Spondylodiscitis Following Oxygen–Ozone Therapy: A Case Report of Lactobacillus iners Infection and a Systematic Literature Review Calogero Velluto, Giovan Giuseppe Mazzella, Michele Inverso, Maria Ilaria Borruto, Andrea Perna, Riccardo Totti, Laura Scaramuzzo, Luca Proietti Diseases, 2026 Background: Oxygen–ozone (O2–O3) therapy is a minimally invasive treatment for discogenic lumbar pain. Although rare, spinal infections—specifically spondylodiscitis—have been reported following intradiscal injections. To date, Lactobacillus iners has not been described as a causative agent in this context. Case Presentation: A 55-year-old immunocompetent woman presented with progressive lumbosciatica and elevated inflammatory markers three months after intradiscal O2–O3 therapy. MRI revealed L4–L5 spondylodiscitis with paravertebral involvement. Surgical biopsy confirmed L. iners as the pathogen. She underwent decompression and received targeted intravenous antibiotics, achieving full clinical and radiological recovery. Methods: A systematic literature review was performed using PubMed, MEDLINE, and Scopus to identify reports of spondylodiscitis following oxygen–ozone therapy. Six cases were included based on predefined inclusion criteria. Results: The 8 identified cases involved a range of pathogens, including Staphylococcus aureus, Streptococcus beta-haemolyticus, Escherichia coli, Achromobacter xylosoxidans, Mycobacterium abscessus, and Streptococcus intermedius, and one culture-negative infection. Clinical presentations varied from radiculopathy to sepsis. Management strategies encompassed both conservative (antibiotics alone) and surgical approaches, depending on neurological status and abscess formation. Outcomes were favorable in all cases except one fatality. Conclusions: This report is the first to describe L. iners spondylodiscitis in an immunocompetent patient following O2–O3 therapy. Clinicians should vigilantly evaluate post-infiltration spinal infections, maintain a low threshold for imaging and biopsy, and implement pathogen-targeted antibiotic regimens, with surgical intervention as needed.
A drop of blood, a hint of risk: neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as early predictors and risk stratifiers in pyogenic spondylodiscitis Andrea Perna, Maria Ilaria Borruto, Giuseppe Rovere, Laura Scaramuzzo, Franco Lucio Gorgoglione, Calogero Velluto, Luca Proietti, Domenico Alessandro Santagada European Spine Journal, 2026 Pyogenic spondylodiscitis (PSD) is a severe spinal infection with potential for significant morbidity. Early identification of patients at risk for poor outcomes is crucial. This study investigated the prognostic value of neutrophil-to-lymphocyte ratio (NLR) and platelet- to-lymphocyte ratio (PLR) at Emergency Department (ED) admission. This retrospective, single-center cohort study included 187 patients diagnosed with PSD or vertebral osteomyelitis (VO) between January 2017 and December 2023. NLR and PLR were calculated from routine blood tests at admission. Outcomes included prolonged hospitalization (> 15 days), 90-day readmission, and one-year mortality. ROC analysis determined optimal cut-offs for NLR (7.78) and PLR (174.2). Multivariate logistic regression assessed the association of elevated ratios with outcomes. Elevated NLR and PLR at admission were significantly associated with adverse outcomes. Patients with NLR > 7.78 had a 2.1-fold increased risk of prolonged hospitalization (95% CI 1.08–4.07), a 1.7-fold higher risk of 90-day readmission (95% CI 1.01–2.94), and a 2.4-fold increased risk of one-year mortality (95% CI 1.18–5.07). Similarly, PLR > 174.2 was associated with a 1.8-fold increased risk of prolonged hospitalization (95% CI 1.01–3.28) and a 1.8-fold increased risk of one-year mortality (95% CI 1.02–3.42). Patients with both elevated NLR and PLR had a 3.4-fold increased risk of prolonged hospitalization, a 2.4-fold increased risk of 90-day readmission, and a 3.3-fold increased risk of one-year mortality. Elevated NLR and PLR at ED admission are independent predictors of adverse outcomes in patients with PSD/VO. These simple hematological markers may serve as valuable tools for early risk stratification and warrant further investigation for integration into clinical management pathways.
