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Accurate segmentation of cervical spinous processes on lateral X-rays is essential for reliable anatomical landmarking, surgical planning, and longitudinal assessment of spinal deformity. However, no publicly available dataset provides pixel-level annotations of these structures, and manual delineation remains time-consuming and operator dependent. To address this gap, we curated an expert-labeled dataset of 500 cervical spine radiographs and developed CervSpineNet, a hybrid deep learning framework for automated spinous process segmentation. CervSpineNet integrates a transformer-based encoder to capture global anatomical context with a lightweight convolutional decoder to refine local boundaries. Training used a compound loss function that combines Dice, Focal Tversky, Hausdorff distance transform, and Structural Similarity (SSIM) terms to jointly optimize region overlap, class balance, structural fidelity, and boundary accuracy. The model was trained and evaluated on three dataset variants: original images, contrast-enhanced images using CLAHE, and augmented images. Performance was benchmarked against four baselines: U-Net, DeepLabV3+, the Segment Anything Model (SAM), and a text-guided SegFormer. Across all experimental settings, CervSpineNet consistently outperformed competing methods, achieving mean Dice coefficients above 0.93, IoU values above 0.87, and SSIM above 0.98, with substantially lower HD95 distances. The model demonstrated strong agreement with ground truth, with global MAE ≈ 0.005, and maintained efficient inference times of 5-10 seconds per image. With a compact footprint of approximately 345 MB, CervSpineNet runs on standard clinical hardware and reduces manual annotation time by about 96%. These results indicate that combining transformer-driven global context with convolutional boundary refinement enables robust and reproducible spinous process segmentation on lateral cervical radiographs. By pairing an expert-annotated dataset with a high-performing, computationally efficient model, this work provides a scalable foundation for AI-assisted cervical spine analysis, supporting rapid segmentation for surgical evaluation, deformity monitoring, and large-scale retrospective studies in both research and clinical practice.

Study Design Cadaveric Biomechanical. Objective To investigate the biomechanical characteristics of a new screw trajectory, which we have deemed the “pedicle inlet” trajectory. Methods Four surgeons familiar with standard and image-guided cervical pedicle screw fixation techniques placed 3.5 mm diameter cervical fixation screws randomized at each sub-axial level to one of three fixation techniques: cervical pedicle, pedicle inlet, and lateral mass screw. A total of 180 screws were placed from C3 to C7 in 18 cadaveric spine samples. Maximal insertional torque was measured during the final seating of the screws. After confirmation of accuracy of screws with post-procedural CT-imaging, individual screws in the cadaveric samples were biomechanically tested for pull-out strength. Results All screws were placed without breach into neurovascular spaces. The final insertional torque was equivalent (ANOVA, P > .05, 3.6 ± 1.7 Nm) across cervical pedicle screws, pedicle inlet, and lateral mass screws. Maximal pullout strength was observed for cervical pedicle screws (814.6 ± 387.3 N). Pedicle inlet screws had a 51% higher pullout strength as compared to lateral mass screws (593.2 ± 289.9 N v 392.4 ± 284.0 N, P < .01). All differences were statistically distinct from each other (ANOVA, P < .01). Conclusions Use of image-guidance allows for safe placement along the pedicle inlet trajectory, with no recorded screw malposition, and a 51% improvement in pull out strength as compared to lateral mass screws. The pedicle inlet trajectory offers an alternative to traditional lateral mass screws with better fixation quality and may have particular application in percutaneous or minimally invasive posterior fusions.

Study Design Narrative Review. Objective Pelvic fixation is a crucial technique in modern adult spinal deformity surgery, yet complications and failure rates remain high. Significant controversy exists regarding the type and number of points of pelvic fixation needed but remains poorly defined. The purpose of this article is to summarize current literature on pelvic fixation techniques, complications, and outcomes, discuss controversies, and suggest future directions. Methods A literature search was conducted in PubMed for publications written in English with full text available from January 2000 to January 2022 using the following search terms: “spinopelvic fixation”, “sacroiliac fixation”, “iliac screw”, “S2AI screw” and “complications” or “outcomes” together with “adult spinal deformity” and “scoliosis”. Results Twenty-two articles were identified as describing complications/outcomes comparing pelvic fixation techniques (S2AI vs iliac; n = 6) or as reporting on a single technique (n = 16). The main categories of pelvic fixation complications were mechanical, pseudarthrosis, wound infection, sacroiliac joint pain, and revision. Four studies found lower complication rates for S2AI screws vs iliac screws. Descriptive studies reported high rates of complications for both S2AI and iliac screws. The frequency of complications was as follows: screw fracture 1.9%-9%, screw loosening 2%-65%, L5-S1 pseudarthrosis 6%-23.9%, sacroiliac joint pain 3.2%-52.5%, revision rate 2.4%-50%. Conclusions Pelvic fixation with either S2AI or iliac screws provides significant stability to constructs that extend to the sacrum. Further study is needed to characterize the number of points of pelvic fixation needed and clarify the role of pelvic fixation in causation or treatment of sacroiliac joint pain.

