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Clinical Advancements in Spine Surgery: Best Practices and Outcomes

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: 20 September 2026 | Viewed by 15472

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Special Issue Editor

Prof. Dr. Mitsuru Yagi

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Guest Editor

Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-8520, Japan
Interests: spine and spinal cord disease; bioimaging; frailty; biomechanics

Special Issue Information

Dear Colleagues,

This Special Issue, titled “Clinical Advancements in Spine Surgery: Best Practices and Outcomes”, aims to provide an interdisciplinary platform for sharing cutting-edge research and innovative techniques in spinal surgery. Current clinical challenges revolve around refining surgical procedures, optimizing patient outcomes, and minimizing adverse events. By addressing gaps in perioperative care, rehabilitation, and long-term monitoring, this Special Issue seeks to foster the development of evidence-based treatment strategies that can be integrated into routine clinical practice. Core problems to be explored include the need for standardized approaches to complex spine conditions, technological integration into surgical workflows, and robust patient-reported outcome measurements.

The scope of this collection encompasses topics ranging from minimally invasive spine surgery techniques and novel biologics to the use of advanced imaging modalities, robotics, and computer-assisted navigation systems. Articles focusing on the integration of enhanced recovery after surgery (ERAS) protocols, patient-specific planning tools, and rigorous research methodologies are highly encouraged. The Special Issue also welcomes review articles, clinical trials, and meta-analyses that elucidate the impact of surgical interventions on functional recovery and healthcare resource utilization.

Mobilization efforts will include broad outreach to neurosurgeons, orthopedic surgeons, biomechanical engineers, rehabilitation specialists, and researchers, encouraging interdisciplinary collaboration and the dissemination of findings that will ultimately improve patient care in spine surgery.

Prof. Dr. Mitsuru Yagi
Guest Editor

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Keywords

adult spinal deformity
scoliosis
frailty
biological age
big data analysis

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Published Papers (10 papers)

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Research

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18 pages, 1120 KB

Open AccessArticle

Elixhauser Comorbidity Index to Predict Perioperative Bleeding and Adverse Spine Surgery Outcomes

by Mitchell K. Ng, Michael A. Mont, Mosadoluwa Afolabi, Prathiksha N. V, Amitha Kumar and Stephen S. Johnston

J. Clin. Med. 2026, 15(5), 1791; https://doi.org/10.3390/jcm15051791 - 27 Feb 2026

Viewed by 245

Abstract

Introduction: As spine surgery volume continues to grow, ensuring patient safety and minimizing complications are increasingly critical. Disruptive bleeding—defined as hemorrhagic events requiring clinical intervention—is a significant perioperative challenge. This study aimed to: (1) quantify disruptive bleeding incidence; (2) evaluate associations between patient demographics, Elixhauser Comorbidity Index (ECI), and bleeding risk; and (3) assess the impact of disruptive bleeding on mortality, ventilator use, length of inpatient stay, 90-day readmissions, and inpatient costs. Methods: A nationwide healthcare database was used to identify patients who underwent spine surgery in 2019. Patients were subdivided by the Elixhauser Comorbidity Index (ECI) from 0 to ≥6, and multivariate logistic regression was employed to analyze for potential association with disruptive bleeding. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated for each ECI classification. After controlling for baseline demographics, generalized linear models were used to evaluate how disruptive bleeding influenced hospital mortality, ventilator use, 90-day readmission rates, lengths of inpatient stay, and inpatient costs. Results: Among 165,461 patients undergoing spine surgery, 15,337 (9.3%) experienced disruptive bleeding. Women and Medicare coverage were associated with higher bleeding risk (p < 0.05). Disruptive bleeding odds increased with comorbidity burden, ranging from OR = 2.31 (95% CI 1.92–2.77) for ECI = 5 to OR = 3.32 (95% CI 2.73–4.06) for ECI ≥ 6. Disruptive bleeding was associated with increased ventilator use (18.4 versus 8.2% for ECI ≥ 6; p < 0.001) and inpatient mortality (3.0 versus 0.7% for ECI ≥ 6; p < 0.001). Hospital stays were significantly prolonged (10.4 versus 6.6 days for ECI ≥ 6; p < 0.001), 90-day readmission rates were higher (19.8 versus 14.7%; p < 0.001), and inpatient costs increased substantially ($68,000 versus $37,500; p < 0.001). Conclusions: Disruptive bleeding in spine surgery is more frequent among patients with elevated comorbidity burdens and is linked to greater mortality, ventilator dependence, and healthcare resource use. These findings highlight the importance of proactive risk stratification and targeted perioperative management strategies for high-risk patients undergoing spine surgery. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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11 pages, 458 KB

