Assessment of influential authors and articles in spine surgery research: a narrative review

Introduction

Bibliometric analyses offer a powerful lens for assessing the scholarly evolution of spine surgery (1,2). By quantifying publication trends, citation patterns, and authorship networks, these studies help define the intellectual architecture of a discipline, highlighting what is being studied and who is driving the conversation (1-3). In spine surgery research, where both orthopaedic and neurosurgical perspectives intersect, understanding the influence of individual contributors and landmark publications is particularly important for shaping evidence-based practice and guiding future inquiry.

Despite the evolution of spine surgery, few studies have systematically examined the most cited authors and articles within this field (4). A bibliometric evaluation of research within spine surgery can elucidate how the field has developed, who its key contributors have been, and which topics have left a lasting impact. Furthermore, citation metrics, while imperfect, offer a window into academic visibility and perceived influence (5,6). Previous bibliometric work and evaluations of academic productivity have often aggregated data across multiple journals for a specific topic within spine surgery or focused only on first authorship, potentially overlooking broader contribution patterns (4,7,8). The aim of this study is to conduct a focused bibliometric analysis of 19 spine surgery-related journals to identify the most frequently cited authors in first, last and any author position and the 20 most cited articles, both of all time and in the last 10 years. By characterizing the content, authorship, and impact of these contributions we hope to better understand the trajectory of academic influence in spine surgery and the evolving nature of spine research.

In this article, we examine the core bibliometric characteristics of the top cited authors and articles related to spine surgery to quantify research impact. By comparing metrics between author cohorts and publication periods, we identify influential contributors and characterize trends shaping the current trajectory of spine surgery research. We present this article in accordance with the Narrative Review reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0044/rc).

Methods

The following methodology was adapted from two previous papers analyzing notable authors and publications in the Journal of Orthopaedic Trauma (JOT), Lefaivre et al. in 2010 and Box et al. in 2025 (1,9). The Web of Science (WoS) Core Collection database from Science Citation Index Expanded (Clarivate Analytics, Philadelphia, PA) was queried on December 5, 2025 for all articles and reviews published in the following journals from January 1, 1979 to December 31, 2024: Asian Spine Journal, Clinical Spine Surgery, European Spine Journal, Global Spine Journal, International Journal of Spine Surgery, Journal of Craniovertebral Junction and Spine, Journal of Neurosurgery: Spine, Journal of Spinal Disorders, Journal of Spinal Disorders Techniques, Journal of Spine Surgery, JOR Spine, Neurospine, Scoliosis and Spinal Disorders, Spinal Cord, Spinal Cord Series and Cases, Spine, Spine Deformity, Spine Surgery and Related Research, and The Spine Journal. These journals have been previously identified as journals encompassing the field of spine surgery (10,11). Editorials, letters, notes, and corrections were excluded. The included date range began at 1979 because it was the oldest publication year available for the journal cohort and concluded at 2024 because it is the most recent complete year as 2025 would have yielded incomplete data. Publications were sorted by the number of total citations. A summary of the search strategy can be found in Table 1.

Top cited authors

The number of citations for each author published in all the journals mentioned above was determined. The top 20 most cited authors in (I) first author position, (II) any author position, and (III) last author position were identified and listed separately. Each author’s citation count was found by downloading all articles identified in our search and extracting each author’s name, authorship position, and article citation count. A pivot table was then used to calculate the number of citations per author as first, any, and last author. For the first and last author iterations, articles with only one author were excluded. The citation number was confirmed for each author in their respective author position through a search of the author’s name in the WoS database. Per the previously reported protocol, the MEDLINE database was utilized to find the number of published articles at the corresponding authorship position associated with each author’s name within our cohort of selected journals (1,9). To compare the number of citations per publication within each cohort, the relative citations per publication (RCPP) was calculated by dividing each author’s total number of citations in their respective author position by the associated number of published articles in that corresponding position then normalizing this value by the average number of citations per publications in the associated authorship position cohort. Finally, the level of training and current institution were determined for each author, and the accuracy of the results was corroborated by two independent reviewers (N.M.K. and S.B.). Normally distributed data is presented as the mean ± standard deviation while non-normally distributed data is presented at median [interquartile range (IQR)]. Normality was determined using the Shapiro-Wilk test. Differences in the number of publications, number of citations and RCPP between first and last author groups were evaluated using the Mann-Whitney U test. Significance was set at P<0.05.

