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Lumbar Region

Lumbar disc herniation, spinal stenosis, and degenerative spondylolisthesis — management strategies and the transition from open to minimally invasive surgery (MISS).

Overview

Defining lumbar spinal stenosis requires consensus on unambiguous radiological criteria to ensure diagnostic accuracy and reliable study inclusion [2]. While evidence for spinal fusion or disc replacement in non-specific low back pain remains poor, with fusion restricted to randomized controlled trials and disc replacement contraindicated [28], specific pathologies warrant intervention. Posterior lateral lumbar fusion preserving partial unilateral facet joints offers greater benefits under strict adherence to surgical indications [76].

Patient selection is critical across age and comorbidity profiles. Age is not a contraindication for decompressive surgery, with posterior decompression and instrumented fusion proving safe and effective for patients aged 80 and older [11, 65]. Similarly, obesity does not preclude lumbar spinal fusion [22]. For total disc replacement, outcomes in patients with herniated nucleus pulposus and radiculopathy mirror those of classic indications, suggesting these are not absolute or relative contraindications [21]. Best indications for lumbar laminoplasty include young, active patients with central spinal stenosis [23].

Nonsurgical management remains a reasonable option for select patients when weighing risks, costs, and outcomes against surgery, despite inconclusive long-term efficacy data for epidural steroid injections [5]. Surgical timing varies by region: failure to improve after six weeks is the threshold for lumbar intervention, contrasting with six months for cervical and failure of conservative measures for thoracic levels [26]. Lateral lumbar interbody fusion at L4-L5 demonstrates low rates of persistent neurological, psoas-related, and abdominal complications in appropriately selected patients using standardized techniques [4].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Global lumbar spine kinematics do not reflect regional lumbar spine kinematics [7], and the position of the center of rotation varies with load [10] and movement type [10]. Distinct motion patterns exist in the lower lumbar spine [10], while increasing load significantly impacts the coupled translational movement of lumbar facet joints [51]. Asymmetry affects facet joint response and must be considered in biomechanical studies [37], and the biomechanics of the lumbar spine may differ with each individual [53]. Individual kinematic variables have weak to moderate effects on intervertebral range of motion at other levels [64], as does lumbar lordosis [64]. Four subgroups of lumbo-pelvic flexion kinematics are present in people with and without persistent low back pain, with unequal distribution among these groups [66]. Loading in the anterior-oblique direction requires lower external force or moment to maintain a neutral position compared to vertical or posterior-oblique directions [67].

Spinopelvic and Postural Mechanics

Lumbosacral and hip motions are the major contributors to global alignment postural change [59]. With advancing age, spinopelvic biomechanics demonstrate decreased spinal mobility but increased pelvic and hip mobility [50]. Longer spinal fusion or inclusion of the pelvis critically impacts hip-spine biomechanics [43] and significantly affects the ability to compensate in the standing-to-sitting transition [43]. L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation owing to hyperextension injury [53]. Further biomechanical and neuroanatomic studies are needed to elucidate the effects of lumbar spine disease in relation to gluteal tears [58].

Surgical and Instrumentation Considerations

Both dynamic stabilization systems result in degeneration at the fixed segment [46]. Total laminectomy changes the biomechanics in normal lumbar models [62] and in spondylolisthesis models [62]. Data on the posterior bony column of the lumbar spine can provide theoretical references for spinal implant materials [63]. The computer BS-II system is designed for biomechanical measurements of the lumbar part of the human spine [71] and for verification of surgical fixation methods [71].

Classification

Lumbar Degenerative Disease: Evaluation emphasizes distinguishing spinal from extraspinal causes of low back pain [1]. Radiological findings include Modic changes, with Type 2 being particularly frequent [3]. These changes most frequently occur at the L4/L5 and L5/S1 levels [3]. Spinal classification may serve as a predictor of lumbar disc degeneration [42].

Thoracolumbar Injury Classification and Severity Score (TLICS): Developed to address limitations of prior systems, TLICS defines injury based on morphology, posterior ligamentous complex integrity, and neurologic status [68]. The system offers prognostic information and aids medical decision-making [68]. A modified TLICS system is a practical tool for the classification and assessment of thoracolumbar fractures [70]. This modified system has guiding significance for clinical treatment [70], though the operation rate was slightly lower with the modified system than with the standard TLICS system [70].

Degenerative Thoracolumbar Kyphosis: A novel classification proposes four types of degenerative thoracolumbar kyphosis based on thoracolumbar kyphosis and balance [73]. Targeted treatment strategies are associated with various types in this novel classification [73].

