Ashish Dhar Diwan

Background: Conventional radiographic assessment of postoperative lumbar alignment relies predominantly on Cobb angle measurements, which incompletely characterize global spinal morphology. We evaluated whether geometric morphometrics (GM) provides complementary quantitative information for assessing postoperative lumbar morphology after TLIF and decompression. Methods: Ninety-nine patients (TLIF n = 70; decompression n = 29) underwent landmark-based GM analysis of pre- and post-surgical lateral lumbar radiographs (48 landmarks, L1–S1). Because TLIF and decompression patients were imaged at markedly different postoperative intervals as a matter of routine clinical practice, the primary analyses tested whether each technique’s own pre-to-post shape change, adjusted for baseline L1–S1 angle, log centroid size, sex, age, number of operated levels, and degenerative spondylolisthesis, was significant (sign-flip permutation test), along with lordosis change (paired t-test, unadjusted). Cobb analyses assessed global lumbar lordosis (L1–S1) and operated level(s). Results: TLIF showed a significant within-group reduction in global lumbar lordosis at early postoperative imaging (Δ = −3.75°, paired t-test p < 0.001) and a significant, systematic change in overall lumbar shape (sign-flip permutation p < 0.001); decompression showed no significant within-group change in global lordosis (Δ = +0.47°, p = 0.733) or overall shape (p = 0.31), but a small increase in segmental lordosis at the operated level(s) (Δ = +1.44°, p = 0.036) that was not robust to sensitivity analysis. Conclusions: In this retrospective cohort, TLIF was associated with reduced lumbar lordosis and a systematic shape change at early postoperative imaging, while decompression showed preserved global lordosis and a small gain in segmental lordosis at long-term imaging. GM provided a consistent quantitative framework, with strong correlation and level-dependent agreement against manual Cobb measurement, for characterizing these within-technique postoperative changes.

Low back pain is a leading cause of disability worldwide. While non-specific low back pain accounts for the majority of cases, older adults are at increased risk of pathological and structural causes related to age-associated spinal degeneration, including intervertebral disc degeneration. Despite widespread use, conventional diagnostic imaging often fails to reliably identify pain-generating sources. Treatment decisions remain challenging, with many current interventions providing limited long-term efficacy. This perspective reviews the cellular pathways and risk factors contributing to disc degeneration specifically in an aging spine. Mechanical degeneration within the spine is explored alongside a correlation to pain generating sources. The role of surgical treatment is explored alongside emerging techniques and contributors to enhanced outcomes. Intervertebral disc degeneration reflects molecular, cellular, and biomechanical changes within the spine that are increasingly prevalent in an aging population. Recent advances in the understanding of the pathophysiology of disc degeneration reveal a complex relationship between intrinsic aging and the role of the exposures in progressive degeneration. Radiological evaluation remains limited in diagnostic certainty though emerging technologies offer improved identification of pain generating sources and may offer trajectory tracking of spinal pathologies. Evolving surgical techniques and patient selection may improve outcomes in patients that require structural intervention in their aging spine.

Study Design: Experimental laboratory study; fully factorial hydrogel formulation design with mechanical benchmarking against published spinal cord tissue data. Objectives To develop and characterise polyacrylamide-alginate (PAAm-alginate) double-network hydrogels as surrogates for the transverse compressive response of cervical spinal cord tissue, and to identify the formulation variables governing surrogate stiffness. Setting: University biomechanics laboratory, Adelaide, Australia. Methods Twenty-seven formulations combined three alginate concentrations (4.7, 7.8, 10.3% w/v), three ionic crosslinkers (CaCl₂, FeCl₃, AlCl₃) and three immersion durations (1, 2, 3 h). 313 elliptical specimens were tested in transverse compression at four displacement rates (~ 0.01 to 140 s⁻¹). Characteristic curves were generated by arc-length re-parameterisation, compared by statistical parametric mapping, and benchmarked against published human and porcine cervical cord data. Results All formulations showed J-shaped, rate-dependent viscoelastic responses. Crosslinking ion valency had the greatest influence, trivalent species being approximately five times stiffer than divalent CaCl₂; alginate concentration had a moderate, diminishing effect and immersion duration had little effect beyond 2 h. CaCl₂ formulations matched the benchmarks most closely at every rate; at ~ 50 s⁻¹, CaCl₂ / 10.3% / pooled 2 h + 3 h matched porcine cervical cord in tangent modulus (~ 1180 kPa) and stress at benchmark failure strain (~ 490 kPa). Conclusions PAAm-alginate double-network hydrogels reproduce the nonlinear, rate-dependent transverse compressive behaviour of cervical spinal cord tissue and can be tuned to published benchmarks, most closely under dynamic loading. They provide a basis for instrumentable cord surrogates for ex vivo injury biomechanics and surgical simulation. Sponsorship: University of Adelaide Medical School Development Grant.

