Spinal Pathologies & Diseases

Management of inflammatory, infectious, and neoplastic spinal pathologies, including spinal tuberculosis and metastatic disease, with a focus on deformity and neurological deficits.

Overview

Appropriate patient selection is critical for achieving successful surgical outcomes in metastatic cervical spine tumors, specifically to restore spinal stability and improve quality of life [1]. In contrast, the natural history of Langerhans cell histiocytosis lesions in the spine, absent systemic disease or deformity, typically precludes aggressive surgical management, necessitating only follow-up to monitor recovery and spinal balance [3]. For Charcot arthropathy of the spine, treatment goals focus on limiting symptoms and providing stabilization, though surgical intervention can be demanding and may require alternative instrumentation techniques [9].

Management of degenerative spine diseases in an aging society requires a thorough understanding of clinical aging indices to select effective treatment approaches [16]. While age is not a contraindication for decompressive lumbar spine surgery in elderly patients [24], the optimal indications for lumbar laminoplasty remain young, active patients with central spinal stenosis [26]. Absolute surgical indications for disc herniation include deteriorating neurological deficits with myelopathy and cauda equina syndrome [30], whereas spondylolisthesis of grade 3 or 4 in children and teenagers warrants spine fusion as the best surgical treatment [31].

A systematic approach involving patient assessment, differential diagnosis formulation, and familiarity with various surgical approaches is required for adult patients presenting with late or chronic complications after spinal surgery [13]. Retrospective assessment of spinal surgery outcomes has been shown to be highly reproducible [17]. Furthermore, there is an established need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis and formulate reliable inclusion criteria for clinical studies [23].

Anatomy & Pathophysiology

Thoracolumbar degenerative conditions encompass a spectrum from asymptomatic states to catastrophic malalignment and disability [5], while cervical spinal deformity presents as a debilitating condition with diverse etiologies [18]. Recent efforts prioritize classification schemes and treatment algorithms to clarify outcomes and the relationship between cervical and thoracolumbar alignment [18]. Clinical examination findings can be evaluated to identify the most common patho-anatomical disorders in the lumbar spine [6].

Osseous & Biomechanical Characteristics: Su's three-column theory aligns with vertebral physiological structure, fracture characteristics, and biomechanics [58]. The biomechanics of the lumbar spine vary by individual [65], where L4–5 dislocation may represent a variant of lumbosacral (L5-S1) dislocation due to hyperextension injury [65]. Total laminectomy alters biomechanics in both normal lumbar models and spondylolisthesis models [74]. Different forms of scoliosis exhibit distinct vibrational characteristics, with scoliotic vertebrae acting as weak links under whole-body vibration loading [92]. The severity of spinal deformity, rather than curvature direction, primarily determines its impact on cardiac health [88].

Pathophysiology of Degeneration & Herniation: In type I thoracolumbar disc herniation, disc degeneration accelerates due to regional kyphosis [89], whereas type II herniation involves excessive mechanical stress directly loaded at the thoracolumbar apex [89]. Both single-segment dynamic stabilization systems result in degeneration at the fixed segment [60]. The combination of lumbar spine characteristics, including bony canal and vertebral body dimensions, is highly associated with symptomatic degenerative lumbar spinal stenosis onset rather than any sole variable [90]. A study aimed to identify pathoanatomical pathways of degeneration in lumbar motion segments by clustering MRI findings [94].

Cervical & Thoracic Pathology: Axial loading of the cervical spine is the primary injury mechanism in catastrophic cervical spine injuries in football players [91]. Kinematic MRI demonstrates dynamic pathoanatomical changes, such as canal stenosis in different positions, in patients with cervical spinal cord injury without fracture and dislocation [79]. Further studies are needed to elicit the specific underlying mechanism between sagittalization of the cervical facet joints and cervical spinal stenosis pathology [93]. Numerous associated and risk factors for thoracic spine pain exist across biopsychosocial categories, including concurrent musculoskeletal pain, psychological factors, and specific postural or lifestyle factors, though many associations between risk factors and thoracic spine pain were weak or inconsistent across studies [98].

Deformity Progression & Classification: Scoliosis in Duchenne muscular dystrophy children is fully reducible in the initial stage, but spinal curve flexibility decreases over time as the curve progresses [96]. A parameter for compensatory classification in spine sagittal malalignment with lumbar degeneration might help evaluate spine sagittal alignment in elderly patients with lumbar degeneration [95]. Fusion and fixation range selection in intervertebral surgery for thoracolumbar and lumbar tuberculosis effectively restores physiological curvature and reduces degeneration of adjacent vertebral bodies [21]. A novel rabbit model of angular kyphosis provides a reliable platform for investigating the pathophysiology of spinal deformities and evaluating therapeutic interventions [14].

Classification

Lumbar Degenerative Disease: This condition is characterized by a high prevalence of asymptomatic degeneration [4]. Distinguishing spinal causes from extraspinal causes is critical during the evaluation of low back pain [4]. Thoracolumbar degenerative conditions span a spectrum from asymptomatic states to catastrophic spinal malalignment and disability [5]. Furthermore, spinal classification can serve as a predictor of lumbar disc degeneration [50].

Cervical Spinal Deformity: Cervical spinal deformity is a debilitating condition with diverse etiologies [18]. Recent efforts focus on classification schemes and treatment algorithms to understand outcomes [18]. These schemes aim to elucidate the relationship between cervical and thoracolumbar spinal alignment [18].

Pediatric Spine Disorders: Pediatric spine disorders include idiopathic scoliosis, congenital anomalies, and tumors [32]. Evaluation requires detailing pathoanatomy, classification, and treatment recommendations based on natural history [32]. A novel classification system for early-onset scoliosis was developed utilizing formal consensus-building methods [62]. The Classification of Early-Onset Scoliosis (C-EOS) demonstrated substantial to excellent interobserver reliability for all core components [62].

Lumbar Disc Herniation: The modified classification for migrated lumbar disc herniation possesses good reliability [63]. This reliability is not affected by the experience level of spine surgeons [63].

Thoracic and Lumbar Fractures: Classifications of thoracic and lumbar fractures are generalizations that provide an efficient means of communication [64]. However, many original reports describing common thoracic and lumbar injury classifications lack a rigorous scientific foundation [64]. These original reports were often based largely on the insights of experienced surgeons [64]. The Thoracolumbar Injury Classification and Severity Score (TLICS) was developed to address limitations of prior systems [71]. TLICS defines injury based on morphology, posterior ligamentous complex integrity, and neurologic status [71]. TLICS offers prognostic information and aids medical decision making [71].

