Skip to content

Fusion & Stabilization

Spinal fusion and stabilization for degenerative, traumatic, or infectious instability — indications for bony union versus motion preservation.

Overview

Fusion remains the mainstay for isthmic spondylolisthesis in adults, with pedicle-screw instrumentation widely accepted as an adjunct despite unproven safety and efficacy [14]. Stand-alone anterior lumbar interbody cages provide sufficient stability for fusion, serving as an alternative to circumferential fixation [1]. In long-segment constructs, transsacral fixation may enable safe lumbosacral fusion without iliac fixation in carefully selected patients [5]. For C1-C2 instability in children with skeletal dysplasias, rigid fixation with screws and rods improves fusion rates [9].

Long-term stability remains challenging in kyphoscoliotic patients with neurological deficits, often necessitating additional fusion procedures [2]. Long-level posterolateral fusion maintains acceptable clinical and radiological outcomes compared to short-level fusion at minimum 10-year follow-up [3]. While initial studies suggest posterior dynamic stabilization results may match fusion, longer follow-up is required to define their role [4]. Anterior spinal growth tethering avoided fusion in 13 of 17 skeletally immature scoliosis patients, yielding a 59% success rate and 41% revision rate [7]. No additional patients required conversion to posterior spinal fusion with anterior vertebral body tethering, indicating potential long-term survivorship [6].

Total disc arthroplasty demonstrates dramatic, maintained reductions in disability and pain for 1- and 2-level lumbar disease, with low rates of index-level revision, reoperation, or adjacent-level surgery relative to long-term fusion data [8]. Fiber-suture offers an alternative to steel wire for scapulothoracic fusion, though longer-term outcome comparisons are needed [13]. Fusion surgery is indicated for recurrent shoulder instability in epileptic patients, provided they are comprehensively counselled regarding functional deficits [10].

Anatomy & Pathophysiology

Kinematics and Biomechanical Stability

Modern segmental screw-based fixation systems provide superior rigidity and fusion rates approaching 100%, offering greater biomechanical stability and user-friendliness than previous wiring techniques [16]. A stand-alone anterior lumbar interbody fusion cage supplies the stability required for interbody fusion [1]. Biomechanical stability precedes the radiographic appearance of solid fusion by at least eight weeks, with immature woven bone providing substantial stiffness to the fusion mass [19]. Dual-cord dynamic stabilization systems demonstrate improved biomechanical stability with minimal adjacent segment compromise [17]. Finite element analysis confirms that cervical vertebrae following percutaneous posterior endoscopic cervical discectomy exhibit good biomechanical performance and stability [35]. In total cervical disc replacement, a 5 mm implant height yields biomechanical properties similar to intact specimens, whereas larger implant heights alter facet joint mechanics [36]. Tested vertebral body tethering constructs provide stability for the spine in lateral bending [37], and rod fracture in the thinnest profile of the spinal hybrid elastic rod system still affords nearly sufficient spine support with gentle adjacent segment stress [38]. Advances in fixation systems enable reliable stabilization that permits early mobilization for thoracolumbar fractures [39].

Motion Coupling and Adjacent Segment Effects

Understanding the biomechanical principles of spinal instrumentation and motion coupling is essential for optimizing three-dimensional correction of thoracolumbar spinal deformities and achieving favorable mechanical environments for fusion [29]. Mobility and stability of rotational and translational joints are key factors influencing both fusion rates and the progression of adjacent segment degeneration [40]. Motion in the coronal plane decreased by 77% following anterior vertebral body tethering, yet sagittal motion remained greater than coronal motion at 1 year [20]. Noncontinuous cervical disc arthroplasty preserves intradiscal pressure and facet joint forces at adjacent and intermediate levels, maintaining cervical spine kinematics near preoperative values [30]. Skip-level cervical disc arthroplasty has fewer biomechanical effects on the intermediate segment than skip-level fusion, with the intermediate segment not experiencing additive range of motion or stress in the intervertebral disc or facet joints [43]. Spinal fusion surgery results in greater shear load magnitude, muscle activation, and forces at the epifusional segment in patients with adjacent segment degeneration compared to those without [42]. Transforaminal endoscopic lumbar discectomy combined with a spinal dynamic stabilization system alters the biomechanical environment of adjacent segments and offers potential advantages over posterior lumbar interbody fusion in mitigating adjacent segment disease occurrence [41].

Interspinous and Dynamic Devices

Interspinous devices reduce range of motion in extension and can reduce disc pressure, though they often fail to fully compensate for destabilization in other planes or adjacent levels [33].

Classification

Anterior Lumbar Interbody Fusion: A new stand-alone anterior lumbar interbody fusion cage provided stability required for interbody fusion, supporting its use as an alternative to circumferential fixations [1]. Anterior fusion is of distinct value in effecting stabilization for fracture-dislocations, destructive lesions, and spontaneous dislocations [12].

Long-Level and Posterolateral Fusion: Long-level posterolateral fusion maintained acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up [3]. Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficit, often requiring additional fusion procedures [2].

Posterior Dynamic Stabilization: Initial studies suggest posterior dynamic stabilization results may be comparable to fusion, though longer clinical and radiographic follow-up is required to define their role [4]. Non-fusion procedures using PEEK rod systems might be a viable alternative for the treatment of lumbar degenerative diseases [23].

Transsacral and Iliac Fixation: Transsacral fixation/fusion may allow for safe lumbosacral fusion without iliac fixation in long-segment constructs in carefully selected patients [5]. Minimized invasive spine implant systems exhibit correction loss, implying that unstable spine fractures might benefit from stabilization with conventional implants like the Universal Spinal System [55].

Anterior Growth Tethering: Anterior spinal growth tethering avoided fusion in 13 of 17 skeletally immature patients with scoliosis, with an overall success rate of 59% and a 41% revision rate [7]. Anterior vertebral body tethering showed no additional patients requiring conversion to posterior spinal fusion, indicating potential long-term survivorship [6].

