Young-Seo Park

Background/Objectives: Cauda equina syndrome (CES) is a rare but severe complication of lumbar disc herniation (LDH). This study aimed to assess the diagnostic value of the dural sac cross-sectional area (DSCSA) in predicting CES in affected patients. Methods: In this retrospective observational study, we analyzed 99 patients who underwent surgery for LDH, including cases with CES, between 2014 and 2023. The DSCSA was measured at the narrowest level of the dural sac using axial T2-weighted magnetic resonance imaging. Univariable and multivariable logistic regression were performed on DSCSA and other candidate risk factors. Results: Among the patients with LDH, nine (9.1%) had CES. In multivariable logistic regression, DSCSA was associated with CES, with an adjusted odds ratio of 0.79 (95% confidence interval [CI]: 0.62–0.90, p = 0.011). Exploratory receiver operating characteristic analysis identified an optimal DSCSA cut-off of 31.16 mm², yielding 100% sensitivity, 92.2% specificity, and an area under the curve of 0.974 (95% CI: 0.944–1.000, p < 0.001). Conclusions: Smaller DSCSA was associated with CES in patients with LDH. Patients with a DSCSA of approximately 30 mm² or less may require closer monitoring for the development of CES symptoms. Given the limited number of CES cases, these findings should be interpreted cautiously and validated in larger studies.

Minimally invasive spine surgery (MISS), supported by advancements in endoscopic systems, tubular retractors, lateral access corridors, image-guided navigation, and robotic assistance, has progressively expanded its role in the management of a broad spectrum of spinal disorders. These approaches were developed to limit muscular disruption and soft tissue damage while maintaining clinical and radiographic outcomes comparable to those of conventional open techniques. Current evidence across multiple surgical procedures indicates reductions in intraoperative blood loss, hospitalization duration, postoperative analgesic requirements, and time to functional recovery. Despite these advantages, MISS remains constrained by technical and procedural limitations. Restricted visualization, reduced working space, and dependence on fluoroscopy for navigation contribute to substantial operative complexity and prolonged learning curves. Procedure-specific risks persist, including increased radiation exposure during minimally invasive transforaminal lumbar interbody fusion, limited haptic feedback in endoscopic spine surgery, and neural or retroperitoneal complications during lateral interbody fusion. Although navigation and robotic platforms improve implant accuracy and the surgeon's radiation safety, high acquisition and maintenance costs, workflow integration challenges, and patients' radiation exposure continue to limit their widespread adoption. Future development will require cost-efficient technological refinement, standardized training pathways, and enhanced intraoperative feedback and decision support systems. Integration of artificial intelligence with robotic platforms is anticipated to further optimize surgical precision and workflow efficiency, supporting the continued evolution of MISS.