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    Orthopaedics

    The Use of Corticosteroid Treatment Protocols in Compressive Epidural Spinal Metastases

    September 1, 2026: 51(17):E439-E452

    Study Design.

    Systematic review.

    Objective.

    To evaluate current protocols for corticosteroid use in patients with compressive epidural spinal metastasis.

    Summary of Background Data.

    Spinal metastases are common in oncological patients. Although spinal cord compression is a less frequent manifestation, its occurrence represents a medical emergency. Despite over three decades of literature reporting recommendations for corticosteroid use in patients with metastatic spinal cord compression, there remains a lack of consensus regarding the optimal timing, dosage, and duration of treatment.

    Methods.

    A systematic review was conducted in May 2025, including terms for epidural spinal metastasis and corticosteroids. Eight hundred thirty-five articles were screened for compressive metastatic epidural spinal lesions treated with systemic corticosteroids. Ultimately, 39 articles were included for final analysis, which included patient demographics, clinical characteristics, treatment modalities, adverse effects, and survival and ambulation outcomes. Studies were grouped into pre- and post-1997 based on NASCIS III, as well as evenly across three time periods.

    Results.

    Dexamethasone, hydrocortisone, methylprednisolone, and prednisone were used, with dexamethasone being the most common. The proportion of patients receiving steroid treatment and experiencing adverse effects was both significantly higher pre-1997 (P<0.0001). Survival outcomes were significantly higher post-1997 at all time frames. Pretreatment ambulation was significantly higher post-1997 (P<0.0001). The proportion of patients ambulating pretreatment was significantly higher with each subsequent period (42.11% vs. 62.72% vs. 70.59%; P<0.0001, P<0.0001, P<0.0001).

    Conclusion.

    There remains a lack of consensus in the literature for steroid use in compressive metastatic spine disease. Recent studies generally suggest 12 to 32 mg/day of dexamethasone. There are improvements in overall survival but not ambulation in patients with symptomatic metastatic spine disease, likely from improved overall oncological care but not necessarily treatment of the spinal metastases themselves. Development of clear guidelines for corticosteroid use in this population is imperative to optimize prognostic outcomes.

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    Orthopaedics

    Complications Following Cervical Laminoplasty With Reconstruction

    September 1, 2026: 51(17):E427-E438

    Study Design.

    Systematic review and meta-analysis.

    Objective.

    To synthesize pooled complication rates after cervical laminoplasty with reconstruction and to evaluate differences by surgical indication

    Summary of Background Data.

    Cervical laminoplasty with reconstruction is a widely and increasingly used posterior decompression technique for degenerative cervical myelopathy (DCM) and ossification of the posterior longitudinal ligament (OPLL). Despite effectiveness, postoperative complications remain a concern, and a focused quantitative synthesis of complication incidence is lacking.

    Methods.

    PubMed, Embase, and Scopus were searched from inception to March 2026 for clinical studies reporting postoperative complications after cervical laminoplasty with reconstruction. Random-effects meta-analysis of proportions using Freeman-Tukey double arcsine transformation was performed for each complication category. Subgroup analysis compared DCM and OPLL cohorts, and meta-regression assessed the association between follow-up duration and complication incidence. Sensitivity analyses included leave-one-out analysis, exclusion of large registry studies, and restriction to studies with minimum 12-month follow-up.

    Results.

    Sixty-eight studies (n=6732 patients) met inclusion criteria. Pooled complication incidences were: C5 palsy 4.07% (95% CI: 3.08–5.17%), axial neck pain 13.74% (9.14–19.02%), reoperation 2.72% (1.38–4.39%), dural/CSF complications 1.48% (0.60–2.62%), wound infection 1.89% (1.16–2.75%), hematoma 0.25% (0.00–0.89%), airway issues/dysphagia 0.68% (0.16–1.45%), and progressive kyphosis 0.80% (0.03–2.11%). C5 palsy was significantly higher in OPLL (5.86%) than DCM (3.34%) cohorts (P=0.021). Meta-regression revealed no significant association between follow-up duration and complication incidence for any category. Substantial heterogeneity (I²: 34.9–91.3%) reflected variability in complication definitions and reporting practices across studies.

    Conclusions.

    This meta-analysis provides pooled incidence estimates for complications after cervical laminoplasty with reconstruction. C5 palsy is the most reliably reported complication and occurs more frequently in OPLL populations. Axial neck pain is the most common complication but is limited by highly variable definitions. Standardized complication definitions and consistent reporting are needed to improve future comparisons.