Hip-Spine Classification: This system allows surgeons to make appropriate evaluations preoperatively [74]. It guides the use of dual mobility (DM) components in patients with spinopelvic pathology [74] and is used to reduce the risk of dislocation in high-risk patients [74].

Other Considerations: Global lumbar spine kinematics do not reflect regional lumbar spine kinematics [7]. The position of the lumbar spine center of rotation changes with variations in load [10] and differs between movement types [10]. Distinct motion patterns exist in the lower lumbar spine [10]. While classifications are generalizations that can provide an efficient means of communication [61], many original reports describing common thoracic and lumbar injury classifications lack a rigorous scientific foundation [61] and were based largely on the insights of experienced surgeons [61]. Numerous classification systems exist for patients with leg pain [75], but a minority focus specifically on distinguishing between different presentations of leg pain [75]. No clinically applicable and validated classification of spinal stenosis has been published [79], a lack that has substantially limited the development of an evidence-based algorithm for treatment [79]. A new classification system that incorporates spinopelvic balance in radiographic assessment may aid orthopaedic surgeons in identifying patients who would benefit from partial reduction and fusion [81].

Clinical Presentation

Lumbar degenerative disease and low back pain exhibit a high prevalence of asymptomatic degeneration [1]. Distinguishing spinal etiologies from extraspinal causes is critical during evaluation [1]. A thorough history and physical examination, coupled with selective diagnostic testing, can differentiate between symptomatic hip osteoarthritis and degenerative lumbar spinal stenosis [14]. Recognition of concurrent hip and lumbar pathologies reduces misdiagnosis risk, while managing both entities in the appropriate sequence mitigates persistent symptoms [9].

Radiological findings often lack strong correlation with symptoms. Single MRI findings frequently show weak associations with low back pain (LBP) [17], and few MRI findings demonstrate large magnitude associations with symptom outcomes even when using specific definitions [16]. However, subgroups with multiple and severe lumbar MRI findings correlate more strongly with LBP than milder degeneration [17]. Modic changes, particularly Type 2, are common radiological findings, most frequently occurring at the L4/L5 and L5/S1 levels [3]. Lumbar spinal endplate lesions (LEPLs) are also common on lumbar MRIs in the general population, particularly in men [12].

Specific pathologies present with distinct patterns. Double-level lumbar spondylolysis and spondylolisthesis occur more often in women, with the L3–L5 region being the most common site [18]. In degenerative lumbar scoliosis (DLS), gender differences exist: low back pain is more pronounced in males, while scoliosis severity is greater in females [40]. Patients with signs of nerve root involvement are the most severely affected among LBP patients, followed by those with pain referral to the legs [36]. MRI-visible nerve involvement significantly underestimates nerve involvement detected by physical examination and pain drawing in patients with long-standing nerve root symptoms [15].

Diagnostic challenges arise from mimics and comorbidities. Sacral insufficiency fractures (SIFs) are often diagnosed by lumbar spine MRI because symptoms mimic lumbar pathology, and variable comorbid causes contribute to these diagnoses [8]. SIFs are more commonly diagnosed via lumbar spine MRI than non-lumbar imaging modalities [8]. Back pain in children is common and mostly idiopathic, though structural causes like disk disease, spondylolysis, and spondylolisthesis are frequent and require evaluation to rule out serious conditions [38]. There remains a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis to improve diagnostic accuracy [2]. Finally, a thorough understanding of complications associated with anterior lumbar surgery aids in the prevention, recognition, and management of these rare problems [13].

Investigations

Plain radiography: While lumbar degenerative disease and low back pain evaluation emphasizes distinguishing spinal from extraspinal causes [1], there remains a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis [2]. Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion [102].

MRI: Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels [3]. Lumbar endplate lesions (LEPLs) are common findings on lumbar MRIs in the general population and are particularly common in men [12]. Sacral insufficiency fractures (SIFs) are more commonly diagnosed by lumbar spine MRI than non-lumbar imaging modalities [8]. MRI findings are common in asymptomatic people, and the association between single MRI findings and low back pain is often weak [17]. Subgroups of multiple and severe lumbar MRI findings have a stronger association with low back pain than those with milder degrees of degeneration [17], yet findings on magnetic resonance scans were not predictive of the development or duration of low-back pain in asymptomatic subjects [29]. Few MRI findings showed large magnitude associations with symptom outcomes even when applying more specific definitions for spine-related symptom outcomes [16]. MRI consistently underestimated the lumbar spinal canal cross-sectional area compared to CT in patients with lumbar spinal stenosis [85]. MRI may be inaccurate in assessing containment status of lumbar disc herniations in 30% of cases [88]. MRI-visible nerve involvement significantly underestimates the presence of nerve involvement detected by physical examination and pain drawing in patients with long-standing nerve root symptoms [15]. Early MRI is associated with increased length of disability in patients with acute low back pain without red flags [99]. After posterior lumbar fusion, the volume of the multifidus muscles was markedly decreased, a change apparent in the MRI [98]. Patients undergoing lumbar decompressive surgery should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression [97]. Whole spine MRI should remain a routine investigation, especially in patients with abnormal abdominal reflexes [101].

