Sean Barber

Introduction: Epidural steroid injection (ESI) techniques have demonstrated effectiveness in improving short- and intermediate-term pain and disability outcomes; however, their efficacy may vary depending on the specific approach used. This meta-analysis aims to compare disability and pain outcomes among different ESI techniques - transforaminal (TFESI), interlaminar (ILESI), caudal (CESI), and combined approaches - in patients with lumbar radiculopathy. Methods: The authors searched PubMed/MEDLINE, Scopus, and Cochrane from inception to December 16, 2025, in accordance with PRISMA guidelines. Studies comparing disability and pain outcomes between different ESIs were assessed. Random-effects meta-analyses were performed to estimate the pooled mean difference between treatment groups at different follow-up timepoints. Sensitivity analyses and publication bias assessments were conducted. Results: In total, 31 studies comprising 2,452 patients were included. Compared with ILESI, TFESI demonstrated significantly greater pain reduction at 2 weeks and 1 month of follow-up, as well as superior improvements in both disability and pain at 3 and 6 months. Compared with CESI, TFESI showed superior disability improvements at 2 weeks and 1 month, with pain outcomes remaining superior at 1 and 3 months; however, both disability and pain outcomes plateaued by 6 months. At 12-month follow-up, TFESI demonstrated improved disability scores compared with CESI, with no significant difference in pain outcomes. Across all follow-up timepoints, the combined TFESI + CESI approach was associated with significantly greater improvements in both disability and pain relief compared with TFESI alone. Conclusions: TFESI demonstrated superior short- and intermediate-term improvements in disability and pain compared with ILESI, but its advantages over CESI remained inconsistent. Limited evidence suggests that the combined TFESI + CESI approach may offer additional benefits over TFESI alone. Further prospective randomized trials are warranted to better define the efficacy and long-term outcomes of the combined approach. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261320804

The transforaminal (TF) and interlaminar (IL) approaches compose the two endoscopic approaches to lumbar discectomy. There is a growing tendency to utilize the TF route for higher lumbar disc herniations and the IL approach related to anatomical factors for the caudal lumbar levels. The L5-S1 level produces a particular challenge due to anatomical barriers, including the height of the iliac crest and the orientation of the facet when confronted with a lateral or far-lateral disc herniation. Traditional approaches can lead to significant joint destabilization in the effort to resect the disc fragment Here we present an operative video with technical nuances of the TF approach utilized to perform both a far-lateral and paracentral discectomy at L5-S1 to treat a 52-year-old male with two distinct and noncontiguous herniations with severe acute right-sided L5 and S1 radiculopathy. This would have otherwise required either two different endoscopic approaches or a more extensive open approach for successful discectomy

The transforaminal (TF) and interlaminar (IL) approaches compose the two endoscopic approaches to lumbar discectomy. There is a growing tendency to utilize the TF route for higher lumbar disc herniations and the IL approach related to anatomical factors for the caudal lumbar levels. The L5-S1 level produces a particular challenge due to anatomical barriers, including the height of the iliac crest and the orientation of the facet when confronted with a lateral or far-lateral disc herniation. Traditional approaches can lead to significant joint destabilization in the effort to resect the disc fragment Here we present an operative video with technical nuances of the TF approach utilized to perform both a far-lateral and paracentral discectomy at L5-S1 to treat a 52-year-old male with two distinct and noncontiguous herniations with severe acute right-sided L5 and S1 radiculopathy. This would have otherwise required either two different endoscopic approaches or a more extensive open approach for successful discectomy

BACKGROUND: The authors report the case of a 65-year-old male with a 22-year delayed recurrence of a spinal chordoma. The patient originally underwent resection of a C4–5 chordoma in 2001 in Boston followed by proton beam radiotherapy. OBSERVATIONS: In August 2023, the patient presented with neck pain, shoulder pain, urinary frequency, and increased mechanical falls and was found to have a recurrence of chordoma. He underwent an anterior cervical corpectomy from C3 to C6, followed by C2–T2 posterior fusion and stereotactic body radiotherapy (SBRT). As of October 2024, there are no suspicious lesions or suspicious uptake on PET CT. LESSONS: The case is notable due to the extreme length of time between the initial resection and the recurrence. The frequency of follow-up imaging is determined by how complete the resection was, but in general, chordomas should be imaged every 6 months for the first 5 years. After 5 years, annual MRI for at least 15 years is recommended by the Chordoma Foundation. However, this case shows that recurrence can occur later than 15 years, suggesting that annual MRI with and without contrast for the duration of life may be more prudent to detect late recurrence. https://thejns.org/doi/10.3171/CASE25337