Top cited articles

The top 20 most cited articles of all time and in the most recent complete 10-year period (2014–2024) were exported for further review. Author, title, publication year, number of citations (within the WoS Core database), and citations per year were collected for all articles. Each article was reviewed for article type (basic science, statistics or clinical), subtype, subject, level of evidence (LOE), and country of origin. The LOE was assigned following the guidelines of The Oxford 2011 Levels of Evidence, if not already stated within the abstract (12). While clinical guidelines contain a variety of evidence types, they were collectively assigned LOE V to reflect their inclusion of expert opinions. Since clinical guidelines can be categorized into multiple levels of evidence, we also examined LOE proportions after clinical guidelines were excluded. The accuracy of the LOE and type of study were corroborated for each article by two independent reviewers (A.L. and S.B.).

VOSViewer version 1.6.20 was used to perform a co-occurrence analysis to generate a keyword network map using WoS full record and cited references data for the 20 most cited articles from both time periods (1979–2024 and 2014–2024). A Sankey diagram was constructed in R from a thematic evolution analysis using the same WoS data.

Results

In total, the WoS search yielded 49,754 publications.

Top 20 cited authors

For the 20 most cited first authors, the median number of citations was 3,021 (IQR: 1,865). The median RCPP was 1.17 (IQR: 1.53). The average number of articles published as first author was 21±13 (Table 2).

For the 20 most cited authors in any authorship position, the average number of citations was 16,773±5,162. The median RCPP was 1.02 (IQR: 2.38). The average number of articles published was 303±187 (Table 3).

For the 20 most cited last authors, the median number of citations was 3,266 (IQR: 2,140). The median RCPP was 1.19 (IQR: 1.38). The median number of articles published as the last author was 27 (IQR: 35) (Table 4). No significant differences were found when comparing the number of citations, RCPP or number of publications between the first and last author cohorts (P>0.99, P=0.797, P=0.116, respectively). To account for the influence of authors with a low number of publications, a sensitivity analysis was performed, excluding authors with less than 10 publications and still no significant differences were seen between first and last authorship cohorts (number of citations, P=0.917; number of publications, P=0.128; RCPP, P=0.647).

Among the top 20 cited first authors, 12 had some role in authorship in one of the top 20 cited articles from either timepoint, with eight authors listed as first authors and over half of all authors identified in all cohorts having at least one article in the top 20. D.E. Beaton authored the top cited article of all time and was the most cited first author (Table 2; Table 5). Nine of the most cited authors in last position were last authors on a top article.

Top 20 cited articles

The top 20 most cited articles of all time are listed in Table 5 (13-32). Approximately two-thirds (65%) of the articles were from Spine. The median number of citations was 1,500 (IQR: 668). The median number of citations per year was 72 (IQR: 36). Nine of the top 20 most cited articles had recurring authors. C. Bombardier was involved in the most articles (n=3), followed by A. Furlan (n=2), S. Glassman (n=2), M. van Tulder (n=2), J. Fairbank (n=2), M. Roland (n=2) and L. Bouter (n=2). M. Roland was the only repeating first author with two first author top articles, both regarding disability assessment (17,24).

Among the top cited articles, 17 were clinically focused, with the most common topic being measurement or outcome tools (35%), followed by back pain (15%). The majority of the top articles were methodological reviews/studies (30%) or literature reviews (25%). These studies varied in their levels of evidence, with 80% of the top articles classified as having lower levels of evidence (IV and V) (79% when excluding clinical guidelines) and only 10% classified as having higher levels of evidence (I and II) (11% when excluding clinical guidelines).

Top 20 cited articles 2014–2024

The top 20 most cited articles of the last decade (2014–2024) are listed in Table 6 (33-52). There was a more even spread of journals with the European Spine Journal and The Spine Journal having the highest proportion of articles (25% each), followed by Spine (20%). The median number of citations was 397 (IQR: 175). The median number of citations per year was 55 (IQR: 23). Eight of the articles had recurring authors (M. Fehlings, J. Dettori, A. Singh, M. van Tulder, D. Brodke, S. Bess, C. Maher, and L. Tetreault) with no repeating first authors. Among the top cited articles, 19 were clinically focused, spanning a variety of topics with lumbar disc disease/herniation/radiculopathy, surgical techniques and complications, and back pain each accounting for 15% of the studies. Clinical practice guidelines and literature reviews were the most common study types (30% and 25%, respectively). These studies varied in their levels of evidence, with 70% of the top articles categorized as having lower levels of evidence (IV and V) (57% when excluding clinical guidelines) and 20% categorized as having higher levels of evidence (I and II) (29% when excluding clinical guidelines).

