Open research questions in Cervical and Thoracic Myelopathy

What the literature leaves open

• Intraoperative supply costs in ACDF vary widely and are dominated by implant selection, yet absolute cost figures are institution-specific and cannot be compared across sites.

  Measuring Variability and Value of Single- and Two-Level Anterior Cervical Discectomy and Fusion Using Impact Scores · 2026 · DOI

• Most importantly, the composite challenging anatomy classifi- cation has not been validated against actual procedural outcomes—such as caudal epidural block success rates, technical difficulty scores, or complication rates—and should therefore be regarded as a hypothesis-generating framework pending prospective outcome validation. Furthermore, although the cohort encompassed diverse ethnic groups, the sample size was insufficient for sub- stantive subgroup analyses.

  MDCT-based prevalence of anatomically challenging sacral hiatus morphology in adults: implications for procedural safety · 2026 · DOI

• Conventional anterior techniques are limited by their inability to apply focal force directly to locked facets, resulting in failure rates of 4%–40% for anterior open reduction [3,7,8].

  Surgical management protocol for anterior-only reduction and fixation for acute, delayed and old subaxial cervical facet dislocation: a retrospective study of 87 consecutive cases in China · 2026 · DOI

• Future research should explore the influence of FHP on upper- and lower-extremity biomechanics using longitudinal designs that include diverse age and occupational groups and dynamic postural tasks.

  DOES CERVICAL POSTURE REALLY AFFECT PAIN AND POSTURAL CONTROL ACROSS THE KINETIC CHAIN? A CROSS - SECTIONAL STUDY · 2026 · DOI

• Agreement pharyngeal and esophageal phases of swallowing and to determine treatment strategies to minimize aspiration risk and increase swallow efficiency UEG/ESNM might consider the use of ultrasonograpy to evaluate muscles thickness and hyoid bone motion in patients with dysphagia, but the lack of standardized parameters limits its clinical utility UEG/ESNM suggest the use of pharyngeal high‐resolution manometry in patients in whom the pharyngeal and UES function remains unclear and who present with abnormal swallow efficiency (residue) or safety (aspiration) There is no clearly effective medical treatment able to improve motor function in patients with ineffective motility disorders.

  Surgical management of dysphagia at the oropharyngeal-esophageal junction due to cervical spondylosis: Two case reports · 2026 · DOI

• Agreement and functional esophageal disease when endoscopy and HRM did not fully explain symptoms UEG/ESNM recommends the use of EndoFLIP as an adjunctive diagnostic test in patients with dysphagia and inconclusive diagnoses from previous explorations including upper endoscopy and high‐resolution esophageal manometry UEG/ESNM recommended the use of imaging studies when no endoscopic abnormalities are found and when the results of esophageal motility studies are atypical or inconclusive UEG/ESNM do not recommend clinical swallow evaluation alone to definitely characterize oropharyngeal dysphagia UEG/ESNM indicate FEES for (1) symptoms and signs of oropharyngeal dysphagia (OD), (2) selecting optimal dietary conditions, (3) designing a patient‐ tailored OD treatment plan, and (4) verifying treatment outcomes and disease progression. UEG/ESNM do not recommend FEES in patients with bilateral complete nasal obstruction, a respiratory rate > 35/ min, impaired consciousness, or refusal of oral food administration.

  Surgical management of dysphagia at the oropharyngeal-esophageal junction due to cervical spondylosis: Two case reports · 2026 · DOI

• Agreement nursing homes. Moreover, the development of nutritional and respiratory complications, such as malnutrition and respiratory infections, has been associated with an independent increase in long‐ term costs for follow‐up, especially in post‐stroke patients.