Objective: To examine the efficacy of conservative (non-surgical) treatments, usual care, and no treatment for chronic radicular and non-specific back pain. Design: Time course network meta-analysis. Data sources: Six electronic databases (Medline, SPORTDiscus, CINAHL, PsycINFO, Embase, and CENTRAL), searched from inception to 24 July 2020, and 302 previous systematic reviews. Eligibility criteria for selecting studies: Full peer reviewed publications in English or German of randomised controlled trials, randomised clinical trials, randomised controlled cluster trials, or randomised crossover trials in adults (aged ≥18 years) receiving common conservative treatments for non-specific and radicular chronic low back pain. Treatments examined were acupuncture, education or advice, electrotherapy (including heat and ice electrotherapeutic modalities applied non-invasively), exercise training, manual treatments or manipulation, massage, the McKenzie method, pharmacotherapy, psychological treatments, traction, physical therapy (otherwise not falling into specific treatment combinations), placebo, multidisciplinary pain management, usual care (eg, management by a doctor), and no treatment (true control). Results: Back pain intensity, leg pain intensity, disability, and mental health outcomes were reported immediately (3 and <12 months), and long term (≥12 months) time points. 581 reports of 551 studies (71 126 patients) were included. 510 trials included people with non-specific chronic low back pain and 41 trials included those with radicular chronic low back pain. For back pain (0-100 scale), acupuncture (mean difference −20.91, 95% credible interval −24.00 to −11.95), electrotherapy (−18.98, −21.84 to−10.95), exercise (−15.59, −17.51 to −10.05), manual treatment (−19.48, −22.17 to −11.74), massage (−25.61, −30.42 to −10.91), and multidisciplinary pain management (−18.96, −22.26 to −9.58) exceeded the minimal clinically important difference (set at 0.5 standard deviation) in the short term. For disability (0-100 scale), acupuncture (mean difference −10.52, 95% credible intervals −11.84 to −6.59), massage (−9.95, −11.45 to −5.50), and multidisciplinary pain management (−12.56, −13.91 to −8.55) were clinically effective in the short term. In the immediate and intermediate term only, the McKenzie method and massage, respectively, exceeded the minimal clinically important difference. In the long term, although two of the 14 treatments for back pain and nine of 14 treatments for disability had statistically significant benefits compared with no treatment, the effects were not clinically significant. The certainty of the evidence based on the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework was low (1.4%) to very low (98.6%) across interventions and time points. Findings for massage and the McKenzie method were not stable in the sensitivity analyses. Treatment effects for radicular chronic low back pain did not seem to differ from those for non-specific chronic low back pain. Conclusions: Some treatments were effective for pain and function in non-specific chronic low back pain, but improvements did not persist long term. Most of the evidence was for non-specific chronic low back pain; the evidence base for radicular chronic low back pain was limited. Although sensitivity analyses did not provide evidence for a different response in radicular chronic low back pain, an evidence gap remains for this subpopulation. Future work should explore strategies to establish the long term efficacy of modifications to lifestyle and behaviour. Systematic review registration: PROSPERO CRD42020182039

Older adults often have impaired physiologic reserve and are at higher risk for postoperative complications after spinal fusion surgery. To evaluate the efficacy of multimodal prehabilitation plus Enhanced Recovery After Surgery (PREERAS) versus ERAS alone on 90-day postoperative complications in older adults undergoing elective spinal fusion. Multicenter, open-label, assessor-blinded, 1:1 parallel-group randomized controlled trial. (ClinicalTrials.gov: NCT06140797). 3 tertiary hospitals in China. Adults aged 75 years or older undergoing elective spinal fusion surgery between May 2024 and May 2025. Participants were randomly assigned to receive either preoperative Vivifrail-based, multimodal PREERAS (PREERAS group) or ERAS alone (ERAS group). The 4-week prehabilitation program integrated supervised group sessions, Vivifrail multicomponent exercise, nutritional optimization, and psychological interventions. The primary outcome was the occurrence of any postoperative complication within 90 days of surgery, recorded and graded per the Clavien-Dindo classification system. A total of 312 patients were assessed for eligibility, with 164 randomly assigned. Of the 159 patients included in the final analysis (mean age, 78.7 years; 59% women), 59 patients (74.7%) in the PREERAS group and 73 patients (91.2%) in the ERAS group experienced at least 1 complication (risk ratio, 0.80 [95% CI, 0.67 to 0.95]; risk difference, -18.0% [CI, -27.0% to -9.0%]). Unblinded participants and clinicians. Generalizability may be limited with longer hospital stays in the Chinese health care system. The implementation of multimodal prehabilitation in 3 tertiary hospitals in China reduced 90-day postoperative complications in older adults undergoing enhanced recovery after spinal fusion surgery. However, individual sites will need to consider applicability of findings and resource requirements of prehabilitation before implementation. Capital's Funds for Health Improvement and Research.

