Maria Auron

Degenerative lumbar spondylolisthesis (DLS) combines neural compression with a variable mechanical phenotype, creating uncertainty over whether decompression alone is sufficient or fusion is required. Over the last few decades, endoscopic spine surgery (ESS) has opened new avenues for ultra-minimally invasive decompression with minimal bony resection, reducing the risk of iatrogenic destabilization. Against this background, the emergence of ESS has added a new dimension to the debate over surgical decision-making in DLS. This debate-style review compares endoscopic decompression versus fusion for DLS across 7 domains: learning curve and training, technical feasibility and surgical nuances, patient selection and indications, clinical and radiological outcomes, complication profile and management, cost-effectiveness and economic analysis, and reoperation/revision rates. The literature supports endoscopic decompression as a tissue-preserving option for carefully selected patients with stable, low-grade DLS and predominant leg symptoms, whereas fusion remains appropriate when objective instability, mechanical pain, or destabilizing decompression makes reconstruction necessary. Clinical outcomes may be similar in selected stable disease phenotypes, but fusion provides more predictable radiographic correction, with the durability of DLS-specific endoscopic outcomes remaining less certain in the longer term. Additionally, endoscopic decompression and fusion have different risk profiles: the former concentrates concerns around technical execution, incomplete decompression, and delayed conversion to revision or later fusion, while the latter introduces potential approach-, implant-, pseudarthrosis-, and adjacent segment-related complications. An international survey of 63 ESS-experienced spine surgeons supported endoscopic decompression for stable single-level disease (60 of 63, 95.2%) and fusion in case of instability (49 of 63, 77.8%), while intermediate scenarios remained divided. Respondents strongly endorsed long-term multicenter randomized comparisons (62 of 63, 98.4%). Because the panel consisted of ESSexperienced surgeons who predominantly favored decompression-only procedures, its results quantify structured expert opinion rather than treatment preferences in the wider spine community. The aggregate evidence therefore supports equipoise rather than a universal winner. The clinically relevant question is which strategy best matches the patient’s symptom generator, mechanical phenotype, operative risk, local resources, and surgeon expertise.

Degenerative lumbar spine disease is common in the elderly, but spinal fusion is often avoided in patients over 90 years due to perceived risks of surgical or anaesthesia-related complications. Full-endoscopic transforaminal lumbar interbody fusion (FE-TLIF) via the trans-Kambin approach offers a minimally invasive alternative that can be performed without general anaesthesia. We report a nonagenarian patient with recurrent symptomatic foraminal stenosis at L4–L5 after prior decompression surgeries who underwent FE-TLIF under local anaesthesia. The procedure was well tolerated, with significant pain relief, early mobilisation and radiological evidence of initial fusion at 10 months follow-up. This case illustrates that age alone should not be considered an absolute contraindication for spinal fusion. Surgical decision-making should prioritise physiological rather than chronological age, and in experienced hands, endoscopic spinal fusion may represent a safe and effective treatment option even in carefully selected nonagenarians.

Background: The prevalence of sacral insufficiency fractures resulting from minor trauma has been on the rise in parallel with the globally aging population. For similar injuries typical to the elderly population, such as hip fractures, surgery and early mobilization have been shown to improve postoperative mortality and morbidity rates. As such, there has been a recent increase in the literature in studies advocating for early surgical fixation for sacral insufficiency fractures. However, traditional fluoroscopic techniques are technically demanding and bear an inherent complication risk even in experienced hands. Robotic-assisted surgery has emerged as a promising technological advancement in spinal and pelvic surgery. We share our experience with this surgical technique. Methods: We conducted a retrospective analysis of five consecutive patients with sacral insufficiency fractures who failed non-operative management. Using the Mazor X robotic system, patients underwent CT-planned, guided placement of fenestrated sacroiliac screws followed by cement augmentation. Primary outcomes included surgical time, radiation exposure, complications, and mobilization, with a minimum three-month follow-up. Results: The cohort consisted of five females with a mean age of 78 years. The mean operative time was 36 min (15–47), and the median fluoroscopy count was 13 shots (6–19). All patients reported significant pain relief and achieved successful mobilization on postoperative day 1. No operative or postoperative complications were recorded. Conclusions: This pilot study suggests that robotic-assisted percutaneous sacroiliac fixation with cement augmentation is a safe, efficient, and minimally invasive approach for the treatment of sacral insufficiency fractures. The precision of the robotic system facilitates stable fixation, providing immediate pain relief and early mobilization with a favorable complication profile. Further studies should be performed to verify these findings.

Background/Objectives: Long-term bisphosphonate (BP) therapy is an effective treatment for osteoporosis but has been associated with rare complications such as atypical femoral fractures (AFFs). Emerging reports suggest that similar insufficiency fractures may also occur in other skeletal sites, including the lumbar pedicles. This study reports two rare cases of isolated bilateral lumbar pedicle stress fractures in patients on prolonged BP therapy. Along with a structured literature review, the objective was to evaluate whether diagnostic criteria derived from those used for AFFs may apply to these atypical vertebral fractures. Methods: Two patients with osteoporosis and on long-term BP therapy diagnosed with isolated lumbar pedicle stress fractures were retrospectively analyzed. A structured literature review identified similar reported cases. All cases were evaluated using the 2010 American Society for Bone and Mineral Research AFF criteria to assess applicability to isolated pedicle stress fractures. Results: Both patients demonstrated bilateral lumbar pedicle fractures without vertebral body involvement. One was treated conservatively; the other underwent robotic-assisted percutaneous pedicle screw fixation with documented fracture healing at six months. The literature review identified eight similar cases of isolated pedicle fractures in patients on prolonged BP therapy. Clinical course and imaging findings demonstrated stress-type features analogous to AFFs. The proposed AFF-based diagnostic criteria for pedicular insufficiency fractures were found to be applicable to all ten patients. Conclusions: Isolated bilateral pedicle stress fractures may represent a spinal analog of AFFs. Based on shared clinical and imaging features, we propose preliminary diagnostic criteria for atypical pedicular insufficiency fractures. Increased awareness and standardized criteria may aid in early diagnosis and reporting, encouraging further studies on this rare spinal entity.