Low Back-Related Leg Pain: Numerous classification systems exist for patients with low back-related leg pain [67]. A minority of these systems focus specifically on distinguishing between different presentations of leg pain [67].

Spinal Stenosis: No clinically applicable and validated classification of spinal stenosis has been published [53]. The lack of a clinically applicable and validated classification has substantially limited the development of an evidence-based algorithm for treatment [53].

Hip-Spine Pathology: The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively [54]. This system guides the use of dual mobility components in patients with spinopelvic pathology [54]. It is also used to reduce the risk of dislocation in high-risk patients with spinopelvic pathology [54].

Historical Context: The 1948 work by Jean Saidman features a detailed atlas of roentgenography and extensive diagnostic descriptions of spine diseases [33]. Treatment sections in this 1948 work are generally characterized [33].

Other Considerations: Distinguishing spinal causes from extraspinal causes is important in the evaluation of low back pain [4]. Thoracolumbar degenerative conditions range from asymptomatic states to catastrophic spinal malalignment and disability [5].

Clinical Presentation

Appropriate patient selection is critical for surgical management of metastatic cervical spine tumors to restore stability and improve quality of life [1]. Evaluation of lumbar degenerative disease and low back pain requires distinguishing spinal causes from extraspinal etiologies, as these conditions frequently present with a high prevalence of asymptomatic degeneration [4]. Thoracolumbar degenerative conditions span a wide spectrum from asymptomatic states to catastrophic malalignment and disability [5]. Clinical examination findings must be evaluated for their ability to identify the most common patho-anatomical disorders in the lumbar spine [6].

Physical examination of the spine includes inspection, palpation, range of motion testing, and neurologic evaluation to identify spinal pathology, nonspinal conditions, and signs of symptom magnification [45]. Recognition of both hip and lumbar spine pathologies may reduce misdiagnosis, and managing both in the appropriate sequence helps reduce persistent symptoms [10]. Shoulder and spine surgeons must remain vigilant in accurately diagnosing the etiology of presenting symptoms to ensure proper management and optimize prognosis [38]. Evaluation of cervical degenerative disorders emphasizes recognizing key signs and symptoms to differentiate presentations ranging from mild neck pain to severe spinal cord and nerve root injury [37].

Red-flag patterns: The most frequently reported clinical feature of spinal infection is the classic triad of spinal pain, fever, and neurological dysfunction [44]. Spinal infections are common in immunosuppressed patients and often cause significant morbidity and mortality [43, 44]. Diagnostic delay in anaerobic spondylodiscitis may occur due to atypical radiographs when patients report only back pain without fever [12]. Delayed diagnosis of musculoskeletal tuberculosis can result in incurable spinal damage [2]. Echinococcosis of the spine presents with specific clinical, laboratory, and diagnostic findings [42].

Pediatric and developmental considerations: Pediatric cervical spine disorders pose unique challenges requiring an understanding of normal growth variations and disparate presentations from infancy through adolescence [39]. In the absence of systemic disease or spinal deformity, aggressive surgical management is usually not indicated for Langerhans Cell Histiocytosis of the spine in children; only follow-up is necessary to monitor recovery and spinal balance [3]. Late diagnosis of scoliosis caused by benign osteoblastoma of the thoracic or lumbar spine, particularly when structural changes or instability occur, may require correction and stabilization [7]. Accessory ossicles of the spine exhibit varied prevalence and clinical significance, with some presenting minor associations with symptoms and others linked to specific syndromes or spinal disorders [40].

Diagnostic limitations and approaches: Few MRI findings show large magnitude associations with symptom outcomes such as chronic low back pain or radicular symptoms [11]. A systematic approach to treatment for adult patients presenting with late or chronic complications after spinal surgery involves patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches [13]. A novel rabbit model of angular kyphosis provides a reliable platform for investigating the pathophysiology of spinal deformities and evaluating therapeutic interventions [14].

Investigations

Plain radiography: While a 1948 work features a detailed atlas of roentgenography and extensive diagnostic descriptions [33], plain radiographs have limitations in infectious contexts. Diagnostic delay in anaerobic spondylodiscitis may occur because of atypical spinal radiographs if the patient reports only back pain but no fever [12].

MRI: Magnetic resonance imaging is the modality of choice for evaluation of ligamentous and other soft tissue structures, disc, spinal cord, and occult osseous injuries in acute spinal trauma [75]. It is invaluable for identifying infectious spondylitis, assessing its extent, and guiding treatment [55]. In children with discitis, MRI provides necessary anatomical detail to determine the extent of infection and the condition of surrounding soft tissues as a non-invasive, non-irradiating modality [73]. Due to multifocal spondylodiscitis being found in approximately 13% of cases, MRI imaging of the total spine is recommended to avoid overlooking additional infection levels [70]. Gas accumulation in the spinal canal is a common clinical disease which can be identified by CT and MRI [66]. Investigation represents the best available evidence regarding the radiographic and clinical natural history of cervical degeneration [68], with a progression of degenerative changes detected in nearly all subjects over a 20-year period [77]. However, MRI abnormalities examined are not major predictors of outcome in patients with low back pain [78], and few MRI findings showed large magnitude associations with spine-related symptom outcomes even when applying more specific definitions for symptom outcomes [11].

CT: The combination of MRI and CT allows for making the correct diagnosis in most cases of hematopoietic islands mimicking osteoblastic metastases within the axial skeleton [76].

Other Considerations: Appropriate patient selection for surgical management of metastatic cervical spine tumors can lead to successful outcomes by restoring spinal stability and improving quality of life [1]. Delayed diagnosis and treatment of musculoskeletal tuberculosis can result in incurable spinal damage and other consequences [2]. Aggressive surgical management is usually not indicated for Langerhans cell histiocytosis of the spine in children in the absence of systemic disease or spinal deformity; only follow-up is necessary to monitor recovery and spinal balance [3]. Thoracolumbar degenerative conditions comprise a wide spectrum of pathology ranging from asymptomatic states to catastrophic spinal malalignment and disability [5]. Clinical examination findings have been evaluated in a comprehensive systematic review for their ability to identify the most common patho-anatomical disorders in the lumbar spine [6]. Late diagnosis of scoliosis caused by benign osteoblastoma of the thoracic or lumbar spine, particularly when structural changes are present or instability occurs due to excision extent, may require correction and stabilization [7]. Recognition of both hip and lumbar spine pathologies may help reduce the likelihood of misdiagnosis [10], and management of both hip and lumbar spine pathologies in the appropriate sequence may help reduce the likelihood of persistent symptoms [10]. Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging [72] and most frequently occur at L4/L5 and L5/S1 levels [72].

