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Study design: Prospective observational cohort study.

Objective: To prospectively evaluate the utility of traditional and single-level vertebral bone quality (VBQ) scores for preoperative bone mineral density (BMD) assessment in patients undergoing lumbar fusion surgery, and to validate their diagnostic performance against dual-energy x-ray absorptiometry (DEXA) and quantitative computed tomography (QCT).

Summary of background data: Magnetic resonance imaging (MRI)-based VBQ score has been proposed to assess BMD, but prospective evidence comparing different vertebral levels is lacking.

Materials and methods: Participants were classified into normal, osteopenia, and osteoporosis groups based on DEXA T -score and QCT-vBMD. Intergroup differences were analyzed, with post hoc corrections for multiple comparisons. Correlations between VBQ scores and BMD were evaluated, while receiver operating characteristic (ROC) analysis assessed their diagnostic performance. Linear and logistic regression models were further applied to examine the independent association between VBQ scores and osteoporosis.

Results: Among 198 patients (58.9±11.8 yr; 56.6% female), groups differed significantly in age and sex ( P <0.001). VBQ scores varied significantly across groups and were negatively correlated with both DEXA T -score and QCT-vBMD at most vertebral levels, with stronger correlations observed for QCT ( r =-0.412 to -0.563). ROC analysis confirmed that VBQ scores effectively differentiated normal, osteopenia, and osteoporosis. Multivariable regression identified higher L1-L4 VBQ scores as independent predictors of lower BMD (DEXA: β=-0.412; QCT: β=-0.469) and increased osteoporosis risk (DEXA: OR=3.201, 95% CI=1.056-9.704; QCT: OR=2.741, 95% CI=1.061-7.080).

Conclusion: This prospective study demonstrated that the L1-L4 VBQ score exhibited superior stability and generalizability compared with single-level measurements, supporting its potential use as a practical surrogate marker for opportunistic BMD screening in patients undergoing spinal surgery. Specific single-level scores, such as those at L1, L2, and S1, may still provide supplementary diagnostic value in detecting early bone quality alterations.

Level of evidence: Level 2.

Study design: Multicenter prospective cohort study.

Objective: To evaluate the influence of preoperative mental health status on clinical outcomes following surgery for degenerative cervical myelopathy (DCM).

Summary of background data: Surgical treatment for DCM is known to improve neurological function and relieve symptoms. However, the impact of preoperative mental health on postoperative changes in pain, function, and quality of life (QOL) remains unclear.

Materials and methods: A total of 759 patients who underwent surgery for DCM at 10 institutions were prospectively enrolled and stratified into two groups based on preoperative 36-Item Short-Form Health Survey (SF-36) Mental Component Summary (MCS) scores: lower MCS (<50; n=339) and higher MCS (≥50; n=420). Demographic, surgical, and radiographic data, along with clinical outcomes, were compared between groups. Outcome measures included the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS), JOA Cervical Myelopathy Evaluation Questionnaire, SF-36, and Neuropathic Pain Symptom Inventory.

Results: Baseline demographics and surgical characteristics were similar; however, psychiatric disorders (4.7% vs. 1.2%, P =0.003) and diabetes (26.0% vs. 19.8%, P =0.042) were more prevalent in the lower MCS group. Neurological recovery was comparable (ΔJOA: 3.0 vs. 2.9, P =0.948). However, the lower MCS group demonstrated significantly greater improvement in neck pain (ΔVAS: -10.4 vs. -4.7, P =0.016), vitality (15.0 vs. 0.7, P <0.001), mental health (15.9 vs. 2.3, P <0.001), and burning pain (-0.5 vs. -0.3, P =0.014). Preoperative MCS was not associated with ΔJOA or recovery rate, but positively correlated with changes in SF-36 mental domains and negatively with burning pain.

Conclusions: Preoperative mental health status does not impact neurological improvement but significantly affects recovery in pain and QOL. These findings suggest that evaluating patients' psychological well-being before surgery could enhance perioperative planning and support more accurate prognostic counseling.

Level of evidence: Level II.

Study design: Retrospective analysis.

Objective: To compare clinical outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) among patients with different radiographic difficult spondylolisthesis.

Background: High-grade vertebral slip, collapsed disc, and less mobile segments can complicate segmental parameter restoration in MIS-TLIF. Few studies have examined if MIS-TLIF can achieve comparable outcomes in these challenging cases.

