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Optimizing TLIF Approach Selection: An Algorithmic Framework with Illustrative Cases.
(Journal of clinical medicine, 2025-06) Bartlett, Alyssa M; Shabana, Summer; Folz, Caroline C; Paturu, Mounica; Shaffrey, Christoper I; Quist, Parastou; Danisa, Olumide; Than, Khoi D; Passias, Peter; Abd-El-Barr, Muhammad M
Transforaminal lumbar interbody fusion (TLIF) is a commonly employed surgical technique for managing lumbar degenerative disease and spinal instability. While it offers advantages over posterior lumbar interbody fusion (PLIF), traditional TLIF often involves prolonged recovery and morbidity due to muscle retraction. To improve outcomes, several alternative techniques have emerged, including minimally invasive TLIF (MIS-TLIF), trans-Kambin percutaneous TLIF (PE-TLIF), and transfacet TLIF (TF-TLIF). Each approach presents distinct anatomical and technical advantages, yet no standardized framework exists to guide their selection based on individual patient anatomy. In this study, we review the evolution of TLIF techniques and propose a novel algorithm that integrates patient-specific imaging, anatomical variability, and segmentation data to guide surgical decision-making. By analyzing the surgical corridors, indications, and limitations of each approach, and presenting representative clinical cases, we demonstrate how this algorithm can be applied in practice. For instance, TF-TLIF may be optimal in patients requiring direct decompression without major deformity, while PE-TLIF may be appropriate for those with Kambin's triangles measuring ≥ 9 mm, allowing for indirect decompression. This tailored framework aims to optimize outcomes and reduce complications. Further prospective validation and incorporation of AI-driven segmentation tools are needed to support broader clinical implementation.
Defining cervical spondylotic myelopathy surgical endotypes using comorbidity clustering: a Quality Outcomes Database cervical spondylotic myelopathy study.
(Neurosurgical focus, 2025-07) Yang, Eunice; Howell, Harrison; Mummaneni, Praveen V; Chou, Dean; Bydon, Mohamad; Bisson, Erica F; Shaffrey, Christopher I; Gottfried, Oren N; Asher, Anthony L; Coric, Domagoj; Potts, Eric A; Foley, Kevin T; Wang, Michael Y; Fu, Kai-Ming; Virk, Michael S; Knightly, John J; Meyer, Scott; Park, Paul; Upadhyaya, Cheerag D; Yen, Chun-Po; Uribe, Juan S; Tumialán, Luis M; Turner, Jay D; Haid, Regis W; Chan, Andrew K
Coexisting medical conditions are increasingly prevalent in surgical populations. The impact of multiple comorbidities on patient-reported outcomes (PROs) and endotypes of frequently co-occurring conditions for cervical spondylotic myelopathy (CSM) remain unclear. This study explores whether CSM patients with multimorbidity have worse baseline and postoperative PROs and less functional improvement after surgery compared to those with few or no comorbidities. The authors also investigated whether distinct comorbidity endotypes exist among CSM surgical patients and whether they influence postoperative outcomes. The prospective Quality Outcomes Database (QOD) was used to assess patients undergoing surgery for CSM. Multimorbidity was defined as ≥ 2 chronic conditions, including diabetes, coronary artery disease, peripheral vascular disease, arthritis, chronic renal disease, chronic obstructive pulmonary disease, Parkinson's disease, multiple sclerosis, depression, and anxiety. Baseline characteristics and 24-month PROs were assessed across multiple-comorbidity status, including modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), visual analog scale for neck and arm pain, EQ-5D, and patient satisfaction scores. Clusters were identified from the full cohort using k-medoids, revealing subgroups with similar comorbidity endotypes. The final cohort included 1141 CSM patients (83.1% reaching 24-month follow-up), with 761 (66.7%) having 0 or 1 comorbidity and 380 (33.3%) ≥ 2 comorbidities. The multimorbidity cohort was older (mean age 62.6 ± 11.2 vs 59.5 ± 12.0 years, p < 0.001), more likely to be female (52.9% vs 44.7%, p = 0.011), and had a higher BMI (mean 31.1 ± 6.7 vs 29.7 ± 6.2 kg/m2, p < 0.001). Multimorbidity patients exhibited worse mJOA, NDI, and EQ-5D scores at baseline and 24 months (p < 0.05). On multivariable analysis, the total number of comorbidities was not significantly associated with any PRO measures. Four comorbidity clusters were identified: low burden, arthritis, diabetes, and high burden. On one-way ANOVA, the baseline mJOA score was significantly different across clusters (p = 0.003). At 24 months, the mJOA score was significantly lower in the diabetes and high-burden endotypes. Twenty-four-month score change and minimal clinically important difference (MCID) achievement of all PROs remained similar across clusters (p > 0.05). While patients with multimorbidity have worse baseline and postoperative PROs, they achieve similar functional and pain-related improvements following CSM surgery. Similarly, the comorbidity endotypes identified in this QOD cohort suggest that certain patterns of coexisting chronic conditions, such as overlapping diabetes and arthritis, are associated with different levels of disability but may not diminish the effectiveness of surgical intervention.