Introduction: Spinal cord injury (SCI) animal models often utilize an open surgical laminectomy, which results in animal morbidity and also leads to changes in spinal canal diameter, spinal cord perfusion, cerebrospinal fluid flow dynamics, and spinal stability which may confound SCI research. Moreover, the use of open surgical laminectomy for injury creation lacks realism when considering human SCI scenarios.Methods: We developed a novel, image-guided, minimally invasive, large animal model of SCI which utilizes a kyphoplasty balloon inserted into the epidural space via an interlaminar approach without the need for open surgery.Results: The model was validated in 5 Yucatán pigs with imaging, neurofunctional, histologic, and electrophysiologic findings consistent with a mild compression injury.Discussion: Few large animal models exist that have the potential to reproduce the mechanisms of spinal cord injury (SCI) commonly seen in humans, which in turn limits the relevance and applicability of SCI translational research. SCI research relies heavily on animal models, which typically involve an open surgical, dorsal laminectomy which is inherently invasive and may have untoward consequences on animal morbidity and spinal physiology that limit translational impact. We developed a minimally invasive, large animal model of spinal cord injury which utilizes a kyphoplasty balloon inserted percutaneously into the spinal epidural space. Balloon inflation results in a targeted, compressive spinal cord injury with histological and electrophysiological features directly relevant to human spinal cord injury cases without the need for invasive surgery. Balloon inflation pressure, length of time that balloon remains inflated, and speed of inflation may be modified to achieve variations in injury severity and subtype.

Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, potentially causing spinal cord or nerve root compression. Traditional surgical treatment for patients with thoracic disc herniations requires relatively invasive anterior or posterolateral approaches that involve extensive muscular dissection and removal of bone in order to access and remove the disc herniation without causing undue compression of the spinal cord. Full endoscopic thoracic discectomy is a minimally invasive technique which allows for the resection of thoracic disc herniations through a small (1 cm) incision, minimizing collateral tissue trauma and obviating the need for the extensive muscle dissection and bony removal required for traditional surgical approaches. In this article, we describe in detail the operative technique for full endoscopic thoracic discectomy and discuss the pearls and pitfalls of the technique. We also provide a review of the outcomes and complications as seen in the literature.

Chordoma is a low-grade notochordal tumor of the skull base, mobile spine and sacrum which behaves malignantly and confers a poor prognosis despite indolent growth patterns. These tumors often present late in the disease course, tend to encapsulate adjacent neurovascular anatomy, seed resection cavities, recur locally and respond poorly to radiotherapy and conventional chemotherapy, all of which make chordomas challenging to treat. Extent of surgical resection and adequacy of surgical margins are the most important prognostic factors and thus patients with chordoma should be cared for by a highly experienced, multi-disciplinary surgical team in a quaternary center. Ongoing research into the molecular pathophysiology of chordoma has led to the discovery of several pathways that may serve as potential targets for molecular therapy, including a multitude of receptor tyrosine kinases (e.g., platelet-derived growth factor receptor [PDGFR], epidermal growth factor receptor [EGFR]), downstream cascades (e.g., phosphoinositide 3-kinase [PI3K]/protein kinase B [Akt]/mechanistic target of rapamycin [mTOR]), brachyury—a transcription factor expressed ubiquitously in chordoma but not in other tissues—and the fibroblast growth factor [FGF]/mitogen-activated protein kinase kinase [MEK]/extracellular signal-regulated kinase [ERK] pathway. In this review article, the pathophysiology, diagnosis and modern treatment paradigms of chordoma will be discussed with an emphasis on the ongoing research and advances in the field that may lead to improved outcomes for patients with this challenging disease.