Network analysis of the top 20 cited articles from 1979 to 2024 and from 2014 to 2024

The keyword co-occurrence analysis demonstrated that the top 20 cited articles from 1979 to 2024 had fewer keywords compared to the top 20 cited articles from 2014 to 2024. We also identified a high occurrence of general keywords such as reliability and quality of life for this time period (Figure 1A). The keyword co-occurrence analysis of the top cited articles from 2014 to 2024 revealed a larger network with a higher diversity in topics, focused more on specific topics such as herniation and fusion (Figure 1B). Both maps show back pain as being a common topic for the top cited articles in each time period. The thematic analysis comparing the top cited articles across these two time periods revealed a shift in themes over time. Focus has seemed to shift from patient outcomes and general research methodology to specific topics such as disc herniation and lumbar interbody fusion (Figure 1C).

Figure 1 Co-occurrence network map for the top cited articles from 1979 to 2024 (A) and 2014 to 2024 (B) using keywords. Each node represents a keyword and the size of the node corresponds with the number of occurrences. (C) Sankey diagram examining changes in themes across the top cited articles from 1979 to 2024 (P1) and 2014 to 2024 (P2).

Discussion

Through an analysis of citation patterns across authorship positions and different timeframes, this study presents a quantitative overview of how the influence within spine surgery research has evolved over nearly five decades.

Top cited authors in spine surgery

Notably, the top ranked first author, D.E. Beaton, has only two first author publications (with only 5 spine-related publications), but achieved the highest citation count as first author. Citation count is one metric commonly used to quantify the impact and quality of research, although it cannot be used to directly evaluate the rigor of an author’s research (53). Beaton’s disproportionately high citation count relative to publication volume emphasizes how methodological contributions may lead to increased influence even with lower publication volume, as many of Beaton’s publications are methodologies that may be more likely to be cited by future researchers who are applying the framework to other scenarios. Additionally, Beaton is the first author of the top ranked article, “Guidelines for the process of cross-cultural adaptation of self-report measures” (13). This article outlines steps for adapting health questionnaires to different languages and cultures, promoting accessibility and equity in research. Her next most cited spine article, “Understanding the relevance of measured change through studies of responsiveness”, discusses how to analyze the sensitivity of research to detect changes in patient-reported outcomes (54). Beaton’s work provides a foundation for health status measurement tools in spine research. Beaton holds a master’s degree in epidemiology and a PhD in health outcomes, focusing on musculoskeletal health. Beaton’s background in epidemiology and health outcomes highlights the value of multidisciplinary teamwork to guide impactful research. Encouraging multidisciplinary approaches in spine research can influence the field through promoting innovation and application across multiple specialties.

It is generally accepted that the two most influential positions within authorship order are first, typically the author that contributes the most to the manuscript, or last, normally reserved for senior authors or the principal investigator (55-57). As a result, senior authors’ scholarly contributions to the field may be underemphasized when only examining first author position. For this reason, we ranked the top 20 last authors by citation count. Interestingly, the number of citations, RCPP and number of publications, demonstrated no significant differences between the top cited first authors and the top cited last authors (P>0.99, P=0.797, P=0.116, respectively). This pattern may reflect the different roles of first and last authors. First authors likely represent highly active researchers in the early to middle phases of their careers who are actively collecting and analyzing data and writing manuscripts, whereas last authors are typically well-established researchers who may primarily provide expertise and mentorship, rather than directly drafting the manuscript (56,58). While these are distinct roles, our results suggest that first and last authors have comparable citation-based influence, reflecting their complementary but separate contributions to research productivity. We acknowledge that senior authors may take on middle author roles when there are multiple senior authors, which is not accounted for in our analysis.