Total Disc Arthroplasty: Patients undergoing 1 and 2-level lumbar total disc arthroplasty had dramatic and maintained reductions in disability and pain scores over time [8]. Total disc arthroplasty demonstrated low rates of index-level revision, reoperation, and adjacent-level surgery relative to published long-term fusion data [8].

Cervical Spine Fixation: Rigid fixation with screws and rods improves fusion rates for C1-C2 instability in children with skeletal dysplasias [9]. Modern segmental screw-based fixation systems for the upper cervical spine are biomechanically more stable and user-friendly than previous wiring techniques [16]. Modern segmental screw-based fixation systems offer superior rigidity and fusion rates approaching 100% [16].

Revision and Complex Reconstruction: Bone fusion was achieved by revision surgery using the posterior approach alone after instrumentation failure following total en bloc spondylectomy [11]. Treatment of degenerative spondylolisthesis has evolved with numerous prospective randomized trials assessing fusion, instrumentation, bone morphogenetic proteins, and soft-tissue stabilization devices [56].

Other Considerations: The evidence base encompasses a spectrum of stabilization modalities ranging from stand-alone cages to circumferential constructs, with specific outcomes varying by patient skeletal maturity, spinal deformity type (kyphoscoliosis), and injury mechanism (fracture-dislocation vs. degenerative).

Clinical Presentation

Stability and Fusion Indications: A new stand-alone anterior lumbar interbody fusion cage provides the stability required for interbody fusion [1]. Anterior fusion is of distinct value in effecting stabilization for fracture-dislocations, destructive lesions, and spontaneous dislocations of the cervical spine [12]. In patients with metastatic disease of the spine, the lack of bony fusion does not appear to negatively affect overall survival or ambulatory status [21]. Circumduction fusion is effective in immobilizing the spine and arresting disease when solid [25].

Long-Segment and Complex Constructs: Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficit, often requiring additional fusion procedures [2]. Long-level posterolateral fusion maintains acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up [3]. Transsacral fixation/fusion may allow for safe lumbosacral fusion without iliac fixation in carefully selected patients with long-segment constructs [5]. In patients undergoing long fusion to the sacrum, realignment based on T4-L1-Hip Axis targets may lead to fewer mechanical failures [51].

Dynamic Stabilization and Growth Modulation: Initial studies suggest posterior dynamic stabilization results may be comparable to fusion, though longer follow-up is required to define their role [4]. Anterior vertebral body tethering showed no additional patients requiring conversion to posterior spinal fusion, indicating potential long-term survivorship [6]. Anterior spinal growth tethering avoided fusion in 13 of 17 skeletally immature patients with scoliosis, with an overall success rate of 59% and a 41% revision rate [7]. Biodegradable rods may present more favourable clinical outcomes for lumbar fusion by providing sufficient initial stability while gradually transferring loading to adjacent segments as rigidity decreases over time [22].

Disc Arthroplasty Outcomes: Patients undergoing 1 and 2-level lumbar total disc arthroplasty demonstrated dramatic and maintained reductions in disability and pain scores over time [8]. These patients had low rates of index-level revision, reoperation, and adjacent-level surgery relative to published long-term fusion data [8].

Shoulder and Scapulothoracic Considerations: Fusion surgery should be considered for recurrent shoulder instability in epileptic patients, though patients must be comprehensively counselled regarding resulting functional deficits [10]. Fiber-suture offers an alternative to steel wire to achieve scapulothoracic fusion, though further cases with longer term follow-up are needed to determine outcome differences [13].

Adjacent Segment Pathology and Decompression: Patients treated with posterior or combined anterior and posterior arthrodesis were far more likely to develop clinical adjacent-segment pathology requiring surgery than those treated with posterior decompression or anterior arthrodesis [46]. The unilateral biportal endoscopic (UBE) technique achieves satisfactory short-term clinical outcomes in patients with adjacent segment pathology following lumbar fusion without exacerbating spinal instability [48]. The presence of dynamic spondylolisthesis and facet effusions suggests that decompression alone may result in a greater likelihood of failure, warranting consideration of stabilization procedures [49].

Adjuncts and Technical Considerations: Firm conclusions about the efficacy of electrical bone stimulation in spinal fusion are difficult to establish due to inconsistencies in determining a reliable end point for fusion and incorporating patient parameters [24]. A new approach for mouse lumbar spine fusion is described as safe, efficient, and highly reproducible [50].

Investigations

Plain radiography: Five specific radiological parameters correlate with the need for distal extension of the fusion in posterior spinal fusion for adolescent idiopathic thoracolumbar/lumbar scoliosis, and an equation incorporating these five parameters reliably informs selection of the lowest instrumented vertebra [65]. Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficit, often necessitating additional fusion procedures [2]. Long-level fusion groups maintained acceptable clinical and radiological outcomes compared to short-level fusion groups at a minimum of 10 years of follow-up [3]. Radiological findings support the thesis of posterior dynamic stabilization by the used interspinous distraction device at 24 months [66].

CT: Biomechanical properties of a stable spinal fusion preceded the radiographic appearance of a solid fusion by at least eight weeks [19]. Immature woven bone provided substantial stiffness to the fusion mass [19].

Bone scan: 18F-fluoride PET/CT six weeks after posterior lumbar interbody fusion provides prognostic information on bony fusion at one year [62].