Treatment

Non-Operative

Conservative management remains a viable strategy for specific spinal pathologies. Nonoperative treatment with collar immobilization and activity modification improves functional status in selected patients with mild cervical spondylotic myelopathy, though careful monitoring is necessary as neurological deterioration can occur [82]. Non-surgical spinal decompression is associated with a reduction in discogenic low back pain and an increase in disc height [87]. Platelet-rich plasma epidural injection is recommended for treating single-level lumbar herniated nucleus pulposus due to its efficacy and safety [46]. Management of lumbar degenerative disease and low back pain emphasizes the high prevalence of asymptomatic degeneration and the importance of distinguishing spinal from extraspinal causes [4].

Operative

Indications: Surgical intervention is indicated for absolute neurological compromise, including deteriorating neurological deficits with myelopathy or cauda equina syndrome in disc herniation [30]. Spondylolisthesis of grade 3 or 4 serves as an indication for surgical treatment in children and teenagers [31]. Age is not a contraindication for decompressive lumbar spine surgery in elderly patients with lumbar spinal stenosis [24], and operative treatment of lumbar stenosis and degenerative spondylolisthesis offers significant benefit over nonoperative treatment in patients at least eighty years of age [86]. Recent prospective randomized studies demonstrate that surgery is superior to nonsurgical management for controlling pain and improving function in lumbar spinal stenosis [80], with short-term data indicating operative management provides more effective relief than nonoperative treatment [8]. Surgical selection of fusion and fixation range in intervertebral surgery for thoracolumbar and lumbar tuberculosis effectively restores physiological curvature and reduces degeneration of adjacent vertebral bodies [21]. Treatment of scoliosis is effective in limiting curve progression, particularly with preservation of motion segments [51].

Surgical Approach / Technique: For Charcot arthropathy of the spine, surgical treatment can be demanding and may require alternative techniques of instrumentation to limit symptoms and provide stabilization [9]. Staged surgery effectively achieves neurological functional recovery in patients with multi-segment spinal stenosis in the thoracic and lumbar regions, demonstrating favorable efficacy and safety [47]. Both oblique lumbar interbody fusion (OLIF) and posterior lumbar interbody fusion (PLIF) interventions show good clinical efficacy for lumbar degenerative diseases [48]. Isobar hybrid dynamic stabilization with posterolateral fusion presents an alternative treatment for individuals with mild and moderate lumbar degenerative disease [41]. Successful and reliable treatment has been developed for mild or moderate involvement of spondylolysis and spondylolisthesis in children and adolescents, whereas the role of surgical reduction for severe deformities in this population remains undefined [84].

Implant Selection: Spine fusion is the best surgical treatment for spondylolisthesis of grade 3 or 4 in children and teenagers [31]. The general clinical efficacy of Isobar hybrid dynamic stabilization with posterolateral fusion is equivalent to titanium rod fusion surgery for mild and moderate lumbar degenerative disease [41]. Autograft (AG) may be the optional treatment for spinal tuberculosis owing to outcomes of surgical safety [49].

Alignment / Balancing Strategy: Surgical selection of fusion and fixation range in intervertebral surgery for thoracolumbar and lumbar tuberculosis reduces the degeneration of adjacent vertebral bodies in the spinal column [21].

Pain Management: Guidelines for the management of cervical, thoracic, and lumbar fractures discuss both surgical and nonsurgical strategies [83]. Conservative and surgical treatments are safe and effective and produce good clinical outcomes for patients with lumbosacral tuberculosis [52].

Other Considerations: Appropriate patient selection for metastatic cervical spine tumors can lead to successful surgical outcomes by restoring spinal stability and improving quality of life [1]. Delayed diagnosis and treatment of spinal tuberculosis may result in incurable spinal damage and other consequences [2]. Thorough understanding of patient characteristics is essential when managing degenerative spine diseases, particularly in selecting effective treatment approaches for an aging society [16]. Retrospective assessment of spinal surgery outcome is highly reproducible [17]. There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis to improve diagnostic accuracy and formulate reliable inclusion criteria for clinical studies [23]. The best indications for the lumbar laminoplasty procedure are young and active patients with central spinal stenosis [26]. Prospective studies comparing nonoperative and operative interventions on the long-term natural history of lumbar spinal stenosis are needed [8]. The authors recommend the revision of the DGUV recommendations for the evaluation of occupational diseases of the lumbar spine [69].

Complications

Delayed Diagnosis and Progression: Delayed diagnosis and treatment of spinal tuberculosis can lead to incurable spinal damage and other consequences [2]. The natural history of untreated spondylothoracic dysostosis confirms a restrictive pulmonary pattern but notes better quality of life scores than neuromuscular populations [34]. A thorough knowledge of the natural history of congenital kyphosis and kyphoscoliosis is essential to prevent progression of the deformity and neurological complications [25]. Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficit, often requiring additional fusion procedures [27].

Neurological Sequelae and Deficits: Many patients with cauda equina syndrome continued to experience sexual issues in long-term follow-up, with rates ranging from 14% to 100% [20]. Adults with sacral myelomeningocele have much poorer outcomes than children, do not uniformly do well on a long-term basis, and need continued orthopaedic care into adulthood [22]. Diabetes, advanced age, and long-term cervical spondylotic myelopathy symptoms adversely affect outcomes of cervical laminoplasty [56].

Reoperation and Instability: Cervical and lumbar spinal lesions led to reoperations in patients undergoing posterior decompression and fusion for thoracic ossification of the posterior longitudinal ligament, though these did not affect quality of life [15]. Relative improvement in outcomes was maintained even after 10 years for patients undergoing posterior decompression and fusion for thoracic ossification of the posterior longitudinal ligament [15]. Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficit, often requiring additional fusion procedures [27].

