Efficacy Comparison of Arthroscopic-assisted Uniportal Spinal Surgery and Percutaneous Endoscopic Discectomy for Adjacent Segment Lumbar Disc Herniation After Fusion Surgery

Efficacy Comparison of Arthroscopic-assisted Uniportal Spinal Surgery and Percutaneous Endoscopic Discectomy for Adjacent Segment Lumbar Disc Herniation After Fusion Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy Comparison of Arthroscopic-assisted Uniportal Spinal Surgery and Percutaneous Endoscopic Discectomy for Adjacent Segment Lumbar Disc Herniation After Fusion Surgery Tao Liu, Zhongzheng Zhi, Jian Kang, Jinhao Miao, Zhimin He, Desheng Wu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8341787/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Apr, 2026 Read the published version in European Spine Journal → Version 1 posted 6 You are reading this latest preprint version Abstract Background Adjacent segment lumbar disc herniation (ASLDH), a recognized complication following lumbar fusion (LF) surgeries, can be managed with various techniques; however, evidence supporting the arthroscopic-assisted uniportal spinal surgery (AUSS) technique for adjacent segment LDH is currently lacking. Objective To explore the application and validate the safety and efficacy of Arthroscopic-assisted Uniportal Spinal Surgery (AUSS) in the treatment of adjacent segment LDH. Methods One hundred and twelve patients diagnosed with ASLDH were enrolled from 2018 to 2024. Fifty-five patients underwent the AUSS technique, comprising the AUSS group, and fifty-seven patients received percutaneous endoscopic lumbar discectomy (PELD), comprising the PELD group. Perioperative indicators, including 6-month postoperative efficacy rate, postoperative complications, Visual Analogue Scale (VAS), Japanese Orthopaedic Association (JOA) scores, Oswestry Disability Index (ODI), and Short Form-36 Survey Scale (SF-36), were recorded and compared between the two groups at each follow-up time point. Results Compared with PELD, AUSS demonstrated a shorter operation time and hospital stay, as well as less blood loss (P < 0.001). The overall efficacy rate in the AUSS group (98.2%) was higher than that in the PELD group (86.0%, P < 0.05) at 6 months postoperatively, and the total incidence of postoperative complications in the AUSS group (3.6%) was lower than that in the PELD group (28.1%, P < 0.001). At each follow-up time point, indicators of serum pain mediators, VAS-Back Pain (VAS-BP), VAS-Leg Pain (VAS-LP), JOA and ODI scores, and each dimension of SF-36 in the AUSS group were superior to those in the PELD group (P < 0.001). Conclusion Both the AUSS technique and PELD represent viable surgical options for ASLDH following LF. However, AUSS demonstrates significantly superior functional recovery rates and a lower incidence of procedure-related complications, supporting its broader clinical application. Fusion lumbar disc herniation arthroscopic-assisted uniportal spinal surgery percutaneous endoscopic lumbar discectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Adjacent segment lumbar disc herniation (ASLDH)[1], a progressively radiographical and symptomatic lumbar disc degeneration adjacent to the previously operated spinal segment, represents a well-documented complication of lumbar fusion (LF) surgery, with a reported incidence ranging from 5.2% to 18.5%[2]. While previous studies have identified numerous risk factors associated with the development and progression of adjacent segment disc degeneration, a clear consensus on its pathogenesis remains elusive[3,4,5]. In addition to causing significant neurofunctional impairments, symptomatic ASLDH detrimentally impacts mental and psychological health and substantially reduces patients' quality of life[6,7]. Therefore, it is imperative to highlight this concern and explore effective preventive and therapeutic measures for ASLDH. Surgical intervention becomes necessary for ASLDH when conservative management fails[8], and both repeated open fusion (FIGURE 1) procedures and minimally invasive spine surgery (MISS) techniques can achieve adequate neural decompression[9–12]. Established and conventional open spinal fusion techniques, including posterior lumbar interbody fusion (PLIF), posterior laminectomy with fusion (PLF), oblique lumbar interbody fusion (OLIF), and anterior lumbar interbody fusion (ALIF), are employed in the treatment of ASLDH. However, it cannot be denied that open fusion techniques induce a second painful experience and substantial trauma to the muscle tissue, and revision surgeries do not consistently yield satisfactory clinical outcomes, potentially diminishing patient satisfaction. In contrast, MISS has emerged and gained preference as a preferred method for ASLDH due to its minimal incision, which mitigates damage to facet joints and posterior ligaments, and results in less muscle tissue injury[13]. Furthermore, MISS techniques have been widely used for their lower incidences of perioperative complications, such as nerve root injury and dural tear, which is particularly advantageous in the setting of pre-existing surgical scars and instrumentation[11,12]. Thus, MISS techniques appear to have more advantages compared with open repeated operations in treating ASLDH. Further developments in endoscopic spinal surgeries provide various options for lumbar disc herniation (LDH). As an alternative solution and a key component of MISS techniques, percutaneous endoscopic lumbar discectomy (PELD) has been widely recognized for encouraging results and is accepted for various presentations of LDH, including ASLDH. In addition, as a uniportal, non-coaxial spinal endoscopic surgery (UNSES), arthroscopic-assisted uniportal spinal surgery (AUSS) aligns with the principles of open surgery and offers outstanding advantages in instrument channel design, enhancing endoscopic visualization and operational flexibility[14,15]. Crucially, the integration of a 30° arthroscope provides a wider field of view and compatibility with various spinal surgical techniques and instruments. Therefore, the superior maneuverability suggests broader applicability for degenerative disc conditions compared to coaxial systems like PELD for ASLDH. Thus, this study aimed to compare the safety and efficacy of these two prominent MISS techniques—PELD and AUSS—in the treatment of ASLDH following LF. We retrospectively analyzed clinical data from 112 consecutive ASLDH patients who underwent either PELD or AUSS. Materials and Methods Participants The study was approved by the authors’ institutional review board. All surgeries described in this study were approved by the ethics committee of our institution. In addition, the study has been reported in line with the STROCSS criteria. ASLDH was predominantly diagnosed via symptoms, signs, and imaging findings in the department of spine surgery from 2018 to 2024. The inclusion criteria for the study were as follows: (I) patients who had undergone LF surgery and had a diagnosis of ASLDH confirmed by X-rays, CT, and MRI; (II) patients who underwent the AUSS technique or PELD surgery; (III) patients with a follow-up period longer than 12 months and complete clinical and follow-up data. The exclusion criteria were: (I) patients with other causes (e.g., osteoporosis, lumbar instability, fractures, spinal tumors, or inflammatory spinal conditions) leading to low back pain and leg pain; (II) patients with severe comorbidities (such as pneumopathy or cardiovascular or cerebrovascular disease) who could not tolerate general anesthesia; (III) patients with mental and psychological disorders who could not comply with regular follow-up. Methods All surgical interventions were carried out by a single senior spinal surgeon with extensive experience. AUSS Group The AUSS procedures were conducted under general anesthesia. Patients were placed in a prone position on a carbon fiber radiolucent operating table. Abdominal suspension was employed to decrease intra-abdominal pressure and limit surgical blood loss. The target spinal level was initially approximated using superficial anatomical landmarks and subsequently confirmed precisely under real-time C-arm fluoroscopic guidance by inserting a Kirschner wire into the intended intervertebral space. A longitudinal skin incision, measuring about 1.5–1.8 cm, was created adjacent to the pedicles at the midline, carefully dissecting through the skin, subcutaneous tissue, and lumbar dorsal fascia. The arthroscope, coupled with the working sheath, was introduced alongside connections for the light source, motorized drill, radiofrequency ablator, and continuous saline irrigation, thereby exposing the facet joint's articular capsule. Radiofrequency ablation ensured local