Purpose
This study aimed to compare the clinical effectiveness and potential benefits of ultrasound (US)-guided versus fluoroscopy (FL)-guided cervical retrolaminar block (RLB) in patients with cervical facet joint pain.
Materials and Methods
A total of 27 patients aged 40 years or older who were diagnosed with cervical facet joint syndrome based on physical examination and imaging modalities were included. 12 patients of group I treated with US-guided RLB and 15 patients of group II treated with FL-guided RLB. The position of the needle and the distribution of contrast agent were confirmed using fluoroscopic images, and the changes in numeric rating scale (NRS) and neck disability index (NDI) before and 2 weeks after the procedure were compared in the two groups.
Results
Radiologically, the target agreement of needle placement in group I was 75%. There was no difference in contrast medium spread between the two groups. Clinically, the mean NRS improved from 7.08±0.52 to 3.08±0.90 in group I (p=0.01) and from 7.20±0.56 to 3.33±0.72 in group II (p=0.01). The mean NDI decreased from 41.67±2.27 before the procedure to 20.83±2.33 after the procedure in group I (p=0.01), and from 40.87±2.61 before the procedure to 21.67±2.02 after the procedure in group II (p=0.01), with no difference between the two groups.
Conclusions
US-guided cervical RLB is an effective, radiation-free alternative to FL-guided RLB for managing cervical facet joint pain, offering comparable pain relief and functional improvement.

Purpose
Thoracolumbar vertebral compression fractures (VCFs) are a leading cause of kyphosis and related biomechanical complications, often resulting in chronic back pain and reduced function. Balloon kyphoplasty has been widely used as a minimally invasive intervention to provide pain relief and restore vertebral height. The SpineJack system is a relatively novel technique that introduces mechanical distraction, offering potentially enhanced vertebral restoration. This study aims to compare these two effective treatments for thoracolumbar fractures.
Materials and Methods
This study analyzed 30 patients with thoracolumbar VCFs surgically treated, using the Spine-Jack system (n=10) or balloon kyphoplasty (n=20). Back pain was evaluated as VAS pain score and functional disability was assessed with Oswestry Disability Index (ODI) preoperatively and immediately postoperatively. Radiological outcomes were measured on plain lateral X-rays, including vertebral height restoration, segmental kyphosis angle, and sagittal vertical axis (SVA). Complications, such as cement leakage and adjacent vertebrae fractures, were recorded. Continuous variables – with t-tests and categorical variables- with chi-square tests, were analyzed. P-value less than 0.05 was considered statistically significant.
Results
Both the Spine-Jack system and balloon kyphoplasty were effective in reducing back pain and improving patients’ function, with significant improvements in VAS and ODI scores. However, the Spine-Jack system demonstrated superior vertebral height restoration (85% vs. 72%, p=0.03) and segmental kyphosis angle correction (12° vs. 9°, p=0.032) when compared to balloon kyphoplasty. Complication rates were all low and comparable between the two groups.
Conclusions
Although the Spine-Jack system and balloon kyphoplasty are all effective for thoracolumbar VCFs, the Spine-Jack system offered superior radiological outcomes in selected cases. Further studies may explore their complementary roles in managing thoracolumbar VCFs.

Purpose
The impact of skeletal muscle mass and bone mineral density (BMD) on frailty after osteoporotic vertebral fractures (OVFs) remains unclear. This study aimed to assess the interplay between frailty, skeletal muscle mass, and bone mineral density in OVFs.
Materials and Methods
A total of 66 patients with osteoporotic vertebral compression fractures were enrolled. We collected clinical and radiological data, including age, body mass index (BMI), frailty index, and parameters such as lumbar lordosis, thoracic kyphosis, skeletal muscle mass, and BMD. We then analyzed the relationships between frailty and these variables.
Results
The mean age, BMI, BMD T-score, skeletal muscle mass, and frailty index were 78.0±7.8 years, 22.3±3.3 kg/ m², -3.59±0.96, 37.84±6.24 kg, and 2.59±1.08, respectively. Of the 66 patients, 14 (21.1%) were frail prior to fracture, while 37 (56.1%) were frail after fracture, indicating a worsening frailty status. Specifically, 23 patients (34.8%) transitioned from pre-frail to frail following their fracture and had both lower BMD (T-score: -3.7±0.93) and lower skeletal muscle mass (35.74±3.83 kg). Frailty was negatively correlated with BMD (r=-0.28, p=0.02), while BMD was positively correlated with skeletal muscle mass (r=0.29, p=0.02). OVFs were positively correlated with frailty (r=0.33, p=0.01), especially in terms of fatigue (r=0.31, p=0.01) and ambulation (r=0.21, p=0.01).
Conclusions
In patients with osteoporotic vertebral fractures, decreased muscle mass and low BMD appear to exacerbate frailty. Furthermore, frailty may be both a contributing and a resulting factor in the development of osteoporotic vertebral fractures.