Open AccessArticle

Degenerative Scoliosis Correction Is Safe in Elderly Patients with Coronary Artery Disease

by Yousaf B. Ilyas, Mojeed Fagbemi, Kristina P. Kurker, Gabriel S. Gonzales-Portillo, Dario A. Marotta, Morteza Sadeh, Nauman S. Chaudhry and Ankit I. Mehta

J. Clin. Med. 2026, 15(2), 729; https://doi.org/10.3390/jcm15020729 - 16 Jan 2026

Viewed by 394

Abstract

Background/Objectives: Coronary Artery Disease (CAD) is one of the leading causes of death in the United States. Although there is a plethora of studies about CAD, there remains a gap in the literature in examining the role of CAD in patients who undergo spine surgery. In this study, we examine the role of CAD in postoperative outcomes in adult patients who underwent surgery for degenerative scoliosis. Methods: The Scoliosis Research Society Database was queried for patients with degenerative scoliosis and divided into two cohorts: CAD and non-CAD. To minimize confounding bias, propensity score matching was done on comorbidities and patient demographics. Outcomes examined included: intraoperative complications, postoperative outcomes, and mortality rate. After matching, there were 139 patients in each group. Results: The CAD group had significantly higher rates of cardiac-related complications (5.8% vs. 0%, p = 0.012). No other intraoperative complications had significant differences between the groups. Interestingly, the non-CAD group had both a higher rate of returning to surgery (46.8% vs. 33.8%, p = 0.038) and antibiotic-related complications (5.8% vs. 0.7%, p = 0.042) respectively. There were no other differences regarding postoperative outcomes, including mortality. Conclusions: Our study found that aside from cardiac-related complications, the CAD group did not have any worse outcomes, and in some cases did better. These results are promising and may be due to more extensive preoperative screening and more risk aversion in patients with CAD. Our findings suggest that if spine surgeons exercise risk management for cardiac complications, CAD patients may benefit greatly from scoliosis surgery at no increased risk. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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11 pages, 621 KB

Open AccessArticle

Association Between Lumbar Spinal Stenosis and Accelerated Biological Aging Estimated by PhenoAge

by Norihiro Isogai, Haruki Funao, Ryo Mizukoshi, Keirato Ito, Shigeto Ebata and Mitsuru Yagi

J. Clin. Med. 2025, 14(21), 7852; https://doi.org/10.3390/jcm14217852 - 5 Nov 2025

Viewed by 803

Abstract

Background/Objectives: PhenoAge utilizes biochemical biomarkers to differentiate mortality risk in persons of the same chronological age. However, the details of the relationship between PhenoAge and lumbar spinal stenosis (LSS) remain unclear. We investigated the association between lumbar spinal stenosis (LSS) and biological age quantified by PhenoAge and PhenoAge acceleration (PhenoAgeAccel), comparing surgically treated patients with age- and BMI-matched controls. Methods: This study included 208 LSS patients who underwent surgery. The patients were categorized into four subgroups based on gender and age (≥70 years) at the time of surgery. Demographic data, blood biomarkers, body composition measurements, and Phenotypic age acceleration (PhenoAgeAccel), which was assessed by calculating the residuals from regressing PhenoAge on chronological age were compared among the groups. We also compared control groups matched for age and body mass index (BMI) for each of the four groups using medical examination data. Results: The mean age was 70.2 ± 9.3 years and the mean PhenoAgeAccel was −5.7 ± 6.5 years in the LSS group. PhenoAgeAccel was significantly lower in the control group (−8.5 ± 3.7 years) than in the LSS group, especially in young male (LSS: −2.9 ± 6.7, Control: −7.0 ± 2.8 years), old male (−4.8 ± 4.4, −6.7 ± 4.0 years), and old female (−6.9 ± 5.9, −10.8 ± 3.2 years) subgroups. In the correlation coefficient between PhenoAgeAccel and BMI, there were weak positive correlations (CC: 0.08–0.31) across all subgroups in the control group, whereas there was a weak negative correlation (CC: −0.29) in the old female subgroup in the LSS group. Conclusions: The impact of LSS on PhenoAgeAccel varied by age and gender, and the adverse effect of LSS could be particularly pronounced in elderly women with low BMIs. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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12 pages, 1505 KB