Other Considerations: Rigid fixation with screws and rods improves fusion rates for C1-C2 instability in children with skeletal dysplasias [9]. Anterior fusion is of distinct value in effecting stabilization for fracture-dislocations, destructive lesions, and spontaneous dislocations [12]. Crossed rod configurations used in posterior occipitocervical and atlantoaxial fixations have greater fixation stability and a higher rate of early bone fusion compared to parallel rod configurations, despite having a relatively weaker reduction force [15]. Transpedicular bi-vertebrae wedge osteotomy achieves satisfying correction and fusion rates with adequate decompression of neurological elements in the treatment of post-tubercular spinal deformity [18]. Biodegradable rods may present more favourable clinical outcomes for lumbar fusion by providing sufficient initial stability while gradually transferring loading to adjacent segments as rigidity decreases over time [22]. Cervical facet fusion yields long-term structural stability without the development of progressive deformity when performed correctly for control of instability following laminectomy [26]. Transsacral fixation/fusion may allow for safe lumbosacral fusion without iliac fixation in the setting of long-segment constructs in carefully selected patients [5]. Initial studies suggest that results of posterior dynamic stabilization may be comparable to those of fusion, though longer periods of clinical and radiographic follow-up are required [4]. Fiber-suture offers an alternative to steel wire to achieve scapulothoracic fusion, though further cases with longer term follow-up are needed to determine if significant differences in outcomes exist between constructs [13]. Bone fusion was achieved by revision surgery using the posterior approach alone after instrumentation failure following total en bloc spondylectomy [11]. No additional patients had conversion to a posterior spinal fusion with anterior vertebral body tethering, which may indicate long-term survivorship [6]. Fusion was avoided for 13 of 17 patients with anterior spinal growth tethering for skeletally immature patients with scoliosis, with an overall success rate of 59% and a 41% revision rate [7].

Treatment

Non-Operative

Non-operative management remains a viable option for stable thoracolumbar burst fractures and low-grade lytic spondylolisthesis, demonstrating excellent long-term outcomes and lower complication rates compared to instrumented approaches [45]. Relative indications for surgery vary by level, requiring six months of persisting symptoms for cervical pathology, failure of conservative measures for thoracic issues, and failure to improve after six weeks for lumbar conditions [58].

Operative

Indications: Fusion surgery is indicated for recurrent shoulder instability in epileptic patients, provided comprehensive preoperative counseling regarding functional deficits occurs [10]. Arthrodesis remains the mainstay of surgical treatment for isthmic spondylolisthesis in adults [14]. Anterior fusion offers distinct value for stabilization in fracture-dislocations, destructive lesions, and spontaneous dislocations [12]. Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficits, often necessitating additional fusion procedures [2].

Surgical Approach / Technique: A technique to determine the optimum position for shoulder arthrodesis prior to operation involves local anesthesia and temporary fixation with two small Steinmann pins [61]. Bone fusion can be achieved via revision surgery using the posterior approach alone following instrumentation failure after total en bloc spondylectomy [11]. Transpedicular bi-vertebrae wedge osteotomy achieves satisfying correction and fusion rates with adequate decompression of neurological elements in post-tubercular spinal deformity [18]. Posterior instrumentation on affected vertebrae is a safe, effective, and feasible fixation method for lumbar tuberculosis under strict surgical indications [44].

Implant Selection: A new stand-alone anterior lumbar interbody fusion cage provides stability required for interbody fusion, supporting its use as an alternative to circumferential fixations [1]. ALIF instrumentation with the Latero or SynFix cage provides acceptable stability for clinical use without requiring additional posterior fixation [47]. Transsacral fixation/fusion may allow for safe lumbosacral fusion without iliac fixation in long-segment constructs in carefully selected patients [5]. Rigid fixation with screws and rods improves fusion rates for C1-C2 instability in children with skeletal dysplasias [9]. Pedicle-screw instrumentation has gained wide acceptance as an adjunct to fusion for isthmic spondylolisthesis, despite not yet being proved safe and effective [14]. Fiber-suture offers an alternative to steel wire to achieve scapulothoracic fusion, though further cases with longer term follow-up are needed to determine outcome differences [13]. Modern segmental screw-based fixation systems are biomechanically more stable and user-friendly than previous wiring techniques, offering superior rigidity and fusion rates approaching 100% [16]. Crossed rod configurations in posterior occipitocervical and atlantoaxial fixations have greater fixation stability and a higher rate of early bone fusion compared to parallel configurations, despite relatively weaker reduction force [15]. Cortical Bone Trajectory (CBT) provides a method of minimizing dissection and achieving stable fixation in posterior spinal fusion [32].

Alignment / Balancing Strategy: Long-level posterolateral fusion maintained acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up [3]. Patterns of loss of correction after posterior wedge osteotomy in ankylosing spondylitis-related thoracolumbar kyphosis are primarily observed in the proximal non-fused segments and distal intervertebral discs [59].

Pain Management: Cannabinoid receptor agonists should be further investigated as a potential alternative approach for postoperative analgesia following spinal fusion and other orthopaedic procedures requiring bone-healing [54]. A multimodal analgesic (MMA) protocol was superior to patient-controlled analgesia (PCA) in treating pain and improving length of stay and disposition status in patients undergoing multilevel spinal fusion [57].

Adjuncts: Initial studies suggest posterior dynamic stabilization results may be comparable to fusion, though longer clinical and radiographic follow-up is required to define their role [4]. A dual-cord dynamic stabilization system demonstrates improved biomechanical stability with minimal adjacent segment compromise [17]. Decompression coupled with dynamic stabilization techniques can more effectively alleviate postoperative lumbar stiffness and functional impairment compared to traditional decompression combined with rigid fusion surgery [31]. Non-fusion procedures using PEEK rod systems might be a viable alternative for treatment of lumbar degenerative diseases [23].

Revision: The lack of bony fusion in patients with metastatic disease of the spine does not appear to negatively affect overall survival or ambulatory status [21]. Patients undergoing 1 and 2-level lumbar total disc arthroplasty had dramatic and maintained reductions in disability and pain scores over time [8]. Lumbar total disc arthroplasty demonstrated low rates of index-level revision, reoperation, and adjacent-level surgery relative to published long-term fusion data [8].

