Search Results (64)

Objective: Bilateral facetectomy (BF) within minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) remains debated regarding its advantages over unilateral facetectomy (UF) in restoring segmental lordosis, addressing spondylolisthesis and decompressing both neural foramina. The evidence is limited. We sought to determine the benefits of contralateral facetectomy on radiographic and clinical outcomes. Methods: We conducted a single-center retrospective analysis on patients with lumbar degenerative disease who underwent single-level percutaneous instrumentation and MI-TLIF with either UF or BF. Plain radiographs, CT and MRI were utilized for comparative radiographic analysis. Various intraoperative and clinical parameters were evaluated to assess surgical effort and clinical outcomes. Results: We included 81 UF and 23 BF cases; complete radiological data were available for 27 and 13 patients, respectively. Both techniques demonstrated a comparable increase in segmental lordosis (UF 2.1° ± 5.3° vs. BF 4.3° ± 5.4°, p > 0.1), which is below the study’s minimum detectable effect (MDE ≈ 5.1° at 80% power). Spondylolisthesis reduction was similar, with UF achieving a mean of 2.8 ± 2.2 mm and BF 2.4 ± 1.9 mm (p > 0.1). Mean posterior disc height did not differ significantly between groups (p > 0.1). The mean intraoperative blood loss was significantly higher with BF (803 ± 347 mL) compared to UF (437 ± 207 mL, p < 0.001). The mean duration of surgery was significantly longer for BF (240 ± 48 min) compared to UF (197 ± 37 min, p = 0.001). Conclusions: This study found no evidence of a large advantage of BF over UF in restoring segmental lordosis, spondylolisthesis and posterior disc height in monosegmental MI-TLIF surgery. Given the higher blood loss and longer operative time observed with BF, its use should be selective for specific indications. Full article

Background/Objectives: Unilateral biportal endoscopic spine surgery (UBE) has gained popularity due to its minimal invasiveness, endoscopic magnification, bloodless visual field, and broad application to various spinal disorders. We proposed the “no-punch” technique for UBE spine surgery, emphasizing its capability to prevent neural injury and preserve facet joints. This study aims to examine its efficacy in reducing the risk of incidental durotomy through a comparative study. Methods: A total of 914 consecutive patients with various degenerative spine disorders who underwent UBE surgery between October 2018 and July 2023 by a single surgeon in a single institute were included. The Punch Group consisted of 660 patients (830 segments) who underwent UBE surgeries using Kerrison punches. The No-Punch Group included 254 patients (330 segments) who underwent UBE surgeries without using Kerrison punches. We retrospectively reviewed the medical records and operative videos to identify surgical complications, their management, and final treatment outcomes. Results: Sixty-three surgical complications (58 in the Punch Group), including incidental dural tears, nerve root injuries, incomplete decompression, epidural hematoma, and broken instruments, were identified. The No-Punch Group exhibited a significantly lower overall complication rate (8.8% vs. 2.0%), along with a reduced incidence of dural tears (3.9% vs. 0) and neural injuries (5.3% vs. 0.4%). The improvement was particularly notable in lumbar decompression surgeries (5.0% vs. 0.8%) and revision surgeries (9.9% vs. 0%). Conclusions: The “no-punch” technique enhances the safety of UBE surgery for degenerative spine disorders by understanding the injury mechanisms and modifying the surgical techniques accordingly. Full article

Accurate segmentation of surgical instruments in endoscopic videos is crucial for robot-assisted surgery and intraoperative analysis. This paper presents a Segment-then-Classify framework that decouples mask generation from semantic classification to enhance spatial completeness and temporal stability. First, a Mask2Former-based segmentation backbone generates class-agnostic instance masks and region features. Then, a bounding box-guided instance-level spatiotemporal modeling module fuses geometric priors and temporal consistency through a lightweight transformer encoder. This design improves interpretability and robustness under occlusion and motion blur. Experiments on the EndoVis 2017 and 2018 datasets demonstrate that our framework achieves mIoU improvements of 3.06%, 2.99%, and 1.67% and mcIoU gains of 2.36%, 2.85%, and 6.06%, respectively, over previously state-of-the-art methods, while maintaining computational efficiency. Full article