  Surgical management of dysphagia at the oropharyngeal-esophageal junction due to cervical spondylosis: Two case reports · 2026 · DOI

• and on Figure 1 schematically summarizes the main findings regarding the diagnostic approach to esophageal dysphagia. The consensus supports the performance of EGD with multiple esophageal biopsies as the initial diagnostic modality, mainly to search for anatomical and mucosal lesions. The next diagnostic modality recommended by the consensus is HRM, a modality that evaluate the esophageal motility as well as the LES function. In case of negative findings at HRM, the next step is patient's symptoms phenotyping to GERD/hypersensitive esophagus or dysphagia with inconclusive diagnosis. In these clinical scenarios, either ambulatory reflux monitoring or FLIP/Barium swallows are performed. In patients with persistent symptoms and additional testing might be required, such as imaging (CT, MRI, EUS). Functional dysphagia is the diagnosis in case of negative diagnostics. Figure 2 illustrates recommendations regarding treatment schematically. A strong consensus was achieved for the “wait and see” approach and for the discontinuation of opioids for patients with EGJOO. Very weak/low recommendation was reached regarding surgical and endoscopic treatment for structural EGJOO as well as for CCB, nitrates, sildenafil, botulinum toxin, balloon dilation and myotomy—for the treatment of functional EGJOO. Moreover, weak/low recommendation was reached for PPI, CCB, nitrates, sildenafil, TCA, SSRI, NSRI, SARI, peppermint oil as well as botulinum toxin, balloon dilation and myotomy—for the treatment of hypercontractile esophagus. For patients with ineffective esophageal motility, a strong consensus was achieved for the treatment of concomitant clinical scenario such as GERD. Moreover, weak/low recommendation was reached for buspirun, bethanechol and prucalopride. The consensus voted against the use of prokinetics such as donperidone, metoclopramide and mosapride. A strong consensus was achieved for the use of TCA, SSRI, NSRI, SARI‐ for the treatment of functional dysphagia. Peripheral neuromodulatory techniques, such as NMES, PES, or PMS, have all been applied to post‐stroke dysphagia, showing moderate (PES) to good (NMES) results [338, 340, 343]. Even though NMES has shown better results when combined with traditional therapy, systematic appraisal of the literature showed high heterogeneity in protocols and experimental variables, as well as inconsistent reporting [337, 341]. DBS in PS is shown to have beneficial effects at specified frequencies and site of electrode placement in the subcortical areas. The effect of peripheral interventions on the central nervous system remains questionable, leaving this aspect a gray area in this context. Further high‐quality research is necessary in order to clarify which stimulation protocols, parameters, and therapy settings are the most beneficial for certain patient groups and degrees of impairment. Figure 3 schematically summarizes the main findings regarding the diagnostic approach to oropharyngeal dysphagia. The consensus recommends that an initial clinical swallow evaluation should be followed by instrumental assessments such as FEES, VFSS, or pharyngeal manometry (when feasible). Additional tests, including endoscopy, barium swallow, and imaging studies, may be conducted as necessary. Figure 4 illustrates recommendations regarding treatment schematically. The consensus supports the classification of oropharyngeal dysphagia based on the etiology. For anatomic conditions, a strong consensus was achieved for specific treatment scenario such as zenker diverticulopexy or diverticulectomy, malignancy, congenital condition and external compression. For neurological diseases, a very low/low recommendations were achieved for swallow therapies were is lack of 879 TABLE 3 | Questions, statements, and recommendations on the dysphagia guidelines.

  Surgical management of dysphagia at the oropharyngeal-esophageal junction due to cervical spondylosis: Two case reports · 2026 · DOI

• Undersized implants have been associated with subsidence; however, the impact of the IWUW ratio on fusion status and PROMIS outcomes has not been previously reported.

  Investigating the Cervical Implant Width to Uncovertebral Width Ratio (IWUW) in Single-Level Anterior Cervical Discectomy and Fusions · 2026 · DOI

• Background Laminectomy fusion fixation (LF) and single open-door laminoplasty (LP) are common posterior surgeries for central cord syndrome without fracture/dislocation (CCSWOFD), yet a comprehensive comparison is lacking.

  Laminectomy vs. laminoplasty for treating multi-segment cervical canal stenosis combined with central cord syndrome in the absence of fracture or dislocation: a retrospective study · 2026 · DOI

• BACKGROUND: Diabetes mellitus (DM) may adversely affect neurological recovery after cervical decompression, but its relationship with postoperative plantar pressure restoration in cervical spondylotic myelopathy (CSM) remains insufficiently defined.