Materials and methods: This study included patients who underwent single-level MIS-TLIF for degenerative spondylolisthesis. Radiographic difficulty was defined using a "difficulty point" system: disc height (<5 mm = 1point), angular flexibility at the operated level by preoperative flexion-extension standing x-ray (<5° = 1point), and slippage rate (>25% = 1 point). Patients were categorized into "simple" (0 point), "moderate" (1 point), and "difficult" (2-3 points) cohorts. Outcomes included radiographic parameters (postoperative disc height, segmental lordosis restoration, and slippage reduction), complications, and patient-reported outcomes such as Oswestry Disability Index (ODI) from 2 weeks to 1 year postoperatively.

Results: A total of 208 patients were included, with 52 in the difficult, 89 in the moderate, and 67 in the simple. The difficult cohort showed significantly greater restoration of disc height (161.0% vs . 26.5% vs . 9.3%, P < 0.001), resulting in similar postoperative disc height (8.3 vs . 9.0 vs . 0.1 mm, P = 0.10) and segmental lordosis at the operated level (14.5° vs . 13.0° vs . 12.5°, P = 0.17). Postoperative outcomes indicated a greater improvement trend in ODI in the difficult group compared with the moderate group (β = 7.3, 9 = 0.011), with similar minimal clinically important difference achievement rate in ODI at 1-year postoperatively (difficult, 69.2% vs . moderate, 62.8% vs . simple, 54.3%, P = 0.46).

Conclusion: MIS-TLIF is a feasible treatment option in patients with technically challenging radiographic parameters, achieving comparable postoperative radiographic and clinical outcomes.

Level of evidence: Level III.

Study design: Agreement analysis of retrospectively collected data.

Objective: To perform an agreement analysis between the Sanders maturity scale and pelvic maturity indicators in patients with idiopathic scoliosis.

Summary of background data: A reliable maturity assessment is mandatory for adolescent idiopathic scoliosis treatment. The two most common skeletal maturity surrogates are the Sanders maturity scale (SMS) and Risser staging (RS). The relationship between these has been scarcely investigated.

Materials and methods: From a previous brace study, 130 consecutive patients with both pelvic and hand radiographs with a maximum 3-month interval between examinations were selected. The pelvic maturity indicators (PMI) scale combining the Risser sign and triradiate cartilage stage was developed. The PMI consists of six stages (2-7) that were tested against corresponding SMS stages. An agreement analysis between the PMI based on the pelvic radiograph and the SMS of the hand image was conducted. The Spearman rank correlation and Cohen κ with Gwet's AC1 coefficient were the measures of correlation and agreement, respectively.

Results: The PMI and SMS showed a strong correlation (Spearman ρ= 0.79; 95% CI: 0.72, 0.85) and substantial agreement (Gwet's AC1 = 0.76; 95% CI: 0.70, 0.82). The highest accuracy in matching PMI to SMS was observed for PMI 2, 3, and 7, with 83.3%, 80.0%, and 88.9% correctly matched SMS stage to corresponding PMI stage. The regression model accurately predicted five of six SMS stages from pelvic radiographs.

Conclusions: The triradiate cartilage staging facilitated the maturity assessment of the pelvic radiographs and showed a strong correlation to and substantial agreement with the SMS. The most important stages for AIS development, SMS 2, 3, and 7, showed the best matching accuracy to PMI. The pelvic image of PMI 3 with closing triradiate cartilage corresponds to SMS stage 3.

Level of evidence: Level III.

Study design: Retrospective matched cohort study.

Objective: To evaluate and compare the predictive value of different preoperative imaging measurements and modalities for postoperative C5P.

Summary of background: C5 palsy (C5P) is a debilitating complication following cervical spine surgery with unpredictable but typically favorable recovery. While research has explored preoperative radiographic measurements in predicting C5P development, their findings remain inconclusive.

Materials and methods: Adult patients who underwent anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) from 2010 to 2023 with available preoperative imaging (MRI or radiographs) and subsequently developed a C5P were matched 1:3 to control patients without C5P. Demographic/surgical/outcome data were collected. Preoperative radiographic measurements included C2-7 Cobb angle, sagittal vertical axis, C2 tilt, C2 and T1 slope, and Pavlov-Torg ratio/stenosis. MRI measurements included anteroposterior canal diameter, bilateral foraminal diameter, bilateral cord-lamina angle, bilateral nerve root diameter, cord/canal cross-sectional area, and stenosis based on Kim grading system. Statistical analysis was conducted with alpha set at 0.05.