Open AccessArticle

Systemic Inflammatory Response Index as a Predictor of Postoperative Infectious Complications in Elderly Patients Undergoing Posterior Spinal Instrumentation

by Anil Agar, Sefa Key and Hamza Yavuz

J. Clin. Med. 2025, 14(21), 7632; https://doi.org/10.3390/jcm14217632 - 28 Oct 2025

Cited by 2 | Viewed by 811

Abstract

Objective: To assess the predictive value of systemic inflammatory markers for postoperative complications in older adults undergoing posterior spinal instrumentation for either lumbar spinal stenosis (LSS) or osteoporotic vertebral fractures (OVFs). This study design as a retrospective observational study. Methods: Fifty-four patients aged ≥ 55 years who underwent posterior spinal instrumentation between 2020 and 2023 were retrospectively analyzed. Patients were grouped into LSS (n = 27) and OVF (n = 27) cohorts. Preoperative, early postoperative, and 6-month follow-up systemic inflammatory marker levels, including the Systemic Inflammatory Response Index (SIRI), Systemic Immune-Inflammation Index (SII), Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Monocyte-to-Lymphocyte Ratio (MLR), were recorded. The primary outcome was the occurrence of postoperative infectious complications. ROC curve analysis was conducted to evaluate the discriminatory power of each marker. Results: SIRI values were significantly higher in the OVF group than in the LSS group at all time points (p < 0.05). Postoperative complications occurred in 7.4% of patients, equally distributed between groups. ROC analysis showed that preoperative SIRI had the highest predictive value (AUC = 0.743), with a cutoff value of 2.69 yielding 100% sensitivity and 65.3% specificity. Other indices showed poor predictive accuracy (AUC < 0.70). Conclusions: Preoperative SIRI is a promising, easily obtainable biomarker for identifying older patients at higher risk of postoperative complications following posterior spinal instrumentation. Its implementation may improve preoperative risk stratification in spine surgery. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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12 pages, 432 KB

Open AccessArticle

Impact of Lumbar Arthrodesis on Activities of Daily Living in Japanese Patients with Adult Spinal Deformity Using a Novel Questionnaire Focused on Oriental Lifestyle

by Naobumi Hosogane, Takumi Takeuchi, Kazumasa Konishi, Yosuke Kawano, Masahito Takahashi, Azusa Miyamoto, Atsuko Tachibana and Hitoshi Kono

J. Clin. Med. 2025, 14(15), 5482; https://doi.org/10.3390/jcm14155482 - 4 Aug 2025

Viewed by 770

Abstract

Background/Objectives: Correction surgery for adult spinal deformity (ASD) reduces disability but may lead to spinal stiffness. Cultural diversity may also influence how this stiffness affects daily life. We aimed to evaluate the impact of correction surgery on Japanese patients with ASD using a newly developed questionnaire and to clarify how these patients adapt to their living environment postoperatively in response to spinal stiffness. Methods: This retrospective study included 74 Japanese patients with operative ASD (mean age: 68.2 ± 7.5 years; fusion involving >5 levels) with a minimum follow-up of 1 year. Difficulties in performing various activities of daily living (ADLs) were assessed using a novel 20-item questionnaire tailored to the Oriental lifestyle. The questionnaire also evaluated lifestyle and environmental changes after surgery. Sagittal and coronal spinal parameters were measured using whole-spine radiographs, and clinical outcomes were assessed using the ODI and SRS-22 scores. Results: Coronal and sagittal alignment significantly improved postoperatively. Although the total ADL score remained unchanged, four trunk-bending activities showed significant deterioration. The lower instrumented vertebrae level and pelvic fusion were associated with lower scores in 11 items closely related to trunk bending or the Oriental lifestyle. After surgery, 61% of patients switched from a Japanese-style mattress to a bed, and 72% swapped their low dining table for one with chairs. Both the ODI and SRS-22 scores showed significant postoperative improvements. Conclusions: Trunk-bending activities worsened postoperatively in Japanese patients with ASD, especially those who underwent pelvic fusion. Additionally, patients often modified their living environment after surgery to accommodate spinal stiffness. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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11 pages, 3920 KB