Complications With Navigation-Assistance in Thoraco-Lumbar Spine Surgery Takeshi Fujii, Patricia Lipson, Kenneth T. Nguyen, Gianluca Vadalà, Laura Scaramuzzo, Patrick Hsieh, Katie Krause, Sangwook Tim Yoon, Philip K. Louie, and Global Spine Journal, 2026 Study design Narrative review. Objectives While the use of navigation systems in thoracolumbar spine surgeries has become increasingly popular, few studies exist focusing on the intra- and postoperative complications. The aim was to review the various complications that have been associated with navigation use in the thoraco-lumbar spine and propose surgical techniques to avoid and address associated complications. Methods We queried the existing literature mentioning complications with navigation-assistance in thoraco-lumbar spine surgery and propose surgical pearls to avoid and address associated complications. Results A common complication with computer-assisted navigation (CAN) in the thoraco-lumbar spine surgery is technical failures, such as system malfunctions, software glitches, or loss registration. These errors likely contribute to a missed screw rate of up to approximately 10% for screws placed using navigation. Several strategies can be employed to minimize the risk of intraoperative complications, including reference array shifting, excessive bone and soft-tissue pressure, and initial skiving. Although multiple studies have reported a lower rate of pedicle screw-related perioperative complications with CAN, compared to non-navigation procedures, limitations in learning curve and cost-effectiveness still exist. Conclusions With evolving technology, the navigation system has become increasingly more adaptive in thoracolumbar spine surgery, improving its safety and efficacy. Despite the potential benefits of CAN systems for clinical outcomes, further studies and innovation are required to improve performance to reduce complications and show cost-effectiveness.
Optimising postoperative spine outcomes: an umbrella review of enhanced recovery after spinal surgery (ERASS) protocols Daniel Sescu, Devika Dahiya, Laura Scaramuzzo, Stipe Corluka, Sathish Muthu, Samuel K. Cho, Zorica Buser, Tim Sangwook Yoon, Andreas K. Demetriades British Journal of Anaesthesia, 2025 BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols aim to improve recovery, reduce complications, and optimise surgical outcomes. Despite increasing use in spinal surgery, no standardised ERAS for spinal surgery (ERASS) exists and evidence synthesis is limited. This umbrella review consolidates findings from systematic reviews (SRs) and meta-analyses (MAs) to evaluate the clinical and economic impact of ERASS and identify research gaps. METHODS: A systematic search of MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Web of Science (1990-2024) identified SRs and MAs on ERASS. Data extraction followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Preferred Reporting Items for Overviews of Reviews (PRIOR), with quality assessed using AMSTAR-2 and ROBIS. Overlapping primary studies were removed before recalculating pooled estimates using fixed or random-effects models based on heterogeneity. Primary outcomes included length of stay, postoperative complications, readmission rates, healthcare costs, pain scores, and opioid consumption. RESULTS: Seventeen SRs and 55 MAs (319 primary studies; n=221 605 participants) were included. ERASS significantly reduced length of stay (-1.55 days; 95% confidence interval [CI] -1.83 to -1.27 days; P<0.01), postoperative complications (relative risk=0.61; 95% CI 0.52-0.72; P<0.01), opioid consumption (-7.26 mg morphine equivalents; 95% CI -10.82 to -3.70 mg; P<0.01), and healthcare costs (-$1029.41 per patient; 95% CI -$1630.17 to -$428.65; P<0.01). Readmission rates were not significantly impacted (relative risk=0.91; P=0.38). Pain scores showed a modest, non-significant reduction (-0.27; 95% CI -0.66 to 0.13; P=0.19). High heterogeneity was observed, reflecting protocol and design variation. CONCLUSIONS: ERASS protocols significantly improve surgical efficiency and safety. Standardised guidelines and future research addressing heterogeneity, under-represented ERASS elements, and long-term outcomes are needed. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42024578786).
