Background: Obesity is often associated with worse outcomes after lumbar fusion surgery, but its impact on patient-reported outcomes in spondylolisthesis remains unclear. This study assesses the effect of body mass index (BMI) on outcomes for degenerative and isthmic spondylolisthesis patients undergoing lumbar fusion.
Methods: We conducted a retrospective analysis of 86 patients with low-grade lumbar degenerative and isthmic spondylolisthesis, categorized by BMI into nonobese (<30 kg/m²), obesity class I (30.0-34.9 kg/m²), obesity class II (35.0-39.9 kg/m²), and obesity class III (≥40.0 kg/m²). Outcomes were measured using the visual analog scale (VAS) for pain and the Oswestry Disability Index (ODI) at baseline and 12 months postoperatively. Statistical analyses included a 1-way analysis of variance, Bonferroni post hoc comparisons, and Kruskal-Wallis tests.
Results: Significant disability improvements (mean ODI improvement: 15.6 points, P < 0.001) were observed across all BMI categories, while pain improvements were less pronounced (mean VAS improvement: 2.1 points, P < 0.001). Nonobese and class II patients maintained improvements at 12 months. Degenerative spondylolisthesis patients showed better ODI outcomes compared with isthmic patients (P = 0.019), while VAS outcomes were similar (P = 0.251).
Conclusion: Lumbar fusion results in significant disability reduction across BMI categories, with sustained improvements in nonobese and obesity class II patients. These findings suggest that obesity should not be a contraindication for lumbar fusion in well-selected patients, as meaningful improvements can be achieved, particularly in disability outcomes.
Clinical relevance: Clinically, this supports a more individualized approach to surgical candidacy, emphasizing functional goals and symptom burden over BMI alone, thereby promoting equitable access to care and helping guide preoperative counseling and shared decision-making.
Level of evidence: 3:
Background: The transforaminal (TF) approach in full endoscopic spine surgery (FESS) is the least invasive spinal surgery, as it can be performed under local anesthesia with only an 8-mm skin incision. Transforaminal FESS-based foraminotomy was first performed in the early 2000s for the decompression of foraminal stenosis. The technique has improved year by year over the past 2 decades. In our hospital, full endoscopic lumbar foraminotomy (FELF) has been performed since 2015. Since our development of the FESS undercutting laminectomy procedures in 2019, the size of the decompressed area achieved by FELF has increased.
Objective: To estimate the technical alteration of FELF over time by comparing the pre- and postoperative osseous foraminal areas (FAs) between traditional and advanced FELF techniques.
Methods: Fifty-two cases were retrospectively reviewed. In the early phase of FELF before 2019, partial or total resection of the superior articular process (SAP) was performed. Twenty-six of the patients were treated using the traditional FELF procedure (SAP-ectomy group). The remaining 26 underwent advanced FELF procedures, including SAP-ectomy, undercutting laminectomy, and removal of the ligamentum flavum (advanced FELF group). Clinical outcomes were assessed using the modified MacNab score. Pre- and postoperative osseous FAs were measured on sagittal computed tomography, and data were compared between the SAP-ectomy and advanced FELF groups. Paired and unpaired t tests were used for statistical analysis.
Results: By the modified MacNab score, the excellent/good rate was 82.6% in the SAP-ectomy group and 95.5% in the advanced FELF group. The improvement was greater in advanced FELF but not significantly. FA prior to surgery was 87.5 ± 27.0 mm2 in the SAP-ectomy group and 95.7 ± 34.3 mm2 in the advanced FELF group, with postoperative increases to 151.4 ± 45.5 mm2 and 195.3 ± 39.1 mm2, respectively (P < 0.05). FA increased by 63.9% and 99.6% in the SAP-ectomy and advanced FELF groups, respectively.
Conclusion: Full endoscopic foraminotomy techniques have evolved over time. The recently developed advanced FELF technique appears to safely and effectively achieve better clinical outcomes by significantly enlarging FA.
Clinical relevance: The advanced FELF technique contributes to improved decompression of the exiting nerve root.
