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Advances and Challenges in Spine Surgery

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

Deadline for manuscript submissions: closed (25 November 2024) | Viewed by 33375

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Special Issue Editors

Dr. Yi Lu

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Guest Editor

Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Interests: spinal cord injury; low back pain; disc degeneration; minimally invasive spine surgery; spinal deformity; traumatic brain injury

Prof. Dr. Micheal Wang

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Guest Editor

Department of Neurosurgery and Rehab Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
Interests: minimally invasive spine surgery; awake spine surgery; ERAS (enhanced recovery after surgery); endoscopic spine surgery; spinal deformity; robotics; spinal cord injury biomarkers

Special Issue Information

Dear Colleagues,

Spine surgery has undergone tremendous advancement in the past several decades. We have gained a much deeper understanding of how to approach the spine while minimizing trauma to the normal tissue, how to stabilize the spine respecting the natural spine biomechanics, and how to maintain or restore optimal spine alignment when performing reconstructive spine surgeries. Significant technological advancements have reshaped how we treat spinal ailments. Modern segmental fixation and hardware technologies have allowed more secure and stable spinal fixation. The refinement of spinal navigation has helped spine surgeons place hardware more safely and with greater accuracy. The innovations in biological material technology have greatly facilitated successful bony healing and fusion after spine surgery.

We have started to gain a better understanding of the pathophysiology of the origin of back pain. In addition, we have also begun to understand the molecular changes occurring after spinal cord injury and the basic molecular process involved in spinal axon regeneration.

There are still plenty of challenges facing us in spine surgery. How to decrease the rate of disc degeneration and minimize discogenic back pain, how to accurately determine the etiologies of various kinds of back pain, how to preserve spinal motion and physiological flexibility with spinal instrumentation, how to avoid adjacent level disease with spinal fusion, and how to minimize delayed iatrogenic spinal instability with spinal decompression are all examples of the issues facing spine surgeons on a daily basis. In addition, spinal cord injury remains one of the most challenging and unresolved issues in modern neuroscience. We have yet to find an effective treatment to reverse the functional loss for patients suffering from severe spinal cord injury.

The current Special Issue will present the most up-to-date advances in spine surgery, discuss our new understanding of the pathophysiology of the spine and spinal cord biology, and introduce the challenges that remain to be solved in spine surgery.

Dr. Yi Lu
Prof. Dr. Micheal Wang
Guest Editors

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Keywords

spinal surgery
low back pain
spinal biomechanics
spinal surgical anatomy
minimally invasive spine surgery
spinal deformity
spinal cord injury
spinal trauma
spinal oncology

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Published Papers (12 papers)

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Research

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10 pages, 1469 KiB

Open AccessArticle

Machine Learning Models Leveraging Smartphone-Based Patient Mobility Data Can Accurately Predict Functional Outcomes After Spine Surgery

by Hasan S. Ahmad, Daksh Chauhan, Mert Marcel Dagli, Ryan W. Turlip, Malek Bashti, Ali Hamade, Patrick T. Wang, Yohannes Ghenbot, Andrew I. Yang, Gregory W. Basil, William C. Welch and Jang Won Yoon

J. Clin. Med. 2024, 13(21), 6515; https://doi.org/10.3390/jcm13216515 - 30 Oct 2024

Viewed by 470

Abstract

Objective: The development of adjacent segment disease or the progression of spondylosis following the surgical treatment of spinal stenosis and spondylolisthesis is well documented and can lead to subsequent functional decline after a successful index surgery. The early detection of negative inflection points during patients’ functional recovery can improve timely intervention. In this study, we developed machine learning (ML) models to predict the occurrence of post-operative decline in patient mobility. Methods: Patients receiving spine surgery for degenerative spinal stenosis or spondylolisthesis were retroactively consented and enrolled. Activity data (steps-per-day) previously recorded across a 4-year peri-operative were collected alongside relevant clinical and demographic variables. Logistic regression (LR), random forest (RF), and extreme gradient boosting (XGBoost) ML models were constructed and trained on 80% of the dataset and validated using the remaining 20%. The study’s primary endpoint was the models’ ability to predict post-operative decline in patient mobility. Results: A total of 75 patients were included. Following training, RF and XGBoost models achieved accuracy values of 86.7% (sensitivity 80%, specificity 90%) and 80% (sensitivity 60%, specificity 90%), respectively, in predicting post-operative functional decline. The LR model was the least effective with an accuracy of 73.3% (sensitivity 50%, specificity 88.8%). Receiver operating characteristic curves showed an area under the curve of 0.80 for RF, 0.70 for XGBoost, and 0.69 for LR. Conclusions: ML models trained on activity data collected from smartphones successfully forecast functional decline in post-operative activity following spine surgery. These results lay the groundwork for the future integration of ML into the surgeon’s toolbox for prognostication and surgical planning. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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8 pages, 688 KiB

