Patients suffering from chronic mechanical low back pain secondary to multifidus dysfunction represent a unique and increasingly recognized subset of the overall chronic mechanical low back pain population. Neuromuscular inhibition and fatty infiltration of the dysfunctional multifidus muscle contribute to persistent pain, spinal instability, and disability that fail to resolve with conventional therapy. As of October 2024, the introduction of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code M62.85 provides formal classification of this disease entity and allows providers to diagnose this condition with a higher level of specificity. Permanently implanted restorative neurostimulation systems, of which the ReActiv8 device (Mainstay Medical) is currently the only US Food and Drug Administration (FDA)-approved technology (FDA Product Code QLK), directly target chronic low back pain associated with lumbar multifidus dysfunction to treat the underlying condition. This 2025 International Society for the Advancement of Spine Surgery guideline update (1) summarizes the high-quality clinical data supporting long-term efficacy and safety of restorative neurostimulation, including longitudinal outcomes from a 5-year pivotal study, randomized controlled trials, and other clinical studies, (2) updates all coding guidance to reflect current ICD-10 and FDA device status, and (3) reports on payer trends, including the recent positive Anthem Blue Cross Blue Shield coverage decision. The International Society for the Advancement of Spine Surgery reaffirms its support for coverage of implantable restorative neurostimulation by payers in appropriately selected patients, consistent with the demonstrated evidence.
Objective: To develop consensus-based guidance for bone health optimization in instrumented spine surgery, specifically addressing the limited guidance available in the Thai context.
Methods: The study utilized a modified Delphi technique, engaging 10 orthopedic surgeons from Thailand with expertise in complex spine surgery and osteoporosis management. A targeted literature review was conducted, followed by 2 online surveys and a face-to-face consensus meeting to develop and refine the statements. Twenty-five main statements and 45 substatements that focused on patient evaluation, assessment tools, and risk stratification were drafted for the panel's deliberation.
Results: There was unanimous agreement on the necessity of evaluating bone health before instrumented spine surgery in patients aged ≥60 years, while evaluation was considered optional for those aged 50 to 59 years. The panelists supported using the fracture risk assessment tool score for clinical evaluation and recommended using several assessment tools, including dual-energy x-ray absorptiometry scans for specific age groups, Computed Tomography Hounsfield Unit, Trabecular Bone Score, and vertebral fracture assessment for bone health evaluation if available. Treatment recommendations included bone-forming agents as the first-line therapy for patients at high risk and very high risk and specialized surgical techniques for patients at very high risk. Surgical delay of at least 3 months should also be considered for patients at very high risk/with severe osteoporosis who have been scheduled for instrumented spine surgery.
Conclusion: This guidance includes patient screening, evaluation, and treatment for patients with poor bone health based on risk stratification, including normal/low risk, osteopenia/intermediate risk, osteoporosis/high risk, and severe osteoporosis/very high risk. Spine surgeons should be aware of poor bone health and consider bone health optimization to improve surgical outcomes and prevent osteoporosis-related complications.
Clinical relevance: Bone health optimization is crucial for instrumented spine surgery. Spine surgeons should consider bone health optimization guidance, including patient screening for poor bone health, assessment tools for evaluating bone health, and treatment for patients with poor bone health, to improve surgical results and minimize poor bone health-related complications.
Level of evidence: 5:
Background: Alkaptonuria is a rare metabolic disorder, an autosomal recessive disease caused by the deficiency of an enzyme, homogentisate 1,2-dioxygenase. As a consequence, there is an accumulation of homogentisic acid, which deposits in connective tissues, leading to ochronotic arthropathy.
Case presentation: In this case, a 35-year-old man who was diagnosed as having alkaptonuria in 2023 at the National Institutes of Health, underwent urine analysis that showed a peak homogentisic acid level of 3383 mmol/mol creatinine. He reported that 20 days prior to admission, he woke up at night due to sudden and intense cervical pain (visual analog scale 10), with shock-like pain radiating to the lateral sides of the arms and dorsoradial areas of the forearms, which was associated with weakness in elbow flexion and signs of pyramidal release. He underwent magnetic resonance imaging of the cervical spine, which revealed an acute extruded C5 to C6 disc herniation. He subsequently underwent a C5 to C6 discectomy and anterior arthrodesis, where an ochronotic-pigmented disc was observed intraoperatively. On the first postoperative day, an improvement in elbow flexion strength was noted, and he was discharged 5 days later.
Discussion: There is currently no effective and proven treatment for alkaptonuria; nitisinone has shown potential as the first effective treatment but may lead to corneal issues due to triggered tyrosinemia. The treatment for ochronotic arthropathy is primarily symptomatic, with surgical procedures reserved for more advanced degenerative cases.
Conclusion: This study aims to enhance understanding of the pathophysiology of the spinal column in alkaptonuria and to explore the best surgical therapy strategies for this disease.
Objectives: Hangman's fracture, caused by high-energy hyperextension with axial loading trauma, remains challenging to manage. Unstable types (IIa and III) can be treated by a variety of surgical options. Lag-screw fixation has recently gained attention owing to its compatibility with navigation, minimally invasive instrumentation, and lower surgical morbidity.
