Background: Posterior cervical decompression and fusion (PCF) is a common procedure for treating patients with multilevel degenerative cervical spine disease. The selection of lower instrumented vertebra (LIV) relative to the cervicothoracic junction (CTJ) remains controversial. This study aimed to compare the outcomes of PCF construct terminating at the lower cervical spine and crossing the CTJ. Methods: A comprehensive literature search was performed for relevant studies in the PubMed, EMBASE, Web of Science, and Cochrane Library database. Complications, rate of reoperation, surgical data, patient-reported outcomes (PROs), and radiographic outcomes were compared between PCF construct terminating at or above C7 (cervical group) and at or below T1 (thoracic group) in patients with multilevel degenerative cervical spine disease. A subgroup analysis based on surgical techniques and indications was performed. Results: Fifteen retrospective cohort studies comprising 2071 patients (1163 in the cervical group and 908 in the thoracic group) were included. The cervical group was associated with a lower incidence of wound-related complications (RR, 0.58; 95% CI 0.36 to 0.92, p = 0.022; 831 patients in cervical group vs. 692 patients in thoracic group), a lower reoperation rate for wound-related complications (RR, 0.55; 95% CI 0.32 to 0.96, p = 0.034; 768 vs. 624 patients), and less neck pain at the final follow-up (WMD, −0.58; 95% CI −0.93 to −0.23, p = 0.001; 327 vs. 268 patients). However the cervical group also developed a higher incidence of overall adjacent segment disease (ASD, including distal ASD and proximal ASD) (RR, 1.87; 95% CI 1.27 to 2.76, p = 0.001; 1079 vs. 860 patients), distal ASD (RR, 2.18; 95% CI 1.36 to 3.51, p = 0.001; 642 vs. 555 patients), overall hardware failure (including hardware failure of LIV and hardware failure occurring at other instrumented vertebra) (RR, 1.48; 95% CI 1.02 to 2.15, p = 0.040; 614 vs. 451 patients), and hardware failure of LIV (RR, 1.89; 95% CI 1.21 to 2.95, p = 0.005; 380 vs. 339 patients). The operating time was reasonably shorter (WMD, −43.47; 95% CI −59.42 to −27.52, p < 0.001; 611 vs. 570 patients) and the estimated blood loss was lower (WMD, −143.77; 95% CI −185.90 to −101.63, p < 0.001; 721 vs. 740 patients) when the PCF construct did not cross the CTJ. Conclusions: PCF construct crossing the CTJ was associated with a lower incidence of ASD and hardware failure but a higher incidence of wound-related complications and a small increase in qualitative neck pain, without difference in neck disability on the NDI. Based on the subgroup analysis for surgical techniques and indications, prophylactic crossing of the CTJ should be considered for patients with concurrent instability, ossification, deformity, or a combination of anterior approach surgeries as well. However, long-term follow-up outcomes and patient selection-related factors such as bone quality, frailty, and nutrition status should be addressed in further studies.

One of the most common surgical cures for lumbar degenerative illnesses is lumbar fusion. Traditional open lumbar fusion is often used in clinical settings and has positive clinical results. However, there are some disadvantages of the traditional open approach, such as tremendous surgical invasiveness and a high risk of complications in the perioperative period. The gold standard for minimally invasive surgical techniques in recent years has been minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). With the advancement of full-endoscopic spine surgical techniques, endoscopic lumbar surgery has rapidly developed from simple discectomy to decompression of spinal stenosis. Currently, the endoscopic lumbar interbody fusion procedure has been performed. On the basis of adequate spinal canal decompression and dependable interbody fusion, endoscopic lumbar interbody fusion could reduce surgical invasiveness and improve patient recovery. In this chapter, we will give a brief introduction to the advance in endoscopic transforaminal lumbar interbody fusion, focusing on the indication, technical aspects, clinical effectiveness, safety, fusion devices, and novel techniques that could be applied in the near future.