  Preoperative glycated hemoglobin predicts postoperative plantar pressure improvement after posterior cervical laminoplasty in patients with cervical spondylotic myelopathy and diabetes mellitus · 2026 · DOI

• for FOS faces in to solidify edema provide definitive evidence confirming FOS diagnosis (19). Given that FOS presents with a characteristic nerve injury, diagnostic nerve root blocks further assist in precisely localizing the compressed spinal nerve segment, providing corroborative evidence the diagnosis of FOS (14). Besides, electrophysiological methods find applications in the clinical assessment in select cases (17). However, this technique remains relatively immature. The definitive diagnosis still rests squarely on radiographic imaging and confirmatory selective nerve root blocks. This situation inevitably leads to a large number of patients being missed or misdiagnosed. Currently, no internationally standardized criteria exist for assessing the severity of FOS. Castellvi classification was established to assess LSTV, but failed to quantify neurocompressive sequelae. Advancing validated FOS-specific metrics will selecting conservative management vs. surgical intervention. standardization evidence-based enable in The characteristics of FOS necessitate surgical intervention for effective relief, and the development of the surgical treatment has evolved alongside a growing boosting of surgical technology. We have summarized the relevant literature regarding the surgical management of FOS in Table 1. Initially, the surgery was primarily performed with the assistance of a microscope, with both anterior (20) and posterior (21) approaches being reported. Subsequently, with the maturation of endoscopic techniques, some teams began attempting endoscopic decompression around 2009 (22). By 2016, clinical reports related to FOS generally adopted microendoscopic assistance, with a standardized posterior approach (predominantly paraspinal approach) (23, 24).

  O-arm navigation-guided uni-portal non-coaxial spinal endoscopic surgery for the precise treatment of far-out syndrome—a case report and literature review · 2026 · DOI

• Although dynamic changes in alignment could be assessed with flexion-extension radiographs, the behavior of the spinal cord and discs under dynamic condi- tions could not be evaluated owing to the absence of kine- matic MRI.

  Preoperative Disc Height as a Prognostic Factor in Laminoplasty for Cervical Spondylotic Myelopathy with Degenerative Spondylolisthesis · 2026 · DOI

• Vit Kotheeranurak1,2 · Peem Sarasombath3 · Khanathip Jitpakdee4 · Wongthawat Liawrungrueang5 · Weerasak Singhatanadgig1 · Worawat Limthongkul1 · Wicharn Yingsakmongkol1 · Jin-Sung Kim6 Received: 21 April 2026 / Revised: 26 April 2026 / Accepted: 23 May 2026 © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2026 Dear Editor, We greatly appreciate the thoughtful and constructive com- mentary by Choi regarding our study on intraoperative neuromonitoring (IONM) in posterior endoscopic cervi- cal decompression (PECD) [1, 2]. The author proposes a signal–event–response framework for conceptualizing the clinical utility of IONM, and we find this perspective to be a valuable extension of the findings presented in our report. We concur with the central argument that IONM should not be evaluated solely on its capacity to predict postopera- tive neurological deficits. As we noted in our article, over 85% of patients in the IONM group demonstrated intra- operative signal changes, primarily reductions in motor- evoked potential (MEP) amplitude, yet none developed new postoperative neurological deficits. Rather than concluding that IONM has limited predictive value, we interpreted this finding as evidence that timely intraoperative responses to IONM alerts may have helped avert potential neural injury. This interpretation aligns directly with the process-based framework proposed by the authors. Indeed, our study included a standardized IONM response protocol. When predefined alert criteria were met (MEP amplitude reduction ≥ 80% from baseline or SSEP amplitude decrease ≥ 50%), the surgical team immediately paused the procedure and initiated a structured reassess- ment, including inspection for mechanical irritation, reduc- tion of instrument pressure, field irrigation, and verification of systemic parameters such as mean arterial pressure and anesthetic depth. Surgery resumed only after signal stabi- lization or partial recovery was confirmed. In five cases where MEP signals failed to recover intraoperatively, SSEP stabilization guided the decision to resume. All five patients achieved favorable postoperative outcomes, consistent with the authors’ hypothesis that timely corrective responses, rather than monitoring alone, determine clinical safety.