Background: There remains no clear consensus regarding expected range of motion (ROM) loss after anterior cervical discectomy and fusion (ACDF) across varying level constructs. This systematic review aimed to evaluate changes in cervical ROM and the correlation between ROM and patient-reported outcomes measures (PROMs) following single-level and multilevel ACDF. Methods: A literature search was conducted across PubMed, Embase, and Scopus databases, spanning from their inception to July 2025, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria consisted of human comparative studies reporting baseline and postoperative cervical ROM across single and multilevel ACDF. The Methodological Index for Nonrandomized Studies criteria were used to assess study quality. Primary outcome measures consisted of changes in cervical ROM from baseline after surgery. Secondary outcome measures included the modalities used to measure ROM and correlations between changes in changes in ROM and PROMs from baseline to final follow-up. Results: Ten studies (7 Level II, 3 Level III) involving 832 patients (1- to 4-level ACDF) with mean follow-up ranging from 3 to 38 months were included. ROM was assessed through radiographs (5), electromagnetic tracking (2), computed tomography modeling (1), inclinometry (1), and linkage devices (1). In single-level ACDF, sagittal ROM changes ranged from −15.0% to +19.5%, with 6 of 7 studies reporting stable or increased motion. Lateral bending (+20.2% to +23.3%) and rotation (+7.3% to +13.7%) consistently increased on dynamic analysis. In 2-level fusions, sagittal ROM changes ranged from −33.4% to +9.1% (6 decrease, 3 increase). In 3-level to 4-level fusions, changes ranged from −49.1% to +36.4%. Radiographic studies consistently reported ROM reductions in 2+ level fusions, whereas dynamic analyses demonstrated preserved baseline ROM. All studies showed significant improvements in Neck Disability Index and Visual Analogue Scale neck pain, which correlated weakly or nonsignificantly with ROM changes. Conclusion: Single-level ACDF does not significantly reduce cervical ROM from baseline. In multilevel fusions, a discrepancy exists: radiographs show modest reductions, while dynamic motion analyses suggest that baseline ROM is preserved. Dynamic motion analyses provide a more clinically accurate representation of mobility changes following single-level and multilevel fusions. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Post-operative surgical site infections (SSIs) remain a major source of morbidity following spinal surgery, contributing to prolonged hospitalisations, re-operation, implant failure and increased healthcare costs. Despite advances in surgical technique and peri-operative care, SSI prevention in spine surgery remains challenging. Objective: To provide a narrative synthesis of contemporary evidence relating to the prevention of SSIs in spinal surgery across the pre-operative, intra-operative, and post-operative phases, with additional emphasis on emerging and translational technologies. Methods: A structured literature review of MEDLINE/PubMed (1990–2024) was performed. Systematic reviews, randomized controlled trials, high-quality cohort studies, and major international guideline statements were selectively included to synthesise current preventive strategies in spinal surgery. Results: SSI prevention in spinal surgery requires a multimodal peri-operative strategy. Pre-operative optimisation includes smoking cessation, glycaemic control, nutritional assessment, anaemia correction, and targeted Staphylococcus aureus screening and decolonisation. Intra-operative measures supported by moderate-to-high-quality evidence include chlorhexidine–alcohol skin preparation, weight-adjusted antibiotic prophylaxis with appropriate re-dosing, dilute povidone–iodine irrigation, meticulous tissue handling, and intrawound vancomycin powder in selected high-risk posterior instrumented cases. Post-operative interventions such as extended occlusive dressings, silver-impregnated dressings, and prophylactic negative-pressure wound therapy may reduce SSI risk in high-risk populations. Prolonged post-operative antibiotic administration beyond 24 h has not demonstrated additional benefit and may increase antimicrobial resistance. Emerging technologies targeting biofilm formation and antimicrobial resistance represent promising future directions. Conclusions: Preventing SSIs in spinal surgery requires an integrated peri‑operative approach informed by evolving evidence. While several strategies are supported by consistent data, significant gaps remain, particularly regarding emerging technologies. Ongoing high‑quality clinical studies are needed to refine SSI prevention frameworks in spine surgery.

Degenerative cervical myelopathy (DCM) is a progressive degeneration of the cervical spine, leading to compression of the spinal cord [1,2]. It is characterised by progressive neurological symptoms...

Objective: This retrospective study assesses the efficacy of Hsu-lace technique in creating a “soft landing” for patients submitted to thoraco-lumbar-pelvic reconstruction intending to reduce proximal junction failure and reoperation rates. The present study aims to show a new technique in Adult Spine Deformity (ASD) surgery looking into the effects of the artificial interspinous Nylon and Tendon soft stabilization on proximal junction kyphosis/failure (PJK/PJF) and extension of fusion rates. Methods: A retrospective review was conducted on 53 patients who underwent thoraco-lumbar-pelvis fusion for ASD since 2019. Patients were categorized in two groups based on artificial interspinous stabilization in which the use was determined based on the instrumentation chose in each case – Nile-Life Health Care (LHC)( n = 27) or Tendon/Ausbio-APM( n = 26). Data collection included demographics, surgical details, follow-up, PJK, time of PJK, reoperation, and extension of fusion. Results: 8 patients developed PJK before 6 months and 5 were submitted to extension of fusion. 80% of these patients extended were from the Nile-LHC group. Despite this, we had 3 patients that developed PJK but had no proximal junction failure (PJF). Conclusion: We believe the Hsu-lace technique is valid and changed our practice reducing our PJF and extension of fusion rates.