. Functional recovery diverged: lumbar return-to-work fell at onset but stabilized, while cervical return-to-work stayed steady and improved post-COVID. Readmission causes shifted, with pulmonary complications rising initially then declining, while electrolyte, pharmacologic, and stroke-related etiologies decreased progressively. Conclusions: Spine surgery outcomes remained largely stable through the COVID-19 pandemic. Although certain complications temporarily increased during onset-COVID, outcomes normalized as systems adapted.
Retrospective cohort study of recovery trajectories following anterior versus posterior fusion surgery for cervical degenerative pathology
Background: Anterior cervical discectomy and fusion (ACDF) and posterior decompression and instrumented fusion (PDIF) are two common spinal procedures for treating cervical degenerative pathology. While previous studies have compared outcomes and complication profiles between ACDF and PDIF, there is limited outcomes data investigating the rates and patterns of clinical improvement of the two techniques. The purpose of this study was to (I) compare trends in patient reported neck disability index (NDI) scores perioperatively between ACDF and PDIF; (II) identify demographic and perioperative characteristics that may influence rate of improvement; and (III) compare surgical intraoperative complications and reoperation rates. Methods: A retrospective review from 2019–2023 was performed identifying 309 consecutive patients undergoing primary or revision ACDF (n=271) or PDIF (n=38) for degenerative disease. A minimal clinically important difference (MCID) of 11 was assumed based on previous literature. Results: Average follow-up was 2.2 years. ACDF patients were younger (56.1 vs. 60.4 years, P=0.02), had more primary surgeries (99% vs. 74%, P<0.001) for radiculopathy (67% vs. 35%, P<0.001), less blood loss (34.9 vs. 128.2 mL, P<0.001), and shorter hospital stays (2.0 vs. 2.9 days, P=0.001). There was no difference in intraoperative complication or revision rates. ACDF patients had lower NDI scores at all timepoints (P<0.001) and greater delta improvement at final follow-up (−24.1±16.9 vs. −15.9±17.7, P=0.006). MCID achievement rates for ACDF vs. PDIF were: 3 months (72% vs. 46%, P=0.004), 6 months (76% vs. 50%, P=0.005), and 1 year (78% vs. 61%, P=0.04). There was similar MCID improvement between radiculopathy, myelopathy, and myeloradiculopathy diagnoses and single vs. multilevel fusion at all timepoints (P>0.05). No demographic or perioperative factors influenced NDI improvement. Conclusions: Both ACDF and PDIF achieve long-term improvement exceeding MCID with similar rates. ACDF patients demonstrated faster recovery and higher MCID achievement rates at 1-year. Clinical improvement was comparable across diagnoses and number of fusion levels. These findings provide guidance in preoperative counseling, establishing realistic recovery timelines, and managing postoperative expectations.
A single-arm retrospective feasibility study of biphasic calcium phosphate bone graft with submicron surface topography in anterior cervical discectomy and fusion (ACDF) procedures 6 months postoperative
Background: Spinal fusion surgeries are a common procedure for cervical trauma, degenerative spondylosis, and radiculopathy and/or myelopathy. Though this surgical approach has excellent patient clinical outcomes, there is a paucity of rigorous data quantifying fusion rates at early time points. This retrospective safety and feasibility study evaluates a biphasic calcium phosphate bone graft with submicron surface topography (BCP<µm putty) with or without autograft in anterior cervical discectomy and fusion (ACDF) procedures. Methods: An independent neuroradiologist blinded to the clinical status provided evaluation of computed tomography (CT) images obtained at 6 months and graded each treated level based on the extent of bridging trabecular bone. Twenty subjects were enrolled in the study. A total of 43 spinal levels were treated with an average of 2.15 levels per subject (C3-C4 to C6-C7). Results: The primary endpoint of CT-based fusion was 97.7% (42/43 levels) based on the presence of bridging bone between the endplates at 6 months. This cohort included 35% of patients treated with BCP<µm putty with ICBG and 65% of patients fused with BCP<µm putty standalone. The observed fusion rates were accompanied by an improvement in pain scores. No graft-related adverse events (AEs) were reported. Limitations of this study include a small sample size and a heterogeneous surgical population. Conclusions: The high fusion rate observed at 6 months postoperative and favorable safety profile support the performance of BCP<µm putty for use with or without autograft in cervical interbody fusion procedures.