    Level of Evidence.

    Level III: systematic review of observational studies.

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    Orthopaedics

    Factors Associated With the Decision to Undergo Spine Surgery

    September 1, 2026: 51(17):1265-1270

    Study Design.

    Prospective cohort study.

    Objective.

    To compare demographic, psychosocial, and lifestyle factors between patients who chose to undergo spine surgery and those who did not.

    Summary of Background Data.

    The decision to undergo spine surgery is both complex and multifaceted, as it is influenced by a combination of clinical and psychological symptom management behaviors. Specifically, psychosocial metrics, such as resilience and pain self-efficacy, have demonstrated important relationships between spine surgery outcomes.

    Methods.

    Adult patients at a single academic institution from 2020 to 2022 who were seeking consultation from a spine surgeon were administered questionnaires during their visit, which included the Brief Resilience Scale (BRS), 2-question Pain Self-Efficacy Questionnaire (PSEQ-2), and a pain tolerance question. Baseline demographic, social, and clinical metrics were recorded. Patients were followed for a mean of 44 months. Individuals who underwent surgery were assigned to the operative group (OP) and those who did not were assigned to the nonoperative group (non-OP).

    Results.

    A total of 269 patients had full survey data and were included. 85 in the OP group and 184 in the non-OP group. Significant differences between the groups were observed with respect to age (OP: 65.0 y vs. non-OP: 59.4 y, P=0.0112) and time of consult Visual Analog Scale (VAS) pain scores (OP: 6.57 vs. non-OP: 5.13, P<0.001). The non-OP group reported higher pain self-efficacy scores (PSEQ-2) compared with the OP group (7.11 vs. 5.69, P=0.00108). Regression analysis adjusting for VAS pain scores showed higher PSEQ-2 was independently associated with remaining nonoperative (OR=0.917; 95% CI[0.841, 0.997]).

    Conclusion.

    Higher pain self-efficacy, independent of pain level, was associated with a lower likelihood of undergoing spine surgery, suggesting that a patient’s perception of their ability to manage their symptoms factors into the choice to undergo surgery. These findings highlight the importance of psychosocial factors, such as pain self-efficacy, in surgical decision-making and may inform patient counseling strategies.

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    Orthopaedics

    The Impact of Metformin on Postoperative Opioid Consumption and Patient-Reported Outcomes After Lumbar Fusion

    September 1, 2026: 51(17):1258-1264

    Study Design.

    Retrospective cohort.

    Objective.

    To examine metformin use on postoperative outcomes among patients with diabetes undergoing lumbar fusion.

    Summary of Background.

    Several animal studies have demonstrated that metformin, a first-line treatment for type 2 diabetes (T2DM), can attenuate neuropathic pain through decreased activation of microglia and suppression of inflammatory signaling.

    Methods.

    Adult diabetic patients who underwent a 1–2-level posterior lumbar decompression and fusion (PLDF) (2017–2023) were identified and demographics, surgical data, metformin use/dosage, opioid consumption and patient-reported outcome measures (PROMs) were collected. Statistical analysis was performed with alpha set at 0.05.

    Results.

    Of the 299 diabetic patients who underwent a 1–2 level PLDF, 203 (67.9%) were taking metformin. There were no differences in morphine milligram equivalents (MMEs) in the 30 days before or the 30 days after surgery between groups. Patients on metformin had a lower Elixhauser (2.26±1.48 vs. 2.79±1.71; P = 0.005), lower HgbA1c (7.15±1.12 vs. 7.48±1.59; P = 0.018), and fewer females (59.4% vs. 42.4%, P = 0.009) but were otherwise demographically/surgically similar. Despite both groups having similar preoperative opioid use, metformin use was associated with lower MMEs at 30 to 90 days (31.8±60.4 vs. 52.0±92.0; P = 0.018) and 90–365 d (65.0±183 vs. 129±292 MME; P = 0.001), and greater improvement from preoperative to postoperative PCS at 6 months (5.12±8.96 vs. −1.34±8.57, P = 0.048) and at 1-year (4.96±9.47 vs. −1.87±7.55, P = 0.027). Linear regression analysis identified metformin use as independently predictive of fewer postoperative MMEs 30 to 90 days postoperatively (estimate −16.03, 95% CI: −31.51 to −0.56; P = 0.043).

    Conclusions.