Complications

Instability: Long-term spinal stability remains a significant challenge, often requiring additional fusion procedures [2]. Rigid fixation with screws and rods improves fusion rates [9], and while some techniques offer weaker reduction forces, they provide greater fixation stability and higher rates of early bone fusion [15]. Motion in the coronal plane decreased by 77% following anterior vertebral body tethering [20], and early outcome studies indicate that growth modulation with this technique is safe, achieves good results, and preserves motion in select patients [75]. Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up [27].

Pseudarthrosis: The rate of fusion was 90 per cent in patients with painful degenerative disease, 93 per cent in those with spondylolisthesis, and 65 per cent in those with preoperative pseudarthrosis [74]. Bone fusion was achieved by revision surgery using the posterior approach alone [11], and modern iliac screws and S2-alar-iliac screws are associated with relatively low rates of pseudarthrosis [72]. One technique did not alter the rate of pseudarthrosis compared to previous reports, but the overall rate of complications was much lower than in previous series [73]. Patients with multiple-level infected disks had a low bone union rate, suggesting treatment strategies should be cautiously considered [67].

Adjacent-Level and Revision Complications: Long-term spinal stability often necessitates additional fusion procedures [2], though long-level fusion groups maintained acceptable clinical and radiological outcomes compared to short-level fusion groups at a minimum of 10 years of follow-up [3]. Transsacral fixation/fusion may allow for safe lumbosacral fusion without iliac fixation in the setting of long-segment constructs in carefully selected patients [5]. No additional patients had conversion to a posterior spinal fusion, which may indicate long-term survivorship [6]. Fusion was avoided for 13 of the 17 patients, with an overall success rate of 59% and a 41% revision rate [7]. Patients had dramatic and maintained reductions in disability and pain scores over time and low rates of index-level revision or reoperation and adjacent-level surgery relative to published long-term fusion data [8].

Other Considerations: Pedicle-screw instrumentation has gained wide acceptance as an adjunct to fusion despite not yet being proved safe and effective [14]. While BMP-2 is effective for achieving high fusion rates and equal clinical outcomes compared to autograft, safety concerns and conflicts of interest in original trials complicate its routine use [70]. Short-term studies demonstrate similar clinical improvements for both disk replacements and fusion procedures at up to 2-year follow-up [28], and short-term results from randomized control trials clearly showed noninferiority of cervical disk arthroplasty compared with fusion [69]. The most common complications are infection and proximal junctional kyphosis (PJK), with PJK being associated with larger pre-operative thoracic kyphosis [71]. Firm conclusions about efficacy are difficult to establish because of inconsistencies in determining a reliable end point for fusion and incorporating patient parameters [24], and precise indications for durable long-term correction remain to be defined [64].

Recovery

Light activity (weeks): Evidence regarding specific week ranges for light activity, such as desk work or driving, is not explicitly provided in the current evidence base. However, patients undergoing 1 and 2-level lumbar total disc arthroplasty demonstrated dramatic and maintained reductions in disability and pain scores over time, suggesting a trajectory for early functional return [8].

Full activity (months): Specific month ranges for full activity, manual work, or sport are not explicitly detailed in the provided evidence. Long-term spinal stability remains a significant challenge in kyphoscoliotic patients with neurological deficits, often necessitating additional fusion procedures [2]. Conversely, the long-level fusion group maintained acceptable clinical and radiological outcomes compared to the short-level fusion group at a minimum of 10 years of follow-up [3].

Complete recovery / outcome plateau (months): Functional gains from scapulothoracic arthrodesis in facioscapulohumeral muscular dystrophy are retained for three to twenty-one years postoperatively [60]. Immediate and sustained neurological recovery can be achieved with posterior decompression and stabilization for spinal metastases [63]. Cervical facet fusion yields long-term structural stability without the development of progressive deformity when performed correctly [26]. Circumduction fusion is effective in immobilizing the spine and arresting disease when solid [25].

Rehabilitation protocol: The primary goals of posterior instrumentation using distraction and ligamentotaxis reduction for thoracolumbar fractures are sagittal realignment and fracture stabilization rather than decompression of neural elements [52]. A realistic long-term goal for the management of early-onset scoliosis appears to be spine elongation and maintenance of pulmonary function at a level that is no less than the percentage of normal at initial presentation [53]. Patients treated with long segmental stabilization for unstable midthoracic spine fractures in the elderly had a significantly lower rate of sequential vertebral body fractures during follow-up [27].

Functional milestones: Patients undergoing 1 and 2-level lumbar total disc arthroplasty had low rates of index-level revision or reoperation relative to published long-term fusion data [8]. These patients also had low rates of adjacent-level surgery relative to published long-term fusion data [8]. Short-term studies demonstrate similar clinical improvements for both disk replacements and fusion procedures at up to 2-year follow-up [28]. Fusion was avoided for 13 of the 17 patients in the Anterior Spinal Growth Tethering study, with an overall success rate of 59% and a 41% revision rate [7]. No additional patients had conversion to a posterior spinal fusion in the Anterior Vertebral Body Tethering cohort, which may indicate long-term survivorship [6].

Other Considerations: Initial studies suggest that the results of posterior dynamic stabilization may be comparable to those of fusion [4]. The dual-cord dynamic stabilization system demonstrates improved biomechanical stability with minimal adjacent segment compromise [17]. A new stand-alone anterior lumbar interbody fusion cage provided the stability required for interbody fusion [1]. Fusion surgery should be considered for recurrent shoulder instability in epileptic patients, though patients must be comprehensively counselled preoperatively given the functional deficit that results from the procedure [10]. SCAPS fixation combined with vertebroplasty appears to be a safe and effective surgical approach for stage III Kummell's disease, with significant correction of spinal kyphosis [68]. This approach also demonstrates restoration of vertebral height [68], improvement in neurological function [68], and maintenance of long-term spinal stability [68].