CT: Recognition of both hip and lumbar spine pathologies may help reduce the likelihood of misdiagnosis [9]. Management of both hip and lumbar spine entities in the appropriate sequence may help reduce the likelihood of persistent symptoms [9].

Treatment

Non-Operative

Management of thoracolumbar and lumbosacral spine-related pain is highly individualized based on pathology, symptomatic involvement, and the activity or physical demands of the patient, with nonsurgical treatment usually serving as the first line of therapy [6]. Lumbar epidural steroid injections are a reasonable nonsurgical option in select patients when weighing surgical alternatives, associated risks, costs, and outcomes, despite inconclusive evidence regarding long-term efficacy [5]. The overall incidence of regression is 63% among non-surgically treated symptomatic lumbar disc herniation patients [69].

Operative

Indications: Relative indications for surgery include failure to improve after six weeks for lumbar disc herniation [26]. Careful selection of patients for lumbosacral fusion is essential, requiring persistent, disabling pain unrelieved by non-surgical treatment [92]. Recent prospective randomized studies have demonstrated that surgery is superior to nonsurgical management in terms of controlling pain and improving function in patients with lumbar spinal stenosis [83]. Operative treatment of lumbar stenosis and degenerative spondylolisthesis offered a significant benefit over nonoperative treatment in patients at least eighty years of age [91]. Lumbar surgery effectively improved the clinical decision limit stage in patients with lumbar spinal stenosis [45]. Percutaneous endoscopic lumbar discectomy is effective for the treatment of lumbar spinal stenosis in elderly patients [11]. Conservative and surgical treatments are safe and effective and produce good clinical outcomes for patients with lumbosacral tuberculosis [54].

Surgical Approach / Technique: Open posterior lumbar surgery is an effective treatment for degenerative lumbar disease which provides pain reduction and lumbar curve improvement with a considerable satisfaction rate [47]. The best indications for the lumbar laminoplasty procedure were young and active patients with central spinal stenosis [23]. Both oblique lumbar interbody fusion and posterior lumbar interbody fusion interventions showed good clinical efficacy for lumbar degenerative diseases [55]. Modified transforaminal lumbar interbody fusion's efficacy and safety are comparable to that of posterior lumbar interbody fusion, particularly in terms of early relief of low back pain and improvement in quality life following surgery [48]. Lateral lumbar interbody fusion at L4-L5 has a low rate of persistent neurological, psoas-related, and abdominal complications in patients with the appropriate indications and using a standardized surgical technique [4]. Both percutaneous endoscopic large channels nerve decompression through translaminar approach and percutaneous endoscopy conventional channels nerve decompression through transforaminal approach can achieve satisfactory clinical efficacy in treating degenerative lumbar 4/5 spinal stenosis [56]. The approach using large-channel spinal endoscope for lumbar decompression alleviated pain, reduced ODI and JOA scores, and restored lumbar function, with decreased incidence of adverse reactions, thereby promoting patient recovery [49]. Staged surgery can effectively achieve neurological functional recovery in patients with multi-segment spinal stenosis in thoracic and lumbar regions, with favorable efficacy and safety [60].

Implant Selection: Spinal fusion should only be performed as part of a randomized controlled trial for non-specific low back pain, and lumbar disc replacement should not be performed [28]. Outcomes in lumbar total disc replacement patients with herniated nucleus pulposus and radiculopathy were similar to outcomes in patients with classic indications, suggesting these diagnoses may not have to be considered absolute or relative contraindications [21]. The general clinical efficacy of Isobar hybrid dynamic stabilization with posterolateral fusion is equivalent to titanium rod fusion surgery, presenting an alternative treatment for individuals with mild and moderate lumbar degenerative disease [41]. Results demonstrate significant improvements in clinical outcomes and pain reduction after lumbar spinal fusion with topping off at 2 years after surgery [57]. New hybrid systems might improve the outcome of lumbar spine fusion, but to date there is no convincing published data on effectiveness or safety of these topping off systems [52].

Adjuncts: The routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas, and the absence of a drain does not lead to a significant change in the incidence of wound infection [90].