  Response to the letter to the editor: Intraoperative neuromonitoring in endoscopic cervical decompression: a signal–event–response perspective · 2026 · DOI

• Several limitations should be acknowledged. First, all included core studies were computational. These mod- els provide useful mechanistic insight but depend on assumptions regarding anatomy, tissue properties, mus- cle representation, loading conditions, and postopera- tive adaptation [14–21]. Second, heterogeneity in spinal region, fusion procedure, muscle-related exposure, modeling framework, and biomechanical endpoints pre- cluded quantitative pooling. Third, publication bias is possible because studies showing clear biomechanical effects of muscle injury or atrophy may be more likely to be published than neutral studies. Fourth, age, sex, bone quality, sarcopenia, obesity, deformity, osteoporo- sis, frailty, and comorbidity burden were not consistently incorporated into the models, limiting generalizability to complex clinical populations. Fifth, the clinical studies discussed above were observational and were used only as contextual evidence; they do not establish causality or directly validate the computational models. Finally, this review was not prospectively registered in PROSPERO, although the review question, eligibility criteria, search concepts, and extraction framework were defined before final study selection.

  Paraspinal muscle injury, atrophy, and postoperative biomechanical burden after spinal fusion: a systematic review of computational biomechanical evidence · 2026 · DOI

• 2026 Yokogawa et al. Cureus 18(5): e109541. DOI 10.7759/cureus.109541 7 of 9 In this study, we presented the largest sample size to date to examine the association between atlas hypoplasia, aging, and subaxial stenosis. There are several limitations, as with any study. The retrospective design using a homogeneous cohort may affect generalizability and result in selection bias. The study also did not include patients with associated genetic disorders that could cause atlas-level stenosis, such as os odontoideum and Klippel-Feil syndrome. Additional research into predisposing pathologies may be warranted. In addition, this study did not evaluate soft tissue damage, spinal cord injury, or atlantoaxial instability. Further analysis of the degree of cord compression and factors associated with stenosis, along with atlas hypoplasia, would be useful. The atlas hypoplasia subgroup was small, with only 17 patients, which limits the statistical strength of conclusions drawn from this subgroup analysis and should be interpreted with caution. Furthermore, while CT measurements were performed by fellows under the supervision of orthopaedic spine surgeons with experience in cervical radiographic anatomy, formal intra-rater and inter-rater reliability testing was not conducted, which represents an additional methodological limitation. Finally, this study was intentionally designed as a radiographic and anatomical investigation and did not include correlation with clinical symptoms, neurologic examination findings, MRI-based cord signal changes, or long-term patient outcomes. Such correlations would substantially strengthen the clinical relevance of these findings and are identified as a priority area for future investigation.

  Hypoplasia of the Atlas Does Not Correlate With Subaxial Canal Stenosis: A Retrospective Cohort Study · 2026 · DOI

• Furthermore, the specific contribu- tion of glial-neuronal interactions to CSR pathogenesis and the dif- ferential regulatory effects of NWM on distinct cell types warrant further investigation.

  Needle-warming moxibustion alleviates pain in rats with cervical spondylotic radiculopathy by modulating the NF-κB/ROS/NLRP3 pathway · 2026 · DOI