Robot-assisted radical prostatectomy (RARP) has become the most prevalent treatment for patients with organ-confined prostate cancer. Despite superior outcomes, suboptimal vesicourethral anastomosis (VUA) may lead to serious complications, including urinary leakage, prolonged catheterization, and extended hospitalization. A precise localization of both the surgical needle and the surrounding vesical and urethral tissues to coadapt is needed for fine-grained assessment of this task. Nonetheless, the identification of anatomical structures from endoscopic videos is difficult due to tissue distortions, changes in brightness, and instrument interferences. In this paper, we propose and compare two Deep Learning (DL) pipelines for the automatic segmentation of the mucosal layers and the suturing needle in real RARP videos by exploiting different architectures and training strategies. To train the models, we introduce a novel, annotated dataset collected from four VUA procedures. Experimental results show that the nnU-Net 2D model achieved the highest class-specific metrics, with a Dice Score of 0.663 for the mucosa class and 0.866 for the needle class, outperforming both transformer-based and baseline convolutional approaches on external validation video sequences. This work paves the way for computer-assisted tools that can objectively evaluate surgical performance during the critical phase of suturing tasks. Full article

Background and Clinical Significance: Posteriorly migrated lumbar disc herniation [PMLDH] is a rare entity that may present with atypical clinical and radiological features, often mimicking other spinal pathologies. Migration of sequestered fragments through the interlaminar space is exceptionally uncommon, and diagnostic challenges are further amplified in the presence of spinal instability. While MRI and CT are generally sufficient for diagnosis, undetected lesions on preoperative imaging may complicate clinical management. Case Presentation: A 59-year-old male presented with acute low back pain and left-sided radiculopathy. Examination revealed mild motor weakness in ankle dorsiflexion. MRI showed L4–L5 segmental instability with central canal stenosis but no migrated disc fragment. Owing to neurological deficit, decompressive laminectomy with posterior instrumentation was performed. Intraoperatively, a posteriorly migrated sequestered fragment compressing the thecal sac was excised and confirmed as degenerative disc material. Postoperatively, the patient’s neurological deficit and radicular pain resolved, with no new complaints at 3-month follow-up. Conclusions: This case highlights an unusual presentation of PMLDH in a patient with lumbar stenosis and spinal instability, undetected on preoperative imaging. Recognition of the biomechanical predisposition at the L3–4 and L4–5 levels is important in understanding such rare migrations. Although literature emphasizes early surgical intervention for PMLDH, our patient required urgent surgery due to neurological deficits rather than a definitive preoperative diagnosis. Further studies are warranted to clarify the relationship between instability and posterior migration. Full article

Background: Surgical site infections (SSIs) are a significant postoperative complication in instrumented lumbar spine surgery, and the selection and duration of appropriate prophylactic antibiotics are key to their prevention. The aim of our study was to evaluate the effectiveness of various prophylactic antibiotics, primarily cefazolin and clindamycin, as well as the role of the duration of antibiotic prophylaxis in the development of SSI in instrumented lumbar spine surgeries through retrospective analysis. Methods: We performed a retrospective analysis of data from 915 patients who underwent instrumented lumbar spine surgery between 2016 and 2024 in a university center database. We examined the incidence of SSI according to the type of antibiotic used (cefazolin 1 g or 2 g, or clindamycin 0.6 g) and the duration of prophylaxis (single dose versus 72 h administration). We used the Fisher test and Welch test as a statistical analysis to examine the differences between SSI rates. Results: The incidence of SSI was 11.7%. We measured a significantly lower infection rate with cefazolin compared to clindamycin (OR = 0.45; 95% CI: 0.23–0.94; p = 0.0206), regardless of the duration of antibiotic administration. The 72 h cefazolin prophylaxis showed a slight but statistically insignificant advantage over single dose prophylaxis. The risk of SSI was significantly higher in multi-segment surgeries (p = 0.0005). Conclusions: Cefazolin is a more effective prophylactic antibiotic than clindamycin during instrumented lumbar spine surgery. The duration of antibiotic administration has less influence on the risk of SSI development; therefore, short-term, adequate-dose cefazolin prophylaxis is recommended, which also minimizes the risk of antimicrobial resistance and side effects. Full article

Background and Objectives: The use of Artificial Intelligence (AI) in the medical field is rapidly expanding. This review aims to explore and summarize all published research on the development and validation of deep learning (DL) models in gynecologic laparoscopic surgeries. Materials and Methods: MEDLINE, IEEE Xplore, and Google scholar were searched for eligible studies published between January 2000 and May 2025. Selected studies developed a DL model using datasets derived from gynecologic laparoscopic procedures. The exclusion criteria included non-gynecologic datasets, non-laparoscopic datasets, non-Convolutional Neural Network (CNN) models, and non-English publications. Results: A total of 16 out of 621 studies met our inclusion criteria. The findings were categorized into four main application areas: (i) anatomy classification (n = 6), (ii) anatomy segmentation (n = 5), (iii) surgical instrument classification and segmentation (n = 5), and (iv) surgical action recognition (n = 5). Conclusions: This review emphasizes the growing role of AI in gynecologic laparoscopy, improving anatomy recognition, instrument tracking, and surgical action analysis. As datasets grow and computational capabilities advance, these technologies are poised to improve intraoperative guidance and standardize surgical training. Full article

