The optimal surgical management of lumbar spinal stenosis (LSS) in the presence of stable low-grade degenerative spondylolisthesis remains a subject of ongoing debate. This study aimed to evaluate the clinical outcomes and radiological stability of Lumbar full-endoscopic unilateral laminotomy with bilateral decompression (LE-ULBD) in this patient population. Specifically, we sought to determine whether this minimally invasive approach compromises spinal stability or leads to progression of spondylolisthesis over time. A total of 36 patients diagnosed with LSS and grade I degenerative spondylolisthesis who underwent LE-ULBD at the Minimally Invasive Spine Center between February 2019 and December 2023 were retrospectively reviewed. All patients completed at least 12 months of follow-up. Clinical outcomes were assessed preoperatively, at 12 months, and at the final follow-up using the visual analog scale for back pain (VAS back), visual analog scale for leg pain (VAS leg), and Oswestry Disability Index (ODI). Radiological evaluations included canal cross-sectional area (CSA), lumbar lordosis (LL), segmental lumbar lordosis (SLL), sagittal vertical axis (SVA), slip percentage (Slip%), pelvic tilt (PT), and other sagittal alignment parameters. All clinical outcome measures demonstrated statistically significant improvement from baseline at both 12 months and final follow-up (p < 0.001 for all comparisons). Pain scores and functional disability were markedly reduced, indicating sustained clinical benefit of the procedure. Notably, the canal cross-sectional area (CSA) significantly increased at final follow-up (from 51.49 ± 28.41 mm² preoperatively to 90.30 ± 50.60 mm², p = 0.001), suggesting effective and lasting neural decompression. While lumbar lordosis and segmental lumbar lordosis angles did not exhibit statistically significant changes (p > 0.1), the slip percentage remained stable throughout the postoperative period (preoperative: 12.40 ± 5.33%; final follow-up: 11.99 ± 4.62%, p = 0.724), indicating no progression of vertebral slippage. Additionally, pelvic tilt improved significantly at the 12-month mark (from 20.37 ± 7.92° to 12.77 ± 8.47°, p < 0.001), although this change was not maintained at the final follow-up. Subgroup analysis (baseline: age, BMI, slip percentage, gender, lumbar lordosis) showed no significant differences in 12-month VAS back scores, VAS leg scores, or ODI changes across all subgroups (all p > 0.05), but lumbar lordosis subgroup had significant VAS back difference at the final follow-up(p = 0.03), marginal VAS leg trend, and no ODI difference. LE-ULBD appears to be a safe and effective option for carefully selected patients with stable grade I degenerative spondylolisthesis, providing durable symptom relief without compromising spinal stability. Future prospective studies with larger cohorts and extended follow-up are warranted to further substantiate these findings.

Background/Objectives: Long-term bisphosphonate (BP) therapy is an effective treatment for osteoporosis but has been associated with rare complications such as atypical femoral fractures (AFFs). Emerging reports suggest that similar insufficiency fractures may also occur in other skeletal sites, including the lumbar pedicles. This study reports two rare cases of isolated bilateral lumbar pedicle stress fractures in patients on prolonged BP therapy. Along with a structured literature review, the objective was to evaluate whether diagnostic criteria derived from those used for AFFs may apply to these atypical vertebral fractures. Methods: Two patients with osteoporosis and on long-term BP therapy diagnosed with isolated lumbar pedicle stress fractures were retrospectively analyzed. A structured literature review identified similar reported cases. All cases were evaluated using the 2010 American Society for Bone and Mineral Research AFF criteria to assess applicability to isolated pedicle stress fractures. Results: Both patients demonstrated bilateral lumbar pedicle fractures without vertebral body involvement. One was treated conservatively; the other underwent robotic-assisted percutaneous pedicle screw fixation with documented fracture healing at six months. The literature review identified eight similar cases of isolated pedicle fractures in patients on prolonged BP therapy. Clinical course and imaging findings demonstrated stress-type features analogous to AFFs. The proposed AFF-based diagnostic criteria for pedicular insufficiency fractures were found to be applicable to all ten patients. Conclusions: Isolated bilateral pedicle stress fractures may represent a spinal analog of AFFs. Based on shared clinical and imaging features, we propose preliminary diagnostic criteria for atypical pedicular insufficiency fractures. Increased awareness and standardized criteria may aid in early diagnosis and reporting, encouraging further studies on this rare spinal entity.