Study Design: Systematic literature review Objective: To critically analyze the literature and describe the complications associated with the use of allograft in 1- or 2- level anterior cervical discectomy and fusion (ACDF) Methods: A systematic search of PubMed/MEDLINE, EMBASE, and ClinicalTrials.gov databases was conducted for literature published between January 2000 and August 2020 reporting complications associated with the use of allograft in 1- or 2- level ACDF. Results: From 584 potentially relevant citations, 21 met the inclusion criteria (4 randomized controlled trials (RCT), 4 prospective, and 13 retrospective studies). The patient number varied between 26 and 463 in comparative studies (RCT and non-RCT) and between 29 and 345 in non-comparative studies. Fusion rate was reported in 14 studies and ranged between 68.5-100%. The most frequently reported complication was post-operative dysphagia or dysphonia, with incidences ranging between .5% and 14.4%. Revision surgery was the second most reported complication (14 studies) and ranged between 0% and 10.3%. Wound-related complications were reported in 6 studies and ranged between 0% and 22.8%. Conclusion: The overall reporting of complications was low with very few comparative studies. Reported complications with allografts are within the range of other osteobiologics and autografts and in most cases may not attributable to the use of osteobiologics and may be complications of the procedure itself. Comparative studies with a more robust methodology analyzing complications with allograft and other osteobiologics are needed to inform current practice with strong recommendations.

Study Design Systematic Review and Meta-Analysis. Objectives To compare complication incidence in patients with or without the use of recombinant human Bone Morphogenic Protein-2 (BMP2) undergoing anterior cervical discectomy and fusion (ACDF) for degenerative conditions. Methods A systematic search of eight online databases was conducted using PRISMA guidelines. Inclusion criteria included English language studies with a minimum of 10 adult patients undergoing instrumented ACDF surgery for a degenerative spinal condition in which BMP2 was used in all patients or one of the treatment arms. Studies with patients undergoing circumferential fusions, with non-degenerative indications, or which did not report post-operative complication data were excluded. Patients with and without BMP2 were compared in terms of the incidence of dysphagia/dysphonia, anterior soft tissue complications (hematoma, seroma, infection, dysphagia/dysphonia), nonunion, medical complications, and new neurologic deficits. Results Of 1832 preliminary search results, 27 manuscripts were included. Meta-analysis revealed the relative risk of dysphagia or dysphonia (RR = 1.39, CI 95% 1.18 – 1.64, P = <.001), anterior soft tissue complications (RR = 1.43, CI 95% 1.25-1.64, P = <.001), and medical complications (RR = 1.32, CI 95% 1.06-1.66, P = .013) were statistically significant in the BMP2 group while the relative risk of non-union (RR = .5, CI 95% .23 - 1.13, P = .09) trended lower in the BMP2 group. Neurological deficit (RR = 1.06, CI 95% .82-1.37, P = .66), and additional medical complications (RR = 1.53, CI 95% .98-2.38, P = .06) were not found to be statistically different between the groups. Conclusions This meta-analysis identified a high rate of arthrodesis when BMP2 was used in ACDF, but confirmed increased rates of dysphagia and anterior soft tissue complications. Surgeons may consider reserving BMP2 implementation for cases with a high risk of non-union, and should be aware of the risk of airway compromise.