Purpose
To develop and validate a deep learning–based artificial intelligence (AI) model for automated measurement of lumbar lordosis (LL) angles from whole spine lateral radiographs.
Materials and Methods
A total of 888 lateral spine X-rays (2019–2021) were retrospectively collected and annotated with four anatomical keypoints (L1 and S1 vertebral landmarks). An AI model using Detectron2 with a Keypoint R-CNN and ResNeXt-101 backbone was trained with data augmentation. Performance was evaluated on 50 test images, comparing AI results to manual annotations by two orthopedic surgeons using intraclass correlation coefficient (ICC), Pearson’s correlation, and Bland–Altman analysis.
Results
The model achieved an average precision of 71.63 for bounding boxes and 86.61 for keypoints. ICCs between AI and human raters ranged from 0.918 to 0.962. Pearson correlation coefficients were r=0.849 and r=0.903. Bland–Altman analysis showed minor underestimation biases (–3.42° and –4.28°) with acceptable agreement.
Conclusions
The AI model showed excellent agreement with expert measurements and high reliability in LL angle assessment. Despite a slight underestimation, it offers a scalable, consistent tool for clinical use. Further studies should evaluate generalizability and interpretability in broader settings.

Citations

• Efficacy of Biportal Endoscopic Decompression for Lumbar Spinal Stenosis: A Meta-Analysis With Single-Arm Analysis and Comparative Analysis With Microscopic Decompression and Uniportal Endoscopic Decompression
  Shuangwen Lv, Haiwen Lv, Yupeng He, Xiansheng Xia
  Operative Neurosurgery.2024; 27(2): 158.     CrossRef

Purpose
Metabolic syndrome is a multifactorial condition associated with increased risks of cardiovascular disease and type 2 diabetes. This study aims to evaluate whether combining AI-based abdominal CT metrics with traditional InBody analysis enhances the prediction of metabolic syndrome.
Materials and Methods
This retrospective study included 977 adults who underwent both abdominal CT and InBody assessments. AI-derived measurements were obtained using a deep-learning V-Net model trained to segment seven body tissue types. InBody measurements included BMI, body fat percentage, fat mass, and waist-hip ratio. Metabolic syndrome was defined by NCEP-ATP III criteria. Logistic regression and ROC analyses were used to evaluate the predictive performance of AI-derived metrics, InBody metrics, and their combination.
Results
Body fat percentage and waist-hip ratio from InBody analysis were strong predictors of metabolic syndrome (AUC 0.82). AI-derived visceral fat was also significantly associated with metabolic syndrome (AUC 0.61). Combining both AI and InBody metrics slightly improved predictive performance (AUC 0.83), indicating a complementary diagnostic value.
Conclusions
While InBody metrics remain superior in predicting metabolic syndrome due to their close association with metabolic processes, AI-derived body composition metrics, particularly visceral fat, offer structural insights. The modest improvement in prediction when combined suggests the potential of an integrated diagnostic model in clinical practice.

Advanced imaging technologies have revolutionized the diagnosis and management of spinal pathologies by providing superior precision and efficiency. Modalities such as PET-CT, SPECT, diffusion tensor imaging (DTI), and magnetic resonance spectroscopy (MRS) offer unique insights into the metabolic, structural, and functional aspects of spinal diseases, enabling better differentiation of lesions, improved surgical planning, and early detection of pathological changes. Furthermore, the integration of artificial intelligence (AI) has enhanced imaging workflows by enabling automated analysis, prediction of clinical outcomes, and segmentation of spinal structures. Despite these advancements, challenges such as technical limitations, high costs, and ethical concerns, including issues of data privacy and AI-generated inaccuracies, hinder widespread adoption. This review explores the clinical applications, limitations, and future directions of these emerging technologies, highlighting the need for multidisciplinary collaboration and large-scale research to standardize protocols and optimize patient outcomes. The seamless integration of advanced imaging and AI represents a transformative potential for improving diagnostic accuracy and treatment efficacy in spinal care.