The management of adult spinal deformity (ASD) has evolved dramatically over the past century, transitioning from external bracing and in situ fusion to complex, technology-driven surgical interventions. This review traces the historical development of spinal deformity correction and highlights contemporary enabling technologies that are redefining the surgical landscape. Advances in stereoradiographic imaging now allow for precise, low-dose three-dimensional assessment of spinopelvic parameters and segmental bone density, facilitating individualized surgical planning. Robotic assistance and intraoperative navigation improve the accuracy and safety of instrumentation, while patient-specific rods and interbody implants enhance biomechanical conformity and alignment precision. Machine learning and predictive modeling tools have emerged as valuable adjuncts for risk stratification, surgical planning, and outcome forecasting. Minimally invasive deformity correction strategies, including anterior column realignment and circumferential minimally invasive surgery (cMIS), have demonstrated equivalent clinical and radiographic outcomes to traditional open surgery with reduced perioperative morbidity in select patients. Despite these advancements, complications such as proximal junctional kyphosis and failure remain prevalent. Adjunctive strategies—including ligamentous tethering, modified proximal fixation, and vertebral cement augmentation—offer promising preventive potential. Collectively, these innovations signal a paradigm shift toward precision spine surgery, characterized by data-informed decision-making, individualized construct design, and improved patient-centered outcomes in spinal deformity care. Full article

Background/Objectives: Proximal junctional kyphosis (PJK) is one of the most frequently discussed complications following corrective surgery in patients with neuromuscular scoliosis (NMS). Despite its clinical relevance, the etiology of PJK remains incompletely understood and appears to be multifactorial. Biomechanical and limited clinical studies suggest that preoperative hyperkyphosis, resection of the spinous processes with consequent disruption of posterior ligamentous structures, and rod contouring parameters may contribute as risk factors. Methods: To validate these findings, we retrospectively analyzed 99 NMS patients who underwent posterior spinal fusion using a standardized screw-rod system between 2009 and 2017. Radiographic assessments were conducted at three time points: preoperatively (preOP), postoperatively (postOP), and at a mean follow-up (FU) of 29 months. Clinical variables collected included patient age, weight, height, sex, and Risser sign. Radiographic evaluations encompassed Cobb angles, thoracic kyphosis (TK), lumbar lordosis, the levels of the upper (UIV) and lower (LIV) instrumented vertebrae, the total number of fused segments, parameters of sagittal alignment, the rod contour angle (RCA), and the postoperative mismatch between RCA and the proximal junctional angle (PJA). Based on the development of proximal junctional kyphosis, patients were categorized into PJK and non-PJK groups. Results: The overall incidence of PJK was 23.2%. In line with previous biomechanical findings, spinous process resection was significantly associated with PJK development. Furthermore, the PJK group demonstrated significantly higher preoperative TK (59.3° ± 29.04° vs. 34.5° ± 26.76°, p < 0.001), greater RCA (10.2° ± 4.01° vs. 7.7° ± 4.34°, p = 0.021), and a larger postoperative mismatch between PJA and RCA (PJA−RCA: 3.8° ± 6.76° vs. −1.8° ± 6.55°, p < 0.001) compared to the non-PJK group. Conclusions: Spinous process resection, a pronounced mismatch between postoperative PJA and RCA (odds ratio [OR] = 1.19, p = 0.002), excessive rod bending (i.e., high RCA), and severe preoperative thoracic hyperkyphosis with an expected increase in the risk of PJK of approximately 6.5% per degree of increase in preoperative TK are significant risk factors for PJK. These variables should be carefully considered during the surgical planning and execution of deformity correction in NMS patients. Full article

Accurate femoral tunnel positioning is crucial for successful anterior cruciate ligament reconstruction (ACLR), yet traditional arthroscopic techniques face significant challenges in spatial orientation and precise anatomical localization. This study presents a novel marker-less computer-assisted navigation system that integrates three-dimensional femoral modeling with real-time arthroscopic guidance. The system employs advanced image processing techniques for accurate condyle segmentation and implements the Bernard and Hertel (BH) grid system for standardized positioning. A curvature-based feature extraction approach precisely identifies the capsular line reference (CLR) on the lateral condyle surface, forming the foundation for establishing the BH reference grid. The system’s two-stage registration framework, combining SIFT-ICP algorithms, achieves accurate alignment between preoperative models and arthroscopic views. Validation results from expert surgeons demonstrated high precision, with 71.5% of test groups achieving acceptable or excellent performance standards (mean deviation distances: 1.12–1.86 mm). Unlike existing navigation solutions, our system maintains standard surgical workflow without requiring additional surgical instruments or markers, offering an efficient and minimally invasive approach to enhance ACLR precision. This innovation bridges the gap between preoperative planning and intraoperative execution, potentially improving surgical outcomes through standardized tunnel positioning. Full article