Additionally, multiple authors were identified in more than one cohort. Nine authors were identified in two cohorts: D. Beaton, M. Ferraz, S. Glassman, V. Lafage, M. Panjabi, F. Schwab, J. Smith, M. van Tulder and G. Waddell. M. Fehlings was identified as a top cited author within all three cohorts. The overlap in authors demonstrated in the present study may reflect the concept of cumulative advantage; well-established and highly regarded researchers may be more likely to receive attention, further securing their position as top cited authors while potentially limiting the visibility of lesser known or debut authors (59,60). Additionally, highly cited authors may be more likely to be selected for publication, termed “repeat authorship”, which perpetuates this cycle (59,60). Highly regarded journals may be more susceptible to repeat authorship because established researchers are more likely to produce high-quality and highly cited work which may improve the journal’s citation metrics and visibility (59,60). One way to mitigate the effect of “repeat authorship” is having a blinded peer-review process. However, an author’s identity may still be inferred through writing style or citations, and blinding reviewers limits their ability to identify conflicts of interest (61). Many journals engage in a double-blind review process for most manuscripts, reducing the influence of an author’s reputation on the review process. Although blinding reviewers is a step in the right direction, it is important to recognize the presence of cumulative advantage and conflicts of interest, especially in highly ranked journals, to ensure that emerging and possibly impactful research is not overlooked by the shadow of a well-established citation count.

One other important point to consider is the authors’ countries. A majority of articles published in spine surgery come from authors from high-income countries compared to low- and middle-income countries (LMICs) (62). Because of this, spine-related concerns of LMICs are less likely to be specifically addressed even though these countries have been found to have a higher prevalence of disability, with back pain being a leading cause (63,64). All of the top cited authors identified in this study are from high-income countries. Because of this, current research is less likely to be able to address the unique concerns and gaps in research of patients in LMICs. It is important to recognize this gap and create networks that investigate and establish research communities in LMICs (65).

Top 20 cited articles in spine surgery

Spine published a significant number of the top cited articles of all time. Among spine-specific publications, Spine has historically served as a platform for the publication of influential clinical and translational research in both orthopaedic and neurosurgical domains, earning an impact factor (IF) of 3.5 (8,66,67). However, in more recent years, there has been a greater contribution in top cited articles from other journals such as the European Spine Journal (IF 2.7) and The Spine Journal (IF 4.7), which may suggest a more equal distribution of influence across the field (68,69).

Among the top cited articles of all time, none were published in the last decade, and thus may not accurately reflect the current landscape or direction of spine surgery research. This may be attributed to the study’s use of citation count as a proxy for quality when comparing publications. Older articles tend to have more citations because they are around for a longer period of time which may disadvantage more recent studies regardless of their impact. By examining the top cited articles in the last 10 years (2014–2024), we can gain a better understanding of the evolution of spine surgery research and understand its current direction while mitigating the temporal bias of cumulative citation metrics.

Across medical specialties, the majority of articles tend to be classified as having lower levels of evidence largely because of the challenges of executing the randomization and blinding methodologies required for studies with higher levels of evidence (I and II) (70-73). Nonetheless, the continued publication of research encompassing all levels of evidence remains important, as many impactful publications originate from preliminary research and lower tier studies (72,74,75). This study revealed that the most common study types among the top 20 cited articles related to spine surgery were methodological reviews and literature reviews, both of which are generally considered lower tier evidence. Over half of the studies in both the top cited articles of all time and top cited articles from 2014 to 2024 were LOE V. Notably, the top cited article, “Guidelines for the process of cross-cultural adaptation of self-report measures”, is a methodological review, a format traditionally considered to be of lower evidence level (13). Moreover, there is a trade-off between research volume and research quality. Tchetchik et al. (2015) reported that healthcare system quality is positively correlated with both the quality and quantity of research produced from institutions (53). However, this correlation is stronger for high quality research. Interestingly, when the two time periods were compared, more recent highly cited articles had a greater proportion of high-level evidence studies (I and II) than the top cited articles of all time (20% vs. 10%), reflecting an increasing emphasis on studies of higher levels of evidence in recent years. This is also evidenced by the increase in clinical guidelines seen in the recent top cited articles; although these articles were rated as LOE V due to the incorporation of expert opinion, the clinical guidelines included in this study commonly synthesized data from high-level evidence studies (LOE I and II) to inform clinical decision making.