Evaluating the advantages and limitations of three-dimensional (3D) endoscopy as an innovative tool in spine surgery for degenerative pathologies: a case series
Background: Endoscopic spine surgery reduces tissue damage, blood loss and postoperative pain. However, the two-dimensional (2D) view prevents depth perception and spatial orientation, contributing to a steep learning curve. Three-dimensional (3D) endoscopes improve depth perception but introduce increased scope diameter, workflow disruption and reduced image quality. A novel algorithm-based 3D visualisation system enables real-time conversion of standard 2D endoscopic images into 3D without requiring a dedicated 3D endoscope. Its impact on surgical workflow and intraoperative performance in spine surgery remains unknown. Case Description: 14 patients with degenerative spinal pathology underwent endoscopic surgery using a real-time 2D-to-3D conversion system (13 uniportal, 1 biportal). Outcomes were assessed across predefined domains: (I) visualisation; (II) instrument handling; (III) haemostasis; (IV) educational impact; (V) workflow; and (VI) ergonomics. Improved visualisation (depth perception and spatial orientation) were observed in all cases. Improved instrument handling (navigation and drill control) was observed in all decompression cases (10/10). Enhanced haemostasis recognition was reported in 6/10 applicable cases. Educational benefit was observed in 6/14 cases. Workflow disruption occurred in 4/14 cases and ergonomic symptoms (mild dizziness or double vision) were reported in 6/14 cases. Field of view was equivalent between 2D and 3D imaging. No dural injuries, neurological deficits or reoperations occurred. All patients demonstrated recovery consistent with expected postoperative trajectories. Conclusions: This case series demonstrates the potential for 3D endoscopy to be used as an adjunct in endoscopic spine surgery with improvements in depth perception, instrument handling and visualisation of spatial relationships without altering endoscope diameter or access corridors. While an initial familiarisation phase is required, the system demonstrates potential workflow and educational value. Further prospective studies with quantitative metrics and long-term outcomes are warranted.
Single-incision uniportal endoscopic bilateral decompression for two adjacent levels of lumbar spinal stenosis: a technical report
Endoscopic lumbar decompression has become an important minimally invasive technique for the treatment of lumbar spinal stenosis (LSS). Decompression of adjacent levels often requires multiple skin incisions or portals. Strategies to reduce surgical footprint while maintaining effective neural decompression remain an important goal in minimally invasive spine surgery. To our knowledge, single-incision uniportal bilateral decompression at two adjacent lumbar levels has not been formally described. We describe a single-incision uniportal endoscopic technique that allows bilateral decompression of two adjacent lumbar levels through one paraspinal incision, presented through an illustrative clinical case. Laminotomy, medial facetectomy, and flavectomy were performed using an over-the-top contralateral decompression technique with a standardized operative workflow. Adequate bilateral decompression at L3–4 and L4–5 was achieved through a single 0.7-cm incision. Operative time was 115 minutes with six brief fluoroscopy exposures. The patient experienced immediate postoperative symptom relief and ambulated within 24 hours. At 2- and 6-month follow-up, the visual analogue scale (VAS) score improved from 8 to 0. Postoperative clinical assessment confirmed satisfactory bilateral decompression at both levels. Single-incision uniportal bilateral decompression for two adjacent lumbar levels is technically feasible and may further reduce surgical invasiveness compared with conventional multi-portal techniques. While the individual components of this technique are well-established, their integration into a standardized single-incision workflow represents a meaningful technical refinement. Further studies with larger patient cohorts and longer follow-up are required to validate long-term clinical outcomes.
Navigation-assisted unilateral biportal endoscopic decompression using a 0-degree endoscope for upper lumbar spinal stenosis: a technical note on facet preservation
Upper lumbar spinal stenosis at L1/2 and L2/3 is technically demanding because of the narrow interlaminar spaces, steep facet orientation, and deep working corridors. Excessive bone work on the approach side may increase the risk of ipsilateral facet violation. This study aimed to describe a navigation-assisted unilateral biportal endoscopic (UBE) technique using a 0-degree endoscope for upper lumbar spinal stenosis and to discuss a structural rationale by which the straight-view configuration may function as a procedural control strategy for preserving the approach-side facet joint. This retrospective technical note included six consecutive patients with degenerative upper lumbar spinal stenosis (L1/2 or L2/3) treated with navigation-assisted UBE using a 0-degree endoscope. Patients with ossification of the ligamentum flavum, marked deformity, or concomitant fusion procedures were excluded. Perioperative outcomes and postoperative computed tomography (CT) findings were reviewed to assess the adequacy of decompression and facet preservation. All procedures were completed successfully without intraoperative complications or conversion to open surgery. Adequate bilateral decompression was achieved in all patients. Postoperative CT confirmed sufficient decompression with preservation of the approach-side facet joint. Clinical symptoms improved, with Visual Analogue Scale (VAS) scores for back pain decreasing from 75.0 to 35.8 and leg pain from 73.3 to 32.5. Navigation-assisted UBE using a 0-degree endoscope is a feasible and intuitive option for upper lumbar decompression. Under specific anatomical and navigational conditions, the straight-view configuration may help control excessive approach-side exposure and contribute to facet joint preservation.