Sacral and Pelvic Insufficiency Fractures Following Adult Spinal Deformity Surgery: A Case Report and Systematic Literature Review Calogero Velluto, Achille Marciano, Gianmarco Vavalle, Maria Ilaria Borruto, Andrea Perna, Laura Scaramuzzo, Luca Proietti Journal of Clinical Medicine, 2025 Background: Sacral and pelvic insufficiency fractures (SIFs and PIFs) are increasingly recognized yet frequently underdiagnosed complications after adult spinal deformity (ASD) surgery, particularly in patients undergoing long-segment spinal fusion to the sacrum or pelvis. Methods: We present a representative case of sacral and pelvic insufficiency fractures following extensive spinal fusion, highlighting diagnostic and therapeutic challenges. In addition, a systematic review of the literature was performed according to PRISMA guidelines through PubMed, MEDLINE, and Scopus databases, including studies up to December 2024. Data regarding demographics, risk factors, diagnostic modalities, management strategies, and outcomes were extracted and narratively synthesized. Results: A total of 21 studies comprising 89 patients were included. The majority were elderly postmenopausal women with osteoporosis and additional risk factors such as chronic corticosteroid therapy or high body mass index. Diagnosis was frequently delayed due to low sensitivity of plain radiographs, whereas computed tomography was the most reliable modality. Management was surgical in 49 patients (55%)—most commonly extension of fixation to the pelvis or use of S2-alar-iliac screws—with favorable fracture healing reported in most cases. Conservative treatment, employed in 40 patients (45%), included bracing, restricted activity, and bone health optimization, also leading to healing in the majority of cases. Conclusions: Sacral and pelvic insufficiency fractures represent an underrecognized but clinically significant complication after ASD surgery. Early recognition through cross-sectional imaging (CT/MRI) is crucial, and both surgical and conservative approaches can be effective if tailored to patient and fracture characteristics.
Traumatic Bilateral Lumbosacral Jumped Facet Without Fracture in Childhood: Case Report and Systematic Review Maria Ilaria Borruto, Michele Pomponi, Calogero Velluto, Achille Marciano, Luca Proietti, Laura Scaramuzzo Journal of Clinical Medicine, 2025 Background/Objectives: Traumatic dislocation of the lumbosacral facet joints without associated fractures is exceedingly rare in the pediatric population. Due to the unique anatomical and biomechanical features of the pediatric spine, such injuries present diagnostic and therapeutic challenges. This study aims to describe a rare case of bilateral L5–S1 jumped facets without fracture in a 13-year-old boy and to review the existing literature on pediatric traumatic facet dislocations. Methods: We performed a systematic review according to PRISMA guidelines, searching PubMed, Embase, Scopus, and the Cochrane Library up to 16 January 2025. Keywords included “pediatric traumatic spondylolisthesis” and “pediatric traumatic facet joint”. Eligible studies reported traumatic lumbosacral or thoracolumbar facet dislocations in patients aged <18 years. In addition, we report the clinical course, surgical management, and outcome of a representative case from our institution. Results: The systematic review identified 14 pediatric cases across 11 studies. Most patients were male (71.4%), with high-energy trauma as the primary mechanism. The L5–S1 level was most frequently involved (57.1%). Neurological impairment was present in 57.1% of cases. All patients underwent surgical treatment, with posterior fixation being the most common approach. Our case involved bilateral L5–S1 jumped facets without fracture, successfully treated with open reduction and posterior fusion. Postoperative recovery was favorable, with neurological improvement. Conclusions: Traumatic bilateral facet dislocation without fracture is an extremely rare but serious condition in pediatric patients. Early recognition and surgical stabilization are essential to prevent permanent neurological damage. This study reinforces the importance of advanced imaging and prompt multidisciplinary management in optimizing outcomes.
Do More Screws Mean Better Stability? Four (4S) vs. Six (6S) Screws for Short-Segment Fixation in Thoracolumbar Fractures—A Systematic Review and Meta-Analysis Andrea Perna, Andrea Franchini, Giuseppe Rovere, Calogero Velluto, Maria Ilaria Borruto, Laura Scaramuzzo, Felice Barletta, Luca Proietti, Franco Gorgoglione Journal of Clinical Medicine, 2025 Purpose: Thoracolumbar burst fractures represent a significant proportion of spinal injuries, with management strategies remaining a subject of debate. While four-screw (4S) short-segment posterior fixation is commonly used, recent biomechanical studies suggest that adding pedicle screws at the fractured level (six-screw, 6S, construct) may improve stability and clinical outcomes. However, the clinical relevance of these findings remains uncertain. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Three databases (Scopus, PubMed/MEDLINE, Cochrane Library) were searched for studies comparing 4S and 6S constructs in thoracolumbar fractures. Inclusion criteria encompassed comparative clinical studies reporting perioperative, functional, and radiological outcomes. Data were extracted and analyzed using Review Manager 5.4.1, applying fixed- or random-effects models based on heterogeneity. Results: Twenty-two studies involving 1595 patients were included. The 6S group showed significantly improved postoperative pain scores (VAS), better short- and long-term sagittal alignment, and a lower implant failure rate. However, this technique was associated with longer operative times, increased intraoperative blood loss, and extended hospital stays. No significant differences in long-term functional disability (ODI) or infection rates were found. Conclusions: The addition of intermediate screws improves radiological outcomes and reduces implant failure but increases surgical burden. Further high-quality studies focusing on patient-reported outcomes and specific fracture subtypes are needed to refine clinical indications.
