Evolving paradigms in lumbar disc herniation: new Knowledge Forum focus issue is published in Neurospine

A new special issue developed through a collaboration between the AO Spine Knowledge Forum (KF) Degenerative and the Neurospine society is now live in Neurospine Journal. It spotlights the evolution of lumbar disc herniation (LDH) management from symptom-based decision-making to prediction-informed precision surgery. The publication is an example of global spine leaders uniting to advance prediction-driven care, personalized surgical strategies, and future-facing disc research.

The focus issue brings together international experts to address a shared clinical challenge, how to identify which patients benefit from conservative care, which require surgery, and how surgical techniques can be individualized to improve durable outcomes. It frames LDH as a heterogeneous condition influenced by anatomy, biology, psychosocial factors, and evolving technology. 

“We developed this special issue in the AO Spine KF Degenerative to capture the ongoing paradigm shift in lumbar disc herniation—from a purely mechanical view of the disease to a multidisciplinary, precision-medicine approach integrating biology, imaging, and surgical innovation,” Guest Editor Gianluca Vadalà explained.

The collection moves beyond traditional imaging-based paradigms and explores how emerging tools—ranging from predictive modeling and biomarkers to endoscopic techniques and annular repair—may reshape daily surgical practice worldwide.

KF Degenerative Chairperson Samuel Cho highlighted the significant collaboration between Neurospine and AO Spine Knowledge Forum Degenerative behind the issue: “By concentrating on Lumbar Disc Herniation—one of the most common pathologies we treat—we have created a practical, high-impact resource for spine surgeons worldwide. I strongly encourage our community to leverage this material to refine their diagnostic and therapeutic strategies.”

From prediction to precision: a new clinical mindset

Lumbar disc herniation remains among the most common causes of radiculopathy, surgical intervention, and disability worldwide. Yet outcomes continue to vary, driven by differences in patient biology, pain processing, functional demands, and recurrence risk. 

“Bringing together emerging evidence on prediction, biology, and surgical techniques is essential to improve patient selection, optimize outcomes, and reduce unnecessary interventions,” Vadalà said. “This special issue aims to connect research and clinical practice, helping translate new scientific insights—from disc resorption mechanisms to minimally invasive and endoscopic surgery—into more personalized and evidence-based care pathways.”

The issue highlights a growing consensus: the future of LDH care lies in stratification and personalization. “Clinicians can use this collection as a practical reference to better understand when to operate, when to wait, and how new technologies and biological insights may influence decision-making in lumbar disc herniation management,” Vadalà said.

Rather than asking whether surgery works, contributors focus on more clinically relevant questions:

• Which patients are most likely to improve without surgery?
• Who benefits from earlier intervention?
• How can surgical technique be matched to disc morphology, annular integrity, and recurrence risk?
• What role will artificial intelligence, biomarkers, and microbiome research play in treatment selection?

By integrating these perspectives, the new focus issue aims to help orthopedic surgeons and spine specialists refine patient counseling, optimize timing of intervention, and tailor operative strategies, whether through conventional microdiscectomy, endoscopic approaches, or recurrence-mitigation techniques such as annular repair.

Snapshots from experts in the field

Ashish Kumar and Benjamin Gantenbein from University of Bern commented on the article “The Gut-Disc Axis: Unraveling the Microbiome’s Role in Lumbar Disc Herniation”
“…The strength of this article is its inclusion of research from 2006–2025, spanning almost 20 years. This brings together evidence from many countries, indicating that studying the gut-disc axis is important worldwide … . The authors have systematically included studies from diverse groups, including human, animal, genetic, and metabolomic data, to propose the concept of the gut-disc axis. Additionally, the review article also discusses two important concepts. Firstly, the link between the gut microbiome and LDH, and secondly, the link between the local disc microbiome and LDH. …”

Jin-Sung Kim from The Catholic University of Korea commented on the article “International Practice Patterns in the Surgical Management of Primary Lumbar Disc Herniation: An AO Spine Cross-Sectional Study”
“…This study provides a valuable benchmark for the current “standard of care,” confirming that despite the marketing of novel technologies, the mini-open microscopic approach remains the dominant global gold standard (54.2%). Furthermore, the study establishes a reassuring ethical hierarchy in surgical decision-making, where neurological status is prioritized over subjective pain or patient demand. …”