Other Considerations: Obesity is not a contraindication to lumbar spinal fusion [22]. Age is not a contraindication for decompressive lumbar spine surgery [11]. Decompression alone demonstrates non-inferiority in terms of efficacy for treating low back pain due to degenerative spondylolisthesis compared to fusion, with additional benefits in operation time and blood loss [93].

Complications

Other Considerations: Lumbar epidural steroid injections remain a reasonable nonsurgical option for select patients when weighing surgical alternatives, risks, costs, and outcomes, despite inconclusive evidence regarding long-term efficacy [5]. A thorough understanding of complications associated with anterior lumbar surgery is essential for the prevention, recognition, and management of these rare problems [13]. Primary isolated aggressive lumbar myeloid sarcoma is rarely seen and presents with unclear specific symptoms and medical history [35]. Long-term follow-up of cauda equina syndrome patients reveals that many continue to experience sexual issues ranging from 14% to 100% [77].

Instability: Double-level lumbar spondylolysis and spondylolisthesis occur more frequently in women, with the L3–L5 segment being the most common site [18]. In the short term, patients with > 50% inferior articular process (IAP) defects show no difference in lumbar stability or clinical outcomes compared to those with ≤ 50% defects after percutaneous endoscopic interlaminar lumbar discectomy [20]. However, complete loss of the inferior articular process remains a concern for long-term instability [20]. Percutaneous spinal endoscopy with a unilateral interlaminar approach for bilateral decompression did not cause meaningful changes in IHI, CDS, and spine stability in short-term follow-up [24].

Revision and Fusion Outcomes: Lumbar diskectomy demonstrates 84% durability at 4-year follow-up, with early revision surgery for complications occurring in 3.3% of patients and late revision for recurrent pathology occurring in 11.6% [19]. Patients with osteoporosis undergoing 2- to 3-level lumbar fusion for degenerative disc disease experience a higher rate of medical and surgical complications, as well as revision surgeries, at the 2-year follow-up [80]. Suboptimal clinical outcomes are expected following posterior lumbar interbody fusion with unilateral cage insertion at postoperative 1 year, regardless of similar clinical outcomes at postoperative 2 years [82].

Adjacent Joint Complications: Patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their total hip arthroplasty than age- and gender-matched patients without a lumbar spinal fusion [33]. Conversely, patients with known lumbar spine disease who underwent hip arthroscopy had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, though outcomes were ultimately not significantly different [34].

Recovery

Light activity (weeks): Specific week ranges for light activity are not explicitly defined in the provided evidence; however, walking time in the week after lumbar surgery is a predictor of substantial functional improvement at six months [105]. Day surgery for lumbar disc herniation using percutaneous endoscopic lumbar discectomy (PELD) offers advantages including short hospital stay and less intraoperative blood loss [89].

Full activity (months): Evidence does not provide a specific month range for full activity return. In the short term, patients with >50% inferior articular process (IAP) defects show no difference in clinical outcomes compared to those with ≤50% defects [20]. Percutaneous spinal endoscopy with a unilateral interlaminar approach for bilateral decompression demonstrates good clinical and radiographic efficacy in short-term follow-up without causing meaningful changes in IHI, CDS, or spine stability [24].

Complete recovery / outcome plateau (months): Lumbar diskectomy demonstrates 84% durability at 4-year follow-up [19]. Early revision surgery for complications occurs in 3.3% of patients, while late revision surgery for recurrent pathology occurs in 11.6% of patients following lumbar diskectomy [19]. At an average follow-up of 3.6 years, 68% of patients undergoing surgical treatment of adult scoliosis were free of pain [104]. Long-level fusion groups maintain acceptable clinical and radiological outcomes compared to short-level fusion groups at a minimum of 10 years of follow-up [27].

Rehabilitation protocol: Complete IAP loss remains a concern for long-term instability despite short-term stability findings in patients with >50% defects [20]. In terms of outcomes with an average follow-up time of 2 years, deeper pedicle screw insertion depth within the safe range may better restore spino-pelvic sagittal balance and improve quality of life [84]. In terms of short-term outcomes, the 6S group exhibited better spinal sagittal restoration and stability than the 4S group in isthmic L5–S1 spondylolisthesis [87]. Postoperative lower back pain is significantly diminished following pedicle screw fixation and posterior fusion for lumbar degenerative diseases [25].

Functional milestones: Functional trajectories vary by procedure; the 1-year postoperative recurrence rate for day surgery lumbar disc herniation undergoing PELD is relatively high [89]. Patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their total hip arthroplasty than age- and gender-matched patients without a lumbar spinal fusion [33]. Conversely, patients with known lumbar spine disease who underwent hip arthroscopy had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, though ultimate outcomes were not significantly different [34]. Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for femoroacetabular impingement syndrome when compared with patients without spine pathology [103].