Purpose
To compare the 3-month outcomes of romosozumab and percutaneous vertebroplasty in patients with acute osteoporotic vertebral compression fractures (OVCFs).
Background
Vertebroplasty provides rapid pain relief in acute OVCFs but carries risks such as cement leakage and adjacent fractures. Romosozumab, an anti-sclerostin monoclonal antibody, promotes bone formation and reduces fracture risk; however, its effectiveness in acute OVCFs remains unclear. Material and Methods: This retrospective study included 84 patients with MRI-confirmed acute OVCFs treated between January 2022 and December 2024. Patients received either monthly subcutaneous romosozumab injections (n=52) or vertebroplasty followed by weekly oral alendronate (n=32). All received daily calcium (500 mg) and vitamin D₃ (1,000 IU). Clinical outcomes were assessed using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI), and radiographic changes were evaluated based on anterior vertebral body height at baseline, 1 month, and 3 months.
Results
Both groups showed significant improvements in VAS and ODI scores at 1 and 3 months, with no significant differences between them. Vertebral height changes were also comparable.
Conclusions
Romosozumab-based conservative therapy may be a viable non-invasive alternative to vertebroplasty in treating acute OVCFs, offering similar short-term clinical and radiographic outcomes.

Objective
To investigate the utility of a deep learning model in diagnosing traumatic lumbar fractures on computed tomography (CT) images.
Summary of Background
Data: CT scans are widely used as the first choice for detecting spinal fractures in patients with severe trauma. Although CT scans have high diagnostic accuracy, fractures can occasionally be missed. Recently, deep learning has been applied in various fields of medical imaging.
Methods
CT images from 480 patients (3695 vertebrae) who visited a level-one trauma center with lumbar fractures were retrospectively analyzed. The diagnostic results were confirmed by two experienced musculoskeletal radiologists and one experienced spine surgeon using magnetic resonance imaging (MRI). Deep learning networks were employed for diagnosis, with 425 cases used for training and 55 cases for testing. Sensitivity, specificity, accuracy, and the area under the receiver operating characteristic curve (AUROC) were calculated to evaluate diagnostic performance.
Results
The model successfully identified 107 out of 129 vertebrae with fractures, achieving a sensitivity of 82.95%, a specificity of 93.24%, an AUROC of 0.936, and an overall accuracy of 88.45%.
Conclusions
This study demonstrated that the deep learning model showed high accuracy in diagnosing traumatic lumbar fractures. This approach has the potential to assist spine specialists, radiologists, and trauma care experts. Further validation is needed to determine its effectiveness in clinical settings.

Objective
Postoperative urinary retention (POUR) is a common complication following lumbar spine surgery, significantly affecting functional recovery and Enhanced Recovery After Surgery (ERAS) protocols. POUR can lead to bladder overdistension, infections, prolonged hospital stays, and long-term detrusor dysfunction. Postoperative delirium (POD) can impair cognitive function and mobility, potentially triggering or exacerbating POUR. This study aims to investigate whether POD serves as an independent risk factor for POUR and to analyze other contributing factors to provide clinical management strategies.
Materials and Methods
A retrospective cohort study was conducted involving 420 patients who underwent lumbar spine surgery at a single tertiary medical institution between March 2021 and February 2024. POUR was defined as a post-void residual (PVR) bladder volume ≥300 mL measured via bladder ultrasound or requiring catheter reinsertion due to urinary retention. POD was diagnosed within 72 hours postoperatively using the Confusion Assessment Method (CAM) and was classified into three subtypes: hyperactive, hypoactive, and mixed. Multivariate logistic regression analysis was employed to identify the relationship between POD and POUR, with sensitivity and specificity assessed through Receiver Operating Characteristic (ROC) curve analysis.
Results
Among 420 lumbar spine surgery patients, 44 (10.5%) experienced POD. Of these, 16 (36.4%) were classified as hyperactive, 20 (45.5%) as hypoactive, and 8 (18.2%) as mixed type. POUR occurred in 28 of the POD patients (63.6%) compared to 71 of 376 patients without POD (18.9%), demonstrating a statistically significant difference (p<0.001). The analysis of POUR incidence by POD subtype revealed rates of 62.5% (10/16) for hyperactive POD, 60.0% (12/20) for hypoactive POD, and 75.0% (6/8) for mixed POD. Patients with mixed POD showed the highest POUR incidence, with a significant difference compared to hyperactive and hypoactive POD (p<0.05). Multivariate logistic regression analysis identified POD as an independent risk factor for POUR, increasing the likelihood by approximately 3.7 times (Odds Ratio, OR: 3.71; 95% Confidence Interval, CI: 1.95–7.06; p<0.001). Among POD subtypes, mixed POD presented the strongest association with POUR, increasing the risk by 4.8 times (OR: 4.84; 95% CI: 2.10–11.15; p<0.001). Hyperactive and hypoactive POD were also significant risk factors, increasing POUR risk by 3.0 times (OR: 3.04; 95% CI: 1.45–6.35; p=0.003) and 3.5 times (OR: 3.48; 95% CI: 1.69–7.19; p=0.001), respectively.
Conclusions
This study confirms that postoperative delirium (POD) is an independent risk factor for postoperative urinary retention (POUR) in lumbar spine surgery. The occurrence and subtype of POD significantly influence POUR incidence, with mixed POD presenting the highest risk. These findings highlight the importance of early diagnosis and prevention of POD as a strategy to effectively reduce POUR. A multidisciplinary approach integrating POD and POUR management could optimize postoperative outcomes and improve patient recovery.