Thoracic endoscopic spine surgery: systematic review of the literature and exploring the margin of benefit
Background: Thoracic disc herniations are rare and challenging to treat surgically due to their complex regional anatomy, and conventional open approaches are associated with considerable morbidity. While full endoscopic approaches have demonstrated success in the cervical and lumbar spine, their role in the thoracic spine is not as well defined. We performed a systematic review of the literature on full endoscopic surgery for thoracic disc herniations in order to elucidate its safety, efficacy, and potential benefit over conventional open approaches. Methods: The PubMed, Web of Science, and Embase databases were queried from inception to February 2026. Studies describing endoscopic approaches to thoracic disc herniations in at least 5 adult patients with reported postoperative outcomes were included. Exclusion criteria included exclusive reporting of open/thoracoscopic approaches, cadaveric studies, and non-English studies. Data on patient characteristics, operative variables, and perioperative outcomes were extracted. Results: Our systematic review included 23 articles with 695 patients, of which 586 (84.3%) underwent endoscopic surgery and 109 (15.7%) underwent traditional open surgery. In the endoscopic cohort, the most common indication for surgery was radiculopathy (44.2%), followed by myelopathy (43.7%); and myelopathy (70.6%) in the open cohort. Several calcified or partially calcified discs were treated in both the endoscopic and open cohorts (29.8% vs. 36.4%). Endoscopic approaches were associated with shorter operative time (82.3 vs. 201.4 minutes), lower blood loss (18.8 vs. 355.1 mL), reduced fusion rates (1.4% vs. 94.1%), shorter length of stay (2.65 vs. 10.5 days), and lower cost ($7,625.7 vs. $21,055) compared to open approaches. Readmission (3.3% vs. 9.2%), reoperation (3.7% vs. 5.5%), and disc recurrence rates (2.2% vs. 0%) were comparable between cohorts, as were pain and functional outcomes. Conclusions: Full endoscopic approaches to thoracic disc herniations are safe and effective alternatives to traditional open approaches in carefully selected patients, offering meaningful advantages with comparable postoperative outcomes. High quality, direct comparative, multicenter studies are needed to better define their margin of benefit.
Endoscope-assisted prone lateral retropleural 360° reconstruction of thoracic pathological fracture in metastatic melanoma: a case report and technical note
Background: Advances in oncological therapies have increased survival rates, however, these may result in more patients developing secondary disease processes, including pathological spinal fractures requiring surgical decompression and stabilisation. Traditional open approaches carry significant morbidity, particularly for thoracic anterior column reconstruction. A minimally invasive single-position prone lateral retropleural (PRP) approach allows for optimal surgeon ergonomics, simultaneous anterior and posterior access, releases, deformity correction and fixation, while minimising pleural and tissue disruption, implant point loading and surgical time, and eliminating single-lung ventilation. Endoscope-assistance improves illumination and magnification, improving anatomical localisation and minimising complications. Real-time visualisation may shorten the learning curve. Case Description: A 67-year-old man with metastatic melanoma presented with progressive mechanical thoracic pain and myelopathy from a pathological T9 fracture. After initial posterior decompression and fusion, he re-presented 9 months later with hardware failure, fractured rods and subsequent progressive kyphosis. He underwent a mini-thoracotomy and endoscope-assisted minimally invasive PRP T9 corpectomy with posterior construct revision to achieve 360° reconstruction. The endoscope provided visualisation along pleural contours to enable safer vertebrectomy, ventral decompression, neurovascular protection, and cage placement. A titanium quad-rod construct with crosslink reinforced the posterior column. He remained well at 12-month follow-up. Conclusions: This novel endoscope-assisted PRP case unifies two modern spine surgery techniques, offering a promising minimally invasive alternative for thoracic 360° reconstruction of complex fractures. By enabling simultaneous, single-position anterior and posterior column access and improving deformity correction, surgeon ergonomics and visualisation, it facilitates efficient surgery and could assist in navigating the steep learning curve associated with retropleural access while improving clinical outcomes. Future larger-scale observational studies can help provide insight into the generalisability of the technique and its clinical outcomes.