Study Design Network meta-analysis. Objectives To compare the fusion outcome and complications of different 1 or 2-level anterior cervical decompression and fusion (ACDF) constructs performed with and without the application of autografts. Methods We performed an independent and duplicate search in electronic databases including PubMed, Embase, Web of Science, Cochrane, and Scopus for relevant articles published between 2000 and 2020. We included comparative studies reporting fusion rate and complications with and without the use of autografts in ACDF across 5 different fusion constructs. A network meta-analysis was performed in Stata, categorized based on the type of fusion constructs utilized. Fusion constructs were ranked based on p-score approach and surface under cumulative ranking curve (SUCRA) scores. The confidence of results from the analysis was appraised with Cochrane’s CINeMA approach. Results A total of 2216 patients from 22-studies including 6 Randomized Controlled Trials (RCTs) and 16 non-RCTs were included in network analysis. The mean age of included patients was 49.3 (±3.62) years. Based on our meta-analysis, we could conclude that use of autograft in 1- or 2-level ACDF did not affect the fusion and mechanical implant-related complications. The final fusion and mechanical complication rates were also not significantly different across the different fusion constructs. The use of plated constructs was associated with a significant increase in post-ACDF dysphagia rates [OR 3.42; 95%CI (.01,2.45)], as compared to stand-alone constructs analysed. Conclusion The choice of fusion constructs and use of autografts does not significantly affect the fusion and overall complication rates following 1 or 2-level ACDF surgery.

Study Design: Retrospective study. Objective: Proximal junctional failure (PJF) commonly occurs as a recognized potential outcome of fusion surgery. Here we describe a unique series of patients with multilevel spine fusion including the cervical spine, who developed PJF as an odontoid fracture. Methods: We performed a single site retrospective review of patients with prior fusion that included a cervical component, who presented with an odontoid fracture between 2012 and 2019. Radiographic measurements included C2-C7 SVA, C2-C7 lordosis, T1 slope, Occiput-C2 angle, proximal junctional kyphosis, and cervical mismatch. Associated fractures, medical comorbidities, and treatments were determined via chart review after IRB approval. Results: Nine patients met inclusion criteria. 5 reported trauma with subsequent onset of pain. All patients sustained a Type II odontoid fracture. 5 with associated C1/Jefferson fractures. In all patients, pre-injury Occiput-C2 angle was outside normative range; C2-C7 SVA was greater than 4 cm in 6 patients; T1-slope minus cervical lordosis was greater than 18.5 degrees in 6 patients. 7 patients were treated operatively with extension of fusion to C1 and 2 patients declined operative treatment. Conclusion: In this series of 9 patients with multilevel fusion with type II odontoid fractures, all patients demonstrated abnormal pre-fracture sagittal alignment parameters and a greater than normal association of C1 fractures was noted. Further study is needed to establish the role of poor sagittal alignment with compensatory occiput-C2 angulation as a predisposing factor for odontoid fracture as a proximal junctional failure mechanism.

Background Increasing national expenditures and use associated with TKA have resulted in pressure to reduce costs through various reimbursement cuts. However, within the arthroplasty literature, few studies have examined the association of medical comorbidities on resource use and length of stay after joint arthroplasty. Questions/purposes The purpose of this study was to examine the association between individual patient characteristics (including demographic factors and medical comorbidities) on resource allocation and length of stay (LOS) after TKA. Methods We queried the 2009 Nationwide Inpatient Sample dataset for International Classification of Diseases, 9 th Revision code, 81.54, for TKAs. An initial 621,029-patient cohort was narrowed to 516,745 after inclusion of elective TKAs on patients aged between 40 and 95 years. Using generalized linear models, we estimated the effect of comorbidities on resource use (using cost-to-charge conversions to estimate hospital costs) and the LOS controlling for patient and hospital characteristics. Across the 2009 national cohort with TKAs, 12.7% had no comorbidities, whereas 32.6% had three or more. The most common conditions included hypertension (67.8%), diabetes (20.0%), and obesity (19.8%). Mean hospital costs were USD 14,491 (95% confidence interval [CI], 14,455–14,525) and mean hospital LOS was 3.3 days (95% CI, 3.29–3.31) in this data set. Results Patients with multiple comorbidities were associated with increased resource use and LOS. Higher marginal costs and LOS were associated with patients who had an inpatient death (USD +8017 [95% CI, 8006–8028], +2.3 [CI, 2.15–2.44] days over baseline), patients with recent weight loss (USD +4587 [95% CI, 4581–4593], +1.5 [CI, 1.45–1.61) days], minority race (USD +1037 [95% CI, 1035–1038], +0.3 [CI, 0.28–0.33] days), pulmonary-circulatory disorders (USD +3218 [95% CI, 3214–3221], +1.3 [CI, 1.25–1.34] days), and electrolyte disturbances (USD +1313 [95% CI, 1312–1314], +0.6 [CI, 0.57–0.60] days). All p values were < 0.001. Conclusion Multiple patient comorbidities were associated with additive resource use and LOS after TKA. Current reimbursement may not adequately account for these patient characteristics. To avoid potential loss of access to care for sicker patients, payment needs to be adjusted to reflect actual resource use. Level of Evidence Level IV, economic and decision analysis. See the Instructions for Authors for a complete description of levels of evidence.