Open AccessArticle

Minimal Invasive Pre-Op CT-Guided Gold-Fiducials in Local Anesthesia for Easy Level Localization in Thoracic Spine Surgery

by Fee Keil, Frank Hagemes, Matthias Setzer, Bedjan Behmanesh, Gerhard Marquardt, Elke Hattingen, Vincent Prinz, Marcus Czabanka and Markus Bruder

J. Clin. Med. 2024, 13(19), 5690; https://doi.org/10.3390/jcm13195690 - 25 Sep 2024

Viewed by 606

Abstract

Background: The accurate identification of intraoperative levels is of paramount importance in spinal surgery, particularly in cases of obesity or anatomical anomalies affecting the thoracic spine. The aim of this work was to clarify whether the preoperative percutaneous placement of fiducial markers under local anesthesia only, with minimal discomfort to the patient, can be performed safely and efficiently. Methods: Patients treated at our institution between June 2019 and June 2020 for thoracic intraspinal lesions with preoperative percutaneous gold fiducial placement were analyzed. A total of 10 patients underwent CT-guided gold fiducial placement 2–48 h prior to surgery on an outpatient or inpatient basis. Patient characteristics, CT intervention time, and perioperative complications were recorded. Results: In all cases, the gold markers were placed under local anesthesia alone and were easily visualized intraoperatively with fluoroscopy. There was no preoperative dislocation or malposition. The procedure was performed without X-ray exposure to the neuroradiology interventionalist. The average CT intervention time from the planning scout to the final control time was 14.3 min. The percentage of anatomical norm variants in our observation group was high, as 2 of the 10 patients had lumbarization of the first sacral vertebra, resulting in a six-link lumbar spine. Conclusions: Preoperative CT-guided transcutaneous submuscular placement of gold markers under local anesthesia is a practical and safe method for rapid and accurate intraoperative level determination in thoracic spine surgery in a time-saving minimally invasive manner. The virtually painless procedure can be performed either preoperatively on an outpatient basis or as an inpatient procedure. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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12 pages, 2428 KiB

Open AccessArticle

Early Experience with Prone Lateral Interbody Fusion in Deformity Correction: A Single-Institution Experience

by Alyssa M. Bartlett, Christopher F. Dibble, David A. W. Sykes, Peter N. Drossopoulos, Timothy Y. Wang, Clifford L. Crutcher, Khoi D. Than, Deb A. Bhomwick, Christopher I. Shaffrey and Muhammad M. Abd-El-Barr

J. Clin. Med. 2024, 13(8), 2279; https://doi.org/10.3390/jcm13082279 - 15 Apr 2024

Viewed by 1505

Abstract

Background/Objectives: Lateral spine surgery offers effective minimally invasive deformity correction, but traditional approaches often involve separate anterior, lateral, and posterior procedures. The prone lateral technique streamlines this process by allowing single-position access for lateral and posterior surgery, potentially benefiting from the lordosing effect of prone positioning. While previous studies have compared prone lateral to direct lateral for adult degenerative diseases, this retrospective review focuses on the outcomes of adult deformity patients undergoing prone lateral interbody fusion. Methods: Ten adult patients underwent single-position prone lateral surgery for spine deformity correction, with a mean follow-up of 18 months. Results: Results showed significant improvements: sagittal vertical axis decreased by 2.4 cm, lumbar lordosis increased by 9.1°, pelvic tilt improved by 3.3°, segmental lordosis across the fusion construct increased by 12.2°, and coronal Cobb angle improved by 6.3°. These benefits remained consistent over the follow-up period. Correlational analysis showed a positive association between improvements in PROs and SVA and SL. When compared to hybrid approaches, prone lateral yielded greater improvements in SVA. Conclusions: Prone lateral surgery demonstrated favorable outcomes with reasonable perioperative risks. However, further research comparing this technique with standard minimally invasive lateral approaches, hybrid, and open approaches is warranted for a comprehensive evaluation. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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Review