Framework for Adoption of Enabling Technologies for Improved Outcomes in Spine Surgery Sathish Muthu, Swaminathan Ramasubramanian, Madhan Jeyaraman, Roger Hartl, Javad Tavakoli, Samuel K Cho, Laura Scaramuzzo, Hardeep Singh, Philip K Louie, Andreas K. Demetriades, Patrick C. Hsieh, Stipe Ćorluka, Yabin Wu, Xiaolong Chen, Hai V. Le, Gianluca Vadala, Waeel Hamouda, Zorica Buser, Jeffrey C Wang, Hans-Jorg Meisel, Tim Yoon, Amit Jain, and Global Spine Journal, 2025 Study Design Narrative Review. Objectives We aim to investigate the integration and impact of enabling technologies, such as augmented reality, virtual reality, mixed reality, navigation, robotics, and artificial intelligence within the domain of spinal surgery. Methods We made a literature review for articles that examined the progression of adoption from initial to subsequent adopters. We also analysed the key determinants that influence adopting these technologies into clinical settings. These include cost-effectiveness, ease of integration, patient acceptance, learning curves, and availability of training resources. Based on the available data a suggestion has been made on the adoption framework for clinical utility. Results These technological advancements have the potential to transform surgical practice, offering improved precision and efficiency. The journey toward widespread adoption presents challenges, which include the financial implications, the necessity for specialized training, and the complexities associated with integration. To navigate these hurdles, the study proposes recommendations aimed at improving cost efficiency, streamlining technology integration, investing in professional development, and nurturing a culture of innovation and research. Conclusions A framework has been established for the evaluation and integration of state-of-the-art technologies in spinal surgery, thereby maximizing their potential impact on surgical outcomes and patient welfare.
How Reliable is the Assessment of Fusion Status Following ACDF Using Dynamic Flexion-Extension Radiographs? Christopher T. Martin, Sangwook Tim Yoon, Ram Kiran Alluri, Edward C. Benzel, Chris M. Bono, Samuel K. Cho, Dean Chou, Xiaolong Chen, Jason P.Y. Cheung, Juan P. Cabrera, Stipe Ćorluka, Andreas K. Demetriades, Matthew F. Gary, Zoher Ghogawala, Waeel Hamouda, Inbo Han, Dimitri Hauri, Patrick C. Hsieh, Amit Jain, Jun S. Kim, Hai V. Le, Philip K. Louie, Zhuojing Luo, Hans-Jörg Meisel, Sathish Muthu, Dal-Sung Ryu, Charles A. Sansur, Andrew J. Schoenfeld, Laura Scaramuzzo, Gregory D. Schroeder, Shanmuganathan Rajasekaran, Veranis Sotiris, Gianluca Vadalà, Pieter-Paul A. Vergroesen, Jeffrey C. Wang, Yabin Wu, K. Daniel Riew, and Global Spine Journal, 2025 Study Design Reliability study. Objectives The radiographic diagnosis of non-union is not standardized. Prior authors have suggested using a cutoff of <1 mm interspinous process motion (ISPM) on flexion-extension radiographs, but the ability of practicing surgeons to make these measurements reliably is not clear. Methods 29 practicing spine surgeons measured ISPM on 19 levels of ACDF from 9 patients. Surgeons relied on these measurements to report on fusion status. Inter-observer correlation co-efficients (ICC), standard error (SEM) and the minimum detectable difference (MD) of these measurements were calculated. We screened for clerical errors by checking measurements more than one standard deviation from the group mean. Results The ICC for ISPM was .76 (.64; .88) with a SEM of 1 mm and a MD of 2.76 mm. Agreement on fusion status was moderate, with an ICC of .6 (.44; .76). After screening for and removing clerical errors, the ICC improved to .82 (.71; .91), SEM improved to .83 mm, and MD improved to 2.29 mm. Six reviewers had an ICC >.9. The ICC from these high performing reviewers was .94 (.9; .97), SEM was .45 mm, and MD was 1.26 mm. Conclusions The MD of 2.29 mm in our study group was not precise enough to support a cutoff of <1 mm ISPM as the sole measurement technique in screening for non-union after ACDF, and there was only moderate agreement amongst surgeons on fusion status based on dynamic radiographs. More stringent techniques are necessary to avoid mis-diagnosing non-union in clinical studies. Future studies should consider auditing measurements to identify clerical errors.