hemostasis, and a rongeur was utilized to clear and expose the articular capsule. Bony decompression was performed with a high-speed drill, following a predetermined circular trajectory (FIGURE 2) that involved: 1) the spinous process base and inferior lamina of the cranial vertebra; 2) the facet joint process; and 3) the spinous process base and superior lamina of the caudal vertebra. The decompression zone provided visualization of the superior articular process, ligamentum flavum, nerve root, and intervertebral disc. The nerve root was gently retracted and shielded, after which the annulus fibrosus was opened using a miniature blade. Herniated nucleus pulposus material was meticulously extracted with specialized forceps. Successful decompression was indicated by a relaxed, non-tensioned nerve root. Finally, radiofrequency ablation was applied to thermally coagulate the annulus fibrosus, aiming to minimize recurrence risk. Endoscopic inspection reaffirmed nerve root relaxation. The endoscope was then withdrawn, a negative-pressure drainage bulb was positioned, the wound was sutured, and a sterile dressing was applied. PELD Group Patients in the PELD group were administered general anesthesia and positioned prone. The affected spinal segment was localized and marked under C-arm fluoroscopy. An initial puncture was made roughly 10 cm from the midline, directed through the intervertebral foramen towards the pathological site. C-arm imaging confirmed accurate needle placement. A minor skin incision allowed insertion of a guidewire, followed by sequential dilators to accomplish foraminoplasty. An endoscopic system designed for the intervertebral foramen was then introduced. Under direct endoscopic vision, hemostasis was secured via electrocoagulation, and the pathological nucleus pulposus tissue was identified and removed. Confirmation of complete nerve root decompression was obtained. The procedure concluded after verifying restored nerve root pulsation and absence of active bleeding; the endoscope was removed and the incision closed. Clinical Data and Evaluation Clinical Indicators The following parameters were documented and analyzed preoperatively and at 3, 6, and 12 months post-surgery: (1) Pain intensity, evaluated via the Visual Analogue Scale (VAS) for both lower back pain (VAS-BP) and lower limb pain (VAS-LP). (2) Neurological function, gauged using the Japanese Orthopaedic Association (JOA) scoring system. (3) Functional disability, measured by the Oswestry Disability Index (ODI). (4) Quality of life, assessed with the Short Form-36 (SF-36) health survey. (5) Postoperative complications, including nerve root injury, dysesthesia in the affected limb, epidural hematoma, incidental dural tear, hip pain, delayed wound healing, and surgical site infection. (6) Serum pain mediator levels. Fasting venous blood samples (5 mL) were obtained preoperatively and at 3, 6, and 12 months postoperatively. After centrifugation (2500 rpm for 10 minutes, 6 cm radius), serum concentrations of 5-hydroxytryptamine (5-HT), substance P (SP), and norepinephrine (NE) were quantified using enzyme-linked immunosorbent assay (ELISA). Therapeutic Efficacy Rate Clinical success at the six-month postoperative mark was determined according to modified MacNab criteria, classifying outcomes as: (1) Excellent: Absence of symptoms, unrestricted return to pre-disease activity levels; (2) Good: Minimal residual symptoms not interfering with daily function; (3) Fair: Moderate symptom improvement but with significant activity limitations; (4) Poor: Little to no improvement or worsening condition. The overall success rate was defined as the proportion of patients with Excellent or Good outcomes relative to the total cohort, serving as the primary measure of surgical efficacy. Statistical Analysis Statistical analysis was performed using SPSS version 26.0 (IBM, Armonk, New York, USA), with P < 0.05 considered statistically significant. Continuous data are summarized as mean ± standard deviation. Intergroup comparisons of continuous variables were performed using independent samples t-tests, while intragroup comparisons employed paired samples t-tests. Categorical data, expressed as percentages, were analyzed via the Chi-square test. Results Demographics Patient demographic and baseline characteristics are detailed in Table 1. The two groups were statistically comparable regarding gender distribution, age, and duration of follow-up (P > 0.05). However, the AUSS group exhibited significantly reduced intraoperative blood loss, shorter operative duration, and decreased length of hospital stay compared to the PELD group (P < 0.001). Functional Indicators The clinical indicators of VAS, JOA, and ODI are compared and exhibited in FIGURES 3-6. At each follow-up time point, the JOA score was higher in the AUSS group than in the PELD group (P < 0.001), while VAS-BP, VAS-LP, and ODI scores were lower in the AUSS group than in the PELD group (P < 0.001). Quality of Life The scores of the eight dimensions of the SF-36 at 3, 6, and 12 months postoperatively increased in both groups compared with the preoperative values (P < 0.001). The dimension scores for physical functioning (PF), role limitations due to physical health problems (RP), bodily pain (BP), general health perceptions (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH) in the AUSS group were higher than those in the PELD group at each follow-up time point (P < 0.001) (Table 2-1,2-2,2-3). Serum Pain Mediators Significant reductions in serum levels of 5-HT, SP, and NE were observed postoperatively in both groups (P < 0.001). Notably, the AUSS group displayed consistently lower concentrations of all three pain mediators compared to the PELD group at the 3-, 6-, and 12-month time points (P < 0.001), detailed in Table 3. Operative Success Rate Based on the modified MacNab criteria, the overall clinical success rate at 6 months was significantly higher in the AUSS group (98.2%) than in the PELD group (86.0%) (P < 0.05), as shown in Table 4. Complications The incidence of postoperative complications was significantly lower in the AUSS group (3.6%) compared to the PELD group (28.1%) (P < 0.001). Specific complications are itemized in Table 5. Discussion As an increasingly recognized long-term complication following instrumented lumbar fusion surgery, adjacent segment lumbar disc herniation (ASLDH) presents with distinct clinical and imaging features[1,16]. While fundamentally rooted in disc degeneration, ASLDH pathogenesis is multifactorial, involving physiological aging, biomechanical alterations secondary to fusion, iatrogenic factors during the index surgery, and patient-specific variables[9,17]. Numerous investigations have illustrated that the incidence of ASLDH progressively increases over time following lumbar fusion surgeries[17,18]. Multiple factors related to the characteristics of the first operation, including surgical approach, length of fusion, sacral fusion, disrupted integrity of the posterior complex, rigid instrumentation, and pre-existing disc degeneration, contribute to the unique nature of ASLDH[19]. Management of symptomatic ASLDH initially aligns with the principles for lumbar disc herniation. However, controversy arises when conservative measures fail, necessitating surgical intervention, and the therapeutic crossroads stems directly from the inherent complexity of ASLDH[11,20]. Therefore, the interplay of diverse causative factors, encompassing etiology and pathological characteristics, collectively contributes to the ongoing debate regarding the optimal surgical strategy for revision ASLDH surgery. Various surgical methods contribute their advantages to promote neurofunctional recovery for ASLDH[21–23]. Conventional open operative management with instrumentation can provide direct and complete decompression of the nerve root, reconstruct spinal alignment and stability, and potentially achieve favorable clinical outcomes. However, repeated open surgeries carry significant risks of perioperative complications and impose a profound physical and psychological burden. Consequently, to avoid or mitigate repeat operation-related trauma, secondary musculoskeletal injury, and potential nerve root or dural injury, spinal endoscopic techniques have rapidly emerged as predominant minimally invasive solutions. Chen HC et al[24]reported that the PELD method provided complete decompression and had overwhelming superiority over repeated open lumbar surgery in the surgical treatment of ASLDH. Similarly, the AUSS technique can effectively achieve nucleus pulposus removal for nerve root decompression, avoid secondary damage to the posterior and paraspinal structures, preserve the facet