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21 pages, 2192 KiB

Open AccessReview

Challenges in Contemporary Spine Surgery: A Comprehensive Review of Surgical, Technological, and Patient-Specific Issues

by Emmanuel O. Mensah, Joshua I. Chalif, Jessica G. Baker, Eric Chalif, Jason Biundo and Michael W. Groff

J. Clin. Med. 2024, 13(18), 5460; https://doi.org/10.3390/jcm13185460 - 14 Sep 2024

Viewed by 1802

Abstract

Spine surgery has significantly progressed due to innovations in surgical techniques, technology, and a deeper understanding of spinal pathology. However, numerous challenges persist, complicating successful outcomes. Anatomical intricacies at transitional junctions demand precise surgical expertise to avoid complications. Technical challenges, such as underestimation of the density of fixed vertebrae, individual vertebral characteristics, and the angle of pedicle inclination, pose additional risks during surgery. Patient anatomical variability and prior surgeries add layers of difficulty, often necessitating thorough pre- and intraoperative planning. Technological challenges involve the integration of artificial intelligence (AI) and advanced visualization systems. AI offers predictive capabilities but is limited by the need for large, high-quality datasets and the “black box” nature of machine learning models, which complicates clinical decision making. Visualization technologies like augmented reality and robotic surgery enhance precision but come with operational and cost-related hurdles. Patient-specific challenges include managing postoperative complications such as adjacent segment disease, hardware failure, and neurological deficits. Effective patient outcome measurement is critical, yet existing metrics often fail to capture the full scope of patient experiences. Proper patient selection for procedures is essential to minimize risks and improve outcomes, but criteria can be inconsistent and complex. There is the need for continued technological innovation, improved patient-specific outcome measures, and enhanced surgical education through simulation-based training. Integrating AI in preoperative planning and developing comprehensive databases for spinal pathologies can aid in creating more accurate, generalizable models. A holistic approach that combines technological advancements with personalized patient care and ongoing education is essential for addressing these challenges and improving spine surgery outcomes. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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24 pages, 383 KiB

Open AccessReview

Advances and Challenges in Spinal Cord Injury Treatments

by Mohammed Ali Alvi, Karlo M. Pedro, Ayesha I. Quddusi and Michael G. Fehlings

J. Clin. Med. 2024, 13(14), 4101; https://doi.org/10.3390/jcm13144101 - 13 Jul 2024

Viewed by 3205

Abstract

Spinal cord injury (SCI) is a debilitating condition that is associated with long-term physical and functional disability. Our understanding of the pathogenesis of SCI has evolved significantly over the past three decades. In parallel, significant advances have been made in optimizing the management of patients with SCI. Early surgical decompression, adequate bony decompression and expansile duraplasty are surgical strategies that may improve neurological and functional outcomes in patients with SCI. Furthermore, advances in the non-surgical management of SCI have been made, including optimization of hemodynamic management in the critical care setting. Several promising therapies have also been investigated in pre-clinical studies, with some being translated into clinical trials. Given the recent interest in advancing precision medicine, several investigations have been performed to delineate the role of imaging, cerebral spinal fluid (CSF) and serum biomarkers in predicting outcomes and curating individualized treatment plans for SCI patients. Finally, technological advancements in biomechanics and bioengineering have also found a role in SCI management in the form of neuromodulation and brain–computer interfaces. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

