Jun Jae Shin, Sun Joon Yoo, Se Jun Park, Dong Kyu Kim, Hyun Jun Jang, Bong Ju Moon, Kyung Hyun Kim, Jeong Yoon Park, Sung Uk Kuh, Dong Kyu Chin, Keun Su Kim, Yong Eun Cho, Chang Kyu Lee, Dong Ah Shin, Seong Yi, Keung Nyun Kim, Joongkyum Shin, Yoon Ha
Neurospine 2025;22(4):937-948. Published online December 31, 2025
Objective To evaluate the clinical significance of a negative K-line in the neck flexion position (FK-line [-]), which indicates that cervical ossification of the posterior longitudinal ligament (OPLL) crosses the K-line during flexion, and to compare surgical outcomes between laminoplasty (LP) and laminectomy with fusion (LF) for multilevel FK-line (-) cervical OPLL.
Methods A total of 349 patients with multiple cervical OPLL who underwent posterior decompression surgery (LP or LF) with a minimum of 2 years of follow-up were stratified by FK-line status. Clinical and radiological parameters were compared between the FK-line (+) and FK-line (-) groups. Subgroup analysis of FK-line (-) patients evaluated the efficacy of LP versus LF. Multivariate regression identified predictors of neurological recovery.
Results Patients with FK-line (-) OPLL exhibited a smaller FK-line distance, more kyphotic alignment, greater cervical flexion, and lower recovery ratios compared to those with FK-line (+). In the FK-line (-) subgroup, LF achieved a significantly greater increase in FK-line distance, better correction of the flexion angle, and more neurological recovery than LP. Multivariate analyses identified postoperative FK-line distance, C2–7 flexion angle, and preoperative dynamic extension reserve as independent predictors of neurological outcomes.
Conclusion FK-line status reflects the sagittal cord position and predicts surgical outcomes in cervical OPLL. In FK-line (-) patients, LF provides better neurological recovery and more effective posterior cord shift and kyphotic alignment correction than LP. Incorporating FK-line assessment to guide surgical planning could improve individualized treatment outcomes for multilevel OPLL.
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A Commentary on “Flexion K-Line Status Predicts Surgical Strategy in Multilevel Cervical Ossification of the Posterior Longitudinal Ligament: A Multicenter Comparison of Laminoplasty and Laminectomy With Fusion” John H. Chi Neurospine.2025; 22(4): 951. CrossRef
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Jun Jae Shin, Sun Joon Yoo, Dong Kyu Kim, Hyun Jun Jang, Bong Ju Moon, Kyung Hyun Kim, Jeong Yoon Park, Sung Uk Kuh, Dong Kyu Chin, Keun Su Kim, Yong Eun Cho, Won Joo Jeong, Tae Woo Kim, Chang Kyu Lee, Dong Ah Shin, Seong Yi, Keung Nyun Kim, Joongkyum Shin, Yoon Ha
Neurospine 2025;22(2):337-348. Published online June 30, 2025
Objective To evaluate the impact of the K-line and canal-occupying ratio (COR) on surgical outcomes in patients with multilevel cervical ossification of the posterior longitudinal ligament (OPLL).
Methods Patients with cervical myelopathy due to multilevel OPLL who underwent decompression surgery (anterior or posterior) from 2013 to 2022, with 2-year minimum follow-up, were enrolled. Radiological evaluations included K-line, COR, OPLL type/level, and cervical parameters (C2 slope [C2S], T1 slope [T1S], K-line tilt). Clinical outcomes included Japanese Orthopaedic Association (JOA) score and neck-pain visual analogue scale. Patients were categorized by K-line status (+/-) and COR (<50% or ≥50%).
Results Among 575 patients, JOA recovery was significantly better in the K-line (+) and in low COR (<50%). In high COR (≥50%), K-line (-) was associated with poorer recovery. In low COR, outcomes were similar regardless of K-line. Anterior decompression with fusion (ADF) yielded the best outcomes. Laminoplasty (LP) was optimal for COR ≥50% and/or K-line (+), while laminectomy with fusion (LF) was better for COR ≥50% and K-line (-). In high COR, K-line was influenced by cervical alignment, C2S, and T1S, while in low COR, it was mainly affected by COR percentage.