Other Considerations: Findings on magnetic resonance scans are not predictive of the development or duration of low-back pain in asymptomatic subjects [29]. The natural history of thoracolumbar burst fractures without neurology appears to be benign [30]. The observed epidemiology of lumbar spinal degeneration in community-based populations is consistent with an ordered progression beginning in the anterior structures for the majority of individuals [31]. Nearly all elderly patients requiring surgeries for degenerative diseases of the lumbar spine and lower extremities had advanced conditions (LS stage 2) [32]. Primary isolated aggressive lumbar myeloid sarcoma is rarely seen with unclear specific symptoms and medical history [35]. A short lumbosacral curve accompanied with a long thoracic or thoracolumbar curve toward the opposite side, and a relatively straight sagittal profile have been noted in adolescents with lumbar disc herniation presenting with scoliotic posture [106]. High-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes for transcutaneous vagus nerve stimulation in chronic low back pain [86]. Long-term follow-up is needed to study clinical effects of percutaneous transforaminal endoscopic decompression with removal of the posterosuperior region underneath the slipping vertebral body for lumbar spinal stenosis with degenerative lumbar spondylolisthesis [78].

Key Evidence

  • [L1] There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies. (10.1186/1471-2474-12-175)
  • [L4] Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels. (10.1186/s12891-025-09182-x)
  • [L3] LLIF involving the L4-5 disc level has a low rate of persistent neurological, psoas-related, and abdominal complications in patients with the appropriate indications and using a standardized surgical technique. (10.1302/0301-620x.106b1.bjj-2023-0693.r2)
  • [L4] Despite inconclusive evidence regarding long-term efficacy, lumbar epidural steroid injections are a reasonable nonsurgical option in select patients when weighing surgical alternatives, associated risks, costs, and outcomes. (10.5435/00124635-200704000-00006)
  • [L3] Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, which has implications for interpretation of measures of spinal posture, motion and loading. (10.1186/1471-2474-9-152)
  • [L4] SIFs are more commonly diagnosed by L-spine MRI than non-lumbar imaging modalities, because of symptoms that mimic lumbar spine pathology and variable comorbid causes of pain. (10.1186/s12891-018-2189-1)
  • [L5] The recognition of both hip and lumbar spine pathologies may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms. (10.5435/jaaos-d-15-00740)
  • [L4] The position of the lumbar spine center of rotation changes with variations in load and differs between movement types, suggesting distinct motion patterns in the lower lumbar spine. (10.1186/s12891-025-08410-8)
  • [L4] Age is not a contraindication for decompressive lumbar spine surgery. (10.1186/s13018-020-01968-0)
  • [L3] LEPLs are common findings on lumbar MRIs in the general population, particularly in men. (10.1186/s12891-023-06379-w)
  • [L4] A thorough understanding of the complications associated with anterior lumbar surgery will aid in prevention, recognition, and management of these rare problems. (10.5435/00124635-201105000-00002)
  • [L5] A thorough history and physical examination, coupled with selective diagnostic testing, can differentiate between symptomatic osteoarthritis of the hip and degenerative lumbar spinal stenosis to help prioritize management and determine the order in which to address these conditions. (10.5435/jaaos-20-07-434)
  • [L3] In patients with long-standing nerve root symptoms referred for lumbar MRI, MRI-visible nerve involvement significantly underestimates the presence of nerve involvement detected by a physical examination and a pain drawing. (10.1186/1471-2474-11-202)
  • [L2] Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. (10.1186/1471-2474-15-152)
  • [L3] Although MRI findings are common in asymptomatic people and the association between single MRI findings and LBP is often weak, our results suggest that subgroups of multiple and severe lumbar MRI findings have a stronger association with LBP than those with milder degrees of degeneration. (10.1186/s12891-018-1978-x)
  • [L4] Double-level lumbar spondylolysis and spondylolisthesis occurred more often in women, with the most common site being L3–L5. (10.1186/s13018-018-0723-3)
  • [L3] Lumbar diskectomy is a relatively durable procedure (84% durability) at 4-year follow-up, with early revision surgery for complications occurring in 3.3% of patients and late revision for recurrent pathology occurring in 11.6%. (10.5435/jaaos-d-25-00292)
  • [L4] In the short term, patients with > 50% IAP defects show no difference in lumbar stability or clinical outcomes compared to those with ≤ 50% defects, though complete IAP loss remains a concern for long-term instability. (10.1186/s12891-025-09004-0)