Other Considerations: Aggressive surgical management is usually not indicated for Langerhans Cell Histiocytosis of the spine in children in the absence of systemic disease or spinal deformity; only follow-up is necessary [3]. Operative management for degenerative lumbar stenosis provides more effective relief than nonoperative treatment in the short term, though prospective studies comparing nonoperative and operative interventions on the long-term natural history of lumbar spinal stenosis are needed [8]. The natural history of lumbar spinal stenosis differs according to the grade of maximal central and foraminal stenoses [19]. Long-term follow-up is needed to study the clinical effects of percutaneous transforaminal endoscopic decompression for lumbar spinal stenosis with degenerative lumbar spondylolisthesis [28]. Understanding the complexity of spinal surgery patients' long-term well-being is crucial in effectively treating chronic debilitating somatic diseases and associated mental illnesses [29]. The natural history of vertebral involvement in histiocytosis X involves restoration of varying degrees in vertebral height, which can occur even after complete collapse (vertebra plana) [35]. Monostotic fibrous dysplasia of the spine has a benign natural history where symptoms typically resolve within two years, and lesions generally remain static over long-term follow-up without progression to sarcoma or pathologic fracture [36]. Most studies indicate that long-term outcomes are not negatively affected if dural tears are diagnosed early and managed appropriately [57]. Kennedy suffered from degenerative disease of the lumbar spine rather than congenital instability or osteoporosis [85].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity or return to desk work across the provided literature. However, appropriate patient selection for metastatic cervical spine tumors is critical to restore stability and improve quality of life [1], while aggressive surgical management is generally not indicated for pediatric Langerhans cell histiocytosis of the spine absent systemic disease or deformity, necessitating only follow-up to monitor recovery and spinal balance [3].

Full activity (months): The literature does not define a specific month range for full activity or return to manual labor. Correction and stabilization are required for scoliosis caused by benign osteoblastoma of the thoracic or lumbar spine if late diagnosis, structural changes, or instability from excision occur [7]. Operative management for degenerative lumbar stenosis provides more effective short-term relief than nonoperative treatment, though prospective studies comparing long-term natural history are still needed [8].

Complete recovery / outcome plateau (months): Long-term outcomes for posterior decompression and fusion in thoracic ossification of the posterior longitudinal ligament show relative improvement maintained even after 10 years [15]. Vertebra plana demonstrates significant long-term reconstitution of vertebral height, particularly in younger patients, with no residual kyphosis or symptoms in adulthood [99]. Conversely, long-term follow-up of cauda equina syndrome patients reveals persistent sexual issues ranging from 14% to 100% [20], with frequent reports of severe back pain and ongoing autonomic dysfunction at a mean follow-up of five years [61]. Adults with sacral myelomeningocele have poorer outcomes than children, do not uniformly do well long-term, and require continued orthopaedic care into adulthood [22].

Rehabilitation protocol: A thorough knowledge of the natural history of congenital kyphosis and kyphoscoliosis is essential to plan appropriate, timely treatment to prevent deformity progression and neurological complications [25]. Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficits, often requiring additional fusion procedures [27]. The goals of treatment for Charcot arthropathy of the spine are to limit symptoms and provide stabilization, though surgical treatment can be demanding and may require alternative instrumentation techniques [9]. Delayed diagnosis and treatment of musculoskeletal tuberculosis can result in incurable spinal damage [2].

Functional milestones: Patients with a history of lumbosacral pathology achieve significantly lower short-term meaningful clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome compared to those without spine pathology [97]. Cervical and lumbar spinal lesions in patients with thoracic ossification of the posterior longitudinal ligament led to reoperations but did not affect quality of life [15]. Untreated adult patients with spondylothoracic dysostosis exhibit a restrictive pulmonary pattern but report better quality of life scores than neuromuscular populations [34]. Understanding the complexity of spinal surgery patients' long-term well-being is crucial for treating chronic debilitating somatic diseases and associated mental illnesses [29].

Other Considerations: The natural history of lumbar spinal stenosis differs according to the grade of maximal central and foraminal stenoses [19]. Long-term follow-up is needed to study the clinical effects of percutaneous transforaminal endoscopic decompression with removal of the posterosuperior region underneath the slipping vertebral body for lumbar spinal stenosis with degenerative lumbar spondylolisthesis [28]. The natural history of vertebral involvement in histiocytosis X involves restoration of varying vertebral height, which can occur even after complete collapse (vertebra plana) [35]. Monostotic fibrous dysplasia of the spine has a benign natural history where symptoms typically resolve within two years and lesions remain static without progression to sarcoma or pathologic fracture [36]. Long-term follow-up of six patients with intervertebral-disc calcification in childhood revealed cervical spine abnormalities in four, suggesting a more guarded prognosis for long-term normal function than previously assumed [59].