Conclusion Combining K-line and COR is essential for surgical planning in multilevel OPLL. When COR is high, K-line plays a significant role in predicting neurological recovery. ADF led to superior recovery, whereas for patients with K-line (-) and high COR, LF offered better results than LP. Cervical parameters at high COR influence the K-line more.
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Objective Spinal stenosis is a prevalent condition; however, the optimal surgical treatment for central lumbar stenosis remains controversial. This study compared the clinical outcomes and radiological parameters of 3 surgical methods: unilateral laminectomy bilateral decompression with unilateral biportal endoscopy (ULBD-UBE), conventional subtotal laminectomy (STL), and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).
Methods This retrospective study included 86 patients, divided into ULBD-UBE (n=34), STL (n=24), and MIS-TLIF (n=28) groups. We evaluated demographics and perioperative factors and assessed clinical outcomes using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and neurogenic intermittent claudication (NIC). Radiological parameters assessed included lumbar lordosis, L4S1 Cobb angle (L4S1), T12S1 Cobb angle (T12S1), increased cross-sectional dural area (CSA), dynamic angulation (DA), dynamic slip (DS), and development of postoperative instability.
Results The ULBD-UBE group showed a significantly shorter hospital stay duration and operation time and reduced blood loss than the other groups (p<0.001). ULBD-UBE group showed a trend towards greater VAS and ODI improvement at 1 month and postoperative NIC symptom relief. Radiologically, MIS-TLIF group exhibited lower postoperative DA and DS (p<0.001), indicating higher postoperative stability. Postoperative instability was lower in the ULBD-UBE group (2.9%) than in the STL group (16.7%) and similar to the MIS-TLIF group (0.0%) (p=0.028). The CSA was highest in the MIS-TLIF group (295.5%) compared to that in the other groups (ULBD-UBE, 216.3%; STL, 245.2%) (p<0.001).
Conclusion Compared to other procedures, ULBD-UBE is a safe, effective, and viable surgical procedure for treating lumbar central stenosis.
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Objective We aimed to investigate the incidence of delayed-onset neurological deficits (DONDs), DOND-related reoperation rates following adult spinal deformity (ASD) surgery, and efficacy of transverse process hooks (TPHs) at the uppermost instrumented vertebra (UIV) compared to pedicle screws (PSs).
Methods We included 90 consecutive patients who underwent instrumented fusion from the sacrum to the distal thoracic spine for ASD, with a minimum follow-up of 24 months. Clinical and radiological outcomes were compared between 33 patients in the TPH group and 57 patients in the PS group, using the Scoliosis Research Society-22 Outcomes questionnaire (SRS-22), Medical Outcomes Study Questionnaire Short-Form 36 (SF-36), and various spinal sagittal parameters.
Results While absent in the TPH group, myelopathy occurred in 15.8% of the PS group, wherein 15 patients underwent reoperation. The change in the proximal junctional angle, from the pre- to postoperative assessment, was lower in the TPH group than in the PS group (0.2 vs. 6.6, p=0.002). Postoperative facet degeneration in the PS group progressed more significantly than in the TPH group (0.5 vs. 0.1, p=0.002). Surgical outcomes were comparable for both groups, except for the back visual analogue scale (3.5 vs. 4.1, p=0.010) and SRS-22 domains, including pain and satisfaction (3.3 vs. 2.9, p=0.033; 3.7 vs. 3.3, p=0.041). No intergroup difference was observed in SF-36.
Conclusion Using TPHs at the UIV level can prevent DOND, and thereby prevent postoperative myelopathy that necessitates reoperation; thus, TPHs is preferable over PSs in ASD surgery.
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Objective We investigated the clinical efficacy of anabolic agents compared with bisphosphonates (BPs) for the incidence of new osteoporotic vertebral fracture (OVF) and fracture healing of OVF in the patients with OVF via meta-analyses of randomized controlled trials (RCTs).
Methods Electronic databases, including PubMed, Embase, and Cochrane Library were searched for published RCTs till December 2022. The RCTs that recruited participants with osteoporosis at high-/very high-risk of fracture (a history of osteoporotic vertebral or hip fracture) or fresh OVF were included in this study. We assessed the risk of bias on every included RCTs, estimated relative risk (RR) for the incidence of new OVF and fracture healing of OVF, and overall certainty of evidence. Meta-analyses were performed by Cochrane review manager (RevMan) ver. 5.3. Cochrane risk of bias 2.0 and GRADEpro/GDT were applied for evaluating methodological quality and overall certainty of evidence, respectively.