joints, and relieve the patient's impaired neurological function, as does PELD surgery. Accordingly, the two techniques are unquestionably applicable to the surgical treatment of ASLDH. Compared with open revision, both the AUSS technique and the PELD approach align with the primary principles of minimally invasive surgery. AUSS offers specific technical advantages, minimizing instrument interference through its single-portal design and stable intraoperative approach[13]. Furthermore, the 30° arthroscope provides a 360° ultra-wide-angle surgical field of view[13,14], and pre-existing internal fixation facilitates more convenient intraoperative localization and less radiation exposure. These features may contribute to a relatively gentler learning curve for less experienced surgeons. In contrast, PELD surgery requires exceptional proficiency in foraminal anatomy and demands experienced imaging navigation skills. Moreover, the PELD procedure carries inherent risks of inaccurate puncture and nerve root injury, which are amplified in the setting of post-surgical epidural adhesions and scar tissue, resulting in a steeper and potentially longer learning curve[14]. Therefore, although the two minimally invasive techniques demonstrate advantages in treating ASLDH, the AUSS technique may be more likely to be adopted and promoted for its safety and maneuverability. The significant changes in functional indicators demonstrated the efficacy and safety of AUSS and PELD. Patients with ASLDH differ from those with first-time simple lumbar disc degeneration; although they may have similar nerve lesions and functional impairments, ASLDH patients have a greater mental and psychological burden[1]. Consequently, in addition to the indications and contraindications for the operation, factors such as patient preference, acceptance of reoperation, pathological situation, and characteristics of ASLDH must be fully considered before the final surgical decision-making. Although PELD achieves encouraging results in clinical practice, concerns persist regarding muscle trauma, decompression accuracy and extent, risks of incidental durotomy and cerebrospinal fluid leakage, significant radiation exposure, and reports suggesting relatively higher recurrence rates[25,26]. Comparing PELD surgery for ASLDH, AUSS demonstrates potential superiority across several domains: surgical strategy flexibility, neurofunctional recovery, perioperative complication profile, and quality of life improvement. The enhanced outcomes observed with AUSS may stem from its precise surgical planning, superior visualization via the 30° arthroscope, and greater operational flexibility. Utilizing a single incision for both working and viewing channels, the AUSS technique facilitates wider decompression and higher operability, potentially enabling bilateral decompression through a unilateral approach[27]. This technique maximizes the preservation of lumbar bony structures, thereby enhancing spinal stability and biomechanical properties while simultaneously accelerating functional recovery. Crucially, patient satisfaction is intrinsically linked to neurological recovery and is significantly impacted directly by perioperative complications, particularly symptom recurrence. Hence, the AUSS technique is theoretically superior to that of PELD surgery. In this investigation, the AUSS group demonstrated better performance in terms of less blood loss and shorter operation time and hospital stay. Improvements in functional outcome measures, including JOA, ODI, and SF-36 scores, were significantly better in both groups. Evidence of high rates of overall clinical efficacy and lower total complication incidences further supports this finding. General serum pain mediators, including 5-HT, SP, and NE, are associated with nociceptive pain effects, and the variation trends of these indicators were parallel to those of the VAS scores in the study. As is known, with the transformation from tension to relaxation of the nerve, pain mediators rise and fall accordingly. This phenomenon indicates that the more sufficient the nerve decompression, the lower the content of pain factors and the pain score will be. However, from horizontal comparisons at identical postoperative time points between the two groups, the PELD group exhibited significantly lower JOA and SF-36 scores, alongside higher ODI and VAS scores, and relatively elevated levels of serum pain mediators. Therefore, a comprehensive cross-comparative analysis and rigorous validation of substantial datasets consistently demonstrate a significant trend towards superior outcomes with the AUSS technique relative to PELD surgery in treating ASLDH. Nonetheless, there are still some limitations to this study that should be acknowledged. First, the retrospective design and relatively small sample size (n = 112) inherently constrain the generalizability of the findings and introduce potential biases. Consequently, future prospective studies with larger cohorts are essential to validate these results. Second, inherent selection bias exists, as patients were assigned to AUSS or PELD based on pathological characteristics and surgeon assessment, meaning not all patients were candidates for both techniques. Finally, both procedures demand significant technical expertise. AUSS, in particular, requires mastery of incision planning, endoscopic manipulation, and arthroscopic assistance, necessitating a substantial learning curve typically achieved only by experienced spinal surgeons. Conclusion Both the AUSS technique and PELD surgery represent effective minimally invasive options for managing ASLDH following lumbar fusion surgery. However, AUSS demonstrates superior outcomes, including significantly improved functional recovery rates, a lower incidence of procedure-related complications, and enhanced patient-reported quality of life. These advantages support the broader clinical application of AUSS for suitable indications. While AUSS demonstrates outstanding advantages in specific situations, prudent surgical decision-making necessitates viewing it as an integrative component within the therapeutic armamentarium, complementing rather than displacing established techniques. Abbreviations ASD adjacent segment disease LDH lumbar discs degeneration LF lumbar fusion AUSS arthroscopic-assisted uni-portal spinal surgery UNSES uni-portal non-coaxial spinal endoscopic surgery PELD percutaneous endoscopic lumbar discectomy PLIF posterior lumbar interbody fusion PLF posterior laminectomy with fusion OLIF oblique lumbar interbody fusion ALIF anterior lumbar interbody fusion MISS minimally invasive spine surgeries JOA Japanese Orthopedic Association VAS Visual Analog Scale ODI Oswestry Disability Index SF-36 Short Form-36 Survey Scale Declarations Conflict of interest statement The authors declare that the study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethical Review Committee Statement Ethical approval for this study was provided by the Ethical Committee of Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine (Ethics number: SYLL20233027), China, Shanghai. Funding This study was supported by Hongkou District Clinical Key Specialty of Shanghai (HKLCZD2024B03). Consent for publication Not Applicable Declaration of data availability The datasets generated during the current study are not publicly available due the rules and regulations and respect the privacy rights of patients, but are available from the corresponding author on reasonable request. References McDonald CL, Alsoof D, Glueck J, et al. Adjacent Segment Disease After Spinal Fusion. JBJS Reviews. 2023;11(6): e23.00028. Park P, Garton HJ, Gala VC, et al. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976). 2004;29(17):1938-44. Huang X, Cai Y, Chen K, et al. Risk factors and treatment strategies for adjacent segment disease following spinal fusion (Review). Mol Med Rep. 2025;31(2):33. Maragkos GA, Atesok K, Papavassiliou E. Prognostic Factors for Adjacent Segment Disease After L4-L5 Lumbar Fusion. Neurosurgery. 2020;86(6):835-842. Alentado VJ, Lubelski D, Healy AT, et al. Predisposing Characteristics of Adjacent Segment Disease After Lumbar Fusion. Spine (Phila Pa 1976). 2016 ;41(14):1167-1172. Huang X, Cai Y, Chen K, et al. Risk factors and treatment strategies for adjacent segment disease following spinal fusion (Review). Mol Med Rep. 2025;31(2):33. Yokoyama K, Yamada M, Tanaka H, et al. Factors of Adjacent Segment Disease Onset After Microsurgical Decompression for Lumbar Spinal Canal Stenosis. World Neurosurg. 