Study Design
A retrospective comparative study.
Purpose
This study aimed to evaluate the reliability of the external auditory meatus (EAM) as a reference point for determining the cranial center in patients with sagittal spinal deformity. Specifically, we assessed the radiographic visibility and spatial relationship of the EAM relative to the midpoint of the nasion-inion line (MNI) and compared it with the sella turcica. Overview of Literature: The cranial center is commonly defined as the midpoint of the nasion-inion line (MNI). The EAM has been widely used as an approximate surrogate of the MNI; however, its radiographic clarity and consistency are often limited. In contrast, the sella turcica is a singular anatomical structure that is more distinctly visualized on radiographic imaging.
Methods
A total of 71 patients who underwent corrective surgery for spinal deformity between 2021 and 2024 were included. Preoperative full-spine radiographs were analyzed to evaluate the spatial relationship between both the EAM and the sella turcica relative to the MNI. Radiographic visibility was classified into three categories: single-point and clear, duplex but distinguishable, and unclear.
Results
The EAM was located, on average, 1.1 mm posterior and 17.1 mm inferior to the MNI, whereas the sella turcica was located 13.8 mm anterior and 2.0 mm superior to the MNI. Relative to the femoral head axis, angular analysis revealed that the EAM exhibited a mean posterior tilt of 0.2°, while the sella turcica showed a mean anterior tilt of 1.3°. The sella turcica was clearly identifiable in 84.5% of cases, whereas the EAM was clearly visualized in only 14.1%, with the majority being either duplicated or indistinct (p<0.001).
Conclusions
Although the EAM is anatomically closer to the MNI, its radiographic visibility and consistency are inferior to those of the sella turcica, thereby reducing its reliability as a cranial reference point. Further studies are needed to determine whether the sella turcica can serve as a more reliable alternative reference.

Purpose
This study was conducted to identify risk factors predicting the loss of cervical lordosis (LCL) in patients with multilevel ossification of the posterior longitudinal ligament (OPLL) following laminoplasty. Material and Methods: We conducted a retrospective analysis of data from patients who underwent laminoplasty at Chonnam National University Hospital between January 2013 and December 2022. Various radiological parameters and clinical outcome measures were collected perioperatively. Patients were divided into 2 groups according to the severity of LCL. We examined preoperative radiological parameters associated with LCL.
Results
We analyzed data from 109 patients (92 men and 17 women; mean age, 60.31±10.80 years). A higher T1 slope (odds ratio [OR], 1.420; p<0.001) and a lower extension ratio (OR, 0.883; p=0.019) were associated with a higher risk of LCL. T1 slope was shown to be an excellent predictor of LCL, with a cut-off value of 28° (p<0.001, area under the curve=0.918). Also, The T1 slope and extension ratio were statistically significant correlated with clinical outcomes.
Conclusions
T1 slope and extension ratio were significantly associated with LCL in patients with multilevel OPLL following laminoplasty. The cut-off value for the T1 slope was 28°, and the cut-off value for the extension ratio was 33. Therefore, in multilevel OPLL patients with a T1 slope exceeding 28° or an extension ratio below 33, a warning regarding the potential LCL should be given before performing cervical laminoplasty.

Study Design
Retrospective comparative study.
Purpose
To evaluate and compare the clinical outcomes and complication profiles of decompression alone versus decompression with instrumented fusion in elderly patients aged 75 and older with lumbar spinal stenosis. Overview of Literature: Lumbar spinal stenosis is a common cause of disability in elderly patients. The decision between decompression alone and fusion surgery in the geriatric population remains controversial due to surgical risks and comorbidities.
Methods
A retrospective analysis of 121 patients aged ≥75 years treated either with laminectomy alone (n=60) or with posterior lumbar interbody fusion (PLIF, n=61) from April 2016 to December 2022. Baseline characteristics, perioperative parameters, and postoperative outcomes were compared.
Results
There were no significant differences in baseline characteristics. The PLIF group showed longer operative times, greater blood loss, and longer hospital stay, but similar complication rates. Both groups showed significant postoperative improvement in VAS, ODI, and EQ-5D scores.
Conclusions
Decompression alone and fusion surgery both provide substantial clinical benefit in elderly patients with spinal stenosis. With careful selection, fusion may be safely considered even in the elderly.

