Study DesignCross-sectional survey.ObjectiveWe explore the demographic factors amongst surgeons responsible for decision-making in the management of Grade I L4-5 degenerative lumbar spondylolisthesis(DLS).MethodsA survey presenting three clinical scenarios of DLS with varying degrees of neurological compression and instability was distributed to the AOSpine members globally to ascertain surgical management preferences. Management options such as decompression only or decompression and fusion and the techniques that would be employed were presented to the responders.ResultsAfter dissemination, 479 surgeons responded to the survey. Direct decompression was preferred for all three scenarios with and without neurologic deficits(82.5, 81.2, and 56.8%), with the majority favoring open procedures over minimally invasive or endoscopic procedures. Notably, younger, less experienced, and fellowship-trained surgeons showed a higher inclination toward minimally invasive and indirect decompression methods. A strong preference for surgical fusion over decompression(75.2, 92.5 and 86.6%, respectively) was also significantly observed, reflecting a general consensus on the need to achieve segmental stability.ConclusionThe results of this study demonstrate a pronounced preference for direct decompression and fusion among a group of global surgeons when treating L4-5 Grade I DLS across all demographics. This indicates a consensus on achieving decompression and stability; however, there are some trends indicating the impact of surgical management based on age, experience, and training of the treating providers. These findings suggest an evolution of surgical interventions toward less invasive techniques, particularly among younger surgeons, highlighting the need for global education to adopt innovative approaches in the management of DLS.

Study DesignRetrospective Cohort Study.ObjectiveIsthmic spondylolisthesis is frequently encountered in spine surgical practice, though there is a significant variation in surgical management strategies. We sought to evaluate revision rates between patients who underwent anterior-approach lumbar interbody fusion (ALIF) alone, posterolateral fusion (PLF) alone, PLIF/TLIF, and ALIF+PSF.MethodsThis retrospective study utilized a large commercial insurance claims database of patients ≤65 years-old. Patients with isthmic spondylolisthesis who underwent single-level instrumented arthrodesis were included, and those who underwent revision surgery, surgery for deformity, multi-level surgery, or surgery for traumatic, infectious, or neoplastic etiologies were excluded, as determined by ICD-10-CM and CPT codes. Patients were assigned to surgical cohorts of ALIF alone, PLF alone, PLIF/TLIF, and ALIF+PSF based on CPT codes. Additional independent variables included age, sex, decompression at index surgery, and region. The primary outcome was revision arthrodesis or decompression, defined using CPT codes. Kaplan-Meier analysis and Cox Proportional Hazards regression were utilized to assess differences in revision occurrence between cohorts.Results1014 patients who underwent single-level arthrodesis for isthmic spondylolisthesis were included. The mean age was 48.6 years, with a mean follow-up of 637.6 days. The majority of patients underwent PLIF/TLIF (60.6%, n = 614), followed by ALIF+PSF (18.5%, n = 188), PLF alone (14.4%, n = 146), and ALIF alone (6.5%, n = 66). The 5-year revision-rate was 11.0% for all patients in the Kaplan-Meier analysis. In multivariable analysis adjusting for confounding factors, ALIF-alone demonstrated significantly higher occurrence of revision compared to both ALIF+PSF (HR 5.0, P = 0.0026) and PLIF/TLIF (HR 5.8, P < 0.0001) groups. Similarly, PLF alone demonstrated significantly higher occurrence of revision surgery compared to PLIF/TLIF (HR 2.4, P = 0.0379) while other comparisons were not statistically significant.ConclusionsIn this analysis of single-level arthrodesis for isthmic spondylolisthesis, patients who underwent ALIF alone had higher revision rates than those who underwent PLIF/TLIF and ALIF+PSF surgery, and those who underwent PLF alone had higher revision rates than those who underwent PLIF/TLIF. Surgical strategies providing both anterior and posterior column support resulted in lower real-world revision rates.

STUDY DESIGN: Narrative Review. OBJECTIVES: We aim to investigate the integration and impact of enabling technologies, such as augmented reality, virtual reality, mixed reality, navigation, robotics, and artificial intelligence within the domain of spinal surgery. METHODS: We made a literature review for articles that examined the progression of adoption from initial to subsequent adopters. We also analysed the key determinants that influence adopting these technologies into clinical settings. These include cost-effectiveness, ease of integration, patient acceptance, learning curves, and availability of training resources. Based on the available data a suggestion has been made on the adoption framework for clinical utility. RESULTS: These technological advancements have the potential to transform surgical practice, offering improved precision and efficiency. The journey toward widespread adoption presents challenges, which include the financial implications, the necessity for specialized training, and the complexities associated with integration. To navigate these hurdles, the study proposes recommendations aimed at improving cost efficiency, streamlining technology integration, investing in professional development, and nurturing a culture of innovation and research. CONCLUSIONS: A framework has been established for the evaluation and integration of state-of-the-art technologies in spinal surgery, thereby maximizing their potential impact on surgical outcomes and patient welfare.

STUDY DESIGN: Reliability study. OBJECTIVES: The radiographic diagnosis of non-union is not standardized. Prior authors have suggested using a cutoff of <1 mm interspinous process motion (ISPM) on flexion-extension radiographs, but the ability of practicing surgeons to make these measurements reliably is not clear. METHODS: 29 practicing spine surgeons measured ISPM on 19 levels of ACDF from 9 patients. Surgeons relied on these measurements to report on fusion status. Inter-observer correlation co-efficients (ICC), standard error (SEM) and the minimum detectable difference (MD) of these measurements were calculated. We screened for clerical errors by checking measurements more than one standard deviation from the group mean. RESULTS: The ICC for ISPM was .76 (.64; .88) with a SEM of 1 mm and a MD of 2.76 mm. Agreement on fusion status was moderate, with an ICC of .6 (.44; .76). After screening for and removing clerical errors, the ICC improved to .82 (.71; .91), SEM improved to .83 mm, and MD improved to 2.29 mm. Six reviewers had an ICC >.9. The ICC from these high performing reviewers was .94 (.9; .97), SEM was .45 mm, and MD was 1.26 mm. CONCLUSIONS: The MD of 2.29 mm in our study group was not precise enough to support a cutoff of <1 mm ISPM as the sole measurement technique in screening for non-union after ACDF, and there was only moderate agreement amongst surgeons on fusion status based on dynamic radiographs. More stringent techniques are necessary to avoid mis-diagnosing non-union in clinical studies. Future studies should consider auditing measurements to identify clerical errors.