14 pages, 1904 KiB

Open AccessReview

Advances and Challenges in Minimally Invasive Spine Surgery

by Timothy Y. Wang and Michael Y. Wang

J. Clin. Med. 2024, 13(11), 3329; https://doi.org/10.3390/jcm13113329 - 5 Jun 2024

Cited by 1 | Viewed by 1782

Abstract

Minimally invasive spine surgery continues to grow and develop. Over the past 50 years, there has been immense growth within this subspecialty of neurosurgery. A deep understanding of the historical context and future directions of this subspecialty is imperative to developing safe adoption and targeted innovation. This review aims to describe the advancements, and challenges that we face today in minimally invasive spine surgery. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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20 pages, 3059 KiB

Open AccessReview

Pushing the Limits of Minimally Invasive Spine Surgery—From Preoperative to Intraoperative to Postoperative Management

by Peter N. Drossopoulos, Arnav Sharma, Favour C. Ononogbu-Uche, Troy Q. Tabarestani, Alyssa M. Bartlett, Timothy Y. Wang, David Huie, Oren Gottfried, Jeanna Blitz, Melissa Erickson, Shivanand P. Lad, W. Michael Bullock, Christopher I. Shaffrey and Muhammad M. Abd-El-Barr

J. Clin. Med. 2024, 13(8), 2410; https://doi.org/10.3390/jcm13082410 - 20 Apr 2024

Cited by 1 | Viewed by 2528

Abstract

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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15 pages, 1664 KiB

Open AccessReview

Evolution of Cervical Endoscopic Spine Surgery: Current Progress and Future Directions—A Narrative Review

by Chuan-Ching Huang, Jamal Fitts, David Huie, Deb A. Bhowmick and Muhammad M. Abd-El-Barr

J. Clin. Med. 2024, 13(7), 2122; https://doi.org/10.3390/jcm13072122 - 6 Apr 2024

Cited by 3 | Viewed by 1791

Abstract

Cervical endoscopic spine surgery is rapidly evolving and gaining popularity for the treatment of cervical radiculopathy and myelopathy. This approach significantly reduces muscular damage and blood loss by minimizing soft tissue stripping, leading to less postoperative pain and a faster postoperative recovery. As scientific evidence accumulates, the efficacy and safety of cervical endoscopic spine surgery are continually affirmed. Both anterior and posterior endoscopic approaches have surfaced as viable alternative treatments for various cervical spine pathologies. Newer techniques, such as endoscopic-assisted fusion, the anterior transcorporeal approach, and unilateral laminotomy for bilateral decompression, have been developed to enhance clinical outcomes and broaden surgical indications. Despite its advantages, this approach faces challenges, including a steep learning curve, increased radiation exposure for both surgeons and patients, and a relative limitation in addressing multi-level pathologies. However, the future of cervical endoscopic spine surgery is promising, with potential enhancements in clinical outcomes and safety on the horizon. This progress is fueled by integrating advanced imaging and navigation technologies, applying regional anesthesia for improved and facilitated postoperative recovery, and incorporating cutting-edge technologies, such as augmented reality. With these advancements, cervical endoscopic spine surgery is poised to broaden its scope in treating cervical spine pathologies while maintaining the benefits of minimized tissue damage and rapid recovery. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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14 pages, 1101 KiB

Open AccessEditor’s ChoiceReview

Advances and Challenges of Endoscopic Spine Surgery

by Daniel Burkett and Nathaniel Brooks

J. Clin. Med. 2024, 13(5), 1439; https://doi.org/10.3390/jcm13051439 - 1 Mar 2024

Cited by 4 | Viewed by 2909

Abstract

The purpose of this paper is to review the data supporting current endoscopic surgical techniques for the spine and the potential challenges and future of the field. The origins of endoscopic spine surgery can be traced back many decades, with many important innovations throughout its development. It can be applied to all levels of the spine, with many robust trials supporting its clinical outcomes. Continued clinical research is needed to explore its expanding indications. Although the limitations of starting an endoscopic program can be justified by its cost effectiveness and positive societal impact, challenges facing its widespread adoption are still present. As more residency and fellowship programs include endoscopy as part of their spine training, it will become more prevalent in hospitals in the United States. Technological advancements in spine surgery will further propel and enhance endoscopic techniques as they become an integral part of a spine surgeon’s repertoire. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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22 pages, 2021 KiB