Purpose
Few studies have assessed the prevalence of cervical and thoracic and lumbar (thoracolumbar) intervertebral disc disorders, respectively, using data from the Korean National Health Insurance Service (KNHIS). The aim is to show the changing prevalence of cervical and thoracolumbar intervertebral disc disorder over the last decade.
Methods
Data spanning 2012 to 2021 were collected from the KNHIS, encompassing primary diagnoses related to cervical and thoracolumbar intervertebral disc disorder (ICD 10 code: M50.x and M51.x except M51.4). The agestandardized prevalence was computed using the estimated Korean population in 2020 as a reference. Additionally, age-standardized number of general spinal operations per year was illustrated using the Statistical Yearbook of Major Surgeries in 2021.
Results
In 2012, the age-standardized prevalence of cervical intervertebral disc disorder was 11,383 persons per 100,000 decreasing to 8,860 persons per 100,000 persons in 2021. This decline was observed in both male (from 10,101 to 8,012) and female (from 12,690 to 9,709). For thoracolumbar intervertebral disc disorders, the agestandardized prevalence decreased from 27,506 to 18,903 persons per 100,000 persons from 2012 to 2021. Notably, the age-standardized prevalence showed a greater increase in individuals aged 60 or older compared to those aged 50, for both sexes. However, there was an increase in the number of general spinal operation from 2012 to 2021.
Conclusions
While the overall age-standardized prevalence of cervical and thoracolumbar intervertebral disc disorders decreased between 2012 and 2021 across all age groups, the number of general spinal operations increased during the same period.

The standard method for treating posterior pelvic ring injuries involves sacroiliac joint cannulated lag screw fixation, necessitating repeated fluoroscopy and leading to radiation exposure. The O-arm navigation system, designed for spine screw fixation, is applied in pelvic injuries to enhance precision. A successful case involved a 39-year-old male with a complex pelvic injury, where sacroiliac screw fixation was performed in the prone position using the O-arm guide. The patient, injured at a construction site, showed fractures and widening of the symphysis pubis and right sacroiliac joint. Surgery was planned for both lumbar and pelvic regions due to an L3 burst fracture. The O-arm system demonstrated efficacy in precise screw placement, reducing surgical duration, and minimizing complications. The discussion emphasizes early pelvic fixation benefits, with percutaneous iliosacral screws standing out. Conventional fluoroscopy-guided methods pose challenges, and the O-arm system proves advantageous, especially for less experienced surgeons. Future advancements may enable pelvic surgery using the O-arm without C-arm guidance if instrumentation for pelvis fixation is developed.

Object: This pilot study aimed to evaluate the effectiveness of cervical epidural block (CEB) in improving upper extremity muscle strength in individuals diagnosed with cervical disc herniation.
Materials and Methods
5 patients diagnosed with cervical disc herniation were included and underwent a single CEB treatment. Patients were monitored weekly for 2 weeks via an outpatient clinic. Hand grip strength of affected side and difference of hand grip strength between affected and unaffected side (DHGS) was recorded using dynamometers; before treatment, immediate after treatment, after 1week and 2weeks of treatment. Pain on neck and radiating pain to upper extremity (UE) were measured using the visual analogue scale (VAS) before treatment and 2weeks after treatment.
Results
The median age of the patients was 48 (37.0-78.0) years, and the affected disc levels were C5-6 (3 patients), C6-7 (1 patient), and C5-6-7 (1 patient) respectively. In terms of pain, VAS of neck decreased from 6.8 to 3.2, and VAS of UE decreased from 7.4 to 3.0. Both hand grip strength of affected side and DHGS showed improvement when comparing before and after treatment (immediate, 1 week and 2 weeks after treatment) (p<0.001). However, there was no difference between immediate, 1 week and 2 weeks after treatment. The result was same for adjusting age and sex as covariates (p<0.001).
Conclusions
These findings suggest that CEB has the potential in improving pain and UE muscle weakness associated with cervical disc herniation. Further large-scale studies are necessary to validate these preliminary outcomes and establish the long-term effectiveness and sustainability of CEB in managing cervical disc herniation.

Spinal cord injury (SCI) distinguishes itself from peripheral nerve injury by causing devastating and irreversible damage to the spine, resulting in profound motor, sensory, and autonomic dysfunction. The ensuing complex microenvironment of SCI, characterized by hemorrhage, inflammation, and scar formation, poses substantial challenges to regeneration and complicates numerous transplantation strategies. Recent research has shifted its focus towards manipulating the intricate SCI microenvironment to enhance regeneration, with some approaches demonstrating significant therapeutic efficacy. Consequently, the reconstruction of an appropriate microenvironment post-transplantation emerges as a potential therapeutic solution for SCI. This review aims to provide a comprehensive overview, firstly summarizing the influential compositions of the microenvironment and their diverse effects on regeneration. Secondly, we highlight recent research employing various transplantation strategies to modulate distinct microenvironments induced by SCI, aiming to facilitate regeneration. Lastly, we discuss prospective transplantation strategies for SCI, emphasizing the importance of addressing the complex microenvironment for successful therapeutic outcomes.