Results Five hundred eighteen studies were screened, and finally 6 eligible RCTs were included in the analysis. In the patients with prevalent OVF, anabolic agents significantly reduced the incidence of new OVF (teriparatide and romosozumab vs. alendronate and risedronate [RR, 0.57; 95% confidence interval, 0.45–0.71; p < 0.00001; high-certainty of evidence]; teriparatide vs. risedronate [RR, 0.50; 95% confidence interval, 0.37–0.68; p < 0.0001; high-certainty of evidence]). However, there was no evidence of teriparatide compared to alendronate in fracture healing of OVF (RR, 1.23; 95% confidence interval, 0.95–1.60; p = 0.12; low-certainty of evidence).
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Neurospine 2023;20(4):1272-1280. Published online December 31, 2023
Objective Although adult spinal deformity (ASD) surgery aims to restore and maintain alignment, proximal junctional kyphosis (PJK) may occur. While existing scoring systems predict PJK, they predominantly offer a generalized 3-tier risk classification, limiting their utility for nuanced treatment decisions. This study seeks to establish a personalized risk calculator for PJK, aiming to enhance treatment planning precision.
Methods Patient data for ASD were sourced from the Korean spinal deformity database. PJK was defined a proximal junctional angle (PJA) of ≥ 20° at the final follow-up, or an increase in PJA of ≥ 10° compared to the preoperative values. Multivariable analysis was performed to identify independent variables. Subsequently, 5 machine learning models were created to predict individualized PJK risk post-ASD surgery. The most efficacious model was deployed as an online and interactive calculator.
Results From a pool of 201 patients, 49 (24.4%) exhibited PJK during the follow-up period. Through multivariable analysis, postoperative PJA, body mass index, and deformity type emerged as independent predictors for PJK. When testing machine learning models using study results and previously reported variables as hyperparameters, the random forest model exhibited the highest accuracy, reaching 83%, with an area under the receiver operating characteristics curve of 0.76. This model has been launched as a freely accessible tool at: (https://snuspine.shinyapps.io/PJKafterASD/).
Conclusion An online calculator, founded on the random forest model, has been developed to gauge the risk of PJK following ASD surgery. This may be a useful clinical tool for surgeons, allowing them to better predict PJK probabilities and refine subsequent therapeutic strategies.
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Neurospine 2021;18(3):608-617. Published online September 30, 2021
Objective This study aimed to identify the sagittal parameters associated with health-related quality of life and genetic variations that increase the risk of adult spinal deformity (ASD) onset in the older population.
Methods We recruited 120 participants who had a sagittal vertical axis > 50 mm in a sagittal imbalance study. Sagittal radiographic parameters, cross-sectional area, and intramuscular fatty infiltration using the Goutallier classification in the paraspinal lumbar muscles were evaluated. Functional scales included the self-reported Oswestry Disability Index (ODI), 36-item Short Form Health Survey (SF-36), and visual analogue scales (VAS) for back and leg pain. We performed whole-exome sequencing and an exome-wide association study using the 100 control subjects and 63 individuals with severe phenotypes of sagittal imbalance.
Results Pelvic incidence minus lumbar lordosis (PI–LL) mismatch was negatively associated with the SF-36 and positively correlated with ODI and VAS for back and leg pain. PI–LL was related to the quality and size of the paraspinal muscles, especially the multifidus muscle. We identified common individual variants that reached exome-wide significance using single-variant analysis. The most significant single-nucleotide polymorphism was rs78773460, situated in an exon of the SVIL gene (odds ratio, 9.61; p = 1.15 × 10-9).
Conclusion Older age, higher body mass index, and a more significant PI–LL mismatch were associated with unfavorable results on functional scales. We found a genetic variation in the SVIL gene, which has been associated with the integrity of the cytoskeleton and the development of skeletal muscles, in severe ASD phenotypes. Our results help to elucidate the pathogenesis of ASD.
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Objective The purpose of the present study was to evaluate the natural course of primary degenerative sagittal imbalance (PDSI), its aggravating factors, and health-related quality of life (HRQoL) associated with various spinal alignment parameters (SAPs) in patients with PDSI who have not undergone surgery.