The Effect of Race on Outcomes in Veterans With Hepatocellular Carcinoma at a Single Center.
(Federal practitioner : for the health care professionals of the VA, DoD, and PHS, 2022-08) Reynolds, Jackson; Hashimi, Sarah; Nguyen, Ngan; Infield, Jordan; Weir, Alva; Khattak, Amna
Background
Black patients have a higher incidence and mortality associated with hepatocellular carcinoma (HCC) compared with that of White patients in many retrospective analyses. This study sought to determine whether veterans treated for HCC at the Memphis Veterans Affairs Medical Center (VAMC) in Tennessee showed similar disparities in terms of stage at diagnosis, type of therapy received, and overall survival (OS).Methods
A retrospective review evaluated 132 White and 95 Black patients treated for HCC between 2009 and 2021. We evaluated the impact on OS of age, sex, comorbidities, tumor stage, α-fetoprotein level, method of diagnosis, first-line treatment, systemic treatment, and surgical options offered. Kaplan-Meier analysis was used to investigate differences in OS and cumulative hazard ratio for death. Cox regression multivariate analysis evaluated discrepancies among investigated variables.Results
The study found no significant difference in OS between Black and White veterans with HCC. Significant differences were found in who received surgical treatment and systemic therapy. More White veterans received any form of treatment compared with Black veterans (P < .001), and White veterans were more likely to undergo surgical resection and transplant (P = .052). There was no significant difference between age or stage at diagnosis, receipt of systemic therapy, alcohol, tobacco or drug use, HIV coinfection, or cirrhosis.Conclusions
Black veterans with HCC at the Memphis VAMC were less likely to receive any form of treatment, surgical resection, or transplant compared with White veterans, but this did not have a statistically significant effect on OS.Long-Term Toxicity after Non-Myeloablative Conditioning Regimens Using Total Body Irradiation.
(Advances in radiation oncology, 2025-04) Patel, Pranalee; Wan, Zihan; Dillon, Mairead; Niedzwiecki, Donna; Crowell, Kerri-Anne; Horwitz, Mitchell E; Wang, Edina; Kelsey, Chris R
Purpose
To evaluate long-term health risks after allogeneic hematopoietic stem cell transplantation (HSCT) using non-myeloablative total body irradiation (TBI).Methods and materials
All adult patients undergoing non-myeloablative allogeneic HSCT using TBI-based conditioning from 1995 to 2020 at our institution were included. Long-term toxicities, defined as events persisting beyond or occurring after 6 months from the date of transplant, were graded per the National Cancer Institute's Common Terminology Criteria for Adverse Events version 5.0. A competing risk analysis was performed to assess the risk of developing long-term toxicities within major organ systems using the Fine-Gray model. Outcomes were compared with a cohort of patients undergoing myeloablative TBI.Results
A total of 174 patients undergoing nonmyeloablative HSCT were assessed along with 378 myeloablative patients. Nonmyeloablative recipients were older (58 vs 43 years, P < .001), less likely to be transplanted for acute leukemia (35% vs 64%, P < .001), more likely to be transplanted for non-malignant conditions (33% vs 11%, P < .001), and were more likely to have used tobacco (33% vs 22%, P = .009). The median follow-up was 7.4 years. The cumulative incidences of long-term toxicities at 5 years for nonmyeloablative and myeloablative patients, taking into account the competing risk of death, were pulmonary (4% vs 4.8%, P > .9), cardiac (6.8% vs 3.3%, P = .11), renal (4.3% vs 4.1%, P = .9), thyroid (3.6% vs 1.5%, P = .2), other endocrine (3.1% vs 8.8%, P = .04), and cataracts (2.5% vs 2.8%, P = .7). The risk of developing a secondary malignancy was 3.5% vs 1.1% (P = .2) between the 2 cohorts. The proportion of all toxicities that were high-grade (3-5) for nonmyeloablative and myeloablative regimens, respectively, were pulmonary (60% and 69%), cardiac (17% and 45%), renal (27% and 21%), and other endocrine (4% and 2%).Conclusions
Recipients of nonmyeloablative conditioning regimens, despite receiving much lower doses of TBI and chemotherapy, are at risk of developing significant, long-term medical conditions comparable with those undergoing myeloablative HSCT.Anubis Pilot Project Report - June 2025
(2025-06-26) Aery, Sean
In May & June 2025, Duke University Libraries (DUL) staff successfully implemented Anubis, a configurable open source web application firewall (WAF), in order to stave off persistent onslaughts of AI-related bot scraping activity. During this pilot period (May 1 - June 10, 2025), aggressive bot scraping led to extended outages for three critical library platforms (Duke Digital Repository, Archives & Manuscripts, and the Books & Media Catalog), and in each case, implementing Anubis mitigated the problem.