Purpose
To report an uncommon case of Opalski syndrome following traumatic C4–C5 facet dislocation with vertebral artery dissection, and to discuss its diagnostic and therapeutic implications.
Materials and Methods
A 60-year-old woman presented after a motor vehicle collision with bilateral upper limb weakness. Cervical X-ray, CT, MRI, and CT angiography revealed C4–C5 facet dislocation and left vertebral artery occlusion. Urgent anterior cervical discectomy and fusion were performed, and the postoperative course was monitored.
Results
Immediate postoperative improvement to 4/5 strength in both arms was noted; however, new left facial numbness appeared at 12 hours and left lower limb weakness with gait ataxia at 48 hours. Brain MRI confirmed left lateral medullary infarction, and aspirin therapy was initiated. At one month, left arm strength recovered to 4/5, but ataxia persisted.
Conclusions
In cervical trauma patients with C4–C5 facet dislocation and vertebral artery injury on initial imaging, the possibility of delayed lateral medullary infarction—particularly Opalski syndrome—should be considered. Prompt brainstem imaging and tailored antithrombotic therapy are essential when new neurologic deficits arise.

Purpose
The biplanar whole body imaging system (EOS) is a new tool for measuring whole body sagittal alignment in a limited space. This tool may affect the sagittal balance of patients compared to conventional whole spine radiography (WSX). This study is to investigate the difference in sagittal alignment between WSX and EOS.
Materials and Methods
We compared spinal and pelvic sagittal parameters in 80 patients who underwent EOS and WSX within one month between July 2018 and September 2019.The patients were divided based on sagittally balanced and imbalanced groups according to pelvic tilt (PT) >20˚, pelvic incidence-lumbar lordosis >10°, C7-sagittal vertical axis (SVA) > 50 mm in WSX.
Results
In sagitally imbalanced group, for WSX versus EOS, the pelvic parameters demonstrated compensation in EOS with smaller PT (27.4±11.6° vs. 24.9±10.9°, p=0.003), greater sacral slope (SS), and patients tended to stand more upright with smaller C7-SVA (58.4±17 mm vs. 48.9±57.3 mm, p=0.003), T1-pelvic angle (TPA), T5-T12, and T2-T12. However, in sagitally balanced group, these differences were less pronounced only with smaller PT (10.8±6.9° vs. 9.4±4.7°, p=0.04), TPA and T2-T12 angle, but SS and C7-SVA were similar (p>0.05).
Conclusions
EOS shows a negative SVA shift and lesser pelvic tilt than WSX especially in patients with sagittal imbalance. When making a surgical plan, surgeon should consider these differences between EOS and WSX.

After posterior cervical arthrodesis, many problems can arise, including adjacent segment degeneration and the related adjacent segment disease (ASD). As indicated by studies on the causes of ASD, posterior cervical arthrodesis can produce biomechanical and kinematic changes in adjacent unfused segments due to inappropriate forces. Several studies have been conducted to determine the appropriate lowest instrumented vertebra, specifically regarding whether to cross the cervicothoracic junction via extension of long-segment posterior cervical fusion. We searched for relevant articles in electronic databases including PubMed, the Cochrane Registry, Embase, and Ovid. Five meta-analyses were reviewed on this topic. Among these, Goyal et al. (2019), Rajjoub et al. (2022), and Chang et al. (2022) argued that ending instrumentation at the cervical level was associated with higher rates of ASD and reoperation. However, Truumees et al. (2022) and Coban et al. (2022) found no statistically significant differences between cases of instrumentation ending at the cervical and thoracic levels in the rates of ASD and requirement of revision surgery. Cervicothoracic junction breakage is a known possibility after cervical spine surgery because of the anatomical fragility of the junction. Terminating at the thoracic level reduces the stress on the cervicothoracic junction, thereby decreasing complications such as cervicothoracic junction breakage and lowering the frequency of reoperation. Based on the findings published to date, instrumentation across the cervicothoracic junction can be reasonably recommended in cases of multilevel posterior cervical fusion based on the lower reoperation and higher fusion rate.