Key Evidence

  • [L5] This device provided the stability required for interbody fusion, which supports clinical trials of the cage as an alternative to circumferential fixations. (10.1186/1471-2474-9-88)
  • [L4] However, long-term spinal stability remains a significant challenge, often requiring additional fusion procedures. (10.2106/00004623-196042060-00010)
  • [L3] The long-level fusion group maintained acceptable clinical and radiological outcomes compared to the short-level fusion group at a minimum of 10 years of follow-up. (10.1186/s12891-015-0836-3)
  • [L5] Initial studies suggest that the results of posterior dynamic stabilization may be comparable to those of fusion; however, longer periods of clinical and radiographic follow-up are required to fully define the role these devices may play in the management of the degenerative lumbar spine. (10.5435/00124635-201010000-00001)
  • [L4] Transsacral fixation/fusion may allow for safe lumbosacral fusion without iliac fixation in the setting of long-segment constructs in carefully selected patients. (10.1007/s11999-013-3335-6)
  • [L3] No additional patients had conversion to a posterior spinal fusion, which may indicate long-term survivorship. (10.2106/jbjs.23.01229)
  • [L4] Fusion was avoided for 13 of the 17 patients, with an overall success rate of 59% and a 41% revision rate. (10.2106/jbjs.18.00287)
  • [L3] Patients had dramatic and maintained reductions in disability and pain scores over time and low rates of index-level revision or reoperation and adjacent-level surgery relative to published long-term fusion data. (10.2106/jbjs.23.00735)
  • [L3] Rigid fixation with screws and rods improves fusion rates. (10.2106/jbjs.n.00503)
  • [L4] Fusion surgery should be considered in this patient population, though patients must be comprehensively counselled preoperatively given the functional deficit that results from the procedure. (10.1302/0301-620x.96b11.33754)
  • [L4] Bone fusion was achieved by revision surgery using the posterior approach alone. (10.1186/s12891-020-03622-6)
  • [L4] Anterior fusion is of distinct value in effecting stabilization for fracture-dislocations, destructive lesions, and spontaneous dislocations. (10.2106/00004623-196042060-00023)
  • [L4] Fiber-suture offers an alternative to steel wire to achieve fusion, though further cases with longer term follow-up are needed to determine if significant differences in outcomes exist between constructs. (10.1016/j.xrrt.2021.01.003)
  • [L4] Arthrodesis continues to be the mainstay of surgical treatment, while pedicle-screw instrumentation has gained wide acceptance as an adjunct to fusion despite not yet being proved safe and effective. (10.5435/00124635-199607000-00004)
  • [L3] Although this technique has a relatively weaker reduction force, it has greater fixation stability and a higher rate of early bone fusion. (10.1186/s13018-024-05330-6)
  • [L5] Modern segmental screw-based fixation systems are biomechanically more stable and user-friendly than previous wiring techniques, offering superior rigidity and fusion rates approaching 100%. (10.5435/00124635-201102000-00001)
  • [Paper] The dual-cord dynamic stabilization system demonstrates improved biomechanical stability with minimal adjacent segment compromise. (10.1186/s13018-025-06130-2)
  • [L4] This technique achieves satisfying correction and fusion rates with adequate decompression of neurological elements. (10.1186/s12891-021-04220-w)
  • [L5] The biomechanical properties of a stable spinal fusion preceded the radiographic appearance of a solid fusion by at least eight weeks, suggesting that immature woven bone provided substantial stiffness to the fusion mass. (10.2106/00004623-199711000-00013)
  • [L4] Motion in the coronal plane decreased by 77% following anterior vertebral body tethering. (10.2106/jbjs.20.01533)
  • [L3] The lack of bony fusion in patients with metastatic disease of the spine does not appear to negatively affect their overall survival or their ambulatory status. (10.5435/jaaos-d-19-00244)
  • [L5] Biodegradable rods may present more favourable clinical outcomes for lumbar fusion by providing sufficient initial stability while gradually transferring loading to adjacent segments as rigidity decreases over time. (10.1371/journal.pone.0188034)
  • [L4] The non-fusion procedure using PEEK rod systems might be a viable alternative for treatment of lumbar degenerative diseases. (10.1186/s12891-016-0913-2)
  • [L4] Firm conclusions about efficacy are difficult to establish because of inconsistencies in determining a reliable end point for fusion and incorporating patient parameters. (10.5435/00124635-200303000-00002)
  • [L4] Circumduction fusion is effective in immobilizing the spine and arresting disease when solid. (10.2106/00004623-195638020-00002)
  • [L4] When performed correctly, it yields long-term structural stability without the development of progressive deformity. (10.2106/00004623-197759080-00001)
  • [L3] Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up. (10.1186/s12891-021-04049-3)
  • [L5] Short-term studies demonstrate similar clinical improvements for both disk replacements and fusion procedures at up to 2-year follow-up. (10.5435/00124635-200612000-00002)
  • [L5] Understanding the biomechanical principles of spinal instrumentation and motion coupling is essential for optimizing three-dimensional correction of thoracolumbar spinal deformities and achieving favorable mechanical environments for fusion. (10.5435/jaaos-d-24-01156)
  • [L5] Noncontinuous CDA could preserve IDP and facet joint forces at the adjacent and intermediate levels to maintain the kinematics of cervical spine near preoperative values. (10.1186/s13018-020-1549-3)
  • [L3] Compared to traditional decompression combined with rigid fusion surgery, decompression coupled with dynamic stabilization techniques can more effectively alleviate postoperative lumbar stiffness and functional impairment in patients. (10.1186/s13018-025-05837-6)
  • [L5] CBT provides a method of minimizing dissection and achieving stable fixation in posterior spinal fusion. (10.5435/jaaos-d-15-00597)
  • [L4] The paper reviews biomechanical studies to clarify the effects of interspinous devices on treated and adjacent spinal segments, noting that while devices reduce range of motion in extension and can reduce disc pressure, they often fail to fully compensate for destabilization in other planes or adjacent levels. (10.1155/2014/839325)
  • [L5] From the perspective of finite element analysis, the cervical vertebrae after PPECD treatment showed good biomechanical performance and stability. (10.1186/s13018-019-1113-1)
  • [L5] The study suggests that a 5 mm implant height provides biomechanical properties similar to intact specimens, whereas larger heights alter facet joint mechanics. (10.1186/s13018-020-02157-9)
  • [L5] However, the tested VBT constructs provide stability for the spine in lateral bending. (10.1186/s13018-025-06455-y)
  • [L5] The study concluded the biomechanical effects still afford nearly sufficient spine support and gentle adjacent segment stress after rod fracture in a worst-case scenario of the thinnest PS of the SHE rod system. (10.1186/s12891-022-05768-x)
  • [L5] Advances in biomechanics and fixation systems have enabled reliable stabilization that permits early mobilization. (10.5435/00124635-200411000-00007)