Key Evidence

• [L5] Appropriate patient selection can lead to successful surgical outcomes by restoring spinal stability and improving quality of life. (10.5435/jaaos-23-01-38)
• [L4] If the diagnosis and treatment are delayed, spinal damage and other consequences might be incurable. (10.1186/s12891-021-04426-y)
• [L4] The natural history of these lesions in the spine in the absence of systemic disease or spinal deformity is such that aggressive surgical management is usually not indicated; only follow-up is necessary to monitor recovery and spinal balance. (10.2106/00004623-200408000-00019)
• [L1] This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. (10.1186/s12891-017-1549-6)
• [L4] In the event of late diagnosis and the presence of structural changes in the spine, or when the spine becomes unstable due to the extent of the excision, correction and stabilization may be required. (10.2106/00004623-198163070-00012)
• [L5] Short-term follow-up data indicate that operative management provides more effective relief than nonoperative treatment, but prospective studies comparing the effects of nonoperative and operative interventions on the long-term natural history of lumbar spinal stenosis are needed. (10.5435/00124635-199907000-00004)
• [L5] The goals of treatment are to limit symptoms and provide spinal stabilization, though surgical treatment can be demanding and may require alternative techniques of instrumentation. (10.5435/jaaos-d-22-00212)
• [L5] The recognition of both hip and lumbar spine pathologies may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms. (10.5435/jaaos-d-15-00740)
• [L2] Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. (10.1186/1471-2474-15-152)
• [L4] Diagnostic delay may occur because of atypical spinal radiographs if the patient reports only back pain but no fever. (10.1186/s12891-022-05749-0)
• [L5] A systematic approach to treatment is required for the adult patient presenting with late or chronic complications after spinal surgery, involving patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches. (10.5435/jaaos-d-16-00530)
• [L5] It provides a reliable platform for investigating the pathophysiology of spinal deformities and evaluating therapeutic interventions. (10.1186/s13018-025-06220-1)
• [L4] The long-term outcomes revealed that although cervical and lumbar spinal lesions led to reoperations, they did not affect QoL, and relative improvement was maintained even after 10 years. (10.2106/jbjs.23.01475)
• [L3] Thorough understanding of these characteristics is essential when managing degenerative spine diseases, particularly in the selection of effective treatment approaches for the increasingly aging society in the future. (10.1186/s12891-025-09185-8)
• [L4] Retrospective assessment of spinal surgery outcome is highly reproducible. (10.1186/1471-2474-13-83)
• [L4] Cervical spinal deformity is a debilitating condition with diverse etiologies; recent efforts focus on classification schemes and treatment algorithms to understand outcomes and the relationship between cervical and thoracolumbar spinal alignment. (10.5435/jaaos-d-17-00546)
• [L3] The natural history of lumbar spinal stenosis differs according to the grade of maximal central and foraminal stenoses. (10.1186/s12891-022-05510-7)
• [L2] However, long-term follow-up of cauda equina syndrome patients revealed that many continued to experience sexual issues (14% to 100%). (10.1186/s12891-025-08736-3)
• [L3] It effectively restores the physiological curvature of the spine and reduces the degeneration of adjacent vertebral bodies in the spinal column. (10.1186/s12891-021-04335-0)
• [L4] The outcomes for adults who have a sacral myelomeningocele seem to be much poorer than those reported for children; they do not uniformly do well on a long-term basis and they need continued orthopaedic care into adulthood. (10.2106/00004623-199409000-00003)
• [L1] There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies. (10.1186/1471-2474-12-175)
• [L4] Age is not a contraindication for decompressive lumbar spine surgery. (10.1186/s13018-020-01968-0)
• [L3] A thorough knowledge of the natural history is essential in the planning of appropriate and timely treatment to prevent progression of the deformity and neurological complications. (10.2106/00004623-199910000-00002)
• [L4] The best indications for the lumbar laminoplasty procedure were young and active patients with central spinal stenosis. (10.2106/jbjs.e.00211)
• [L4] However, long-term spinal stability remains a significant challenge, often requiring additional fusion procedures. (10.2106/00004623-196042060-00010)
• [L4] However, long-term follow-up is needed to study clinical effects. (10.1186/s12891-024-07267-7)
• [L3] Understanding the complexity of spinal surgery patients' long-term well-being is crucial in effectively treating chronic debilitating somatic diseases and the associated mental illnesses. (10.1186/s12891-022-05711-0)
• [L5] Absolute surgical indications for disc herniation include deteriorating neurological deficits with myelopathy or cauda equina syndrome. (10.1302/2058-5241.6.210020)
• [L4] Spondylolisthesis of grade 3 or 4 is an indication for surgical treatment, with spine fusion being the best surgical treatment. (10.2106/00004623-197153070-00005)
• [L5] This monumental work is a comprehensive synthesis of literature on spine diseases, featuring a detailed atlas of roentgenography and extensive diagnostic descriptions, though treatment sections are generally characterized. (10.2106/00004623-194830040-00038)
• [L4] The study characterizes the natural history of untreated spondylothoracic dysostosis, confirming a restrictive pulmonary pattern but noting better quality of life scores than neuromuscular populations. (10.2106/jbjs.23.00800)
• [L4] The natural history of vertebral involvement in histiocytosis X is one of restoration of varying degree in vertebral height, which can occur even after complete collapse (vertebra plana). (10.2106/00004623-196951070-00014)
• [L4] Monostotic fibrous dysplasia of the spine is a rare condition with a benign natural history; symptoms typically resolve within two years, and lesions generally remain static over long-term follow-up without progression to sarcoma or pathologic fracture. (10.2106/jbjs.i.00727)
• [L5] Shoulder and spine surgeons should be wary and vigilant of accurately diagnosing the etiology of the presenting symptoms to ensure proper management and optimize prognosis. (10.1016/j.xrrt.2024.02.007)
• [L4] Accessory ossicles of the spine exhibit varied prevalence and clinical significance, with some presenting minor associations with symptoms and others linked to specific syndromes or spinal disorders. (10.1186/s13018-024-05407-2)
• [L3] The general clinical efficacy is equivalent to titanium rod fusion surgery, presenting an alternative treatment for individuals with mild and moderate lumbar degenerative disease. (10.1186/s12891-023-06329-6)
• [L4] This article summarizes the clinical findings of echinococcosis of the spine, discusses specific laboratory and diagnostic findings, lists current treatment options, and reviews patient outcomes. (10.1302/2058-5241.6.200130)
• [L2] In this review, spinal infection was common in those who had conditions associated with immunosuppression, and the most frequently reported clinical feature was the classic triad of spinal pain, fever, and neurological dysfunction. (10.1186/s12891-019-2949-6)
• [L1] Due to its efficacy and safety, the procedure is recommended in treating single level lumbar HNP. (10.1186/s12891-023-06429-3)
• [L4] Staged surgery can effectively achieve neurological functional recovery in patients with multi-segment spinal stenosis in thoracic and lumbar regions, with favorable efficacy and safety. (10.1186/s12891-015-0672-5)
• [L1] Both OLIF and PLIF interventions showed good clinical efficacy for lumbar degenerative diseases. (10.1186/s13018-023-04312-4)
• [L1] The results indicated that AG might be the optional treatment for spinal tuberculosis owing to the outcomes of surgical safety. (10.1186/s13018-023-03848-9)
• [L3] Spinal classification could be used as a predictor of lumbar disc degeneration. (10.1186/s13018-019-1537-7)
• [L4] The study confirms the detrimental effects of scoliosis on patient-reported outcomes, the value of treatment to limit curve progression, and the effectiveness of surgical treatment, especially with preservation of motion segments. (10.2106/jbjs.18.00180)
• [L4] Conservative and surgical treatments are safe and effective and produce good clinical outcomes for patients with lumbosacral tuberculosis. (10.1371/journal.pone.0130185)