Thoracic medial branch peripheral nerve stimulation for adjacent segment pain in a patient with a long construct fusion: a case report
Background: Adjacent segment degeneration is a known late complication of long construct fusions. While several experimental treatment options exist, including medial branch blocks, no definitive treatment options have been identified. Previous studies have demonstrated the benefit of restorative stimulation of the erector spinae group on patients’ pain, physical function, and disability. This case hypothesizes that motor and sensory programming at the segment adjacent to the long-construct fusion has the potential to be both therapeutic for this patient’s adjacent segment thoracic pain and protective through improved muscular stability. Case Description: A 71-year-old woman with a past medical history of rheumatoid arthritis and prior T11 to S1 laminectomy with fusion and bilateral pedicle osteotomy presented with moderately severe 7/10 adjacent segment pain. She had previously completed conservative therapy, including physical therapy, epidural steroid injections, and medication management with NSAIDs, muscle relaxants, anticonvulsants, topical lidocaine, and chronic daily opioid use totally 30 morphine milliequivalents daily, without significant relief. Physical exam was significant for bilateral T8–T10 facet pain and flat back kyphosis, without focal or motor sensory deficits. She underwent a peripheral nerve stimulator device implantation with bilateral four electrode leads placed at the bilateral T10 medial branches using a minimally invasive retrograde approach to accommodate the fusion. Leads were advanced in a cephalad to caudad direction aimed at the transverse process of T9. Stimulation was programmed using a combined motor- and sensory-based approach to address both functional restoration and pain control. An external therapy disc was utilized to deliver stimulation, allowing the patient to independently apply and remove therapy, supporting day-to-day management of stimulation based on symptom severity, activity level, and personal preference. At her 3-month follow-up, the patient reports significant relief in her pain with an average pain score of 3/10, improved physical function, and a decrease in her pain medication usage. Conclusions: Restorative neuromodulation using motor and sensory programming is a potentially effective treatment adjunct for select patients with adjacent segment degeneration, with treatment sessions aligned towards pain relief and functional restoration. Further studies are needed to better define its role, protective effects and expected outcomes in this patient population.
Endoscopic management of a duplicate nerve root—case report and technique
Background: Nerve root anomalies (NRAs), including duplicate and conjoined exiting nerve roots, are uncommon lumbar anatomic variants that increase the risk of neural injury during foraminal and extraforaminal surgery. Fully endoscopic descriptions remain limited, with only a small number of prior reports. We present a case and technique note on the endoscopic management of a duplicate exiting nerve root with a concomitant far-lateral disc herniation through a transforaminal approach and build on the existing literature to describe a structured, reproducible intraoperative sequence for safe decompression. Case Description: A 69-year-old woman presented with right lower-extremity radicular pain and progressive foot drop following a far-lateral disc herniation at L4–L5. She underwent a right L4–L5 far-lateral endoscopic microdiscectomy via a transforaminal approach. A Type IIB duplicate right L4 exiting nerve root was identified on meticulous preoperative imaging review by the operating surgeon (not described on the radiology report) and confirmed intraoperatively within the neural foramen. A structured intraoperative sequence, adapting commonly taught endoscopic approaches but not formally published termed “rotating neural blockade”, was employed, in which each limb of the duplicated root was sequentially protected, allowing for safe discectomy and foraminal decompression without neural injury. The patient’s radicular pain and dorsiflexion weakness improved postoperatively. Conclusions: This case represents one of the first reports of fully endoscopic transforaminal management of a duplicate exiting nerve root and describes a reproducible intraoperative framework for safe decompression in the setting of a Type IIB NRA.
Restorative neuromodulation for chronic lumbar spine pain secondary to a long construct spinal fusion: a case report
Background: Persistent low back pain is a known complication of long construct fusions, often resulting in long term impacts on patients’ physical function. While available treatment options manage patients’ pain, there are few options available that also work to improve the patients’ physical function. Prior studies have demonstrated the benefit of restorative stimulation of the multifidus muscles on patients’ pain, function, and disability levels. This case hypothesizes that medial branch restorative neuromodulation at the L2 segment may be therapeutic for the patient’s chronic lumbar spine pain, and potentially protective through improved multifidi stability. Case Description: A 70-year-old female with a past medical history of rheumatoid arthritis, scoliosis status post multiple long-construct spinal fusions now fused to T10 to Pelvis, presented with significant chronic lumbar spine and leg pain. The patient presented to the clinic with 9/10 pain around the T9–T10 level and bilateral iliac crests. Her current pain management regimen included chronic hydrocodone and duloxetine, with minimal benefit for pain, and a home exercise program. Physical exam was significant for flat back kyphosis and S-shaped scoliosis with associated paraspinal muscle spasm. Prone instability and multifidus lift testing were positive bilaterally, and there was magnetic resonance imaging (MRI) evidence of multifidus atrophy. She underwent a permanent peripheral nerve stimulator placement, with lead placement at the L2 medial branches bilaterally, to provide restorative motor stimulation of the multifidus muscle. She completed 30-minute, twice daily restorative motor stimulation sessions. At her most recent follow-up visit, she reports pain is now 6/10, with improvement in several Patient-Reported Outcomes Measurement Information System (PROMIS)-29 domains. Additionally, the patient reports experiencing notable strong contractions of multifidus muscles bilaterally during stimulation sessions. She reports improvements in her quality of life, ability to walk without her cane, and less difficulty with activities of daily living. Conclusions: Restorative neuromodulation using motor programming may represent a potential adjunctive intervention for management of post-fusion pain in select patients by improving segmental stability. The device implantation is minimally invasive, and therapeutic sessions are aligned with functional restoration. Further study is needed to better define its role, mechanisms, and expected outcomes in post-surgical populations.