Objective: Coronal balance and shoulder balance affect the results of surgical treatments. Numerous studies on these topics in moderate scoliosis have been reported. However, the risk factors and the association between coronal imbalance and shoulder imbalance in complex spinal deformity remain unknown. The purpose of this study is to investigate whether shoulder imbalance as well as other radiographic factors could predict ultimate coronal imbalance in severe and rigid scoliosis. Methods: A retrospective study was conducted at our hospital between January 2009 and December 2018. Fifty‐one patients with severe and rigid thoracic/thoracolumbar scoliosis (main curve Cobb angle > 80° and flexibility < 25%) were recruited. Patients were divided into the Coronal balance (CB) group (C7PL‐CSVL ≤ 20 mm) and the Coronal imbalance (CIB) group (C7PL‐CSVL > 20 mm). Then, the patients in the CIB group were stratified based on the aggravation of C7PL‐CSVL for further subgroup analysis. Potential risk factors for coronal imbalance and decompensation, including shoulder height data and various radiographic parameters, were analyzed between groups and summarized in a quantitative predictive equation. Results: Of all patients, 43.1% (22/51) showed coronal imbalance at the last follow‐up. Univariate analysis showed that the following parameters were significantly greater in CIB group: shoulder height data including immediately postoperative radiographic shoulder height (RSH, p = 0.001), postoperative clavicle angle (CA, p = 0.000), and postoperative C7PL‐CSVL ( p = 0.000). Logistic regression identified that immediately postoperative CA [odds ratio (OR) = 6.837, p = 0.008] and C7PL‐CSVL (OR = 1.071, p = 0.010) were the independent risk factors for ultimate coronal imbalance. The predictive equation was Risk Index = −5.277 + 1.922 × postoperative CA + 0.068 × postoperative C7PL‐CSVL, with positive and negative predictive values of 86.7% and 85.7%, respectively. Conclusions: The prevalence of coronal imbalance at the last follow‐up remained high in severe and rigid scoliosis. Postoperative shoulder imbalance and residual trunk shift could be used as predictors for ultimate coronal imbalance. The aggravation of coronal imbalance might represent a possible compensatory response to shoulder imbalance, as suggested by the observed adverse trends. However, this interpretation should be considered hypothetical, since a direct causal relationship could not be verified yet. Surgeons should pay attention to restore an appropriate relationship between curves in surgical planning for better results.

Study design: A retrospective cohort study. Objective: Severe rigid spine deformity presents major challenges in surgical correction. Although three-column osteotomies (3-CO) provide powerful correction, they are associated with prolonged operative time, increased blood loss, and high neurological risk. This study aimed to compare the radiographic correction, surgical parameters, and complication profiles between staged halo-pelvic traction combined with posterior spinal fusion (HPT+PSF) and one-stage posterior spinal fusion (PSF) in patients with severe rigid spine deformity requiring 3-CO. Methods: This retrospective cohort study included 110 patients (mean age, 25.7 ± 8.5 years) with severe rigid deformity (Cobb angle or maximal kyphosis >90°, flexibility <30%) who underwent either staged HPT+PSF (n = 60) or single-stage PSF (n = 50) between 2016 and 2023. Radiographic parameters, including the main curve Cobb angle and maximal kyphosis (MK), were measured preoperatively, post-traction, postoperatively, and at the latest follow-up. Operative time (ORT), estimated blood loss (EBL), osteotomy grade, intraoperative neuromonitoring (IONM) alerts, and complications were compared between groups. Pulmonary function tests (PFTs) were evaluated longitudinally. Results: Following traction, the main curve Cobb angle and MK in the HPT+PSF group improved from 132.4° ± 23.3° to 65.1° ± 20.7° and from 122.3° ± 29.7° to 53.3° ± 24.1°, respectively. At the last follow-up, the correction rate of the main curve and MK were significantly higher in the HPT+PSF group than in the PSF group (62.9% vs 55.2%, P = 0.004; 67.7% vs 54.5%, P < 0.001). The HPT+PSF group demonstrated significantly reduced ORT (298.3 ± 64.7 vs 361.9 ± 76.3 min, P < 0.001) and EBL (490.5 ± 183.3 vs 1010.6 ± 252.1 mL, P < 0.001). The rate of IONM alerts (3.3% vs 20.0%, P = 0.005) and neurological deficits (3.3% vs 14.0%, P = 0.042) were markedly lower in the HPT+PSF group. Although traction-related complications occurred in 16.7% of patients, all were transient and resolved after adjustment of HPT devices. Conclusion: Staged HPT followed by PSF provides a safe and effective strategy for the management of severe rigid spine deformities. In terms of radiographic correction and perioperative safety profile, this staged approach demonstrated significant advantages over one-stage 3-CO, notably reducing operative time, blood loss, and neurological risks. Preoperative traction effectively decreases deformity stiffness and magnitude, facilitating safer and less invasive surgical correction.