• [L5] No clinically applicable and validated classification of spinal stenosis has been published, which has substantially limited the development of an evidence-based algorithm for treatment. (10.5435/jaaos-d-15-00034)
• [L3] The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. (10.1302/0301-620x.103b7.bjj-2020-2448.r2)
• [L5] Imaging techniques, especially MRI, are invaluable tools for clinicians in identifying this condition, assessing its extent, and guiding treatment. (10.1186/s13018-025-05781-5)
• [L2] Diabetes with advanced age and long-term cervical spondylotic myelopathy symptoms adversely affected cervical laminoplasty outcomes. (10.2106/jbjs.n.00064)
• [L5] Most studies indicate that long-term outcomes are not negatively affected if dural tears are diagnosed early and managed appropriately. (10.5435/00124635-201009000-00005)
• [L4] The authors provide strong evidence that Su's three-column theory complies with the characteristics of vertebral physiological structure, vertebral fracture, and vertebral biomechanics. (10.1186/s12891-020-03550-5)
• [L3] However, both systems result in degeneration at the fixed segment, indicating a need for further improvements to mimic the natural biomechanics of the spine more closely. (10.1186/s12891-024-07837-9)
• [L3] Persistent severe back pain and ongoing autonomic dysfunction were frequently reported at a mean follow-up of five years. (10.1302/0301-620x.103b9.bjj-2021-0094.r1)
• [L4] Utilizing formal consensus-building methods in a large group of surgeons experienced in treating early-onset scoliosis, a novel classification system for early-onset scoliosis was developed with all core components demonstrating substantial to excellent interobserver reliability. (10.2106/jbjs.m.00253)
• [L3] The modified classification has good reliability and its experience level of spine surgeons does not affect the reliability. (10.1186/s13018-023-03688-7)
• [L5] Classifications are generalizations that can provide an efficient means of communication, but many original reports describing common thoracic and lumbar injury classifications lack a rigorous scientific foundation and were based largely on the insights of experienced surgeons. (10.5435/00124635-200209000-00008)
• [L4] The biomechanics of the lumbar spine may differ with each individual, and L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation, owing to hyperextension injury. (10.1186/s12891-019-2921-5)
• [L4] Gas accumulation in the spinal canal is a common clinical disease, which can be identified by CT and MRI. (10.1186/s13018-025-05895-w)
• [L1] Numerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. (10.1186/s12891-016-1074-z)
• [L4] The investigation represents the best available evidence regarding the radiographic and clinical natural history of cervical degeneration, with data that will have a critical influence on discussions with patients regarding their MRI findings. (10.2106/jbjs.18.00071)
• [L4] The authors recommend the revision of the DGUV recommendations for the evaluation of occupational diseases of the lumbar spine. (10.1186/s12891-019-2878-4)
• [L3] Due to multifocal spondylodiscitis being found in approximately 13% of cases, MRI imaging of the total spine is recommended to avoid overlooking additional infection levels, which can impact the therapeutic strategy chosen. (10.1186/s12891-020-03928-5)
• [L5] The Thoracolumbar Injury Classification and Severity Score (TLICS) was developed to address limitations of prior systems by defining injury based on morphology, posterior ligamentous complex integrity, and neurologic status, offering prognostic information and aiding medical decision making. (10.5435/00124635-201002000-00001)
• [L4] Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels. (10.1186/s12891-025-09182-x)
• [L4] Magnetic resonance imaging is a non-invasive, non-irradiating imaging modality that provides necessary anatomical detail to determine the extent of infection and the condition of surrounding soft tissues in children with discitis. (10.2106/00004623-198870060-00022)
• [L5] In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models. (10.1186/s13018-024-04681-4)
• [L5] MRI is the modality of choice for evaluation of ligamentous and other soft tissue structures, disc, spinal cord, and occult osseous injuries. (10.1186/s12891-016-1169-6)
• [L4] However, the combination of MRI and CT allows for making the correct diagnosis in most cases. (10.1186/s12891-022-05402-w)
• [L3] A progression of degenerative changes in the cervical spine on MRI over the 20-year period was detected in nearly all subjects. (10.2106/jbjs.17.01347)
• [L2] Our findings suggest that the MRI abnormalities examined are not major predictors of outcome in patients with LBP. (10.1186/1471-2474-12-234)
• [L4] Kinematic MRI demonstrated dynamic pathoanatomical changes, such as canal stenosis in different positions, in patients with cervical spinal cord injury without fracture and dislocation. (10.1186/s13018-023-03745-1)
• [L5] Recent prospective randomized studies have demonstrated that surgery is superior to nonsurgical management in terms of controlling pain and improving function in patients with lumbar spinal stenosis. (10.5435/jaaos-20-08-527)
• [L5] Nonoperative treatment with collar immobilization and modification of activities improves functional status in selected patients with mild cervical spondylotic myelopathy, but careful monitoring is necessary as neurological deterioration can occur. (10.2106/jbjs.f.00014)
• [L5] Successful and reliable treatment has been developed for mild or moderate involvement of spondylolysis and spondylolisthesis in children and adolescents, while the role of surgical reduction for severe deformities remains undefined as only a small proportion of patients present with such deformities. (10.2106/00004623-198971070-00020)
• [L4] Kennedy suffered from degenerative disease of the lumbar spine rather than congenital instability or osteoporosis. (10.2106/jbjs.e.01077)
• [L2] Operative treatment of lumbar stenosis and degenerative spondylolisthesis offered a significant benefit over nonoperative treatment in patients at least eighty years of age. (10.2106/jbjs.n.00313)
• [L3] Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. (10.1186/1471-2474-11-155)
• [L3] The severity of the spinal deformity, rather than the curvature direction, is the main determinant of its impact on cardiac health. (10.1186/s13018-025-06113-3)
• [L4] In type I, disc degeneration was accelerated by regional kyphosis, while in type II, excessive mechanical stress was directly loaded at the thoracolumbar apex. (10.1186/s12891-021-04033-x)
• [L3] Our results indicate that combination of lumbar spine characteristics such as bony canal and vertebral body dimensions rather than the presence of a sole variable is highly associated with symptomatic DLSS onset. (10.1186/s12891-023-06330-z)
• [L5] Axial loading of the cervical spine is the primary injury mechanism in catastrophic cervical spine injuries in football players, with profound implications for preventative measures. (10.2106/00004623-200201000-00017)
• [L5] Different forms of scoliosis exhibit different vibrational characteristics, with scoliotic vertebrae acting as weak links under whole body vibration loading. (10.1186/s12891-019-2728-4)
• [L3] Further studies are needed to elicit the specific underlying mechanism between sagittalization of the cervical facet joints and the pathology of CSS. (10.1186/s12891-024-07279-3)
• [L4] The study aimed to identify pathoanatomical pathways of degeneration in lumbar motion segments by clustering MRI findings, but the provided text does not contain the authors' explicit conclusion statement. (10.1186/1471-2474-14-198)
• [L3] This parameter might help evaluate spine sagittal alignment in elderly patients with lumbar degeneration. (10.1186/s12891-023-06310-3)
• [L4] Afterward, as spinal curve progresses, flexibility decreases over time. (10.1186/s12891-019-2661-6)
• [L3] Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for FAIS when compared with patients without spine pathology. (10.1177/0363546519892916)
• [L2] The review identified numerous associated and risk factors for thoracic spine pain across biopsychosocial categories, including concurrent musculoskeletal pain, psychological factors, and specific postural or lifestyle factors, though many associations were weak or inconsistent across studies. (10.1186/1471-2474-10-77)
• [L4] Vertebra plana shows significant long-term reconstitution of vertebral height, particularly in younger patients, with no residual kyphosis and no symptoms related to the original disease in adulthood. (10.2106/00004623-198466090-00006)