Primary glioblastoma of the spinal cord is a rare and aggressive tumor, comprising less than 1.5% of spinal neoplasms. It typically affects young adult males and arises in the cervical or thoracic regions. We report an unusual case of intradural extramedullary spinal glioblastoma in a 62-year-old man with prior lymphoma in remission. The patient presented with a 7-month history of progressive lower limb weakness, numbness, and radiating pain. MRI revealed a contrast-enhancing mass at the T6–7 level, initially suspected as lymphoma. Surgical resection via total laminectomy was performed, and en-bloc tumor removal achieved. Histopathological analysis confirmed WHO grade IV glioblastoma, IDH-wildtype, without Histone H3 mutation. This case highlights an atypical radiologic and anatomical presentation, complicating preoperative diagnosis. Histopathologic and molecular studies were essential for confirmation. Postoperative treatment included adjuvant radiotherapy and temozolomide, though their efficacy remains uncertain in spinal glioblastoma due to limited evidence and spinal cord radiosensitivity. Early biopsy and a multimodal diagnostic approach are critical for managing rare spinal tumors presenting with nonspecific clinical and imaging features.

Objective
To investigate stiffness-related disability (SRD) following surgical treatment in adolescent idiopathic scoliosis (AIS) patients particularly with respect to the lowest instrumented vertebra (LIV).
Summary of Background
Extensive spinal fusion inevitably results in loss of mobility which may induce SRD during activities of daily living. Few studies have examined SRD after surgical correction for AIS.
Methods
Patients who underwent surgical correction for AIS between 2014 and 2021 and were followed up for two years were included. The degree of SRD was evaluated using the Stiffness-Related Disability Index (SRDI) which consists of four categories, each containing three questions, giving a total of 12 components of the questionnaire. The SRDI scores were compared according to the (LIV) levels. Correlation analysis was performed to examine the relationship between the SRDI and legacy health-related quality of life (HRQOL) measurements.
Results
This study included 174 patients (47 males, 127 females) with a mean age of 13.8 years. Among the 12 items of the SRDI, the scores of nine items showed a significant increase after surgery. The total sum of the SRDI scores also significantly increased after surgery. Pearson correlation analysis showed that the SRDI scores were significantly correlated with ODI (Oswestry disability index), nearly all domains, and the total sum of SRS-22 (Scoliosis Research Society-22 questionnaire), and SF-36 (Short Form 36 health questionnaire). No differences in the SRDI score were found among cases with the LIV between T12 and L3. However, The SRDI scores of patients with LIV at L4 were significantly higher than those of patients with other LIV levels. .
Conclusions
Various degree of SRD occurred after spinal fusion for AIS. The SRDI significantly correlated with the HRQOL measures. The SRDI score was highest in patients with the LIV at L4 compared to those with other LIV levels.

Background
This study aims to assess the clinical and radiographic outcomes of biportal endoscopic lumbar discectomy compared to microscopic lumbar discectomy in obese patients with lumbar herniated discs. Previous research has established a positive correlation between operation time and estimated blood loss in obese patients undergoing microscopic lumbar discectomy, based on an increase in body mass index. However, no studies have specifically examined the outcomes of biportal endoscopic lumbar discectomy in this patient population. Therefore, this study seeks to fill this research gap and provide valuable insights into the effectiveness of these two surgical approaches for obese patients with lumbar herniated discs.
Methods
This retrospective multicenter study analyzed and compared clinical and radiological data from 48 obese patients with a body mass index (BMI) greater than 30 kg/m² who underwent either microscopic or biportal endoscopic lumbar discectomy. The study assessed clinical outcomes using the visual analog scale (VAS), Oswestry Disability Index (ODI), and EuroQol-5D (EQ-5D) scores. Radiological data were obtained through magnetic resonance imaging (MRI) scans.
Results
The study included a total of 48 patients, with 31 patients undergoing microscopic discectomy and 17 patients undergoing biportal endoscopic discectomy. Both groups showed improvements in VAS, ODI, and EQ-5D scores following surgery compared to preoperative scores. However, there was no significant difference in these outcome measures between the two surgical techniques. Although there was a no significant difference in the occurrence of recurrent disc herniation confirmed by postoperative MRI, there was significant difference in the number of patients requiring additional surgery between the two groups.
Conclusions
For obese patients with lumbar disc herniation that did not respond to conservative treatment, this study found no significant differences in clinical or radiological outcomes between microscopic and biportal endoscopic surgery methods. However, it is worth noting that the biportal group had a lower incidence of reoperation compared to the microscopic group.

Osteoid osteoma is a benign bone-forming tumor that commonly affects young adults and often presents with severe nocturnal pain responsive to NSAIDs. While surgical resection is curative, lesions located in the spine, particularly near critical structures such as the vertebral artery and spinal cord, pose substantial diagnostic and surgical challenges. We report a case of a 24-year-old male with intractable night pain caused by an osteoid osteoma located at the superior margin of the right T1 pedicle. Despite extended NSAID therapy, the patient’s symptoms persisted. Multimodal imaging including MRI, CT, and PET-CT confirmed the diagnosis and revealed the lesion’s proximity to vital neurovascular structures. To minimize morbidity, we employed intraoperative O-arm navigation integrated with preoperative imaging to achieve precise localization and targeted resection through a limited posterior approach. The nidus was successfully excised en bloc without complications. Postoperatively, the patient experienced immediate pain relief and returned to normal activities within days. This case highlights the utility of real-time 3D navigation in managing spinal osteoid osteomas and supports its use as a safe, effective alternative to traditional wide exposure techniques, particularly in anatomically constrained regions of the spine.