Malnutrition and Disability: A Retrospective Study on 2258 Adult Patients Undergoing Elective Spine Surgery Matteo Briguglio, Andrea Campagner, Francesco Langella, Riccardo Cecchinato, Marco Damilano, Pablo Bellosta-López, Tiziano Crespi, Elena De Vecchi, Marialetizia Latella, Giuseppe Barone, Laura Scaramuzzo, Roberto Bassani, Andrea Luca, Marco Brayda-Bruno, Thomas W. Wainwright, Robert G. Middleton, Giovanni Lombardi, Federico Cabitza, Giuseppe Banfi, Pedro Berjano Medicina Lithuania, 2025 Background and Objectives: Malnutrition’s prevalence and its relationship with functional ability in patients with end-stage spine pathologies, i.e., any disease of the vertebral bodies, intervertebral discs, and associated joints requiring surgical intervention, are yet to be explored. This retrospective study aimed to investigate the association between malnutrition, disability, and physical health in patients undergoing elective spine surgery in our Italian hospital. Materials and Methods: Data between 2016 and 2019, recorded at pre-admission visits, were extracted from our institutional spine registry (ClinicalTrials.gov number: NCT03644407), excluding minor patients or those undergoing emergency or oncological surgery. The measures were the Oswestry disability index (ODI) and the physical health (PH) summary of the 36-item Short-Form Health Survey. Clinical data were linked to nine laboratory parameters from pre-operative routine blood tests, and equations to ascertain the risk of malnutrition and its diagnosis were attributed. Results: The study sample included 2258 spine patients (58.15% females) who underwent surgery in our Italian hospital. The ODI and PH significantly varied across body weight difference (BWd) strata in younger adults (adjusted-p = 0.046, η2 = 0.04; adjusted-p = 0.036, η2 = 0.06) and adults (adjusted-p = 0.001, η2 = 0.02; adjusted-p = 0.004, η2 = 0.02). Protein malnutrition with acute/chronic inflammation (PMAC) in both adults (adjusted-p < 0.001, η2 = 0.04; adjusted-p < 0.001, η2 = 0.04) and older adults (adjusted-p = 0.010, η2 = 0.04; adjusted-p = 0.009, η2 = 0.05) had also a discernible impact in determining the ODI and PH. In older adults, the ODI was associated with iron deficit malnutrition (IDM) (adjusted-p = 0.005, η2 = 0.06) and both the ODI and PH were associated with vitamin B deficit (VBD) (adjusted-p = 0.037, η2 = 0.01; adjusted-p = 0.049, η2 = 0.01). Trend monotonicity was diagnosis- and sex-specific, with meaningful ordered patterns being observed mostly in young males and older females. Conclusions: Functional ability showed an association with malnutrition in younger adults and adults when using BWd, in adults and older adults when using PMAC, and in older adults when using IDM and VBD. The authors advocate for the inclusion of nutritional management in the pre-operative evaluation to potentially enhance recovery after spine surgery.
Quality Control for Spine Registries: Development and Application of a New Protocol Alice Baroncini, Francesco Langella, Paolo Barletta, Riccardo Cecchinato, Daniele Vanni, Fabrizio Giudici, Laura Scaramuzzo, Roberto Bassani, Carlotta Morselli, Marco Brayda-Bruno, Andrea Luca, Claudio Lamartina, Pedro Berjano American Journal of Medical Quality, 2023
Response to the letter by Sen Yang, Weimin Jiang Luca Proietti, Laura Scaramuzzo, Sergio Sessa, Giuseppe Rosario Schirò, Carlo Ambrogio Logroscino Orthopaedics and Traumatology Surgery and Research, 2019
Response to the letter by Sen Yang, Weimin Jiang Luca Proietti, Laura Scaramuzzo, Sergio Sessa, Giuseppe Rosario Schirò, Carlo Ambrogio Logroscino Revue De Chirurgie Orthopedique Et Traumatologique, 2019
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Percutaneous acetabuloplasty for metastatic acetabular lesions Giulio Maccauro, Francesco Liuzza, Laura Scaramuzzo, Alessandro Milani, Francesco Muratori, Barbara Rossi, Victor Waide, Giandomenico Logroscino, Carlo A Logroscino, Nicola Maffulli BMC Musculoskeletal Disorders, 2008