Purpose: Direct pars interarticularis repair preserves motion and avoids adjacent segment degeneration associated with fusion. Endoscopic and percutaneous minimally invasive techniques aim to reduce tissue disruption and accelerate recovery, but their outcomes have not been systematically reviewed to evaluate pooled safety, efficacy, and clinical outcomes of these techniques. Methods: A systematic review was conducted according to PRISMA guidelines, searching PubMed, Embase, and Scopus from inception through January 2026 using (“pars interarticularis” OR “spondylolysis”) AND (“endoscopic” OR “percutaneous” OR “minimally invasive”) AND (“repair” OR “fixation” OR “surgery”). English-language human studies reporting clinical outcomes were included. Extracted outcomes included radiographic data, pain and functional scores (VAS, ODI, SF-36), return to activity, complications, and reoperations. Results: Of 140 identified studies, 5 met the inclusion criteria, comprising 47 patients (94 pars defects). Techniques included microendoscopic-assisted, irrigation endoscopic-assisted, tubular retractor-based, and fully percutaneous repair. Computed tomography-confirmed pars union was achieved in a pooled weighted mean of 84.4% (range, 77–100%) at 6–12 months. All studies reported significant pain and functional improvement, with a mean reduction in VAS of 5.5 points. Overall, 91.4% achieved good or excellent Macnab outcomes, and 93.6% returned to preinjury activity or sport. The complication rate was 6.4%, with no major neurologic, vascular, or infectious complications. Heterogeneity existed in surgical techniques and outcome reporting. Conclusions: Endoscopic and percutaneous minimally invasive direct pars repair is a safe, effective motion-preserving option for selected patients with symptomatic lumbar spondylolysis, though further prospective studies with standardized outcomes and longer follow-up are needed.

Purpose of Review Osteoporosis affects more than 53 million Americans and contributes to nearly 2 million fragility fractures each year, yet most patients who sustain fractures never receive guideline-recommended pharmacotherapy. Traditional step-therapy typically begins with bisphosphonates and reserves anabolic agents for later-line use, whereas sequential therapy prioritizes anabolic treatment followed by antiresorptive consolidation. This review synthesizes the evidence comparing these treatment paradigms and examines their relevance to orthopedic populations, in whom bone quality directly influences fracture healing, fixation, fusion, and implant-related outcomes. Recent Findings Among 37 studies meeting PRISMA-ScR inclusion criteria, anabolic-first sequential therapy generally produced greater gains in bone mineral density and greater fracture risk reduction than step-therapy or antiresorptive monotherapy. In one representative trial, romosozumab followed by denosumab achieved a 16.8% increase in lumbar spine bone mineral density versus 7.5% with monotherapy, and 92% versus 47% of patients reached treatment targets. In ARCH, anabolic-first therapy was associated with 48% lower vertebral fracture risk and 38% lower hip fracture risk. In orthopedic settings, emerging evidence suggests that sequential protocols may improve postoperative bone mineral density after hip fracture, support spinal fusion, and mitigate periprosthetic bone loss after arthroplasty. Prior antiresorptive exposure appeared to attenuate subsequent anabolic response, particularly at the hip, supporting the rationale for earlier anabolic use. Economic analyses also suggest that, despite higher upfront drug costs, sequential therapy may be cost-effective in patients at high fracture risk. Summary Current evidence supports anabolic-first sequential therapy as a more effective strategy than step-therapy for improving bone mineral density and reducing fracture risk in appropriately selected high-risk patients. For orthopedic populations, the available data suggest meaningful potential benefits in hip fracture care, spinal reconstruction, and arthroplasty, although subspecialty-specific evidence remains more limited than the broader osteoporosis literature. These findings support reconsideration of formulary and treatment policies that delay anabolic therapy in patients most likely to benefit.

Study Design: Scoping review. Objectives: To map spine literature on large language models, characterize reported use cases, and identify evidence gaps limiting implementation. Methods: A scoping review was conducted according to Joanna Briggs Institute methodology and PRISMA-ScR guidance. PubMed, Embase, Scopus, Web of Science, and Cochrane were searched for English-language, peer-reviewed studies published from January 2023 through May 2026 that evaluated large language models in spinal disease, spine surgery, or spine-related care. Eligible studies were synthesized across clinical decision support, triage, patient communication, automation, surgical education, and implementation barriers. Results: Fifteen studies met inclusion criteria. Most evidence involved early evaluation of commercially available or general-purpose models rather than prospectively validated spine-specific systems. Reported applications included patient education, report simplification, coding support, emergency consultation simulation, spinal cord stimulation referral screening, conservative triage, and surgical education. Performance was strongest for structured text-based tasks, patient communication, documentation support, and simplified decision pathways. Performance was weaker for image interpretation, quantitative radiographic assessment, individualized operative planning, and granular procedure selection. Recurrent limitations included hallucinated or unsupported outputs, unreliable citation generation, limited multimodal capability, privacy and data-governance concerns, bias, unclear medicolegal accountability, and minimal validation. Conclusions: Large language models are an adjunct in spine surgery, with the near-term role in clinician-supervised, text-centered workflows including patient communication, education, documentation, coding, guideline retrieval, and preliminary triage. Current evidence does not support autonomous diagnostic, radiographic, or operative decision-making. Future studies should prioritize spine-specific retrieval-augmented systems, validated multimodal workflows, privacy-preserving deployment, fairness assessment, and prospective evaluation using clinically meaningful outcomes.