Objective
Proximal junctional fracture (PJFx) at the uppermost instrumented vertebra (UIV) or UIV+1 is the most common mechanism of PJF. There are few studies assessing the radiographic progression after PJFx development. Therefore, this study sought to identify the risk factors for radiographic progression of PJFx in surgical treatment for ASD.
Methods
In this retrospective study, among 317 patients aged > 60 years who underwent ≥5-level fusion from the sacrum, 76 with PJFx development were included. According to the change in proximal junctional angle (PJA), two groups were created: Group P (change ≥10°) and Group NP (change <10°). Patient, surgical, and radiographic variables were compared between the groups to demonstrate risk factors for PJFx progression using uni- and multivariate analysis. The receiver operating characteristic (ROC) curve was used to calculate cutoff values. Clinical outcomes, such as visual analog scale (VAS) scores for back and leg pain, the Oswestry Disability Index (ODI) score, and the Scoliosis Research Society (SRS)-22 score, and revision rate were compared between the two groups.
Results
The mean age at the index surgery was 71.1 years, and there were 67 women enrolled in the study (88.2%). There were 45 patients in Group P and 31 in Group NP. A mean increase of PJA was 15.6° (from 23.2° to 38.8°) in Group P and 3.7° (from 17.2° to 20.9°) in Group NP. The clinical outcomes were significantly better in Group NP than Group P, including back VAS score, ODI value, and the SRS-22 scores for all items. Revision rate was significantly greater in group P than in group NP (17.8% vs. 51.6%, p=0.001). Multivariate analysis revealed that overcorrection relative to the age-adjusted ideal pelvic incidence (PI)–lumbar lordosis (LL) target at the index surgery (odds ratio [OR]=4.484, p=0.030], PJA at the time of PJFx identification (OR=1.097, p=0.009), fracture at UIV versus UIV+1 (OR =3.410, p=0.027) were significant risk factors for PJFx progression. The cutoff value of PJA for PJFx progression was calculated as 21° using the ROC curve.
Conclusions
The risk factors for further progression of PJFx were overcorrection relative to age-adjusted PI–LL target at the index surgery, PJA > 21° at initial presentation, and fracture at the UIV level. Close monitoring is warranted for such patients not to miss the timely revision surgery.

Vertebroplasty or kyphoplasty is a widely accepted minimally invasive procedure for treating painful vertebral compression fractures. Although considered safe, rare but serious complications such as spinal subdural hematoma (SDH) can occur, particularly in patients receiving long-term anticoagulation therapy. We present a rare case of spinal SDH following kyphoplasty in a 78-year-old woman with a mechanical aortic valve on chronic warfarin therapy. Anticoagulation was managed perioperatively with warfarin discontinuation and bridging enoxaparin. Postoperative X-ray showed subtle posterior cement leakage. MRI on postoperative day 1 revealed lumbar SDH, which progressed cranially by day 2. The patient remained neurologically intact and was treated conservatively with corticosteroids and temporary suspension of anticoagulation. Follow-up imaging showed gradual hematoma resolution, and she was discharged without deficits. This case suggests the importance of maintaining a high index of suspicion for spinal hematoma in anticoagulated patients, especially when new symptoms or even minor cement leakage are present. Careful perioperative planning, including early imaging and multidisciplinary management, is crucial in such high-risk patients.

Spinal artery aneurysms are exceedingly rare, and their natural history remains poorly understood. Diagnosis can be challenging due to their small size and the difficulty in detection by MR angiography (MRA) or CT angiography (CTA); Digital Subtraction Angiography (DSA) is considered the gold standard diagnostic tool. This case report presents two cases of ruptured thoracic radicular artery aneurysms leading to subdural hematoma (SDH) and subarachnoid hemorrhage (SAH). The first patient, a 71-year-old female, presented with bilateral leg weakness, headache, and severe back pain, where multiple fusiform dilatations of the left T9 radiculopial artery were identified. She showed significant improvement after surgical intervention. The second patient, a 75-year-old female, presented with paraplegia and severe back pain, and a saccular dilatation in the right T10 radiculopial artery was found. She underwent endovascular embolization but showed no neurological improvement. These cases highlight the diverse clinical presentations, diagnostic challenges, and uncertainties in management strategies for ruptured spinal artery aneurysms, emphasizing the need for prompt intervention, especially in cases with significant or progressive neurological deficits.