    Metformin use was found to be independently associated with fewer MME requirements 30 days after surgery.

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    Orthopaedics

    Single-Level Versus Two-Level Decompression for Adjacent Segment Spinal Stenosis

    September 1, 2026: 51(17):1250-1257

    Study Design.

    Retrospective cohort study.

    Objective.

    To investigate clinical outcomes between lumbar decompression without fusion by matching canal area between the adjacent level in one-level decompression and the upper level in two-level decompression procedures.

    Summary of Background Data.

    In patients with multilevel lumbar stenosis, surgeons face the dilemma of whether to decompress only the symptomatic level or to prophylactically include adjacent stenotic segments. Current literature shows little consensus on this decision, with comparative studies indicating that single-level and two-level decompressions yield similar pain relief, functional outcomes, and reoperation rates. Furthermore, no comparison has been made between decompression groups that accounts for the severity of stenosis at the upper adjacent level.

    Materials and Methods.

    Preoperative imaging was evaluated for dural sac cross-sectional area (DSCSA) and spinopelvic parameters. A 1:2 propensity score-matched analysis was performed using age, sex, comorbidity, and DSCSA to compare reoperation rates and patient-reported outcome measures (PROMs).

    Results.

    A total of 349 patients were included in the matching process. In matched cohort, overall reoperation rates were similar between groups (21.2% vs. 21.2%). However, reoperation at the upper adjacent level showed a trend toward higher rates in the single-level group [16.7% vs. 3.0%; P=0.057; number needed to treat (NNT) = 8], although this did not reach statistical significance. Both groups exhibited similar improvements in PROMs and recovery patterns.

    Conclusions.

    Single-level and two-level decompression groups exhibited similar clinical outcomes in patients with symptomatic stenosis at one level and radiographic stenosis at the upper adjacent level. The two-level decompression group may be associated with a relatively lower reoperation rate at the upper adjacent level, suggesting possible benefit of two-level decompression.

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    Perioperative Anabolic Osteoporosis Pharmacotherapy is Associated with Lower Rates of Proximal Junctional Kyphosis After Adult Spinal Deformity Surgery

    Spine. August 17, 2026

    Study Design:

    Systematic review and meta-analysis.

    Objective:

    To determine whether perioperative anabolic osteoporosis pharmacotherapy is associated with lower rates of (1) proximal junctional kyphosis (PJK) and (2) reoperation for mechanical failure following adult spinal deformity surgery.

    Summary of Background Data:

    Mechanical complications occur in 15 to 40 percent of patients following adult spinal deformity surgery. Although poor bone quality has been associated with mechanical failure, no quantitative synthesis has tested whether perioperative pharmacotherapy alters these outcomes.

    Methods:

    PubMed, Embase, Scopus, and Cochrane CENTRAL were searched through April 30, 2026 (PROSPERO CRD420261374961). Random-effects meta-analysis was performed for the primary and prespecified secondary outcomes. The primary pool comprised anabolic-exposed studies; a class-agnostic pool that additionally included a single antiresorptive-dominant, claims-based study was retained as a sensitivity analysis.

    Results:

    Thirteen studies (one randomized controlled trial, twelve observational; 2,247 patients) met inclusion criteria. Teriparatide was the primary or sole study agent in nine of thirteen studies. Anabolic pharmacotherapy was associated with reduced odds of PJK (pooled OR 0.51, 95% CI 0.30 to 0.86, P=0.012; I2=0%, k=5) and of reoperation for mechanical failure (OR 0.36, 95% CI 0.14 to 0.88, P=0.025; I2=55%, k=4). A broadened-class sensitivity analysis including the antiresorptive-dominant study was directionally consistent (OR 0.63, 95% CI 0.42 to 0.94, P=0.024). Leave-one-out sensitivity analysis preserved the direction of the PJK effect across all iterations.

    Conclusions:

    Perioperative anabolic osteoporosis pharmacotherapy is associated with lower rates of proximal junctional kyphosis and reoperation following adult spinal deformity surgery, providing the first pooled evidence that the underlying bone-quality substrate may be pharmacologically modifiable. The certainty of this evidence is low; these findings support incorporating bone health optimization into perioperative planning as a modifiable target and prioritizing randomized trials of specific agents.

    Level of Evidence:

    II

    Level of Evidence: II: Systematic review of cohort studies with one randomized controlled trial

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    Prevalence of Lumbar MRI Changes Associated with Nerve Root Compression Among Middle-aged People - A Northern Finland Birth Cohort 1966 Study

    Spine. August 17, 2026

    Study design.