2020;144: e110-e118. Shan X, An J, Li L, et al. An innovative minimally invasive technique for lumbar adjacent segment disease: a retrospective comparative analysis between extreme-oblique lumbar interbody fusion combined with percutaneous endoscopic lumbar discectomy(XOLIF-PELD) and posterior lumbar interbody fusion(PLIF) revision. J Orthop Surg Res. 2025;20(1):609. Paziuk T, Neuman BJ, Conaway W, et al. Does decompression adjacent to arthrodesis in the lumbar spine predispose patients to adjacent segment degeneration and disease: A retrospective analysis. J Orthop. 2023; 40:52-56. Jeong TS, Son S, Lee SG, et al. Comparison of adjacent segment disease after minimally invasive versus open lumbar fusion: a minimum 10-year follow-up. J Neurosurg Spine. 2021;36(4):525-533. Yun YI, Jeon I, Kim SW, et al. Risk factors for adjacent segment disease requiring reoperation after posterior lumbar interbody fusion with screw fixation: focus on paraspinal muscle, facet joint, and disc degeneration. Acta Neurochir (Wien). 2022;164(3):913-922. Li T, Zhu B, Liu X. Revision Strategy of Symptomatic Lumbar Adjacent Segment Degeneration: Full Endoscopic Decompression versus Extended Posterior Interbody Fusion. World Neurosurg. 2020;142: e215-e222. Yuan S, Lu X, Zang L, et al. Percutaneous Transforaminal Endoscopic Discectomy for Adjacent Segment Disease versus Lumbar Disc Herniation in Elderly Patients. J Pain Res. 2024; 17:2257-2265. Li J, Ge Z, Zhang D, et al. Comparison of the efficacy of arthroscopic-assisted uni-portal spinal surgery and percutaneous endoscopic lumbar discectomy in the treatment of far lateral lumbar disc herniation: a retrospective controlled study. Eur Spine J. 2025. Zhou S, Xu X, Guo T, et al. Comparison of short-term clinical outcomes and muscle injury in patients with lumbar spinal stenosis undergoing arthroscopic-assisted uni-portal spinal surgery, unilateral biportal endoscopic surgery, and percutaneous interlaminar lumbar discectomy: a six-month follow-up. J Orthop Surg Res. 2025;20(1):684. Wong HPN, Naidu D, Wong SYW, et al. Endoscopic spinal surgery in adjacent segment disease-a viable alternative to transforaminal lumbar interbody fusion: a case report. J Spine Surg. 2025;11(2):387-395. Burkhard MD, Chiapparelli E, Hambrecht J, et al. Multifidus Degeneration: The Key Imaging Predictor of Adjacent Segment Disease. Global Spine J. 2025;15(4):2348-2358. Jokeit M, Tsagkaris C, Altorfer FCS, et al. Impact of iatrogenic alterations on adjacent segment degeneration after lumbar fusion surgery: a systematic review. J Orthop Surg Res. 2025;20(1):425. Huang P, Ye B, Xie F, et al. Comparative analysis of anterior lumbar interbody fusion and transforaminal lumbar interbody fusion in clinical outcomes: ALIF associated with lower rates of adjacent segment degeneration (ASD) in a long-term follow-up study. Int Orthop. 2025;49(7):1731-1737. Feng F, Li G, Meng H, et al. Clinical efficacy of unilateral biportal endoscopic technique for adjacent segment pathology following lumbar fusion. J Orthop Surg Res. 2025;20(1):628. Zhang C, Berven SH, et al. Adjacent Segment Degeneration Versus Disease After Lumbar Spine Fusion for Degenerative Pathology: A Systematic Review with Meta-Analysis of the Literature. Clin Spine Surg. 2016;29(1):21-9. Yang Z, Chang J, Sun L, et al. Comparing Oblique Lumbar Interbody Fusion with Lateral Screw Fixation and Transforaminal Full-Endoscopic Lumbar Discectomy (OLIF-TELD) and Posterior Lumbar Interbody Fusion (PLIF) for the Treatment of Adjacent Segment Disease. Biomed Res Int. 2020; 2020:4610128. Liu X, Yuan S, Tian Y, et al. Comparison of percutaneous endoscopic transforaminal discectomy, microendoscopic discectomy, and microdiscectomy for symptomatic lumbar disc herniation: minimum 2-year follow-up results. J Neurosurg Spine. 2018;28(3):317-325. Chen HC, Lee CH, Wei L, et al. Comparison of percutaneous endoscopic lumbar discectomy and open lumbar surgery for adjacent segment degeneration and recurrent disc herniation. Neurol Res Int. 2015; 2015:791943. Zhou S, Jiancuo A, Xu X, et al. Evaluation of Hidden Blood Loss and Clinical Outcomes of Arthroscopy-Assisted Uni-Portal Spinal Surgery for Lumbar Disc Herniation with Lateral Recess Stenosis. World Neurosurg. 2025; 198:124026. Ba Z, Pan F, Liu Z, et al. Percutaneous endoscopical transforaminal approach versus PLF to treat the single-level adjacent segment disease after PLF/PLIF: 1-2 years follow-up. Int J Surg. 2017;42: 22-26. Wang F, Wang R, Zhang C, et al. Clinical effects of arthroscopic-assisted uni-portal spinal surgery and unilateral bi-portal endoscopy on unilateral laminotomy for bilateral decompression in patients with lumbar spinal stenosis: a retrospective cohort study. J Orthop Surg Res. 2024;19(1):167. Tables Tables 1 to 5 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 15 Apr, 2026 Read the published version in European Spine Journal → Version 1 posted Reviews received at journal 11 Jan, 2026 Reviewers agreed at journal 08 Jan, 2026 Reviewers invited by journal 06 Jan, 2026 Editor assigned by journal 13 Dec, 2025 Submission checks completed at journal 13 Dec, 2025 First submitted to journal 11 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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2","display":"","copyAsset":false,"role":"figure","size":2786838,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"FIGURE2.png","url":"https://assets-eu.researchsquare.com/files/rs-8341787/v1/d3ade8b6d9be964e5c90f3cf.png"},{"id":100365719,"identity":"bf231fdf-9894-41f5-b203-52eb5b889440","added_by":"auto","created_at":"2026-01-16 07:55:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3012815,"visible":true,"origin":"","legend":"\u003cp\u003eIndicators comparison of preoperative, 3 month, 6 month and12 month postoperatively (X ̅±s). Note: Compared with the preoperative period in the same group, ***P\u0026lt;0.001; compared with the PELD group in the same period, ###P\u0026lt;0.001.\u003c/p\u003e","description":"","filename":"FIGURE3.png","url":"https://assets-eu.researchsquare.com/files/rs-8341787/v1/c6e7a070e3551b0194769a7f.png"},{"id":100093833,"identity":"0177a054-8aad-4931-8d96-540ce265809a","added_by":"auto","created_at":"2026-01-13 01:27:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":3509112,"visible":true,"origin":"","legend":"\u003cp\u003eIndicators comparison of preoperative, 3 month, 6 month and12 month postoperatively (X ̅±s). Note: Compared with the preoperative period in the same group, ***P\u0026lt;0.001; compared with the PELD group in the same period, ###P\u0026lt;0.001.\u003c/p\u003e","description":"","filename":"FIGURE4.png","url":"https://assets-eu.researchsquare.com/files/rs-8341787/v1/064f70c19cdb446401c872cf.png"},{"id":100365166,"identity":"d3f43ef4-c5ac-4bf3-8df4-c4624da33f21","added_by":"auto","created_at":"2026-01-16 07:54:46","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2842638,"visible":true,"origin":"","legend":"\u003cp\u003eIndicators comparison of preoperative, 3 month, 6 month and12 month postoperatively (X ̅±s). Note: Compared with the preoperative period in the same group, ***P\u0026lt;0.001; compared with the PELD group in the same period, ###P\u0026lt;0.001.\u003c/p\u003e","description":"","filename":"FIGURE5.png","url":"https://assets-eu.researchsquare.com/files/rs-8341787/v1/103c2af2243ac85c4e26c558.png"},{"id":100365473,"identity":"6a5fbfdb-33c9-43e0-a509-da78baa5843d","added_by":"auto","created_at":"2026-01-16 07:55:14","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":3008870,"visible":true,"origin":"","legend":"\u003cp\u003eIndicators comparison of preoperative, 3 month, 6 month and12 month postoperatively (X ̅±s). Note: Compared with the preoperative period in the same group, ***P\u0026lt;0.001; compared with the PELD group in the same period, ###P\u0026lt;0.001.\u003c/p\u003e","description":"","filename":"FIGURE6.png","url":"https://assets-eu.researchsquare.com/files/rs-8341787/v1/bf832e7a999c9e59ce1cd500.png"},{"id":107351086,"identity":"009dc4a2-e920-47f3-8357-3e33ea6616e4","added_by":"auto","created_at":"2026-04-20 16:09:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":13061464,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8341787/v1/9de920cd-6e54-4e12-9f0c-d9f8debcef54.pdf"},{"id":100093831,"identity":"9460d950-fe7f-4fc7-928e-6844ebb64ff3","added_by":"auto","created_at":"2026-01-13 01:27:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30395,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8341787/v1/7fe27aa54081c7a65cf60835.