Background: Degenerative lumbar disc disease (DLDD) can contribute to substantial low back pain and radicular leg pain. Emerging evidence suggests that racial and ethnic disparities in DLDD care could impact clinical outcomes, yet these trends remain largely unexplored. This study investigates differences in health literacy, access to care, and healthcare utilization among patients with DLDD using the All of Us (AoU) Research Program. Methods: Adults diagnosed with DLDD were identified from the AoU database using ICD-9 and ICD-10 diagnostic codes. Participants were stratified by race and ethnicity into White, Black, Hispanic, and Other. Demographics, socioeconomic status, health literacy (BRIEF score), healthcare access, and treatment utilization across racial and ethnic groups were compared across cohorts using chi-square analyses. Multivariate logistic regressions evaluated these outcomes while adjusting for demographic and socioeconomic status. Results: In total, 30,775 participants with DLDD were identified. Most participants were 65+ years (62.8%) and female (65.3%), with 74.0% self-identifying as White, 10.7% as Black, 8.1% as Hispanic, and 7.2% as Other. Compared to Whites, Black and Hispanic participants were significantly more likely to report limited health literacy (White = 15.3%, Black = 22.2%, Hispanic = 28.1%, Other = 21.3%, P < 0.001). In addition, they were more likely to be denied insurance coverage (9.7%, 10.5%, 14.5%, 13.8%) and report difficulty affording care, including prescription medications (11.5%, 20.9%, 19.0%, 18.9%) and follow-up visits (6.2%, 10.0%, 10.7%, 9.3%) (all P < 0.001). Finally, Black participants, in particular, were more likely to receive nonoperative treatments such as physical therapy (25.7%, 28.2%, 23.1%, 25.9%), steroid injections (14.4%, 16.7%, 12.8%, 12.4%), and opioids (49.1%, 53.4%, 42.5%, 48.3%) compared to White participants (all P < 0.001). Many of these disparities persisted in multivariate models after adjusting for demographic and socioeconomic covariates. Conclusion: Disparities in DLDD are multifactorial, reflecting the intersection of age, sex, race/ethnicity, comorbidities, and social determinants of health. Despite most participants being Medicare-eligible, minority groups continued to report access and affordability barriers, suggesting the role of underinsurance and coverage gaps. These findings underscore the need for targeted interventions to improve access, promote education, and ensure equitable treatment of DLDD across minority populations.

Biportal endoscopic (BE) spine surgery has gained increasing attention as a minimally invasive alternative to conventional spinal procedures, yet the distribution of procedural applications and anatomic targets within influential BE-specific publications has not been clearly synthesized. This study aimed to synthesize influential publications on BE spine surgery to describe the evolution of procedural applications, anatomic focus, and clinically relevant themes reflected in the literature. A comprehensive search of the Web of Science database was performed using terms related to biportal and multiportal endoscopic spine techniques. Influential articles were identified using citation frequency as a screening criterion, and relevant study characteristics, including publication year, authorship, institutional affiliation, geographic region, journal, and spinal region addressed, were extracted. Full-text screening confirmed inclusion of true biportal endoscopic spinal procedures and categorized the anatomical region and surgical technique addressed. Publications spanned 1997 to 2023, with a marked increase after 2018 and peak productivity in 2022. Influential publications were most frequently published in World Neurosurgery, with substantial contributions originating from South Korea, including work by Dae-Jung Choi. Most studies focused on lumbar procedures, primarily decompression techniques and transforaminal lumbar interbody fusion. Overall, this review highlights the rapid clinical growth of BE spine surgery, with influential literature emphasizing lumbar applications and underscoring the need for further research on outcomes, learning curves, and broader international adoption.

BACKGROUND Despite decades of data showing likely benefit with minimal risk, commercialization efforts, and large potential markets, the competitive landscape of virtual reality (VR) analgesia remains fragmented in terms of regulatory status, funding, and business strategy. For emerging technologies that are rapidly evolving outside of medicine, like VR, artificial intelligence (AI), and robotics, the traditional medical regulatory pathways and business models may not be agile enough to keep up, unintentionally increasing cost and delaying or even preventing access to products that could be beneficial. A better understanding of how an idea becomes a product that can easily be used by a patient is increasingly important for healthcare providers. OBJECTIVE This market analysis aims to map and analyze the most prevalent US and European companies developing VR and AI products for pain management. The focus is on therapeutic targets, technological approaches, regulatory milestones, and commercial positioning to identify current market trends and growth opportunities. METHODS A broad search of regulatory Databases (Food and Drug Administration(FDA) 510(k), DeNovo decision summaries, Conformité Européenne(CE), Medical Device Regulation(MDR) registries), peer-reviewed publications in PubMed, official company websites, press releases, and Pitchbook were performed to identify companies developing VR/AI technologies for pain management in the United States and Europe. Search terms included “VR pain management,” “virtual reality analgesics,” “AI pain therapy,” “digital therapeutics for pain,” “FDA 510(k) VR pain,” and “CE-marked VR pain solutions.” Data were extracted and synthesized primarily by geography, commercialization stage, and regulatory pathway. RESULTS Fifteen companies developing VR/AI-based pain therapies were identified across the United States and Europe. Six (40%) held FDA clearance, five (33%) had CE/MDR approval, one (7%) held both, and three (20%) were in progress toward regulatory approval. Funding ranged from under $2 million to over $300 million. Therapeutic targets included adult chronic pain (33%), pediatric pain (20%), geriatric care (7%), and multiple age groups (40%). Technology types encompassed cognitive based therapy (CBT)-VR, hypnosis, mirror therapy, and AI-enabled telehealth platforms integrating motion tracking and clinician dashboards. Among those with U.S. market clearance, several have achieved commercialization and active revenue generation, Applied VR and XRHealth report multimillion-dollar annual revenues through payer-reimbursed and telehealth-based models, while Luminopia has entered the pediatric ophthalmology market with prescription-based distribution. CognifiSense remains limited to pilot deployment despite FDA clearance. However, no company has yet demonstrated sustained profitability or operating margins indicative of commercial success. Across the cohort, commercialization generally remains in the early growth phase, with revenues concentrated among a few companies and most ventures dependent on continued venture capital or grant support to sustain operations. CONCLUSIONS Although data have shown that many VR solutions exist for pain management, there remain few FDA-cleared, CMS-reimbursed VR products deployable at scale for pain management. Only a small subset of companies has translated early-stage research into commercial products with regulatory clearance, and none have yet achieved profitability, highlighting the distinction between regulatory approval, market entry, and true commercial success. These findings provide a structured view of the emerging digital pain-therapeutics market and may inform clinicians, policymakers, and investors as they evaluate readiness, adoption barriers, and future opportunities CLINICALTRIAL Not applicable