  • [L3] Outcomes in lumbar TDR patients with HNP and radiculopathy were similar to outcomes in patients with the classic indication, suggesting these diagnoses may not have to be considered absolute or relative contraindications. (10.1186/1471-2474-12-275)
  • [L1] Based on these results, obesity is not a contraindication to lumbar spinal fusion. (10.1302/0301-620x.97b10.35724)
  • [L4] The best indications for the lumbar laminoplasty procedure were young and active patients with central spinal stenosis. (10.2106/jbjs.e.00211)
  • [L4] The clinical and radiographic efficacies of this surgery for central lumbar spinal stenosis were good in short-term follow-up, and this surgery did not cause meaningful changes in IHI, CDS, and spine stability in short-term follow-up. (10.1186/s12891-021-04100-3)
  • [L3] Postoperative lower back pain was significantly diminished at follow-up visits. (10.1186/s12891-016-0927-9)
  • [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)
  • [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] The evidence for spinal fusion or disc replacement in non-specific low back pain is poor; spinal fusion should only be performed as part of a randomised controlled trial, and lumbar disc replacement should not be performed. (10.1302/0301-620x.99b8.bjj-2017-0199.r1)
  • [L2] The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. (10.2106/00004623-200109000-00002)
  • [L4] The natural history of thoracolumbar burst fractures without neurology would appear to be benign. (10.1302/0301-620x.98b1.36121)
  • [L3] The observed epidemiology of lumbar spinal degeneration in the community-based population is consistent with an ordered progression beginning in the anterior structures, for the majority of individuals. (10.1186/1471-2474-12-202)
  • [L3] Nearly all elderly patients requiring surgeries for degenerative diseases of the lumbar spine and lower extremities had advanced conditions (LS stage 2). (10.1186/s12891-020-03547-0)
  • [L3] Patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their THA than age- and gender-matched patients without a lumbar spinal fusion. (10.1302/0301-620x.99b5.bjj-2016-0657.r1)
  • [L3] Patients with known lumbar spine disease who underwent hip arthroscopy had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, and outcomes were ultimately not significantly different. (10.1177/0363546520929344)
  • [Case_report] Primary isolated aggressive lumbar myeloid sarcoma is rarely seen with unclear specific symptoms and medical history. (10.1186/s12891-021-04066-2)
  • [L4] LBP patients with pain referral to the legs were more severely affected than those with local LBP, and patients with signs of nerve root involvement were the ones most severely affected. (10.1186/1471-2474-13-236)
  • [Paper] The effect of asymmetry on facet joint response should be fully considered in biomechanical studies of lumbar spine, especially in post structures subjected to physiological loadings. (10.1186/s12891-016-0980-4)
  • [L4] Gender differences exist in DLS patients regarding clinical and radiological presentation, with low back pain being more pronounced in male patients and scoliosis being more severe in female patients. (10.1186/s13018-023-04357-5)
  • [L3] The general clinical efficacy is equivalent to titanium rod fusion surgery, presenting an alternative treatment for individuals with mild and moderate lumbar degenerative disease. (10.1186/s12891-023-06329-6)
  • [L3] Spinal classification could be used as a predictor of lumbar disc degeneration. (10.1186/s13018-019-1537-7)
  • [L3] Longer spinal fusion or inclusion of the pelvis in the fusion critically impacts hip-spine biomechanics and significantly affects the ability to compensate in the standing-to-sitting transition. (10.1016/j.arth.2017.04.051)
  • [L3] Lumbar surgery effectively improved the CDL stage in patients with LSS. (10.1186/s12891-023-06966-x)
  • [L3] However, both systems result in degeneration at the fixed segment, indicating a need for further improvements to mimic the natural biomechanics of the spine more closely. (10.1186/s12891-024-07837-9)
  • [L3] Open posterior lumbar surgery is an effective treatment for degenerative lumbar disease which provides pain reduction and lumbar curve improvement with a considerable satisfaction rate. (10.1186/s12891-022-06066-2)
  • [L3] M-TLIF's efficacy and safety are comparable to that of PLIF, particularly in terms of early relief of low back pain and improvement in quality of life following surgery. (10.1186/s13018-024-04531-3)
  • [L2] The approach also alleviated pain, reduced ODI and JOA scores, and restored lumbar function, with decreased incidence of adverse reactions, thereby promoting patient recovery. (10.1186/s13018-023-04389-x)
  • [L3] With advancing age, spinopelvic biomechanics demonstrate decreased spinal mobility and increased pelvic/hip mobility. (10.1302/0301-620x.106b8.bjj-2023-1197.r1)
  • [L5] Increasing the load has a significant impact on the coupled translational movement of lumbar facet joints. (10.1186/s13018-022-03016-5)
  • [L2] New hybrid systems might improve the outcome of lumbar spine fusion, but to date there is no convincing published data on effectiveness or safety of these topping off systems. (10.1186/1471-2474-12-239)