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy Comparison of Arthroscopic-assisted Uniportal Spinal Surgery and Percutaneous Endoscopic Discectomy for Adjacent Segment Lumbar Disc Herniation After Fusion Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdjacent segment lumbar disc herniation (ASLDH)[1], a progressively radiographical and symptomatic lumbar disc degeneration adjacent to the previously operated spinal segment, represents a well-documented complication of lumbar fusion (LF) surgery, with a reported incidence ranging from 5.2% to 18.5%[2]. While previous studies have identified numerous risk factors associated with the development and progression of adjacent segment disc degeneration, a clear consensus on its pathogenesis remains elusive[3,4,5]. In addition to causing significant neurofunctional impairments, symptomatic ASLDH detrimentally impacts mental and psychological health and substantially reduces patients' quality of life[6,7]. Therefore, it is imperative to highlight this concern and explore effective preventive and therapeutic measures for ASLDH.\u003c/p\u003e \u003cp\u003eSurgical intervention becomes necessary for ASLDH when conservative management fails[8], and both repeated open fusion (FIGURE 1) procedures and minimally invasive spine surgery (MISS) techniques can achieve adequate neural decompression[9\u0026ndash;12]. Established and conventional open spinal fusion techniques, including posterior lumbar interbody fusion (PLIF), posterior laminectomy with fusion (PLF), oblique lumbar interbody fusion (OLIF), and anterior lumbar interbody fusion (ALIF), are employed in the treatment of ASLDH. However, it cannot be denied that open fusion techniques induce a second painful experience and substantial trauma to the muscle tissue, and revision surgeries do not consistently yield satisfactory clinical outcomes, potentially diminishing patient satisfaction. In contrast, MISS has emerged and gained preference as a preferred method for ASLDH due to its minimal incision, which mitigates damage to facet joints and posterior ligaments, and results in less muscle tissue injury[13]. Furthermore, MISS techniques have been widely used for their lower incidences of perioperative complications, such as nerve root injury and dural tear, which is particularly advantageous in the setting of pre-existing surgical scars and instrumentation[11,12]. Thus, MISS techniques appear to have more advantages compared with open repeated operations in treating ASLDH.\u003c/p\u003e \u003cp\u003eFurther developments in endoscopic spinal surgeries provide various options for lumbar disc herniation (LDH). As an alternative solution and a key component of MISS techniques, percutaneous endoscopic lumbar discectomy (PELD) has been widely recognized for encouraging results and is accepted for various presentations of LDH, including ASLDH. In addition, as a uniportal, non-coaxial spinal endoscopic surgery (UNSES), arthroscopic-assisted uniportal spinal surgery (AUSS) aligns with the principles of open surgery and offers outstanding advantages in instrument channel design, enhancing endoscopic visualization and operational flexibility[14,15]. Crucially, the integration of a 30\u0026deg; arthroscope provides a wider field of view and compatibility with various spinal surgical techniques and instruments. Therefore, the superior maneuverability suggests broader applicability for degenerative disc conditions compared to coaxial systems like PELD for ASLDH. Thus, this study aimed to compare the safety and efficacy of these two prominent MISS techniques\u0026mdash;PELD and AUSS\u0026mdash;in the treatment of ASLDH following LF. We retrospectively analyzed clinical data from 112 consecutive ASLDH patients who underwent either PELD or AUSS.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e The study was approved by the authors\u0026rsquo; institutional review board. All surgeries described in this study were approved by the ethics committee of our institution. In addition, the study has been reported in line with the STROCSS criteria.\u003c/p\u003e \u003cp\u003eASLDH was predominantly diagnosed via symptoms, signs, and imaging findings in the department of spine surgery from 2018 to 2024. The inclusion criteria for the study were as follows: (I) patients who had undergone LF surgery and had a diagnosis of ASLDH confirmed by X-rays, CT, and MRI; (II) patients who underwent the AUSS technique or PELD surgery; (III) patients with a follow-up period longer than 12 months and complete clinical and follow-up data. The exclusion criteria were: (I) patients with other causes (e.g., osteoporosis, lumbar instability, fractures, spinal tumors, or inflammatory spinal conditions) leading to low back pain and leg pain; (II) patients with severe comorbidities (such as pneumopathy or cardiovascular or cerebrovascular disease) who could not tolerate general anesthesia; (III) patients with mental and psychological disorders who could not comply with regular follow-up.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMethods\u003c/h3\u003e\n\u003cp\u003eAll surgical interventions were carried out by a single senior spinal surgeon with extensive experience.\u003c/p\u003e\n\u003ch3\u003eAUSS Group\u003c/h3\u003e\n\u003cp\u003eThe AUSS procedures were conducted under general anesthesia. Patients were placed in a prone position on a carbon fiber radiolucent operating table. Abdominal suspension was employed to decrease intra-abdominal pressure and limit surgical blood loss. The target spinal level was initially approximated using superficial anatomical landmarks and subsequently confirmed precisely under real-time C-arm fluoroscopic guidance by inserting a Kirschner wire into the intended intervertebral space. A longitudinal skin incision, measuring about 1.5\u0026ndash;1.8 cm, was created adjacent to the pedicles at the midline, carefully dissecting through the skin, subcutaneous tissue, and lumbar dorsal fascia. The arthroscope, coupled with the working sheath, was introduced alongside connections for the light source, motorized drill, radiofrequency ablator, and continuous saline irrigation, thereby exposing the facet joint's articular capsule. Radiofrequency ablation ensured local hemostasis, and a rongeur was utilized to clear and expose the articular capsule. Bony decompression was performed with a high-speed drill, following a predetermined circular trajectory (FIGURE 2) that involved: 1) the spinous process base and inferior lamina of the cranial vertebra; 2) the facet joint process; and 3) the spinous process base and superior lamina of the caudal vertebra. The decompression zone provided visualization of the superior articular process, ligamentum flavum, nerve root, and intervertebral disc. The nerve root was gently retracted and shielded, after which the annulus fibrosus was opened using a miniature blade. Herniated nucleus pulposus material was meticulously extracted with specialized forceps. Successful decompression was indicated by a relaxed, non-tensioned nerve root. Finally, radiofrequency ablation was applied to thermally coagulate the annulus fibrosus, aiming to minimize recurrence risk. Endoscopic inspection reaffirmed nerve root relaxation. The endoscope was then withdrawn, a negative-pressure drainage bulb was positioned, the wound was sutured, and a sterile dressing was applied.\u003c/p\u003e\n\u003ch3\u003ePELD Group\u003c/h3\u003e\n\u003cp\u003ePatients in the PELD group were administered general anesthesia and positioned prone. The affected spinal segment was localized and marked under C-arm fluoroscopy. An initial puncture was made roughly 10 cm from the midline, directed through the intervertebral foramen towards the pathological site. C-arm imaging confirmed accurate needle placement. A minor skin incision allowed insertion of a guidewire, followed by sequential dilators to accomplish foraminoplasty. An endoscopic system designed for the intervertebral foramen was then introduced. Under direct endoscopic vision, hemostasis was secured via electrocoagulation, and the pathological nucleus pulposus tissue was identified and removed. Confirmation of complete nerve root decompression was obtained. The procedure concluded after verifying restored nerve root pulsation and absence of active bleeding; the endoscope was removed and the incision closed.\u003c/p\u003e\n\u003ch3\u003eClinical Data and Evaluation\u003c/h3\u003e\n\u003cp\u003eClinical Indicators\u003c/p\u003e \u003cp\u003eThe following parameters were documented and analyzed preoperatively and at 3, 6, and 12 months post-surgery: (1) Pain intensity, evaluated via the Visual Analogue Scale (VAS) for both lower back pain (VAS-BP) and lower limb pain (VAS-LP). (2) Neurological function, gauged using the Japanese Orthopaedic Association (JOA) scoring system. (3) Functional disability, measured by the Oswestry Disability Index (ODI). (4) Quality of life, assessed with the Short Form-36 (SF-36) health survey. (5) Postoperative complications, including nerve root injury, dysesthesia in the affected limb, epidural hematoma, incidental dural tear, hip pain, delayed wound healing, and surgical site infection. (6) Serum pain mediator levels. Fasting venous blood samples (5 mL) were obtained preoperatively and at 3, 6, and 12 months postoperatively. After centrifugation (2500 rpm for 10 minutes, 6 cm radius), serum concentrations of 5-hydroxytryptamine (5-HT), substance P (SP), and norepinephrine (NE) were quantified using enzyme-linked immunosorbent assay (ELISA).