Open AccessReview

Updates on Pathophysiology of Discogenic Back Pain

by Rohan Jha, Joshua D. Bernstock, Joshua I. Chalif, Samantha E. Hoffman, Saksham Gupta, Hong Guo and Yi Lu

J. Clin. Med. 2023, 12(21), 6907; https://doi.org/10.3390/jcm12216907 - 2 Nov 2023

Cited by 9 | Viewed by 8471

Abstract

Discogenic back pain, a subset of chronic back pain, is caused by intervertebral disc (IVD) degeneration, and imparts a notable socioeconomic health burden on the population. However, degeneration by itself does not necessarily imply discogenic pain. In this review, we highlight the existing literature on the pathophysiology of discogenic back pain, focusing on the biomechanical and biochemical steps that lead to pain in the setting of IVD degeneration. Though the pathophysiology is incompletely characterized, the current evidence favors a framework where degeneration leads to IVD inflammation, and subsequent immune milieu recruitment. Chronic inflammation serves as a basis of penetrating neovascularization and neoinnervation into the IVD. Hence, nociceptive sensitization emerges, which manifests as discogenic back pain. Recent studies also highlight the complimentary roles of low virulence infections and central nervous system (CNS) metabolic state alteration. Targeted therapies that seek to disrupt inflammation, angiogenesis, and neurogenic pathways are being investigated. Regenerative therapy in the form of gene therapy and cell-based therapy are also being explored. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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20 pages, 2241 KiB

Open AccessFeature PaperReview

Advances and Evolving Challenges in Spinal Deformity Surgery

by Ruchit V. Patel, Alexander G. Yearley, Hannah Isaac, Eric J. Chalif, Joshua I. Chalif and Hasan A. Zaidi

J. Clin. Med. 2023, 12(19), 6386; https://doi.org/10.3390/jcm12196386 - 6 Oct 2023

Cited by 5 | Viewed by 1824

Abstract

Background: Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes. Methods: We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases. Results: Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed. Conclusions: The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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35 pages, 1283 KiB

Open AccessSystematic Review

Epidural Spinal Cord Stimulation for Spinal Cord Injury in Humans: A Systematic Review

by J. I. Chalif, V. S. Chavarro, E. Mensah, B. Johnston, D. P. Fields, E. J. Chalif, M. Chiang, O. Sutton, R. Yong, R. Trumbower and Y. Lu

J. Clin. Med. 2024, 13(4), 1090; https://doi.org/10.3390/jcm13041090 - 14 Feb 2024

Cited by 4 | Viewed by 5298

Abstract

(1) Background: Spinal cord injury (SCI) represents a major health challenge, often leading to significant and permanent sensorimotor and autonomic dysfunctions. This study reviews the evolving role of epidural spinal cord stimulation (eSCS) in treating chronic SCI, focusing on its efficacy and safety. The objective was to analyze how eSCS contributes to the recovery of neurological functions in SCI patients. (2) Methods: We utilized the PRISMA guidelines and performed a comprehensive search across MEDLINE/PubMed, Embase, Web of Science, and IEEE Xplore databases up until September 2023. We identified studies relevant to eSCS in SCI and extracted assessments of locomotor, cardiovascular, pulmonary, and genitourinary functions. (3) Results: A total of 64 studies encompassing 306 patients were identified. Studies investigated various stimulation devices, parameters, and rehabilitation methods. Results indicated significant improvements in motor function: 44% of patients achieved assisted or independent stepping or standing; 87% showed enhanced muscle activity; 65% experienced faster walking speeds; and 80% improved in overground walking. Additionally, eSCS led to better autonomic function, evidenced by improvements in bladder and sexual functions, airway pressures, and bowel movements. Notable adverse effects included device migration, infections, and post-implant autonomic dysreflexia, although these were infrequent. (4) Conclusion: Epidural spinal cord stimulation is emerging as an effective and generally safe treatment for chronic SCI, particularly when combined with intensive physical rehabilitation. Future research on standardized stimulation parameters and well-defined therapy regimens will optimize benefits for specific patient populations. Full article

(This article belongs to the Special Issue Advances and Challenges in Spine Surgery)

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