Hans Jörg Meisel from BG Klinikum Bergmannstrost Halle gGmbH commented on the article “Preoperative Clinical and Radiographic Risk Factors for Recurrent Lumbar Disc Herniation: Systematic Review and Meta-analysis”
“…The principal strength of this work lies in its comprehensive and structured assessment of recurrence risk factors. Unlike prior meta-analyses that often focused on isolated variables, this study organizes predictors into baseline, clinical, and detailed radiographic categories. This framework shifts the discussion away from surgical technique alone and toward patient-specific biological and biomechanical factors. The identification of elevated body mass index (BMI), diabetes mellitus, increased segmental range of motion, and Modic changes as significant predictors provides a robust, evidence-based risk profile for rLDH. ...”

Patrick C. Hsieh from University of Southern California Keck School of Medicine commented on the article “Beyond the Microscope: Is Endoscopic Discectomy the Next Gold Standard for Lumbar Disc Herniation?”
“…In their attempt to determine whether endoscopic discectomy is superior to traditional microdiscectomy, the authors conducted a well-designed systematic review of the literature over 25 years. The study’s findings are strengthened by the relatively large sample sizes, which include a substantial number of randomized controlled trials. … The question of whether endoscopic discectomy is superior to microscopic spine surgery remains unanswered … . Spine surgery is evolving toward minimally invasive techniques to improve outcomes, and endoscopic procedures are likely to become the gold standard if they truly demonstrate better clinical results, lower risks, and cost-effectiveness. …”

Practical value for surgeons

For practicing surgeons, precision starts with better phenotyping and outcome tracking. Contributors emphasize structured clinical assessment, neurologic deficit, pain dominance, psychosocial factors, and imaging concordance as the foundation for individualized care. Surgical discussions extend beyond decompression, addressing technique selection (including unilateral biportal endoscopy), extent of disc removal, and strategies to reduce reherniation.

Equally important, the issue underscores the need to measure what matters most to patients: leg pain relief, functional recovery, return to work, and long-term durability. These metrics, combined with expanding registries and predictive analytics, are expected to power the next generation of clinical decision-support tools.

Looking ahead: open questions for future research

The contributors acknowledge unanswered questions that will define the next phase of LDH care: Which predictors are most reliable? How can recurrence truly be reduced? And how do we ensure that innovation improves equity and access across diverse healthcare systems?

A truly global collaboration

This special issue reflects a growing alignment between research communities and clinical practice leaders. The partnership between AO Spine KF Degenerative and the Neurospine society represents shared commitment to translating scientific insight into actionable surgical guidance.

These platforms will provide surgeons, researchers, and industry partners with opportunities to explore how prediction models, regenerative strategies, and precision surgical techniques can be responsibly integrated into clinical workflows. Practicing clinicians are encouraged to adopt standardized patient phenotyping, track long-term outcomes, and engage in collaborative research networks that accelerate validation of new approaches.

List of articles in the focus issue:

1. Gianluca Vadalà, on behalf of the AO Spine Knowledge Forum Degenerative: Evolving Paradigms in Lumbar Disc Herniation: From Prediction to Precision Surgery
2. Luca Ambrosio, Jordy Schol, Stone Sima, Clara Ruiz-Fernandez, Victor Chen, Fabrizio Russo, In-Ho Han, Daisuke Sakai, Gianluca Vadalà, Vincenzo Denaro, Ashish D. Diwan, AO Spine Knowledge Forum Degenerative: The Gut-Disc Axis: Unraveling the Microbiome’s Role in Lumbar Disc Herniation
3. Luca Ambrosio, Sathish Muthu, Patrick C. Hsieh, S. Tim Yoon, Jeffrey C. Wang, Gianluca Vadalà, Hans Jörg Meisel, Stipe Ćorluka, Zorica Buser, AO Spine Knowledge Forum Degenerative: International Practice Patterns in the Surgical Management of Primary Lumbar Disc Herniation: An AO Spine Cross-Sectional Study
4. Mohamed A.R. Soliman, Hendrick Francois, Alexander O. Aguirre, Asham Khan, Waeel Hamouda, Stipe Ćorluka, Zorica Buser, Samuel K. Cho, S. Tim Yoon, AO Spine Knowledge Forum Degenerative: Preoperative Clinical and Radiographic Risk Factors for Recurrent Lumbar Disc Herniation: Systematic Review and Meta-analysis
5. Borriwat Santipas, Jin Sung Kim, Korawish Mekariya, John Y.S. Choi, Samuel K. Cho: Beyond the Microscope: Is Endoscopic Discectomy the Next Gold Standard for Lumbar Disc Herniation?
6. Carla Cunha, Hanzhi Yang, Zorica Buser, Carola Rojas, Marisa Cunha, Paulo Pereira, In Ho Han, Li Jin, Xudong Li, AO Spine Knowledge Forum Degenerative: Lumbar Disc Herniation Resorption: When and How Does It Occur?
7. Rachel Bratescu, Anthony Robayo, Evan Wang, Chibuikem A. Ikwuegbuenyi, Lawrance K. Chung, Noah Willett, Andreas K. Demetriades, Sun-Ho Lee, Roger Härtl, AO Spine Knowledge Forum Degenerative: Socioeconomic Implications of Recurrent Lumbar Disc Herniation: A Narrative Review
8. Waeel O. Hamouda, Stipe Ćorluka, Sathish Muthu, Luca Ambrosio, Carla Cunha, Stjepan Ivandic, Mohamed A.R. Soliman, Fabrizio Russo, Sibylle Grad, In Ho Han, Gianluca Vadala, Hans-Jorg Meisel, Sam K. Cho, Tim S. Yoon, Jeffrey C. Wang, Amit Jain, Zorica Buser, AO Spine Knowledge Forum Degenerative: Bracing and Activity Restriction After Lumbar Discectomy Surgery: An International Survey of AO Spine Members
9. Noah Willett, Chibuikem A. Ikwuegbuenyi, Evan Wang, Lawrance K. Chung, Anthony Robayo, Albert Antar, Galal Elsayed, Gianluca Vadalà, Ibrahim Hussain, Roger Härtl, AO Spine Knowledge Forum Degenerative: Mechanical and Biological Treatments for Annulus Fibrosus Repair and Closure: A Review of Clinical Studies
10. Carla Cunha, Junxuan Ma, Veronica Tilotta, In Ho Han, Gianluca Vadalà, Sibylle Grad, AO Spine Knowledge Forum Degenerative: Emerging Circulating Molecular Biomarkers: New Horizons in Lumbar Disc Herniation
11. Gianluca Vadala, Fabrizio Russo, In-Ho Han, Amit Jain, Javad Tavakoli, AO Spine Knowledge Forum Degenerative: The Biomechanical Landscape of Lumbar Disc Herniation: Mechanobiological Insights Into Injury and Regeneration
12. Hyun-Jun Jang, Dongkyu Kim, Bong-Ju Moon, Kyung-Hyun Kim, Jeong-Yoon Park, Sung-Uk Kuh, Keun-Su Kim, Dong-Kyu Chin: Disuse Bone Loss in Fusion Constructs After Multilevel Lumbar Fusion: A Computed Tomography Hounsfield Unit Analysis
13. Joonoh Seo, Woo-Seok Jung, Tae Hyun Park, Sung-Jae Lee, Ji-Won Kwon, Kyung-Soo Suk, Byung Ho Lee: Biomechanical Analysis Comparison of Different Cervical Posterior Screw Fixation Techniques: A Finite Element Study
14. Jiaheng Han, Jie Huang, Zhili Ding, Qiang Jiang, Guangnan Yang, Zhengcao Lu, Jingbo Ma, Yan Zhang, Yu Ding: TAFA4 Mitigates Intervertebral Disc Degeneration by Modulating Macrophage Polarization and Inhibiting ROS-NLRP3 Inflammasome Activation
15. Worawat Limthongkul, Natavut Prasertkul, Pakawas Praisarnti, Maruay Tanayavong, Surachat Jaroenwareekul, Wicharn Yingsakmongkol, Weerasak Singhatanadgige, Vit Kotheeranurak: Optimal Positioning for Single-Position Lateral Lumbar Interbody Fusion