\u003c/p\u003e \u003cp\u003eTherapeutic Efficacy Rate\u003c/p\u003e \u003cp\u003eClinical success at the six-month postoperative mark was determined according to modified MacNab criteria, classifying outcomes as: (1) Excellent: Absence of symptoms, unrestricted return to pre-disease activity levels; (2) Good: Minimal residual symptoms not interfering with daily function; (3) Fair: Moderate symptom improvement but with significant activity limitations; (4) Poor: Little to no improvement or worsening condition. The overall success rate was defined as the proportion of patients with Excellent or Good outcomes relative to the total cohort, serving as the primary measure of surgical efficacy.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS version 26.0 (IBM, Armonk, New York, USA), with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant. Continuous data are summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Intergroup comparisons of continuous variables were performed using independent samples t-tests, while intragroup comparisons employed paired samples t-tests. Categorical data, expressed as percentages, were analyzed via the Chi-square test.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient demographic and baseline characteristics are detailed in Table 1. The two groups were statistically comparable regarding gender distribution, age, and duration of follow-up (P \u0026gt; 0.05). However, the AUSS group exhibited significantly reduced intraoperative blood loss, shorter operative duration, and decreased length of hospital stay compared to the PELD group (P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional Indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe clinical indicators of VAS, JOA, and ODI are compared and exhibited in FIGURES 3-6. At each follow-up time point, the JOA score was higher in the AUSS group than in the PELD group (P \u0026lt; 0.001), while VAS-BP, VAS-LP, and ODI scores were lower in the AUSS group than in the PELD group (P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of Life\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe scores of the eight dimensions of the SF-36 at 3, 6, and 12 months postoperatively increased in both groups compared with the preoperative values (P \u0026lt; 0.001). The dimension scores for physical functioning (PF), role limitations due to physical health problems (RP), bodily pain (BP), general health perceptions (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH) in the AUSS group were higher than those in the PELD group at each follow-up time point (P \u0026lt; 0.001) (Table 2-1,2-2,2-3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSerum Pain Mediators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSignificant reductions in serum levels of 5-HT, SP, and NE were observed postoperatively in both groups (P \u0026lt; 0.001). Notably, the AUSS group displayed consistently lower concentrations of all three pain mediators compared to the PELD group at the 3-, 6-, and 12-month time points (P \u0026lt; 0.001), detailed in Table 3.\u003c/p\u003e\n\u003cp\u003eOperative Success Rate\u003c/p\u003e\n\u003cp\u003eBased on the modified MacNab criteria, the overall clinical success rate at 6 months was significantly higher in the AUSS group (98.2%) than in the PELD group (86.0%) (P \u0026lt; 0.05), as shown in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe incidence of postoperative complications was significantly lower in the AUSS group (3.6%) compared to the PELD group (28.1%) (P \u0026lt; 0.001). Specific complications are itemized in Table 5.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs an increasingly recognized long-term complication following instrumented lumbar fusion surgery, adjacent segment lumbar disc herniation (ASLDH) presents with distinct clinical and imaging features[1,16]. While fundamentally rooted in disc degeneration, ASLDH pathogenesis is multifactorial, involving physiological aging, biomechanical alterations secondary to fusion, iatrogenic factors during the index surgery, and patient-specific variables[9,17]. Numerous investigations have illustrated that the incidence of ASLDH progressively increases over time following lumbar fusion surgeries[17,18]. Multiple factors related to the characteristics of the first operation, including surgical approach, length of fusion, sacral fusion, disrupted integrity of the posterior complex, rigid instrumentation, and pre-existing disc degeneration, contribute to the unique nature of ASLDH[19]. Management of symptomatic ASLDH initially aligns with the principles for lumbar disc herniation. However, controversy arises when conservative measures fail, necessitating surgical intervention, and the therapeutic crossroads stems directly from the inherent complexity of ASLDH[11,20]. Therefore, the interplay of diverse causative factors, encompassing etiology and pathological characteristics, collectively contributes to the ongoing debate regarding the optimal surgical strategy for revision ASLDH surgery.\u003c/p\u003e \u003cp\u003eVarious surgical methods contribute their advantages to promote neurofunctional recovery for ASLDH[21\u0026ndash;23]. Conventional open operative management with instrumentation can provide direct and complete decompression of the nerve root, reconstruct spinal alignment and stability, and potentially achieve favorable clinical outcomes. However, repeated open surgeries carry significant risks of perioperative complications and impose a profound physical and psychological burden. Consequently, to avoid or mitigate repeat operation-related trauma, secondary musculoskeletal injury, and potential nerve root or dural injury, spinal endoscopic techniques have rapidly emerged as predominant minimally invasive solutions. Chen HC et al[24]reported that the PELD method provided complete decompression and had overwhelming superiority over repeated open lumbar surgery in the surgical treatment of ASLDH. Similarly, the AUSS technique can effectively achieve nucleus pulposus removal for nerve root decompression, avoid secondary damage to the posterior and paraspinal structures, preserve the facet joints, and relieve the patient's impaired neurological function, as does PELD surgery. Accordingly, the two techniques are unquestionably applicable to the surgical treatment of ASLDH.\u003c/p\u003e \u003cp\u003eCompared with open revision, both the AUSS technique and the PELD approach align with the primary principles of minimally invasive surgery. AUSS offers specific technical advantages, minimizing instrument interference through its single-portal design and stable intraoperative approach[13]. Furthermore, the 30\u0026deg; arthroscope provides a 360\u0026deg; ultra-wide-angle surgical field of view[13,14], and pre-existing internal fixation facilitates more convenient intraoperative localization and less radiation exposure. These features may contribute to a relatively gentler learning curve for less experienced surgeons. In contrast, PELD surgery requires exceptional proficiency in foraminal anatomy and demands experienced imaging navigation skills. Moreover, the PELD procedure carries inherent risks of inaccurate puncture and nerve root injury, which are amplified in the setting of post-surgical epidural adhesions and scar tissue, resulting in a steeper and potentially longer learning curve[14]. Therefore, although the two minimally invasive techniques demonstrate advantages in treating ASLDH, the AUSS technique may be more likely to be adopted and promoted for its safety and maneuverability.