Discal pseudocyst after lumbar tubular microdiscectomy: case report and evidence-informed management with literature review
Background: Postoperative discal pseudocyst (PDP) is a rare but increasingly recognized cause of recurrent radiculopathy after lumbar discectomy. Although its true incidence, risk factors, and natural history remain poorly defined, awareness of this entity is important to avoid misdiagnosis as recurrent disc herniation. This report describes PDP following tubular microdiscectomy and highlights diagnostic and management considerations. Case Description: A 21-year-old male developed left S1 radiculopathy secondary to an L5–S1 disc protrusion. After 6 weeks of unsuccessful conservative treatment, he underwent left L5–S1 tubular microdiscectomy, which immediately relieved the symptoms. Several months later, identical radicular pain recurred. Contrast-enhanced magnetic resonance imaging (MRI) demonstrated a 1.0 cm extradural cyst at the prior discectomy site (T1-hypointense, T2-hyperintense) with a narrow tract communicating with the L5–S1 disc and compression of the left S1 nerve root without a recurrent disc fragment. We performed revision surgery involving cyst drainage, cyst wall excision, and coagulation of the annular defect. Histopathology confirmed a fibrous pseudocyst. The patient’s symptoms resolved completely postoperatively. Conclusions: PDP should be considered in patients presenting with recurrent radiculopathy after lumbar discectomy. Recognition of disc-cyst communication on MRI is critical for accurate diagnosis and differentiation from recurrent disc herniation. A stepwise management approach, ranging from observation to minimally invasive drainage or surgical excision with treatment of the annular defect, can result in favorable outcomes and help avoid misdiagnosis as failed back surgery syndrome.
Occult residual disease after presumed gross-total resection of a predominantly intramuscular paraspinal lumbar schwannoma: a case report introducing the VERIFY-GTR end-of-resection bundle
Background: Paraspinal schwannomas arising from exiting lumbar nerve roots are uncommon but clinically important because deep intramuscular extension can obscure tumor boundaries. In multilobulated lesions, an intraoperative declaration of gross-total resection (GTR) based on direct visualization alone can be misleading. Case Description: A 60-year-old man presented with 12 months of progressive left anterolateral thigh pain and numbness [Visual Analogue Scale (VAS) 6/10; Oswestry Disability Index (ODI) 70%] without motor deficit. Magnetic resonance imaging (MRI) demonstrated a large, predominantly extraforaminal/paraspinal dumbbell schwannoma from L1 to L2 (30 mm × 43 mm × 72 mm; ellipsoid volume approximately 48.6 cm3). Computed tomography (CT)-guided biopsy confirmed schwannoma [World Health Organization (WHO) grade 1]. Microsurgical excision was performed via a posterior paramedian (Wiltse) muscle-splitting corridor with limited L1–L2 hemilaminectomy and continuous neurophysiological monitoring. Recovery was uncomplicated with complete symptom resolution by 2 months (VAS 0; ODI 0%). Nevertheless, contrast-enhanced MRI demonstrated a residual enhancing nodule (15 mm × 22 mm × 23 mm; ellipsoid volume approximately 4.0 cm3), approximately 8% (8.2%) of the initial tumor volume. Conclusions: Occult residual tumor can persist after apparent GTR and complete clinical recovery. We propose VERIFY-GTR: a proposed, auditable end-of-resection verification bundle coupled with an early postoperative contrast-enhanced MRI baseline (ideally within 48–72 hours when feasible) to define a combined surgical plus radiologic endpoint for radiologically verified GTR, avoid premature finalization of GTR status based on intraoperative inspection alone, and to guide surveillance intensity.