Background/Objectives: Lumbar fusion for degenerative pathology is increasingly common, yet revision surgery, often due to adjacent segment disease, remains a major concern. While sagittal alignment has been widely studied, the role of preoperative lumbar retrolisthesis is less clear. This study evaluated the prevalence, distribution, and clinical significance of preoperative retrolisthesis in patients undergoing single-level L4–L5 fusion, with a focus on its association with revision surgery. Materials and Methods: A retrospective cohort study of 116 adult patients undergoing single-level L4–L5 posterior fusion with multilevel decompression from 2018 to 2022 was performed. Retrolisthesis was defined as posterior translation ≥ 2 mm and assessed across lumbar levels. Patients were stratified by revision status. Statistical comparisons and Cox proportional hazards models were used to evaluate associations between retrolisthesis burden, radiographic parameters, and revision risk. Results: Preoperative retrolisthesis was present in 78.4% of patients, most commonly at L3–L4 and L2–L3, and frequently involved multiple levels. Presence of retrolisthesis alone was not associated with revision (85.7% vs. 77.5%, p = 0.73). However, patients with ≥3 retrolisthesis levels demonstrated reduced revision-free survival, with a higher hazard of revision on univariate analysis (HR 3.65, p = 0.055). In multivariate analysis, ≥3 levels (HR 5.50, p = 0.018) and greater absolute L4–S1 lordosis change (HR 1.09 per degree, p = 0.031) were independent predictors of revision. Conclusions: Retrolisthesis is highly prevalent in patients undergoing L4–L5 fusion but is not predictive of revision when considered alone. A greater multilevel retrolisthesis burden, particularly when combined with larger segmental lordosis change, may represent a mechanically vulnerable spine phenotype associated with increased revision risk. These findings should be interpreted as exploratory and require validation in larger cohorts.

Background/Objectives: Posterior C1–C2 fusion is commonly used for unstable traumatic odontoid injuries, but it is less commonly used for patients who initially undergo nonoperative management and later require salvage fusion. This study compared hospital length of stay, short-term complications, and postoperative radiographic alignment between salvage posterior C1–C2 fusion after failed nonoperative management and primary posterior C1–C2 fusion. Materials and Methods: A retrospective cohort study was performed of 106 adult patients who underwent posterior C1–C2 instrumented fusion for traumatic cervical spine injuries from 2011 to 2023. Patients were stratified into the salvage fusion group after radiographic nonunion following attempted nonoperative management with external immobilization or the primary fusion group, who underwent initial surgical management. The primary outcome was hospital length of stay. Secondary outcomes included postoperative radiographic alignment, screw loosening, hardware failure, revision surgery, and 30-day emergency department visits. Propensity score matching and full-cohort augmented inverse probability weighting were used to account for baseline differences between groups. Results: Twenty-seven patients underwent salvage fusion and 79 underwent primary fusion. Propensity score matching produced 25 matched pairs. In the matched cohort, salvage fusion was associated with significantly shorter length of stay than primary fusion, with a median of 2 versus 5 days, respectively (p < 0.001). This remained significant in the full-cohort augmented inverse probability weighting analysis, where salvage fusion was associated with a 2.41-day reduction in length of stay (95% CI, −3.63 to −1.19; p < 0.001). Short-term complications were uncommon in both groups, and no clear sign of increased screw loosening, hardware failure, revision surgery, or 30-day emergency department visits was observed in the salvage cohort. Salvage fusion was also associated with lower postoperative C2–C7 lordosis and a greater C1 lamina–occiput distance. Conclusions: Salvage posterior C1–C2 fusion for radiographic nonunion after attempted nonoperative management was not associated with higher short-term complication rates compared with primary fusion. While surgical-admission length of stay was shorter in the salvage cohort, this difference should be interpreted cautiously because salvage and primary fusion occur in different admission contexts and do not reflect the total episode-of-care burden. Early postoperative alignment differences were observed, but these were not correlated with clinical outcomes or longitudinal imaging, and their long-term significance remains unclear. Future multicenter studies should evaluate total healthcare utilization, fusion status, longitudinal alignment, and patient-reported outcomes after salvage C1–C2 fusion.