See Also

• Disc Degeneration
• Deformities
• Functional Status
• Pain Management
• Fusion Procedures

References

[1] Management of Metastatic Cervical Spine Tumors. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-23-01-38

[2] Evaluation of patients admitted with musculoskeletal tuberculosis: sixteen years’ experience from a single center in Turkey. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04426-y

[3] Langerhans Cell Histiocytosis of the Spine in Children. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200408000-00019

[4] Chapter 18 Lumbar Degenerative Disease and Low Back Pain. 2019.

[5] Chapter 49 Thoracolumbar Conditions. 2020.

[6] Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1549-6

[7] Scoliosis caused by benign osteoblastoma of the thoracic or lumbar spine.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163070-00012

[8] Degenerative Lumbar Stenosis: Diagnosis and Management. Journal of the American Academy of Orthopaedic Surgeons. 1999. DOI: 10.5435/00124635-199907000-00004

[9] Charcot Arthropathy of the Spine. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-22-00212

[10] Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00740

[11] Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-152

[12] Anaerobic spondylodiscitis: a retrospective analysis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05749-0

[13] An Approach to Lumbar Revision Spine Surgery in Adults. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00530

[14] Development of a novel rabbit model of angular kyphosis and characterization of its neuropathological features. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06220-1

[15] Ten-Year Follow-up of Posterior Decompression and Fusion Surgery for Thoracic Ossification of the Posterior Longitudinal Ligament. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.01475

[16] Comparative analysis of surgically treated degenerative cervical and lumbar spine diseases using multiple clinical aging indices. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09185-8

[17] Accuracy and reproducibility of a retrospective outcome assessment for lumbar spinal stenosis surgery. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-83

[18] Cervical Spine Deformity: Indications, Considerations, and Surgical Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00546

[19] Probability for surgical treatment in patients with lumbar spinal stenosis according to the stenotic lesion severity: a 5–10-year follow-up study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05510-7

[20] The implications of surgery on sexual dysfunction in patients with lumbar disc herniation with cauda equina syndrome: a systematic review. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08736-3

[21] Selection of the fusion and fixation range in the intervertebral surgery to correct thoracolumbar and lumbar tuberculosis: a retrospective clinical study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04335-0

[22] Myelomeningocele at the sacral level. Long-term outcomes in adults.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199409000-00003

[23] Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-175

[24] Linical efficacy of percutaneous endoscopic lumbar discectomy for the treatment of lumbar spinal stenosis in elderly patients: a retrospective study. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01968-0

[25] Natural History of Congenital Kyphosis and Kyphoscoliosis. A Study of One Hundred and Twelve Patients. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199910000-00002

[26] Clinical and Radiographic Results of Expansive Lumbar Laminoplasty in Patients with Spinal Stenosis. Journal of Bone and Joint Surgery. 2005. DOI: 10.2106/jbjs.e.00211

[27] Transposition of the Compressed Spinal Cord in Kyphoscoliotic Patients with Neurological Deficit. The Journal of Bone & Joint Surgery. 1960. DOI: 10.2106/00004623-196042060-00010

[28] Percutaneous transforaminal endoscopic decompression with removal of the posterosuperior region underneath the slipping vertebral body for lumbar spinal stenosis with degenerative lumbar spondylolisthesis: a retrospective study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07267-7

[29] Genetic variants of interleukin 1B and 6 are associated with clinical outcome of surgically treated lumbar degenerative disc disease. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05711-0

[30] Herniated discs: when is surgery necessary?. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.210020

[31] Spondylolysis and Spondylolisthesis in Children and Teen-Agers. The Journal of Bone & Joint Surgery. 1971. DOI: 10.2106/00004623-197153070-00005

[32] Chapter 140 Pediatric Spine. 2019.

[33] Diagnostic et Traitement des Maladies de la Colonne Vertébrale (Diagnosis and Treatment of Diseases of the Spine). Jean Saidman. Paris, G. Doin et Cie, 1948. 4,500 francs. The Journal of Bone & Joint Surgery. 1948. DOI: 10.2106/00004623-194830040-00038

[34] Long-Term Follow-up of Untreated Adult Patients with Spondylothoracic Dysostosis (Jarcho-Levin Syndrome). Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.23.00800

[35] Reconstitution of Vertebral Height in Histiocytosis X. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951070-00014

[36] Monostotic Fibrous Dysplasia of the Spine. The Journal of Bone and Joint Surgery-American Volume. 2010. DOI: 10.2106/jbjs.i.00727

[37] Chapter 48 Cervical Degenerative Conditions. 2020.

[38] Untwining the intertwined: a comprehensive review on differentiating pathologies of the shoulder and spine. JSES Reviews, Reports, and Techniques. 2024. DOI: 10.1016/j.xrrt.2024.02.007

[39] Chapter 35 Pediatric Cervical Spine Disorders. 2020.

[40] Anatomical variability, morphofunctional characteristics, and clinical relevance of accessory ossicles of the back: implications for spinal pathophysiology and differential diagnosis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-024-05407-2

[41] Isobar hybrid dynamic stabilization with posterolateral fusion in mild and moderate lumbar degenerative disease. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06329-6

[42] Echinococcosis of the spine. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.200130

[43] Chapter 51 Spinal Column Infections. 2020.