• This study has several limitations that should be con- sidered when interpreting the findings. First, the survey instrument did not separate mechanistically distinct pat- terns of “central canal stenosis.” Respondents were given a single “central canal stenosis” item, which implicitly bundled (1) disc- driven paracentral or central compres- sion and (2) fixed posterior element hypertrophy from ligamentum flavum buckling, facet overgrowth, or bony stenosis. In current practice, many experienced trans- foraminal surgeons approach paracentral/central disc compression as a natural extension of lateral recess decompression. As a result, some respondents likely treated “lateral canal stenosis” and “central canal ste- nosis” as essentially the same surgical problem when answering the survey. This conceptual merging would both (i) produce modest but nonzero residual correla- tion between those items and (ii) make TELD appear Transforaminal Endoscopic Lumbar Decompression: Defining Its Scope and LimitationsInternational Journal of Spine Surgery, Vol. 00, No. 0 more broadly applicable to “central canal stenosis” than it realistically is for severe, ligamentous/bony central canal narrowing. Future surveys should explicitly dis- tinguish disc- dominant central compression from pos- terior hypertrophic central stenosis, as these represent different levels of technical difficulty, risk tolerance, and biomechanical consequence for TELD. Second, although we used Rasch modeling, DIF, and Q3 residual correlation analysis to improve psy- chometric rigor, the data remain surgeon- reported per- ceptions rather than prospective patient- level outcomes. The weak residual correlations we observed between items were interpreted as exploratory patterns in how surgeons think about indications, not as proof that skill in 1 domain automatically translates to another. These perception- based consensus patterns therefore gener- ate hypotheses but do not replace direct comparative outcome data. Third, the discussion of ILS was included for con- textual comparison—to illustrate how other motion- preserving decompression strategies evolved from investigational to reimbursed procedures—not as evi- dence derived from this survey. Both ILS and trans- foraminal endoscopic decompression share the goal of neural element decompression with preservation of stability and motion, but they achieve it through differ- ent surgical corridors—midline/posterior for ILS and lateral/transforaminal for TELD. In this manuscript, we reference ILS in that limited sense: not as a direct com- parison group within our survey, but to illustrate that posterior motion- preserving stabilization has already progressed through definable coverage pathways and CPT recognition. For clarity, “ILS” reflects the current CPT and ISASS terminology encompassing both inter- laminar and interspinous device geometries, whereas the earlier literature (including Lewandrowski et al35) used the narrower term “IPS” to describe first- generation implants placed strictly between the spinous processes. Quantitative data from that prior meta- analysis are cited here only to support this conceptual parallel between posterior ILS stabilization and lateral endoscopic decompression within a shared minimally invasive phi- losophy, not to imply that these devices were evaluated in or form part of the present survey dataset. Finally, as with any voluntary international survey, the respondent cohort may reflect selection bias toward surgeons with established experience or interest in endoscopic techniques. Nevertheless, the geographic and specialty diversity, together with acceptable Rasch reliability indices, supports the representativeness of the observed consensus trends.

  Transforaminal Endoscopic Lumbar Decompression: Defining Its Scope and Limitations · 2026 · DOI

• The future directions section identifies the need for a graphical user interface with automated alarm mechanisms for clinical implementation, but does not specify thresholds for triggering alerts (e.g., risk probability cutoffs for delayed discharge, ICU monitoring, or prophylactic intubation). Prospective studies defining clinically actionable risk stratification thresholds derived from the CatBoost model are necessary for clinical decision support deployment.

  Artificial intelligence–based detection of acute postoperative airway complications following anterior cervical spine surgery: a retrospective imaging evaluation · 2026 · DOI

• The study mentions variability between radiographic environments using plain radiographs and CT scans but does not specify which imaging modality produced superior performance for detecting edema and hematoma. Systematic comparison of AI model accuracy across different imaging protocols (plain radiographs vs. CT) for airway complication detection in post-ACDF patients is needed.

  Artificial intelligence–based detection of acute postoperative airway complications following anterior cervical spine surgery: a retrospective imaging evaluation · 2026 · DOI

• The small number of airway obstruction cases in the dataset raises concerns about overfitting despite k-fold cross-validation mitigation. External validation using prospectively collected, multicenter imaging data from anterior cervical spine surgery cohorts with larger absolute numbers of postoperative airway compromise cases is required to establish robust model generalization.

  Artificial intelligence–based detection of acute postoperative airway complications following anterior cervical spine surgery: a retrospective imaging evaluation · 2026 · DOI

• The model relies on postoperative imaging for prediction and cannot be applied to patients who deteriorate clinically before imaging is obtained. Development of an alternative AI-based approach using intraoperative or immediate postoperative clinical parameters (vital signs, physical exam findings) to predict airway obstruction in the pre-imaging period is an actionable research direction.

  Artificial intelligence–based detection of acute postoperative airway complications following anterior cervical spine surgery: a retrospective imaging evaluation · 2026 · DOI

• The study cohort contained a high proportion of corpectomy cases, limiting generalizability to cervical spine surgery centers where discectomy-only procedures are more commonly performed. Future validation of the CatBoost AI model across different surgical technique distributions is needed to confirm its applicability in diverse clinical practice settings.