  • [L4] The biomechanics of the lumbar spine may differ with each individual, and L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation, owing to hyperextension injury. (10.1186/s12891-019-2921-5)
  • [L4] Conservative and surgical treatments are safe and effective and produce good clinical outcomes for patients with lumbosacral tuberculosis. (10.1371/journal.pone.0130185)
  • [L1] Both OLIF and PLIF interventions showed good clinical efficacy for lumbar degenerative diseases. (10.1186/s13018-023-04312-4)
  • [L3] Both surgical methods can achieve satisfactory clinical efficacy in treating degenerative lumbar 4/5 spinal stenosis. (10.1186/s12891-025-08623-x)
  • [L4] Results demonstrate significant improvements in clinical outcomes and pain reduction after lumbar spinal fusion with topping off at 2 years after surgery. (10.1186/s13018-018-0905-z)
  • [L3] Further biomechanical and neuroanatomic studies may elucidate the effects of lumbar spine disease in relation to gluteal tears. (10.2106/jbjs.24.00012)
  • [L3] The lumbosacral and hip motions were the major contributors to global alignment postural change. (10.1186/s12891-021-04865-7)
  • [L4] Staged surgery can effectively achieve neurological functional recovery in patients with multi-segment spinal stenosis in thoracic and lumbar regions, with favorable efficacy and safety. (10.1186/s12891-015-0672-5)
  • [L5] Classifications are generalizations that can provide an efficient means of communication, but many original reports describing common thoracic and lumbar injury classifications lack a rigorous scientific foundation and were based largely on the insights of experienced surgeons. (10.5435/00124635-200209000-00008)
  • [L5] In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models. (10.1186/s13018-024-04681-4)
  • [L5] These data can be useful in future spinal biomechanics research leading to better biomechanical compatibility and provide theoretical references for spinal implant materials. (10.1186/s13018-017-0631-y)
  • [L4] This study found weak to moderate effects of individual kinematic variables and lumbar lordosis on IV-RoMmax at other intervertebral levels. (10.1186/s12891-016-0975-1)
  • [L4] With proper patient selection, posterior decompression with instrumented fusion can be safe and effective for patients 80 years of age and older with degenerative lumbar conditions. (10.1186/s12891-016-1239-9)
  • [L4] Four subgroups of lumbo-pelvic flexion kinematics were revealed with an unequal distribution among people with and without a history of persistent LBP. (10.1186/s12891-018-2233-1)
  • [L5] Loading in the anterior-oblique direction required lower external force or moment to keep the lumbar spine in the neutral position compared to vertical or posterior-oblique directions. (10.1155/2018/4517471)
  • [L5] The Thoracolumbar Injury Classification and Severity Score (TLICS) was developed to address limitations of prior systems by defining injury based on morphology, posterior ligamentous complex integrity, and neurologic status, offering prognostic information and aiding medical decision making. (10.5435/00124635-201002000-00001)
  • [L1] The overall incidence of regression is 63% among non-surgically treated symptomatic lumbar disc herniation patients. (10.1186/s12891-020-03548-z)
  • [L3] The modified TLICS system is a practical tool for the classification and assessment of thoracolumbar fractures with guiding significance for clinical treatment, and the operation rate was slightly lower than that of the TLICS system. (10.1186/s13018-023-03958-4)
  • [L5] The designed computer BS-II system is designed for biomechanical measurements of the lumbar part of the human spine, especially for verification of surgical fixation methods. (10.1186/s13018-019-1463-8)
  • [L2] This document describes the protocol for a randomised controlled trial to assess the impact of activity restrictions on clinical outcomes following lumbar discectomy, aiming to provide an evidence base for postoperative care. (10.1186/s12891-017-1681-3)
  • [L3] The study proposed a novel classification with four types of degenerative thoracolumbar kyphosis based on thoracolumbar kyphosis and balance, followed by targeted treatment strategies for various types. (10.1186/s13018-025-05713-3)
  • [L3] The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. (10.1302/0301-620x.103b7.bjj-2020-2448.r2)
  • [L1] Numerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. (10.1186/s12891-016-1074-z)
  • [L3] Under strict adherence to surgical indications, posterior lateral lumbar fusion surgery which preserves partial facet joint unilaterally during neural decompression can offer greater benefits to patients. (10.1186/s13018-024-05020-3)
  • [L2] However, long-term follow-up of cauda equina syndrome patients revealed that many continued to experience sexual issues (14% to 100%). (10.1186/s12891-025-08736-3)
  • [L4] However, long-term follow-up is needed to study clinical effects. (10.1186/s12891-024-07267-7)