\u003c/p\u003e \u003cp\u003eThe significant changes in functional indicators demonstrated the efficacy and safety of AUSS and PELD. Patients with ASLDH differ from those with first-time simple lumbar disc degeneration; although they may have similar nerve lesions and functional impairments, ASLDH patients have a greater mental and psychological burden[1]. Consequently, in addition to the indications and contraindications for the operation, factors such as patient preference, acceptance of reoperation, pathological situation, and characteristics of ASLDH must be fully considered before the final surgical decision-making. Although PELD achieves encouraging results in clinical practice, concerns persist regarding muscle trauma, decompression accuracy and extent, risks of incidental durotomy and cerebrospinal fluid leakage, significant radiation exposure, and reports suggesting relatively higher recurrence rates[25,26]. Comparing PELD surgery for ASLDH, AUSS demonstrates potential superiority across several domains: surgical strategy flexibility, neurofunctional recovery, perioperative complication profile, and quality of life improvement. The enhanced outcomes observed with AUSS may stem from its precise surgical planning, superior visualization via the 30\u0026deg; arthroscope, and greater operational flexibility. Utilizing a single incision for both working and viewing channels, the AUSS technique facilitates wider decompression and higher operability, potentially enabling bilateral decompression through a unilateral approach[27]. This technique maximizes the preservation of lumbar bony structures, thereby enhancing spinal stability and biomechanical properties while simultaneously accelerating functional recovery. Crucially, patient satisfaction is intrinsically linked to neurological recovery and is significantly impacted directly by perioperative complications, particularly symptom recurrence. Hence, the AUSS technique is theoretically superior to that of PELD surgery.\u003c/p\u003e \u003cp\u003eIn this investigation, the AUSS group demonstrated better performance in terms of less blood loss and shorter operation time and hospital stay. Improvements in functional outcome measures, including JOA, ODI, and SF-36 scores, were significantly better in both groups. Evidence of high rates of overall clinical efficacy and lower total complication incidences further supports this finding. General serum pain mediators, including 5-HT, SP, and NE, are associated with nociceptive pain effects, and the variation trends of these indicators were parallel to those of the VAS scores in the study. As is known, with the transformation from tension to relaxation of the nerve, pain mediators rise and fall accordingly. This phenomenon indicates that the more sufficient the nerve decompression, the lower the content of pain factors and the pain score will be. However, from horizontal comparisons at identical postoperative time points between the two groups, the PELD group exhibited significantly lower JOA and SF-36 scores, alongside higher ODI and VAS scores, and relatively elevated levels of serum pain mediators. Therefore, a comprehensive cross-comparative analysis and rigorous validation of substantial datasets consistently demonstrate a significant trend towards superior outcomes with the AUSS technique relative to PELD surgery in treating ASLDH.\u003c/p\u003e \u003cp\u003eNonetheless, there are still some limitations to this study that should be acknowledged. First, the retrospective design and relatively small sample size (n\u0026thinsp;=\u0026thinsp;112) inherently constrain the generalizability of the findings and introduce potential biases. Consequently, future prospective studies with larger cohorts are essential to validate these results. Second, inherent selection bias exists, as patients were assigned to AUSS or PELD based on pathological characteristics and surgeon assessment, meaning not all patients were candidates for both techniques. Finally, both procedures demand significant technical expertise. AUSS, in particular, requires mastery of incision planning, endoscopic manipulation, and arthroscopic assistance, necessitating a substantial learning curve typically achieved only by experienced spinal surgeons.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBoth the AUSS technique and PELD surgery represent effective minimally invasive options for managing ASLDH following lumbar fusion surgery. However, AUSS demonstrates superior outcomes, including significantly improved functional recovery rates, a lower incidence of procedure-related complications, and enhanced patient-reported quality of life. These advantages support the broader clinical application of AUSS for suitable indications. While AUSS demonstrates outstanding advantages in specific situations, prudent surgical decision-making necessitates viewing it as an integrative component within the therapeutic armamentarium, complementing rather than displacing established techniques.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eadjacent segment disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elumbar discs degeneration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elumbar fusion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAUSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003earthroscopic-assisted uni-portal spinal surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNSES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003euni-portal non-coaxial spinal endoscopic surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePELD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epercutaneous endoscopic lumbar discectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLIF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eposterior lumbar interbody fusion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eposterior laminectomy with fusion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOLIF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eoblique lumbar interbody fusion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALIF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eanterior lumbar interbody fusion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMISS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eminimally invasive spine surgeries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJOA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJapanese Orthopedic Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVisual Analog Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eODI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOswestry Disability Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSF-36\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eShort Form-36 Survey Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Review Committee Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was provided by the Ethical Committee of Shanghai Fourth People\u0026apos;s Hospital Affiliated to Tongji University School of Medicine (Ethics number: SYLL20233027), China, Shanghai.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Hongkou District Clinical Key Specialty of Shanghai (HKLCZD2024B03).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of data availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during the current study are not publicly available due the rules and regulations and respect the privacy rights of patients, but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMcDonald CL, Alsoof D, Glueck J, et al. Adjacent Segment Disease After Spinal Fusion. JBJS Reviews. 2023;11(6): e23.00028.\u003c/li\u003e\n \u003cli\u003ePark P, Garton HJ, Gala VC, et al. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976). 2004;29(17):1938-44.\u003c/li\u003e\n \u003cli\u003eHuang X, Cai Y, Chen K, et al. Risk factors and treatment strategies for adjacent segment disease following spinal fusion (Review). Mol Med Rep. 2025;31(2):33.\u003c/li\u003e\n \u003cli\u003eMaragkos GA, Atesok K, Papavassiliou E. Prognostic Factors for Adjacent Segment Disease After L4-L5 Lumbar Fusion. Neurosurgery. 2020;86(6):835-842.\u003c/li\u003e\n \u003cli\u003eAlentado VJ, Lubelski D, Healy AT, et al. Predisposing Characteristics of Adjacent Segment Disease After Lumbar Fusion. Spine (Phila Pa 1976). 2016 ;41(14):1167-1172.\u003c/li\u003e\n \u003cli\u003eHuang X, Cai Y, Chen K, et al. Risk factors and treatment strategies for adjacent segment disease following spinal fusion (Review). Mol Med Rep. 2025;31(2):33.\u003c/li\u003e\n \u003cli\u003eYokoyama K, Yamada M, Tanaka H, et al. Factors of Adjacent Segment Disease Onset After Microsurgical Decompression for Lumbar Spinal Canal Stenosis. World Neurosurg. 2020;144: e110-e118.\u003c/li\u003e\n \u003cli\u003eShan X, An J, Li L, et al. An innovative minimally invasive technique for lumbar adjacent segment disease: a retrospective comparative analysis between extreme-oblique lumbar interbody fusion combined with percutaneous endoscopic lumbar discectomy(XOLIF-PELD) and posterior lumbar interbody fusion(PLIF) revision. J Orthop Surg Res. 2025;20(1):609.\u003c/li\u003e\n \u003cli\u003ePaziuk T, Neuman BJ, Conaway W, et al. Does decompression adjacent to arthrodesis in the lumbar spine predispose patients to adjacent segment degeneration and disease: A retrospective analysis. J Orthop. 2023; 40:52-56.