  • [L5] The mobility and stability of rotational and translational joints are key factors for fusion rate and adjacent segment degeneration progression. (10.1186/s13018-024-04629-8)
  • [L5] Although TELD-SDSS application alters the biomechanical environment of the adjacent segments, it has potential biomechanical advantages over PLIF in the mitigation of ASD occurrence. (10.1186/s12891-025-08825-3)
  • [L3] Patient-specific biomechanical simulation revealed that spinal fusion surgery resulted in greater shear load magnitude and muscle activation and therefore greater forces at the epifusional segment in those with ASD compared with those without ASD. (10.1186/s12891-021-04916-z)
  • [L5] The intermediate segment does not experience additive range of motion or stress in the intervertebral disc or facet joints after skip-level arthroplasty, which has fewer biomechanical effects on the intermediate segment than does skip-level fusion. (10.1186/s12891-019-2425-3)
  • [L3] Under strict surgical indications, posterior instrumentation on affected-vertebrae is a safe, effective, and feasible fixation method in the treatment of lumbar TB. (10.1186/s13018-018-0902-2)
  • [L5] Non-operative treatment for stable thoracolumbar burst fractures and uninstrumented fusion for low-grade lytic spondylolisthesis demonstrate established clinical proficiency with excellent long-term outcomes and lower complication rates compared to instrumented approaches. (10.1302/0301-620x.98b1.37508)
  • [L3] Patients treated with posterior or combined anterior and posterior arthrodesis were far more likely to develop clinical adjacent-segment pathology requiring surgery than those treated with posterior decompression or anterior arthrodesis. (10.2106/jbjs.m.01482)
  • [L5] ALIF instrumentation with the Latero or SynFix cage provides an acceptable stability for clinical use without the requirement of additional posterior fixation. (10.1186/1471-2474-14-281)
  • [L4] The UBE technique achieves satisfactory short-term clinical outcomes in patients with ASP following lumbar fusion without exacerbating spinal instability. (10.1186/s13018-025-06034-1)
  • [L3] The presence of dynamic spondylolisthesis and facet effusions suggests that decompression alone may result in a greater likelihood of failure, and the addition of stabilization procedures should be considered. (10.5435/jaaos-d-24-00763)
  • [L5] We describe a new approach for mouse lumbar spine fusion that is safe, efficient, and highly reproducible. (10.1186/1749-799x-8-2)
  • [L3] In patients undergoing long fusion to the sacrum, realignment based on these targets may lead to fewer mechanical failures. (10.2106/jbjs.23.00372)
  • [L5] The primary goals of this procedure are sagittal realignment and fracture stabilization rather than decompression of neural elements. (10.5435/00124635-200711000-00008)
  • [L4] A realistic long-term goal for the management of early-onset scoliosis appears to be spine elongation and maintenance of pulmonary function at a level that is no less than the percentage of normal at initial presentation. (10.2106/jbjs.16.00796)
  • [L5] This supports that cannabinoid receptor agonists should be further investigated as a potential alternative approach for postoperative analgesia following spinal fusion and other orthopaedic procedures requiring bone-healing. (10.2106/jbjs.20.00573)
  • [L5] These findings quantify the correction loss for minimally invasive spine implant systems and imply that unstable spine fractures might benefit from stabilization with conventional implants like the USS. (10.1186/s12891-016-0983-1)
  • [L5] Treatment of degenerative spondylolisthesis has evolved with numerous prospective randomized trials assessing fusion and instrumentation, and the use of bone morphogenetic proteins or soft-tissue stabilization devices. (10.5435/00124635-200804000-00004)
  • [L3] The MMA protocol was superior to PCA in treating pain and improving length of stay and disposition status in patients undergoing multilevel spinal fusion. (10.5435/jaaos-d-24-01442)
  • [L5] Relative indications vary by level: six months of persisting symptoms for cervical, failure of conservative measures for thoracic, and failure to improve after six weeks for lumbar. (10.1302/2058-5241.6.210020)
  • [L4] The patterns of loss of correction are primarily observed in the proximal non-fused segments and distal intervertebral discs. (10.1186/s12891-017-1834-4)
  • [L4] The functional gains are retained for three to twenty-one years postoperatively. (10.2106/00004623-199303000-00008)
  • [L4] A technique to determine the optimum position before operation using local anesthesia and temporary fixation of the joint with two small Steinmann pins is described and used successfully in two patients. (10.2106/00004623-196244040-00005)
  • [L2] 18F-fluoride PET/CT six weeks after PLIF provides prognostic information on bony fusion at one year. (10.1186/s13018-025-05814-z)
  • [L3] Immediate and sustained neurological recovery can be achieved with posterior decompression and stabilization. (10.2106/00004623-199704000-00006)
  • [L4] The paper is an important addition to the literature regarding VBT outcomes in AIS, but precise indications for durable long-term correction remain to be defined. (10.2106/jbjs.24.01045)
  • [L3] Five radiological parameters correlate with the need for distal extension of the fusion, and an equation incorporating these parameters reliably informs selection of the lowest instrumented vertebra. (10.1302/0301-620x.96b8.33837)
  • [L4] The radiological findings support the thesis of posterior dynamic stabilization by the used implant. (10.1186/s12891-016-0945-7)
  • [L3] Patients with multiple-level infected disks had a low bone union rate, suggesting treatment strategies should be cautiously considered. (10.1186/s12891-024-07993-y)
  • [L4] SCAPS fixation combined with vertebroplasty appears to be a safe and effective surgical approach for stage III KD, with significant correction of spinal kyphosis, restoration of vertebral height, improvement in neurological function, and maintenance of long-term spinal stability. (10.1186/s13018-026-06723-5)
  • [L5] Short-term results from randomized control trials clearly showed noninferiority of CDA compared with fusion. (10.5435/jaaos-d-17-00231)
  • [L5] While BMP-2 is effective for achieving high fusion rates and equal clinical outcomes compared to autograft, safety concerns and conflicts of interest in original trials complicate its routine use. (10.5435/jaaos-20-09-547)
  • [L4] The most common complications are infection and proximal junctional kyphosis (PJK), with PJK being associated with larger pre-operative thoracic kyphosis. (10.1186/s13018-021-02267-y)
  • [L5] Modern iliac screws and S2-alar-iliac screws are associated with relatively low rates of pseudarthrosis. (10.2106/jbjs.o.00576)
  • [L4] The technique did not alter the rate of pseudarthrosis compared to previous reports, but the overall rate of complications was much lower than in previous series. (10.2106/00004623-198971090-00005)
  • [L4] The rate of fusion was 90 per cent in patients with painful degenerative disease, 93 per cent in those with spondylolisthesis, and 65 per cent in those with preoperative pseudarthrosis. (10.2106/00004623-199173080-00006)
  • [L4] Early outcome studies show that growth modulation with vertebral body tethering is safe, can achieve good results, and preserve motion in select patients. (10.5435/jaaos-d-23-00312)