[44] Red flags for the early detection of spinal infection in back pain patients. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2949-6

[45] Chapter 12 Physical Examination of the Spine. 2019.

[46] “Platelet-Rich Plasma” epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06429-3

[47] Multilevel thoracic ossification of ligamentum flavum coexisted with/without lumbar spinal stenosis: staged surgical strategy and clinical outcomes. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0672-5

[48] Comparison between oblique lumbar interbody fusion and posterior lumbar interbody fusion for the treatment of lumbar degenerative diseases: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04312-4

[49] Comparison of clinical efficacy and surgical safety among three bone graft modalities in spinal tuberculosis: a network meta-analysis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03848-9

[50] Different spinal subtypes with varying characteristics of lumbar disc degeneration at specific level with age: a study based on an asymptomatic population. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-019-1537-7

[51] Long-Term Outcome for Scoliosis Is Dependent on Several Factors. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.18.00180

[52] Outcomes and Treatment of Lumbosacral Spinal Tuberculosis: A Retrospective Study of 53 Patients. PLOS ONE. 2015. DOI: 10.1371/journal.pone.0130185

[53] Lumbar Spinal Stenosis: How Is It Classified?. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00034

[54] 2021 Otto Aufranc Award: A simple Hip-Spine Classification for total hip arthroplasty. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b7.bjj-2020-2448.r2

[55] Diagnostic imaging confusion in infectious spondylitis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05781-5

[56] Risk Factors for Poor Outcome of Cervical Laminoplasty for Cervical Spondylotic Myelopathy in Patients with Diabetes. The Journal of Bone and Joint Surgery-American Volume. 2014. DOI: 10.2106/jbjs.n.00064

[57] Dural Tears in Spine Surgery. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201009000-00005

[58] Analysis and improvement of the three-column spinal theory. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03550-5

[59] Intervertebral-Disc Calcification in Childhood: A DISTINCT CLINICAL SYNDROME.. The Journal of Bone and Joint Surgery. American Volume. 1964.

[60] Correlation of the single-segment dynamic stabilization with different segmental mobility and zygapophysial (facet) joint degeneration: a retrospective study in northern China. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07837-9

[61] Long-term core outcomes in cauda equina syndrome. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b9.bjj-2021-0094.r1

[62] Development and Initial Validation of the Classification of Early-Onset Scoliosis (C-EOS). Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00253

[63] Independent reliability and availability analyses of modified classification for migrated lumbar disc herniation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03688-7

[64] Classifications of Thoracic and Lumbar Fractures: Rationale and Supporting Data. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200209000-00008

[65] Traumatic bilateral L4-5 facet fracture dislocation: a case presentation with mechanism of injury. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2921-5

[66] Gas accumulation in the spinal canal: a systematic review and a novel CT-based classification. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05895-w

[67] Classification of patients with low back-related leg pain: a systematic review. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1074-z

[68] More Than a Snapshot of the Spine. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.18.00071

[69] Evaluation criteria for the assessment of occupational diseases of the lumbar spine - how reliable are they? -. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2878-4

[70] Total spine magnetic resonance imaging for detection of multifocal infection in pyogenic spondylodiscitis: a retrospective observational study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-020-03928-5

[71] Thoracolumbar Spine Trauma Classification. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201002000-00001

[72] Prevalence of modic changes in patients with low back pain and association with degenerative spinal findings: a retrospective MRI study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09182-x

[73] Magnetic resonance imaging in a child who had clinical signs of discitis. Report of a case.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870060-00022

[74] Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04681-4

[75] Role of magnetic resonance imaging in acute spinal trauma: a pictorial review. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1169-6

[76] Hematopoietic islands mimicking osteoblastic metastases within the axial skeleton. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05402-w

[77] A 20-Year Prospective Longitudinal Study of Degeneration of the Cervical Spine in a Volunteer Cohort Assessed Using MRI. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.01347

[78] Predictors of long-term pain and disability in patients with low back pain investigated by magnetic resonance imaging: A longitudinal study. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-234

[79] Dynamic evaluation of the cervical spine by kinematic MRI in patients with cervical spinal cord injury without fracture and dislocation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03745-1

[80] Degenerative Lumbar Spinal Stenosis. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-08-527

[82] Operative Treatment of Cervical Spondylotic Myelopathy. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.f.00014

[83] Chapter 22 Spinal Trauma. 2020.

[84] Spondylolysis and spondylolisthesis in children and adolescents.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971070-00020

[85] Failed Spine Surgery Syndrome in the Life and Career of John Fitzgerald Kennedy. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.01077

[86] Effectiveness of Surgery for Lumbar Stenosis and Degenerative Spondylolisthesis in the Octogenarian Population. The Journal of Bone and Joint Surgery-American Volume. 2015. DOI: 10.2106/jbjs.n.00313

[87] Restoration of disk height through non-surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-155

[88] Effects of severe scoliosis on cardiac structure and function in resting patients: a retrospective study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06113-3

[89] Analysis of sagittal profile and radiographic parameters in symptomatic thoracolumbar disc herniation patients. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04033-x

[90] Predictive factors for degenerative lumbar spinal stenosis: a model obtained from a machine learning algorithm technique. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06330-z

[91] Injuries to the Cervical Spine in American Football Players. The Journal of Bone and Joint Surgery-American Volume. 2002. DOI: 10.2106/00004623-200201000-00017

[92] Differential response to vibration of three forms of scoliosis during axial cyclic loading: a finite element study. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2728-4

[93] A possible correlation between facet orientation and development of degenerative cervical spinal stenosis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07279-3

[94] Can pathoanatomical pathways of degeneration in lumbar motion segments be identified by clustering MRI findings. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-198

[95] Compensatory classification in spine sagittal malalignment with lumbar degeneration. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06310-3

[96] Scoliosis in Duchenne muscular dystrophy children is fully reducible in the initial stage, and becomes structural over time. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2661-6

[97] The Influence of Lumbosacral Spine Pathology on Minimum 2-Year Outcome After Hip Arthroscopy: A Nested Case-Control Analysis. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519892916

[98] Thoracic spine pain in the general population: Prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-77

[99] Vertebra plana. Long-term follow-up in five patients.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466090-00006