    A cross-sectional study.

    Objective.

    To evaluate the prevalence of lumbar MRI changes associated with nerve root compression in a large, unselected middle-aged population.

    Summary of Background Data.

    While degenerative spinal changes are frequently observed in imaging, their clinical relevance remains poorly understood. Furthermore, large-scale, population-based studies evaluating comprehensively the full spectrum of lumbar spine imaging variations associated with nerve root compression in MRI are lacking.

    Methods.

    At the age of 45–47 years, Northern Finland Birth Cohort 1966 members were invited to a follow-up. As part of the follow-up, lumbar MRI was performed on 1,534 participants in the Oulu region. Due to missing images and withdrawn consents, the final number of scanned individuals included in our study was 1,440. The following MRI changes were evaluated: disc herniations (both axial and sagittal planes), the degree of canal compromise, central and lateral recess stenoses, foraminal stenosis, spondylolisthesis and synovial cysts. Prevalences were reported descriptively.

    Results.

    The prevalence of focal protrusions across the whole lumbar spine (at least one finding at any lumbar level) was 38.2%, while broad-based protrusions accounted for 24.0%. Of the disc herniations, 11.4% were extrusions and 0.3% were sequestrations. Disc herniations were mostly central and located at disc level, and the degree of canal compromise was mild in 46.8% of the cases. The prevalence of mild changes was 99.1% in central stenosis (Grade A), 53.8% in lateral recess stenosis (Grade 1), 6.0% and 26.2% in foraminal stenosis (Grade 1, transversal and vertical perineural obliteration) and 100% in spondylolisthesis (Grade 1). Grade 2 was the highest grade of synovial cysts (prevalence of 0.3%) with no cysts of grades 3-5.

    Conclusion.

    Lumbar MRI changes associated with nerve root compression were frequent, and their severity was mostly mild in general middle-aged population.

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    Impact of Concomitant Hip Osteoarthritis on Pelvic Decompensation, Spinopelvic Alignment, and Surgical Outcomes in Degenerative Lumbar Scoliosis

    Spine. August 14, 2026

    Study Design.

    Retrospective study

    Summary of Background Data.

    A considerable proportion of patients with degenerative lumbar scoliosis (DLS) have concomitant hip osteoarthritis (OA). However, the effect of hip OA on DLS patients remains unclarified.

    Purpose.

    To investigate the impact of concomitant hip OA on patient-reported outcome measures (PROMs) and global spinopelvic alignment in DLS.

    Methods.

    Patients were divided into severe and low OA groups based on the Kellgren-Lawrence (KL) classification, with grades 0 to 2 classified as low OA and grades 3 or 4 classified as severe OA. Radiographic parameters and PROMs including the Visual Analog Scale (VAS), Scoliosis Research Society-22 (SRS-22), and Oswestry Disability Index (ODI) were compared among 3 groups: Bilateral severe, Unilateral severe, or Bilateral low. Multivariable regression analysis was performed to assess the effect of hip OA on pelvic decompensation and PROMs.

    Results.

    A total of 134 patients were enrolled: 61 Bilateral severe, 25 Unilateral severe, and 48 Bilateral low. Bilateral severe hip OA was independently associated with pelvic decompensation (OR 1.37, 95% CI: 1.09-1.54, P=.016). At 2-year postoperatively, severe OA patients exhibited worse global sagittal malalignment and inferior clinical outcomes. Multivariate analysis showed that bilateral severe OA was significantly associated with worse baseline ODI (B=0.352, 95% CI: 0.082 to 0.622) and SRS-function (B=−0.405, 95% CI: −0.749 to −0.062), and 2-year VAS-back pain (B=0.223, 95% CI: 0.021 to 0.425), VAS-leg pain (B=0.365, 95% CI: 0.057 to 0.673), SRS-pain (B=−0.326,95% CI: −0.619 to −0.020 ), SRS-function (B=−0.337, 95% CI: −0.734 to −0.090) and ODI (B=0.323, 95% CI: 0.039 to 0.607).

    Conclusions.

    Severe hip OA was associated with pelvic decompensation and reduced hip extension. Patients with severe hip OA had worse baseline sagittal malalignment and inferior PROMs that persisted 2 year following surgery. These findings underscore the importance of evaluating hip OA during preoperative planning for DLS.

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