Delayed decompression for metastatic epidural spinal cord compression (MESCC) is a common real-world problem, yet short-interval recovery after patients have already remained nonambulatory for at least 48 h is poorly defined. We retrospectively evaluated 41 surgically selected patients with MRI-confirmed epidural MESCC (Bilsky grade 2–3) and preoperative nonambulatory neurological deficit (Frankel grades A–C) lasting at least 48 h. The primary outcome was early neurological improvement, defined as a gain of at least one Frankel grade by postoperative days 10–14. The secondary outcome was early ambulation recovery, defined as postoperative Frankel grade D or E at the same interval. Early neurological improvement occurred in 20/41 patients (48.8%), and early ambulation recovery occurred in 15/41 (36.6%). No patient received postoperative index-level radiotherapy before the POD10–14 neurological assessment. Recovery was most common among patients with baseline Frankel grade C. In exploratory adjusted Firth-penalized models, ECOG performance status 3–4 was associated with lower odds of both outcomes. Rapid-growth tumors, classified using a pragmatic adapted growth-category framework, were associated with lower odds of early neurological improvement. Baseline Frankel grade C favored early ambulation recovery. Higher standardized HALP showed an exploratory association with early neurological improvement but did not alter the main clinical interpretation. Meaningful early recovery was observed in a subset of surgically selected MESCC patients despite delayed surgery, although these findings do not establish equivalence to earlier surgery or isolate the effect of surgery from multimodal oncologic care.

Retrospective cohort. Pelvic incidence (PI) has been regarded as a fixed anatomical parameter; however, accumulating evidence challenges this assumption. W

Proximal junctional disease (PJD) remains a formidable challenge in adult spinal deformity (ASD) surgery. While disc degeneration is a recognized risk fact

Aim: Distal adding-on (DOA) is an important postoperative concern after thoracolumbar fusion in adolescent idiopathic scoliosis (AIS); however, its mechanical drivers, particularly the role of sagittal spinopelvic compensation, remain poorly understood.Materials and Methods: We reviewed Lenke type 1 and 2 AIS patients with a minimum 2-year follow-up. To isolate biomechanical failure patterns and minimize confounding variables, a targeted, exploratory analysis was performed on the Lenke 1A subgroup (n=21). Firth penalized logistic regression was utilized as an exploratory method to identify preliminary "radiographic signals" rather than definitive associated factors, given the low-event nature of the cohort.Results: We analyzed 72 patients and found that 6.9% (n=5) experienced distal adding-on (DOA). A preliminary analysis of the Lenke 1A subgroup (n=21) revealed a potential failure pattern: all 3 DOA events occurred when the lowest instrumented vertebra (LIV) was placed at the last touched vertebra (LTV) level. Conversely, extending the fusion beyond this point was associated with a reduced risk of this outcome (p=0.030). Additionally, we identified a potential 'warning sign': patients who developed DOA showed a more anteverted pelvic tilt after surgery compared to those who did not (-3.67° ± 12.50° vs. 8.39° ± 6.41°, p=0.016).Conclusions: DOA remains a rare but relevant clinical challenge. Our exploratory findings suggest that the LTV may be an insufficient standalone landmark in Lenke 1A subtypes, and that pelvic anteversion may serve as a mechanical warning sign for potential junctional failure. These observations underscore the necessity of a more comprehensive, three-dimensional approach to LIV selection and require further prospective validation studies.

Background/Objectives: Surgery for extradural spinal metastases must balance neurologic and mechanical goals against limited survival. We evaluated whether a predefined three-tier surgical-intensity classification aligned with established measures of operative burden and whether intensity was associated with 90-day mortality or overall survival. Methods: This retrospective cohort included 141 adults with extradural spinal metastases operated on between June 2020 and December 2025. Surgical intensity was classified as low, moderate, or high. SMII was calculated for all patients as a secondary convergent construct measure. Firth penalized logistic regression and Cox regression adjusted for performance status, albumin, and tumor biology. Results: There were 37 low-, 39 moderate-, and 65 high-intensity procedures. Median SMII increased from 6 [5–11] to 14 [11.5–18.5] and 23 [18–28] across the three groups (p < 0.001; Spearman ρ = 0.711). High-intensity surgery was concentrated among unstable SINS lesions and was associated with longer operative time, transfusion, and hospitalization. Ninety-day mortality was 24.3%, 12.8%, and 23.1% for low-, moderate-, and high-intensity procedures, respectively. High intensity was not statistically associated with 90-day mortality (adjusted OR 0.81, 95% CI 0.28–2.36) or overall survival (adjusted HR 1.08, 95% CI 0.65–1.80). ECOG ≥ 3 and aggressive solid/unknown tumor biology were associated with worse outcomes. Conclusions: The intensity classification showed strong convergent validity with SMII and perioperative burden. Within this surgically selected cohort, intensity was not independently associated with early mortality or overall survival, although clinically meaningful differences cannot be excluded. Operative magnitude should be interpreted alongside mechanical need, systemic reserve, and tumor biology.