Knowledge of realistic loads is crucial in the engineering design process of medical devices and for assessing their interaction with the spinal system. Depending on the type of modeling, current numerical spine models generally either neglect the active musculature or oversimplify the passive structural function of the spine. However, the internal loading conditions of the spine are complex and greatly influenced by muscle forces. It is often unclear whether the assumptions made provide realistic results. To improve the prediction of realistic loading conditions in both conservative and surgical treatments, we modified a previously validated forward dynamic musculoskeletal model of the intact lumbosacral spine with a muscle-driven approach in three scenarios. These exploratory treatment scenarios included an extensible lumbar orthosis and spinal instrumentations. The latter comprised bisegmental internal spinal fixation, as well as monosegmental lumbar fusion using an expandable interbody cage with supplementary posterior fixation. The biomechanical model responses, including internal loads on spinal instrumentation, influences on adjacent segments, and effects on abdominal soft tissue, correlated closely with available in vivo data. The muscle forces contributing to spinal movement and stabilization were also reliably predicted. This new type of modeling enables the biomechanical study of the interactions between active and passive spinal structures and technical systems. It is, therefore, preferable in the design of medical devices and for more realistically assessing treatment outcomes. Full article

Limb-sparing techniques for appendicular primary bone tumors are still associated with a high rate of complications. Three-dimensional (3D)-printed patient-specific instruments could reduce these complications. The aim of this study is to describe a limb-sparing surgery using 3D-printed patient-specific guides (PSGs) and an endoprosthesis (PSE) to treat femoral chondrosarcoma in a dog. An eight-year-old female Golden Retriever presented with persistent lameness of the right hind limb, reluctance to move and difficulty in maintaining a standing position. Palpation of the right femur revealed an approximately 4 cm painful lesion. Cytological analysis of the needle aspiration supported the clinical and radiological suggestion of a cartilaginous bone neoplasm. Computed tomography (CT) scans suggested the presence of an aggressive lesion on the right distal femur. CT scans of the femur and tibia were then reconstructed using a bone tissue algorithm and processed with computer-aided design (CAD) software, which allowed for performing virtual surgical planning (VSP) and the fabrication of both the PSG and the PSE. Anti-inflammatory drugs and monoclonal antibodies were used for pain management while waiting for surgery. Adjuvant chemotherapy was also administered. An ostectomy of the distal third of the femur to completely remove the tumor was performed with the designed PSG, while the bone defect was filled with the designed PSE. Histopathological examination of the osteotomized bone segment confirmed a grade 2 central chondrosarcoma. There was no excessive tumor growth during the 28 days between the CT scans and surgery. Both PSG and PSE fitted perfectly to the bone surfaces. PSG eliminated the need for intraoperative imaging and ensured a faster and more accurate osteotomy. PSE optimized load sharing and eliminated the complications of the commercial endoprosthesis, such as incongruity and the need for manual intraoperative adjustment. Overall, the use of VSP, 3D-printed PSG and PSE significantly reduced surgical time, risk of infection and intra- and postoperative complications. Full article