Open AccessArticle

The Effectiveness and Practical Application of Different Reduction Techniques in Burst Fractures of the Thoracolumbar Spine

by Jan Cerny, Jan Soukup, Lucie Loukotova, Marek Zrzavecky and Tomas Novotny

J. Clin. Med. 2025, 14(13), 4700; https://doi.org/10.3390/jcm14134700 - 3 Jul 2025

Viewed by 1741

Abstract

Background: The objective was to evaluate and compare the efficacy of direct fragment impaction, indirect reduction through ligamentotaxis, and the combination of both techniques in burst fractures of the thoracolumbar (TL) spine. Methods: The fractures were categorized using the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and assessed via standard computed tomography (CT) scans for spinal canal area (SCA) and mid-sagittal diameter (MSD). The Frankel classification was used to assess neurological deficits. Only single vertebrae AO types A3 and A4 thoracic or lumbar fractures were included. All patients received bisegmental posterior stabilization, one of the reduction techniques, and, if neurological deficits were present, a spinal decompression. Mean preoperative (µSCApre/µMSDpre), postoperative (µSCApost/µMSDpost) and difference (∆SCA/∆MSD) in radiographic values were obtained and analyzed using the Mumford formula. The significance of the reduction from preoperative stenosis was assessed using a t-test, while the effectiveness of the reduction techniques was compared using the Kruskal–Wallis test and Dunn’s post hoc test. The manuscript was focused primarily on radiographic outcomes; therefore, aside from the neurostatus, no other clinical parameters were statistically analyzed. Results: Thirteen patients (38.2%) received stand-alone indirect reduction, 13 patients (38.2%) underwent direct reduction, and a combined reduction was used in eight patients (23.6%). All methods resulted in a statistically significant reduction in spinal canal stenosis (p < 0.05), with a minimal mean ∆SCA of 19%. Patients in the direct reduction group had significantly higher µSCApre values compared to those in the indirect reduction group (p = 0.02). Conclusions: All of the tested reduction techniques provided a significant reduction in spinal canal stenosis. Patients who underwent mere direct reduction had significantly higher preoperative spinal canal stenosis compared to the indirect reduction group. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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Review

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20 pages, 30041 KB

Open AccessReview

Dural Tear and Cerebrospinal Fluid Leakage in Anterior Cervical Spine Surgery: Pathophysiology, Management, and Evolving Repair Techniques

by Jae Jun Yang, Jiwon Park, Jong-Beom Park and Suo Kim

J. Clin. Med. 2025, 14(23), 8478; https://doi.org/10.3390/jcm14238478 - 29 Nov 2025

Cited by 1 | Viewed by 1695

Abstract

Dural tear (DT) and cerebrospinal fluid (CSF) leakage, though uncommon complications, represent a potentially serious risk of anterior cervical spine surgery, particularly in patients with ossification of the posterior longitudinal ligament (OPLL). While the incidence in routine anterior cervical discectomy and fusion (ACDF) or corpectomy (ACCF) is typically below 0.5%, it rises sharply to 4–32% in OPLL cases. Furthermore, it exceeds 60% when dural ossification (DO) is present. Adhesion and ossification obliterate the normal epidural plane, creating a fragile osteofibrotic interface that is highly susceptible to tearing during decompression. This review synthesizes current evidence on the pathophysiology of DT and CSF leakage in anterior cervical spine surgery, provides a framework for risk stratification, and outlines evolving techniques for successful repair and management. Intraoperative management has shifted from direct resection toward dura-preserving floating decompression and biologically reinforced multilayer repair using fascia, collagen matrix, fibrin adhesives, and polyethylene glycol (PEG) hydrogel sealants. Postoperative care emphasizes controlled CSF pressure regulation, sterile wound management, and early ambulation. Most DTs achieve successful closure with timely recognition and standardized treatment. However, persistent leakage may require escalation to composite reconstruction, epidural blood patch, or vascularized flap reinforcement. Emerging technologies such as bioactive hydrogels, 3D-printed dural scaffolds, and artificial intelligence–assisted imaging offer potential future improvements, although clinical adoption remains limited. This review summarizes current evidence on the mechanisms, risk factors, diagnostic predictors, repair strategies, and postoperative management of DT and CSF leakage, with specific attention to OPLL-related DO. A more apparent distinction between established clinical practice and emerging investigational technologies is provided to guide evidence-based decision-making. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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25 pages, 7842 KB