Results: Sixty-three patients with postoperative C5P and accessible preoperative radiographs were matched with 189 controls. Among the 63 patients with C5P, 42 patients with accessible MRI images were matched to an additional 126 controls. Both cohorts demonstrated similar demographic/surgical variables between C5P and control patients. Among the radiograph cohort, C5P patients had a greater preoperative C2-7 Cobb angle (11.4° vs. 6.39°; P =0.001). All other measurements were similar between patients with C5P and no C5P. Among the MRI cohort, C5P patients had similar measurements as controls. Both MRI and radiographs demonstrated poor predictive power with the highest area under the curve being 0.636 (C2-7 Cobb angle).

Conclusion: Neither preoperative radiographic nor MRI measurements demonstrated predictive power for postoperative C5P in this study thereby highlighting the need for additional strategies to preoperatively identify patients at risk for C5P.

Study design: Anatomic and histologic study of human cadaveric specimens.

Objective: To clarify the detailed anatomy of the cervical ligamentum flavum (LF), evaluate its presence at the craniocervical junction, and describe novel cervicodural ligaments with potential clinical implications.

Summary of background data: The cervical ligamentum flavum is clinically important yet remains anatomically controversial, particularly regarding its presence and morphology at C1.

Materials and methods: Twelve adult cadaveric necks were examined (six gross dissections, six histologic analyses). Specimens were sectioned coronally, sagittally, and axially. The Masson trichrome staining was used to identify ligamentous structures and their relationships with adjacent tissues.

Results: A distinct LF was consistently present between C2 and C7 vertebrae, attaching to adjacent laminae, blending laterally with the capsular ligament, and posteriorly with the interspinous ligament. No LF was identified at C0-C1. Instead, fibrous connections extended from the posterior arch of C1 and the lamina of C2 to the dura, forming previously undescribed atlantodural and axiodural ligaments. These cervicodural ligaments created a thickened dural region at C1-C2 and contained muscle fibers corresponding to the myodural bridge. A midline gap was observed between the right and left LF, traversed by vascular structures supplying the posterior cervical elements.

Conclusions: The cervical LF is absent at C0-C1 ( i.e., posterior atlanto-occipital membrane), where novel cervicodural ligaments connect C1-C2 to the dura. These findings refine the surgical anatomy of the craniocervical junction and may provide an anatomic basis for cervicogenic headache.

Background context: Preoperative laboratory testing can identify patients with health conditions that increase perioperative risk and represent opportunities for optimization.

Purpose: To assess the effect of preoperative and postoperative day 1 (POD1) hydration status on outcomes after single-level lumbar fusion surgery.

Study design/setting: Retrospective cohort.

Patient sample: Adult patients who underwent primary, elective, single-level lumbar fusion (2017-2021). Patients were excluded if they had chronic kidney disease (CKD) or end-stage renal disease (ESRD).

Outcome measures: Length of stay (LOS), transfusion requirements, discharge disposition, 90-day emergency department (ED) visit, 90-day readmission, and one-year spine reoperation.

Methods: Patients were analyzed based on their preoperative and postoperative day 1 BUN/creatinine ratio. Patients with a ratio ≥20 were considered dehydrated. Dehydrated patients were compared with hydrated patients preoperatively, postoperatively, and postoperatively within the group who were dehydrated preoperatively.

Results: Preoperatively, 281/752 (37.4%) patients were dehydrated (BUN/Cr: 24.2 vs . 14.6; P <0.001). Preoperatively dehydrated patients were more likely to be older, female, and less likely to be current smokers ( P <0.05). On multivariate regression, preoperative dehydration was independently predictive of reoperation and requiring a transfusion. Patients who remained dehydrated on POD1 were more likely to be older and have higher comorbidity burden. Among the full dehydrated group on POD1 (preoperatively either hydrated or dehydrated), patients were older, more commonly female, had higher comorbidity burden, and greater mean levels decompressed. On multivariate analysis, postoperative dehydration was independently predictive of transfusion need, but not non-home discharge or length of stay.

Conclusions: Preoperatively dehydrated patients seem to be at increased risk of blood transfusion and spine reoperation after single-level lumbar fusion. Remaining or becoming dehydrated postoperatively, despite intraoperative rehydration, seems to be associated with increased age, female sex, more medical comorbidities, and more extensive surgical decompression. These results suggest that hydration status may be another useful marker to risk-stratify and optimize patients during the preoperative and in-hospital period.