Methods: A systematic review and meta-analysis of surgical efficacy and safety of lag screw fixation was undertaken. Nine studies, which included a total of 128 patients, assessed outcomes of lag screw fixation, including neck range of motion, intervertebral angle (C2-C3), postoperative pain (visual analog scale), intraoperative parameters, and complications.
Results: Significant improvements were observed in pooled range of motion (extension: 6.28°, flexion: 5.13°) and correction of the C2 to C3 angle by -3.54° (P < 0.001) vs baseline. Pain decreased across early and late timepoints, although heterogeneity reflects variable follow-up and unreported analgesic/analgesia protocols. Reported complications were low in the included series.
Conclusion: C2 transpedicular lag-screw fixation restores alignment and preserves motion with low reported complications in available case series. Larger comparative trials are needed to define its role relative to fusion techniques.
Clinical relevance: Direct osteosynthesis of unstable hangman's fractures via lag-screw fixation offers a viable motion-preserving alternative to C2-C3 fusion. By avoiding fusion, this technique maintains physiological cervical biomechanics and reduces the risk of adjacent segment disease. However, clinicians must carefully weigh these benefits against the technical demands of screw placement and the current lack of high-level comparative evidence.
Level of evidence: 4:
Background: Accidental dural tear (ADT), an unintended intraoperative breach of the dura mater, is a recognized complication in lumbar spine surgery for degenerative conditions. Postoperative surgical site infections are serious adverse outcomes in this context. However, the role of ADT in increasing postoperative infection risk remains insufficiently defined. This systematic review and meta-analysis aimed to comprehensively assess the association between ADT and the occurrence of postoperative infection.
Methods: A systematic literature search was performed in PubMed, ScienceDirect, and CENTRAL from inception to 6 August 2024. Studies involving degenerative lumbar surgery and reporting data on both incidental durotomy and postoperative infections were included. Study quality, including risk of bias analysis, was appraised by 2 independent observers. Subsequently, 2 meta-analyses were conducted, estimating the pooled incidence of infection among patients with ADT and another calculating pooled odds ratios to evaluate infection risk.
Results: Fourteen studies comprising 376,164 patients met the inclusion criteria. The incidence of ADT ranged from 1.9% to 11.8%, with higher rates observed in revision surgeries. Key risk factors included obesity, diabetes, revision surgery, advanced age, and extended operative time. The meta-analysis comprised 7 studies, including 7500 patients with dural tears and 189,058 patients without dural tears. The pooled incidence of postoperative infection among patients with ADT was 13.1% (95% CI: 6.8%-23.8%), which was significantly higher compared with 5.4% (95% CI: 3.1%-7.5%) among patients without ADT (P = 0.00078). Substantial heterogeneity was observed across studies (I 2 = 76.5% for ADT patients and 96.0% for non-ADT patients; Tau2 = 0.63). A separate meta-analysis of 5 studies reported a pooled odds ratio of 3.86 (95% CI: 2.48-6.3, P < 0.00001), indicating a significantly increased infection risk associated with ADT.
Conclusion: ADTs during lumbar spine surgery for degenerative conditions are associated with a significantly increased risk of postoperative infections. Although this relationship is multifactorial, affected by surgical complexity and patient comorbidities, these findings underscore the importance of heightened vigilance in infection prevention and control following ADT to reduce infection-related morbidity.
Clinical relevance: Incidental dural tear during lumbar spine surgery for degenerative conditions significantly increases the risk for postoperative infection and should be a focus of preventive strategies.
Level of evidence: 1:
Background: Anterior lumbar interbody fusion (ALIF) is a well-established procedure for the treatment of spondylosis, spondylolisthesis, and degenerative disc disease but can cause sexual dysfunction and retrograde ejaculation (RE).
Objective: We assessed the occurrence of sexual dysfunction and RE and explored associations between patient and surgical characteristics with sexual dysfunction, RE, and patient satisfaction with the outcome of surgery.
Methods: This is a retrospective survey study. A short questionnaire on changes in sexual function, RE, and patient satisfaction was sent to 170 male patients aged 18 to 60 years who underwent a primary ALIF at L5/S1, L4/L5, or both via retroperitoneal approach between 2015 and 2020 in a high-volume spine centre in Switzerland. Factors associated with changes in sexual function and with RE were examined in univariable and multivariable logistic regressions. The multivariable logistic regression model was adjusted for age at surgery, time since surgery, level of surgery, and fusion material. The associations between satisfaction with the outcome of surgery and time since surgery and changes in sexual function were also assessed using univariable logistic regression.
Results: Of the 170 patients contacted, 98 (58%) agreed to participate. The most frequent fusion level was L5/S1 (n = 74, 76% of respondents), and InductOs was generally used (n = 69, 70%). Overall, 21 patients (21%) reported changes in sexual function, and 11 (11%) felt signs of RE. The majority of patients were satisfied with the surgical outcome (n = 83, 85%) and would undergo the surgery again (n = 83, 85%). In all regression models, changes in sexual function and RE were not associated with any of the studied factors. The odds of being satisfied with the surgery were 4× higher for patients who did not observe changes in sexual function than those who did (95% CI, 1.24-12.86).