\u003c/li\u003e\n \u003cli\u003eJeong TS, Son S, Lee SG, et al. Comparison of adjacent segment disease after minimally invasive versus open lumbar fusion: a minimum 10-year follow-up. J Neurosurg Spine. 2021;36(4):525-533.\u003c/li\u003e\n \u003cli\u003eYun YI, Jeon I, Kim SW, et al. Risk factors for adjacent segment disease requiring reoperation after posterior lumbar interbody fusion with screw fixation: focus on paraspinal muscle, facet joint, and disc degeneration. Acta Neurochir (Wien). 2022;164(3):913-922.\u003c/li\u003e\n \u003cli\u003eLi T, Zhu B, Liu X. Revision Strategy of Symptomatic Lumbar Adjacent Segment Degeneration: Full Endoscopic Decompression versus Extended Posterior Interbody Fusion. World Neurosurg. 2020;142: e215-e222.\u003c/li\u003e\n \u003cli\u003eYuan S, Lu X, Zang L, et al. Percutaneous Transforaminal Endoscopic Discectomy for Adjacent Segment Disease versus Lumbar Disc Herniation in Elderly Patients. J Pain Res. 2024; 17:2257-2265.\u003c/li\u003e\n \u003cli\u003eLi J, Ge Z, Zhang D, et al. Comparison of the efficacy of arthroscopic-assisted uni-portal spinal surgery and percutaneous endoscopic lumbar discectomy in the treatment of far lateral lumbar disc herniation: a retrospective controlled study. Eur Spine J. 2025.\u003c/li\u003e\n \u003cli\u003eZhou S, Xu X, Guo T, et al. Comparison of short-term clinical outcomes and muscle injury in patients with lumbar spinal stenosis undergoing arthroscopic-assisted uni-portal spinal surgery, unilateral biportal endoscopic surgery, and percutaneous interlaminar lumbar discectomy: a six-month follow-up. J Orthop Surg Res. 2025;20(1):684.\u003c/li\u003e\n \u003cli\u003eWong HPN, Naidu D, Wong SYW, et al. Endoscopic spinal surgery in adjacent segment disease-a viable alternative to transforaminal lumbar interbody fusion: a case report. J Spine Surg. 2025;11(2):387-395.\u003c/li\u003e\n \u003cli\u003eBurkhard MD, Chiapparelli E, Hambrecht J, et al. Multifidus Degeneration: The Key Imaging Predictor of Adjacent Segment Disease. Global Spine J. 2025;15(4):2348-2358.\u003c/li\u003e\n \u003cli\u003eJokeit M, Tsagkaris C, Altorfer FCS, et al. Impact of iatrogenic alterations on adjacent segment degeneration after lumbar fusion surgery: a systematic review. J Orthop Surg Res. 2025;20(1):425.\u003c/li\u003e\n \u003cli\u003eHuang P, Ye B, Xie F, et al. Comparative analysis of anterior lumbar interbody fusion and transforaminal lumbar interbody fusion in clinical outcomes: ALIF associated with lower rates of adjacent segment degeneration (ASD) in a long-term follow-up study. Int Orthop. 2025;49(7):1731-1737.\u003c/li\u003e\n \u003cli\u003eFeng F, Li G, Meng H, et al. Clinical efficacy of unilateral biportal endoscopic technique for adjacent segment pathology following lumbar fusion. J Orthop Surg Res. 2025;20(1):628.\u003c/li\u003e\n \u003cli\u003eZhang C, Berven SH, et al. Adjacent Segment Degeneration Versus Disease After Lumbar Spine Fusion for Degenerative Pathology: A Systematic Review with Meta-Analysis of the Literature. Clin Spine Surg. 2016;29(1):21-9.\u003c/li\u003e\n \u003cli\u003eYang Z, Chang J, Sun L, et al. Comparing Oblique Lumbar Interbody Fusion with Lateral Screw Fixation and Transforaminal Full-Endoscopic Lumbar Discectomy (OLIF-TELD) and Posterior Lumbar Interbody Fusion (PLIF) for the Treatment of Adjacent Segment Disease. Biomed Res Int. 2020; 2020:4610128.\u003c/li\u003e\n \u003cli\u003eLiu X, Yuan S, Tian Y, et al. Comparison of percutaneous endoscopic transforaminal discectomy, microendoscopic discectomy, and microdiscectomy for symptomatic lumbar disc herniation: minimum 2-year follow-up results. J Neurosurg Spine. 2018;28(3):317-325.\u003c/li\u003e\n \u003cli\u003eChen HC, Lee CH, Wei L, et al. Comparison of percutaneous endoscopic lumbar discectomy and open lumbar surgery for adjacent segment degeneration and recurrent disc herniation. Neurol Res Int. 2015; 2015:791943.\u003c/li\u003e\n \u003cli\u003eZhou S, Jiancuo A, Xu X, et al. Evaluation of Hidden Blood Loss and Clinical Outcomes of Arthroscopy-Assisted Uni-Portal Spinal Surgery for Lumbar Disc Herniation with Lateral Recess Stenosis. World Neurosurg. 2025; 198:124026.\u003c/li\u003e\n \u003cli\u003eBa Z, Pan F, Liu Z, et al. Percutaneous endoscopical transforaminal approach versus PLF to treat the single-level adjacent segment disease after PLF/PLIF: 1-2 years follow-up. Int J Surg. 2017;42: 22-26.\u003c/li\u003e\n \u003cli\u003eWang F, Wang R, Zhang C, et al. Clinical effects of arthroscopic-assisted uni-portal spinal surgery and unilateral bi-portal endoscopy on unilateral laminotomy for bilateral decompression in patients with lumbar spinal stenosis: a retrospective cohort study. J Orthop Surg Res. 2024;19(1):167.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Fusion, lumbar disc herniation, arthroscopic-assisted uniportal spinal surgery, percutaneous endoscopic lumbar discectomy","lastPublishedDoi":"10.21203/rs.3.rs-8341787/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8341787/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdjacent segment lumbar disc herniation (ASLDH), a recognized complication following lumbar fusion (LF) surgeries, can be managed with various techniques; however, evidence supporting the arthroscopic-assisted uniportal spinal surgery (AUSS) technique for adjacent segment LDH is currently lacking.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo explore the application and validate the safety and efficacy of Arthroscopic-assisted Uniportal Spinal Surgery (AUSS) in the treatment of adjacent segment LDH.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eOne hundred and twelve patients diagnosed with ASLDH were enrolled from 2018 to 2024. Fifty-five patients underwent the AUSS technique, comprising the AUSS group, and fifty-seven patients received percutaneous endoscopic lumbar discectomy (PELD), comprising the PELD group. Perioperative indicators, including 6-month postoperative efficacy rate, postoperative complications, Visual Analogue Scale (VAS), Japanese Orthopaedic Association (JOA) scores, Oswestry Disability Index (ODI), and Short Form-36 Survey Scale (SF-36), were recorded and compared between the two groups at each follow-up time point.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCompared with PELD, AUSS demonstrated a shorter operation time and hospital stay, as well as less blood loss (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The overall efficacy rate in the AUSS group (98.2%) was higher than that in the PELD group (86.0%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) at 6 months postoperatively, and the total incidence of postoperative complications in the AUSS group (3.6%) was lower than that in the PELD group (28.1%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). At each follow-up time point, indicators of serum pain mediators, VAS-Back Pain (VAS-BP), VAS-Leg Pain (VAS-LP), JOA and ODI scores, and each dimension of SF-36 in the AUSS group were superior to those in the PELD group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBoth the AUSS technique and PELD represent viable surgical options for ASLDH following LF. However, AUSS demonstrates significantly superior functional recovery rates and a lower incidence of procedure-related complications, supporting its broader clinical application.\u003c/p\u003e","manuscriptTitle":"Efficacy Comparison of Arthroscopic-assisted Uniportal Spinal Surgery and Percutaneous Endoscopic Discectomy for Adjacent Segment Lumbar Disc Herniation After Fusion Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 01:27:30","doi":"10.21203/rs.3.rs-8341787/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-11T10:28:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"72075239537086159615910349157640102115","date":"2026-01-08T12:04:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T11:45:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-13T17:45:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-13T17:45:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-12-12T04:44:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0b6e0a60-02df-4c75-adfd-ac58a91c0121","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:06:46+00:00","versionOfRecord":{"articleIdentity":"rs-8341787","link":"https://doi.org/10.1007/s00586-026-09899-w","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2026-04-15 15:57:58","publishedOnDateReadable":"April 15th, 2026"},"versionCreatedAt":"2026-01-13 01:27:30","video":"","vorDoi":"10.1007/s00586-026-09899-w","vorDoiUrl":"https://doi.org/10.1007/s00586-026-09899-w","workflowStages":[]},"version":"v1","identity":"rs-8341787","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8341787","identity":"rs-8341787","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}