Equity in health care has become a focal point of debate. However, the disparity between insurance payer types in total joint arthroplasty is poorly defined. The authors identified 1312 consecutive patients who underwent elective primary total hip or knee arthroplasty with available preoperative Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index surveys and stratified them into groups based on insurance type (Iowa Care [a state-run insurance program for patients who are indigent], Medicare, Medicaid, or private insurance) to compare demographics, access to care, and functional data. Significance was a Equity in health care has become a focal point of debate. However, the disparity between insurance payer types in total joint arthroplasty is poorly defined. The authors identified 1312 consecutive patients who underwent elective primary total hip or knee arthroplasty with available preoperative Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index surveys and stratified them into groups based on insurance type (Iowa Care [a state-run insurance program for patients who are indigent], Medicare, Medicaid, or private insurance) to compare demographics, access to care, and functional data. Significance was a P value less than .05 after a Turkey-Kramer adjustment for multiple comparisons. A multivariate analysis identified independent predictors of Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index preoperative functional status. Few differences existed between patients with Iowa Care and Medicaid, but both groups had significantly lower Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index scores across every category compared with patients with Medicare or private insurance ( P <.05 for each comparison). In addition, patients with Iowa Care and Medicaid had a higher incidence of current smoking and higher mean body mass index and traveled an average of 29 to 30 miles farther for access to care ( P <.05 for each comparison). Payer type was an independent predictor of preoperative Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index functional scores in the multivariate analysis ( P <.02). Significant differences exist between payer types in total joint arthroplasty. Further research is necessary to better inform health policy decisions.

Background The influence of resident involvement on short-term outcomes after orthopaedic surgery is mostly unknown. Questions/purposes The purposes of our study were to examine the effects of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay, and reoperation rate and to analyze these parameters by level of training. Methods The 2005–2011 American College of Surgeons National Surgical Quality Improvement Program data set was queried using Current Procedural Terminology codes for 66,817 cases across six orthopaedic procedural domains: 28,686 primary total joint arthroplasties (TJAs), 2412 revision TJAs, 16,832 basic and 5916 advanced arthroscopies, 8221 lower extremity traumas, and 4750 spine arthrodeses (fusions). Bivariate and multivariate logistic regression and propensity scores were used to build models of risk adjustment. We compared the morbidity and mortality rates, length of operating time, hospital length of stay, and reoperation rate for cases with or without resident involvement. For cases with resident participation, we analyzed the same parameters by training level. Results Resident participation was associated with higher morbidity in TJAs (odds ratio [OR], 1.6; range, 1.4–1.9), lower extremity trauma (OR, 1.3; range, 1.2–1.5), and fusion (OR, 1.4; range, 1.2–1.7) after adjustment. However, resident involvement was not associated with increased mortality. Operative time was greater (all p < 0.001) with resident involvement in all procedural domains. Longer hospital length of stay was associated with resident participation in lower extremity trauma (p < 0.001) and fusion cases (p = 0.003), but resident participation did not affect length of stay in other domains. Resident involvement was associated with greater 30-day reoperation rates for cases of lower extremity trauma (p = 0.041) and fusion (p < 0.001). Level of resident training did not consistently influence surgical outcomes. Conclusions Results of our study suggest resident involvement in surgical procedures is not associated with increased short-term major morbidity and mortality after select cases in orthopaedic surgery. Findings of longer operating times and differences in minor morbidity should lead to future initiatives to provide resident surgical skills training and improve perioperative efficiency in the academic setting. Level of Evidence Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.