Conclusions: The risk of sexual dysfunction and RE after ALIF is relevant, and patients need to be adequately informed about these complications, especially if they want to have children. At the same time, the ALIF procedure remains a successful treatment option with high patient satisfaction.
Clinical relevance: The study emphasizes the need to provide patients with adequate information regarding ALIF surgery.
Level of evidence: 4:
Background: Minimally invasive transfacet transforaminal lumbar interbody fusion (TF-TLIF) offers advantages over open approaches, including reduced tissue disruption and faster recovery. However, limited visualization increases the risk of neural injury, particularly to the exiting nerve roots and thecal sac.
Innovation: This case report illustrates the integration of augmented reality (AR) to enhance real-time visualization during TF-TLIF. A 53-year-old man with symptomatic L4 to L5 spondylolisthesis underwent AR-assisted TF-TLIF. Preoperative imaging included magnetic resonance imaging, computed tomography, and advanced neurography sequences (Multi-Echo iN Steady-state Acquisition, Short Tau Inversion Recovery, and Dixon T1), which were used to generate a 3D model of critical anatomy. A safe transfacet trajectory was planned preoperatively and overlaid onto the surgical field through the operative microscope, using intraoperative 3D imaging for registration. Intraoperative neurophysiological monitoring complemented visual guidance.
Clinical relevance: AR enabled continuous visualization of neural structures during drilling, discectomy, and cage placement. The patient had no complications and was discharged on postoperative day 1 without new neurological deficits. While limited to a single case, this report demonstrates the feasibility of AR-assisted TF-TLIF. This technology may serve as a promising adjunct in minimally invasive spine surgery. Further studies are needed to assess the impact on efficiency and outcomes.
Level of evidence: 4:
Brief problem: Robot-assisted (RA) techniques with pedicle implant placement have demonstrated improved accuracy and safety in thoracolumbar surgery, but their application in the cervical spine is less described. Although multiple robotic systems are currently approved for spinal fusion procedures, most studies focus on thoracolumbar instrumentation. As a result, cervical RA procedures remain underdiscussed regarding safety and efficacy.
Innovation: A total of 8 patients (4 women [50%]) with a mean age of 63.1 years (range 49-75), in whom 50 cervical pedicle screws were placed, were identified. Preoperative diagnoses included degenerative (n = 2), tumor (n = 2), trauma (n = 2), and deformity (n = 2). The 50 pedicle screws were distributed at C1 (8 screws), C2 (8), C3 (6), C4 (6), C5 (6), C6 (8), and C7 (8). There was 1 inferior grade B breach on a C7 screw without clinical sequelae that was repositioned for a 98% total screw accuracy.
Clinical relevance: RA cervical pedicle screw placement appears to be a safe and effective adjunct in complex cervical spine surgery. The proposed stepwise workflow is reproducible and adaptable and includes several specific recommendations: the use of a Mayfield Halo, intraoperative computed tomography for registration, lower drill rates per minute, and additional cannulas. Further studies need to validate these findings in larger cohorts and evaluate long-term patient outcomes.
Level of evidence: 4:
Background: Regenerative and wellness medicine is rapidly reshaping health care, particularly in the management of degenerative spine conditions. Noninvasive or minimally invasive options such as stem cell therapy, platelet-rich plasma (PRP) injections, and holistic wellness programs are increasingly selected by patients who wish to avoid the risks, costs, and prolonged recovery associated with elective spine surgery.
Purpose: This perspective article examines whether regenerative and wellness approaches function primarily as a boon or a barrier to innovation in spine surgery and explores their impact on traditional, insurance-based surgical care models.
Methods: Using a narrative, opinion-based framework, this article synthesizes current trends in regenerative and wellness treatments, their economic growth relative to conventional spine care, and their penetration into nonsurgical spine markets. It further considers how these trends intersect with policy, reimbursement, and professional society initiatives.
Results: The rapid expansion of regenerative and wellness interventions has created a powerful economic sector that, in some areas of nonsurgical spine care, is projected to surpass traditional medicine. Many of these therapies lack robust clinical evidence, yet the absence of data does not equate to inefficacy. These resulting strategic challenges will likely have a greater effect on spine surgeons who aredependent primarily on insurance-based reimbursement. At the same time, integrating validated regenerative options can broaden the surgical practice portfolio and better match patient preferences for personalized, minimally invasive care. Policy changes expanding coverage for evidence-based regenerative treatments may further accelerate this shift.
Conclusions: To remain relevant in an increasingly patient-driven health care environment, spine surgeons and organizations such as the International Society for the Advancement of Spine Surgery must proactively adapt to the growth of regenerative and wellness medicine. Failure to engage may relegate spine surgery largely to trauma, tumor, and infection, while regenerative and wellness strategies could dominate the management of painful degenerative spine disorders.
Clinical relevance: Regenerative and wellness medicine is rapidly reshaping how patients with degenerative spine conditions seek care, forcing spine surgeons to decide whether to integrate these modalities or risk losing a growing segment of nonsurgical spine patients.
Level of evidence: 5:
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