Level of evidence: 3:
Patients with symptomatic lumbar disc herniation with radiculopathy where there is a large residual annular defect following discectomy are at greater risk of reherniation with symptom recurrence and revision surgery. These patients may benefit from primary annular repair. In 2019, the International Society for the Advancement of Spine Surgery published clinical guidelines supporting the use of bone-anchored annular closure in patients with large annular defects who are at greater risk for recurrent disc herniation. This 2025 update is provided to (1) summarize the current, increased clinical evidence for bone-anchored annular closure with greater follow-up durations and (2) update guidance for coding in light of new diagnostic and upcoming current procedural terminology codes. Based on accumulating clinical evidence, the International Society for the Advancement of Spine Surgery reiterates its position that in patients with symptomatic lumbar disc herniation with radiculopathy undergoing primary discectomy with large (≥6 mm wide) annular defects, bone-anchored annular closure may be used to sustain the treatment benefits of discectomy.
Background: This study aims to evaluate patient perceptions of the outcomes following awake transforaminal endoscopic lumbar decompression surgery for treating degenerative spine diseases.
Methods: Over a 1-year period from 2022 to 2023, awake transforaminal endoscopic spine surgeries were performed on 183 patients using local anesthesia and sedation, allowing patients to communicate with the surgical team throughout the procedure. A follow-up app-based survey was sent to these patients to assess their perceptions and outcomes related to the surgery.
Results: Out of 183 recipients, 102 patients completed the survey. At the 1-year follow-up, 89.2% of the respondents reported better outcomes in comparison to traditional spine surgeries, and 98% expressed willingness to recommend the procedure to others with similar conditions.
Conclusions: The findings demonstrate notable advancements in minimally invasive spine surgery, with awake transforaminal endoscopic decompression showing high satisfaction rates tied closely to meeting patient expectations. The study also identifies areas for improvement, particularly in managing postoperative pain and aligning patients' expectations with clinical results.
Clinical relevance: Effective preoperative communication and consistent pain management practices are critical in enhancing patient satisfaction and postoperative recovery, along with the integration of conservative treatments such as physical therapy and acupuncture to maximize surgical outcomes.
Level of evidence: 2:
Background: To evaluate the impact of anterior lumbar interbody fusion (ALIF) vs posterior lumbar interbody fusion (PLIF) at the lumbosacral junction on mechanical complications and fusion rate at the caudal lumbar segments in adult spinal deformity (ASD) surgery.
Methods: This retrospective cohort study included ASD patients with coronal or sagittal imbalance who underwent thoracolumbar to pelvic fusion with ALIF or PLIF technique at the lumbosacral junction and a minimum follow-up of 2 years. The primary focus was on mechanical complications, including material failure and sacral fracture, implant-related pain, pseudarthrosis, and reoperation. Patient-specific and perioperative characteristics were also analyzed at the 2-year follow-up. The primary focus was on mechanical complications, including material failure and sacral fracture, implant-related pain, pseudarthrosis, and reoperation. Patient-specific and perioperative characteristics were also analyzed.
Results: A total of 56 patients were included, comprising 32 ALIF and 24 PLIF patients, with a mean age of 79.5 ± 6.6 years. The overall mechanical complication rate was 19.6%, including screw loosening (7.1%), rod breakage (5.4%), sacral fracture (3.6%), and screw breakage (1.8%). Pseudarthrosis and reoperation rates were 10.7% each. ALIF significantly reduced mechanical complications compared with PLIF (9.4% vs 37.5%, P = 0.011). The ALIF group also showed lower rates of pseudarthrosis, implant-related pain, and reoperation (P < 0.05). Regression analysis identified PLIF as an independent risk factor for mechanical complications (P = 0.006). Length of hospital stay, operative time, and pseudarthrosis rate were significantly associated with an increased rate of mechanical complications, but patient demographics had no significant impact.