See Also

References

[1] Biomechanical comparison of a new stand-alone anterior lumbar interbody fusion cage with established fixation techniques – a three-dimensional finite element analysis. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-88

[2] 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

[3] Long-term outcomes of long level posterolateral fusion in lumbar degenerative disease: comparison of long level fusion versus short level fusion: a case control study. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0836-3

[4] Pedicle Screw-based Posterior Dynamic Stabilization in the Lumbar Spine. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201010000-00001

[5] Does Minimally Invasive Transsacral Fixation Provide Anterior Column Support in Adult Scoliosis?. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-013-3335-6

[6] Anterior Vertebral Body Tethering. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.01229

[7] Anterior Spinal Growth Tethering for Skeletally Immature Patients with Scoliosis. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.18.00287

[8] Clinical Outcomes After 1 and 2-Level Lumbar Total Disc Arthroplasty. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00735

[9] Rigid Fixation Improves Outcomes of Spinal Fusion for C1-C2 Instability in Children with Skeletal Dysplasias. The Journal of Bone and Joint Surgery-American Volume. 2015. DOI: 10.2106/jbjs.n.00503

[10] Glenohumeral arthrodesis for the treatment of recurrent shoulder instability in epileptic patients. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b11.33754

[11] Revision surgery for instrumentation failure after total en bloc spondylectomy: a retrospective case series. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03622-6

[12] Stabilization of the Cervical Spine by Anterior Fusion. The Journal of Bone & Joint Surgery. 1960. DOI: 10.2106/00004623-196042060-00023

[13] Scapulothoracic fusion using nonabsorbable suture fixation: surgical technique and review of the literature. JSES Reviews, Reports, and Techniques. 2021. DOI: 10.1016/j.xrrt.2021.01.003

[14] Isthmic Spondylolisthesis in the Adult. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199607000-00004

[15] Comparison of crossed and parallel rod configurations used in posterior occipitocervical and atlantoaxial fixations: a retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05330-6

[16] Posterior Fixation of the Upper Cervical Spine: Contemporary Techniques. Journal of the American Academy of Orthopaedic Surgeons. 2011. DOI: 10.5435/00124635-201102000-00001

[17] Evaluating the performance of a novel double-threaded dynamic stabilization system: a finite element study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06130-2

[18] Transpedicular bi‐vertebrae wedge osteotomy in treatment of post‐tubercular spinal deformity: a retrospective study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04220-w

[19] Maturation of the Posterolateral Spinal Fusion and Its Effect on Load-Sharing of Spinal Instrumentation. The Journal of Bone and Joint Surgery (American Volume). 1997. DOI: 10.2106/00004623-199711000-00013

[20] Measurable Thoracic Motion Remains at 1 Year Following Anterior Vertebral Body Tethering, with Sagittal Motion Greater Than Coronal Motion. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01533

[21] Necessity of Bony Fusion After Surgical Treatment of Metastatic Spine Tumors. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-19-00244

[22] Assessment of the suitability of biodegradable rods for use in posterior lumbar fusion: An in-vitro biomechanical evaluation and finite element analysis. PLOS ONE. 2017. DOI: 10.1371/journal.pone.0188034

[23] Non-fusion procedure using PEEK rod systems for lumbar degenerative diseases: clinical experience with a 2-year follow-up. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0913-2

[24] Use of Electrical Bone Stimulation in Spinal Fusion. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200303000-00002

[25] Circumduction Fusion of the Spine. The Journal of Bone & Joint Surgery. 1956. DOI: 10.2106/00004623-195638020-00002

[26] Cervical facet fusion for control of instability following laminectomy. The Journal of Bone & Joint Surgery. 1977. DOI: 10.2106/00004623-197759080-00001

[27] Midterm outcome after posterior stabilization of unstable Midthoracic spine fractures in the elderly. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04049-3

[28] Total Disk Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200612000-00002

[29] Biomechanical Principles of Spinal Deformity Correction in the Thoracolumbar Spine. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01156

[30] Biomechanical comparison of noncontiguous cervical disc arthroplasty and noncontiguous cervical discectomy and fusion in the treatment of noncontinuous cervical degenerative disc disease: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-1549-3