Measurement and outcome tools were the most common topic among the top cited articles of all time with a shift toward a more diverse range of topics in recent years, such as lumbar disc disease/herniation/radiculopathy, surgical techniques and complications, and back pain (Tables 5,6). This is also showcased in the keyword network maps and Sankey diagram which show this shift from general outcomes and methodology to a broader range of specific topics in more recent years (Figure 1). This likely aligns with the increasing expansion of spine surgery and specialization which has increased the focus on targeted, high-impact research topics that reflect patient needs (76,77). The oldest article in the top cited articles of all time is from 1983, and the most recent article is from 2009, whereas the oldest article in the top cited articles in the most recent complete decade is from 2014 and the most recent is from 2022, covering a much smaller timeframe. This likely influences the differences in generality versus specificity seen across the two timeframes. Additionally, back pain was a common topic in both categories, which is unsurprising given that the World Health Organization estimated that more than 619 million people suffer from low back pain globally (78). This aligns with prior work demonstrating that the top five publications in the field of spine research focused on low back pain (79).

By looking at citation patterns within the most cited authors and the most cited articles, these findings illustrate how authorship structure, methodological framework and evidence standards influence and shape the landscape of spine surgery research.

Strengths

This study employs a large dataset that includes almost 50,000 publications and 19 spine surgery-related journals across approximately five decades, enabling a comprehensive analysis of citation patterns at both the authorship and temporal level. This study evaluates citation metrics across multiple authorship positions, which allows for a better understanding of scholarly influence and contributions compared to analyses that only focus on first position, which has traditionally been used. Furthermore, examining the most cited articles across two time periods helps reduce the temporal bias inherent to bibliometric analyses and provides an understanding of the evolution of spine surgery research. Additionally, this study builds upon previously established bibliometric protocols. Lastly, the dual analysis of highly cited authors and articles allows for a more holistic characterization of academic influence within spine surgery research.

Limitations

One of the primary limitations of this study is the heavy reliance on citation data to quantify impact, an issue intrinsic to most bibliometric analyses. This reliance can skew the results, favoring older articles. We sought to address this limitation by evaluating the top cited articles in the most recent complete decade. Additionally, nonsignificant differences observed between first and last authors should be interpreted cautiously as the actual differences between the groups may not be fully observed due to our small sample size. Furthermore, the use of The Oxford 2011 Levels of Evidence to assign LOE may be vulnerable to inherent biases due to authors’ interpretations of the scoring criteria. We sought to mitigate this by having two reviewers independently assign LOE. There is also citation inflation present for articles relevant to multiple disciplines. Publications that are applicable to multiple fields such as the most cited article, “Guidelines for the process of cross-cultural adaptation of self-report measures”, are more likely to have a higher citation count compared to field-specific publications as they are applicable to a larger audience. Additionally, it is inherently difficult to assess the quality of an article or the influence of an author as these measures tend to be subjective and depend on characteristics—citation count, density of citations, LOE, or innovation—pre-determined to be most important. We recognize that with the use of select search engines, including Web of Science and MEDLINE, some publications or citations may be missed, which could alter data capture. Likewise, WoS has been reported to be biased toward inclusion of older journals and publications written in English (80). Because only 19 spine-related journals were included, we would also like to acknowledge that there may be other journals and publications that are highly influential to the spine field that were not included. Furthermore, publications written by the same author may have been indexed under inconsistent author name abbreviations, which may have affected the retrieval of total publication numbers for each author and subsequent RCPP calculations. We attempted to mitigate this through a manual search of each author in the WoS database by two independent authors. Regardless, we expect these minute differences, if any, to be negligible in our study, which focused on macro trends in citation metrics.

Conclusions

As the global population continues to age, the prevalence of spinal disorders is expected to increase, emphasizing the importance of robust and evolved spine research that spans the full breadth of spinal disorders, from pathophysiology to patient-reported outcomes (81). Advancing the field requires the publication and visibility of high-quality research as well as the integration of diverse perspectives. Many of the top cited articles within spine surgery research are level IV and V evidence, demonstrating the continued challenge of publishing studies with higher levels of evidence, such as randomized controlled trials or large systematic reviews. Importantly, the proportion of studies with a relatively high LOE increased across the two time periods analyzed, suggesting a growing priority for study designs that produced higher quality data in spine surgery research. Furthermore, many of the top cited articles are outdated, emphasizing the importance of analyzing recent citation trends to identify emerging research directions and recognize potential gaps. To address critical challenges in spine-related conditions, it is essential to foster high-quality, up-to-date research across disciplines to support the ongoing development and responsiveness of spine surgery research.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0044/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0044/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0044/coif). R.K.A. is or has been a paid consultant for Medtronic, Orthofix and Globus, has stock ownership in HIA Technologies, NeoOnc and Globus and has received monetary support for research from Max BioPharma and ATEC. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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