Methods One hundred three participants volunteered to participate. The SAPs, including T1 pelvic angle (T1PA), thoracolumbar tilt, and thoracolumbar slope (TLS), were measured on whole-spine standing radiographs. The back and lumbar muscle volumes were measured. To determine HRQoL at baseline and at 2-year follow-up, face-to-face questionnaires were administered, which included visual analogue scale of the back and leg, physical component summary/mental component summary of 36-item Short Form Health Survey, Oswestry Disability Index (ODI), and Mini-Mental State Examination.
Results Overall HRQoL measures had improved after 2 years of follow-up compared to baseline. PDSI aggravation was observed in 18 participants (26.1%). TLS, sagittal vertical axis (SVA), and T1PA were strongly correlated with each other. TLS, SVA, and T1PA were correlated with ODI score. Among them, TLS was most highly correlated with ODI score. TLS greater than -3.5° was a predicting factor for PDSI aggravation (p = 0.034; 95% confidence interval, 1.173–63.61; odds ratio, 8.636).
Conclusion The present study implied that PDSI does not necessarily worsen with aging. TLS is an appropriate parameter for assessing the clinical situation in patients with PDSI. Furthermore, a TLS greater than -3.5° predicts PDSI aggravation; thus, TLS may be a useful parameter for predicting prognosis in PDSI.
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Objective Anterior odontoid screw fixation (AOSF) is a safe and effective treatment for type II and rostral type III odontoid fracture. This study aimed to report the outcomes of the AOSF surgery and evaluate the potential risk factors of surgical failure.
Methods We enrolled 63 patients who underwent AOSF. Follow-up computed tomography was performed 6 months after the surgery and once a year thereafter to evaluate the union. Clinical data including the age, sex, presenting symptoms, cause of injury, fracture gaps, dislocation position, degree of displacement, screw direction angle, and time interval from injury to operation were collected.
Results Successful fusion was achieved in 55 patients (87.3%) and surgical failure occurred in 8 patients (12.7%). Variables such as age, sex, dislocation position, degree of displacement, screw direction angle, and time interval from injury to operation were not significantly associated with the surgical failure. However, surgical failure was statistically significantly associated with the fracture gap. The overall mean fracture gap at the time of injury was 1.29 mm (range, 0–3.11 mm), and the incidence of surgical failure was 8.3 times higher when the fracture gap at the time of injury was > 2 mm (p = 0.019).
Conclusion When performing AOSF in patients with type II or rostral shallow type III odontoid fractures, the displacement of the odontoid fracture fragment should be appropriately reduced to the aligning position before screw insertion and downward reduction should be achieved by perforation of the apical cortex of the odontoid during screw fixation, even if the surgery is delayed.
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Objective The objective of this study was to investigate the surgical outcomes and prognostic factors for thoracic ossification of the ligamentum flavum (OLF) after decompressive laminectomy, focusing on the quantitative signal intensity ratio (SIR) of preoperative magnetic resonance imaging (MRI) and its prognostic significance.
Methods We retrospectively reviewed 24 patients who previously underwent total laminectomy to remove OLF from 2010 to 2015. MRI and computed tomography were performed to detect OLF. The SIR between the regions of interest of high signal intensity lesions and the normal cord at the T1–2 disc levels was calculated. We divided patients into 2 groups based on the extent of the modified Japanese Orthopaedic Association (JOA) recovery rate (RR): good (RR ≥ 50%) and poor (RR < 50%).
Results The mean preoperative and postoperative modified JOA scores for thoracic myelopathy were 6.67 ± 1.73 and 8.63 ± 1.81, respectively (p < 0.001). The preoperative JOA score (7.5 vs. 5.83, p = 0.028), postoperative JOA score (9.83 vs. 7.42, p = 0.000), and SIR (1.16 vs. 1.41, p = 0.009) were significantly different between the good and poor RR groups. A higher preoperative JOA score and lower SIR were associated with a good RR according to the JOA criteria.
Conclusion The clinical outcomes for thoracic OLF after decompressive laminectomy were favorable. A higher RR was correlated with a lower SIR and higher preoperative modified JOA score. Therefore, a relatively low SIR on MRI and a relatively high preoperative JOA score could be positive prognostic indicators for the JOA RR in patients with thoracic OLF.
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