Lumbar spinal stenosis (LSS) commonly presents with neurogenic claudication and low back pain (LBP). Decompression surgery effectively relieves leg symptoms, but its impact on LBP remains inconsistent. While full-endoscopic decompression has emerged as a minimally invasive alternative, evidence regarding its specific effect on LBP is limited. To evaluate the improvement in LBP following full-endoscopic decompression for LSS with or without low-grade degenerative spondylolisthesis (SPL), and to identify the clinical and radiological factors influencing these changes. Consecutive patients undergoing full-endoscopic decompression for LSS between 2017 and 2024 were retrospectively analyzed. Pre- and postoperative clinical and radiographic status were assessed for patients with a follow-up of ≥1 year. The primary outcome was reaching a minimally important clinical difference (MCID) in Visual Analogue Scale (VAS) for LBP. Logistic regression analyses were performed to identify factors associated with achieving MCID, and subgroup analysis assessed the impact of low-grade SPL on outcomes. Sixty-four patients (mean age 63.8 years, 53.1% female) with mean follow-up of 24.9 months were included. 35.9% had low-grade SPL. MCID was achieved in 84.5% of patients at 12 months and 79.7% at last follow-up. Greater baseline back pain severity was associated with achieving MCID (OR = 2.31, 95% CI 1.31 - 4.08, p = 0.004), and low-grade SPL was not associated with inferior clinical outcomes. Full-endoscopic decompression for LSS is associated with clinically meaningful improvement in LBP in most patients, and the presence of low-grade SPL does not appear to negatively affect outcomes.

Degenerative lumbar spondylolisthesis (DLS) combines neural compression with a variable mechanical phenotype, creating uncertainty over whether decompression alone is sufficient or fusion is required. Over the last few decades, endoscopic spine surgery (ESS) has opened new avenues for ultra-minimally invasive decompression with minimal bony resection, reducing the risk of iatrogenic destabilization. Against this background, the emergence of ESS has added a new dimension to the debate over surgical decision-making in DLS. This debate-style review compares endoscopic decompression versus fusion for DLS across 7 domains: learning curve and training, technical feasibility and surgical nuances, patient selection and indications, clinical and radiological outcomes, complication profile and management, cost-effectiveness and economic analysis, and reoperation/revision rates. The literature supports endoscopic decompression as a tissue-preserving option for carefully selected patients with stable, low-grade DLS and predominant leg symptoms, whereas fusion remains appropriate when objective instability, mechanical pain, or destabilizing decompression makes reconstruction necessary. Clinical outcomes may be similar in selected stable disease phenotypes, but fusion provides more predictable radiographic correction, with the durability of DLS-specific endoscopic outcomes remaining less certain in the longer term. Additionally, endoscopic decompression and fusion have different risk profiles: the former concentrates concerns around technical execution, incomplete decompression, and delayed conversion to revision or later fusion, while the latter introduces potential approach-, implant-, pseudarthrosis-, and adjacent segment-related complications. An international survey of 63 ESS-experienced spine surgeons supported endoscopic decompression for stable single-level disease (60 of 63, 95.2%) and fusion in case of instability (49 of 63, 77.8%), while intermediate scenarios remained divided. Respondents strongly endorsed long-term multicenter randomized comparisons (62 of 63, 98.4%). Because the panel consisted of ESSexperienced surgeons who predominantly favored decompression-only procedures, its results quantify structured expert opinion rather than treatment preferences in the wider spine community. The aggregate evidence therefore supports equipoise rather than a universal winner. The clinically relevant question is which strategy best matches the patient’s symptom generator, mechanical phenotype, operative risk, local resources, and surgeon expertise.

Background: The prevalence of sacral insufficiency fractures resulting from minor trauma has been on the rise in parallel with the globally aging population. For similar injuries typical to the elderly population, such as hip fractures, surgery and early mobilization have been shown to improve postoperative mortality and morbidity rates. As such, there has been a recent increase in the literature in studies advocating for early surgical fixation for sacral insufficiency fractures. However, traditional fluoroscopic techniques are technically demanding and bear an inherent complication risk even in experienced hands. Robotic-assisted surgery has emerged as a promising technological advancement in spinal and pelvic surgery. We share our experience with this surgical technique. Methods: We conducted a retrospective analysis of five consecutive patients with sacral insufficiency fractures who failed non-operative management. Using the Mazor X robotic system, patients underwent CT-planned, guided placement of fenestrated sacroiliac screws followed by cement augmentation. Primary outcomes included surgical time, radiation exposure, complications, and mobilization, with a minimum three-month follow-up. Results: The cohort consisted of five females with a mean age of 78 years. The mean operative time was 36 min (15–47), and the median fluoroscopy count was 13 shots (6–19). All patients reported significant pain relief and achieved successful mobilization on postoperative day 1. No operative or postoperative complications were recorded. Conclusions: This pilot study suggests that robotic-assisted percutaneous sacroiliac fixation with cement augmentation is a safe, efficient, and minimally invasive approach for the treatment of sacral insufficiency fractures. The precision of the robotic system facilitates stable fixation, providing immediate pain relief and early mobilization with a favorable complication profile. Further studies should be performed to verify these findings.