Conclusion: Approximately 1 in 5 patients experiences mechanical complications within 2 years of ASD correction surgery. ALIF at the lumbosacral junction significantly reduces mechanical complications and pseudarthrosis compared with PLIF, resulting in lower reoperation rates. These findings suggest that ALIF should be the preferred technique for lumbosacral fusion in long-segment ASD constructs, provided there is no spondylolisthesis or severe spinal stenosis with L5 nerve root compression requiring simultaneous direct posterior decompression and fusion. This is particularly important in patients at risk for mechanical complications and pseudarthrosis, including those undergoing revision procedures.
Level of evidence: 3 - Retrospective comparative study.
Background: Diffuse idiopathic skeletal hyperostosis (DISH) is a metabolic disease that is prevalent in elderly patients and is characterized by spinal ankylosis. Traditional surgical treatment requires open long-segment internal fixation. Percutaneous kyphoplasty (PKP), as a minimally invasive spinal surgery technology, can accurately relieve pain and improve quality of life. The objective of this study was to evaluate the efficacy and reliability of PKP in treating vertebral fractures with DISH.
Methods: We retrospectively investigated 209 patients with thoracic or lumbar fractures receiving PKP between January 2019 and December 2020. The patients were divided into 2 groups according to the diagnostic criteria. The anterior and posterior vertebral height restoration ratio and the local kyphotic angle (LKA) were used to evaluate the radiographic results. The visual analog scale score and the Oswestry Disability Index questionnaire were used for the assessment of the clinical function.
Results: The average age of the DISH group was significantly older than that of the non-DISH group (P < 0.05). The perioperative prognostic nutritional index measured in the DISH group was significantly worse than that in the non-DISH group (P < 0.05). PKP in DISH patients achieved a significant restoration in the anterior and posterior vertebral height restoration ratio between pre- and postoperative measurements (P < 0.05). The postoperative LKA was significantly corrected at 1 day, 1 month, and the last follow-up (P < 0.05). Significant reductions in visual analog scale and Oswestry Disability Index scores were obtained during follow-up (P < 0.05).
Conclusion: For vertebral fractures in elderly DISH patients, PKP may be effective and feasible, which restores the vertebral height, corrects the LKA, and achieves pain relief and satisfactory functional improvement.
Level of evidence: 3:
Background: While studies have identified urinary tract infection (UTI) as a complication after spine fusion, UTI is understudied in the context of fusion for spinal deformity. This study sought to determine both UTI incidence after multilevel posterior fusion for spinal deformity and whether pooled risk factors (RFs) increased UTI risk.
Methods: Patients who had posterior fusion for spinal deformities between 2010 to 2019 were queried from the PearlDiver database, separated by the number of levels operated on (<7, 7-12, and >12), matched for age/gender, and analyzed for UTI incidence within 1 week and 1, 2, and 3 months. Any patient with a note of diabetes, obesity, rheumatoid arthritis, or coronary artery disease within 1-year prior to surgery and who contracted UTI within 1 month after fusion was included in the RF group for each level span. Patients of each level span with any RF were compared with those without any RFs. χ 2 tests were used for statistical analyses.
Results: A total of 20,893 patients underwent posterior fusion for spinal deformities from 2010 to 2019. After matching, each level set had 2239 patients. At 1, 2, and 3 months, the >12 levels subgroup showed statistically higher UTI incidence than the 7 to 12 and <7 levels subgroups. At 3 months, UTI was similar between the <7 and 7 to 12 subgroups, with 3.8% and 3.9%, respectively (P = 0.41), and UTI was statistically higher in the >12 subgroup at 4.6% (<7 vs 7-12: P = 0.005; <7 vs >12: P < 0.001). For each level group, the RF groups had significantly higher UTI rates at 1, 2, and 3 months. ORs were significantly greater than 1 for RF groups across all level subgroups (<7 OR = 2.8, P < 0.001; 7-12 OR = 2.1, P < 0.001; >12 OR = 2.3, P < 0.001).
Conclusions: Diabetes, obesity, rheumatoid arthritis, and coronary artery disease were associated with a higher risk of UTI after posterior fusion for spinal deformity for all level sets. patients who underwent procedures for more than 12 levels had the highest rate of UTI. This is the first study to analyze and compare UTI incidence following fusion for spinal deformity.
Level of evidence: 3:
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