  • [L5] No clinically applicable and validated classification of spinal stenosis has been published, which has substantially limited the development of an evidence-based algorithm for treatment. (10.5435/jaaos-d-15-00034)
  • [L3] Patients with osteoporosis undergoing 2- to 3-level lumbar fusion for DDD experienced a higher rate of medical and surgical complications, as well as revision surgeries, at the 2-year follow-up. (10.5435/jaaos-d-21-01258)
  • [L5] A new classification system that incorporates spinopelvic balance in the radiographic assessment may aid orthopaedic surgeons in identifying patients who would benefit from partial reduction and fusion. (10.5435/jaaos-20-04-194)
  • [L3] Furthermore, suboptimal clinical outcomes are expected following PLIF with unilateral cage insertion at postoperative 1 year regardless of similar clinical outcomes at postoperative 2 year. (10.1186/s12891-021-04852-y)
  • [L5] Recent prospective randomized studies have demonstrated that surgery is superior to nonsurgical management in terms of controlling pain and improving function in patients with lumbar spinal stenosis. (10.5435/jaaos-20-08-527)
  • [L3] In terms of outcomes with an average follow-up time of 2 years, the deeper the screw depth is within the safe range, the better the spino-pelvic sagittal balance may be restored and the better the quality of life may be. (10.1186/s12891-021-04736-1)
  • [L4] MRI consistently underestimated the lumbar spinal canal cross-sectional area compared to CT, which could impact surgical planning and outcomes. (10.1186/s13018-025-05653-y)
  • [L1] Therefore, high-quality trials and long-term follow-up are recommended to evaluate disability, quality of life, and pain outcomes. (10.1186/s12891-024-07569-w)
  • [L3] In terms of short-term outcomes, the 6S group exhibited better spinal sagittal restoration and stability than the 4S group. (10.1186/s12891-022-05098-y)
  • [L2] MRI may be inaccurate in assessing containment status of lumbar disc herniations in 30% of cases. (10.1186/1749-799x-3-46)
  • [L3] Although the 1-year postoperative recurrence rate was relatively high, day surgery for lumbar disc herniation undergoing PELD had advantages in terms of less blood loss intraoperatively, short hospital stay, efficacy for back pain, and efficiency to maintain lumbar physiological curvature. (10.1186/s12891-021-04038-6)
  • [L1] The routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas, and the absence of a drain does not lead to a significant change in the incidence of wound infection. (10.1302/0301-620x.98b7.37190)
  • [L2] Operative treatment of lumbar stenosis and degenerative spondylolisthesis offered a significant benefit over nonoperative treatment in patients at least eighty years of age. (10.2106/jbjs.n.00313)
  • [L1] Decompression alone demonstrates non-inferiority in terms of efficacy for treating low back pain due to DS compared to fusion, with additional benefits in operation time and blood loss. (10.1186/s13018-025-06550-0)
  • [L4] The authors advise that patients undergoing lumbar decompressive surgery should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression. (10.1302/0301-620x.95b10.31222)
  • [L3] After posterior lumbar fusion, the volume of the multifidus muscles was markedly decreased, and the degree of decrease was apparent in the MRI. (10.1186/s12891-020-3104-0)
  • [L1] Early MRI is associated with increased length of disability in patients with acute LBP without red flags. (10.1186/s12891-021-04863-9)
  • [L4] The authors suggest that whole spine MRI should remain a routine investigation, especially in patients with abnormal abdominal reflexes. (10.1302/0301-620x.99b6.bjj-2016-1159.r1)
  • [L3] Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion. (10.1186/s13018-015-0186-8)
  • [L3] Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for FAIS when compared with patients without spine pathology. (10.1177/0363546519892916)
  • [L4] At an average follow-up of 3.6 years, 68 per cent of patients were free of pain and a solid fusion was obtained in all but six patients. (10.2106/00004623-198163020-00013)
  • [L3] Walking time in the week after lumbar surgery is one of several predictors of substantial improvement in function at six months. (10.1186/s12891-019-2806-7)
  • [L4] A short lumbosacral curve accompanied with a long thoracic or thoracolumbar curve toward the opposite side, and a relatively straight sagittal profile have been noted in all the patients. (10.1186/1471-2474-12-216)

See Also

References

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[5] The Use of Lumbar Epidural/Transforaminal Steroids for Managing Spinal Disease. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200704000-00006

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[38] Chapter 36 Back Pain, Disk Disease, Spondylolysis, and Spondylolisthesis. 2020.

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

[47] Risk factors for failed back surgery syndrome following open posterior lumbar surgery for degenerative lumbar disease. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-06066-2

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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.