Cervical kyphosis is a debilitating disease, and its surgical treatment involves correction to restore sagittal alignment. Few studies have explored the appropriate degree of correction, and the biomechanical impact of correction on the cervical spine is still unclear. This study aimed to compare the biomechanical changes in the cervical spine after different degrees of correction by two-level anterior cervical discectomy and fusion (ACDF). Three-dimensional finite element (FE) models of the intact cervical spine (C2–C7) with normal physiological lordosis and kyphosis were constructed. Based on the kyphotic model, three two-level ACDF in C4–6 surgical models were developed: (1) non-correction: only the intervertebral heights were restored; (2) partial correction: the cervical curvature was adjusted to straighten; (3) complete correction: the cervical curvature was adjusted to physiological lordosis. A pure moment of 1.0 Nm combined with a follower load of 73.6 N was applied to the C2 vertebra to simulate flexion, extension, lateral bending, and axial rotation. The stress of vertical bodies and facet joints, intradiscal pressure (IDP), and the overall ROMs of all models were computed. The peak von Mises stress on the upper (C4) and lower (C6) instrumented vertebral bodies in the kyphotic model was greater than that of the physiological lordosis model, with the exception of C6 under lateral bending. The maximum stress was observed in C4 during lateral bending after complete correction, which increased by 145% compared to preoperative von Mises stress. For the middle (C5) instrumented vertebral body, the peak von Mises stress increased after surgery. The maximum stress was observed in partial correction during flexion. Compared to physiological lordosis, the peak von Mises stress on the facet joints in kyphotic segments was lower; however, it was higher in the adjacent segments, except C4/5 in extension. The stress on the facet joints in kyphotic segments decreased, with the most significant decrease observed in partial correction. The IDPs in adjacent segments, except for C6/7 in flexion, showed no significant difference before and after surgery. Additionally, correction seemed to have little impact on IDPs in adjacent segments. In conclusion, for the treatment of cervical kyphosis with two-level ACDF, complete correction resulted in the highest peak von Mises stress on the upper instrumented vertebral body. Partial correction mitigated von Mises stress within the facet joints in kyphotic segments, albeit at the expense of high von Mises stress on the middle instrumented vertebral body. Full article

This study investigates radiomic efficacy in post-surgical traumatic spinal cord injury (SCI), overcoming MRI limitations from metal artifacts to enhance diagnosis, severity assessment, and lesion characterization or prognosis and therapy guidance. Traumatic spinal cord injury (SCI) causes severe neurological deficits. While MRI allows qualitative injury evaluation, standard imaging alone has limitations for precise SCI diagnosis, severity stratification, and pathology characterization, which are needed to guide prognosis and therapy. Radiomics enables quantitative tissue phenotyping by extracting a high-dimensional set of descriptive texture features from medical images. However, the efficacy of postoperative radiomic quantification in the presence of metal-induced MRI artifacts from spinal instrumentation has yet to be fully explored. A total of 50 healthy controls and 12 SCI patients post-stabilization surgery underwent 3D multi-spectral MRI. Automated spinal cord segmentation was followed by radiomic feature extraction. Supervised machine learning categorized SCI versus controls, injury severity, and lesion location relative to instrumentation. Radiomics differentiated SCI patients (Matthews correlation coefficient (MCC) 0.97; accuracy 1.0), categorized injury severity (MCC: 0.95; ACC: 0.98), and localized lesions (MCC: 0.85; ACC: 0.90). Combined T₁ and T₂ features outperformed individual modalities across tasks with gradient boosting models showing the highest efficacy. The radiomic framework achieved excellent performance, differentiating SCI from controls and accurately categorizing injury severity. The ability to reliably quantify SCI severity and localization could potentially inform diagnosis, prognosis, and guide therapy. Further research is warranted to validate radiomic SCI biomarkers and explore clinical integration. Full article

Background/Objectives: Surgical treatment of thoracic disc herniation (TDH) is risky and technically demanding due to its proximity to the spinal cord and the high possibility of the TDH being calcified (up to 40%), making the resection even more complex. Calcified TDH may be resected from an anterior via thoracotomy/thoracoscopy, lateral extra-cavitary, or a postero-lateral approach. Here, we present our experience in managing such pathology with an original technique Methods: This original technique, used successfully in more than 40 patients, is introduced, with a precise description of the surgical anatomy and the surgical steps to take. Indications for surgical management and neurological outcomes are also analyzed. This surgical approach consisted of transverso-pediculectomy, most often bilaterally, partial vertebral body drilling, 360° release of the cord, and short fixation. Results: A total of 44 patients were collected, with a mean age of 52.4 ± 11.7 years. Seven patients (15.9%) had complete calcifications, and thirty-one had partial calcifications (70.5%), while the remaining six did not have signs of calcifications. There were only 4 intraoperative complications (2 dural tears and 2 loss of evoked potentials). The TDH could be resected in total for 39 patients (88.6%) and partially, according to the “floating” technique, in 5 patients (11.4%). In the postoperative follow-up, all of the patients except two (presenting with sensory aggravation) reported an improvement in neurological conditions leading to an overall risk of neurological aggravation of 4.5%. Conclusions: The bilateral postero-lateral approach provides a large decompression of the cord (360°) and gives safe access to the TDH, even calcified, permitting high rates of total resection. It also prevents any prejudicial pressure on the spinal cord, reducing the risk of severe postoperative deficits and permitting optimal instrumentation (pedicle screw-based) of the spinal segment. The surgical sequence to resect the bony structures around the spinal cord is of great importance. Full article