[31] Effects of dynamic stabilization and fusion on postoperative paraspinal muscle degeneration and lumbar function recovery. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05837-6

[32] Cortical Bone Trajectory Technique for Posterior Spinal Instrumentation. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00597

[33] Biomechanics of Interspinous Devices. BioMed Research International. 2014. DOI: 10.1155/2014/839325

[35] Biomechanical comparison of percutaneous posterior endoscopic cervical discectomy and anterior cervical decompression and fusion on the treatment of cervical spondylotic radiculopathy. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1113-1

[36] The impact of different artificial disc heights during total cervical disc replacement: an in vitro biomechanical study. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-020-02157-9

[37] Segmental range of motion of vertebral body tethering: an in-vitro analysis of single-tether, double-tether, and hybrid constructs. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06455-y

[38] Finite element analysis after rod fracture of the spinal hybrid elastic rod system. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05768-x

[39] Posterior Instrumentation for Thoracolumbar Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2004. DOI: 10.5435/00124635-200411000-00007

[40] Biomechanical comparison of static and dynamic cervical plates in terms of the bone fusion, tissue degeneration, and implant behavior. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04629-8

[41] Biomechanical effects of transforaminal endoscopic lumbar discectomy combined with spinal dynamic stabilization system use on adjacent segments: a finite element analysis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08825-3

[42] Musculoskeletal biomechanics of patients with or without adjacent segment degeneration after spinal fusion. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04916-z

[43] Biomechanics following skip-level cervical disc arthroplasty versus skip-level cervical discectomy and fusion: a finite element-based study. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2425-3

[44] Five-year outcomes of posterior affected-vertebrae fixation in lumbar tuberculosis patients. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0902-2

[45] Thoracolumbar spinal treatment without screws. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b1.37508

[46] Risk-Factor Analysis of Adjacent-Segment Pathology Requiring Surgery Following Anterior, Posterior, Fusion, and Nonfusion Cervical Spine Operations. The Journal of Bone and Joint Surgery-American Volume. 2014. DOI: 10.2106/jbjs.m.01482

[47] Biomechanical comparison of three stand-alone lumbar cages — a three-dimensional finite element analysis. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-281

[48] Clinical efficacy of unilateral biportal endoscopic technique for adjacent segment pathology following lumbar fusion. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06034-1

[49] Risk Factors for Failure After Lumbar Tubular Microdecompression Without Stabilization. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00763

[50] Posterolateral inter-transverse lumbar fusion in a mouse model. Journal of Orthopaedic Surgery and Research. 2013. DOI: 10.1186/1749-799x-8-2

[51] The T4-L1-Hip Axis: Sagittal Spinal Realignment Targets in Long-Construct Adult Spinal Deformity Surgery. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00372

[52] Thoracolumbar Fracture: Posterior Instrumentation Using Distraction and Ligamentotaxis Reduction. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200711000-00008

[53] Functional and Radiographic Outcomes Following Growth-Sparing Management of Early-Onset Scoliosis. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.16.00796

[54] Effect of Postoperative Analgesic Exposure to the Cannabinoid Receptor Agonist WIN55 on Osteogenic Differentiation and Spinal Fusion in Rats. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.00573

[55] Biomechanical investigation of a minimally invasive posterior spine stabilization system in comparison to the Universal Spinal System (USS). BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0983-1

[56] Degenerative Lumbar Spondylolisthesis: Trends in Management. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200804000-00004

[57] A Multimodal Pain Regimen in Thoracolumbar Spine Surgery Patients Is Associated With Improved Postoperative Recovery and Disposition. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01442

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

[59] The patterns of loss of correction after posterior wedge osteotomy in ankylosing spondylitis-related thoracolumbar kyphosis: a minimum of five-year follow-up. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1834-4

[60] Scapulothoracic arthrodesis in facioscapulohumeral muscular dystrophy. Review of seventeen procedures with three to twenty-one-year follow-up.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199303000-00008

[61] A Technique for Shoulder Arthrodesis. The Journal of Bone & Joint Surgery. 1962. DOI: 10.2106/00004623-196244040-00005

[62] 18F-fluoride PET/CT as an early predictor of bony fusion after posterior lumbar interbody fusion– a prospective study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05814-z

[63] Posterior Decompression and Stabilization for Spinal Metastases. Analysis of Sixty-seven Consecutive Patients. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199704000-00006

[64] Prospective Vertebral Body Tethering Data. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.01045

[65] Posterior spinal fusion for adolescent idiopathic thoracolumbar/lumbar scoliosis. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b8.33837

[66] Posterior dynamic stabilization in the lumbar spine – 24 months results of a prospective clinical and radiological study with an interspinous distraction device. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0945-7

[67] Unique characteristics of bone union at the infected vertebrae after minimally invasive posterior fixation without bone grafting in thoracolumbar pyogenic spondylitis: a retrospective multicenter cohort study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07993-y

[68] Clinical outcomes of short-segment cement-augmented pedicle screw fixation combined with vertebroplasty in patients with stage III Kummell’s disease. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06723-5

[69] Cervical Disk Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00231

[70] Bone Morphogenetic Protein in Spine Surgery: Current and Future Uses. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-09-547

[71] Complications of dual growing rod with all-pedicle screw instrumentation in the treatment of early-onset scoliosis. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02267-y

[72] Pelvic Fixation in Adult and Pediatric Spine Surgery: Historical Perspective, Indications, and Techniques. Journal of Bone and Joint Surgery. 2015. DOI: 10.2106/jbjs.o.00576

[73] Adult idiopathic scoliosis treated with Luque or Harrington rods and sublaminar wiring.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971090-00005

[74] Results of spinal arthrodesis with pedicle screw-plate fixation.. The Journal of Bone & Joint Surgery. 1991. DOI: 10.2106/00004623-199173080-00006

[75] Anterior Vertebral Body Tethering: A Review of the Available Evidence. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00312

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.