  Artificial intelligence–based detection of acute postoperative airway complications following anterior cervical spine surgery: a retrospective imaging evaluation · 2026 · DOI

• The sacral hiatus is the primary bony access point for trans-sacral procedures, but its anatomical variability in living adults remains incompletely characterized on cross-sectional imaging [1, 2].

  MDCT-based prevalence of anatomically challenging sacral hiatus morphology in adults: implications for procedural safety · 2026 · DOI

• The etiology of C5 palsy remains poorly understood and reliable preoperative predictors have yet to be identified.

  Assessing the predictive utility of preoperative canal diameter, foraminal stenosis, and cord-lamina angle for postoperative C5 palsy: a matched cohort validation study · 2026 · DOI

Most-cited papers in Cervical and Thoracic Myelopathy

• The Anatomy and Biomechanics of Acute and Chronic Whiplash Injury · Traffic Injury Prevention · 2009 · 107 citations
• Lateral Rupture of Cervical Intervertebral Disks · Postgraduate Medicine · 1966 · 32 citations
• Demonstration of Autonomic Nervous Function and Cervical Sensorimotor Control After Cervical Lordosis Rehabilitation: A Randomized Controlled Trial · Journal of Athletic Training · 2021 · 29 citations
• Cervical vertebral column morphology in patients with obstructive sleep apnoea assessed using lateral cephalograms and cone beam CT. A comparative study · Dentomaxillofacial Radiology · 2013 · 19 citations
• Reliability and validity of the Neck Disability Index among patients undergoing cervical surgery · International Journal of Rehabilitation Research · 2022 · 16 citations
• Progression of non-carious cervical lesions: 3D morphological analysis · Clinical Oral Investigations · 2021 · 16 citations
• Occlusal problems, mental health issues and non-carious cervical lesions · Odontology · 2021 · 13 citations
• Variations in the Anatomy of Spinal Accessory Nerve and its Landmarks for Identification in Neck Dissection: A Clinical Study · Journal of Maxillofacial and Oral Surgery · 2021 · 12 citations
• Surgical management of large-perforated class 4 invasive cervical root resorption: A case report · Journal of Dental Sciences · 2022 · 10 citations
• Advantages and Disadvantages of the Use of Various Types of Interbody Implants in Cervical Spine Surgery. Critical Review of the Literature · Ortopedia Traumatologia Rehabilitacja · 2020 · 9 citations

Most recent work

• Exoscopic Minimally Invasive Open-Door Laminoplasty with Pedicle Screw Fixation for Cervical Ossification of the Posterior Longitudinal Ligament: A Technical Note and Preliminary Clinical Experience · Journal of Clinical Medicine · 2026
• Machine Learning Prediction of Prevertebral Soft Tissue Swelling after Single-Level Anterior Cervical Surgery : A Proof-of-Concept Study · Journal of Korean Neurosurgical Society · 2026
• Predicting intraoperative blood loss using cervical vertebral bone quality scores in cervical corpectomy and fusion procedure · European Spine Journal · 2026
• Artificial intelligence–based detection of acute postoperative airway complications following anterior cervical spine surgery: a retrospective imaging evaluation · Asian Spine Journal · 2026
• Combined open and minimally invasive strategy for thoracic ossification of posterior longitudinal ligament: a case report and technical notes · Annals of Medicine & Surgery · 2026
• Insights into posterior cervical biportal endoscopic spine surgery outcomes in radiculopathy: a systematic review and meta-analysis · Asian Spine Journal · 2026
• Awake closed manual reduction of cervical spine dislocation as an emergency bridge to surgery: a case report · Frontiers in Medicine · 2026
• The myodural bridge complex: a comprehensive review of morphology, physiology, developmental biology and pathology · Frontiers in Medicine · 2026
• A comprehensive review of the denticulate ligaments: application to surgery of the craniocervical junction and spine · Anatomy & Cell Biology · 2026
• Clinical observation of Tuina manipulation combined with warming needle therapy in the treatment of cervical spondylotic radiculopathy · Journal of Acupuncture and Tuina Science · 2026

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