Open AccessReview

Cervical Pyogenic Spondylitis: A Comprehensive Review of Diagnosis and Treatment Strategy

by Chae-Gwan Kong, Sung-Kyu Kim and Jong-Beom Park

J. Clin. Med. 2025, 14(10), 3519; https://doi.org/10.3390/jcm14103519 - 17 May 2025

Cited by 1 | Viewed by 2687

Abstract

Cervical pyogenic spondylitis (CPS) is a rare but serious spinal infection with a high risk of neurological compromise due to the cervical spine’s narrow canal and proximity to critical neurovascular structures. Early diagnosis relies on a high index of suspicion supported by MRI, inflammatory markers, blood cultures, and tissue biopsy. Empirical intravenous antibiotics remain the cornerstone of initial treatment, followed by pathogen-specific therapy. Surgical intervention is indicated in cases of neurological deterioration, spinal instability, or failure of conservative management. Anterior approaches, including anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF), are widely used, with anterior plating providing biomechanical advantages in select cases. Posterior or combined anterior–posterior approaches are recommended in multilevel disease, deformity, or posterior element involvement. Graft selection—typically autograft or titanium/PEEK cages—must consider infection severity and biomechanical demands. Challenges in CPS management include optimal debridement extent, graft choice in infected environments, the standardization of antibiotic protocols, and the prevention of recurrence. This narrative review synthesizes the cervical-spine-specific literature on diagnosis, treatment strategies, surgical techniques, and postoperative care and proposes the following practical clinical guidance: (1) early MRI for timely diagnosis, (2) prompt surgical intervention in patients with neurological deficits or mechanical instability, and (3) individualized graft selection based on infection severity and bone quality. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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21 pages, 4894 KB

Open AccessReview

Reoperation Strategy for Failure of Cervical Disc Arthroplasty at Index and Adjacent Levels

by Chae-Gwan Kong and Jong-Beom Park

J. Clin. Med. 2025, 14(6), 2038; https://doi.org/10.3390/jcm14062038 - 17 Mar 2025

Cited by 2 | Viewed by 3853

Abstract

Cervical disc arthroplasty (CDA) is a motion-preserving alternative to anterior cervical discectomy and fusion (ACDF) for cervical degenerative disease, reducing adjacent segment degenerative disease (ASD). Despite its benefits, some patients experience CDA failure due to prosthesis-related complications, heterotopic ossification, segmental kyphosis, ASD, or facet joint degeneration, necessitating revision surgery. Reoperation strategies depend on the failure mechanism, instability, sagittal malalignment, and neural compression. Anterior revision is suited for prosthesis failure, recurrent disc herniation, or ASD, enabling prosthesis removal, decompression, and fusion. In select cases, reimplantation may restore motion. Posterior approaches are preferred for facet degeneration, multilevel stenosis, or posterior hypertrophy, with options including foraminotomy, laminoplasty, or laminectomy and fusion. Complex cases may require combined anterior and posterior surgery for optimal decompression and stability. This narrative review outlines revision strategies, emphasizing biomechanical assessment, radiographic evaluation, and patient-specific considerations. Despite surgical challenges, meticulous planning and execution can optimize outcomes. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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Other

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12 pages, 5233 KB

Open AccessCase Report

New Technique for S1 Nerve Root Transforaminal Percutaneous Fluoroscopically Guided Approach for Difficult Cases of Altered Anatomy

by Łukasz Kubaszewski, Adam Druszcz, Wojciech Łabędź, Zofia Kubaszewska and Mikołaj Dąbrowski

J. Clin. Med. 2025, 14(9), 3126; https://doi.org/10.3390/jcm14093126 - 30 Apr 2025

Cited by 1 | Viewed by 1760

Abstract

Background: S1 nerve roots are difficult to approach during percutaneous procedures for the diagnostic and treatment procedures of low back pain with radicular symptoms. This is harder in older patients with obscure anatomies, due to the low bone density with overimposing degenerative changes in the facets and deformations. The otherwise straightforward procedure for the lumbar nerve roots, placing the needle in the proximity of the S1 under fluoroscopic guidance, becomes quite a challenge. Case presentation: In the proposed technique, the initial target for the needle is the lower part of the S1 facet in the convergent trajectory of the needle. After achieving contact with the bone the tip of the needle is moved caudally as, in proximity, it reaches the dorsal foramina of the S1/S2 segment—this is named “wandering to the hole”. The convergent trajectory of the needle ensures the success of the procedure with a minimal risk of intravenous drug administration, which is characteristic for the suprapedicular technique. Conclusions: The proposed technique is straightforward and reproducible due to the combination of the understanding of the surgical and radiological anatomy of this region, in spite of degenerative changes in the spine. Full article

(This article belongs to the Special Issue Clinical Advancements in Spine Surgery: Best Practices and Outcomes)

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